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ONE REGISTER FOR PHARMACISTS
383
Annotations INFLUENZA 1953
DISASTROUS floods and fogs have made this one of the worst winters for a long time ; and influenza, making its biennial attack in this country, has added to our difficulties. But, in general, influenza has so far its been mild. On previous visit, two years ago, the influenza-A virus swept rapidly through the country, and in the first month of that epidemic there were In the present nearly 5000 deaths from influenza. from the deaths influenza have climbed slowly, epidemic and during the same period there were rather less than Once more, deaths have been most numerous 600. in elderly people-about 90% of those who have died were over the age of 55. A curious feature of this year’s epidemic is that the incidence of influenza has been very much greater in the south of England than in other parts of the country ; but perhaps that is simply a reflection of the higher incidence in the north during the 1950-51 epidemic. Some idea of the size of the epidemic comes from the claims for sickness benefit received by the Ministry of National Insurance ; about 100,000 claims in excess of normalwere recorded for the week ending Feb. 3, and most of these claims were probably the result of influenza. At about the same time as the epidemic appeared in this country, sharp outbreaks were reported from France, Germany, and the U.S.A. Slightly earlier there was a severe epidemic in Japan, and lesser outbreaks have since been reported from’Scandinavia, Finland, Holland, and Switzerland. Detailed laboratory and epidemiological observations must be completed before the source or sources of this year’s influenza can be identified or the method of spread traced. Preliminary laboratory reports indicate, however, that in all the countries involved A-prime viruses have been recovered. Those isolated in this country show an antigenic similarity to strains recovered this year in the U.S.A., Japan, and Denmark, and also to the Scandinavian subtype which was partly responsible for the European epidemic of 1950-51. On the other hand, strains from France and Switzerland seem to resemble the Liverpool subtype which was also prevalent in 1950-51. It seems, therefore, that this year’s epidemic had at least two foci of origin. When the spring has chased these troubles away, the lessons of this year’s epidemic will be clearer. In particular, the results of the influenza vaccine trial, organised by the Ministry of Health and the Medical Research Council, and of the epidemiological investigations of the World Health Organisation influenza programme, will be awaited with great interest in the hope that we shall be able to look forward to our next encounter with the virus with greater confidence. DETERGENTS THE domestic use of detergents has increased enormously, and some of the results are causing concern. Mostly these agents are products of the petroleum industry; they are paraffin-chain salts, their long hydrocarbon chain having an electrolytically dissociated group at or near the end. They thus have strong surface activity which favours the penetration of water into the interstices of fabrics. They also exercise a powerful emulsifying action on greasy dirt ; the film on the threads of cloth is rolled into loosely adherent globules which are easily detached by agitation and can be rinsed away.! In the home detergents are used, as well as for laundering clothes, to wash dishes and utensils ; and in industry they are used for various degreasing processes. They also find a proper use in dermatology as emulsion bases and in antiseptic shampoos and the 1. Adam, N. K., Stevenson, D. G. p. 25.
Endeavour, January, 1953,
like. The domestic detergents foam readily and are apt to be judged by this quality. Foam, however, though it breaks up the oil and mechanically assists removal of dirt, is not necessary for detergent action, which may be little reduced by the addition of antifoaming agents.2 Detergents prove harsh to some skins, and may even cause dermatitis ; they may act as primary irritants or may produce sensitisation. Their action may be partly due to their defatting and drying effect, which may aid the penetration of other irritants or aggravate constitutional skin disease. As Hodgson 3 points out, however, these agents are a valuable aid to the housewife, who soon learns which brand, if any, she must avoid. The commercial firms are aware of the danger, and before marketing their products usually submit them to immersion and patch tests on the human skin. When the detergent leaves the kitchen sink, other problems arise. At the sewage works it is usual, especially on Tuesdays, to find that the agitation in the aeration tanks has produced a surface layer of foam as much as The narrow service " roads " between six feet deep. the tanks are slippery and dangerous ; and huge masses of foam are liable to be whipped off by the wind, perhaps carrying pathogens and certainly a potential danger to car-drivers, on whose windscreens they may alight. In America such masses of foam are believed to have accounted for some "flying saucers." How far detergents interfere with the biological processes of sewage purification is not fully known ; but they are not removed by present methods of treatment and therefore reach the effluents and the rivers into which these may discharge. River and harbour boards are concerned about the possible effect of these agents on fish or on the food of fish. Further, if the river should be a source of water-supply, the water undertaking is perturbed about the possible effects of the continued presence of detergents on the purification plant and on consumers. There is no simple answer to this problem. The use at sewage works of water-sprayers or of chemicals with an anti-foaming action has been suggested. These, however, would increase the cost of sewage treatment and might bring other difficulties in their train. Workers in the U.S.A., who have longer experience of the trouble, have so far not found a solution. Clearly there is urgent need for research, in which we hope that the authorities and scientists interested will have the full cooperation of the manufacturers. ONE REGISTER FOR PHARMACISTS
UNLIKE medicine
or dentistry, pharmacy has two and consequently the term " regisincludes the two groups, "pharmaceutical chemists " and " chemists and druggists." The reasons for this apparent anomaly lie in the history of the profession. The first Pharmacy Act, passed in 1852, sought to prevent ignorant and incompetent persons from assuming the title of, or pretending to be, pharmaceutical chemists or pharmaceutists or members of the Pharmaceutical Society. Accordingly the Act directed that a register of pharmacists and their assistants and apprentices should be established and maintained. Seventeen years later further legislation permitted assistants to become " chemists and druggists," entitled to sell and supply poisons, so that for over eighty years there have been two registers of people with these privileges. Pharmaceutical chemists form less than one-tenth of the membership of the Pharmaceutical Society (membership of the society has been coextensive with registration as a pharmacist since the Pharmacy and Poisons Act, 1933, became law). They have had no advantages, apart from that of title and the benefits of having reached a higher educational standard. Formerly, the majority
statutory registers, tered pharmacist "
2. Sisley, J. P. B. Corps gras industr. 1943, 1, 66. 3. Hodgson, G. Practitioner, 1953, 170, 166.
384 of
pharmaceutical
chemists
first
passed the
minor
examination ; but since the introduction of university
degrees in pharmacy, graduates have obtained this higher by way of a greatly modified examination. In practice, however, no-one outside the profession realised that any distinction or difference existed. Recently the Pharmaceutical Society ceased to examine at the " chemist and druggist " level ; so the holders of this title now form a dwindling group. The Pharmacy Bill, a private member’s Bill now before Parliament, seeks to place all pharmacists on the register of pharmaceutical title
If this becomes law, the present chemists and pharmaceutical druggists will receive the title of chemist " by way of bonus. Perhaps the existing holders of this qualification will feel they have suffered some loss of status and they may wish for a distinctive title as a sign of the standard they have attained. The century-old Act not only prohibited the Pharmaceutical Society from conducting examinations in medicine, surgery, and midwifery, but also debarred members of the medical profession from registering as pharmaceutical chemists ; the new Bill will repeal the latter and retain the former provision. Certain domestic matters of the society, including the abolition of the limit on the annual retention fee paid by members, are also covered by the Bill. The Bill is sponsored by memchemists.
"
bers on both sides of the House and seems to contain little that is controversial. Incidentally, there is talk at the moment of establishing an examination in practical pharmacy for unqualified assistants ; but it is to be hoped that this will not lead to a repetition of history and a demand for legislation to recognise a new class by ata/tte.
-
MEDICINE AND GEOGRAPHY the ORGANISED scientific collaboration between different countries of the British Commonwealth is one happy result of the late world war. Representatives of the Medical Research Council, Department of Scientific and Industrial Research, Agricultural Research Council, and Commonwealth Agricultural Bureaux have met regularly in London since 1946 with scientific representatives of Canada, Australia, Southern Rhodesia, South Africa, India, New Zealand, the Colonies, and latterly also Pakistan and Ceylon, to see what can be done to improve the exchange of scientific information and of specialist scientists, and how national laboratories can work for the benefit of the whole Commonwealth or share in international research. The fruits of this combined approach include an index of English translations of foreign scientific papers, a book listing inter-Commonwealth postgraduate scholarships in science, maps of the prevalence of insect and fungus plant diseases, and the coördination of culture collections of micro-organisms : two reference laboratories of the Public Health Laboratory Service at Colindale (dysentery and food-poisoning) now work for the whole Commonwealth, with the exception of Canada. These and other achievements are recorded in the report, just published,! of a special Commonwealth conference held in Australia last vear. On the whole this scientific liaison work is for the benefit of official science, and relatively little is of medical import ; but geographical anthropometry-the study of the normal physical standards of inhabitants of different countries or of different tribes in a single country-is proposed as suitable for research by collaboration throughout the Commonwealth. This not only is essential for where disease begins, but may also prove a defining good test of the value of somatotyping and similar attempts to classify human physiques. It seems a pity that the conference turned down a proposal to study geographically the prevalence of dental caries-appar1. British Commonwealth Scientific Conference, Australia, 1952 : Report of Proceedings. H.M. Stationery Office. Pp. 74. 3s.
ently because this would be better investigated on a full international scale. The Commonwealth is large enough for useful studies on the geography of many diseases ; and to wait till, say, the World Health Organisation has money for international research of this sort and can persuade its member nations to collaborate may be to wait a very long time. The American Geographical Society has already begun to publish maps of the distribution of diseases2 and how this is changing with the years ; and Sigerist 3 has discussed the kind of useful work to be done. Research on this subject can only be by international collaboration ; and the British Commonwealth Scientific Conference ought to consider further how it might be promoted-for instance, by coordinating the work of national health departments on the notification of disease. RUPTURE OF THE BLADDER of intraperitoneal rupture of the bladder may be difficult. Moreover, Negley4 emphasised its importance by drawing attention to the danger of spread of infection ; he found that the operative mortality within the first twelve hours was 11%it rose to 22% after twelve hours, and. to 43% by the second day. Various tests for the earlier diagnosis of this condition have been suggested and tried. Recently, Cipolla and THE
early diagnosis
his colleagues5 reported that in dogs a 0.5% solution of fluorescein was not absorbed from an intact bladder, but was readily absorbed from the peritoneal cavity and could be detected later in the blaod-stream. Similar results were obtained in experiments on human beings. The authors suggest that in -every case of suspected rupture of the bladder a 10 ml. specimen of blood should be taken, and then 100 ml. of a 0-5% solution of fluorescein passed through a urethral catheter into the bladder. The control serum is compared with three specimens of at intervals of five minutes; the serum removed presence of fluorescein confirms the diagnosis. A tear in the bladder may be plugged by omentum and the perforation may not be detected by other tests. In dogs, Cipolla et al. found that less fluorescein was absorbed when the tear was plugged by omentum than when it was open to the peritoneal cavity ; and they suggest that this finding may be used to distinguish between a ruptured bladder which is sealed with omentum and one which is not. DIAGNOSIS OF MYASTHENIA GRAVIS BEFORE the introduction of neostigmine by Mary Walker in 1935 myasthenia gravis was usually diagnosed by observing the characteristic distribution of the muscles affected-the occular and bulbar muscles and proximal rather than distal limb muscles-and by the history of diurnal fluctuations as well as remissions and relapses The greatest difficulty arose in over months or years. patients with an unusual mode of onset, those with no tendency to remission, and those who in an early stage of the disease showed no physical signs and might be
diagnosed as hysterical. Neostigmine, with its rapid action, was widely welcomed as a diagnostic agent. The patient whose muscular power is not increased by a dose of 1-5 mg. intramuscularly or 0.5 mg. intravenously has not got myasthenia gravis-though the response varies widely from one patient to another. Neostigmine may, however, also cause some temporary improvement in thyrotoxic myopathy 6and in dysphagia due to early progressive bulbar palsy. ’Moreover, it has to be. used with some care, and always with atropine (0-6 mg.) because of its 2. Sci. Amer. February, 1953, p. 22. 3. Sigerist, H. E. A History of Medicine. 1951 ; vol. 1, p. 66. 4. Negley, J. C. J. Urol. 1927, 18, 207. 5.
Cipolla,
A.
New York and London,
F., Khedroo, L. G., Casella, P. A.
33, 102. 6. Laurent, L. P. E. Lancet, 1944, i, 87. 7. Sheldon, J. H., Walker, R. M. Ibid, 1946, i, 342.
Surgery, 1953,
Annotations INFLUENZA 1953
DISASTROUS floods and fogs have made this one of the worst winters for a long time ; and influenza, making its biennial attack in this country, has added to our difficulties. But, in general, influenza has so far its been mild. On previous visit, two years ago, the influenza-A virus swept rapidly through the country, and in the first month of that epidemic there were In the present nearly 5000 deaths from influenza. from the deaths influenza have climbed slowly, epidemic and during the same period there were rather less than Once more, deaths have been most numerous 600. in elderly people-about 90% of those who have died were over the age of 55. A curious feature of this year’s epidemic is that the incidence of influenza has been very much greater in the south of England than in other parts of the country ; but perhaps that is simply a reflection of the higher incidence in the north during the 1950-51 epidemic. Some idea of the size of the epidemic comes from the claims for sickness benefit received by the Ministry of National Insurance ; about 100,000 claims in excess of normalwere recorded for the week ending Feb. 3, and most of these claims were probably the result of influenza. At about the same time as the epidemic appeared in this country, sharp outbreaks were reported from France, Germany, and the U.S.A. Slightly earlier there was a severe epidemic in Japan, and lesser outbreaks have since been reported from’Scandinavia, Finland, Holland, and Switzerland. Detailed laboratory and epidemiological observations must be completed before the source or sources of this year’s influenza can be identified or the method of spread traced. Preliminary laboratory reports indicate, however, that in all the countries involved A-prime viruses have been recovered. Those isolated in this country show an antigenic similarity to strains recovered this year in the U.S.A., Japan, and Denmark, and also to the Scandinavian subtype which was partly responsible for the European epidemic of 1950-51. On the other hand, strains from France and Switzerland seem to resemble the Liverpool subtype which was also prevalent in 1950-51. It seems, therefore, that this year’s epidemic had at least two foci of origin. When the spring has chased these troubles away, the lessons of this year’s epidemic will be clearer. In particular, the results of the influenza vaccine trial, organised by the Ministry of Health and the Medical Research Council, and of the epidemiological investigations of the World Health Organisation influenza programme, will be awaited with great interest in the hope that we shall be able to look forward to our next encounter with the virus with greater confidence. DETERGENTS THE domestic use of detergents has increased enormously, and some of the results are causing concern. Mostly these agents are products of the petroleum industry; they are paraffin-chain salts, their long hydrocarbon chain having an electrolytically dissociated group at or near the end. They thus have strong surface activity which favours the penetration of water into the interstices of fabrics. They also exercise a powerful emulsifying action on greasy dirt ; the film on the threads of cloth is rolled into loosely adherent globules which are easily detached by agitation and can be rinsed away.! In the home detergents are used, as well as for laundering clothes, to wash dishes and utensils ; and in industry they are used for various degreasing processes. They also find a proper use in dermatology as emulsion bases and in antiseptic shampoos and the 1. Adam, N. K., Stevenson, D. G. p. 25.
Endeavour, January, 1953,
like. The domestic detergents foam readily and are apt to be judged by this quality. Foam, however, though it breaks up the oil and mechanically assists removal of dirt, is not necessary for detergent action, which may be little reduced by the addition of antifoaming agents.2 Detergents prove harsh to some skins, and may even cause dermatitis ; they may act as primary irritants or may produce sensitisation. Their action may be partly due to their defatting and drying effect, which may aid the penetration of other irritants or aggravate constitutional skin disease. As Hodgson 3 points out, however, these agents are a valuable aid to the housewife, who soon learns which brand, if any, she must avoid. The commercial firms are aware of the danger, and before marketing their products usually submit them to immersion and patch tests on the human skin. When the detergent leaves the kitchen sink, other problems arise. At the sewage works it is usual, especially on Tuesdays, to find that the agitation in the aeration tanks has produced a surface layer of foam as much as The narrow service " roads " between six feet deep. the tanks are slippery and dangerous ; and huge masses of foam are liable to be whipped off by the wind, perhaps carrying pathogens and certainly a potential danger to car-drivers, on whose windscreens they may alight. In America such masses of foam are believed to have accounted for some "flying saucers." How far detergents interfere with the biological processes of sewage purification is not fully known ; but they are not removed by present methods of treatment and therefore reach the effluents and the rivers into which these may discharge. River and harbour boards are concerned about the possible effect of these agents on fish or on the food of fish. Further, if the river should be a source of water-supply, the water undertaking is perturbed about the possible effects of the continued presence of detergents on the purification plant and on consumers. There is no simple answer to this problem. The use at sewage works of water-sprayers or of chemicals with an anti-foaming action has been suggested. These, however, would increase the cost of sewage treatment and might bring other difficulties in their train. Workers in the U.S.A., who have longer experience of the trouble, have so far not found a solution. Clearly there is urgent need for research, in which we hope that the authorities and scientists interested will have the full cooperation of the manufacturers. ONE REGISTER FOR PHARMACISTS
UNLIKE medicine
or dentistry, pharmacy has two and consequently the term " regisincludes the two groups, "pharmaceutical chemists " and " chemists and druggists." The reasons for this apparent anomaly lie in the history of the profession. The first Pharmacy Act, passed in 1852, sought to prevent ignorant and incompetent persons from assuming the title of, or pretending to be, pharmaceutical chemists or pharmaceutists or members of the Pharmaceutical Society. Accordingly the Act directed that a register of pharmacists and their assistants and apprentices should be established and maintained. Seventeen years later further legislation permitted assistants to become " chemists and druggists," entitled to sell and supply poisons, so that for over eighty years there have been two registers of people with these privileges. Pharmaceutical chemists form less than one-tenth of the membership of the Pharmaceutical Society (membership of the society has been coextensive with registration as a pharmacist since the Pharmacy and Poisons Act, 1933, became law). They have had no advantages, apart from that of title and the benefits of having reached a higher educational standard. Formerly, the majority
statutory registers, tered pharmacist "
2. Sisley, J. P. B. Corps gras industr. 1943, 1, 66. 3. Hodgson, G. Practitioner, 1953, 170, 166.
384 of
pharmaceutical
chemists
first
passed the
minor
examination ; but since the introduction of university
degrees in pharmacy, graduates have obtained this higher by way of a greatly modified examination. In practice, however, no-one outside the profession realised that any distinction or difference existed. Recently the Pharmaceutical Society ceased to examine at the " chemist and druggist " level ; so the holders of this title now form a dwindling group. The Pharmacy Bill, a private member’s Bill now before Parliament, seeks to place all pharmacists on the register of pharmaceutical title
If this becomes law, the present chemists and pharmaceutical druggists will receive the title of chemist " by way of bonus. Perhaps the existing holders of this qualification will feel they have suffered some loss of status and they may wish for a distinctive title as a sign of the standard they have attained. The century-old Act not only prohibited the Pharmaceutical Society from conducting examinations in medicine, surgery, and midwifery, but also debarred members of the medical profession from registering as pharmaceutical chemists ; the new Bill will repeal the latter and retain the former provision. Certain domestic matters of the society, including the abolition of the limit on the annual retention fee paid by members, are also covered by the Bill. The Bill is sponsored by memchemists.
"
bers on both sides of the House and seems to contain little that is controversial. Incidentally, there is talk at the moment of establishing an examination in practical pharmacy for unqualified assistants ; but it is to be hoped that this will not lead to a repetition of history and a demand for legislation to recognise a new class by ata/tte.
-
MEDICINE AND GEOGRAPHY the ORGANISED scientific collaboration between different countries of the British Commonwealth is one happy result of the late world war. Representatives of the Medical Research Council, Department of Scientific and Industrial Research, Agricultural Research Council, and Commonwealth Agricultural Bureaux have met regularly in London since 1946 with scientific representatives of Canada, Australia, Southern Rhodesia, South Africa, India, New Zealand, the Colonies, and latterly also Pakistan and Ceylon, to see what can be done to improve the exchange of scientific information and of specialist scientists, and how national laboratories can work for the benefit of the whole Commonwealth or share in international research. The fruits of this combined approach include an index of English translations of foreign scientific papers, a book listing inter-Commonwealth postgraduate scholarships in science, maps of the prevalence of insect and fungus plant diseases, and the coördination of culture collections of micro-organisms : two reference laboratories of the Public Health Laboratory Service at Colindale (dysentery and food-poisoning) now work for the whole Commonwealth, with the exception of Canada. These and other achievements are recorded in the report, just published,! of a special Commonwealth conference held in Australia last vear. On the whole this scientific liaison work is for the benefit of official science, and relatively little is of medical import ; but geographical anthropometry-the study of the normal physical standards of inhabitants of different countries or of different tribes in a single country-is proposed as suitable for research by collaboration throughout the Commonwealth. This not only is essential for where disease begins, but may also prove a defining good test of the value of somatotyping and similar attempts to classify human physiques. It seems a pity that the conference turned down a proposal to study geographically the prevalence of dental caries-appar1. British Commonwealth Scientific Conference, Australia, 1952 : Report of Proceedings. H.M. Stationery Office. Pp. 74. 3s.
ently because this would be better investigated on a full international scale. The Commonwealth is large enough for useful studies on the geography of many diseases ; and to wait till, say, the World Health Organisation has money for international research of this sort and can persuade its member nations to collaborate may be to wait a very long time. The American Geographical Society has already begun to publish maps of the distribution of diseases2 and how this is changing with the years ; and Sigerist 3 has discussed the kind of useful work to be done. Research on this subject can only be by international collaboration ; and the British Commonwealth Scientific Conference ought to consider further how it might be promoted-for instance, by coordinating the work of national health departments on the notification of disease. RUPTURE OF THE BLADDER of intraperitoneal rupture of the bladder may be difficult. Moreover, Negley4 emphasised its importance by drawing attention to the danger of spread of infection ; he found that the operative mortality within the first twelve hours was 11%it rose to 22% after twelve hours, and. to 43% by the second day. Various tests for the earlier diagnosis of this condition have been suggested and tried. Recently, Cipolla and THE
early diagnosis
his colleagues5 reported that in dogs a 0.5% solution of fluorescein was not absorbed from an intact bladder, but was readily absorbed from the peritoneal cavity and could be detected later in the blaod-stream. Similar results were obtained in experiments on human beings. The authors suggest that in -every case of suspected rupture of the bladder a 10 ml. specimen of blood should be taken, and then 100 ml. of a 0-5% solution of fluorescein passed through a urethral catheter into the bladder. The control serum is compared with three specimens of at intervals of five minutes; the serum removed presence of fluorescein confirms the diagnosis. A tear in the bladder may be plugged by omentum and the perforation may not be detected by other tests. In dogs, Cipolla et al. found that less fluorescein was absorbed when the tear was plugged by omentum than when it was open to the peritoneal cavity ; and they suggest that this finding may be used to distinguish between a ruptured bladder which is sealed with omentum and one which is not. DIAGNOSIS OF MYASTHENIA GRAVIS BEFORE the introduction of neostigmine by Mary Walker in 1935 myasthenia gravis was usually diagnosed by observing the characteristic distribution of the muscles affected-the occular and bulbar muscles and proximal rather than distal limb muscles-and by the history of diurnal fluctuations as well as remissions and relapses The greatest difficulty arose in over months or years. patients with an unusual mode of onset, those with no tendency to remission, and those who in an early stage of the disease showed no physical signs and might be
diagnosed as hysterical. Neostigmine, with its rapid action, was widely welcomed as a diagnostic agent. The patient whose muscular power is not increased by a dose of 1-5 mg. intramuscularly or 0.5 mg. intravenously has not got myasthenia gravis-though the response varies widely from one patient to another. Neostigmine may, however, also cause some temporary improvement in thyrotoxic myopathy 6and in dysphagia due to early progressive bulbar palsy. ’Moreover, it has to be. used with some care, and always with atropine (0-6 mg.) because of its 2. Sci. Amer. February, 1953, p. 22. 3. Sigerist, H. E. A History of Medicine. 1951 ; vol. 1, p. 66. 4. Negley, J. C. J. Urol. 1927, 18, 207. 5.
Cipolla,
A.
New York and London,
F., Khedroo, L. G., Casella, P. A.
33, 102. 6. Laurent, L. P. E. Lancet, 1944, i, 87. 7. Sheldon, J. H., Walker, R. M. Ibid, 1946, i, 342.
Surgery, 1953,