2
361 complications, 3 presented an abnormal tracing. The abnormalities consisted of an absent Q4 together with a positive T4, a diphasic T and a PR interval of 0.24 sec. Such changes are not significant. The electrocardio- graphic changes of cardiovascular syphilis develop late and are usually due to aortic regurgitation, stenosis of the coronary orifices, or rarely to gumma or myocarditis. Uncomplicated aortitis does not lead to electrocardio- graphic abnormality. The development of the radiology of the heart and great vessels at first led to expectations that early aortitis might be detected by repeated careful examinations either by teleradiography or fluoroscopy. They have hardly been fulfilled. The main obstacle is the impossibility of obtaining a standard of’ normal measurement for the size of the aorta. Several methods have. been devised but all show that there is a wide varia- tion in the size of the normal aorta. In the Vaquez- Bordet 3 method the size is arrived at by measuring the distances from the midsternal line to the farthest point of the ascending aorta on the right and to the farthest point of the aortic knob on the left and adding the two together. In 200 normal patients Boharas found that this figure ranged from 3-9 to 7.8 cm. In 200 syphilitics 3% had unequivocal or diffuse enlargement of the aorta, but this was between 18 and 20 years after infection. The width of the root of the aorta in the left oblique position (Hampton’s 4 method) shows a similar wide variation (4.74 cm.), which makes it of little use in the diagnosis of early aortic dilatation. For the same reason, Fray’s 5 method of expressing the width of the aorta in terms of the chest width at the same level in the left oblique position is also unreliable. Fluoroscopy may reveal increased aortic pulsation, local dilatation, in- creased density of the aortic wall or irregularity of its outline. But none of these changes is pathognomonic of syphilis and they do not occur early. Every reported abnormality of the syphilitic aorta detected radiologically has been observed in non-syphilitic aortic disease. Although saccular aneurysm is almost always due to syphilis it should be remembered that in rare instances it may be due to advanced arteriosclerosis. Boharas and his colleagues conclude that a clinical diagnosis of early syphilitic aortitis is. impossible and that radio- logical methods are valuable but limited. BITE OF THE BLACK WIDOW SPII)ERs are the serpents of the insect world ; nearly all possess poison glands which excrete a venom that is - injurious to insects but only in a few species is it danger-. ous to man. Members of the genus latrodectus are specially dangerous, and presumably because of their black attire these sinister insects are known as widow spiders. In southern Europe Latrodectus tredecimguttatus., or the malmignatte, has been the subject of much ill- found imagery and folk-lore. But the true " tarantula "- Lycosa tarantula-is also found in southern Europe and mysterious properties were ascribed to its bite in the Middle Ages, among them the production of the hysteri- cal disease " tarantism." There are poisonous species of lactrodectus in New Zealand, South Africa and Turkestan and the black widow, L. mactans, is well known and much feared in California. Black widows are indeed common throughout the United States and Canada and have been carefully studied by American workers, from whom most of our knowledge of their venom has been gleaned.6 It is said that some 5% of bites by the black widow are fatal. Occasionally its bite gives rise to local gangrene and the formation of a dry black eschar. It is not usually painful, but is followed by a dull numbing pain which 3. Vaquez, H. and Bordet, E. The Heart and the Aorta, New Haven, 1920. 4. Hampton, A. O., Bland, E. F. and Sprague, H. B. Amer. Heart J. 1930, 6, 77. 5. Fray, W. W. Amer. J. Roentgenol. 1932, 27, 585. 6. D’Amour, F. E. Becker, F. E. and Van Riper, W. Quart. Rev. Biol. 1936, 11, 123. Costa, R. S. and Salveraglio, F. J. Arch. urug. Med. 1939, 14, 417. eventually becomes localised in the muscles of the chest, back and abdomen. This nerve pain is attributed to stimulation of the myoneural junctions. The abdominal wall becomes rigid while respiration is impeded by spasm of the thoracic muscles. In fatal cases death takes place within 18-36 hours. The male black widow is 1-1-5 cm. long and the female about five times as large. The adult female is glossy-black with crimson hour-glass abdominal markings, and she produces 1-4 egg sacs, each containing an average of 140 eggs. The pair of poison glands lie superficially and behind the ocular region of the cephalo- thorax. The venom is obtained by macerating the poison glands in salt solution ; about 0-1 mg. of dried venom can be got from one spider, and it is said to be five times as potent as that of the rattlesnake. Har- greaves and Mackenzie have lately described a case of spider bite in a Polish soldier in Palestine. He was admitted to hospital with a tentative diagnosis of acute abdomen and the extreme tenderness and board-like rigidity of his abdominal wall suggested a perforated peptic ulcer. On .these grounds he was admitted to the surgical ward, but when the Polish interpreter arrived, the patient gave a definite history ot a bite by a black spider on the right buttock followed within half a minute by intense pain like cramp which spread up his back to his head, limbs and abdomen, accompanied by vomiting. For three days this imitation of an abdominal emergency persisted. The man’s skin was bathed in cold, clammy sweat, his temperature was subnormal, and he com- plained of aching of all his muscles including those of the face and jaw, and of his teeth. No local lesion at the site of the bite could be detected. A curious finding was a moderate degree of polycythsemia. Subsequently the offending spider was captured and identified as the jet-black female of Latrodectus lugubris which is found in Palestine and Transjordania. Without a clear history this condition might prove a serious pitfall for the surgeon. THE INFANT’S RED CELLS THERE has been a lot of variation in the estimates of the normal range for red-cell count, haemoglobin, and other-values in the blood of infants during the first 10 days of life. Since 1921 at least twenty-six papers have appeared on the subject and the average range of red-cell counts has been put as low as 3.5-4.6 million per c.mm. and as high as 5-9-7-7 million ; the haemoglobin range has been variously estimated as 75-135% Haldane (10-35- 18-63 g. per 100 c.cm.) or 130-162% Haldane (17-94-’ 22-36 g. per 100 c.cm.) ; the average colour-index as from 0-7 to 1-22 ; the average range of packed cell volume -as from 34 to 79% or 52-66<5%. Chuinard, Osgood, and Ellis, viewing this lack of unanimity, judged the effort of repeating these investigations by standardised methods on a sufficient number of subjects worth while. They took 195 infants of both sexes aged between 1 and 10 days ; blood was obtained from the fontanelle and oxalated. During the first 10’days of life little variation in. average values with either age or sex was found so that all the figures were put together for the determination of average values and ranges. The average red-cell count was 4-6 million per c.mm., and 95% of the observed values fell within the range 3-4-5-8 million ; average haemoglobin was 16-3 g. per 100 c.cm. (118% Haldane), with 95% within the range 12-3-20-3 g. per 100 c.cm. (89-149% Haldane) ; average colour- index was 1-28 ; average packed red-cell volume was 43-4%, with 95% of the values within the range 31-5- 55-5%. The cells of the newborn infant were found to be larger and to contain more hemoglobin than adult cells. These values all fall within previously reported ranges but tend on the whole to be lower ; this tendency is ascribed to the early tying of the umbilical cord in all 7. Hargreaves, W. H. and Mackenzie, K. G. F. J. R. Army med. Cps, 1942, 78, 37. 8. Chuinard, E. G., Osgood, E. E. and Ellis, D. M. Amer. J. Dis. Child. 1941, 62, 1188.

THE INFANT'S RED CELLS

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complications, 3 presented an abnormal tracing. Theabnormalities consisted of an absent Q4 together with apositive T4, a diphasic T and a PR interval of 0.24 sec.Such changes are not significant. The electrocardio-

graphic changes of cardiovascular syphilis develop lateand are usually due to aortic regurgitation, stenosis ofthe coronary orifices, or rarely to gumma or myocarditis.Uncomplicated aortitis does not lead to electrocardio-graphic abnormality. The development of the radiologyof the heart and great vessels at first led to expectationsthat early aortitis might be detected by repeated carefulexaminations either by teleradiography or fluoroscopy.They have hardly been fulfilled. The main obstacle isthe impossibility of obtaining a standard of’ normalmeasurement for the size of the aorta. Several methodshave. been devised but all show that there is a wide varia-tion in the size of the normal aorta. In the Vaquez-Bordet 3 method the size is arrived at by measuring thedistances from the midsternal line to the farthest pointof the ascending aorta on the right and to the farthestpoint of the aortic knob on the left and adding the twotogether. In 200 normal patients Boharas found thatthis figure ranged from 3-9 to 7.8 cm. In 200 syphilitics3% had unequivocal or diffuse enlargement of the aorta,but this was between 18 and 20 years after infection.The width of the root of the aorta in the left obliqueposition (Hampton’s 4 method) shows a similar widevariation (4.74 cm.), which makes it of little use in thediagnosis of early aortic dilatation. For the same

reason, Fray’s 5 method of expressing the width of theaorta in terms of the chest width at the same level in theleft oblique position is also unreliable. Fluoroscopy mayreveal increased aortic pulsation, local dilatation, in-creased density of the aortic wall or irregularity of itsoutline. But none of these changes is pathognomonicof syphilis and they do not occur early. Every reportedabnormality of the syphilitic aorta detected radiologicallyhas been observed in non-syphilitic aortic disease.

Although saccular aneurysm is almost always due tosyphilis it should be remembered that in rare instancesit may be due to advanced arteriosclerosis. Boharasand his colleagues conclude that a clinical diagnosis ofearly syphilitic aortitis is. impossible and that radio-

logical methods are valuable but limited.

BITE OF THE BLACK WIDOWSPII)ERs are the serpents of the insect world ; nearly

all possess poison glands which excrete a venom that is -injurious to insects but only in a few species is it danger-.ous to man. Members of the genus latrodectus are

specially dangerous, and presumably because of theirblack attire these sinister insects are known as widow

spiders. In southern Europe Latrodectus tredecimguttatus.,or the malmignatte, has been the subject of much ill-found imagery and folk-lore. But the true

" tarantula "-

Lycosa tarantula-is also found in southern Europe andmysterious properties were ascribed to its bite in theMiddle Ages, among them the production of the hysteri-cal disease " tarantism." There are poisonous species oflactrodectus in New Zealand, South Africa and Turkestanand the black widow, L. mactans, is well known and muchfeared in California. Black widows are indeed commonthroughout the United States and Canada and havebeen carefully studied by American workers, from whommost of our knowledge of their venom has been gleaned.6It is said that some 5% of bites by the black widow arefatal. Occasionally its bite gives rise to local gangreneand the formation of a dry black eschar. It is not usuallypainful, but is followed by a dull numbing pain which3. Vaquez, H. and Bordet, E. The Heart and the Aorta, New Haven,

1920.4. Hampton, A. O., Bland, E. F. and Sprague, H. B. Amer. Heart J.

1930, 6, 77.5. Fray, W. W. Amer. J. Roentgenol. 1932, 27, 585.6. D’Amour, F. E. Becker, F. E. and Van Riper, W. Quart. Rev.

Biol. 1936, 11, 123. Costa, R. S. and Salveraglio, F. J. Arch.urug. Med. 1939, 14, 417.

eventually becomes localised in the muscles of the chest,back and abdomen. This nerve pain is attributed tostimulation of the myoneural junctions. The abdominalwall becomes rigid while respiration is impeded by spasmof the thoracic muscles. In fatal cases death takes placewithin 18-36 hours. The male black widow is 1-1-5 cm.

long and the female about five times as large. The adultfemale is glossy-black with crimson hour-glass abdominal

markings, and she produces 1-4 egg sacs, each containingan average of 140 eggs. The pair of poison glands liesuperficially and behind the ocular region of the cephalo-thorax. The venom is obtained by macerating the

poison glands in salt solution ; about 0-1 mg. of driedvenom can be got from one spider, and it is said to befive times as potent as that of the rattlesnake. Har-

greaves and Mackenzie have lately described a case ofspider bite in a Polish soldier in Palestine. He wasadmitted to hospital with a tentative diagnosis of acuteabdomen and the extreme tenderness and board-likerigidity of his abdominal wall suggested a perforatedpeptic ulcer. On .these grounds he was admitted to thesurgical ward, but when the Polish interpreter arrived, thepatient gave a definite history ot a bite by a blackspider on the right buttock followed within half a minuteby intense pain like cramp which spread up his back tohis head, limbs and abdomen, accompanied by vomiting.For three days this imitation of an abdominal emergencypersisted. The man’s skin was bathed in cold, clammysweat, his temperature was subnormal, and he com-plained of aching of all his muscles including those of theface and jaw, and of his teeth. No local lesion at thesite of the bite could be detected. A curious finding wasa moderate degree of polycythsemia. Subsequently theoffending spider was captured and identified as the

jet-black female of Latrodectus lugubris which is found inPalestine and Transjordania. Without a clear history thiscondition might prove a serious pitfall for the surgeon.

THE INFANT’S RED CELLS

THERE has been a lot of variation in the estimates ofthe normal range for red-cell count, haemoglobin, andother-values in the blood of infants during the first 10days of life. Since 1921 at least twenty-six papers haveappeared on the subject and the average range of red-cellcounts has been put as low as 3.5-4.6 million per c.mm.and as high as 5-9-7-7 million ; the haemoglobin range hasbeen variously estimated as 75-135% Haldane (10-35-18-63 g. per 100 c.cm.) or 130-162% Haldane (17-94-’22-36 g. per 100 c.cm.) ; the average colour-index as

from 0-7 to 1-22 ; the average range of packed cellvolume -as from 34 to 79% or 52-66<5%. Chuinard,Osgood, and Ellis, viewing this lack of unanimity,judged the effort of repeating these investigations bystandardised methods on a sufficient number of subjectsworth while. They took 195 infants of both sexes agedbetween 1 and 10 days ; blood was obtained from thefontanelle and oxalated. During the first 10’days of lifelittle variation in. average values with either age or sexwas found so that all the figures were put together forthe determination of average values and ranges. The

average red-cell count was 4-6 million per c.mm., and95% of the observed values fell within the range 3-4-5-8million ; average haemoglobin was 16-3 g. per 100 c.cm.(118% Haldane), with 95% within the range 12-3-20-3 g.per 100 c.cm. (89-149% Haldane) ; average colour-index was 1-28 ; average packed red-cell volume was43-4%, with 95% of the values within the range 31-5-55-5%. The cells of the newborn infant were found tobe larger and to contain more hemoglobin than adultcells. These values all fall within previously reportedranges but tend on the whole to be lower ; this tendencyis ascribed to the early tying of the umbilical cord in all7. Hargreaves, W. H. and Mackenzie, K. G. F. J. R. Army med.

Cps, 1942, 78, 37.8. Chuinard, E. G., Osgood, E. E. and Ellis, D. M. Amer. J. Dis.

Child. 1941, 62, 1188.

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their subjects, which was done to eliminate as far aspossible the variable factor of expressed placental blood.In spite of these precautions, the ranges of values intowhich 95% of the observations fit are wide. It is clearthat considerable variability in the normal newborninfant’s blood-count must be accepted and we must becorrespondingly cautious about regarding as pathologicalcounts that differ from the expected average.

WATER-BORNE PARATYPHOID B

AN outbreak of water-borne paratyphoid B fever inJuly, 1941, is reported from Brixworth.l It was re.

stricted to the occupants of a group of cottages whosewater-supply was obviously liable to gross pollution.The small surface well of 25 gallons capacity was situatedin a courtyard with a pervious surface and open sluicedrains ; this yard was surrounded by the cottages, a rowof hand-flushed water-closets, ash pits and a farm garden.The water-supply was the only factor common to thecottagers and not shared by the rest of Brixworth ; itwas suspect from the first. Among a population of 34at risk, 4 developed enteric fever and 21 others excretedparatyphoid bacilli in their faeces at some time. The

report draws attention to a number of unusual features.In contrast with typhoid fever, authentic outbreaks ofwater-borne paratyphoid B fever are very uncommon.Bacterinm paratyphosum B has not previously beenisolated from a water-supply. In .this outbreak the

organism was identified by three independent labora--tories. The water remained infected for three weeks.The contamination was so heavy that an almost pureculture was obtained from as little as 0- 1 ml. of one sample.A bacteriophage was also present. The organism waspredominantly, but not exclusively, in the group phasein both water and stools. Agglutination reactions werelikewise interesting-some high titres to salmonella

group suspensions were obtained, as well as significanttitres to paratyphoid B (H and 0). One of the cottagerswas regarded as the primary case and the source of thecontamination of the water-supply, but this was not

proved. It is of interest to note the high proportionof infected persons (25 out of 34 at risk) and the relativelylow proportion of cases among the infected (4 out of 25)..Many of the unusual features of this outbreak can perhapsbe attributed to the exceptionally heavy contaminationof a small water-supply.

FINLAY INSTITUTE OF THE AMERICAS

WITH the help of Columbus and his colleagues Europediscovered the Americas several’ centuries ago ; theAmericas are only discovering each other today. But

they have quickly found what a lot they have in common,and the decision taken at Havana on Jan. 6 to set upthe new Finlay Institute of the Americas should add auseful and enduring link to the bond between the twocontinents. The new institute has been established to" foster research and education in the field of tropicalmedicine and to provide for an increased interchange ofmedical students and teachers among scientific medicalinstitutions in all the American natioiis." Executiveoffices are to be opened in Havana and New York andthe Cuban government have promised an annual grantof 20,000 dollars for maintenance. American industrial-ists and philanthropists have also made substantial con-tributions. Dr. James E. Paullin, president elect of theAmerican College of Surgeons, has been appointed chair-man of the scientific advisory committee, and othermembers will include Dr. Edgar Mayer, assistant pro-fessor of medicine in Cornell University and also, in theUniversity of Havana, Dr. Enrique Saladrigas, directorof the Havana Finlay Institute, Dr. Rafael Menocal,professor of surgery in the University of Havana, andDr. Felix Hurtado, assistant minister of public health for

1. Mon. Bull. emer. publ. Hlth Lab. Serv. February, 1942, p. 1.

Cuba. The constitution of the new institute is now

being drawn up. Readers of the pious biography ofCarlos Finlay, written by his son,l will be pleased thathis work on the mosquito transmission of yellow fevershould receive this honourable commemoration.

HEARTBURN DURING PREGNANCYAT some stage of their pregnancy about two mothers

out of three suffer from heartburn. This is a feeling asif some scalding liquid suddenly appeared at the lowerend of the gullet and from there passed upwards to themouth. It has no obvious relation to food but is oftenrelated to posture, lying on the right side being especiallyliable to bring it on. As a rule it is accompanied byprofuse salivation. Heartburn may be no more than aninconvenience, easily checked by home remedies, or itmay be severe enough to make sleep impossible andresist all efforts at relief. It is most common during the6th, 7th and 8th month of pregnancy, though it mayappear at any stage, and is most severe when it occurs inthe later months. It is aggravated by the causes whichaggravate dyspepsia-worry and overwork, excesses offood or drink, and a nervous temperament. A severeattack may leave the lower end of the oesophagus sensi-tive to hot drinks, or indeed to any food or drink.

Regurgitation of acid gastric juice is the explanationwhich best fits in with the patient’s sensations, and thisexplanation was generally accepted until the changes ingastric acidity during pregnancy were closely studied.It then appeared that gastric acidity falls steadily duringpregnancy, and is lowest in the months when heartburnis most common. It was found, too, that heartburncould as often be relieved with hydrochloric acid as withalkalis. The fault seems to be mechanical rather thanchemical. By means of a swallowed balloon ChesterJones demonstrated that the sensation of heartburncould be produced by distending the lower end of theoesophagus, and he followed this observation by anotherthat the sensation could be produced by introducing evena bland fluid into the lower oesophagus through a

catheter. A barium swallow during an attack of heart-burn revealed that the cardiac sphincter was tightlyclosed and that waves of reverse peristalsis were carryingthe barium upwards. ZVilliams,2 of Beverly Hills,ascribes the heartburn of pregnancy to interference

with the neuromuscular mechanism of the oesophagusarising from the dislocation of the stomach by theenlarging uterus. He has confirmed the observations ofRolf Hansen that in the later stages of pregnancy thestomach comes to lie with its long axis more horizontaland the greater curvature pushed up towards the cardia ;motility is much reduced and the emptying time pro-longed, conditions which favour the regurgitation of

gastric contents into the oesophagus. In Williams’scases of heartburn definite anatomical abnormalities.such as hiatus hernia, were rare. On the analogy ofpostoperative atony he treated 16 cases with injectionsof 1 c.cm. of 1 in 2000 ‘ Prostigmin ’ (Roche), findingthat a single dose relieved 14 of them within 24 hours, therelief lasting for 7-10 days, when a, second injection wasgiven with similar success. By repeated injections thesepatients were kept free from symptoms with no illeffects. But this is not an easy complaint in which toassess the value of treatment, for as A. M. Campbell saidin the discussion of Williams’s paper, many cases can berelieved by attention to emotional and environmentalmaladjustments and a well-balanced diet.

The Minister of Health has appointed Dr. FiNDLATMuRCHiE to be deputy director-general of the EmergencyMedical Services. Dr. Murchie, who is a barrister-at-law of the Middle Temple, has been a principal medicalofficer of the Ministry of Pensions... ’.

1. Lancet, 1941, ii, 167.2. Williams, N. H. Amer. J. Obstet. Gynec. 1941, 42, 814.