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not reduced the incidence of leukaemia in patientswith polycythsemia vera, but on the other hand it hasnot increased it, as might have been anticipated ; noris there any evidence that this treatment has increasedthe subsequent incidence of neoplasms. ,

The average age of the patients treated with P32who died was 67 years, and this is nearly the normalexpectation of life for a group of average 50-7 years -,it compares well with the expectation of life of patientswith properly controlled pernicious ansemia or diabetes.Apart from P32, the only other remedy used in thisseries was venesection, which was needed in ratherless than half the patients to control urgent symptoms,since radiophosphorus takes several weeks to produceits full effect. These are very striking figures, thereduction of thromboses being the most importanteffect, and the one probably responsible for the notablyincreased expectation of life-and useful life at that.Other treatments have produced long remissionsbefore, and they are not remarkable in such a chronicdisease. We are not told how often the treatment was

given to the 72% of patients treated in the first fiveyears who did need more than one course, andLAWRENCE does not mention any failures-perhapsthere were none.

In Belgium SiMON and HENRY 20 have given radio-phosphorus by mouth to four patients with poly-

20. Simon, S., Henry, J. Acta clin. belg. 1949, 4, 382.

cythaemia who had been ill for some years and derivedno ’benefit from - various other treatments. The

patients were treated as outpatients. The radio-

phosphorus was given in fruit-juice on an emptystomach, the initial dose being 6 millicuries, except inone case in which the patient had previously undergoneradiotherapy, thus introducing the risk of excessivereaction. A month later three of the patients weregiven a further 4 millicuries. The fourth patient wasnot given a further dose, because the blood picturehad become normal. After eight months the bloodpictures of all four patients were satisfactory and alltroublesome symptoms had disappeared.

It is clear that in polycytheemia vera radiophos-phorus has produced first-class results-its only reallysustained therapeutic success. Proper precautionsmust be taken when handling P32, and its short half-life of 14 days means that supplies must be availableat short notice ; for clinics near one of the atomiccentres this may not be difficult to arrange. In this

country supplies are controlled through the MedicalResearch Council,21 and they are unlikely to agreeto provide P32 unless they are satisfied that thosewho are handling the material will be properlyprotected. Nevertheless physicians here should now beable to arrange for any suitable cases to havethis treatment.

21. See Lancet, 1948, ii, 469.

Annotations

PREVALENCE OF CORONARY DISEASE

THE apparent increase in deaths from coronary diseasein recent years, particularly among the younger age-groups, is a disturbing observation which the lay presshas not been slow to publicise. The haste and competitionof modern industrial life, with its train of frustration,anxiety, and mental fatigue, contrasted with the less

exacting conditions "

enjoyed or endured by our moreslowly moving agricultural forebears," seems an obviouscause for increase, but Ryle and Russel1,1 from theirclinical and epidemiological survey covering the last

twenty-five years, show that this is by no means thewhole story. Indeed, the Registrar-General’s statisticsreveal that the mortality from coronary disease is nowincreasing less rapidly than before the late war, thatpeople are tending to live longer, and that a changingfashion in death certification may largely account forthe figures. Because of the wider familiarity with theclinical features of coronary thrombosis and the improvedfacilities for confirming the diagnosis-e.g., by electro-cardiography and necropsy study-many deaths previ-ously certified as due to myocardial and cardiovasculardegeneration are now specifically grouped under coronarydisease. Nor is there any good evidence that cigarettesmoking in the hard-pressed citizen of today bears anycausative relation to the deaths from coronary disease,for non-smokers are not immune. The notable dominanceof those occupations which involve much mental activityand responsibility is revealed in the decrease in mortalityfigures with descent in the social scale. This same socio-economic influence seems to explain why the death-ratefrom coronary disease is five times as great in middle-agedmen as in women of the same age-group. Recent emphasisgiven to the incidence of coronary disease in young adultsby the publication of cases which occurred in theForces in the war may have given an exaggerated picture,1. Ryle, J. A., Russell, W. T. Brit. Heart J. 1949, 11, 370.2. French, A. J., Dock, W. J. Amer. med. Ass. 1944, 124, 1233

Newman, M. Lancet, 1946, ii, 409.

for when reviewed statistically coronary disease is stillvery rare at or below the age of 35.

There is no condition in medicine where the prognosisis more difficult to assess. Heredity, age, occupation,evidence of extensive arterial disease, or hypertensionare only a few of the factors which have to be takeninto account. Even when every feature of the case isfavourable, early sudden death may occur; yet theconverse is as often true, and Cassidy 3 reported on twopatients who survived for more than 30 years. It seemsto be on the lines of prevention that the future mayhold most hope, through periodic health examinationsand the organised regulation of conditions of work andpersonal leisure-always providing that these measurescan be put into operation without interfering too muchwith individual freedom. But we cannot afford to ignorethe dietary factor, to which Dr. Closs and Dr. Dedichenagain draw attention in our correspondence columnsthis week. Evidence is accumulating that hyper-cholesterolsemia has a significant bearing on the aetiologyof arteriosclerosis, and cholesterol metabolism can beinfluenced by the amount of fat and protein in thediet, by the lipotropic and oxytropic fractions of thevitamin-B complex, and by thyroid extract. It is notunreasonable to foresee a future enterprising Ministerof Food paying closer attention to these componentsof the nation’s diet.

THE SIXPENNY CONSULTATION

THE sixpenny doctor has long been an almost fabulousmemory ; and his modern equivalent vanished with thecoming of the National Health Service. But some

remember him, among them Dr. G. F. McCleary, whohas lately given us Some Medical Memories. 4 Sixpennypractices were flourishing at the turn of the century in theLondon slums, and many doctors went into them for themere purpose of making enough to get out. A fewstayed and served their patients for the best part of alifetime, and their service was good even by modern

3. Cassidy, M. Lancet, 1946, ii, 587.4. Fortnightly, December, 1949, p. 409.

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standards. Dr. McCleary says of the sixpennydoctor :

" Sometimes he was English ; not infrequently he wasScottish ; more rarely he was coloured ; often he spokewith an Irish accent. Usually he began with what wascalled a ‘ nucleus ’ and if successful he would develop hisnucleus into a lucrative practice, which he would sell andwith the proceeds buy a practice in a genteel suburb...."

Sixpenny doctors worked exceedingly long hours,and at speed, doing their own dispensing from stockmixtures-for a bottle was a part of the bargain.Sometimes they gave Sacchar2cm Ust’urn,

" a medicament

which possesses in a high degree what Hippocrateslaid down as the first essential of medicine-that it shoulddo no harm." Dr. McCleary, who served as a locuin inseveral such practices, is cheerfully unrepentant aboutthese bottles of burnt sugar.

" When I think of the vast quantities of heart-depressingcoal-tar drugs that are swallowed annually in self-medica-tion by an unreflecting public, I recall with satisfactionmy dispensing of Saccharu7n Ustum with its reassuringcolour and complete harmlessness of effect."

Once he worked in a practice in North London wherethere were two waiting-rooms, one for the sixpennypatients and another for those who could afford to paya shilling. The doctor saw two shilling" patients forevery sixpenny patient, so the higher fee saved the

patient a wait. The clientele in the two rooms varied

according to the ready money at their disposal at thetime ; there was no feeling of class distinction about it.

Dr. McCleary would not have us think these doctorswere inefficient or careless :

". Some of the men for whom I worked were skilled,conscientious, and laborious, who loved their work and didtheir best for their patients. They had developed a time-saving technique and a flair for distinguishing the importantfrom the unimportant."

He suggests that Flaubert might have made a classicof the life of one of these doctors. Some will recalla less ambitious work-Sixpenny Pieces, the modesttribute of Neil Lyons to Harry Roberts, in Stepney.

ADRENOCORTICOTROPIC HORMONE AND

HYPERSENSITIVE REACTIONS

IT is sometimes forgotten that the symptoms of diseaseare produced not directly by the external or internalnoxious agent which is acting but by the body’s reactionsto that agent. Even when there is a definite bacterial orvirus cause, the clinical picture-the malaise, fever, pain,and local inflammation-is that of the body’s attempt tocombat the attacker. In some diseases, of which thosecalled allergic are the most striking example, though theyalso include the rheumatic group, periarteritis nodosa,,and others-the body’s reaction is out of all proportionto the severity of the attack and is therefore called a"

hypersensitive " reaction. In these, if the reaction can

be abolished the " disease " is cured-at least for thetime being. A few years ago Hughes 1 suggested that inacute rheumatism any " poison " which would abolishthe body’s reactivity without doing any permanentharm would produce a cure : in his view this explainedthe action of salicylates in rheumatic fever.

The same principle-of treating disease by moderatingthe body’s reaction-is behind the use of antipyretics ingeneral, and of ’ Cryogenine ’ in particular ; and Dr.

Geoffrey Bourne showed in these columns last week thatreduction of temperature with this drug can improvethe condition of patients with lymphadenoma, rheuma-toid arthritis, or tuberculosis.The vast amount of work being done in the U.S.A.

with A.C.T.H. and" Cortisone ’ suggests that one impor-tant effect of these substances is to block hypersensitive

1. Hughes, W. Ann. rheum. Dis. 1942, 3, 89.

reactions. This may explain the observations, made(though still unpublished) in a wide variety of diseases,that A.C.T.H. immediately abolishes the malaise asso-

ciated with them ; it may also be the basis of the goodresults reported by Hench and his co-workers 2 inrheumatoid arthritis and acute rheumatic fever. More-

over, Bordley and his colleagues 3 at Johns Hopkins havenow reported remarkable results with A.C.T.H. in allergicdiseases. The rapid recovery of a patient critically illwith exfoliative dermatitis due to iodine led them totry A.C.T.H. in a case of penicillin sensitivity of serum-disease type, in which the giant urticaria, joint pains,and fever disappeared within 24 hours. They thenobtained equally rapid relief in five patients with severechronic asthma which had not responded to adrenaline,theophylline and ethylenediamine, or rectal ether. Infour of these the symptomatic improvement was accom-panied by the return of a pale cedematous polypoid naso-pharyngeal mucosa to an appearance not far from normal.In accordance with the experience in rheumatoid arthritis,the patients tended to relapse 2-3 weeks after theircourse of treatment. ’ .

THE "BURR" RED BLOOD-CELLHaeMATOLOGISTS are familiar with the spherocyte, the

round fat red cell of haemolytic anemia, and with the"

target " cell, the thin red cell of Mediterranean anaemia,so thin that its sides clap together somewhere about themiddle and make it look, in transmitted light, like aScottish shield or target. Then there are the sickle-shapedcells associated with a familial anaemia in negroes, theoval cells which are also familial, and one or two otherodd shapes of no particular diagnostic import have beendescribed from time to time. The latest addition is the" burr " cell of Schwartz and Motto,4 which is said to befound only in patients with certain diseases, particularlywhere kidney function is impaired.The burr cell is a kind of, poikilocyte. It is a red cell

of normal size with one or more spiny projections alongits edge ; the projections are quite long, varying fromabout a sixth to half the diameter of the red cell, andphotographs show that they are usually sharp andpointed. So it does vaguely resemble the burrs that stickto our clothes or the coats qf our dogs. Burr cells arenot just crenated cells ; they are fairly evenly scatteredover the blood-film, whereas crenated cells tend toaccumulate in groups. The blunt-processed burr cell maywell be difficult to distinguish from a crenated cell, sono cells should be counted as burr cells unless they areapart from crenated groups. Schwartz and Motto foundburr cells in the blood particularly in cases of uraemia,carcinoma of the stomach, and bleeding peptic ulcer. Outof 75 uraemic patients 54 had burr cells in their bloodsmears ; out of 50 with carcinoma of the stomach 34had burr cells ; and the cells were seen in 27 out of 50patients with bleeding peptic ulcer. Two control serieswere studied ; the first comprised 100 consecutive blood-films from patients admitted to the medical wards forsome condition other than a blood disease ; the secondwas made up of 100 patients who had some haematologicalabnormality. No burr cells at all were found in the firstgroup, whereas 21 patients in the second group had them,and the only common factor in these 21 patients wasrenal impairment.What it is that causes red cells to throw out spinous

processes has not yet been determined. Severity of theanaemia, duration of bleeding, degree of nitrogen reten-tion, dehydration, age, sex, and race, have all been

2. See Leading article, Lancet, July 23, p. 159.3. Bordley, J. E., Carey, R. A., Harvey, A. McG., Howard, J. E.,

Kattus, A. A., Newman, E. V., Winkenwerder, W. L. Bull.Johns Hopk. Hosp. 1949, 85, 396.

4. Schwartz, S. O., Motto, S. A. Amer. J. med Sci. 1949, 218,563.