2
1084 blood flow was regarded as slow if it was possible to see the cells distinctly passing through the vessels. It was found that in 30 per cent. of the rheumatoid arthritic class there was a decrease in the number of capillaries, particularly in the region of swollen joints. In 52 per cent. the capillaries were small and constricted. There was slow blood flow in 65 per cent. of the cases, the capillaries were tortuous in 35 per cent., and the surface temperature was subnormal in 52 per cent. In the osteo-arthritic class the capillary picture was somewhat different. A decrease of capillaries was found only in fingers with pronounced Heberden’s nodes ; the size of the capillaries was small in 27 per cent. ; slow blood flow was found in only 52 per cent., while the frequency of tortuous capillaries was increased to 60 per cent. The surface temperature was subnormal in half of the patients. Commenting on their results Kovacs and his collaborators say that the increased tortuosity of the capillaries noted in osteo-arthritics as com- pared with rheumatoid patients was probably physio- logical and due to the higher average age; there was no apparent relation between the degree of tortuosity of the vessels and the severity of the clinical symptoms. The patients with slow blood flow for the most part had severe clinical symptoms and also a low surface temperature. Further, a parallel was found between the rate of blood flow and the sedimentation test, for in all cases with a high sedimentation-rate a slow blood flow was found ; and this suggests that the rate of flow was influenced somewhat by the viscosity of the blood. The general conclusion was reached that although changes from normal do occur in the skin capillaries and skin temperature in many cases of rheumatoid and osteo- arthritis, these cannot be considered uniformly responsible for the pathological changes found. Furthermore it was not established that the condition of the capillaries in the nail-bed resembled the condition of the capillaries supplying the joints. It will be recalled that last September Dr. A. A. Bisset and Mr. A. Woodmansey contributed to our columns some observations which led them to suppose that in most if not all cases of well-established rheumatism the capillaries are in a spastic state. THE ALLERGIC STATE THE West London Medico-Chirurgical Society devoted its last meeting, on May 5th, to a discussion on allergy. Dr. G. H. Oriel defined this as a state in which a person otherwise normal reacted to certain common substances in an abnormal manner. Any protein abnormal to the subject might give rise to sensitisation, he said ; and in cat asthma, for example, the symptoms were provoked by a foreign protein (exogenous allergy). It had recently been shown that on slight modification--e.g., by the addition of a molecule of iodine-the protein molecule might evoke a different reaction, and changes of this kind might give rise to an endogenous allergy. Super- sensitiveness to foreign protein could be demonstrated by skin tests in about half the cases of -asthma, and in the other half the condition was presumably due to an infection. Specific therapy in allergy had for its object the production of immunity by neutralisa- tion of the antibodies, and was carried out by giving injections of the antigen. It was a remarkable fact that allergic symptoms showed considerable improvement during pregnancy, during infections, and when the patient was suffering from trauma, for instance, after operation. Sir William Willcox said it was extraordinary how small an infective focus might give rise to widespread and serious conditions in the body ; it might be that the strepto- coccus or its products combined with the protein and produced some allergic substance, as Dr. Oriel had suggested. Dr. Finkelstein thought that the conception of sensitisation by endogenous substances rested upon very little support, and doubted whether it was true that allergies improved after trauma. Dr. H. H. Sanguinetti referred to recent German publications in which the allergic reaction was discussed in relation to non-proteins, such as arsenic and potassium iodide ; on the continent, at any rate, they did not limit the allergic manifestations to foreign proteins. Towards the close of the discussion Dr. Gerald Slot mentioned that during the last four or five years he had carried out eight post-mortem examinations on patients who had died in allergic states, and had found it extraordinarily difficult, both from macroscopic and microscopic pathology, to give any definite reason as to why they had died at all. All one saw was that the .organs were congested, but there was no obvious reason for death. X RAY THERAPY IN HÆMOLYTIC ICTERUS THE established value of splenectomy in the treatment of heamolytic icterus, and the fact that the operation is usually well supported in older children and young adults, has tended to direct attention away from other possible lines of treatment. The number of cases of the disease reported in infancy and early childhood is still relatively small, but wider recognition of the condition and the routine examination of affected families may be expected to reveal many more. For these an alternative method of treatment that will at least make possible the postponement of splenectomy until later childhood is certainly desirable. The application of X rays to the spleen has been tried by several workers with, on the whole, unfavourable results ; in some cases, however, definite improvement has been claimed, and Dr. Giulio Dondi now reports 2 two cases with amelioration of symptoms following this method of treatment. The first patient was seen at the age of 5 months (in December, 1930) on account of a digestive upset, and it was then noted that there was a subicteric tint of the skin and sclerae, that the liver was palpable one and a half fingers’ breadth below, and the spleen at the level of, the costal margin. Four months later the infant suffered from a haemolytic crisis, becoming definitely jaundiced and anaemic, with a haemoglobin content of 40 per cent., and 13 nucleated red cells per 100 whites. The fragility of the red cells appeared to be normal at this time (haemolysis beginning at 0-48), but later increased definitely. The urine showed a strongly positive Schlesinger’s reaction for urobilin, and the absence of bile pigments with a negative Hay’s test. The direct van den Bergh reaction was weakly positive, and the immediate indirect reaction strongly positive. The infant was treated with a preparation of liver and injections of arsenic, and five applications of X rays to the spleen beginning with an eight minute exposure and a dosage of 80 kw. ; 2 m.a. ; filters 0-5 mm. zinc and 3 mm. aluminium. The infant’s general condition and anaemia slowly improved, with a rapid disappearance of the jaundice; it remained free from symptoms, although the blood still continued to show increased fragility, and a considerable number of nucleated red cells, whilst the spleen was palpable three-fingers’ breadths below the costal margin two years after the first treatment. 1 A case of asthma attributed to chromium was reported in THE LANCET of July 23rd, 1932, by Dr. H. Joules. 2 La Ped. del Med. Prat., 1933, viii., 298.

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1084

blood flow was regarded as slow if it was possibleto see the cells distinctly passing through the vessels.It was found that in 30 per cent. of the rheumatoidarthritic class there was a decrease in the numberof capillaries, particularly in the region of swollenjoints. In 52 per cent. the capillaries were smalland constricted. There was slow blood flow in 65 percent. of the cases, the capillaries were tortuousin 35 per cent., and the surface temperature wassubnormal in 52 per cent. In the osteo-arthritic classthe capillary picture was somewhat different. Adecrease of capillaries was found only in fingers withpronounced Heberden’s nodes ; the size of the

capillaries was small in 27 per cent. ; slow bloodflow was found in only 52 per cent., while the frequencyof tortuous capillaries was increased to 60 per cent.The surface temperature was subnormal in half ofthe patients. Commenting on their results Kovacsand his collaborators say that the increased tortuosityof the capillaries noted in osteo-arthritics as com-pared with rheumatoid patients was probably physio-logical and due to the higher average age; therewas no apparent relation between the degree oftortuosity of the vessels and the severity of theclinical symptoms. The patients with slow bloodflow for the most part had severe clinical symptomsand also a low surface temperature. Further, a

parallel was found between the rate of blood flow andthe sedimentation test, for in all cases with a highsedimentation-rate a slow blood flow was found ;and this suggests that the rate of flow was influencedsomewhat by the viscosity of the blood. The generalconclusion was reached that although changes fromnormal do occur in the skin capillaries and skin

temperature in many cases of rheumatoid and osteo-arthritis, these cannot be considered uniformlyresponsible for the pathological changes found.Furthermore it was not established that the conditionof the capillaries in the nail-bed resembled thecondition of the capillaries supplying the joints.

It will be recalled that last September Dr. A. A.Bisset and Mr. A. Woodmansey contributed to ourcolumns some observations which led them to supposethat in most if not all cases of well-establishedrheumatism the capillaries are in a spastic state.

THE ALLERGIC STATE

THE West London Medico-Chirurgical Societydevoted its last meeting, on May 5th, to a discussionon allergy. Dr. G. H. Oriel defined this as a statein which a person otherwise normal reacted to certaincommon substances in an abnormal manner. Anyprotein abnormal to the subject might give rise tosensitisation, he said ; and in cat asthma, for example,the symptoms were provoked by a foreign protein(exogenous allergy). It had recently been shownthat on slight modification--e.g., by the addition ofa molecule of iodine-the protein molecule mightevoke a different reaction, and changes of this kindmight give rise to an endogenous allergy. Super-sensitiveness to foreign protein could be demonstratedby skin tests in about half the cases of -asthma, andin the other half the condition was presumably dueto an infection. Specific therapy in allergy hadfor its object the production of immunity by neutralisa-tion of the antibodies, and was carried out by givinginjections of the antigen. It was a remarkablefact that allergic symptoms showed considerableimprovement during pregnancy, during infections,and when the patient was suffering from trauma,for instance, after operation. Sir William Willcoxsaid it was extraordinary how small an infectivefocus might give rise to widespread and serious

conditions in the body ; it might be that the strepto-coccus or its products combined with the proteinand produced some allergic substance, as Dr. Orielhad suggested. Dr. Finkelstein thought that the

conception of sensitisation by endogenous substancesrested upon very little support, and doubted whetherit was true that allergies improved after trauma.Dr. H. H. Sanguinetti referred to recent Germanpublications in which the allergic reaction was

discussed in relation to non-proteins, such as arsenicand potassium iodide ; on the continent, at any rate,they did not limit the allergic manifestations to

foreign proteins. Towards the close of the discussionDr. Gerald Slot mentioned that during the last fouror five years he had carried out eight post-mortemexaminations on patients who had died in allergicstates, and had found it extraordinarily difficult,both from macroscopic and microscopic pathology,to give any definite reason as to why they had died atall. All one saw was that the .organs were congested,but there was no obvious reason for death.

X RAY THERAPY IN HÆMOLYTIC ICTERUS

THE established value of splenectomy in thetreatment of heamolytic icterus, and the fact that theoperation is usually well supported in older childrenand young adults, has tended to direct attention

away from other possible lines of treatment. Thenumber of cases of the disease reported in infancyand early childhood is still relatively small, butwider recognition of the condition and the routineexamination of affected families may be expected toreveal many more. For these an alternative methodof treatment that will at least make possible thepostponement of splenectomy until later childhood iscertainly desirable. The application of X raysto the spleen has been tried by several workers with,on the whole, unfavourable results ; in some cases,however, definite improvement has been claimed,and Dr. Giulio Dondi now reports 2 two cases withamelioration of symptoms following this method oftreatment. The first patient was seen at the age of5 months (in December, 1930) on account of a digestiveupset, and it was then noted that there was a subicterictint of the skin and sclerae, that the liver was palpableone and a half fingers’ breadth below, and the spleenat the level of, the costal margin. Four monthslater the infant suffered from a haemolytic crisis,becoming definitely jaundiced and anaemic, witha haemoglobin content of 40 per cent., and 13nucleated red cells per 100 whites. The fragilityof the red cells appeared to be normal at this time(haemolysis beginning at 0-48), but later increaseddefinitely. The urine showed a strongly positiveSchlesinger’s reaction for urobilin, and the absenceof bile pigments with a negative Hay’s test. Thedirect van den Bergh reaction was weakly positive,and the immediate indirect reaction strongly positive.The infant was treated with a preparation of liverand injections of arsenic, and five applications ofX rays to the spleen beginning with an eight minuteexposure and a dosage of 80 kw. ; 2 m.a. ; filters0-5 mm. zinc and 3 mm. aluminium. The infant’sgeneral condition and anaemia slowly improved,with a rapid disappearance of the jaundice; itremained free from symptoms, although the bloodstill continued to show increased fragility, and a

considerable number of nucleated red cells, whilstthe spleen was palpable three-fingers’ breadths belowthe costal margin two years after the first treatment.

1 A case of asthma attributed to chromium was reported inTHE LANCET of July 23rd, 1932, by Dr. H. Joules.

2 La Ped. del Med. Prat., 1933, viii., 298.

Page 2: X RAY THERAPY IN HqMOLYTIC ICTERUS

1085

The second case was that of a boy of 9, who firstcame under observation in September, 1931, whenthe spleen was greatly enlarged and the liver palpabletwo fingers’ breadths below the costal margin. Hethen had a haemoglobin content of 38 per cent., and1,700,000 red cells per c.mm. which were of increasedfragility, haemolysis beginning at 0-58 and beingcomplete at 0-42. He was given similar treatmentwith an initial exposure of ten minutes and a dosageof 180 kw., 2 m.a., with 0-5 mm. zinc filter ; a course

of ten treatments was given, and subsequentlyrepeated. In this case the improvement in the generalcondition was rapid, and was maintained, althoughthe size of the spleen and liver was unaltered andthe fragility of the red cells still increased. The

period of observation in these two cases is not yetlong enough to exclude the possible recurrence of

haemolytic crises, but the method of treatment wouldcertainly appear to warrant further investigation.If haemolysis can be checked and the consequentover-action of the bone-marrow relieved, clinicalimprovement is to be expected, although the fragilityof the red cells may remain unchanged.

POPULAR MEDICINE

THE instruction of the people in medicine, in theunderstanding of its principles, in the meaning of itsprocedures and in the outcome of its labours is atask which many writers have attempted and are.attempting with a success which varies in accordancewith the schemes laid down for themselves by thewriters, and with their qualifications to write. Asa rule some knowledge and literary skill is neededto make the work readable, but the readable dis-

quisition is not always useful information. We have.all read essays sometimes signed by medical menand at other times purporting to draw informationfrom medical men, in which the public have beenurged on no logical grounds to do this or that lestthey suffer for negligence ; have been asked to seedanger in practices where none exists save that ofover indulgence ; have been supplied with unproventheories in the guise of unquestioned facts ; and indeedhave been given so much that is not worth readingthat any real contribution to knowledge afforded bythe author have been smothered. It is a pleasure toreceive a book of popular medicine written by amedical man where conformity to scientific truthaccompanies useful and amusing reading. Dr. MarioMusella, the editor of Riforma Medica, proves thatit is possible to impart a great deal of sound medicalknowledge in, simple phraseology, to be interestingand amusing in so doing, neither to create falsehopes or unnecessary fears, while not stating theories.as if they were facts or assumptions as if they hadbeen proved. He is not a newcomer in this field ofliterature, for he has in two previous books provedthat he can bring before the public in general in anintelligible form sound medical and hygienic know-ledge. His latest essays are of a more ramblingcharacter ; their subjects appear to be selected quiteat random, and they are arranged in no order. Hehas wise things to say on many of the questionswhich are under popular discussion, and he says

_

these things as they occur to him. Thus we have

chapters on the treatment of diabetes, the principlesof healthy diet, the value of opium, the universalfall in birth rates, the ingestion of tea and tobacco,the changing face of disease, the use and abuse of

opium, the undeserved bad character of tomatoes,the value of mountain air and rest, and the real

1 Anni Malanni. By Mario Musella. Bologna: L. Cappelli.1933. Pp. 214. L.8.

significance of blood pressure. These are subjectswhich he knows to be under frequent lay discussion,and he may have had reason to think that some ofthe most dogmatic debaters are not the most accuratelygrounded. Dr. Musella adorns his teaching of medicineand hygiene with amusing historic references and

biological allusions, and has taken pains that his

arguments should be easy to follow. For the Italyof to-day is intensely interested in the questionsof hygiene and public health.

QUININE DISTRIBUTION IN INDIAOuR Calcutta correspondent lately mentioned

difficulties arising out of the Indian Government’squinine policy. This was debated at the Decemberconference of Indian research workers, and an accountof the discussion may be found in the proceedings.’Mr. C. C. Calder, director of the botanical surveyof India, pointed out that the present stock of quininewith the Government of India was 400,000 lb., andLieut.-Colonel J. A. Sinton urged the necessity ofdevising means whereby treatment could be placedwithin the reach of the millions of malarial patients.Major-General (now Sir John) Megaw, the chair-man, said that the Government of India was unlikelyto give or sell the quinine to local governments atless than the prevailing market price for variousreasons. Some believe that the Kina Bureau wouldprobably manage to stop sales on such a scale ; thatthe Indian Government refused to sanction a proposalfor the selling of the stock at Rs.20 per lb. instead ofat the present market price of about Rs.26 (theoriginal buying price was Rs.12) and the giving ofthe balance as a grant to the Indian Research FundAssociation, because this was against the rules of the .

Finance Act; and that, if distributed free, quininewould probably be bought up by dealers and soldadulterated at a great profit. In the meantime the

quinine stocks may soon depreciate in value byalteration in the exchange value of the rupee, so

that so far as quinine is looked on as locked-up capital,this may largely disappear. The suggested way outof the difficulty, to which our correspondent referred,was through an attempt to popularise treatment bymeans of a commercial agency, skilled in advertisingand selling and allowed to make a profit. But tothis some local governments have objected on theground that it would interfere with their own sales.Mr. Calder pointed out that the stock of quinine hadbeen bought by the Government of India for purposesof public health and not for the making of a profit,and that if not so used the responsibility rested withthat Government. The situation is indeed compli-cated, but this at least is clear : profit cannot beplaced before public health.

THE ceremonies in connexion with the centenary ofthe University of Zurich were held at the close ofApril when a small number of honorary doctorateswere awarded. The recipients were mainly attachedto German universities, but among them was SirFrederick Hobday, principal of the Royal VeterinaryCollege, whom we congratulate upon this recognitionof his work.

1 Tenth Conference of Medical Research Workers. Simla:Government of India Press. 1933.

ROYAL BUCKINGHAMSHIRE HOsPITAL.-This Ayles-bury hospital of 80 beds received last year 1461 in-patients,the largest number on record ; in 1922 the figure was only556. The contributory scheme produced jE4541, and anappeal for eggs brought an "almost overwhelming "response in the form of an ample supply for a year.