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BOOMERANG LEG AND YAWS
993 ANÆMIA AND MYXŒDEMA
THE influence of thyroxine on erythropoiesis has hitherto been ill defined. In 1926 G. M. J. Mackenzie1 drew attention to a group of cases with megalocytic hyperchromic anaemia which responded well to treatment with thyroid, though the original diagnosis had been that of pernicious anaemia. Since that date several authors have reported patients with myxcedema and megalocytic hyperchromic anaemia who have responded to treatment with both liver and thyroid but to neither remedy when given alone. The occurrence of a hypochromic type of anaemia in association with myxcedema has also been noted, but the available evidence has not made clear whether such an anaemia would respond to liver alone, thyroid alone, or to combined therapy. S. A. Holb0ll has now studied 28 cases of myxcedema over a five-year
period.22
In 13 of these
patients
the
haemoglobin
below 70 per cent. One patient had typical pernicious anaemia, four had a colour-index above one, the others had a normal or subnormal index. Treatment with liver and stomach preparations was without effect ; iron alone produced no appreciable change in the blood picture. Thyroidin in all cases exercised a favourable influence on the anaemia. In some instances, however, when the haemoglobin reached a level of about 80 per cent. no further improvement occurred until iron was given, when a second rise in haemoglobin took place. If iron and thyroidin were given together the most satisfactory results were obtained. In four cases after a normal blood picture had been reached Holb0ll withdrew thyroid ; in all there was some return of the anaemia. These observations suggest that the hypochromic anaemia found in certain patients with myxcedema is dependent in part upon the absence of thyroxine and is not due to an associated but independent iron deficiency. We do not yet know how thyroxine exerts its influence upon haemopoiesis. was
BOOMERANG LEG AND YAWS THE council of the Royal Society of Tropical Medicine and Hygiene has wisely decided to publish from time to time monographs of outstanding interest to students of tropical medicine. It is happy in its choice of Dr. Hackett to inaugurate this new venture, and he is to be congratulated upon an excellent production,3 the material for which was obtained in the Northern Territory of Australia during the winter of 1934, with assistance from the Sheridan research bequest of the University of Adelaide. The Southern area of the Northern Territory is described as acaciacovered semi-desert and shrub steppe, rising in places to 1000 feet above sea-level. The climate is hot and dry, and temperatures of over 100° F. are frequent in summer, whilst night temperatures below 32° F. are recorded in winter. The annual rainfall is under twelve inches. Hackett’s investigations lead him to believe that syphilis does not occur amongst the natives of Central and Northern Australia, though gonorrhoea is common. At the present time the presence of yaws is well recognised, and some of its manifestations, such as gangosa, have been noted. It may be, too, that the disease known as i7ki-rztjc
amongst the aborigines is in reality yaws. Boomerang is an antero-posterior curvature of the leg below
leg
the knee with
a
forward
convexity; occasionally
1 Jour. Amer. Med. Assoc., 1926, lxxxvi., 832. 2 Acta Med. Scand., 1936, lxxxix., 526. 3 Boomerang Leg and Yaws in Australian Aborigines. By Cecil J. Hackett, M.D., M.R.C.P. Monograph 1. Roy. Soc. Trop. Med. and Hyg. (Manson House, 26, Portland-place, London, W.). 1936. Pp. 66. 5s
the curve is interrupted by bosses of localised periosteal thickening, and they are often associated with cicatrices. The severity of bone pains experienced with these lesions sometimes renders walking impossible. Hackett finds that 84 per cent. of cases give positive Wassermann reactions, whereas a control series of natives without scars or boomerang legs gave negative results. This evidence, together with the fact that sabre tibiae are seen in other parts of the world where yaws is in evidence, supports the conclusion that boomerang legs in Australia are identical with the osteitis of yaws as seen elsewhere. Particularly valuable are the radiographic studies in association with examination of the bones themselves, and the monograph is illustrated by many good radiograms as well as other photographs. The appearances depend upon the severity of the initial lesion and the time which has elapsed since the onset. Areas of rarefaction appear early and the bone becomes deformed. As the more acute stage resolves the rarefied areas clear up, leaving a depressed Lines of arrested bone and a thickened cortex. growth are often seen. Rare lesions found in bones are multiple necrotic foci, periosteal nodes, and
generalised periosteal deposits. PSYCHONEUROTIC WORKMEN
M. Rosenfield on industrial attention to the lack of provision for the treatment of psychoneuroses in industrial health services. This might be linked up with a similar lament in our correspondence columns last week when Dr. J. P. Steel complained of the difficulty of finding suitable light employment for men recovering from physical injury. In industry it often happens that a man must be of full working capacity before he can be re-employed, and Dr. Rosenfield notes that one of the concerns of the industrial psychotherapist must be to keep the worker in useful employment. The psychotherapist should therefore be in close contact with industrial conditions, and it is for this close contact that Dr. Rosenfield makes his plea. Some consider it a dangerous policy, he says, to recognise the nervous worker as one deserving of help in the same way as an injured worker deserves it. This view-the existence of which is undeniable-helps to swell sickness returns with nervous troubles camouflaged under a diagnosis of physical disease, a phenomenon The lack of we are only now coming to recognise. treatment, or of understanding, of psychoneurotic disorders places a definite burden upon industry, and Dr. Rosenfield’s recommendations can therefore be supported as advantageous not only to the sufferer but to the financial side of industry. Psychotherapy of the individual, however, is not sufficient. Many other problems intrude themselves-e.g., wages, accident prevention, rent and houses, travel to and here psychofrom work, dietetic problems, &c.-and in comes contact with the wider therapy subject of the contentment of the worker. The psychoneurotic symptom and the psychoneurotic disability are not identical and a large number of nervous people can be, and are, efficient workers when the working environment places no undue stress upon them. Dr. Rosenfield has, without specifying the point, recognised that the reactions of the psychoneurotic worker act as an indicator of good or bad industrial conditions. There exist the beginnings of an organisation such as Dr. Rosenfield desires; welfare workers are now regularly employed in many industrial AN article by Dr. psychotherapydraws
1 The Human Factor, October, 1936, p. 360.
THE influence of thyroxine on erythropoiesis has hitherto been ill defined. In 1926 G. M. J. Mackenzie1 drew attention to a group of cases with megalocytic hyperchromic anaemia which responded well to treatment with thyroid, though the original diagnosis had been that of pernicious anaemia. Since that date several authors have reported patients with myxcedema and megalocytic hyperchromic anaemia who have responded to treatment with both liver and thyroid but to neither remedy when given alone. The occurrence of a hypochromic type of anaemia in association with myxcedema has also been noted, but the available evidence has not made clear whether such an anaemia would respond to liver alone, thyroid alone, or to combined therapy. S. A. Holb0ll has now studied 28 cases of myxcedema over a five-year
period.22
In 13 of these
patients
the
haemoglobin
below 70 per cent. One patient had typical pernicious anaemia, four had a colour-index above one, the others had a normal or subnormal index. Treatment with liver and stomach preparations was without effect ; iron alone produced no appreciable change in the blood picture. Thyroidin in all cases exercised a favourable influence on the anaemia. In some instances, however, when the haemoglobin reached a level of about 80 per cent. no further improvement occurred until iron was given, when a second rise in haemoglobin took place. If iron and thyroidin were given together the most satisfactory results were obtained. In four cases after a normal blood picture had been reached Holb0ll withdrew thyroid ; in all there was some return of the anaemia. These observations suggest that the hypochromic anaemia found in certain patients with myxcedema is dependent in part upon the absence of thyroxine and is not due to an associated but independent iron deficiency. We do not yet know how thyroxine exerts its influence upon haemopoiesis. was
BOOMERANG LEG AND YAWS THE council of the Royal Society of Tropical Medicine and Hygiene has wisely decided to publish from time to time monographs of outstanding interest to students of tropical medicine. It is happy in its choice of Dr. Hackett to inaugurate this new venture, and he is to be congratulated upon an excellent production,3 the material for which was obtained in the Northern Territory of Australia during the winter of 1934, with assistance from the Sheridan research bequest of the University of Adelaide. The Southern area of the Northern Territory is described as acaciacovered semi-desert and shrub steppe, rising in places to 1000 feet above sea-level. The climate is hot and dry, and temperatures of over 100° F. are frequent in summer, whilst night temperatures below 32° F. are recorded in winter. The annual rainfall is under twelve inches. Hackett’s investigations lead him to believe that syphilis does not occur amongst the natives of Central and Northern Australia, though gonorrhoea is common. At the present time the presence of yaws is well recognised, and some of its manifestations, such as gangosa, have been noted. It may be, too, that the disease known as i7ki-rztjc
amongst the aborigines is in reality yaws. Boomerang is an antero-posterior curvature of the leg below
leg
the knee with
a
forward
convexity; occasionally
1 Jour. Amer. Med. Assoc., 1926, lxxxvi., 832. 2 Acta Med. Scand., 1936, lxxxix., 526. 3 Boomerang Leg and Yaws in Australian Aborigines. By Cecil J. Hackett, M.D., M.R.C.P. Monograph 1. Roy. Soc. Trop. Med. and Hyg. (Manson House, 26, Portland-place, London, W.). 1936. Pp. 66. 5s
the curve is interrupted by bosses of localised periosteal thickening, and they are often associated with cicatrices. The severity of bone pains experienced with these lesions sometimes renders walking impossible. Hackett finds that 84 per cent. of cases give positive Wassermann reactions, whereas a control series of natives without scars or boomerang legs gave negative results. This evidence, together with the fact that sabre tibiae are seen in other parts of the world where yaws is in evidence, supports the conclusion that boomerang legs in Australia are identical with the osteitis of yaws as seen elsewhere. Particularly valuable are the radiographic studies in association with examination of the bones themselves, and the monograph is illustrated by many good radiograms as well as other photographs. The appearances depend upon the severity of the initial lesion and the time which has elapsed since the onset. Areas of rarefaction appear early and the bone becomes deformed. As the more acute stage resolves the rarefied areas clear up, leaving a depressed Lines of arrested bone and a thickened cortex. growth are often seen. Rare lesions found in bones are multiple necrotic foci, periosteal nodes, and
generalised periosteal deposits. PSYCHONEUROTIC WORKMEN
M. Rosenfield on industrial attention to the lack of provision for the treatment of psychoneuroses in industrial health services. This might be linked up with a similar lament in our correspondence columns last week when Dr. J. P. Steel complained of the difficulty of finding suitable light employment for men recovering from physical injury. In industry it often happens that a man must be of full working capacity before he can be re-employed, and Dr. Rosenfield notes that one of the concerns of the industrial psychotherapist must be to keep the worker in useful employment. The psychotherapist should therefore be in close contact with industrial conditions, and it is for this close contact that Dr. Rosenfield makes his plea. Some consider it a dangerous policy, he says, to recognise the nervous worker as one deserving of help in the same way as an injured worker deserves it. This view-the existence of which is undeniable-helps to swell sickness returns with nervous troubles camouflaged under a diagnosis of physical disease, a phenomenon The lack of we are only now coming to recognise. treatment, or of understanding, of psychoneurotic disorders places a definite burden upon industry, and Dr. Rosenfield’s recommendations can therefore be supported as advantageous not only to the sufferer but to the financial side of industry. Psychotherapy of the individual, however, is not sufficient. Many other problems intrude themselves-e.g., wages, accident prevention, rent and houses, travel to and here psychofrom work, dietetic problems, &c.-and in comes contact with the wider therapy subject of the contentment of the worker. The psychoneurotic symptom and the psychoneurotic disability are not identical and a large number of nervous people can be, and are, efficient workers when the working environment places no undue stress upon them. Dr. Rosenfield has, without specifying the point, recognised that the reactions of the psychoneurotic worker act as an indicator of good or bad industrial conditions. There exist the beginnings of an organisation such as Dr. Rosenfield desires; welfare workers are now regularly employed in many industrial AN article by Dr. psychotherapydraws
1 The Human Factor, October, 1936, p. 360.