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THE MANTLE OF FARR.
360
ROEHL’S method is being practised on a expected from its prophylactic use as cases would be treated in the incipient stage when parasites considerable scale at Cambridge and elsewhere. of and The results the present- experiment, of would be relatively few and easily destroyed." others now being conducted at Horton, should also With this object the drug was given in large doses have a noteworthy influence on future antimalarial (0-059 g.) on three consecutive days each week, policy in the world generally, for they indicate that, instead of in small doses daily, as should have been from now onwards, chemoprophylaxis and chemo- done if true prophylaxis was the aim. The therapy may play a larger part in the control of method left the 39 participating members of the malaria than they have done hitherto. Everyone crew unprotected on four days and nights of each will remember that, after Ross’s discovery of the of the nine weeks during which the trial lasted, mosquito cycle of the malaria parasite, KocH, and and it is therefore not surprising that six cases of It was claimed later GRASSZ, believed that the best hope of over- malaria occurred among them. this in’ an that the a scale disease on however, morbidity-rate (15 per cent.), lay coming large endeavour to break the epidemiological chain by indicated a successful result in comparison with the treating the human host, rather than by measures rates of 25 to 30 per cent. among the crews of two aiming at destroying the insect carrier. That view ships which followed the same route and on which has since received support from the success which the usual " quinine prophylaxis " was in force. has attended chemotherapeutic campaigns against Probably the correct explanation of the difference kala-azar and bilharziasis, but, as regards malaria, is that the plasmoquine taken by the crew on field experiments on a similar plan have always Dr. FisCHER’S ship protected them against infection failed because taking quinine, although it cures on three days and nights of each week, whilst the developed attacks, does not prevent either man or quinine taken by the crews of the other ships had mosquitoes from becoming infected. If it is true no true prophylactic effect. that, in addition to quinine, a drug has now become available which, when taken in non-toxic doses by healthy people, prevents their infection, THE MANTLE OF FARR. and when taken by malaria patients prevents WE print in another column an appreciation the development of the parasite in the mosquitoes of the work of Dr. T. H. C. STEVENSON from the which feed upon them, it is reasonable to suppose that a repetition of KocH’s chemotherapeutic pens of the Presidents of the Royal Colleges offield trials might have a very different result. On Physicians and Surgeons, the President of the a smaller scale, of course, the benefits of a drug Royal Statistical Society, the President of the which prevents malaria] infection are clear. For Section of Epidemiology and State Medicine of of Medicine, and of two other example, malaria is the cause of much sickness the Royal Society men of science. It would be someand many deaths among the officers, crews, and distinguished of a work of supererogation to seek to add passengers of ships trading to Africa, India, and thing the Far East. During the years 1918 to 1921 there anything to what has been said by writers so well qualified to givejudgment, and, in any case, it were at least 20 deaths of seamen from acute would be premature to write of the career of a malarial attacks during homeward voyages from scientific man who, we may fairly hope, will still those countries, and at least 65 from recurrences increase the debt of gratitude we owe to him by after arrival in England. In one line of steamers further researches, as if it were at an end. Nevertrading out of Liverpool no fewer than 531 cases of malaria occurred in the course of 12 theless, we may be permitted briefly to recall to months, and instances are on record in which, the memories of our readers something of the of the office which Dr. Stevenson has done during homeward voyages from Africa or India, history so much to dignify. the disease attacked all except two or three of the The General Register Office is, in comparison whole ship’s company. As these merchant ships seldom stay more than a few days and nights in with most of our public offices, a young departmalarious ports, it would be easy to arrange for ment ; it is not yet a centenarian. A century agoall concerned to take the prophylactic doses during such vital statistics as this country possessed were, those relatively short periods and for a few days if anything, below the standard of those of other civilised communities. Within 40 years English thereafter. It is worth while, in this connexion appositely, official vital statistics were admittedly the best. to explain, in the light of the new knowledge, a in the world, and this pre-eminence has never been prophylactic trial of plasmoquine which Dr. lost. Everybody knows, or ought to know, that OTTO FISCHER was deputed by the Institute of this great triumph was primarily due to the Tropical Diseases, Hamburg, to conduct in April, harmonious cooperation of a first-rate admini1926, on a steamship sailing to the African Coast.l strator, GEORGE GRAHAM, and a statistical genius, The details were arranged by Prof. MUHLENS, but, WILLIAM FARR. Scientific and literary powers not regarding the drug as a true prophylactic, he were vouchsafed Farr in abundant measure, but based them on the view that " although these gifts would not have sufficed to establish an efficient public department, and some littleplasmoquine alone is inadequate as a therapeutic meed of praise is owing from posterity to the remedy in subtertian malaria, some result might be forgotten administrator who made the depart-. ment a going concern. Farr was succeeded inFischer, O. : " Über Malariaprophylaxe mit Beihefte zum Arch. für Schiffs- und Tropen-Hygiene, 1927, office by a man of a different type. William xxxi., 43.
auspices
"
"
1
Plasmochin,"
361
OcHjB was, like Farr, a man of the highest character -and public spirit, but, while Farr was a self-taught, energetic man of genius, knowing something of many subjects and without complete mastery of - any one technique, Ogle was a highly educated, exact scholar, with the inhibitions and reserves that regular education imposes, and the publications of the department in his time lost something of the vivacity which Farr supplied. Ogle’s
HYPERTENSION AS A SYMPTOM. time it. has been recognised that the symptoms associated with the earlier stages of hypertension-that is, before the onset of cardioThat vascular changes-are somewhat vague. these diffuse symptoms of ill-health are due to the rise of blood pressure is rendered doubtful, because there is no correlation between the severity of the symptoms and the increase of tension, because the symptoms may often be relieved without reduction of the blood pressure, and also because definite hypertension may be found in people who regard their health as perfect. A year ago J. E. F. RiSEMAN and S. WFlss1 noted that the symptoms found in these early stages are very like those
FOR
some
Dr. JOHN TATHAM, having the of direct experience of public health advantage - administration under modern conditions which his predecessors lacked, effected noteworthy improvements, but even he hardly relieved the annual reports from a certain air of dryness which, in the opinion of some, is the appropriate quality of blue books. Under Dr. Stevenson’s auspices encountered in cases of psycho-neurosis with normal 2 this was changed. We do not mean that Dr. blood pressure. D. AYMAN and J. H. PRATT Stevenson reverted to the flamboyant method of have now investigated a series of 100 patients, Farr, and, like Farr and Silas Wegg, dropped into all of whom had a systolic blood pressure of 160 poetry, or, like Farr, made lists of odd surnames or more and no evidence of renal impairment; and speculated on their derivation. We mean that, 17 of them were men, and 83 women. The like Farr, Dr. Stevenson looked upon the records commonest symptoms complained of were headache, .-as the raw material of research, and, using for the pain, "nervousness," dizziness, fatigue, insomnia, The less frequent most part only the simplest of analytical methods, and vasomotor disorders. gave an impressive demonstration of the great and symptoms were widespread, and referred to all often forgotten truth that very simple methods, parts of the body. Further, these troubles were in the hands of a man of first-rate ability, will lead invariably multiple and of long standing, the -to discoveries which men of less ability, even if average duration being over 10 years. Only equipped with all the so-called mathematics in four of these patients had no complaints. AYMAN and PRATT next examined 50 psycho-neurotic the world, are sure to miss. We fear that few medical men read the annual patients of the same age as the others, but with reports of the Registrar-General. If more did, normal blood pressures, and found that in this medical editors would receive fewer fallacious group the symptoms were almost identical, not arguments for publication, and many journeys in only in character, but also in incidence, multiplicity, search of mares’ nests would never have been and duration. Passing on to inquire further into begun. Nobody has the excuse for neglecting these the onset of symptoms in the patients with high records of research that they are too mathematical blood pressure, they ascertained that this often to be intelligible. We can but hope that Dr. coincided with emotional disturbances or environStevenson may be able to use some of his leisure mental difficulties. AYMAN and PRATT were thus ’in bringing together into a separate volume his unable to differentiate between the symptoms researches into the factors of infant mortality, associated with the early stages of high blood a book which would at once become a standard pressure and those of psycho-neuroses, and as treatise. Dr. Stevenson has, indeed, worn the evidence of a similar causation they remarked mantle of Farr. When a man of great ability that so-called hyperpietic symptoms respond to retires from office it is common form to say that removal of environmental difficulties, to sedatives, his place will be hard to fill. In the present case and to suggestion. A similar series of cases the difficulty may well amount to an impossibility. from which he draws the same conclusions is Farr had so free a hand as an unofficial research reported by D. DAVIS.3 F. R. NuzuM and A. H. ELLIOTT4 have tried to worker, because, 80 years ago, official vital statistics lad very little prestige, and important people or assess the part played by past illnesses, infections, interests cared very little what was said by the and focal sepsis in the setiology of hypertension. Registrar-General or his subordinates. That is In those patients whose increase in blood pressure .all changed, and although few really read the was associated with evidence of renal impairment reports many use extracts from them as they often found a history of scarlet fever and those classified as controversial weapons ; hence there must inevit- acute’ nephritis ; but among " " essential the of infection incidence hypertension ably be a tendency to prefer safety to brilliance, and focal no was than to discourage research, which, in the nature of sepsis among greater things, cannot be safe. Dr. Stevenson has never controls. This investigation also suggested that been deliberately provocative, as Farr often was, there is no familial factor in the causation of but he has had a literary tact, if we may use the high blood pressure, and that it is not unusually expression, which enabled him to say without prevalent in patients with arterio-sclerosis of the provocation many true things not flattering to larger vessels. Excessive obesity, however, was local or even national self-esteem. The task 1 Amer. Jour. Med. Sci., 1930, clxxx., 47. of his successor will not be an easy one. It will 2 Arch. Int. Med., May, 1931, p. 675. 3 Amer. Jour. Med. Sci., June, 1931, p. 850. ,be hard to wear the mantle of Stevenson. 4 Ibid., May, 1931, p. 630. .successor, the late
ROEHL’S method is being practised on a expected from its prophylactic use as cases would be treated in the incipient stage when parasites considerable scale at Cambridge and elsewhere. of and The results the present- experiment, of would be relatively few and easily destroyed." others now being conducted at Horton, should also With this object the drug was given in large doses have a noteworthy influence on future antimalarial (0-059 g.) on three consecutive days each week, policy in the world generally, for they indicate that, instead of in small doses daily, as should have been from now onwards, chemoprophylaxis and chemo- done if true prophylaxis was the aim. The therapy may play a larger part in the control of method left the 39 participating members of the malaria than they have done hitherto. Everyone crew unprotected on four days and nights of each will remember that, after Ross’s discovery of the of the nine weeks during which the trial lasted, mosquito cycle of the malaria parasite, KocH, and and it is therefore not surprising that six cases of It was claimed later GRASSZ, believed that the best hope of over- malaria occurred among them. this in’ an that the a scale disease on however, morbidity-rate (15 per cent.), lay coming large endeavour to break the epidemiological chain by indicated a successful result in comparison with the treating the human host, rather than by measures rates of 25 to 30 per cent. among the crews of two aiming at destroying the insect carrier. That view ships which followed the same route and on which has since received support from the success which the usual " quinine prophylaxis " was in force. has attended chemotherapeutic campaigns against Probably the correct explanation of the difference kala-azar and bilharziasis, but, as regards malaria, is that the plasmoquine taken by the crew on field experiments on a similar plan have always Dr. FisCHER’S ship protected them against infection failed because taking quinine, although it cures on three days and nights of each week, whilst the developed attacks, does not prevent either man or quinine taken by the crews of the other ships had mosquitoes from becoming infected. If it is true no true prophylactic effect. that, in addition to quinine, a drug has now become available which, when taken in non-toxic doses by healthy people, prevents their infection, THE MANTLE OF FARR. and when taken by malaria patients prevents WE print in another column an appreciation the development of the parasite in the mosquitoes of the work of Dr. T. H. C. STEVENSON from the which feed upon them, it is reasonable to suppose that a repetition of KocH’s chemotherapeutic pens of the Presidents of the Royal Colleges offield trials might have a very different result. On Physicians and Surgeons, the President of the a smaller scale, of course, the benefits of a drug Royal Statistical Society, the President of the which prevents malaria] infection are clear. For Section of Epidemiology and State Medicine of of Medicine, and of two other example, malaria is the cause of much sickness the Royal Society men of science. It would be someand many deaths among the officers, crews, and distinguished of a work of supererogation to seek to add passengers of ships trading to Africa, India, and thing the Far East. During the years 1918 to 1921 there anything to what has been said by writers so well qualified to givejudgment, and, in any case, it were at least 20 deaths of seamen from acute would be premature to write of the career of a malarial attacks during homeward voyages from scientific man who, we may fairly hope, will still those countries, and at least 65 from recurrences increase the debt of gratitude we owe to him by after arrival in England. In one line of steamers further researches, as if it were at an end. Nevertrading out of Liverpool no fewer than 531 cases of malaria occurred in the course of 12 theless, we may be permitted briefly to recall to months, and instances are on record in which, the memories of our readers something of the of the office which Dr. Stevenson has done during homeward voyages from Africa or India, history so much to dignify. the disease attacked all except two or three of the The General Register Office is, in comparison whole ship’s company. As these merchant ships seldom stay more than a few days and nights in with most of our public offices, a young departmalarious ports, it would be easy to arrange for ment ; it is not yet a centenarian. A century agoall concerned to take the prophylactic doses during such vital statistics as this country possessed were, those relatively short periods and for a few days if anything, below the standard of those of other civilised communities. Within 40 years English thereafter. It is worth while, in this connexion appositely, official vital statistics were admittedly the best. to explain, in the light of the new knowledge, a in the world, and this pre-eminence has never been prophylactic trial of plasmoquine which Dr. lost. Everybody knows, or ought to know, that OTTO FISCHER was deputed by the Institute of this great triumph was primarily due to the Tropical Diseases, Hamburg, to conduct in April, harmonious cooperation of a first-rate admini1926, on a steamship sailing to the African Coast.l strator, GEORGE GRAHAM, and a statistical genius, The details were arranged by Prof. MUHLENS, but, WILLIAM FARR. Scientific and literary powers not regarding the drug as a true prophylactic, he were vouchsafed Farr in abundant measure, but based them on the view that " although these gifts would not have sufficed to establish an efficient public department, and some littleplasmoquine alone is inadequate as a therapeutic meed of praise is owing from posterity to the remedy in subtertian malaria, some result might be forgotten administrator who made the depart-. ment a going concern. Farr was succeeded inFischer, O. : " Über Malariaprophylaxe mit Beihefte zum Arch. für Schiffs- und Tropen-Hygiene, 1927, office by a man of a different type. William xxxi., 43.
auspices
"
"
1
Plasmochin,"
361
OcHjB was, like Farr, a man of the highest character -and public spirit, but, while Farr was a self-taught, energetic man of genius, knowing something of many subjects and without complete mastery of - any one technique, Ogle was a highly educated, exact scholar, with the inhibitions and reserves that regular education imposes, and the publications of the department in his time lost something of the vivacity which Farr supplied. Ogle’s
HYPERTENSION AS A SYMPTOM. time it. has been recognised that the symptoms associated with the earlier stages of hypertension-that is, before the onset of cardioThat vascular changes-are somewhat vague. these diffuse symptoms of ill-health are due to the rise of blood pressure is rendered doubtful, because there is no correlation between the severity of the symptoms and the increase of tension, because the symptoms may often be relieved without reduction of the blood pressure, and also because definite hypertension may be found in people who regard their health as perfect. A year ago J. E. F. RiSEMAN and S. WFlss1 noted that the symptoms found in these early stages are very like those
FOR
some
Dr. JOHN TATHAM, having the of direct experience of public health advantage - administration under modern conditions which his predecessors lacked, effected noteworthy improvements, but even he hardly relieved the annual reports from a certain air of dryness which, in the opinion of some, is the appropriate quality of blue books. Under Dr. Stevenson’s auspices encountered in cases of psycho-neurosis with normal 2 this was changed. We do not mean that Dr. blood pressure. D. AYMAN and J. H. PRATT Stevenson reverted to the flamboyant method of have now investigated a series of 100 patients, Farr, and, like Farr and Silas Wegg, dropped into all of whom had a systolic blood pressure of 160 poetry, or, like Farr, made lists of odd surnames or more and no evidence of renal impairment; and speculated on their derivation. We mean that, 17 of them were men, and 83 women. The like Farr, Dr. Stevenson looked upon the records commonest symptoms complained of were headache, .-as the raw material of research, and, using for the pain, "nervousness," dizziness, fatigue, insomnia, The less frequent most part only the simplest of analytical methods, and vasomotor disorders. gave an impressive demonstration of the great and symptoms were widespread, and referred to all often forgotten truth that very simple methods, parts of the body. Further, these troubles were in the hands of a man of first-rate ability, will lead invariably multiple and of long standing, the -to discoveries which men of less ability, even if average duration being over 10 years. Only equipped with all the so-called mathematics in four of these patients had no complaints. AYMAN and PRATT next examined 50 psycho-neurotic the world, are sure to miss. We fear that few medical men read the annual patients of the same age as the others, but with reports of the Registrar-General. If more did, normal blood pressures, and found that in this medical editors would receive fewer fallacious group the symptoms were almost identical, not arguments for publication, and many journeys in only in character, but also in incidence, multiplicity, search of mares’ nests would never have been and duration. Passing on to inquire further into begun. Nobody has the excuse for neglecting these the onset of symptoms in the patients with high records of research that they are too mathematical blood pressure, they ascertained that this often to be intelligible. We can but hope that Dr. coincided with emotional disturbances or environStevenson may be able to use some of his leisure mental difficulties. AYMAN and PRATT were thus ’in bringing together into a separate volume his unable to differentiate between the symptoms researches into the factors of infant mortality, associated with the early stages of high blood a book which would at once become a standard pressure and those of psycho-neuroses, and as treatise. Dr. Stevenson has, indeed, worn the evidence of a similar causation they remarked mantle of Farr. When a man of great ability that so-called hyperpietic symptoms respond to retires from office it is common form to say that removal of environmental difficulties, to sedatives, his place will be hard to fill. In the present case and to suggestion. A similar series of cases the difficulty may well amount to an impossibility. from which he draws the same conclusions is Farr had so free a hand as an unofficial research reported by D. DAVIS.3 F. R. NuzuM and A. H. ELLIOTT4 have tried to worker, because, 80 years ago, official vital statistics lad very little prestige, and important people or assess the part played by past illnesses, infections, interests cared very little what was said by the and focal sepsis in the setiology of hypertension. Registrar-General or his subordinates. That is In those patients whose increase in blood pressure .all changed, and although few really read the was associated with evidence of renal impairment reports many use extracts from them as they often found a history of scarlet fever and those classified as controversial weapons ; hence there must inevit- acute’ nephritis ; but among " " essential the of infection incidence hypertension ably be a tendency to prefer safety to brilliance, and focal no was than to discourage research, which, in the nature of sepsis among greater things, cannot be safe. Dr. Stevenson has never controls. This investigation also suggested that been deliberately provocative, as Farr often was, there is no familial factor in the causation of but he has had a literary tact, if we may use the high blood pressure, and that it is not unusually expression, which enabled him to say without prevalent in patients with arterio-sclerosis of the provocation many true things not flattering to larger vessels. Excessive obesity, however, was local or even national self-esteem. The task 1 Amer. Jour. Med. Sci., 1930, clxxx., 47. of his successor will not be an easy one. It will 2 Arch. Int. Med., May, 1931, p. 675. 3 Amer. Jour. Med. Sci., June, 1931, p. 850. ,be hard to wear the mantle of Stevenson. 4 Ibid., May, 1931, p. 630. .successor, the late