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A FOURTH MALARIAL PARASITE?
1058
ANNOTATIONS DIET AND WORK
patient. Often relief is complete ; sometimes it is only partial; rarely there is none. When the treatment is only partly successful it should be repeated after a few days’ interval. Paravertebral injection of alcohol is advised for obstinate intercostal neuralgia, especially of herpetic origin ; and into the solar plexus when this is involved in malignant growths of the upper abdomen. Sympathectomy or, as a last resort, chordotomy is reserved for cases in which alcohol injection fails. The latter operation has now been superseded for the most part by milder measures, for it is a severe one and its results are not always satisfactory. It may be remembered that in the series of 17 cases reported in our columns by G. F. Stebbing3 there were two deaths and several instances of incomplete relief and recurrence of pain. E. L. Stern4 has obtained good results from intraspinal injections of 95 per cent. alcohol, and states that with scrupulous attention to technique the method he describes is safe and usually successful. It sometimes causes partial anaesthesia, but he has never seen motor paralysis. The effect of a single injection may last for as long as eight months. The 19 cases of cancer he records received a total of 26 injections; in 11 relief was complete, in the others it was considerable. De Beule and Schotte have also had good results with intraspinal injections, but in their hands paralysis has occasionally followed. Retention of urine for a few days, due to sensory paralysis of the bladder, may be a sequel to alcohol injection by any route, and also to chordotomy.
THERE is a firmly rooted belief, not supported by much scientific evidence, that large amounts of meat should be taken when training for a feat of endurance. Some interesting experiments have recently been made at the Glasgow Institute of Physiology1 on the output of a racing cyclist on five vegetarian diets of approximately equal calorific value but varying protein content. This man rode a bicycle ergometer for eight hours on each diet ; the amount of work of which he was capable (together with other details of his performance) being measured and compared with his total energy output. The proportion of the latter appearing as work gave his efficiency. Three of the diets were respectively of low, medium, and high protein content ; the fourth was similar to the high protein diet, but the protein was of vegetable instead of animal origin, eggs, milk, and cheese being excluded ; the fifth, chosen by the cyclist himself, approximated to the original high protein diet, and was consumed in small amounts at frequent intervals. As a result of these experiments Dr. G. M. Wishart found that the total amount of work performed during the day was greater on the high protein diet, greater still on the subject’s own diet, but that the gross efficiency was actually less than on the protein poor diets-i.e., there was a proportionately larger amount of energy dissipated as heat. The experiment in which vegetable protein alone was used had to be abandoned on account of abdominal discomfort. From the point of view of performance, therefore, A FOURTH MALARIAL PARASITE? the use of food containing a high proportion of protein THREE parasites of malaria are commonly recognised is justified ; so far as conclusions can be drawn from a limited number of experiments, vegetable protein -viz., Plasmodium malarice of quartan, P. vivax of is inferior, probably on account of its bulk. The tertian, and P. falciparum (in Germany termed significance of this last factor is suggested by the immaculatum) of malignant tertian fever; but as Prof. P. Muhlens mentions in a recent paperothers better performance when food was taken often and in small quantities. Investigation of the excreta by have been observed and named. He quotes Ahmed Emin’s P. vivax, var. minutum (1914), J. W. W. Prof. H. E. C. Wilson failed to provide any rational explanation of the facts recorded. The nitrogen Stephens’s P. tenue (1914), Marzinowsky’s P. caucaoutput was related to the amount of protein ingested sicum (1916), von Ziemann’s Laverania perniciosa rather than to the amount of work done. There was (1917), and finally Stephens’s P. ovale (1922). The of in last named reported first by Stephens from East the value its to that protein lay nothing suggest capacity for repairing " wear and tear " of the tissues. Africa has been since observed in 1927 by Stephens and D. U. Owen from Nigeria, by W. Yorke In another paper in the same issue (p. 207) Dr. R. C. out the G. M. work and Dr. Wishart efficiency and Owen from Nigeria (1930). From another case Garry of bicycle pedalling at different speeds by comparing of Yorke’s, found in the Belgian Congo, S. P. James, W. D. Nicol, and P. G. Shute infected Anopheles the actual work done (1) with the total energy expenditure, (2) with the total energy expenditure minus the maculipennis (the oocysts in its stomach were diswork required to perform similar movements with no tinguishable from those of the other parasites) and load on the bicycle. The first of these measurements from these mosquitoes men were infected and in their gives the gross efficiency, the second the net efficiency. blood the P. ovale was again seen. In 1933 Schwetz The former was found to be less at high speeds and and his helpers, also Rodhain, reported it from the the latter more. The total energy expenditure and Belgian Congo, and in the same year N. H. Fairley the total amount of external work done were both from West Africa and P. H. Manson-Bahr from constantly greater in the trained subject than in the Uganda. P. ovale has thus been reported eight times untrained, while the cost of the " no-load " movement in 12 years. During a course in the tropical medicine was less. school at Hamburg last autumn, Dr. Muhlens, the chanced upon a case that was being shown director, THE SURGICAL RELIEF OF PAIN to the class as clinically tertian, but which after Two recent papers refer to the use of alcohol examination of the thick drop was regarded as quartan injections for relieving intractable pain. F. de Beule though the parasites were not quite typical, Schüffner’s and A. Schottewrite on epidural and paravertebral dots being well marked. In the smears however injection, the first of which, by way of the sacro- the parasites seemed rather to resemble P. ovale coccygeal foramen, is recommended for the pain of being small, compact, early dividing, never with inoperable or recurrent carcinoma of the cervix or more than eight merozoites, almost always in enlarged rectum. The technique is simple and, if a local red corpuscles, themselves showing marked Schuffner’s anaesthetic is first introduced, it should not hurt the 1 Jour. of Physiol., 1934, lxxxii., 184. 2 Rev. beige des sci. méd., 1934, vi., 357.
5
3 THE LANCET, 1929, i., 654. 4 Amer. Jour. Surg., 1934, xxv., 217. Arch. f. Schiffs- u. Tropen.-Hyg., September, 1934, p. 367.
1059 There was notably little pigment, and the of the infected corpuscles were irregular and edges Dr. Shute, who was on a visit to Hamburg, fringed. recognised them as P. ovale,.at his request preparations of Yorke’s parasite were sent for comparison and found to be identical. This Hamburg patient came from West Africa-in his ship were other malarial cases, three malignant tertian, one quartanhis fever was thought to be tertian, and, as in other ovale cases, it was noticed that his pyrexial attacks He reacted at came on in the evening or at night. once to atebrin, was free of parasites in three days, and when re-examined after five months was found to have been quite fever-free in the interval. Attention having been directed to this case, three others were discovered, two from Nigeria during treatment, one from the west coast of South America, clinically supposed to be a double tertian. Dr. Muhlens is satisfied that the parasite seen at Hamburg is that reported and named by Stephens. Whether or not it is a fourth parasite of malaria he has not quite made up his mind, though he inclines to believe that it is a form intermediate between P. malarice and P. vivax. The oval enlarged red corpuscles in which it occurs are never associated with ordinary tertian infections. The paper is well illustrated with microphotographs and coloured drawings.
dots.
TRACHEOTOMY IN LARYNGEAL TUBERCULOSIS
FROM time to time it has been suggested that be useful in the treatment of tuberculosis of the larynx as a means of obtaining rest for the organ ; but almost all authorities agree in condemning its employment for this purpose. StClair Thomson1 states that strict silence will secure almost as complete rest, while Harold Barwell2 says that it does not give rest to the parts but prevents effective coughing, allows secretions to accumulate, and generally does harm. They agree, however, that tracheotomy is necessary in the presence of dyspnoea, which cannot be relieved by rest, silence, and intralaryngeal treatment, Thomson urging that there should be no hesitation in performing it in these circumstances. Four cases reported by F. C.
tracheotomy should
Ormerod3 support these conclusions. Of these, the pulmonary conditions were quiescent in two, and they showed no constitutional disturbance after the operation ; the third, with active disease in the lungs, had fever to 100° F. for two days but made a good recovery and lived for nearly two years. The fourth patient had very active pulmonary disease ; in her case this was much accelerated after tracheotomy, and she died in three weeks. He agrees that any resulting improvement in the larynx is very slight and not enough to justify tracheotomy for therapeutic reasons, and states that the operation, although apparently safe where the disease is quiescent, will be attended by great risks if there are active pulmonary lesions. In Ormerod’s view tracheotomy should be done only for severe dyspnoea, and only after every effort has been made to relieve it by means of rest and other measures. On the other hand, dyspnoea is extremely exhausting, and patients often improve remarkably in health after tracheotomy when the operation has been definitely called for. It is especially indicated when laryngeal stenosis accompanies the more chronic forms of phthisis, but it is doubtful if it should be reserved only for cases where dyspnoea is really severe; 1 Thomson, Sir StClair: Diseases of the Nose and Throat, 3rd ed., London, 1926, pp. 618 and 714. 2 Barwell, H. S.: Diseases of the Larynx, 3rd ed., London,
1928, p. 102.
3 Jour. Laryngol. and Otol., August, 1934, p. 512.
it is possible to make the criticism that Ormerod’s fourth patient, who suffered from severe dyspncea for ten days before tracheotomy, might have done better had the operation been performed sooner. TREATMENT OF MIGRAINE WITH ERGOTAMINE TARTRATE
IN 1928 we gave an account of Dr. Arnault Tzanck’s observations of the treatment of migraine with ergotamine tartrate. Since then Dr. Tzanck has published further communications on this subject and this mode of treatment has been investigated by other workers also. Dr. W. G. Lennox2 has recently published the results of treatment of 45 patients. Ergotamine tartrate, which is sold here under thetrade name of Femergin, is supplied in ampoules containing 0-5 or 0-25 mg. and in tablets containing 1-0 mg. The recommended single dose is 0-5 mg. subcutaneously or 1-0 mg. by the mouth, but because patients vary in their reaction to the drug Dr. Lennox considers it wise to give only half the full subcutaneous dose at the first trial. The dose can be repeated after an interval of two or three hours. For a prompt, sustained effect he prefers 0-5 c.cm. (0-25 mg.) intravenously and at the same time the same amount subcutaneously. The injection usually causes vomiting, increase in systolic blood pressure, decrease in pulse pressure, and bradycardia. Three patients complained of dyspnoea and a sense of constriction in the chest, and one of these had symptoms of angina. In the majority of cases nausea or vomiting occurred. Experience shows that ergotamine tartrate is in most cases effective in cutting short the individual attack. Abrupt termination of the initial attack treated occurred in 40 of the 45 of Dr. Lennox’s patients. Relief of the headache began in 15 to 30 minutes after an intravenous dose, in 1 to 2 hours after a subcutaneous dose, and in 2 to 3 hours when the drug was given orally. Whether ergotamine will lead to Dr. permanent improvement remains doubtful. Lennox states that patients whose attacks are terminated when treatment is first instituted may later fail at times to obtain relief, or else the interval between attacks may be shortened. Although some authors speak hopefully of a diminution in frequency and of the actual disappearance of the attacks under treatment with ergotamine, Dr. Lennox’s experience is less encouraging in this respect and he doubts whether it is of value in preventing the attacks. Drs. Samuel Brock, Mary 0’Sullivan, and David Young3 report an experience similar to that of Dr. Lennox, though with a smaller series of patients. In most cases the injection of 0-25 to 0-5 mg. of ergotamine tartrate caused the headache to disappear in 1 to 3 hours. These workers state that at times the taking of 1 mg. two to four times a day by mouth lessened the frequency and severity of the attacks. Drs. A. H. Logan and E. V. Allen4 have treated nine sufferers from migraine with ergotamine tartrate for 71 headaches, " 67 of which were relieved in a more or less satisfactory manner." In three of the four instances in which relief not was experienced the medicine had been mouth. These authors draw attention given by to the very disagreeable symptoms which followed the injections in some instances, but which could usually be avoided by using the smallest amount of the drug which would relieve the headache, although some patients may be so sensitive 1 THE LANCET, 1928, ii., 665. 2 New Eng. Jour. Med., 1934, ccx., 1061. 3 Amer. Jour. Med. Sci., August, 1934, p. 253. 4 Proc. Staff Meet. Mayo Clinic, 1934, ix., 585.
ANNOTATIONS DIET AND WORK
patient. Often relief is complete ; sometimes it is only partial; rarely there is none. When the treatment is only partly successful it should be repeated after a few days’ interval. Paravertebral injection of alcohol is advised for obstinate intercostal neuralgia, especially of herpetic origin ; and into the solar plexus when this is involved in malignant growths of the upper abdomen. Sympathectomy or, as a last resort, chordotomy is reserved for cases in which alcohol injection fails. The latter operation has now been superseded for the most part by milder measures, for it is a severe one and its results are not always satisfactory. It may be remembered that in the series of 17 cases reported in our columns by G. F. Stebbing3 there were two deaths and several instances of incomplete relief and recurrence of pain. E. L. Stern4 has obtained good results from intraspinal injections of 95 per cent. alcohol, and states that with scrupulous attention to technique the method he describes is safe and usually successful. It sometimes causes partial anaesthesia, but he has never seen motor paralysis. The effect of a single injection may last for as long as eight months. The 19 cases of cancer he records received a total of 26 injections; in 11 relief was complete, in the others it was considerable. De Beule and Schotte have also had good results with intraspinal injections, but in their hands paralysis has occasionally followed. Retention of urine for a few days, due to sensory paralysis of the bladder, may be a sequel to alcohol injection by any route, and also to chordotomy.
THERE is a firmly rooted belief, not supported by much scientific evidence, that large amounts of meat should be taken when training for a feat of endurance. Some interesting experiments have recently been made at the Glasgow Institute of Physiology1 on the output of a racing cyclist on five vegetarian diets of approximately equal calorific value but varying protein content. This man rode a bicycle ergometer for eight hours on each diet ; the amount of work of which he was capable (together with other details of his performance) being measured and compared with his total energy output. The proportion of the latter appearing as work gave his efficiency. Three of the diets were respectively of low, medium, and high protein content ; the fourth was similar to the high protein diet, but the protein was of vegetable instead of animal origin, eggs, milk, and cheese being excluded ; the fifth, chosen by the cyclist himself, approximated to the original high protein diet, and was consumed in small amounts at frequent intervals. As a result of these experiments Dr. G. M. Wishart found that the total amount of work performed during the day was greater on the high protein diet, greater still on the subject’s own diet, but that the gross efficiency was actually less than on the protein poor diets-i.e., there was a proportionately larger amount of energy dissipated as heat. The experiment in which vegetable protein alone was used had to be abandoned on account of abdominal discomfort. From the point of view of performance, therefore, A FOURTH MALARIAL PARASITE? the use of food containing a high proportion of protein THREE parasites of malaria are commonly recognised is justified ; so far as conclusions can be drawn from a limited number of experiments, vegetable protein -viz., Plasmodium malarice of quartan, P. vivax of is inferior, probably on account of its bulk. The tertian, and P. falciparum (in Germany termed significance of this last factor is suggested by the immaculatum) of malignant tertian fever; but as Prof. P. Muhlens mentions in a recent paperothers better performance when food was taken often and in small quantities. Investigation of the excreta by have been observed and named. He quotes Ahmed Emin’s P. vivax, var. minutum (1914), J. W. W. Prof. H. E. C. Wilson failed to provide any rational explanation of the facts recorded. The nitrogen Stephens’s P. tenue (1914), Marzinowsky’s P. caucaoutput was related to the amount of protein ingested sicum (1916), von Ziemann’s Laverania perniciosa rather than to the amount of work done. There was (1917), and finally Stephens’s P. ovale (1922). The of in last named reported first by Stephens from East the value its to that protein lay nothing suggest capacity for repairing " wear and tear " of the tissues. Africa has been since observed in 1927 by Stephens and D. U. Owen from Nigeria, by W. Yorke In another paper in the same issue (p. 207) Dr. R. C. out the G. M. work and Dr. Wishart efficiency and Owen from Nigeria (1930). From another case Garry of bicycle pedalling at different speeds by comparing of Yorke’s, found in the Belgian Congo, S. P. James, W. D. Nicol, and P. G. Shute infected Anopheles the actual work done (1) with the total energy expenditure, (2) with the total energy expenditure minus the maculipennis (the oocysts in its stomach were diswork required to perform similar movements with no tinguishable from those of the other parasites) and load on the bicycle. The first of these measurements from these mosquitoes men were infected and in their gives the gross efficiency, the second the net efficiency. blood the P. ovale was again seen. In 1933 Schwetz The former was found to be less at high speeds and and his helpers, also Rodhain, reported it from the the latter more. The total energy expenditure and Belgian Congo, and in the same year N. H. Fairley the total amount of external work done were both from West Africa and P. H. Manson-Bahr from constantly greater in the trained subject than in the Uganda. P. ovale has thus been reported eight times untrained, while the cost of the " no-load " movement in 12 years. During a course in the tropical medicine was less. school at Hamburg last autumn, Dr. Muhlens, the chanced upon a case that was being shown director, THE SURGICAL RELIEF OF PAIN to the class as clinically tertian, but which after Two recent papers refer to the use of alcohol examination of the thick drop was regarded as quartan injections for relieving intractable pain. F. de Beule though the parasites were not quite typical, Schüffner’s and A. Schottewrite on epidural and paravertebral dots being well marked. In the smears however injection, the first of which, by way of the sacro- the parasites seemed rather to resemble P. ovale coccygeal foramen, is recommended for the pain of being small, compact, early dividing, never with inoperable or recurrent carcinoma of the cervix or more than eight merozoites, almost always in enlarged rectum. The technique is simple and, if a local red corpuscles, themselves showing marked Schuffner’s anaesthetic is first introduced, it should not hurt the 1 Jour. of Physiol., 1934, lxxxii., 184. 2 Rev. beige des sci. méd., 1934, vi., 357.
5
3 THE LANCET, 1929, i., 654. 4 Amer. Jour. Surg., 1934, xxv., 217. Arch. f. Schiffs- u. Tropen.-Hyg., September, 1934, p. 367.
1059 There was notably little pigment, and the of the infected corpuscles were irregular and edges Dr. Shute, who was on a visit to Hamburg, fringed. recognised them as P. ovale,.at his request preparations of Yorke’s parasite were sent for comparison and found to be identical. This Hamburg patient came from West Africa-in his ship were other malarial cases, three malignant tertian, one quartanhis fever was thought to be tertian, and, as in other ovale cases, it was noticed that his pyrexial attacks He reacted at came on in the evening or at night. once to atebrin, was free of parasites in three days, and when re-examined after five months was found to have been quite fever-free in the interval. Attention having been directed to this case, three others were discovered, two from Nigeria during treatment, one from the west coast of South America, clinically supposed to be a double tertian. Dr. Muhlens is satisfied that the parasite seen at Hamburg is that reported and named by Stephens. Whether or not it is a fourth parasite of malaria he has not quite made up his mind, though he inclines to believe that it is a form intermediate between P. malarice and P. vivax. The oval enlarged red corpuscles in which it occurs are never associated with ordinary tertian infections. The paper is well illustrated with microphotographs and coloured drawings.
dots.
TRACHEOTOMY IN LARYNGEAL TUBERCULOSIS
FROM time to time it has been suggested that be useful in the treatment of tuberculosis of the larynx as a means of obtaining rest for the organ ; but almost all authorities agree in condemning its employment for this purpose. StClair Thomson1 states that strict silence will secure almost as complete rest, while Harold Barwell2 says that it does not give rest to the parts but prevents effective coughing, allows secretions to accumulate, and generally does harm. They agree, however, that tracheotomy is necessary in the presence of dyspnoea, which cannot be relieved by rest, silence, and intralaryngeal treatment, Thomson urging that there should be no hesitation in performing it in these circumstances. Four cases reported by F. C.
tracheotomy should
Ormerod3 support these conclusions. Of these, the pulmonary conditions were quiescent in two, and they showed no constitutional disturbance after the operation ; the third, with active disease in the lungs, had fever to 100° F. for two days but made a good recovery and lived for nearly two years. The fourth patient had very active pulmonary disease ; in her case this was much accelerated after tracheotomy, and she died in three weeks. He agrees that any resulting improvement in the larynx is very slight and not enough to justify tracheotomy for therapeutic reasons, and states that the operation, although apparently safe where the disease is quiescent, will be attended by great risks if there are active pulmonary lesions. In Ormerod’s view tracheotomy should be done only for severe dyspnoea, and only after every effort has been made to relieve it by means of rest and other measures. On the other hand, dyspnoea is extremely exhausting, and patients often improve remarkably in health after tracheotomy when the operation has been definitely called for. It is especially indicated when laryngeal stenosis accompanies the more chronic forms of phthisis, but it is doubtful if it should be reserved only for cases where dyspnoea is really severe; 1 Thomson, Sir StClair: Diseases of the Nose and Throat, 3rd ed., London, 1926, pp. 618 and 714. 2 Barwell, H. S.: Diseases of the Larynx, 3rd ed., London,
1928, p. 102.
3 Jour. Laryngol. and Otol., August, 1934, p. 512.
it is possible to make the criticism that Ormerod’s fourth patient, who suffered from severe dyspncea for ten days before tracheotomy, might have done better had the operation been performed sooner. TREATMENT OF MIGRAINE WITH ERGOTAMINE TARTRATE
IN 1928 we gave an account of Dr. Arnault Tzanck’s observations of the treatment of migraine with ergotamine tartrate. Since then Dr. Tzanck has published further communications on this subject and this mode of treatment has been investigated by other workers also. Dr. W. G. Lennox2 has recently published the results of treatment of 45 patients. Ergotamine tartrate, which is sold here under thetrade name of Femergin, is supplied in ampoules containing 0-5 or 0-25 mg. and in tablets containing 1-0 mg. The recommended single dose is 0-5 mg. subcutaneously or 1-0 mg. by the mouth, but because patients vary in their reaction to the drug Dr. Lennox considers it wise to give only half the full subcutaneous dose at the first trial. The dose can be repeated after an interval of two or three hours. For a prompt, sustained effect he prefers 0-5 c.cm. (0-25 mg.) intravenously and at the same time the same amount subcutaneously. The injection usually causes vomiting, increase in systolic blood pressure, decrease in pulse pressure, and bradycardia. Three patients complained of dyspnoea and a sense of constriction in the chest, and one of these had symptoms of angina. In the majority of cases nausea or vomiting occurred. Experience shows that ergotamine tartrate is in most cases effective in cutting short the individual attack. Abrupt termination of the initial attack treated occurred in 40 of the 45 of Dr. Lennox’s patients. Relief of the headache began in 15 to 30 minutes after an intravenous dose, in 1 to 2 hours after a subcutaneous dose, and in 2 to 3 hours when the drug was given orally. Whether ergotamine will lead to Dr. permanent improvement remains doubtful. Lennox states that patients whose attacks are terminated when treatment is first instituted may later fail at times to obtain relief, or else the interval between attacks may be shortened. Although some authors speak hopefully of a diminution in frequency and of the actual disappearance of the attacks under treatment with ergotamine, Dr. Lennox’s experience is less encouraging in this respect and he doubts whether it is of value in preventing the attacks. Drs. Samuel Brock, Mary 0’Sullivan, and David Young3 report an experience similar to that of Dr. Lennox, though with a smaller series of patients. In most cases the injection of 0-25 to 0-5 mg. of ergotamine tartrate caused the headache to disappear in 1 to 3 hours. These workers state that at times the taking of 1 mg. two to four times a day by mouth lessened the frequency and severity of the attacks. Drs. A. H. Logan and E. V. Allen4 have treated nine sufferers from migraine with ergotamine tartrate for 71 headaches, " 67 of which were relieved in a more or less satisfactory manner." In three of the four instances in which relief not was experienced the medicine had been mouth. These authors draw attention given by to the very disagreeable symptoms which followed the injections in some instances, but which could usually be avoided by using the smallest amount of the drug which would relieve the headache, although some patients may be so sensitive 1 THE LANCET, 1928, ii., 665. 2 New Eng. Jour. Med., 1934, ccx., 1061. 3 Amer. Jour. Med. Sci., August, 1934, p. 253. 4 Proc. Staff Meet. Mayo Clinic, 1934, ix., 585.