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A GALLERY OF "TROPICAL DOCTORS"
314
ANNOTATIONS REMOTE CONSEQUENCES OF GASTROINTESTINAL DEFECTS
BRONCHOSPIROMETRY
THE causal relationship between abnormality of the secretion and pernicious anaemia, foreseen by Samuel Fenwick, Faber, Hurst, and many others, is now firmly established by the work of W. B. Castle and his American collaborators. Tropical sprue, which is certainly a primary disease of the gastrointestinal tract, often leads to the appearance of severe macrocytic anaemia or of tetany, whilst cceliac disease has been shown by Bennett, Hunter, and Vaughan to lead at times to several varieties of severe anaemia, to tetany, and to considerable bony softening. These examples illustrate the serious remote effects of certain gastro-intestinal disorders ; consequences which may with complete accuracy be classed as deficiency diseases although they are occasioned not by defective diet but by obscure lesions of the alimentary canal, preventing the proper digestion or absorption of certain essential constituents of the normal diet. The manner in which the deranged alimentary canal can in this way create deficiency diseases is discussed in a recent article by Maurice B. Strauss.’ After reviewing the various experiments responsible for the modern theory of the causation of pernicious anaemia, Strauss quotes the classical case of macrocytic anaemia described by Addison in a patient withL
gastric
,
,
,
ulcerative colitis, and similar
cases
associated withL
prolonged diarrhoea and chronic bacillary dysentery. Macrocytic anaemia which has been described in connexion with chronic gastric fistul2e is strictly comparable to the series which accompany strictures
.
of the small intestine, colon, or caecum. In his own experience hehas seen such a condition arise in a child eight years of age in whom various short circuits between loops of small intestine had occurred following intestinal obstruction of inflammatory origin. Pellagra when it occurred in endemicform is probably due to lack of vitamin B2 (G), but cases have occurred in which all the manifestations of this disease appeared, with normal dietary, in patients with severe alcoholic gastro-enteritis. Pellagra has been reported in 15 cases of cancer of the stomach, usually associated with pyloric obstruction ; it has also been encountered in cancer of the ileum and even in association with strictures of the rectum. Skin lesions identical with those of pellagra have been reported with diarrhoeal diseases such as ulcerative colitis, dysentery, and various forms of rectal disease, and also in certain diseases of the small intestine and even of the aesophagus. Another effect of deficiency occasioned by gastro-intestinal disease is to be found in peripheral polyneuritis. Chronic alcoholism as a cause of neuritis has been known for upwards of 150 years, but it is only recently that Shattuck has formulated the theory that " alcoholic " neuritis is in reality a deficiency disease similar to the neuritis seen in beri-beri. This opinion is confirmed by the work of Minot, Cobb, and Strauss, who have relieved alcoholic neuritis by the oral and hypodermic administration of vitamin B whilst permitting the administration of alcohol to continue. Polyneuritis has been reported fairly
REFERENCE has been already made in these columnsto a method by which the function of the two lungs may be studied separately. One of the authors of the original paper, Dr. S. Bjorkman, has now produced a small monograph on the subject.2 The procedure is to pass a " double bronchoscope," consisting of two tubes one inside the other. The inner tube communicates with one main bronchus, where an air-tight junction is maintained by the inflation of a rubber armlet, and the outer communicates with the lumen of the trachea (and thus with the other main bronchus), a second rubber armlet being inflated just below the lower end of the larynx so as to prevent air passing in any way except through the bronchoscope. By means of recording spirometers connected with the two tubes, accurate measurements of the functional activity of each lung can be obtained. A certain number of normal people have been examined and supply readings which serve as a background for the results in nearly 60 patients suffering from pulmonary disease. Bjorkman says that, normally, the left lung accounts for 40 to 50 per cent. and the right lung 60 to 50 per cent. of the total ventilation, but this relationship is of course much altered, where there is disease of one lung. What is surprising is to learn that often the alteration from normal as regards the distribution of total oxygen intake and total carbon dioxide output on the two sides is not uniform ; so that while the respiratory quotient for the two lungs together is normal, a different quotient was obtained for each lung separately. The suggestion is made that possibly carbon-dioxide is actively excreted by the mucous membrane of the bronchi and that this process is sometimes impaired by disease. The functional activity of the lungs in different postures has been studied, and also the effects of coughing, confirmation being obtained for the view that sputum from a diseased lung may enter a sound lung during this complicated act. Bjorkman admits that his method is applicable only to a small group of subjects, but his observations provide the clinical physiologist with fresh objectives, A
GALLERY
OF
"TROPICAL DOCTORS"
Dr. Gottlier Olpp, who directs the Institute of Medical Missions at Tiibingen and holds a chair in the University, has brought out a remarkable directorys of doctors, living and dead, whose names are associated with service in the tropics. He has spread his net very wide-to include Hippocrates, Imhotep, and Berkefeld, inventor of the filter-aiid has included some 300 biographies of which only quite a modest proportion, not more than one-third, are of German origin ; and the collection is made more remarkable by the fact that he has collected a gallery of excellent portraits with only a few relatively unimportant omissions. Dr. Olpp went out to China as a medical missionary and began at once to collect material to perpetuate the memory of men for whom he conceived a profound admiration. For 20 years past he has gone on collecting with the help of correspondents in many countries-he acknowledges the help of Nuttall in Cambridge, Andrew Balfour and
frequently in cases of pyloric stenosis secondary to peptic ulcer, and it has also been seen in association with dysentery and ulcerative colitis. In fact a mass Manson-Bahr in London, Stephens in Liverpool-and of evidence accumulates to show that a deficiency experts at their own valuation caused by defects of the alimentary canal may accepting living 1 THE LANCET 1933, i., 481. be responsible for this neurological picture quite Acta Med. Scand., Suppl. LVI., Stockholm, 1934, Pp. 199. Hervorragende Tropenärzte in Wort und Bild. Munich : frequently. Otto Gmelin. 446. 2
3
Verlag der Ärztlichen Rundschau,
1
Jour. Amer. Med. Assoc., 1934, ciii., 1.
R.M.30
Pp.
315
although impeded by their inherent modesty. The be doubled. Although corneal ulcers undoubtedly several biographies are interesting in themselves ; heal more quickly when irradiated there is not they have been put together with skill and there is sufficient evidence that the density of the subconsiderable charm in the author’s extreme simplicity sequent scar is less, nor is there any effect on of style. To the inexpert, approaching the history established nebulae. In tuberculous iritis there is of tropical medicine for the first time, he recommends often a suggestion of improvement, but the dosage the reading of biographies in the following order- needs careful watching. Throughout the monograph viz., Leeuwenhoek, Jenner, Meigen, Pollender, Mr. Law maintains a severely critical attitude towards Griesinger, Bilharz, Obermeier, Koch, Laveran, Baelz, his own results. In using radium and X rays for Pasteur, Metchnikoff, Manson, Ross, Reed, Gorgas, eye diseases the danger of inducing cataract must, Carroll, Ehrlich-a list which does credit as much to he says, always be taken into account. Infra-red his sense of proportion as to his freedom from national rays play no part as a therapeutic agent in diseases Having been a medical missionary of the eye ; they are a source of possible injury to prejudice. himself he has allowed himself to go strong in cornea, lens, and retina--e.g., eclipse blindness. recounting missionary endeavour, and here again the reader will be grateful for his indication of seven THE ENGLISH TONGUE biographies which deserve study. Happily in this THE history of the English language is not a matter case there are some survivors. To the biography for philologists ; all persons with claims to education, there is in many cases a bibliography attached, and in the countries where English is spoken, should have the author takes credit for giving the present address some acquaintance with the origin and development of these who are still alive. The production of the book is as distinguished as its authorship. The paper of their own tongue. In the United States of late this feeling has certainly been active, and a short cover is attractive in design, the typesetting beyond article on the subject in the Medical Record for July 4th and the a model for other index effort. criticism, is worth attention. The writer says that few persons The book is indispensable in any medical library. know the origin of " the King’s English," evidently thinking that fuller appreciation of the lineage of PHOTOTHERAPY OF THE EYE languagewould minimise its frequent abuse. His of the Saxon invasion and the settlements A DEPARTMENT for ultra-violet treatment was pithy of of at different epochs gives reasons parts England established at Moornelds Hospital in 1925, under for the evolution of English to its present gradual Sir Stewart Duke-Elder, who summarise his work in it was not until 1385 standard. to him 1 reports issued in 1926 and 1928. In the book before us that the According of the English-speaking peoples language his successor, Mr. F. W. Law, considers all the cases who had a full course of such treatment, general or stepped out of its dialect petticoats to become an local, in the clinic last year, and some of those treated adult tongue, since when it has taken its place as the in the three years preceding. To help towards most universal means of intercommunication. On cover page of the same issue of the Medical Becord assessing the permanence of results a letter was sent the there is a picture of Dr. Thomas L. Stedman, for out to the patients or their parents as to their present many years the editor of the journal, and this is condition. The effect of general phototherapy must for Stedman is a master of English, as opportune, be read in the light of the fact that the patients as a versatile linguist. well Largely through this fact were attending hospital three times a week for a has he made a reputation as a lexicographer, where long period, and therefore received also other treat- an accurate knowledge alike of the subject in hand ment in an unusually thorough way. This resulted and of languages is essential. in a high standard of cleanliness, for the undressing
sketch
of a child three times a week before a nurse has its educative value on the mother. With these provisos Mr. Law endorses the favourable opinions expressed by other writers of the ultra-violet treatment of blepharitis, phlyctenular disease, and conjunctivitis in children. Most forms of keratitis derive some benefit ; this applies, in Mr. Law’s experience, even to interstitial keratitis. Syphilitic iridocyclitis and tuberculous disease failed to react, and, on the whole, his results do not reach the high level of some other workers. General phototherapy is, in fact, no more than an adjunct in treatment. Local irradiation in its own sphere has more to offer. Mr. Law reports 51 cases, nearly all of them corneal ulcers or different forms of keratitis, treated by focusing the rays exactly on the spot. Although he has himself never seen a cataract remotely connected with ultra-violet therapy, the application calls for continual care. Preferably the pupil should be small, although this is not always feasible. The usual initial dose is one of 2 to 2i minutes, but if the duration of the beam has to be as oblique as 45° the time of exposure may be increased by one-half; if to 60° it may 1 Ultra-violet Therapy in Eye Disease, with a review of other By Frank W. Law, M.A., M.D., B.Chir. Camb., F.R.C.S., Assistant Surgeon, Central London Ophthalmic Hospital ; Pathologist and Curator, and Medical Officer in charge of the physico-therapeutic department, Royal London Ophthalmic Hospital (Moorfields). With foreword by Sir Stewart Duke-Elder, M.D., F.R.C.S. Published for the Middlesex Hospital by John Murray. 1934. Pp. 78. 5s.
forms of Radiant Energy.
EPIDEMIC MYALGIA IN SWEDEN
IN a note presented to the permanent committee of the Office International d’Hygiene publique, Dr. R. Hussoutlines the salient features of the epidemic of myalgia which, in the summer and autumn of 1931, claimed many victims in the southern coastal areas of Sweden and in Denmark.2 Though not a single case was fatal, the manifestations of the disease, when it was of the abdominal type, led occasionally to an exploratory laparotomy which proved nothing but the mistake in making it. There was also a thoracic type with bilateral symptoms referable to the lower chest. The most common complications were orchitis (some 50 cases) and dry pleurisy (about a score). Catarrhal symptoms referable to the respiratory tract were rare. Some cases were characterised by euphoria and flushing of the face. It seems that the epidemic had had its forerunners in 1927, 1929, and 1930. The outbreak of 1931 began in the middle of June in the seaport of Marstrand, at which two Swedish warships were stationed from June 18th to 26th. The sickness-rate on these ships a few days after they had left Marstrand was such that about a third of the crews was involved. Between the ages of 14 and 17 there were 190 persons, 72 of whom fell ill. Between the ages of 20 and 30 there were only 1 Bull. de l’Off. Internat. d’hyg. pub., June, 1934, p. 1083. 2 See THE LANCET, 1933, i., 709.
ANNOTATIONS REMOTE CONSEQUENCES OF GASTROINTESTINAL DEFECTS
BRONCHOSPIROMETRY
THE causal relationship between abnormality of the secretion and pernicious anaemia, foreseen by Samuel Fenwick, Faber, Hurst, and many others, is now firmly established by the work of W. B. Castle and his American collaborators. Tropical sprue, which is certainly a primary disease of the gastrointestinal tract, often leads to the appearance of severe macrocytic anaemia or of tetany, whilst cceliac disease has been shown by Bennett, Hunter, and Vaughan to lead at times to several varieties of severe anaemia, to tetany, and to considerable bony softening. These examples illustrate the serious remote effects of certain gastro-intestinal disorders ; consequences which may with complete accuracy be classed as deficiency diseases although they are occasioned not by defective diet but by obscure lesions of the alimentary canal, preventing the proper digestion or absorption of certain essential constituents of the normal diet. The manner in which the deranged alimentary canal can in this way create deficiency diseases is discussed in a recent article by Maurice B. Strauss.’ After reviewing the various experiments responsible for the modern theory of the causation of pernicious anaemia, Strauss quotes the classical case of macrocytic anaemia described by Addison in a patient withL
gastric
,
,
,
ulcerative colitis, and similar
cases
associated withL
prolonged diarrhoea and chronic bacillary dysentery. Macrocytic anaemia which has been described in connexion with chronic gastric fistul2e is strictly comparable to the series which accompany strictures
.
of the small intestine, colon, or caecum. In his own experience hehas seen such a condition arise in a child eight years of age in whom various short circuits between loops of small intestine had occurred following intestinal obstruction of inflammatory origin. Pellagra when it occurred in endemicform is probably due to lack of vitamin B2 (G), but cases have occurred in which all the manifestations of this disease appeared, with normal dietary, in patients with severe alcoholic gastro-enteritis. Pellagra has been reported in 15 cases of cancer of the stomach, usually associated with pyloric obstruction ; it has also been encountered in cancer of the ileum and even in association with strictures of the rectum. Skin lesions identical with those of pellagra have been reported with diarrhoeal diseases such as ulcerative colitis, dysentery, and various forms of rectal disease, and also in certain diseases of the small intestine and even of the aesophagus. Another effect of deficiency occasioned by gastro-intestinal disease is to be found in peripheral polyneuritis. Chronic alcoholism as a cause of neuritis has been known for upwards of 150 years, but it is only recently that Shattuck has formulated the theory that " alcoholic " neuritis is in reality a deficiency disease similar to the neuritis seen in beri-beri. This opinion is confirmed by the work of Minot, Cobb, and Strauss, who have relieved alcoholic neuritis by the oral and hypodermic administration of vitamin B whilst permitting the administration of alcohol to continue. Polyneuritis has been reported fairly
REFERENCE has been already made in these columnsto a method by which the function of the two lungs may be studied separately. One of the authors of the original paper, Dr. S. Bjorkman, has now produced a small monograph on the subject.2 The procedure is to pass a " double bronchoscope," consisting of two tubes one inside the other. The inner tube communicates with one main bronchus, where an air-tight junction is maintained by the inflation of a rubber armlet, and the outer communicates with the lumen of the trachea (and thus with the other main bronchus), a second rubber armlet being inflated just below the lower end of the larynx so as to prevent air passing in any way except through the bronchoscope. By means of recording spirometers connected with the two tubes, accurate measurements of the functional activity of each lung can be obtained. A certain number of normal people have been examined and supply readings which serve as a background for the results in nearly 60 patients suffering from pulmonary disease. Bjorkman says that, normally, the left lung accounts for 40 to 50 per cent. and the right lung 60 to 50 per cent. of the total ventilation, but this relationship is of course much altered, where there is disease of one lung. What is surprising is to learn that often the alteration from normal as regards the distribution of total oxygen intake and total carbon dioxide output on the two sides is not uniform ; so that while the respiratory quotient for the two lungs together is normal, a different quotient was obtained for each lung separately. The suggestion is made that possibly carbon-dioxide is actively excreted by the mucous membrane of the bronchi and that this process is sometimes impaired by disease. The functional activity of the lungs in different postures has been studied, and also the effects of coughing, confirmation being obtained for the view that sputum from a diseased lung may enter a sound lung during this complicated act. Bjorkman admits that his method is applicable only to a small group of subjects, but his observations provide the clinical physiologist with fresh objectives, A
GALLERY
OF
"TROPICAL DOCTORS"
Dr. Gottlier Olpp, who directs the Institute of Medical Missions at Tiibingen and holds a chair in the University, has brought out a remarkable directorys of doctors, living and dead, whose names are associated with service in the tropics. He has spread his net very wide-to include Hippocrates, Imhotep, and Berkefeld, inventor of the filter-aiid has included some 300 biographies of which only quite a modest proportion, not more than one-third, are of German origin ; and the collection is made more remarkable by the fact that he has collected a gallery of excellent portraits with only a few relatively unimportant omissions. Dr. Olpp went out to China as a medical missionary and began at once to collect material to perpetuate the memory of men for whom he conceived a profound admiration. For 20 years past he has gone on collecting with the help of correspondents in many countries-he acknowledges the help of Nuttall in Cambridge, Andrew Balfour and
frequently in cases of pyloric stenosis secondary to peptic ulcer, and it has also been seen in association with dysentery and ulcerative colitis. In fact a mass Manson-Bahr in London, Stephens in Liverpool-and of evidence accumulates to show that a deficiency experts at their own valuation caused by defects of the alimentary canal may accepting living 1 THE LANCET 1933, i., 481. be responsible for this neurological picture quite Acta Med. Scand., Suppl. LVI., Stockholm, 1934, Pp. 199. Hervorragende Tropenärzte in Wort und Bild. Munich : frequently. Otto Gmelin. 446. 2
3
Verlag der Ärztlichen Rundschau,
1
Jour. Amer. Med. Assoc., 1934, ciii., 1.
R.M.30
Pp.
315
although impeded by their inherent modesty. The be doubled. Although corneal ulcers undoubtedly several biographies are interesting in themselves ; heal more quickly when irradiated there is not they have been put together with skill and there is sufficient evidence that the density of the subconsiderable charm in the author’s extreme simplicity sequent scar is less, nor is there any effect on of style. To the inexpert, approaching the history established nebulae. In tuberculous iritis there is of tropical medicine for the first time, he recommends often a suggestion of improvement, but the dosage the reading of biographies in the following order- needs careful watching. Throughout the monograph viz., Leeuwenhoek, Jenner, Meigen, Pollender, Mr. Law maintains a severely critical attitude towards Griesinger, Bilharz, Obermeier, Koch, Laveran, Baelz, his own results. In using radium and X rays for Pasteur, Metchnikoff, Manson, Ross, Reed, Gorgas, eye diseases the danger of inducing cataract must, Carroll, Ehrlich-a list which does credit as much to he says, always be taken into account. Infra-red his sense of proportion as to his freedom from national rays play no part as a therapeutic agent in diseases Having been a medical missionary of the eye ; they are a source of possible injury to prejudice. himself he has allowed himself to go strong in cornea, lens, and retina--e.g., eclipse blindness. recounting missionary endeavour, and here again the reader will be grateful for his indication of seven THE ENGLISH TONGUE biographies which deserve study. Happily in this THE history of the English language is not a matter case there are some survivors. To the biography for philologists ; all persons with claims to education, there is in many cases a bibliography attached, and in the countries where English is spoken, should have the author takes credit for giving the present address some acquaintance with the origin and development of these who are still alive. The production of the book is as distinguished as its authorship. The paper of their own tongue. In the United States of late this feeling has certainly been active, and a short cover is attractive in design, the typesetting beyond article on the subject in the Medical Record for July 4th and the a model for other index effort. criticism, is worth attention. The writer says that few persons The book is indispensable in any medical library. know the origin of " the King’s English," evidently thinking that fuller appreciation of the lineage of PHOTOTHERAPY OF THE EYE languagewould minimise its frequent abuse. His of the Saxon invasion and the settlements A DEPARTMENT for ultra-violet treatment was pithy of of at different epochs gives reasons parts England established at Moornelds Hospital in 1925, under for the evolution of English to its present gradual Sir Stewart Duke-Elder, who summarise his work in it was not until 1385 standard. to him 1 reports issued in 1926 and 1928. In the book before us that the According of the English-speaking peoples language his successor, Mr. F. W. Law, considers all the cases who had a full course of such treatment, general or stepped out of its dialect petticoats to become an local, in the clinic last year, and some of those treated adult tongue, since when it has taken its place as the in the three years preceding. To help towards most universal means of intercommunication. On cover page of the same issue of the Medical Becord assessing the permanence of results a letter was sent the there is a picture of Dr. Thomas L. Stedman, for out to the patients or their parents as to their present many years the editor of the journal, and this is condition. The effect of general phototherapy must for Stedman is a master of English, as opportune, be read in the light of the fact that the patients as a versatile linguist. well Largely through this fact were attending hospital three times a week for a has he made a reputation as a lexicographer, where long period, and therefore received also other treat- an accurate knowledge alike of the subject in hand ment in an unusually thorough way. This resulted and of languages is essential. in a high standard of cleanliness, for the undressing
sketch
of a child three times a week before a nurse has its educative value on the mother. With these provisos Mr. Law endorses the favourable opinions expressed by other writers of the ultra-violet treatment of blepharitis, phlyctenular disease, and conjunctivitis in children. Most forms of keratitis derive some benefit ; this applies, in Mr. Law’s experience, even to interstitial keratitis. Syphilitic iridocyclitis and tuberculous disease failed to react, and, on the whole, his results do not reach the high level of some other workers. General phototherapy is, in fact, no more than an adjunct in treatment. Local irradiation in its own sphere has more to offer. Mr. Law reports 51 cases, nearly all of them corneal ulcers or different forms of keratitis, treated by focusing the rays exactly on the spot. Although he has himself never seen a cataract remotely connected with ultra-violet therapy, the application calls for continual care. Preferably the pupil should be small, although this is not always feasible. The usual initial dose is one of 2 to 2i minutes, but if the duration of the beam has to be as oblique as 45° the time of exposure may be increased by one-half; if to 60° it may 1 Ultra-violet Therapy in Eye Disease, with a review of other By Frank W. Law, M.A., M.D., B.Chir. Camb., F.R.C.S., Assistant Surgeon, Central London Ophthalmic Hospital ; Pathologist and Curator, and Medical Officer in charge of the physico-therapeutic department, Royal London Ophthalmic Hospital (Moorfields). With foreword by Sir Stewart Duke-Elder, M.D., F.R.C.S. Published for the Middlesex Hospital by John Murray. 1934. Pp. 78. 5s.
forms of Radiant Energy.
EPIDEMIC MYALGIA IN SWEDEN
IN a note presented to the permanent committee of the Office International d’Hygiene publique, Dr. R. Hussoutlines the salient features of the epidemic of myalgia which, in the summer and autumn of 1931, claimed many victims in the southern coastal areas of Sweden and in Denmark.2 Though not a single case was fatal, the manifestations of the disease, when it was of the abdominal type, led occasionally to an exploratory laparotomy which proved nothing but the mistake in making it. There was also a thoracic type with bilateral symptoms referable to the lower chest. The most common complications were orchitis (some 50 cases) and dry pleurisy (about a score). Catarrhal symptoms referable to the respiratory tract were rare. Some cases were characterised by euphoria and flushing of the face. It seems that the epidemic had had its forerunners in 1927, 1929, and 1930. The outbreak of 1931 began in the middle of June in the seaport of Marstrand, at which two Swedish warships were stationed from June 18th to 26th. The sickness-rate on these ships a few days after they had left Marstrand was such that about a third of the crews was involved. Between the ages of 14 and 17 there were 190 persons, 72 of whom fell ill. Between the ages of 20 and 30 there were only 1 Bull. de l’Off. Internat. d’hyg. pub., June, 1934, p. 1083. 2 See THE LANCET, 1933, i., 709.