- Email: [email protected]
DEDUCTIO AD ABSURDUM
603 5 had a normal blood-pressure, whilst in the whole series 8 out of every 10 were enabled to return to
work. Other workers 14 17 18 19 have reported results of the same order ; common to all reports has been relief from incapacitating headaches and giddiness and the disappearance of papillcedema and exudates in at least 80% of patients where these were present before operation. KEITH and his associates reported that in malignant hypertension mortality was maximal in the first two years after operation ; of 146 cases only 1 survived four years. PEET has operated on 112 such cases ; 19 were alive and well at periods varying from five to eleven years later ; and similar HAMMERresults have been obtained elsewhere. found that STRÖM 19 operation slightly improved the
prognosis in non-malignant hypertension, especially in men. From a small series PALMER 20 concluded that operation offered a definite improvement in prognosis for grade 4 hypertensives, and slight improvement for the remainder. A more objective evaluation is obtainable by the electrocardiograph. FILL’EY 21 found that all of 44 hypertensives with left ventricular strain were dead within four years, while PAUL WHITE 22 showed that the chances of this change being reversed were about one in ten. With dorsolumbar sympathectomy, however, improvement is obtained in two-thirds and the electrocardiograms became normal in one-third. The question of which cases may expect benefit is still unanswered. SMiTHWiCK excludes from operation those with congestive cardiac failure, renal impairment, cerebral vascular accidents, and hypertensive encephalopathy, and some with malignant hypertension ; ALLEN and AnsoN 23 agree that congestive heart-failure, angina pectoris,
or severe
-hypertensive
contra-indications. PEET accepts encephalopathy below the patients age of 54 with a blood-pressure conare
tinuously above 170/105 mm. Hg, a well-compensated heart, and normal cerebral function; he holds that any case of malignant hypertension should be operated upon. PALMER thinks operation the only hope in malignant hypertension ; it should be offered, he says, to grade 1 cases where continued observation shows progressive increase in blood-pressure, but he is not convinced that operation is helpful to cases in grades 2 and 3. In this country surgical treatment is generally reserved for seriously ill patients with a history of cerebral vascular upsets, incipient or long-standing cardiac failure, incapacitating headaches and vertigo, malignant hypertension, and, especially, of visual failure from papilloedema and haemorrhages. Doubt has been expressed about the advisability of operation in grades 1 and 2 ; and hypertension without symptoms and found by chance is not regarded as an indication for operation unless observation shows a rising blood-pressure and signs of incipient renal, cardiac,
or cerebral failure. Most American workers, the other hand, prefer to operate in the earlier stages before the rise in blood-pressure becomes
on
17. Smithwick, R. H. Ibid, p. 662. 18. de Takats, G., Graupner, G. W., Fowler, E. F., Jensik, R. J. Arch. Surg. 1946, 53, 111. 19. Hammarström, S. Acta med. scand. 1947, suppl. 192. 20. Palmer, R. S. J. Amer. med. Ass. 1947, 134, 9. 21. Filley, G. F. Bull. Johns Hopk. Hosp. 1946, 74, 261. 22. White, P. D., Smithwick, R. H., Mathews, M. W., Evans, E. Amer. Heart J. 1945, 30, 165. 23. Allen, E. V., Adson, A. V. Ann. intern, Med. 1940, 14, 289.
fixed and complications develop. The eventual place of surgery in the treatment of hypertension will not be defined until the fundamental setiological factors are known. Meanwhile the need is for better knowledge of prognosis in the non-operated cases with moderate hypertension, and of the reasons for the varying results of operation. There is, however, ample evidence that sympathectomy often diminishes peripheral resistance. In some cases of malignant hypertension it gives dramatic results ; in a few cases it provides temporary or even permanent stay in the course of the illness ; while in the majority it offers relief from symptoms. ’
.
Annotations DEDUCTIO AD ABSURDUM Wmcx university had the privilege of educating Sherlock HolmesQ Or rather providing the medium in which his peculiar talents developed, for a while, according’ to their own laws of growth ?f Opinion at the Royal Society of Medicine was divided, on April 7, when the section of history met to discuss the relationship of Conan Doyle and Dr. Joseph Bell to the most remarkable of detectives. Mr. S. C. Roberts, the guest of the section, demolished Miss Dorothy Sayers’s published view that Holmes was a ’
Cambridge man—indeed,
an
undergraduate
at
Sidney
Sussex, whose name appears on the college lists of the time. It is clear, he said, that Holmes knew nothing of Cambridge. He even referred, on one occasion, to late train leaving London at 11.15-which, as Mr. Roberts pointed out, would be quite useless to any Cambridge man. Moreover, Holmes talked of " running down " to Cambridge, and once made use of the Trinity drag-hounds, animals whose very existence is questionable. The mere fact that he was bitten in the leg by an undergraduate’s bull terrier while on the way to chapel (the incident on which Miss Sayers founds her case) is not conclusive. True undergraduates are not allowed to keep dogs in college, which suggests that Holmes was living out at the time : and true the firstyear man at Cambridge lives out while the Oxford freshman lives in ; but may he not, Mr. Roberts suggests, have been an Oxford man who stepped across the road to buy some shag on his way to chapel ? As for the Mr. Holmes whose name appears on the list of Sussex, he became a canon of Wells Cathedral, and the author of a work entitled The Parish and Manor of
a
Sidney
Wookey. Mr. Zachary Cope, in a digression on Dr. Watson (whose life has been so brilliantly written by Mr. Roberts), pointed out that Watson was not really so dumbas he is obliged to appear beside Holmes. His qualification (which Holmes on one occasion disparaged) was no less than the M.D. Lond. ; and if he knew nothing, as Holmes scornfully reminded him, of the black formosa corruption," what did the distinguished gathering now met to "
discuss him know of that rare disease ?if Dr. Douglas Guthrie in a scholarly review of the lives of Dr. Joseph Bell and his forbears made it clear that it was only in his remarkable ability for deduction that this great teacher resembled Holmes. Such phrases as " You see, you do not observe " may well have originated with Bell ; but the untidiness, the violin, the cocaine, the indoor revolver practice, and the malodorous chemical experiments were foreign to him. They might be taken as evidence (though Dr. Guthrie did not say so) of the separate existence of the great detective. On the question of how Holmes learnt the characteristics on which he based his deductions, Dr. Trevor Howell suggested that he must at one time
604 have had the run of an outpatient department, where he could examine the patients’ cards. Since we know that for a while he was making chemical studies at Barts, it is likely that he was on terms with the casualty
tofficer. Sir
Arthur
who took the chair, gave
an
able account of Conan Doyle’s adventurous life :
it
he
MacNalty,
responsible, among other remarkable things, for introducing ski-ing into Switzerland. seems
was
PENICILLIN AND SYPHILIS
superlatively chronic
IN a the assessment of
disease such as syphilis is difficult. Since some early cases recover after what is known to be inadequate treatment, or sometimes after none at all, very large numbers of cases must be followed before any useful conclusions can be reached. Such a systematic study was begun in the United States by the National Research Council in 1944, and at the beginning of 1946 was taken over by the United States Public Health Service. The research is nation-wide and includes not only cases treated in naval, military, and public-health clinics, but also those from the best-known general hospitals in the country. In a recent monograph,l Dr. Earle Moore presents a critical balance-sheet of the position as he saw it at the end of 1946. He is fully alive to the fluid nature of the situation and he urges the physician who uses the book as a guide to keep a weather eye cocked on published work for more up-to-date information. Meanwhile it appears that, contrary to expectation, relapse-rates in early syphilis treated with penicillin are not worsening with the lapse of time, which suggests that a majority of such infections, whether acquired or congenital, can be cured by a short course of penicillin alone. On the other hand, the minority remains large, for Dr. Moore2 himself pointed out at the Royal Society of Medicine last July that the failure-rate of penicillin treatment of early syphilis was 25-30% after 18-24 months’ observation. The progress of syphilitic disease of the nervous system can often be arrested by penicillin, and this remedy is nearly 100% effective in the prevention and cure of prenatal syphilis. From the public-health angle, it is important that most early syphilitics can be made non-infectious before the patient defaults. This promises a rapid fall in the incidence of fresh infections, particularly if the present policy of contact-tracing is maintained and intensified. But the efficacy of penicillin in late and latent syphilis calls for prolonged investigation. What matters, as Dr. Moore points out, is what happens to the patient, not what happens to his blood test ; so he must be followed up for a literal lifetime. Cardiovascular syphilitics are notoriously bad lives, and it should therefore be possible to assess the value of treatment quickly in such cases. It is noteworthy that Herxheimer reactions in cardiovascular disease need not be greatly feared. At the Johns Hopkins Hospital, 50 patients with saccular aneurysms or aortic incompetence had been treated with penicillin by the end of 1946-half of them with the small initial dose of 1000 units gradually increased to an average therapeutic dose, and the remainder with doses of 50,000 or 100,000 units from the start. In neither group was there an exacerbation of symptoms, nor was there any change in sedimentation-rates, temperature, leucocyte-counts, or electrocardiographic readings. It thus seems possible that the menace of cardiac shock after strenuous initial treatment may turn out to be fanciful. Probably, however, though treatment may be able to arrest the infective process in cardiovascular syphilis, the ultimate 1. Penicillin in
a
therapeutic agent
By JOSEPH EARLE MOORE, Oxford : Blackwell. 1947. Pp. 319. 2. Proc. R. Soc. Med. 1947, 40, 813. Hopkins).
Syphilis.
M.D.
(Johns
27s. 6d.
can never be good once the damage has . clinical and radiological signs. Penicillin treatment of gonorrhoea is now almost universal, and Dr. Moore is fully alive to the danger of a concurrent syphilitic infection being masked or modiaed by what must be in most cases subminimal treatment for syphilis. He quotes the opinion of Leifer and Martin that " clinical and serologic observation for ninety days from the date of treatment would suffice to detect all but the most exceptional cases of syphilis," but in a footnote he advances this period to at least 4 months. Though in this country blood tests are advised 3 and 6 months after treatment, the early default-rate, particularly among men, is high, and some of these defaulters are no doubt doubly infected. The number, however, must be small, and with a diminishing incidence of syphilis would become smaller still. It is significant that in the United States, where syphilis is far commoner than it is here, it has been decided not to withhold penicillin in gonococcal infections.
prognosis produced
’
A UNIT OF RHEUMATOLOGY
RESEARCH on rheumatism in special wards, which we discussed on March 27, is illustrated by the work of the Royal Free Hospital Unit of Rheumatology. Formerly the British Legion Unit of Rheumatology, it was started through the energy of Dr. C. B. Heald ; last June it was moved from the country to the Lawn Road (L.C.C.) Hospital at Hampstead, and became a unit of the Royal Free under Dr. Ernest Fletcher. Between June and November it carried 50 beds, but on Dec. 1 the number was reduced to 40, half for men, half for women. During the first seven months, 175 patients were admitted and 132 discharged ; and of these dis.charged patients no less than 60 (45%) returned to their ordinary work, while 14 (11%) who were bedridden on admission walked out and 2 of them returned to work. Of the remainder, 37 (28%) were improved, and only 18 (14%) were not. Naturally these figures must be corrected in terms of the relapse-rate, but they show how often chronic locomotor disorders respond to treatment in favourable surroundings. The factors which make these surroundings favourable are easily analysed. First, patients get expert treatment over a long period : and they get it in a pleasant atmosphere of personal rivalry and competition which is a mainspring of recovery. Then the nursing staff are of the highest possible quality, combining special technical skill with devotion to the sick. The physiotherapists are equally keen and competent, and the doctors are encouraged to maintain their interest in general medicine lest they should become overspecialised. Finally, the unit is engaged in active research, though here it has been hampered to some extent by lack of tools. The physiotherapy department was not fully organised until September, and it has still not been possible to instal X-ray apparatus, which means that patients have to go to Gray’s Inn Road for radiography, at the cost of time and energy. The research programme ’has included sacro-iliac biopsies to determine the pathology of the " sacro-iliitis " which precedes ankylosing spondylitis, and a pilot experiment to determine the value of transfusion of pregnant women’s blood in the treatment of rheumatoid arthritis ; studies are also being made of the cerebrospinal fluid in this disease. The nature and extent of the vascular component is being examined in cases of brachial neuralgia, and special attention is being given to the costoclavicular
syndrome. Fletcher notes in his report that since only patients of the 14 who were bedridden on admission returned to work, the likelihood of full recoverv once the patient has taken to his bed is not great. But 34 out of Dr.
2
work. Other workers 14 17 18 19 have reported results of the same order ; common to all reports has been relief from incapacitating headaches and giddiness and the disappearance of papillcedema and exudates in at least 80% of patients where these were present before operation. KEITH and his associates reported that in malignant hypertension mortality was maximal in the first two years after operation ; of 146 cases only 1 survived four years. PEET has operated on 112 such cases ; 19 were alive and well at periods varying from five to eleven years later ; and similar HAMMERresults have been obtained elsewhere. found that STRÖM 19 operation slightly improved the
prognosis in non-malignant hypertension, especially in men. From a small series PALMER 20 concluded that operation offered a definite improvement in prognosis for grade 4 hypertensives, and slight improvement for the remainder. A more objective evaluation is obtainable by the electrocardiograph. FILL’EY 21 found that all of 44 hypertensives with left ventricular strain were dead within four years, while PAUL WHITE 22 showed that the chances of this change being reversed were about one in ten. With dorsolumbar sympathectomy, however, improvement is obtained in two-thirds and the electrocardiograms became normal in one-third. The question of which cases may expect benefit is still unanswered. SMiTHWiCK excludes from operation those with congestive cardiac failure, renal impairment, cerebral vascular accidents, and hypertensive encephalopathy, and some with malignant hypertension ; ALLEN and AnsoN 23 agree that congestive heart-failure, angina pectoris,
or severe
-hypertensive
contra-indications. PEET accepts encephalopathy below the patients age of 54 with a blood-pressure conare
tinuously above 170/105 mm. Hg, a well-compensated heart, and normal cerebral function; he holds that any case of malignant hypertension should be operated upon. PALMER thinks operation the only hope in malignant hypertension ; it should be offered, he says, to grade 1 cases where continued observation shows progressive increase in blood-pressure, but he is not convinced that operation is helpful to cases in grades 2 and 3. In this country surgical treatment is generally reserved for seriously ill patients with a history of cerebral vascular upsets, incipient or long-standing cardiac failure, incapacitating headaches and vertigo, malignant hypertension, and, especially, of visual failure from papilloedema and haemorrhages. Doubt has been expressed about the advisability of operation in grades 1 and 2 ; and hypertension without symptoms and found by chance is not regarded as an indication for operation unless observation shows a rising blood-pressure and signs of incipient renal, cardiac,
or cerebral failure. Most American workers, the other hand, prefer to operate in the earlier stages before the rise in blood-pressure becomes
on
17. Smithwick, R. H. Ibid, p. 662. 18. de Takats, G., Graupner, G. W., Fowler, E. F., Jensik, R. J. Arch. Surg. 1946, 53, 111. 19. Hammarström, S. Acta med. scand. 1947, suppl. 192. 20. Palmer, R. S. J. Amer. med. Ass. 1947, 134, 9. 21. Filley, G. F. Bull. Johns Hopk. Hosp. 1946, 74, 261. 22. White, P. D., Smithwick, R. H., Mathews, M. W., Evans, E. Amer. Heart J. 1945, 30, 165. 23. Allen, E. V., Adson, A. V. Ann. intern, Med. 1940, 14, 289.
fixed and complications develop. The eventual place of surgery in the treatment of hypertension will not be defined until the fundamental setiological factors are known. Meanwhile the need is for better knowledge of prognosis in the non-operated cases with moderate hypertension, and of the reasons for the varying results of operation. There is, however, ample evidence that sympathectomy often diminishes peripheral resistance. In some cases of malignant hypertension it gives dramatic results ; in a few cases it provides temporary or even permanent stay in the course of the illness ; while in the majority it offers relief from symptoms. ’
.
Annotations DEDUCTIO AD ABSURDUM Wmcx university had the privilege of educating Sherlock HolmesQ Or rather providing the medium in which his peculiar talents developed, for a while, according’ to their own laws of growth ?f Opinion at the Royal Society of Medicine was divided, on April 7, when the section of history met to discuss the relationship of Conan Doyle and Dr. Joseph Bell to the most remarkable of detectives. Mr. S. C. Roberts, the guest of the section, demolished Miss Dorothy Sayers’s published view that Holmes was a ’
Cambridge man—indeed,
an
undergraduate
at
Sidney
Sussex, whose name appears on the college lists of the time. It is clear, he said, that Holmes knew nothing of Cambridge. He even referred, on one occasion, to late train leaving London at 11.15-which, as Mr. Roberts pointed out, would be quite useless to any Cambridge man. Moreover, Holmes talked of " running down " to Cambridge, and once made use of the Trinity drag-hounds, animals whose very existence is questionable. The mere fact that he was bitten in the leg by an undergraduate’s bull terrier while on the way to chapel (the incident on which Miss Sayers founds her case) is not conclusive. True undergraduates are not allowed to keep dogs in college, which suggests that Holmes was living out at the time : and true the firstyear man at Cambridge lives out while the Oxford freshman lives in ; but may he not, Mr. Roberts suggests, have been an Oxford man who stepped across the road to buy some shag on his way to chapel ? As for the Mr. Holmes whose name appears on the list of Sussex, he became a canon of Wells Cathedral, and the author of a work entitled The Parish and Manor of
a
Sidney
Wookey. Mr. Zachary Cope, in a digression on Dr. Watson (whose life has been so brilliantly written by Mr. Roberts), pointed out that Watson was not really so dumbas he is obliged to appear beside Holmes. His qualification (which Holmes on one occasion disparaged) was no less than the M.D. Lond. ; and if he knew nothing, as Holmes scornfully reminded him, of the black formosa corruption," what did the distinguished gathering now met to "
discuss him know of that rare disease ?if Dr. Douglas Guthrie in a scholarly review of the lives of Dr. Joseph Bell and his forbears made it clear that it was only in his remarkable ability for deduction that this great teacher resembled Holmes. Such phrases as " You see, you do not observe " may well have originated with Bell ; but the untidiness, the violin, the cocaine, the indoor revolver practice, and the malodorous chemical experiments were foreign to him. They might be taken as evidence (though Dr. Guthrie did not say so) of the separate existence of the great detective. On the question of how Holmes learnt the characteristics on which he based his deductions, Dr. Trevor Howell suggested that he must at one time
604 have had the run of an outpatient department, where he could examine the patients’ cards. Since we know that for a while he was making chemical studies at Barts, it is likely that he was on terms with the casualty
tofficer. Sir
Arthur
who took the chair, gave
an
able account of Conan Doyle’s adventurous life :
it
he
MacNalty,
responsible, among other remarkable things, for introducing ski-ing into Switzerland. seems
was
PENICILLIN AND SYPHILIS
superlatively chronic
IN a the assessment of
disease such as syphilis is difficult. Since some early cases recover after what is known to be inadequate treatment, or sometimes after none at all, very large numbers of cases must be followed before any useful conclusions can be reached. Such a systematic study was begun in the United States by the National Research Council in 1944, and at the beginning of 1946 was taken over by the United States Public Health Service. The research is nation-wide and includes not only cases treated in naval, military, and public-health clinics, but also those from the best-known general hospitals in the country. In a recent monograph,l Dr. Earle Moore presents a critical balance-sheet of the position as he saw it at the end of 1946. He is fully alive to the fluid nature of the situation and he urges the physician who uses the book as a guide to keep a weather eye cocked on published work for more up-to-date information. Meanwhile it appears that, contrary to expectation, relapse-rates in early syphilis treated with penicillin are not worsening with the lapse of time, which suggests that a majority of such infections, whether acquired or congenital, can be cured by a short course of penicillin alone. On the other hand, the minority remains large, for Dr. Moore2 himself pointed out at the Royal Society of Medicine last July that the failure-rate of penicillin treatment of early syphilis was 25-30% after 18-24 months’ observation. The progress of syphilitic disease of the nervous system can often be arrested by penicillin, and this remedy is nearly 100% effective in the prevention and cure of prenatal syphilis. From the public-health angle, it is important that most early syphilitics can be made non-infectious before the patient defaults. This promises a rapid fall in the incidence of fresh infections, particularly if the present policy of contact-tracing is maintained and intensified. But the efficacy of penicillin in late and latent syphilis calls for prolonged investigation. What matters, as Dr. Moore points out, is what happens to the patient, not what happens to his blood test ; so he must be followed up for a literal lifetime. Cardiovascular syphilitics are notoriously bad lives, and it should therefore be possible to assess the value of treatment quickly in such cases. It is noteworthy that Herxheimer reactions in cardiovascular disease need not be greatly feared. At the Johns Hopkins Hospital, 50 patients with saccular aneurysms or aortic incompetence had been treated with penicillin by the end of 1946-half of them with the small initial dose of 1000 units gradually increased to an average therapeutic dose, and the remainder with doses of 50,000 or 100,000 units from the start. In neither group was there an exacerbation of symptoms, nor was there any change in sedimentation-rates, temperature, leucocyte-counts, or electrocardiographic readings. It thus seems possible that the menace of cardiac shock after strenuous initial treatment may turn out to be fanciful. Probably, however, though treatment may be able to arrest the infective process in cardiovascular syphilis, the ultimate 1. Penicillin in
a
therapeutic agent
By JOSEPH EARLE MOORE, Oxford : Blackwell. 1947. Pp. 319. 2. Proc. R. Soc. Med. 1947, 40, 813. Hopkins).
Syphilis.
M.D.
(Johns
27s. 6d.
can never be good once the damage has . clinical and radiological signs. Penicillin treatment of gonorrhoea is now almost universal, and Dr. Moore is fully alive to the danger of a concurrent syphilitic infection being masked or modiaed by what must be in most cases subminimal treatment for syphilis. He quotes the opinion of Leifer and Martin that " clinical and serologic observation for ninety days from the date of treatment would suffice to detect all but the most exceptional cases of syphilis," but in a footnote he advances this period to at least 4 months. Though in this country blood tests are advised 3 and 6 months after treatment, the early default-rate, particularly among men, is high, and some of these defaulters are no doubt doubly infected. The number, however, must be small, and with a diminishing incidence of syphilis would become smaller still. It is significant that in the United States, where syphilis is far commoner than it is here, it has been decided not to withhold penicillin in gonococcal infections.
prognosis produced
’
A UNIT OF RHEUMATOLOGY
RESEARCH on rheumatism in special wards, which we discussed on March 27, is illustrated by the work of the Royal Free Hospital Unit of Rheumatology. Formerly the British Legion Unit of Rheumatology, it was started through the energy of Dr. C. B. Heald ; last June it was moved from the country to the Lawn Road (L.C.C.) Hospital at Hampstead, and became a unit of the Royal Free under Dr. Ernest Fletcher. Between June and November it carried 50 beds, but on Dec. 1 the number was reduced to 40, half for men, half for women. During the first seven months, 175 patients were admitted and 132 discharged ; and of these dis.charged patients no less than 60 (45%) returned to their ordinary work, while 14 (11%) who were bedridden on admission walked out and 2 of them returned to work. Of the remainder, 37 (28%) were improved, and only 18 (14%) were not. Naturally these figures must be corrected in terms of the relapse-rate, but they show how often chronic locomotor disorders respond to treatment in favourable surroundings. The factors which make these surroundings favourable are easily analysed. First, patients get expert treatment over a long period : and they get it in a pleasant atmosphere of personal rivalry and competition which is a mainspring of recovery. Then the nursing staff are of the highest possible quality, combining special technical skill with devotion to the sick. The physiotherapists are equally keen and competent, and the doctors are encouraged to maintain their interest in general medicine lest they should become overspecialised. Finally, the unit is engaged in active research, though here it has been hampered to some extent by lack of tools. The physiotherapy department was not fully organised until September, and it has still not been possible to instal X-ray apparatus, which means that patients have to go to Gray’s Inn Road for radiography, at the cost of time and energy. The research programme ’has included sacro-iliac biopsies to determine the pathology of the " sacro-iliitis " which precedes ankylosing spondylitis, and a pilot experiment to determine the value of transfusion of pregnant women’s blood in the treatment of rheumatoid arthritis ; studies are also being made of the cerebrospinal fluid in this disease. The nature and extent of the vascular component is being examined in cases of brachial neuralgia, and special attention is being given to the costoclavicular
syndrome. Fletcher notes in his report that since only patients of the 14 who were bedridden on admission returned to work, the likelihood of full recoverv once the patient has taken to his bed is not great. But 34 out of Dr.
2