DOUBTS ABOUT DRUGS

THE SI7.E AND SHAPE OF THE HEART

band of skilled orthopaedic experts who have made

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famous their centres in Boston, New York, Baltimore, to mention only a few. There is a brief reference to his helpful colleague Albee, and a note that an invitation to the New York Ruptured and Crippled Hospital, given by a physician, was afterwards withdrawn on the representations of other colleagues. It is clear from the author’s account of his professional activities that in addition to his technical skill and original ideas it was his personality as a whole which made him so acceptable alike to the poorest parents of cripples and to business magnates in U.S.A., as well as to crowned heads in Europe and to presidents of the United States.

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THE SIZE AND SHAPE OF THE HEART

IN his Lumleian lectures, published in the last two issues of THE LANCET, Dr. John Parkinson gave a masterly account of the variations in shape and size of the heart as revealed by radiography. He described the different forms of silhouette of the normal heart associated with different types of body-build, the abnormal appearances produced by such common deformities as scoliosis, and the deviations from the normal attributable to pathological enlargement of the different chambers of the heart. Incidentally he made it abundantly clear that the information given by the senses of touch and hearing, skilfully combined, on which our fathers in medicine chiefly relied, had been proved to be depressingly unreliable. Seeing is believing, and while the exact significance of shadows thrown by gastric ulcers or duodenal deformity may still be in doubt, the cardiac silhouettes visible under the X rays carry conviction interpreted by the experienced cardiologist with a comparatively small margin of error. Not that radiology can tell the whole truth. A radiogram with the patient facing the screen gives us a nearly perfect picture of what we used to try to map out roughly by percussion. But it is still only a diagram in two dimensions; further information can be obtained by rotating the patient, but even so there is no reliable formula for calculating heart volume, -and what we would really like to know is the threedimensional volume of the heart. As Dr. Parkinson has shown, the greatest contribution which radiology has made to our knowledge of the pathological anatomy of the heart is that the shape of the cardiac silhouette in the different positions enables us to say which chambers of the heart are enlarged. The more conservative members of the profession may be disturbed by Dr. Parkinson’s wholesale condemnation of percussion as a means of estimating the size or shape of the heart, and there is something to be said from this point of view. Admitting that the doctor’s coarse thumb and finger often fail to plumb the exact depth and width of the heart, and that radiology can tell us everything which we can learn from percussion with a much greater degree of accuracy, they will contend that it is not, and in the immediate future is not likely to be, available as a routine method for use by the general practitioner. It is certainly incumbent on the clinical teacher to show his students not merely what can be achieved under ideal conditions, but also what they themselves may hope to achieve under the limitations imposed by family practice, where they still have to rely chiefly on their unaided senses. Can we afford entirely to dispense with palpation and percussion ?’? If not we can at least, and this is common ground, teach students the limitations of these methods, and show them, as Dr. Parkinson has done, that the

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they are capable of giving is only a very approximation to the truth. There is another anomaly that has yet to be completely resolved-the fact that both in health and in disease the anatomy of the living heart as revealed by radiography differs considerably from that seen in the post-mortem room. One reason for these differences may well be that the heart of the cadaver is not generally examined in situ. In this respect the investigations of Dr. T. Skene Keith reported on p. 1466 of this issue provide an important connecting link between the clinical and post-mortem findings. Dr. Keith is concerned here chiefly with the four normal types of heart silhouette he has been able to make out from a study of some 50 cases. It is rather disappointing that he makes no reference to any cardiac radiograms that may have been taken during the life of this group of cadavers, but he states that in’a subsequent paper on the diseased heart it will appear that there is a fair degree of agreement between the outline of the heart as seen at autopsy and that obtained in orthodiagrams or teleradiograms. This is likely to be a study valuable to cardiologists, who will join Dr. Keith in gratitude to Dr. Parkinson who put the idea of this investigation into his head and by encouragement kept it there. DOUBTS ABOUT DRUGS ALL plants which have been cultivated by man have been profoundly modified from their wild condition. Of late years this has been carried out deliberately and the difference between a Cox’s orange pippin and the crab apple or between an exhibition rose and a dog rose of the hedgerows would fill us with astonishment if we were not accustomed to it. These thoughts prompted Mr. Harold Deane’s address last Monday afternoon at Bournemouth as chairman of the British Pharmaceutical Conference. Mr. Deane has drugs in his blood, if one may put it that way ; his grandfather was the first president of the conference 70 years ago and practised his calling in those ruder ages when the legislature had not as yet been persuaded that the sale of poisons should be allowed only by those who could read and write. In the case of the apple, as in that of the rose, there are easily applied tests of quality ; thus the orange pippin tastes better than the crab, and the standard rose is more beautiful to look at, more pleasing to the nose, and more enduring than the dog rose. There are no such simple tests for the properties of cultivated drugs ; their medicinal value cannot be judged by their flavour, their appearance, or their colour. Mr. Deane took as an example the cultivated English henbane : " It has," he said, " an altogether different appearance from, and a stronger aroma than, the imported herb. The ordinary pharmaceutist will say it is a much superior drug, and a tincture made direct from the English drug hardly seems the same preparation as the one made by diluting a liquid extract of the foreign drug. Is there any difference in the medicinal activity’? No one really knows." Coming from an eminent pharmacist these observations are a little disquieting. The compilers of the British Pharmacopoeia have assumed that the alkaloids are the only thing that matter and have also assumed that these alkaloids are the same after an extract has been evaporated down as they were before ; while admitting that these assumptions are " quite likely true," the chairman of the conference says " there is no proof of them." Here, it will be seen, is a twofold doubt : are the medicinal virtues of plants due solely to the

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ADJUSTING THE CHILD TO HIS ENVIRONMENT

But even then the pool would become a rich medium for the growth of weeds which, barring the right kind of fauna to keep them within bounds, must impede drug ? It is a curious fact that the earliest list of drugs navigation and themselves become an offence when in existence, the Ebers Papyrus made in Egypt they rot. Colonel Butler remarks that the rise and 4000 years ago, contained a larger number of drugs fall of the tide displaces the purer air of the river than does the latest British Pharmacopoeia. The over its banks and conversely draws the stagnating total number of drugs known to mankind must run air of the streets into the channel. The volume of into tens of thousands, yet there are only 63 in the air so moved is large-about 50 million cubic yards British Pharmacopoeia. It has been inferred from between London Bridge and Albert Dock. But the this that the vegetable drugs of value are strictly movement is spread over some six hours and the limited in number ; it may perhaps be inferred with atmospheric exchange may be insignificant compared more justice that there is much research work with that due to a breeze or to convection from warm to surfaces. be done like the British PharmaThe idea of a Thames barrage is not new, bodies waiting by ceutical Conference. Mr. Deane’s own view is that although earlier schemes were intended to improve there will be a still greater falling on in the use of the seaport rather than to provide an airport, and vegetable drugs and that only such plants as the the tidal flow has had earlier apologists. In his opium poppy, digitalis, and belladonna, which have presidental address to the civil engineers five years active principles with readily determined properties, ago Sir Cyril Kirkpatrick said : " The supremacy of are likely to remain of importance. He admits, London as a port with its approaches from the sea is however, that " there are drugs which have properties due to the tidal scour, which should not be impeded." at present unknown or unproved that may be valuable and research might find them out." Con- ADJUSTING THE CHILD TO HIS ENVIRONMENT tinental opinion favours the view that the day of CHILD guidance clinics usually aim at helping vegetable materia medica has not passed. In many difficult children in two ways : by altering the environcountries vegetable drugs are used more extensively ment to suit the child’s needs, and by direct approach than they are here and several Central European the child to himself. At the Institute of Child Governments are assisting agriculturists to cultivate little attention is paid to the former of Psychology In Soviet Russia elaborate have been them. plans these two methods. The directors, Dr. Margaret made for the cultivation of vegetable drugs, and and Dr. Ethel Lowenfeld Dukes, hold the view that laboratory work is to be encouraged with the object none of us can to have his environment cut expect of sifting the wheat from the chaff in a field which to own measure throughout life, and that the his is rank with tares. It is said that man acquired his first knowledge of the value of medicinal plants by child’s business, therefore, is to learn to fit into his environment. Anvone who has to do with children observing the ways of animals, and after all these will the difficulty of their task. The to the we still be in doubt whether years appear dog child’sappreciate mind is not easily accessible to the Olympians. when he eats the whole herb is not getting the best the Institute the At child is both approached and medicine. treated through the medium of play therapy, and a THE POOL OF LONDON detailed report is written by the worker attending the child on each visit to the clinic. A mass of Sir Cecil Levita’s suggestion in the Times to form information has been collected in this way, for treatan airport for London by damming the Thames at ment extend over years, so that every child’s Woolwich has drawn from Colonel W. Butler a may becomes in time a formidable document. The dossier on certain issues of health. Colonel public rejoinder annual report for 1935 announces that a method of Butler points out that were the river dammed below London it would, during dry summers when the analysing and indexing this valuable psychological material has now been devised, and a system of flow over Teddington Weir is small, become virtually a stagnant pool, its self-purifying powers would thus filing statistical records is already in use. The play be reduced, while the adventitious pollution would therapy rooms are in a sense the most important continue. This is a strong point, although its strength part of the Institute. Plenty of material is available might be obscured for a time by the effect of sedi- to occupy hands, wits, and attention. The enuretie mentation, whereby the mud banks would be boy can, if he will, build a world, and then, Zeus-like, concealed and the supernatant water become clear drown it beneath floods from a watering can. The and (possibly) well oxygenated. But sooner or later aggressive child can dramatise battle, murder, and sudden death with a patient and consenting adult to the mud at the bottom would ferment and the abet him. The aim is not only to obtain the dismasses foul would of mud, resulting gas, buoying up render the Thames as offensive as was the Lee a appearance of those symptoms for which the child was referred, but to eradicate the emotional disfew years ago below Tottenham lock. Possibly the turbance which lies beneath them. Each child is deteriorate from the of the water might beginning examined of tidal motion. There is no doubt that physically at the first visit, and any suppression Good the stirring up of the water of those tidal rivers which necessary medical treatment is arranged. from their geographical position must be muddy, by results are being achieved more easily and quickly as dispersing the lighter (and putrescible) matters of knowledge is gained and mistakes are avoided. All mudbanks, does lead to oxidation of the mud cases discharged are systematically followed up. (although it may thereby reduce the dissolved oxygen A three years’ training course is open to physicians and pyschologists, and a shorter course, of one year, content of the water) besides accelerating the rate of absorption of oxygen by rapid renewal of the air- is available for teachers and social science workers. Parents are interviewed on the occasion of their first On the other hand the sewage water interface. the into Thames above the barrage may visit, and a well-placed hint is often of value in discharged be so successfully purified (as is indeed likely so far changing the parental attitude to the child’s peccadilloes. As the report says : as West Middlesex is concerned) that the oxidation of accumulated as well as of continuing pollution " Though the first aim of treatment is to enable the 1 to cope even with a difficult environment and may go on inoffensively after a time, if not at first. child

alkaloids and does the extract of a plant evaporated by heat possess all the virtues of the original

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