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EPIDEMIC JAUNDICE.
1197
EPtDE’.NTIC! JAUNDICE.
difficult to agree, for some or all of these symptoms may be encountered in cases of epidemic catarrhal -
jaundice. Epidemic non-leptospiral jaundice
THE LANCET. LONDON: SATURDAY, MAY 30, 1931.
EPIDEMIC JAUNDICE. DURING the past few months fresh facts have been added to our knowledge of epidemic jaundice. It is evident that there are at least two epidemic diseases characterised by jaundice and by a number of other clinical symptoms in common. These two diseases are leptospiral jaundice and epidemic catarrhal jaundice, or, as Rolleston and McNee prefer to call it, common infective hepatic jaundice. Both diseases appear to be world-wide in their distribution and by clinical means alone their differentiation is by no means easy. It is therefore important that every epidemic should be both clinically and bacteriologically. exhaustive investigation has recently been carried out by J. Taylor and A. N. Goyle1 on the causation and epidemiology of the jaundice that occurs in the Andamans. Jaundice has been rife in these islands for a very considerable time, and during the last 40 years has been studied by numerous workers. F. A. Barker, in 1926, was the first to demonstrate the presence of leptospira, while two years later, in our own columns, H. C. Brown showed that antibodies to leptospira were present in the blood-serum of jaundiced patients, bringing forward evidence that in the sera examined there were antibodies which, while quite distinct from those produced by the London human and rat strains, were allied to certain strains of leptospira from Sumatra. As a method of diagnosis, Taylor and Goyle find that blood culture is of great value provided it is carried out between the third and sixth day of illness. The serological relationships of the 28 strains of leptospira isolated were also investigated with the result that there appear to be two distinct serological groups. In studying the relationship of L. icterohœmorrhagiœ to the Akiyami A strain, K. Yang and M. Theiler2 have lately raised the question whether it is legitimate to recognise a new strain simply because there is a demonstrable quantitative difference in the potency of the immune serum as manifested for example by the agglutination test. The findings of Taylor and Goyle are, however, so definite that they appear to warrant the serological grouping of the Andaman strains. In discussing the differential diagnosis of leptospiral jaundice, Taylor and Goyle say that in catarrhal jaundice the general pains, albuminuria, conjunctival congestion, and tendency to haemorrhage are absent. To this it is
investigated Such
an
1 2
Ind. Med. Res. Memoirs, 1931, No. 20. Amer. Jour. Trop. Med., 1930, x., 407.
also recently received considerable attention both in this country and abroad. One such outbreak, involving the pupils of three schools, was recorded in our issue of March 28th by J. A. Glover and Joyce Wilson, while another has recently been investigated in Surrey by G. M. Findlay, J. L. Dunlop, and H. C. Brown.3 In its epidemiological and clinical features this Surrey outbreak was very similar to those recorded W. G. Booth and C. C. Okell4 in 1928 from Surrey, by M. T. Morgan and Brown5 in the same year from Northamptonshire, and by W. N. Pickles in 1930 from Yorkshire. The incubation period was found to be a long one and varied from three to five weeks. In leptospiral jaundice, on the other hand, according to Taylor and Goyle, and others, the incubation period is from six to eight days, while V. de Lavergne and Robert-Lévy7 record an incubation period of about five days when the leptospira gain entrance by the mouth and 15 days when they pass through an injured skin surface. An examination of the differential leucocyte count may also be of service in distinguishing leptospiral and epidemic catarrhal jaundice. Taylor and Goyle, as the result of a very large series of blood examinations, come to the conclusion that the most striking feature of the differential count is the relative increase in the number of polymorphonuclear leucocytes. In epidemic catarrhal jaundice, on the other hand, according to Findlay, Dunlop, and Brown, an increase in the polymorphonuclear leucocytes is present, if at all, only during the first few days of the disease. Instead there is a decrease in the number of has
by
polymorphonuclear leucocytes with a corresponding increase in the number of lymphocytes, large mononuclears, and transitional cells. In America, C. M. Jones and G. R. Minot (1923) and E. Thewlis and W. S. Middleton (1925) have recorded similar blood In the
changes course
in epidemic catarrhal jaundice. of the investigation of the Surrey
unsuccessful attempts were made to transmit the disease to guinea-pigs, and to determine the presence of immune bodies to leptospira in the serum. Efforts to infect monkeys (Macacus rhesus) either by the inoculation of blood or by spraying with washings from the nasopharynx of patients in the pre-icteric stage of catarrhal jaundice were also unsuccessful, as were attempts to transmit the disease to rabbits, rats, and mice. The failure to infect Indian monkeys with epidemic catarrhal jaundice occurring in this country is in agreement with the findings of Beeuwkes, Walcott, and Kumm,8 who were also unable to infect monkeys with the form of jaundice
epidemic
numerous
xxv., 1.
3 Trans. Roy. Soc. Trop. Med. and Hyg., 1931, 4 Public Health, 1928, xli., 237. 5 Min. of Health Rep. on Pub. Health and Med. Subjects, No. 42, London, 1928. 6 Brit. Med. Jour., 1930, i., 944. 7 Presse Méd., 1931, 651. 8 Trans. Roy. Soc. Trop. Med. and Hyg., 1931, xxiv., 429.
1198
which has
CANCER AND RACE.
form in considerable difficulties had to be overcome in order to exclude statistical fallacies which have also discuss the been clearly recognised by the author. As a and Brown Findlay, Dunlop, the conclusion is to catarrhal result of of these jaundice relationship epidemic acute yellow atrophy of the liver, or, as it is prefer- reached that the total recorded mortality from ably called, acute necrosis of the liver. In this cancer varies in different Jewish communities country there has been but one recorded fatal case tending to approach that of the non-Jews of each of epidemic catarrhal jaundice-that reported particular city, so that there is no evidence of a by Morgan and Brown. Abroad, however, and racial factor so far as the general mortality from more especially in Sweden, acute yellow atrophy cancer is concerned. has occurred almost in epidemic form as a sequela There are, however, striking differences in the of epidemic catarrhal jaundice. In 1927 acute organ incidence of cancer between Jews and nonyellow atrophy of the liver was responsible for Jews. Thus in all communities investigated the 84 deaths in Sweden, 42 cases being met with in incidence of cancer of the uterus is much lower Stockholm alone. As H. Bergstrand9 points out, among Jewish women than among non-Jewish the initial symptoms of acute yellow atrophy of the women, the incidence for Jewish women varying liver are identical with those of catarrhal jaundice ; from about one-half to one-third of the incidence then, quite suddenly, there appear the well-known in their non-Jewish neighbours. The same is signs of liver insufficiency. The reason why true for cancer of the penis among men, not one epidemic catarrhal jaundice should be so benign case of cancer of the penis having been found in in this country yet on occasions so malignant the 2252 male cancer deaths recorded among the abroad is at present unknown. Possibly the acute Jews of London and Vienna, although from the necrosis of the liver is due to some secondary incidence among non-Jews 12 cases were expected infection which acts on an organ primarily damaged to have occurred. A higher organ incidence by the epidemic catarrhal jaundice. In certain among Jews was found for the lower part of the cases of acute yellow atrophy of the liver gastro-intestinal tract and for the ovaries. These Bergstrand, for example, has obtained Streptococcus differences in the organ incidence are subjected viridans in pure culture from the duodenum. to a detailed discussion, and the conclusion is reached While there is now ample evidence that leptospira that they are not due to racial factors but to are setiologically responsible for one form of environmental factors. Thus the immunity from infectious jaundice, there is as yet no indication cancer of the penis is attributed to circumcision, of the causal agent of epidemic catarrhal jaundice. while the relative freedom from cancer of the Failure to isolate any bacterium of ætiological uterus is explained as being the result of the significance does not, of course, rule out a bacterial greater sexual hygiene imposed upon Jews by origin. It does, however, suggest the possibility religious prescriptions. This latter explanation that epidemic catarrhal jaundice may have to be seems however hardly consistent with the author’s added to the ever-growing number of diseases own data. For while it is true that for each caused by ultra-microscopic viruses. community the incidence of cancer of the uterus is always lower for Jewish women than for their non-Jewish neighbours, a comparison of this incidence among the different communities showss CANCER AND RACE. ONEof the’ legends surrounding the cancer extremely wide variations both for Jewish and women. Thus the Jewish women problem is that Jews are relatively immune from for non-Jewishsuffer cancer of the uterus of from Budapest cancer. Another is that they are particularly as as the non-Jewish women of Vienna susceptible to cancer. Either of these two asser- andfrequently and even more Warsaw, frequently than the tions, if substantiated, would be of considerable non-Jewish women of Amsterdam. It should be general importance, because it would indicate the remembered that the recent detailed very investigaexistence of a factor of racial susceptibility in the carri2d an international statistical tions out by The as ROGERS cancer. WILLIAMS of Jews, ætiology has pointed out, are -particularly suitable for the committee under the auspices of the Health Organisation of the League of Nations on a closely investigation of such a problem because, although related question-namely, the notable differences have the habits the of nonthey general acquired Jewish populations among which they live and are in the incidence of cancer of the breast and uterus Dutch and in English women—has failed subjected to the same general environment, they in find to any environmental factors which could have maintained themselves racially pure. Dr. 10 be made responsible. As regards reasonably SORSBY has attacked this problem by comparing the incidence of cancer of the intestinal higher the recorded cancer mortality in various Jewish tract Jews Dr. SORSBY frankly admits that among communities-London, Amsterdam, Vienna, Budaunable he is an to offer explanation. pest, Warsaw, Lodz, and Leningrad-with each These differences in the organ incidence of cancer, other and with that of the non-Jewish populations in these different cities. In collecting this material which may frequently be found when different groups of populations are compared, are indeed 9 Über die akute und chronische Gelbe Leber-atrophie, very puzzling. What is even more puzzling is Leipzig, 1930. 10 Cancer and Race. A Study of the Incidence of Cancer the fact, to which attention has been drawn in the Among Jews. By Maurice Sorsby, M.D. London : John Bale, recent annual reports of the Imperial CancEr Sons, and Danielsson. 1931. Pp. 120. 7s. 6d.
recently
occurred in
epidemic
West Africa.
investigations
-
EPtDE’.NTIC! JAUNDICE.
difficult to agree, for some or all of these symptoms may be encountered in cases of epidemic catarrhal -
jaundice. Epidemic non-leptospiral jaundice
THE LANCET. LONDON: SATURDAY, MAY 30, 1931.
EPIDEMIC JAUNDICE. DURING the past few months fresh facts have been added to our knowledge of epidemic jaundice. It is evident that there are at least two epidemic diseases characterised by jaundice and by a number of other clinical symptoms in common. These two diseases are leptospiral jaundice and epidemic catarrhal jaundice, or, as Rolleston and McNee prefer to call it, common infective hepatic jaundice. Both diseases appear to be world-wide in their distribution and by clinical means alone their differentiation is by no means easy. It is therefore important that every epidemic should be both clinically and bacteriologically. exhaustive investigation has recently been carried out by J. Taylor and A. N. Goyle1 on the causation and epidemiology of the jaundice that occurs in the Andamans. Jaundice has been rife in these islands for a very considerable time, and during the last 40 years has been studied by numerous workers. F. A. Barker, in 1926, was the first to demonstrate the presence of leptospira, while two years later, in our own columns, H. C. Brown showed that antibodies to leptospira were present in the blood-serum of jaundiced patients, bringing forward evidence that in the sera examined there were antibodies which, while quite distinct from those produced by the London human and rat strains, were allied to certain strains of leptospira from Sumatra. As a method of diagnosis, Taylor and Goyle find that blood culture is of great value provided it is carried out between the third and sixth day of illness. The serological relationships of the 28 strains of leptospira isolated were also investigated with the result that there appear to be two distinct serological groups. In studying the relationship of L. icterohœmorrhagiœ to the Akiyami A strain, K. Yang and M. Theiler2 have lately raised the question whether it is legitimate to recognise a new strain simply because there is a demonstrable quantitative difference in the potency of the immune serum as manifested for example by the agglutination test. The findings of Taylor and Goyle are, however, so definite that they appear to warrant the serological grouping of the Andaman strains. In discussing the differential diagnosis of leptospiral jaundice, Taylor and Goyle say that in catarrhal jaundice the general pains, albuminuria, conjunctival congestion, and tendency to haemorrhage are absent. To this it is
investigated Such
an
1 2
Ind. Med. Res. Memoirs, 1931, No. 20. Amer. Jour. Trop. Med., 1930, x., 407.
also recently received considerable attention both in this country and abroad. One such outbreak, involving the pupils of three schools, was recorded in our issue of March 28th by J. A. Glover and Joyce Wilson, while another has recently been investigated in Surrey by G. M. Findlay, J. L. Dunlop, and H. C. Brown.3 In its epidemiological and clinical features this Surrey outbreak was very similar to those recorded W. G. Booth and C. C. Okell4 in 1928 from Surrey, by M. T. Morgan and Brown5 in the same year from Northamptonshire, and by W. N. Pickles in 1930 from Yorkshire. The incubation period was found to be a long one and varied from three to five weeks. In leptospiral jaundice, on the other hand, according to Taylor and Goyle, and others, the incubation period is from six to eight days, while V. de Lavergne and Robert-Lévy7 record an incubation period of about five days when the leptospira gain entrance by the mouth and 15 days when they pass through an injured skin surface. An examination of the differential leucocyte count may also be of service in distinguishing leptospiral and epidemic catarrhal jaundice. Taylor and Goyle, as the result of a very large series of blood examinations, come to the conclusion that the most striking feature of the differential count is the relative increase in the number of polymorphonuclear leucocytes. In epidemic catarrhal jaundice, on the other hand, according to Findlay, Dunlop, and Brown, an increase in the polymorphonuclear leucocytes is present, if at all, only during the first few days of the disease. Instead there is a decrease in the number of has
by
polymorphonuclear leucocytes with a corresponding increase in the number of lymphocytes, large mononuclears, and transitional cells. In America, C. M. Jones and G. R. Minot (1923) and E. Thewlis and W. S. Middleton (1925) have recorded similar blood In the
changes course
in epidemic catarrhal jaundice. of the investigation of the Surrey
unsuccessful attempts were made to transmit the disease to guinea-pigs, and to determine the presence of immune bodies to leptospira in the serum. Efforts to infect monkeys (Macacus rhesus) either by the inoculation of blood or by spraying with washings from the nasopharynx of patients in the pre-icteric stage of catarrhal jaundice were also unsuccessful, as were attempts to transmit the disease to rabbits, rats, and mice. The failure to infect Indian monkeys with epidemic catarrhal jaundice occurring in this country is in agreement with the findings of Beeuwkes, Walcott, and Kumm,8 who were also unable to infect monkeys with the form of jaundice
epidemic
numerous
xxv., 1.
3 Trans. Roy. Soc. Trop. Med. and Hyg., 1931, 4 Public Health, 1928, xli., 237. 5 Min. of Health Rep. on Pub. Health and Med. Subjects, No. 42, London, 1928. 6 Brit. Med. Jour., 1930, i., 944. 7 Presse Méd., 1931, 651. 8 Trans. Roy. Soc. Trop. Med. and Hyg., 1931, xxiv., 429.
1198
which has
CANCER AND RACE.
form in considerable difficulties had to be overcome in order to exclude statistical fallacies which have also discuss the been clearly recognised by the author. As a and Brown Findlay, Dunlop, the conclusion is to catarrhal result of of these jaundice relationship epidemic acute yellow atrophy of the liver, or, as it is prefer- reached that the total recorded mortality from ably called, acute necrosis of the liver. In this cancer varies in different Jewish communities country there has been but one recorded fatal case tending to approach that of the non-Jews of each of epidemic catarrhal jaundice-that reported particular city, so that there is no evidence of a by Morgan and Brown. Abroad, however, and racial factor so far as the general mortality from more especially in Sweden, acute yellow atrophy cancer is concerned. has occurred almost in epidemic form as a sequela There are, however, striking differences in the of epidemic catarrhal jaundice. In 1927 acute organ incidence of cancer between Jews and nonyellow atrophy of the liver was responsible for Jews. Thus in all communities investigated the 84 deaths in Sweden, 42 cases being met with in incidence of cancer of the uterus is much lower Stockholm alone. As H. Bergstrand9 points out, among Jewish women than among non-Jewish the initial symptoms of acute yellow atrophy of the women, the incidence for Jewish women varying liver are identical with those of catarrhal jaundice ; from about one-half to one-third of the incidence then, quite suddenly, there appear the well-known in their non-Jewish neighbours. The same is signs of liver insufficiency. The reason why true for cancer of the penis among men, not one epidemic catarrhal jaundice should be so benign case of cancer of the penis having been found in in this country yet on occasions so malignant the 2252 male cancer deaths recorded among the abroad is at present unknown. Possibly the acute Jews of London and Vienna, although from the necrosis of the liver is due to some secondary incidence among non-Jews 12 cases were expected infection which acts on an organ primarily damaged to have occurred. A higher organ incidence by the epidemic catarrhal jaundice. In certain among Jews was found for the lower part of the cases of acute yellow atrophy of the liver gastro-intestinal tract and for the ovaries. These Bergstrand, for example, has obtained Streptococcus differences in the organ incidence are subjected viridans in pure culture from the duodenum. to a detailed discussion, and the conclusion is reached While there is now ample evidence that leptospira that they are not due to racial factors but to are setiologically responsible for one form of environmental factors. Thus the immunity from infectious jaundice, there is as yet no indication cancer of the penis is attributed to circumcision, of the causal agent of epidemic catarrhal jaundice. while the relative freedom from cancer of the Failure to isolate any bacterium of ætiological uterus is explained as being the result of the significance does not, of course, rule out a bacterial greater sexual hygiene imposed upon Jews by origin. It does, however, suggest the possibility religious prescriptions. This latter explanation that epidemic catarrhal jaundice may have to be seems however hardly consistent with the author’s added to the ever-growing number of diseases own data. For while it is true that for each caused by ultra-microscopic viruses. community the incidence of cancer of the uterus is always lower for Jewish women than for their non-Jewish neighbours, a comparison of this incidence among the different communities showss CANCER AND RACE. ONEof the’ legends surrounding the cancer extremely wide variations both for Jewish and women. Thus the Jewish women problem is that Jews are relatively immune from for non-Jewishsuffer cancer of the uterus of from Budapest cancer. Another is that they are particularly as as the non-Jewish women of Vienna susceptible to cancer. Either of these two asser- andfrequently and even more Warsaw, frequently than the tions, if substantiated, would be of considerable non-Jewish women of Amsterdam. It should be general importance, because it would indicate the remembered that the recent detailed very investigaexistence of a factor of racial susceptibility in the carri2d an international statistical tions out by The as ROGERS cancer. WILLIAMS of Jews, ætiology has pointed out, are -particularly suitable for the committee under the auspices of the Health Organisation of the League of Nations on a closely investigation of such a problem because, although related question-namely, the notable differences have the habits the of nonthey general acquired Jewish populations among which they live and are in the incidence of cancer of the breast and uterus Dutch and in English women—has failed subjected to the same general environment, they in find to any environmental factors which could have maintained themselves racially pure. Dr. 10 be made responsible. As regards reasonably SORSBY has attacked this problem by comparing the incidence of cancer of the intestinal higher the recorded cancer mortality in various Jewish tract Jews Dr. SORSBY frankly admits that among communities-London, Amsterdam, Vienna, Budaunable he is an to offer explanation. pest, Warsaw, Lodz, and Leningrad-with each These differences in the organ incidence of cancer, other and with that of the non-Jewish populations in these different cities. In collecting this material which may frequently be found when different groups of populations are compared, are indeed 9 Über die akute und chronische Gelbe Leber-atrophie, very puzzling. What is even more puzzling is Leipzig, 1930. 10 Cancer and Race. A Study of the Incidence of Cancer the fact, to which attention has been drawn in the Among Jews. By Maurice Sorsby, M.D. London : John Bale, recent annual reports of the Imperial CancEr Sons, and Danielsson. 1931. Pp. 120. 7s. 6d.
recently
occurred in
epidemic
West Africa.
investigations
-