- Email: [email protected]
INDEX CORRELATIONS.
1695
stringent precautions that the infection could not and the numerous complications of the disease described and tabulated, and then the be carried by individuals who came in contact with are the patients. The exact details are described in writer proceeds to discuss the difficult matter of their communication, and prove that a patient and etiology. Six cases occurred among 27 warders painstaking investigation was carried out. The employed in the prison, and 16 in some 150 men diseases under treatment consisted of scarlet fever, of the King’s African Rifles, whose lines are close diphtheria, rothein, mumps, whooping-cough, to the prison. On the other hand, none occurred measles, and chicken-pox. The arrangement in some 72 Sikhs, also stationed in the neighbourof the ward was an interesting one, and as hood. The rations to prisoners, Sikhs, troops, and the result of their experience Dr. Thomson warders consisted mainly of rice, all drawn from and Mr. Price assert that they could treat the same supply. It is certain that in the case of these infectious diseases in one ward, almost many of the pellagrous prisoners maize has not certainly, with perfect safety if the day of the entered into their diet at all for years. Dr. disease on which the patients were to be admitted Stannus thinks that the data he adduces absocould be selected. The conclusions which were lutely put all maize theories, as such, out of the arrived at are stated with due caution. With regard question. On the other hand, if grain " be subto scarlet fever they consider that the infection is stituted for maize," then the theory is not to be not air-borne. The evidence as to whooping-cough so easily dismissed. At Zomba the prison ration consists of rice and salt, and in the majority of£ was uncertain, but in regard to measles they believe that the infection is probably carried by the air cases little or nothing else. It is therefore quite early in the disease only. The infection of chicken- possible that so restricted a diet may lead to the pox also appears to be air-borne until the third day. appearance of pellagra as the expression of a The number of cases of other diseases which were deficiency, after the analogy of beri-beri. As the treated were too few to be of any definite value. rice is eaten in Nyasaland, part at least of the ’These observations are certainly interesting, and if pericarp is left on the grain. Dr. Stannus, howcorroborated by a larger number of cases would ever, shows that the risk of partaking of damaged rice is considerable. prove of considerable value. Turning to the theory of protozoal infection, Dr. Stannus has made a laborious investigation of the simulium distribuPELLAGRA IN NYASALAND. tion in Nyasaland in its bearing on Dr. Sambo n’s THE awakened interest in the problem of theory of the association of pellagra with the fly. He has found the fly in abundance on pellagra justifies reference to a recent paper by simulium all of the streams in the neighbourhood of Zomba, Dr. Hugh S. Stannus, medical officer at Zomba, and states that he can bring forward no frankly Nyasaland, read before the Society of Tropical facts to militate against Dr. Sambon’s theory. At Medicine and Hygiene, and published in their the same time, he points out that it must be careTransactions. To Dr. Stannus belongs the honour of discovering the existence and describing the fully noted that the data brought forward equally support the theory which lays the cause of the symptomatology of pellagra as it occurs in that disease at the door of malnutrition-i.e., nutrition of in the and this second communicaworld, part in some essential principle. Further, Dr. wanting tion2 be amplifies his previous statements and Stannus declares that in no disease caused by a data for a of the study supplies important etiology virus is a regular -complete cessation of of the disease. During the last two years the living seen, with relapse at a definite season symptoms of in and around the Central spread pellagra months later, such as occurs or may occur many Prison at Zomba has been such that it amounts in and this leads him to believe that if the pellagra, to an actual epidemic, in the course of which condition is associated with a protozoal infection 131 cases have been directly under Dr. Stannus’s be seasonal reinfection or intoxication, there must observation. As far as the symptoms are conand not a relapse. Dr. Stannus’s very careful cerned, stress is laid on the remarkable symmetry clinical observations and investigations form a of the rash, which begins in these African cases valuable contribution to thestudy of the disease. surfaces of the on the antero-lateral upper usually "
"
third of the forearm, the anticubital fossa, and the lower third of the upper arm, appearing thereafter on the back of the hand, the triangles of the neck, the "butternv"" area of face, forehead, and upper surface of pinna. It is very common to find a condition like syphilitic rhagades at the corners of the mouth, where the epithelium becomes sodden and thickened, and cracks appear in it, passing across the mucocutaneous junction a little way into the mouth. A not infrequent affection of the free margin of the prepuce is exactly similar. There is often a glossitis with subse, ,
quent irregular epithelial denudation, giving
anL
appearance described as "geographical"tongue. The whole mucous membrane of the mouthL may be involved, and the process may spread to the fauces and pharynx. Dr. Stannus believes in the possibility of pellagra sine exanthemata, and quotes illustrative instances. The nervous system symptoms, the alimentary symptoms, 1 Transactions of the Society of Tropical Medicine and Hygiene, vol. vii., No. 1., p. 32. 2 See, for reference to the first, THE LANCET, Feb. 3rd, 1912, p. 314.
INDEX
CORRELATIONS.
IN connexion with the Lister Institute of Preventive Medicine a statistical study of index correlations has been undertaken by J. W. Brown, M. Greenwood, jun., and Frances Wood, particulars of which appeared in a paper in the Jozinrnab of the Royal Statistical Society for February last. The problem, which is of some importance in medical statistics, is of the following nature. In a series of districts with populations represented by zo, zi, Z2, &c., the deaths from a certain disease and from some other disease are xo, xi, X2, &c., The question arises whether there is yo, Y], Y2, &c. any association between the x’s and y’s which is independent of the common relation of each with z. In order to obtain the requisite materials for this study the Report of the English Registrar-General for 1901 has been laid under contribution, the investigators having faced the very considerable labour of taking out from that source the first thousand registration subdistricts with
1696
populations between 1000 and 10,000, together that anaphylactic shock is the effect of the with the corresponding numbers of births and reaction between albuminoid antigen and antideaths. The birth- and death-rates were then bodies in the presence of blood serum, the antigen computed and the necessary correlation tables drawn undergoing a fermentative action with the formaup. These data were then completely analysed tion of highly toxic products. But, on the other and the resulting constants appear in Table 10. hand, Doerr has pointed out that fermentative The provisional conclusions derivable from this actions are slow processes, while anaphylactic shock study are fully set forth in the paper, which will often takes place with lightning rapidity, and that be found instructive and suggestive for further the quantity of antigen sufficient to cause fatal shock is so small that it is difficult to imagine how, study of the problem. from the release of so minute a quantity of albumin, sufficient toxic bodies can be produced. ANAPHYLAXIS AND IDIOSYNCRASY. Professor Silvestri, in criticising these views, SINCE the introduction of serum therapy the advances the opinion that just as in true phenomena of hypersensibility and the " serum anaphylaxis, i.e., a poisoning of proteic nature, disease"have been closely followed and studied so in drug idiosyncrasy we have a group of with absorbing interest. One of the latest original symptoms whose peculiarity consists in the rapidity, contributions to the subject is from the pen of violence, and disproportion between cause and Professor T. Silvestri, of the University of Modena, effect, which reproduces exactly the symptoms of published in a recent number of It Policlinico.1 poisoning corresponding to the substance in quesWhether there exist anaphylactic properties in tion. Hence anaphylaxis and drug idiosyncrasy certain drugs, or whether such properties are have essentially something in common, nor is it limited to albuminoid substances or are possessed a valid objection that in the latter we cannot by colloids in general and by certain crystalloids, are explain the mechanism of the accident caused questions which have previously attracted the atten- by substances not biologically active, since we tion of other observers, such as Gubler, Bruck, and are in the same state of ignorance concernKlausner, while E. Friedberger and Ito attempted ing those instances where the system becomes to produce hypersensibility to iodine in guinea-pigs z, tolerant of and accustomed to large doses of by preparing them by injections of iodised albumin. ’, poisonous drugs. It seems to Professor Silvestri Nicola Barbaro in a recent note on the deter- still uncertain whether the field of anaphylaxis mining action of certain crystalloid substances should be so far extended as to cover true drug relates the case of a patient with acute poly- idiosyncrasy, or whether experimental or sponarticular rheumatism in whom a small quantity of taneous anaphylaxis should be considered simply a salicylate of sodium (30 grains daily) and minimum particular instance of idiosyncrasy in general. doses of iodide of potassium (4 to 8 grains) were Anaphylaxis he considers a defensive reaction of followed by gastro-intestinal disturbance, diffuse ancestral origin against anything that threatens the erythema, pyrexia, and blood changes, and another integrity of the economy, either wholly or in part. case of a man, in whom the ingestion of fish gave It is for him a tumultuous reaction, disproportionate rise to urticaria, who exhibited alarming symptoms owing to a lack of adaptation to a given virus after the injection of Hh grain of morphia. These or given substance, a reaction which precedes phenomena may be of an anaphylactic nature, but immunity. It may be that the exceptional gravity as the anaphylaxis is not specific in each case it of the diseases which rage for the first time in a must be admitted that the anaphylactic state may given locality is in some cases an instance of have been prepared or merely brought into action anaphylactic reaction. In evolution, says Professor by the morbid process and determined by the Silvestri, anaphylaxis must have preceded immedicinal crystalloids. While waiting for more munity, as it precedes it, as a rule, in experilight to be thrown on such cases, it might be stated mental and clinical anaphylaxis. If at times provisionally that the crystalloids do not give rise it accompanies or follows immunity-at least in to antibodies, but that where the latter already the laboratory, in animals which furnish a exist they may determine anaphylaxis. In the highly antitoxic serum, and which therefore have present state of our knowledge concerning the acquired a marked immunity with respect to a anaphylaxis of crystalloids it may be affirmed given infection-this fact is not in absolute contrathat it does not yet rest on a solid basis of experi- diction to what has been just stated, for it may be ment, and that although we are not in a position assumed that by repeating the stimulus (injection to deny in an absolute manner the affinity, if not of toxin) for too long a time the organism would the identity, between the manifestations of idio- respond with a paradoxical reaction. This would syncrasy for certain drugs and those of anaphylaxis, constitute another argument in favour of the theory there is a tendency among scientists to recognise of the identity of anaphylaxis and idiosyncrasy in that at least some crystalloid bodies have a general. ____
In all determinant action, direct or indirect. cases of idiosyncrasy the symptoms are those of poisoning by the respective drugs; the peculiarity of the case consists in the rapidity, and especially in the disproportion between cause and effect. Hence we do not speak of anaphylaxis in such cases, but of intolerance or idiosyncrasy towards the drugs used. When, however, we come to investigate the significance of true anaphylactic shock we are struck by the fact that whatever be the antigen used the symptoms are more or less identical. To explain this phenomenon it has been supposed 1 Il Policlinico, 46, Roma.
anno
xxi., fasc. 10, March 8th, 1914. Via del Tritone
____
JAUNDICE
OF
PREGNANCY WITH THE OFFSPRING.
JAUNDICE
IN
case is recorded by Dr. F. E. in the Medical Chronicle (1914, p. 465) of a woman who married at the age of 18 in 1894, and who has since then had eight children. Each child was born prematurely, the first at six months, the second at seven months, and the remainder at eight months. With each pregnancy the woman had jaundice which came on at the third month, increased in intensity, persisting till three months after confinement, and was unassociated with any pain. Its onset was always insidious. She had
A
REMARKABLE
Tylecote
stringent precautions that the infection could not and the numerous complications of the disease described and tabulated, and then the be carried by individuals who came in contact with are the patients. The exact details are described in writer proceeds to discuss the difficult matter of their communication, and prove that a patient and etiology. Six cases occurred among 27 warders painstaking investigation was carried out. The employed in the prison, and 16 in some 150 men diseases under treatment consisted of scarlet fever, of the King’s African Rifles, whose lines are close diphtheria, rothein, mumps, whooping-cough, to the prison. On the other hand, none occurred measles, and chicken-pox. The arrangement in some 72 Sikhs, also stationed in the neighbourof the ward was an interesting one, and as hood. The rations to prisoners, Sikhs, troops, and the result of their experience Dr. Thomson warders consisted mainly of rice, all drawn from and Mr. Price assert that they could treat the same supply. It is certain that in the case of these infectious diseases in one ward, almost many of the pellagrous prisoners maize has not certainly, with perfect safety if the day of the entered into their diet at all for years. Dr. disease on which the patients were to be admitted Stannus thinks that the data he adduces absocould be selected. The conclusions which were lutely put all maize theories, as such, out of the arrived at are stated with due caution. With regard question. On the other hand, if grain " be subto scarlet fever they consider that the infection is stituted for maize," then the theory is not to be not air-borne. The evidence as to whooping-cough so easily dismissed. At Zomba the prison ration consists of rice and salt, and in the majority of£ was uncertain, but in regard to measles they believe that the infection is probably carried by the air cases little or nothing else. It is therefore quite early in the disease only. The infection of chicken- possible that so restricted a diet may lead to the pox also appears to be air-borne until the third day. appearance of pellagra as the expression of a The number of cases of other diseases which were deficiency, after the analogy of beri-beri. As the treated were too few to be of any definite value. rice is eaten in Nyasaland, part at least of the ’These observations are certainly interesting, and if pericarp is left on the grain. Dr. Stannus, howcorroborated by a larger number of cases would ever, shows that the risk of partaking of damaged rice is considerable. prove of considerable value. Turning to the theory of protozoal infection, Dr. Stannus has made a laborious investigation of the simulium distribuPELLAGRA IN NYASALAND. tion in Nyasaland in its bearing on Dr. Sambo n’s THE awakened interest in the problem of theory of the association of pellagra with the fly. He has found the fly in abundance on pellagra justifies reference to a recent paper by simulium all of the streams in the neighbourhood of Zomba, Dr. Hugh S. Stannus, medical officer at Zomba, and states that he can bring forward no frankly Nyasaland, read before the Society of Tropical facts to militate against Dr. Sambon’s theory. At Medicine and Hygiene, and published in their the same time, he points out that it must be careTransactions. To Dr. Stannus belongs the honour of discovering the existence and describing the fully noted that the data brought forward equally support the theory which lays the cause of the symptomatology of pellagra as it occurs in that disease at the door of malnutrition-i.e., nutrition of in the and this second communicaworld, part in some essential principle. Further, Dr. wanting tion2 be amplifies his previous statements and Stannus declares that in no disease caused by a data for a of the study supplies important etiology virus is a regular -complete cessation of of the disease. During the last two years the living seen, with relapse at a definite season symptoms of in and around the Central spread pellagra months later, such as occurs or may occur many Prison at Zomba has been such that it amounts in and this leads him to believe that if the pellagra, to an actual epidemic, in the course of which condition is associated with a protozoal infection 131 cases have been directly under Dr. Stannus’s be seasonal reinfection or intoxication, there must observation. As far as the symptoms are conand not a relapse. Dr. Stannus’s very careful cerned, stress is laid on the remarkable symmetry clinical observations and investigations form a of the rash, which begins in these African cases valuable contribution to thestudy of the disease. surfaces of the on the antero-lateral upper usually "
"
third of the forearm, the anticubital fossa, and the lower third of the upper arm, appearing thereafter on the back of the hand, the triangles of the neck, the "butternv"" area of face, forehead, and upper surface of pinna. It is very common to find a condition like syphilitic rhagades at the corners of the mouth, where the epithelium becomes sodden and thickened, and cracks appear in it, passing across the mucocutaneous junction a little way into the mouth. A not infrequent affection of the free margin of the prepuce is exactly similar. There is often a glossitis with subse, ,
quent irregular epithelial denudation, giving
anL
appearance described as "geographical"tongue. The whole mucous membrane of the mouthL may be involved, and the process may spread to the fauces and pharynx. Dr. Stannus believes in the possibility of pellagra sine exanthemata, and quotes illustrative instances. The nervous system symptoms, the alimentary symptoms, 1 Transactions of the Society of Tropical Medicine and Hygiene, vol. vii., No. 1., p. 32. 2 See, for reference to the first, THE LANCET, Feb. 3rd, 1912, p. 314.
INDEX
CORRELATIONS.
IN connexion with the Lister Institute of Preventive Medicine a statistical study of index correlations has been undertaken by J. W. Brown, M. Greenwood, jun., and Frances Wood, particulars of which appeared in a paper in the Jozinrnab of the Royal Statistical Society for February last. The problem, which is of some importance in medical statistics, is of the following nature. In a series of districts with populations represented by zo, zi, Z2, &c., the deaths from a certain disease and from some other disease are xo, xi, X2, &c., The question arises whether there is yo, Y], Y2, &c. any association between the x’s and y’s which is independent of the common relation of each with z. In order to obtain the requisite materials for this study the Report of the English Registrar-General for 1901 has been laid under contribution, the investigators having faced the very considerable labour of taking out from that source the first thousand registration subdistricts with
1696
populations between 1000 and 10,000, together that anaphylactic shock is the effect of the with the corresponding numbers of births and reaction between albuminoid antigen and antideaths. The birth- and death-rates were then bodies in the presence of blood serum, the antigen computed and the necessary correlation tables drawn undergoing a fermentative action with the formaup. These data were then completely analysed tion of highly toxic products. But, on the other and the resulting constants appear in Table 10. hand, Doerr has pointed out that fermentative The provisional conclusions derivable from this actions are slow processes, while anaphylactic shock study are fully set forth in the paper, which will often takes place with lightning rapidity, and that be found instructive and suggestive for further the quantity of antigen sufficient to cause fatal shock is so small that it is difficult to imagine how, study of the problem. from the release of so minute a quantity of albumin, sufficient toxic bodies can be produced. ANAPHYLAXIS AND IDIOSYNCRASY. Professor Silvestri, in criticising these views, SINCE the introduction of serum therapy the advances the opinion that just as in true phenomena of hypersensibility and the " serum anaphylaxis, i.e., a poisoning of proteic nature, disease"have been closely followed and studied so in drug idiosyncrasy we have a group of with absorbing interest. One of the latest original symptoms whose peculiarity consists in the rapidity, contributions to the subject is from the pen of violence, and disproportion between cause and Professor T. Silvestri, of the University of Modena, effect, which reproduces exactly the symptoms of published in a recent number of It Policlinico.1 poisoning corresponding to the substance in quesWhether there exist anaphylactic properties in tion. Hence anaphylaxis and drug idiosyncrasy certain drugs, or whether such properties are have essentially something in common, nor is it limited to albuminoid substances or are possessed a valid objection that in the latter we cannot by colloids in general and by certain crystalloids, are explain the mechanism of the accident caused questions which have previously attracted the atten- by substances not biologically active, since we tion of other observers, such as Gubler, Bruck, and are in the same state of ignorance concernKlausner, while E. Friedberger and Ito attempted ing those instances where the system becomes to produce hypersensibility to iodine in guinea-pigs z, tolerant of and accustomed to large doses of by preparing them by injections of iodised albumin. ’, poisonous drugs. It seems to Professor Silvestri Nicola Barbaro in a recent note on the deter- still uncertain whether the field of anaphylaxis mining action of certain crystalloid substances should be so far extended as to cover true drug relates the case of a patient with acute poly- idiosyncrasy, or whether experimental or sponarticular rheumatism in whom a small quantity of taneous anaphylaxis should be considered simply a salicylate of sodium (30 grains daily) and minimum particular instance of idiosyncrasy in general. doses of iodide of potassium (4 to 8 grains) were Anaphylaxis he considers a defensive reaction of followed by gastro-intestinal disturbance, diffuse ancestral origin against anything that threatens the erythema, pyrexia, and blood changes, and another integrity of the economy, either wholly or in part. case of a man, in whom the ingestion of fish gave It is for him a tumultuous reaction, disproportionate rise to urticaria, who exhibited alarming symptoms owing to a lack of adaptation to a given virus after the injection of Hh grain of morphia. These or given substance, a reaction which precedes phenomena may be of an anaphylactic nature, but immunity. It may be that the exceptional gravity as the anaphylaxis is not specific in each case it of the diseases which rage for the first time in a must be admitted that the anaphylactic state may given locality is in some cases an instance of have been prepared or merely brought into action anaphylactic reaction. In evolution, says Professor by the morbid process and determined by the Silvestri, anaphylaxis must have preceded immedicinal crystalloids. While waiting for more munity, as it precedes it, as a rule, in experilight to be thrown on such cases, it might be stated mental and clinical anaphylaxis. If at times provisionally that the crystalloids do not give rise it accompanies or follows immunity-at least in to antibodies, but that where the latter already the laboratory, in animals which furnish a exist they may determine anaphylaxis. In the highly antitoxic serum, and which therefore have present state of our knowledge concerning the acquired a marked immunity with respect to a anaphylaxis of crystalloids it may be affirmed given infection-this fact is not in absolute contrathat it does not yet rest on a solid basis of experi- diction to what has been just stated, for it may be ment, and that although we are not in a position assumed that by repeating the stimulus (injection to deny in an absolute manner the affinity, if not of toxin) for too long a time the organism would the identity, between the manifestations of idio- respond with a paradoxical reaction. This would syncrasy for certain drugs and those of anaphylaxis, constitute another argument in favour of the theory there is a tendency among scientists to recognise of the identity of anaphylaxis and idiosyncrasy in that at least some crystalloid bodies have a general. ____
In all determinant action, direct or indirect. cases of idiosyncrasy the symptoms are those of poisoning by the respective drugs; the peculiarity of the case consists in the rapidity, and especially in the disproportion between cause and effect. Hence we do not speak of anaphylaxis in such cases, but of intolerance or idiosyncrasy towards the drugs used. When, however, we come to investigate the significance of true anaphylactic shock we are struck by the fact that whatever be the antigen used the symptoms are more or less identical. To explain this phenomenon it has been supposed 1 Il Policlinico, 46, Roma.
anno
xxi., fasc. 10, March 8th, 1914. Via del Tritone
____
JAUNDICE
OF
PREGNANCY WITH THE OFFSPRING.
JAUNDICE
IN
case is recorded by Dr. F. E. in the Medical Chronicle (1914, p. 465) of a woman who married at the age of 18 in 1894, and who has since then had eight children. Each child was born prematurely, the first at six months, the second at seven months, and the remainder at eight months. With each pregnancy the woman had jaundice which came on at the third month, increased in intensity, persisting till three months after confinement, and was unassociated with any pain. Its onset was always insidious. She had
A
REMARKABLE
Tylecote