KWASHIORKOR

496 in cor pulmonale has been confirmed in catheterisation studies where the right ventricular filling pressure has been shown to fall considerably after such an injection.6 It would be most interesting to hear other physicians’ opinions concerning venesection and digitalis in this

condition. Department of Medicine, University University of Birmingham.

-,

g. W. K. D W DONALD. ’"-

GONORRHŒA IN ANCIENT ROME SIR,-It is surprising that one so highly critical of tradition as Dr. Vertue, who dismisses the generally accepted interpretation of Celsus’s chapter on venereal diseases with a simple " I believe it is wrong," should take the reports of antiquity about " seminal flux " at their face value. The mere fact that we still, in deference to Galen, refer to this disease as gonorrhoea should have preserved him from such a naive error. Classical medicine is full of references to these seminal

discharges, which are described as cold by Aretaeus, as occurring without sexual excitement or imaginings by Celsus, and as biting and burning in character by Hippocrates. Has Dr. Vertue ever come across a case of seminal flux which polluted the patient lying and sitting as described in Leviticus, continuing day and night (Galen) ? .

His acceptance of the orthodox translation of piles for mariscce is equally uncritical. Admittedly, piles rhymes with smiles, and in lay terms any anal excrescence might be referred to as a pile ; but this tells us nothing of the nature of the lesion. Marisca is a kind of fig, and the term ficosus is used by Martial to designate persons with figlike excrescences round the anus : De familia ficosa. Ficosa est uxor, ficosus est ipse maritus filia ficosa est, et gener atque nepos nec dispensator, nec villicus, ulcere turpi nec rigidus fossor, sed nec arator eget.

Are we to assume that Martial is alluding to an epidemic of haemorrhoids on this unfortunate estateI Or is it not more reasonable to infer the contagious nature of these figs from the above epigram ? Whether tumid or humid. the correct translation in medical terms of Juvenal’s marisca must remain an open question. It would be impossible to give in this column all the references to gonorrhoea inantiquity ; but by starting with R. A. Fraser’s monograph on gonorrhoea (H. Kimpton, 1923) and working his way backwards, Dr. Vertue would soon be convinced that, even in the absence of bacteriological proof, there can be no reasonable doubt that gonorrhoea was a common and well-known though badly understood disease in ancient Rome. ERICH GEIRINGER. Edinburgh. WATERHOUSE-FRIDERICHSEN SYNDROME TREATED WITH CORTISONE

SiR,ŁDr. Haynes describes (Jan. 17) how

a

man,

aged 47, considered to show the Waterhouse-Friderichsen syndrome, died in convulsions seven hours after a dose of 100 mg. of cortisone and four hours after 20,000 units of intrathecal penicillin. Dr. Haynes attributes the convulsions to the cortisone, and of course he may be right. Alternatively he may be a little precipitate, as indeed I think he is. He should remember that no convulsions occurred in the two cases described by Nelson and Goldstein7 or in the case described by Newman 8 when much larger doses were used, and they occurred in only one of the cases described by us. Here they were clearly due to the cortical haemorrhages, long recognised as hazards of meningococcal Ferrer, M. I., Harvey, R. M., Catheart, R. F., Webster, C. A., Richards, D. W., Cournand, A. Circulation, 1950, 1, 161. 7. Nelson, J., Goldstein, N. J. Amer. med. Ass. 1951, 146, 1193. 8. Newman, L. R. Ibid, p. 1229. 9. Breen, G. E., Emond, R. T. D., Walley, R. V. Lancet, 1952, i, 1140.

6.

Incidentally it is a pity that Dr. Hayne. does not record the post-mortem findings, if an examina. tion was made, or the effects of the cortisone on thf-

meningitis.

patient’s blood-pressure. One other point seems

to require clarification. We do not recommend the use of cortisone " in meningitis,’ but solely to combat collapse-the essential feature of the Waterhouse-Friderichsen syndrome. Furthermore, I would be prepared to advocate its trial in any fulminant infection in which collapse occurs-for example, some cases of hypertoxic diphtheria and hnemorrhagic smallpox. From the scanty evidence available it seems reasonable to infer that death, so usual in the Waterhouse. Friderichsen syndrome, is due to temporary adrenal exhaustion, resulting in the shortage of some component for which cortisone seems to compensate. The same may apply to other infections, and indeed, in line with Selye’s hypothesis, to shock produced by any form of "

...-t.TC.Ca

" z

South Middlesex Hospital, Isleworth.

G. E. BREEN.

KWASHIORKOR as

SiR,,-Your leading articlestated that this condition. defined by Brock and Autret,2 is a distinct clinical

Although these authors have produced much useful information, their definition of kwashiorkor i8 somewhat arbitrary and impracticable. It is based on " a fundamental group of five signs," and " any clinical syndrome which includes these five characteristics and occurs in Africa, can undoubtedly be called kwashiorkor." Of these five basic criteria, alterations in skin and hair pigmentation are singled out for special attention. The authors are apparently not prepared to include in the syndrome cases without these pigmentary changes. They state, for instance, that the term kwashiorkor cannot be applied to the malnutrition syndrome, formerly prevalent among white children in Europe and the United States of America, which Czerny named Mehlndhrschaden. " If used in this way, the term loses its etymological meaning," they say, because white children show comparatively little alteration of skin and hair pigmentation when they are malnourished. Clearly, Brock and Autret attribute pathognomonic significance to changes in the skin and hair, which may or may not and this is done for occur in malnourished children ;

entity.

etymological reasons. Cicely Williams, who introduced the word kwashiorkor into medical terminology, pointed out recentlya that this narrow application of the term excludes early cases suffering from the ill effects of a poor diet. She is prepared to diagnose the syndrome in infants " with slight swelling of the dorsum of the foot, or with unucountable peevishness, or with failure to gain weight," in the absence of pigmentary changes. I tried to show in

an

earlier letter4 that insistence

on

the presence of

pigmentary changes in the diagnosis of kwashiorkor automatically excludes infants weaned on a water-pap diet at, or shortly after, birth ; because at this age such a diet usually kills so rapidly that pigmentary change: have no time to develop. It seems to me that the definition given in the W.H.O. publication, however correct etymologically, can be of little value to those interested in the ill effects of a bad diet. To insist on pigmentary changes createsa as artificial as that of " infantile pellagra, syndrome in which the dermatoses become the sine qua non of " diagnosis, or nutritional oedema in which the waterlogging of the tissues becomes the all-important sign. It is now accepted nearly everywhere that kwashiorkor can be caused by faulty diet alone-i.e., in the absence "

1. 2.

Lancet, 1952, ii, 1070. Brock, J. F., Autret, M. Kwashiorkor in Africa. Monograph Series, no. 8. Geneva, 1952. 3. Williams, C. D. Brit. med. J. 1952, ii, 1360. 4. Kahn, E. Lancet, 1952, ii, 588.

W.H.

497 of tropical diseases or similar non-dietary factors. The time is therefore ripe to discard more or less arbitrary Instead of arrays of criteria in defining kwashiorkor. studying the phenomena associated with depigmentation, or with cedema, or with dermatoses, we would do better to explore the natural history of the disease produced by a defective diet-and in infancy this is almost universally a pap diet containing little or no milk. With this approach we would note at once that some cases do indeed conform with the criteria mentioned in the W.H.O. publication, but that many others, as shown above, do not. We would also see that the pigmentary changes become less easily recognisable the whiter the skin of the race to which the individual belongs, and that in children of European descent a " muddy " complexion is often a sign of malnutrition. Apart from pigmentary peculiarities, the manifestations of dietary deficiencies would be the same in dark and white races. In fact, variations in the clinical picture of the disease produced by a difference in diet, race, climatic conditions, age, sex, &c., would be no more important than variations in the clinical picture of malaria or typhoid fever. The use of .paps of poor nutritional value for the weaning of infants is world wide. Fifty years ago pap malnutrition was one of the most common disabilities of infancy in Europe and the U.S.A. The reasons were widespread poverty, difficulty in obtaining fresh milk in the towns, and the belief that the casein of cow’s milk The disease picture was harmful to young babies. from little or no milk and diets resulting containing consisting mainly of cereals was then referred to as infantile malnutrition, hypothrepsia, Mehlndhrschaden, After a study of the releBilanzstorzcng, dystrophy, &c. vant literature, I have been unable to discover any basic differences between these syndromes and kwashiorkor. The first effective treatment of infantile malnutrition was presented by Finkelstein in 1907 in the form of his It should not be forgotten famous " protein milk." that it took from 1933 to 1948 to rediscover this treatment for a condition which had in the meantime changed its name to kwashiorkor. It seems doubtful whether it is wise to retain the term kwashiorkor to denote a malnutrition syndrome. The word could be used more satisfactorily to signify pigmentary changes of skin and hair which are potential signs of malnutrition in dark-skinned races. E. KAHN Baragwanath Hospital, Senior Pædiatrician. Johannesburg, South Africa. STANDARDISED SENNA annotation last year1 you discussed SIR,—In standardised senna, with particular reference to the methods developed by Fairbairn and others for assaying preparations of senna. We have made some clinical tests on a new standardised and stabilised preparation of senna marketed under the name ’Senokot.’ In this preparation the powdered pericarp of the senna pod is incorporated in a palatable base of cocoa, malt, and sugar, and made up as granules, which are pleasant and easy to take in a dose of 1½2 teaspoonfuls. The preparation was given to 101 inpatients with constipation, and good responses were obtained in 93. Those who did not respond were patients with chronic constipation which was resistant to other drugs. senokot was effective in 4 patients who did not respond to other commonly used purgatives. Severe griping occurred in 3 patients after the higher dose. More have we found in 25 that, recently patients, experimental tablets of senokot were effective on 65 occasions. an

We

are

supplies

of

grateful

to

Westminster Laboratories Ltd.

for

senokot.

The Middiesex Hospital, London, W.1. 1.

P. FLINTAN G. D. WEEDEN.

Lancet, 1952, i, 655.

REGISTRATION OF FEVER NURSES

SIR,—I congratulate the correspondents who have

ably put the case for the continuation of the Fever Every argument put by your contributors is logical and full of plain common sense. Does the General Nursing Council seriously believe that, because of the pronounced decrease in diphtheria and the temporary decline in the virulence of scarlet fever, dangerous communicable diseases are on the so

Register.

.

way out ? One has only to study the archaic syllabus for fever training which continues to be issued by the General Nursing Council to realise that that body is out of touch with reality. In it, diphtheria and scarlet fever continue to hold pride of place ; and encephalitis lethargica, which has possibly not occurred in this country for many years, is included. Smallpox, which not more than 1 nurse in 500 is likely to have to nurse, has prominence. But not a word about the acute bacterial food-poisoning groups (apart from enteric fever), the bacillary dysenteries, or the acute and dangerous gastro-enteritis of infants. Even the epidemic prevalence of poliomyelitis does not seem to have caused the council to think of including it in the nurse’s training. The council may also have overlooked the report of the recent poliomyelitis conflagration in Copenhagen, where more than 3000 cases were admitted to the municipal contagious diseases’ hospital in a few months. A similar case-incidence in greater London could produce about

20,000

cases.

If the Council persists in its attitude and persuades the Minister of Health to agree, then Dr. Macrae’s suggestion to establish a certificate of training, dissociated from the General Nursing Council, must-and I am sure will-receive warm support from every publichealth authority in the country. Western

Hospital, London, S.W.6.

W. HOWLETT KELLEHER.

SiR,-As matron of a busy infectious-disease trainingschool of just over 100 beds I am concerned that should the Fever Register be closed the services which we provide for the community will be sorely endangered. Like other centres we have noted the increased incidence of infectious disease in the post-war years. Since 1947 we have nursed an epidemic of smallpox, an epidemic of poliomyelitis (1950) during which 208 acute cases were admitted in three months, and an epidemic of diphtheria (1951) when in six months 133 cases were The day-to-day confirmed of which 7 proved fatal. admissions are no less eventful, providing a wide range of experience in all types of infectious-disease nursing. I have been fortunate in being able to maintain an adequate number of trained staff and a steady flow of student-nurse recruits, but I am certain that these numbers will decline when the incentive of a qualifying examination is removed. The closure of the Fever Register will indirectly remove a source of student nurses from entry to the general hospitals, since many girls choose to take their fever certificate as a test of suitability for the profession ; in so doing they gain experience in medical nursing which makes them an asset to the general hospital which they ultimately enter. The practice of secondment of nursing staff from a parent hospital to the special hospital is one which I deprecate not only because little experience can be gained in such a short time, but also because no nurse can be expected to hold a simultaneous loyalty to two hospitals—loyalty to the hospital considerably affects the quality of a nurse’s work. There is one sphere in which the trained infectiousdisease nurse is already sorely missed, and where I feel her complete absence will be a menace to public health. Before 1948 most infectious-disease hospitals maintained