LE ROY EST MORT!

1471 African foodstuffs is worked out by indophenol titration and confirmed in some cases by biological tests. Indophenol titration is admittedly a rough method of estimating vitamin C, being subject to certain well-recognised sources of error, but its use serves to give a general idea of the vitamin-C content of foodstuffs. One material, lucerne, receives special attention, since the leaves were found to have a very high vitamin-C content, about four times that of fresh citrus fruit juice. Lucerne, which is a vetch, is widely used as a food for domestic animals-in South Africa especially for ostriches-but there seems to be no reason why it should not be adapted for human consumption as a salad or spinach, where there would otherwise be a shortage of fresh antiscorbutics. From Calcutta R. K. Chakraborty publishes a similar study,2 in which special attention is paid to the antiscorbutic value of milk, human, cow’s, goat’s and buffalo’s, and of foodstuffs of plant origin. Three fruits were found, species of zizyphus, physalis, and citrus, all of which were more potent sources of vitamin C than the best Indian fruits previously known, the Indian lemon and orange. Both the Indian and African studies will no doubt be extended and investigations of the same sort will eventually have to be undertaken in all parts of the world where the less usual foods are eaten. ELEPHANTIASIS IN

BANCROFTIAN FILARIASIS DURING the last four years Prof. C. K. Drinker and his colleagues have been working on the lymphatic system of the dog. They have produced typical elephantiasis by repeated injections of two sorts given slowly into the lymphatic trunks of the lower limb-namely, a watery suspension of crystalline silica with particles about 1 !J. in diameter, and a solution of quinine hydrochloride with a strength of 2-5 per cent. In the lymph glands the particles of silica get caught up in the endothelial reticulum of the sinuses, and these become filled with large pale cells which later form fibrous tissue ; the effect of quinine in bringing about the closure of varicose veins is well known. These repeated injections, made at normal lymph pressures, act upon new collateral channels as they are formed; and the final effect is that, as the result of lymph blockage and transient periods of sterile inflammation produced by purely physical and chemical means, the part becomes typically elephantoid. Further inflammatory attacks are apt to occur in it, just as they do in elephantoid tissue in man ; they last normally about 48 hours, and each of them adds to the amount of elephantiasis. It has been much debated whether attacks of this kind, occurring in elephantiasis due to Wuchereria bancrofti infection in man, are caused by the filaria, adult or embryo, or by an added bacterial -infection. Drinker has probably explained the different findings, on which these differing opinions are based, by showing that in the first few hours, and in the first few hours only, of such an attack in a dog a h2emolytic streptococcus is present in the oedema fluid from inflamed elephantoid tissue, and that this fluid can be obtained from a dependent leg without prior injection of salt solution. If this pointer is followed it should be possible to settle whether or not these .attacks in man are due to bacterial infection seeded on to a suitable soil. That the elephantoid tissue does afford such a soil is seen in the fact that inflammatory attacks could be induced by injecting into it a small fraction of the number of streptococci needed to produce the same effect in a healthy animal. During 2 Indian Jour. Med. Research, 1935, xxiii., 347.

these attacks the lymph of the inflamed part has a high protein content, amounting to about half that of the plasma, instead of the normal percentage of about one; and in such a medium, used in vitro, connective tissue cells grow well. Further, when the rupture of dilated lymph vessels has allowed of escape of lymph through the epidermis, the protein content of the oedema fluid becomes low and the dog in question has shown little permanent fibrotic enlargement of the limb. The disadvantage of attempting to reproduce this state of affairs in man are clear, but there may be conditions in which upward drainage is possible. The means of doing so were apparently added to in the case of a woman of 19 with double elephantiasis nostras of the lower limbs. The obstruction was high up in the abdomen and by incising large lymphatic vessels lying on the iliac arteries the lymph was made to run into the retroperitoneal space-with what permanent result could not be stated when the report was published.1 There is another feature in which these experiments have fallen in with experience in man. In the typical inflammatory outbreaks which have been mentioned the blood has at all times been free of bacteria ; but in one dog, evidently as the result of infection by a more virulent strain of streptococcus, a septicaemia developed reminiscent of the grave cases which have been so striking a feature of Bancroftian filariasis in British Guiana. In these various ways the new methods used by the physiological laboratory of the Harvard School of Public Health have given a welcome impetus to the study and explanation of this infection in man. LE ROY EST MORT! ANY doctor who has tried to make even a tentative diagnosis solely on the patient’s symptoms as described to him by a friend or relative knows how ludicrously he may be led astray. Nfr. Yearsley is therefore to be congratulated on his courage in diagnosing the causes of death of the Rulers of England on what, in many cases, is very slender and unreliable testimony.2 Perhaps, as may be necessary sometimes in surgery, he has had to learn not only to make up his mind but also to act on insufficient evidence. Be that as it may, and although we cannot unreservedly accept all his diagnoses, it must be admitted that he has written a very interesting little book. The Rulers of England, if Oliver and Richard Cromwell and the luckless Lady Jane Grey are included, number forty from the Norman Conquest to the death of King Edward VII. Of these, no less than eight (20 per cent.) died violent deaths, either in battle or at the hands of the murderer or headsman, but it is reassuring to loyal subjects to note that the practice of regicide grows less common as time The acute infections and cardio-vasculargoes on. renal disease have each accounted for six; syphilis, congenital or acquired, and " dysentery," which covers a multitude of ignorances, have each disposed of four. " Senile decay," a diagnosis no longer as a certified cause of death, is mentioned accepted in three cases and implied in one other. Stephen may have had an appendix abscess, Edward III. gonorrhoea, and Richard II. anorexia nervosa, but Mr. Yearsley thinks that Henry I.’s "surfeit of

lampreys " George IV.

was more

probably ptomaine poisoning. speaking, cirrhosis,

and William IV., pathologically had much in common ; both had hepatic 1 Homans, J., Drinker, Surg., 1934,

c., 812.

C.

K.,

and Field, Madeleine : Ann. of

2 An Account of the Deaths of the Rulers of England. By Macleod Yearsley, F.R.C.S. London: John Heritage, The Unicorn Press. 1935. Pp. 164. 3s. 6d.

1472

pericarditis and, probably, pneumonia. Those who think harshly of James I. will do well to bear in mind that he had Bright’s disease, enlarged tonsils, renal calculi, jaundice, haemorrhoids, dental caries and pyorrhoea, and arthritis-surely enough to sour any man,

THE WORLD

REQUIREMENTS

OF NARCOTIC

DRUGS THE Supervisory Body acting under the 1931 Convention for Limitation of Manufacture of Narcotic Drugs has completed its estimate of the world requirements of morphine and its derivatives, and of cocaine, for The estimates for morphine, heroin, and 1936. cocaine " for use as such" are respectively 9799 kg., 930 kg., and 4503 kg. Compared with the estimates for the two previous years these figures represent a substantial reduction of heroin, some decrease of cocaine, and a slight increase of morphine. No less than 34,279 kg. of morphine were however required for " conversion," chiefly for the manufacture of

codeine, of which 25,710 kg. are estimated as the world requirement for 1936. The increasing demand for morphine for " conversion " has attracted the attention of the Supervisory Body and is being carefully investigated. For 59 countries and 89 territories the estimates were furnished bv the Governments concerned ; in 11countries and 9 territories the Supervisory Board, in default of such returns, had itself to frame them. In tables appended to the report are set out for each narcotic drug the estimated requirements of each country and territory for the year 1936. The compilation of this elaborate return (C. 429. M. 220. 1935. XI.) reflects great credit on the Supervisory Body and the secretariat of the League. THE COMPOSITION OF "WHITE BILE

"

The

cholesterol content was much higher in than in the other. It is hoped by these investigations of the isolated gall-bladder and ducts to get information about the functions of these structures. Unfortunately, in the human is often due to a preliminary their isolation subject inflammatory process which somewhat vitiates the one

case

experiment. THE MARCH OF MEDICINE THE turn of the year is the traditional time for reviewing the year’s events and achievements. The few days that come after the festivities of Christmas and before the New Year’s invitation to good resolutions, should be made to yield an hour or two for detached retrospection, not sentimental, but rather a little critical. Those who have, or aspire to have, a hand in the advancement of medicine, whether by making discoveries, by proclaiming them to the world, or by applying them for the benefit of the sick, may well take the Year Book of General Medicineas the basis for their retrospective meditation. The 1935 volume actually deals with work published between mid-1934 and mid-1935, and can therefore be in our hands before Christmas. It is edited by six physicians of great eminence, who have chosen for abstraction the most valuable papers in their several fields, and have often added for the reader’s great benefit their own brief comments. In the period they cover there has been no single discovery of startling importance, but the march of medicine on many fronts has been steady and progressive. The impetus given to h2ematology by Minot and Castle has not spent itself, but is spreading rather to adjacent subjects ; in their section of the book they call special attention to a report of the production in pigs, through a vitamin-deficient diet, of changes in the oral and gastric mucous membranes, achlorhydria, diarrhoea, muscular weakness, and macrocytic anaemia-a picture so like that of pernicious anaemia that it may be a clue to the causation of that disease and perhaps also of some of the chronic " gastritic" conditions towards which a great deal of interest has lately been directed. In the gastrointestinal section there are several important papers on chronic gastritis, which is now satisfactorily defined in terms of structural changes in the gastric mucosa, although its relation to functional changes and to symptoms, as well as its pathogenesis, remain obscure. Meulengracht’s localisation of the source of the intrinsic (gastric) factor of the anti-pernicious anaemia principle is another notable advance in this field ; medicine is undoubtedly marching, in Napoleonic fashion, on its stomach. Three other sections, on cardiovascular disease, on lung disease, and on infections, complete the book, for " General Medicine " is defined by exclusion, and endocrinology, neurology, psychiatry, and therapeutics find their places in others of the Year Book series. In cardiology, many writers seem to be re-working old ground, often with greater care and more precision than heretofore ; the bold attempt to ameliorate cardiac failure and severe angina by total thyroidectomy is being continued, and " this rather radical procedure still seems definitely indicated in a number of carefully selected cases." Among the infectious diseases, the virus investigators are working quietly ahead. In the chest section, the

A GROUP of workers engaged on a study of gallbladder functionhave been fortunate in obtaining 15 examples of " hydrops " of the gall-bladder from patients in whom the cystic duct was obstructed. In their opinion the sequence of events in these cases is : damage to the biliary system ; obstruction of the entrance of bile into the damaged gall-bladder ; dilution of the gall-bladder contents ; and finally decoloration of the bile by absorption or destruction of the pigment. Whether acute infection plays a part they have not decided. The colourless contents of the gall-bladder are secreted by its damaged mucosal cells, bile salts and bile-pigment being absent. In this white bile chlorides and calcium are found at approximately serum level though sometimes (in 5 of the 15 cases) the calcium content is considerably higher. The amount of cholesterol varies : in 9 cases it was either absent or present in proportions under 9 mg. per 100 c.cm., while in the other 6 the figures ranged from 15 to 143 mg. per 100 c.cm., the higher cholesterol figures being usually associated with a higher calcium content. There is as yet no obvious explanation for these facts. In 2 cases in which the gall-bladder was drained, daily observations were made of the composition of the fluid obtained. Bile salts did not reappear within the period of study, presumably because the cystic duct remained blocked. The chlorides remained at the usual level of 90-120 milli-equivalents per litre. The calcium figures were very constant ; in one Edited by 1 The 1935 Year Book of General Medicine. case they showed a slight gradual decrease, but George F. Dick, M.D., Lawrason Brown, M.D., George R. they were always approximately at serum level. Minot, M.D. S.D., F.R.C.P. (Hon.) Edin., William B. Castle, 1

Riegel, C., Ravdin, T. S., Johnston, C. G., and Morrison, P. J. : Amer. Jour. Med. Sci., November, 1935, p. 655.

M.D., A.M., William D. Stroud, M.D., and George B. Eusterman, M.D. Chicago : The Year Book Publishers, Inc. Pp. 848. 12s. 6d.