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PIRQUET OR MANTOUX?
916 The total number of injections sodium citrate. varies from case to case ; in moderate attacks two are sufficient, in more severe attacks five or six injections may be necessary. Blood transfusion is rarely necessary. At autopsy haemorrhages into different organs and into all cavities present a striking picture. Dr. Blackie concludes that onyalai must be classed among the purpuras showing a quantitative deficiency of platelets, but suggests that there is also some defect in the capillary endothelium. The occurrence of bullse, the recovery following small intramuscular injections of blood, and the relatively acute nature of the condition which apparently does not recur in the same patient, all present interesting differences from idiopathic thrombocytopenic purpura seen among white races. Dr. Blackie has raised absorbing new problems for the hsemato legist. AN ORTHOPÆDIC COLONY
DURING the past year the new Silver Jubilee treatment centre at the Treloar Cripples’ Home and College, Alton, has been completed and occupied which will afford greatly increased facilities, and a new X ray department is now in full working order. In his annual report Sir Henry Gauvain records a decrease in bone and joint tuberculosis, but a relative increase in the glandular forms, possibly due to better diagnosis. Conservative treatment of surgical tuberculosis is still the method of choice, but operative correction of deformities is increasingly employed when the active stages of the disease are over. Work among non-tuberculous cases increases both in variety and quantity. The hospital now serves ten outpatient clinics in London, Hampshire, and the Isle of Wight where children with orthopaedic and postural defects detected at welfare centres, at school medical inspections, or by private practitioners may be sent for advice before serious deformity or disability has developed, and where they may receive treatment by suitable exercises and be provided with apparatus where required. The danger of epidemics is always present in such a hospital population, but routine immunisation of patients and staff against diphtheria has reduced the incidence of this disease to an occasional mild case. A small outbreak of dysentery due to Sonne’s bacillus of unknown origin occurred in the Portsmouth block in May, 1936, but precautionary measures were successful in limiting its spread. This type of dysentery is probably not uncommon in the country in general, though usually unrecognised, and a small proportion of cases no doubt remain carriers of the organism long after the attack, usually a mild one, is forgotten. AUSTRALIAN WORK ON CANCER
THE
Australian cancer conference, of which has reached us, was held in Canberra last April and was attended by medical and scientific representatives from all parts of the Commonwealth. On the recommendation of the previous conference the Commonwealth Government had set up in September, 1936. a National Health and Medical Research Council. An annual sum of 30,000 has been suggested for the purpose of establishing a permanent and reliable system of medical research. The further recommendation to appoint an Australian Cancer Commission was not acted upon, although there are many indications that a lively interest is being taken officially by Australia in the subject of cancer. This is reflected not only in far-reaching action but in certain recent publications. public Dr. C. E. Eddy, physicist in charge of the Commona
eighth
report
wealth X ray and radium laboratory at Melbourne, has with the help of Mr. T. H. Oddie prepared for the health department a booklet entitled Physical Aspects of Radium and Radon Therapy, intended more especially for the use of radiotherapists and officers of local physical services. Within 60 pages an extremely good account is given of the general physics of the substances and radiations used in radiotherapy, together with an account of the many precautions necessary in using them. The advantages and drawbacks of radium and radon, from both technical and dosage points of view, are clearly described.
PIRQUET
OR MANTOUX?
theory medicine is independent of geographical boundaries, certain national preferences tend to persist. The Pirquet test is preferred by the French and the Norwegians, the Mantoux test by the Swedes and the Danes. The inability of such close neighbours as the Danes and the Norwegians to agree over this matter is seemingly the more paradoxical for their possession of many common denominators such as language and scientific standards. Dr. 0. Scheelof the Oslo Ullevaal Hospital has recently drawn attention to a common mistake committed when the Mantoux test is accepted as the standard by which to examine the Pirquet test. For if both tests are on trial, to set up one as the judge of the other is absurd. Dr. Scheel has tried to avoid this difficulty by the introduction of a third factor, radiological evidence, in the light of which both tests can be judged impartially. He has compared the in 1697 students with the radiological findings Pirquet and Mantoux findings in the same material, and he has grouped the students according as the reactions to the two tests were negative or positive in varying degrees, and according as a radiological examination showed (1) only pleural changes, (2) lung shadows, or (3) shadows indicative of calcification in lung or hilus. One of the many conclusions to which he comes from this study is that the Pirquet test is quite reliable in disclosing past tuberculous infections of a character to provoke radiologically demonstrable lesionss in the chest, whereas the Mantoux test, when positive, is apt to indicate a non-existent infection. To supplement his statistical argument by an illustrative example, Dr. Scheel records the case of an Ullevaal probationer who was Pirquetnegative on two occasions but who gave a positive Mantoux reaction to the intracutaneous injection of 1 mg. of tuberculin. The facts that she subsequently developed erythema nodosum and a high sedimentation-rate, as well as becoming strongly Pirquetpositive, are interpreted by Dr. Scheel as. signs of a primary tuberculous infection which had taken place after the probationer had given a positive reaction to the Mantoux test. In Denmark, where only about 60 per cent. of Mantoux-positive persons give a positive reaction to the Pirquet test, students of the Copenhagen University have for some three years been tested with the Mantoux reaction, up to 1 mg. of international standard tuberculin being injected. All the positive Mantoux reactors were radiologically examined, a suspect finding on screening being an indication for radiography. Dr. J. Holm,2who gives an account of these examinations, states that they dealt with 1608 medical students, 1192 of whom proved to be Mantoux-positive. Among these positive reactors were 1161 in whose lungs nothing radiologically WHILE
in
1 Nord. med. Tidskr. 1937, 13, 761. 2 Ibid, 1937, 14, 1456.
917
abnormal could be found.
During
of 1554 years
of these
period developed pulmonary
none
tuberculosis.
an
observation
1161 students On the other
hand, among the 416 originally Mantoux-negative over a period of 683 years there many as 19 who developed pulmonary tuberculosis. Dr. Holm concludes that all the 1192 Mantoux-positive students must actually have already been infected with tubercle bacilli, for otherwise some of them would surely have subsequently developed pulmonary tuberculosis in the period under review to judge by the fate overtaking the 19 abovementioned students. It is to be hoped that this controversy over the respective merits of the two tests will promote further investigations which will not only decide the question at issue but also throw new side-lights on the whole problem of tuberculin
students observed
were as
reactions.
GOATS, COWS, AND ABORTION FROM time to time, at meetings of learned societies and in the medical press, the question is asked : What justification is there for the belief of many of the older farmers that a goat running with a herd of cows protects them from abortion ?‘l The answers have been numerous, varied, and unsatisfying. Scientific workers have generally looked for an immunological explanation. It has been supposed that Brucella melitensis, which causes natural infection in the goat, is able to immunise cows against Brucella abortus, which is the organism chiefly responsible for contagious abortion. Though ingenious and superficially attractive, this explanation will not hold water. In the first place goats in this country have never yet been found to be infected with Br. meUtensis;; and in the second place numerous observations have shown that Br. melitensis, so far from being harmless to cattle, often sets up in them a very active infection, sometimes accompanied by abortion and by excretion of the organisms in the milk. An explanation of quite a different character has recently been put forward in the correspondence columns of the Times. It has been pointed out that certain weeds, such as ragwort, the autumnal hawkbit, and woody nightshade, which are poisonous to cows and are supposed at times to cause abortion, It is sugare non-poisonous to sheep and goats. that these latter whether from animals, gested habit or from their of in certain feeding preference situations, eat up these plants before the cows can get at them. This explanation, even if correct, can apply only to non-contagious abortion which, so far as our present knowledge goes, constitutes but a small proportion of the total amount of abortion among cows in Great Britain. It follows that the protection afforded by the goat is likely to be local and sporadic rather than widespread and frequent. For this reason it is unlikely to be observed by more than a relatively few farmers. Perhaps this is why so many of them disbelieve in it. DEVELOPMENT OF TOOTH GERMS IN VITRO
AMONG the papers read at the annual meeting of the British Dental Association at Cambridge last August, there was one by Miss Shirley Glasstone describing the growth of tooth germs in vitro. Her work was done at the Strangeways Research Laboratory and this is, we believe, the first successful attempt to grow tooth germs artificially. Molar and incisor teeth from mammalian embryos were dissected out under sterile conditions and grown in the same way 1
Brit. dent. J.
Sept. 15th, 1937.
other tissue cultures. These explanted teeth continue to develop both histologically and morphologically. Where molar tooth germs have been explanted before cusp-formation has begun, deep cusps form which are approximately normal in size, number, and arrangement. The pulp cells differentiate into odontoblasts and deposit dentine and the ameloblasts show the beginning of enamel-formation. It has long been believed that the shape of teeth is determined by the enamel epithelium and that even in animals in which enamel is normally absent, such as the edentata, tooth-formation depends on the presence of specialised epithelium. This is borne out by the result of Miss Glasstone’s work. In cultures where the dentine is formed in contact with the epithelium it is deposited in a regular sheet ; but in the absence of epithelium the odontoblasts merely give rise to irregular bands of dentine. Further, the odontoblasts differentiate in vitro only in the presence of ameloblasts. If, for instance, in an explant devoid of epithelium the original odontoblasts degenerate, they are not replaced by any further differentiation of pulp cells. This suggests that the enamel epithelium exerts some influence on the pulp tissue. In addition to this work Miss Glasstone has collaborated with Prof. R. Robison, F.R.S., of the Lister Institute, in a study of the calcifying mechanism in normal embryonic teeth. They have obtained evidence that the process of the calcification of dentine is similar to that of bone. Early embryonic teeth of rats and rabbits have a high phosphatase activity equal to that of embryonic bones. Even more interesting is the fact that uncalcified dentine can be partly calcified by immersion in salt solutions like those that effect calcification of hypertrophic cartilage and osteoid tissue. Miss Glasstone is to be congratulated on her successful application of tissue culture methods to tooth germs. They seem likely to help us with some of the unsolved problems of tooth development and as
calcification. SPANISH REFUGEES
THE number of refugees so far evacuated from northern Spain exceeds 100,000. Of these Great Britain has accepted 4000 children on condition that they are wholly maintained by private subscription. The French Government is at present supporting about 50,000, and the conditions under which they live have lately been described by Commander H. Pursey, R.N.1 When the first refugees arrived it was possible to find them suitable quarters near the coast, but later this was out of the question, and now there are nearly a thousand camps and centres scattered all over France. The cost of feeding is borne by the French Republic, which allows 20 francs for an adult and 7 francs for a child per day ; but the other expenses fall on local, mainly voluntary, funds, " and the supply of such requirements as clothes depends on whether local organisations and people are sympathetic to the refugees or not." In August the Government of France announced that it could not undertake to provide for any more refugees, and could accept them only for transit to other countries. In practice this almost always means transit to Government Spain, and as immigration from Gijon and other Asturian ports continues France is pouring refugees by thousands into Catalonia over the only remaining safe railway line at Puigcerda. The number of homeless people.who have already found refuge in Catalonia-mostly 1
Manchester Guardian, Sept. 30th, 1937, p. 11.
DURING the past year the new Silver Jubilee treatment centre at the Treloar Cripples’ Home and College, Alton, has been completed and occupied which will afford greatly increased facilities, and a new X ray department is now in full working order. In his annual report Sir Henry Gauvain records a decrease in bone and joint tuberculosis, but a relative increase in the glandular forms, possibly due to better diagnosis. Conservative treatment of surgical tuberculosis is still the method of choice, but operative correction of deformities is increasingly employed when the active stages of the disease are over. Work among non-tuberculous cases increases both in variety and quantity. The hospital now serves ten outpatient clinics in London, Hampshire, and the Isle of Wight where children with orthopaedic and postural defects detected at welfare centres, at school medical inspections, or by private practitioners may be sent for advice before serious deformity or disability has developed, and where they may receive treatment by suitable exercises and be provided with apparatus where required. The danger of epidemics is always present in such a hospital population, but routine immunisation of patients and staff against diphtheria has reduced the incidence of this disease to an occasional mild case. A small outbreak of dysentery due to Sonne’s bacillus of unknown origin occurred in the Portsmouth block in May, 1936, but precautionary measures were successful in limiting its spread. This type of dysentery is probably not uncommon in the country in general, though usually unrecognised, and a small proportion of cases no doubt remain carriers of the organism long after the attack, usually a mild one, is forgotten. AUSTRALIAN WORK ON CANCER
THE
Australian cancer conference, of which has reached us, was held in Canberra last April and was attended by medical and scientific representatives from all parts of the Commonwealth. On the recommendation of the previous conference the Commonwealth Government had set up in September, 1936. a National Health and Medical Research Council. An annual sum of 30,000 has been suggested for the purpose of establishing a permanent and reliable system of medical research. The further recommendation to appoint an Australian Cancer Commission was not acted upon, although there are many indications that a lively interest is being taken officially by Australia in the subject of cancer. This is reflected not only in far-reaching action but in certain recent publications. public Dr. C. E. Eddy, physicist in charge of the Commona
eighth
report
wealth X ray and radium laboratory at Melbourne, has with the help of Mr. T. H. Oddie prepared for the health department a booklet entitled Physical Aspects of Radium and Radon Therapy, intended more especially for the use of radiotherapists and officers of local physical services. Within 60 pages an extremely good account is given of the general physics of the substances and radiations used in radiotherapy, together with an account of the many precautions necessary in using them. The advantages and drawbacks of radium and radon, from both technical and dosage points of view, are clearly described.
PIRQUET
OR MANTOUX?
theory medicine is independent of geographical boundaries, certain national preferences tend to persist. The Pirquet test is preferred by the French and the Norwegians, the Mantoux test by the Swedes and the Danes. The inability of such close neighbours as the Danes and the Norwegians to agree over this matter is seemingly the more paradoxical for their possession of many common denominators such as language and scientific standards. Dr. 0. Scheelof the Oslo Ullevaal Hospital has recently drawn attention to a common mistake committed when the Mantoux test is accepted as the standard by which to examine the Pirquet test. For if both tests are on trial, to set up one as the judge of the other is absurd. Dr. Scheel has tried to avoid this difficulty by the introduction of a third factor, radiological evidence, in the light of which both tests can be judged impartially. He has compared the in 1697 students with the radiological findings Pirquet and Mantoux findings in the same material, and he has grouped the students according as the reactions to the two tests were negative or positive in varying degrees, and according as a radiological examination showed (1) only pleural changes, (2) lung shadows, or (3) shadows indicative of calcification in lung or hilus. One of the many conclusions to which he comes from this study is that the Pirquet test is quite reliable in disclosing past tuberculous infections of a character to provoke radiologically demonstrable lesionss in the chest, whereas the Mantoux test, when positive, is apt to indicate a non-existent infection. To supplement his statistical argument by an illustrative example, Dr. Scheel records the case of an Ullevaal probationer who was Pirquetnegative on two occasions but who gave a positive Mantoux reaction to the intracutaneous injection of 1 mg. of tuberculin. The facts that she subsequently developed erythema nodosum and a high sedimentation-rate, as well as becoming strongly Pirquetpositive, are interpreted by Dr. Scheel as. signs of a primary tuberculous infection which had taken place after the probationer had given a positive reaction to the Mantoux test. In Denmark, where only about 60 per cent. of Mantoux-positive persons give a positive reaction to the Pirquet test, students of the Copenhagen University have for some three years been tested with the Mantoux reaction, up to 1 mg. of international standard tuberculin being injected. All the positive Mantoux reactors were radiologically examined, a suspect finding on screening being an indication for radiography. Dr. J. Holm,2who gives an account of these examinations, states that they dealt with 1608 medical students, 1192 of whom proved to be Mantoux-positive. Among these positive reactors were 1161 in whose lungs nothing radiologically WHILE
in
1 Nord. med. Tidskr. 1937, 13, 761. 2 Ibid, 1937, 14, 1456.
917
abnormal could be found.
During
of 1554 years
of these
period developed pulmonary
none
tuberculosis.
an
observation
1161 students On the other
hand, among the 416 originally Mantoux-negative over a period of 683 years there many as 19 who developed pulmonary tuberculosis. Dr. Holm concludes that all the 1192 Mantoux-positive students must actually have already been infected with tubercle bacilli, for otherwise some of them would surely have subsequently developed pulmonary tuberculosis in the period under review to judge by the fate overtaking the 19 abovementioned students. It is to be hoped that this controversy over the respective merits of the two tests will promote further investigations which will not only decide the question at issue but also throw new side-lights on the whole problem of tuberculin
students observed
were as
reactions.
GOATS, COWS, AND ABORTION FROM time to time, at meetings of learned societies and in the medical press, the question is asked : What justification is there for the belief of many of the older farmers that a goat running with a herd of cows protects them from abortion ?‘l The answers have been numerous, varied, and unsatisfying. Scientific workers have generally looked for an immunological explanation. It has been supposed that Brucella melitensis, which causes natural infection in the goat, is able to immunise cows against Brucella abortus, which is the organism chiefly responsible for contagious abortion. Though ingenious and superficially attractive, this explanation will not hold water. In the first place goats in this country have never yet been found to be infected with Br. meUtensis;; and in the second place numerous observations have shown that Br. melitensis, so far from being harmless to cattle, often sets up in them a very active infection, sometimes accompanied by abortion and by excretion of the organisms in the milk. An explanation of quite a different character has recently been put forward in the correspondence columns of the Times. It has been pointed out that certain weeds, such as ragwort, the autumnal hawkbit, and woody nightshade, which are poisonous to cows and are supposed at times to cause abortion, It is sugare non-poisonous to sheep and goats. that these latter whether from animals, gested habit or from their of in certain feeding preference situations, eat up these plants before the cows can get at them. This explanation, even if correct, can apply only to non-contagious abortion which, so far as our present knowledge goes, constitutes but a small proportion of the total amount of abortion among cows in Great Britain. It follows that the protection afforded by the goat is likely to be local and sporadic rather than widespread and frequent. For this reason it is unlikely to be observed by more than a relatively few farmers. Perhaps this is why so many of them disbelieve in it. DEVELOPMENT OF TOOTH GERMS IN VITRO
AMONG the papers read at the annual meeting of the British Dental Association at Cambridge last August, there was one by Miss Shirley Glasstone describing the growth of tooth germs in vitro. Her work was done at the Strangeways Research Laboratory and this is, we believe, the first successful attempt to grow tooth germs artificially. Molar and incisor teeth from mammalian embryos were dissected out under sterile conditions and grown in the same way 1
Brit. dent. J.
Sept. 15th, 1937.
other tissue cultures. These explanted teeth continue to develop both histologically and morphologically. Where molar tooth germs have been explanted before cusp-formation has begun, deep cusps form which are approximately normal in size, number, and arrangement. The pulp cells differentiate into odontoblasts and deposit dentine and the ameloblasts show the beginning of enamel-formation. It has long been believed that the shape of teeth is determined by the enamel epithelium and that even in animals in which enamel is normally absent, such as the edentata, tooth-formation depends on the presence of specialised epithelium. This is borne out by the result of Miss Glasstone’s work. In cultures where the dentine is formed in contact with the epithelium it is deposited in a regular sheet ; but in the absence of epithelium the odontoblasts merely give rise to irregular bands of dentine. Further, the odontoblasts differentiate in vitro only in the presence of ameloblasts. If, for instance, in an explant devoid of epithelium the original odontoblasts degenerate, they are not replaced by any further differentiation of pulp cells. This suggests that the enamel epithelium exerts some influence on the pulp tissue. In addition to this work Miss Glasstone has collaborated with Prof. R. Robison, F.R.S., of the Lister Institute, in a study of the calcifying mechanism in normal embryonic teeth. They have obtained evidence that the process of the calcification of dentine is similar to that of bone. Early embryonic teeth of rats and rabbits have a high phosphatase activity equal to that of embryonic bones. Even more interesting is the fact that uncalcified dentine can be partly calcified by immersion in salt solutions like those that effect calcification of hypertrophic cartilage and osteoid tissue. Miss Glasstone is to be congratulated on her successful application of tissue culture methods to tooth germs. They seem likely to help us with some of the unsolved problems of tooth development and as
calcification. SPANISH REFUGEES
THE number of refugees so far evacuated from northern Spain exceeds 100,000. Of these Great Britain has accepted 4000 children on condition that they are wholly maintained by private subscription. The French Government is at present supporting about 50,000, and the conditions under which they live have lately been described by Commander H. Pursey, R.N.1 When the first refugees arrived it was possible to find them suitable quarters near the coast, but later this was out of the question, and now there are nearly a thousand camps and centres scattered all over France. The cost of feeding is borne by the French Republic, which allows 20 francs for an adult and 7 francs for a child per day ; but the other expenses fall on local, mainly voluntary, funds, " and the supply of such requirements as clothes depends on whether local organisations and people are sympathetic to the refugees or not." In August the Government of France announced that it could not undertake to provide for any more refugees, and could accept them only for transit to other countries. In practice this almost always means transit to Government Spain, and as immigration from Gijon and other Asturian ports continues France is pouring refugees by thousands into Catalonia over the only remaining safe railway line at Puigcerda. The number of homeless people.who have already found refuge in Catalonia-mostly 1
Manchester Guardian, Sept. 30th, 1937, p. 11.