SUCCESSFUL REVACCINATION

464 JOINT CHANGES IN CANCER OF THE LUNG SIR,-Your annotation of March 22 almost coincided with a report by me to the section of medicine of the Royal Society of Medicine of 3 cases of gross pulmonary osteoarthropathy with lung cancer, which have come under my care during the past three years. In these cases the lung tumours were practically symptomless, and the connexion between the joint and lung conditions In all, however, chest was not immediately apparent. radiology in the anteroposterior and lateral planes revealed a tumour, while additional investigations revealed the precise nature of the lung lesion. All 3 me cases were referred to as examples of atypical rheumatoid arthritis. CASE I.-This was a man of 55 whom I- saw at the Rheumatism Unit of the London County Council on account of pain, swelling, and stiffness of both knees, thickening of the long hones, and marked crippling. Examination revealed a rheumatoid type of lesion with effusions into both knee-joints. Examination of the synovial fluid showed a cytology typical of a non-specific rheumatoid lesion. The condition was complicated by gross pulmonary osteoarthropathy with an ossifying periostitis of the radius, ulna, femora, tibiae, and nbulse. The fingers, toes, and even the nose showed gross clubbing. There were no symptoms referable to the chest, but investigation showed a well-defined opacity in the right upper lobe. Mr. R. C. Brock, who kindly saw the patient for me, decided that his condition would only permit a lobectomy. Subsequent histological investigations showed the growth to Almost immediately after its ’ be a bronchial carcinoma. removal the knee-joint swellings began to subside, and the fingers, toes, and nose became less clubbed ; now, nearly two years later, the joint and soft-tissue swellings have almost completely subsided. CASE 2.-A man, aged 48, had similar physical signs and was likewise operated on by Mr. Brock. Secondary mediastinal-gland involvement was treated with deep X-ray therapy, which unfortunately flared up a latent tuberculous focus that was not revealed clinically or radiologically ; and he succumbed to this. CASE 3.-This patient, a man aged 53, is at present under investigation. I first saw him a month ago as a case of " polyarthritis." The history was of rather sudden onset of pain, swelling, and stiffness of the knees some twelve months previously, followed within a month by swellings of the ankles, fingers, and toes. The swellings subsided after a month in bed, and the patient resumed work in spite of disablement. Six months later recurring joint swellings increased his crippledom, and three months ago he was obliged to give up his work. When I saw him he presented a clinical picture’ of a somewhat acute rheumatoid arthritis ; he was febrile (99-100° F) ; there was pronounced anemia, with lymphadenopathy but no clinical enlargement of the spleen. The joint changes included effusions into both knees and some involvement of the wrists, left elbow, left shoulder, and ankles ; and the condition was complicated by gross clubbing of the fingers and toes and thickening of the long bones. Clinical examination of the chest showed no localising physical signs. The knee-joint fluid was typical of a non-specific rheumatoid lesion. X-ray examination of the chest showed in the lateral view a well-defined rounded opacity, 21/2 in. in diameter, lying in the posterior basal segment of the right lower lobe. Although bronchoscopy has revealed little abnormal the findings favour a peripheral carcinoma of the lung. Mr. Brock will be seeing the case for me with a view to thoracotomy and possibly pneumonectomy.

In neither of the first 2 cases was there any real evidence of extensive tissue breakdown or appreciable infection ; and the association of the joint and lung conditions on the basis of infection alone or of anoxia (suggested as possible causes) is difficult to explain. The potential significance of the pituitary in relation to the aetiology of chronic arthritis has received some attention in recent years, and the connexion between acromegaly and pulmonary osteoarthropathy has been noted by Fried1 in his work on lung cancer. He has advanced the theory that the diffuse pulmonary osteoarthropathy found in some cases is probably due to a akin to acromegaly. The possible relation of endocrine imbalance to chronic arthritis and pulmonary

dyspituitarism

1. Fried, B. M.

Arch. intern. Med. 1943, 72, 565.

osteoarthropathy

in these cases is significant, although pathogenesis of diffuse pulmonary osteoarthropathy;, (Bamberger-Marie’s disease) is as obscure today as when it was first described by Bamberger and Pierre Marie in 1889 and 1890 respectively. Can one postulate, as Crump2 has done, an abnormal substance circulating in the blood, affecting the periosteum, the bones, the joints, and the soft parts of the terminal phalanges as evidenced by clubbing of the fingers ? And might not the lungs-" pulmonary glands," as Aschoff 3 among others has suggested-take on additional functions as secretory organs ? Certainly the association of joint changes, osteoarthropathy, and lung cancer is worthy of more detailed investigation.

the

PHILIP ELLMAN.

London, W.l. HEALTH INSURANCE IN

THE

UNITED STATES

Sin,—The commercial insurance interests of America are seeing to it that the proposed Federal health insurance scheme, backed by President Truman, does not become law-not if they can help it. Here is a sample of one of their widely circulated leaflets, headed Socialised Medicine -Bad Medicine for You!! Dr. Edward H. Ochsner of

Chicago testified at the recent Bill hearings in Washington that This is how it was in .BfMM, :: The doctor got back to his office just at 2 o’clock. " How " many ? " he said to his nurse. Forty." Casually, without hurry, he put on his white jacket and poked his head into the waiting-room where the forty patients sat : "Will those of you with headache please stand ? he said. Six stood. The doctor took identical printed prescriptions out of his desk and handed one to each of the six and dismissed them. "Will those of you troubled with a cough please stand ? " Another group got up and again he handed them printed prescriptions and dismissed them. The others he took one by one into his private office for a few minutes. Two hours later the office was empty, the 40 patients gone, an average of 3 minutes per patient. In Germany, under compulsory insurance, some doctors did even better-30 to 40 patients in one hour !

Wagner-Murray

"

This same leaflet lectures insurance managers to be active on the political war-path. " It is, of course, not natural for executives whose job it is to smell a dollar to delve into this field, because there can’t be a profit-the objective being merely to avoid losing money. But it is a matter of large import to private insurance from the long-range standpoint. We need only recall that England has had a cash sickness scheme since 1911 and now industrial life insurance and workmen’s compensation have become lost to commercial insurers ! RONALD DAVISON. Shiplake.

more

"

SUCCESSFUL REVACCINATION SIR,-Ifrequently dispute two widely held inferences about revaccination : that an earlv reaction is evidence of immunity, and that " no reaction " is unacceptable because it is due to failure to vaccinate properly. I welcome Dr. Broom’s paper (March 22) as supporting my views. For revaccination to be properly performed and recorded there are four essentials : the lymph must be potent ; the technique must be correct ; the reading of the reactions must be accurate ; and the interpretations of the findings must be true. I maintain that today it is possible for every one of these factors to be at fault and yet for the subject to be certified as successfully vaccinated. Paradoxically it is the desire to eliminate such faults, by refusing to accept a "no reaction," which has been largely responsible for recent reports of a high incidence of smallpox among the recently vaccinated. It is but a short step from the standpoint that " there must be some reaction to vaccination " to the erroneous and dangerous assumption that any sort of reaction is evidence’ of successful vaccination and no reaction is proof of failure. It is precisely among those early" reactions which are called " reactions of immunity that the most serious errors of interpretation are made. The explanation of my views will be helped if the term immunity is avoided and the subject is considered ’

.

"

2. Crump, C. 3. Aschoff, L.

Virchours Arch. 1929, 271, 467. Z. ges. exp. Med. 1926, 50, 52.

465 in terms of susceptibility. Vaccination ig both a test of susceptibility and an immunising inoculation. The highly susceptible respond by a typical p1’imary vaccinia; the less susceptible show a so-called accelerated reaction,

which is better described as an abortive vaccinia or while the insusceptible show no visible vaceinoid; response at all, as in 238 of Dr. Broom’s 1227cases. Besides these responses others may appear which are not concerned directly with susceptibility ; of these, the most important is the sensitivity reaction to products The reaction develops of the virus, living or dead. in some of those who have had previous experience of vaccine lymph. It may occur in all the above groupsthe highly susceptible, the less susceptible, and the insusceptible-although it is true that there is some association between sensitivity and immunity, because sensitivity implies previous exposure to the virus and an opportunity of acquiring resistance. Now, Sir, despite a vast literature on immunology and allergy, the distinction between immunity and sensitivity is still confused ; and frequently reactions of sensitivity are accepted as evidence of immunity. In vaccination this is particularly dangerous, because vaccination requires the use of a living virus and the sensitivity response can occur with inactive lymph, as the 110 control reactions in Dr. Broom’s series show. It comes to this : if revaccination is followed by primary vaccinia or aborted vaccinia, the subject is susceptible and the vaccination has boosted his resistance to a safe level. (It would help enormously if we restricted the term " successful vaccination " to the susceptible and held that the immune cannot be successfully vaccinated.) If revaccination is followed by an early reaction or by no reaction, no positive inference can be drawn as to the susceptibility of the individual. The early reaction may be specific, non-specific, or traumatic. If specific, it may be a sensitivity response to the products of the virus, living or dead. What is certain is that it is not a reaction of immunity, and this term should be dropped. On the other hand, if no reaction occurs the vaccination may be faulty in some way or the subject may be immune. In face of this uncertainty repeated revaccination may be desirable, but no further inferences For these can be drawn beyond those stated above. reasons I agree with Dr. Broom in advocating a change in the international certificate of vaccination. River Hospitals, Joyce Green, MAURICE MITMAN. Dartford.

INFANTILE INSOMNIA AND MATERNAL GRAVES’S DISEASE

Sm,-The following case-histories show that infantile insomnia may be the presenting symptom of maternal Graves’s disease, and they are also interesting as a study in the emotional relationship between mother and child. Mrs. A

to the outpatient department with her first 5 months. Her complaint was that the baby never slept for more than an hour or two consecutively., The baby proved to be a fine healthy if over-active bottle-fed girl, weighing 14 lb. 12 oz. and looking the picture of health. Her mother, however, said that she herself had lost 10 lb. in weight since the birth of her child. The mother was found to have tachycardia, with a pulse-rate of 100 per min. at rest, slight exophthalmos, a visible swelling of the thyroid, and a fine tremor of her fingers. came

child, aged

Mrs. B, the mother of two boys, separated from her husband for the past year because he had to work in Wales while the home remained in London, brought her son, aged 2 years, with the complaint that he was very restless at night, sleeping a total of 4 hours only. With him came his brother, aged 4 years. They were tough noisy healthy children, over whom their mother had little control. She looked worn out, had wellmarked exophthalmos of some years’ standing, a pulse-rate of 110 per min. at rest, tremor of the fingers and hands, a palpable swelling of her thyroid, and obvious over-anxiety. Mrs. C, an excitable Jewish mother, brought her first child, aged 9 months, with the complaint that the baby girl

apparently

never

slept

either

lackadaisical over-fed child,

day

or

night.

She

was a

large

constipated but otherwise healthy,

over 20 lb. She was in the process of being weaned and had a good mixed diet in addition to four breast feeds daily. The mother was stout, florid, and emotional. She

weighing

she had lost weight herself, but did not know how She had a very variable pulse-rate which was consistently over 100 per min. at rest. Her exophthalmos was not pronounced, but she had a lid-lag and a fine tremor of her fingers. She said her nerves had been bad since she had tried to wean the baby at 6 months and had failed. All these children slept within earshot of their mothers, the two girls in the same room and the boy in the next room with an open communicating door. In the first two histories there was no question of the babies getting too much thyroxine from their mothers’ breast milk, and, although this is a possibility in the last instance, the appearance of positive health with a regular gain in weight in all these infants belied their mothers’ stories of insomnia. It seems probable that they were normal healthy babies whose every cry or movement was heard by an overanxious parent, and whose insomnia if not entirely imagined was induced by their mothers, who picked them up and generally disturbed them every time they so much as whimpered or turned in their sleep. All three patients came to the outpatient department of the Hospital for Sick Children, Great Ormond Street, within a vear. The mothers had to be sent elsewhere for confirmation of the diagnosis and treatment. This confirmation was obtained from the adult hospital in each case. No treatment was given to the children, two of whom are reported, in reply to a written query, to be sleeping well, while their mothers, who are at home, These two say they themselves are much improved. mothers are being treated with thiouracil; the other one has not yet left hospital. I wish to thank the honorary staff of the Hospital for Sick Children for permission to publish these case-histories. R. E. BONHAM CARTER. Institute of Child Health, Hospital for Sick Children,

thought much.

Great Ormond Street.

THIOCYANATE FOR HYPERTENSION

SiR,-In his article of March 15 Dr. Mills claims that

potassium thiocyanate produced striking symptomatic relief in 27 cases of benign hypertension in which headache and dizziness were prominent symptoms. He states, however, that the drug does not permanently lower the blood-pressure, even in cases in which there is much symptomatic relief. These results are at variance with those of other workers published in the past ten years. They have claimed to produce relief of symptoms in a much smaller proportion of cases, but have often found a reduction of blood-pressure. A typical example is the report of Barker et al. on a carefully controlled series of 246 hypertensives treated with thiocyanate for 2-11 Persistent symptomatic improvement occurred years. in 56 %, and reduction of blood-pressure by 30/20 mm. or more was obtained in 67 %., Dr. Mills’s failure to lower the blood-pressure was probably due to inadequate dosage. He aimed at a blood thiocyanate of 5-8 mg. per 100 ml., whereas previous ‘

writers have found 8-12 mg. necessary. One wonders whether the doses Dr. Mills used could have had much real effect on the patients.. In considering the claims of any treatment to relieve the symptoms of hypertension without lowering the blood-pressure, the work of Ayman2 should be borne in mind. He produced decided symptomatic relief in 82 % of a series of hypertensives by administering solemnly and with enthusiasm doses of coloured water. Beverley Emergency Hospital, S. G. SIDDLE. East Yorks.

SiR,-Dr. Geoffrey Evans has asked me to correct a mistake in my paper in your issue ofMarch 15. I stated that in his paper with Dr. D’Silva he maintained " that some benefit was derived from this drug in all cases." Apparently I had not made my meaning clear. I wished to point out that although they likewise found that headache was the symptom which was most relieved by potassium thiocvanate, they also found that all symptoms obtained some benefit in certain cases-for example, insomnia and mental changes (lack of concentration). I was unable to confirm any benefit in cases with such Barker, M. H., Lindberg, H. A., Wald, M. H. Ass. 1941, 117, 1591. 2. Ayman, D. Ibid, 1930, 95, 246.

1.

J. Amer. med.