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THE INVERSE RELATIONS BETWEEN PYREXIA AND GOUT.
EXTERNAL MUSCLES OF THE EYE & DIAGNOSIS OF OCULAR PARALYSIS. There are, however, still
a
few hundred Members
con-
stituting this society who consider it their duty, in spite official discouragement, to keep, as it were, the by-pass
of of reform alight until the time comes, as it certainly will, when College affairs will once more require full illumination. In the opinion of some competent observers the one-portal system of admission to the profession is already in sight. If the London Colleges hope to constitute that portal they will have to adopt a more liberal attitude towards the profes ion at large. Privilege and oligarchies are now completely out of date. I am, Sirs, yours faithfully, W. G. DICKINSON. Dec. 4th, 1905.
THE ACTION OF THE EXTERNAL MUSCLES OF THE EYE, AND THE DIAGNOSIS OF OCULAR PARALYSIS. To the Editors
of
THE
LANCET.
SIRS,-May I draw Dr. D. M. Mackay’s attention to a paper which appeared in the Clin;cal Journal of March 27th, 1895, entitled
"The
Position
I
1729
income have clearly marked inverse relations with gout. Thus recurrent bilious attacks, migraine, and gastralgia associated with anorexia, even simple dyspepsia, have long been noted to alternate in many cases with attacks of articular gout. Hence, doubtless, the anorexia and dyspepsia associated with most pyrexias, together with the febrile regimen enjoined, are efficient reinforcements of the exaggerated combustion. At any rate, they would all conduce to the dispersion of hyper-pyrsemia. It is easy to see how pyrexia prevents for the time being the recurrence of the gouty paroxysm. But it is less easy to understand the permanent cessation of articular gout which sometimes succeeds an attack of some specific fever. Here, however, the permanence of the result can often be explained indirectly. It is recognised that the specific fevers often introduce a"change in the constitution." There may follow more or less chronic dyspepsia, recurrent bilious attacks, some of the paroxysmal neuroses such as migraine or asthma ; or patients previously lean may become obese through enhanced power of fat-formation. And any of these would tend to prevent the re-development of I am, Sirs, yours faithfully, articular gout. FRANCIS HARE. London, W.C., Dec. 4th, 1905.
and Rotation of the False
Image in Paralytic Diplopia represented Diagrammatically"? SEVILLE AS A WINTER RESORT. The diagram which I there published shows the following points : (1) Direction of action of the muscles of the eyeball ; To the Editors of THE LANCET. (2) primary deviation of the eye in paralytic squint ; (3) in of the false of the image SiRS,—Seville has been "boomed" lately as a winter position diplopia ; (4) quality diplopia ; and (5) rotation or torsion of the false image both resort, offering especial advantages to those suffering from for vertical and horizontal images. I venture to think rheumatic and rheumatoid diseases. It is the earnest wish that this diagram is as " concise and easily grasped " as the of both Dr. Karminsky, the German doctor resident here, one Dr. Mackay publishes. and myself, the English doctor here, that the profession and I am, Sirs, yours faithfully, the public should understand that the matter has not got R. BRUCE FERGUSON, M.D. Cantab. beyond the experimental stage. We shall be glad to give New Dec. 1905. Southgate, N.,
2nd
2nd,
1905.
statistics
have collected sufficient cases. I am, Sirs, yours faithfully,
so soon as we
z
THE INVERSE RELATIONS BETWEEN PYREXIA AND GOUT. To the Editors of THE LANCET. SIRs,-In his letter on this subject in THE LANCET of Dec. 2nd, p. 1643, Mr. Joseph Birt pertinently asks whether the inverse relationship between acute disease and gout is to be ascribed to the pyrexia alone, no matter from what disease the pyrexia may have arisen. It is improbable that the origin of the pyrexia has pe1’ se allY bearing on the result, for gout has been dispersed for shorter or longer periods by pyrexias having the most diverse origins. Thus tonsillitis, bronchitis, pneumonia, rheumatic and typhoid fevers, small-pox, vaccination, and various septic conditions, traumatic and other, have all proved effectual. On the other hand, the intensity and duration of the pyrexia appear to be of material importance. After an attack of acute sthenic gout which has been allowed to run its full course the patient is commonly free for a time from all gouty symptoms, articular and abarticular. But there is every gradation between acute and chronic articular gout. In these gradations inflammatory reaction and pyrexia are present in descending degrees. And, conformably, it is found that prolonged arthritis, articular deformity, continued ill health, and liability to subsequent attacks are present in ascending degrees. In chronic articular gout, indeed, the patient remains frankly cachectic. Hence possibly the pyrexia of pneumonia is a more efficient preventive of gout than the pyrexia of the most violent gouty arthritis. It seems clear, however, that the pyrexia is salutary mainly in virtue of the increase of combustion implied in the process. For apyrexial conditions associated with increase of combustion are also effectual. Thus recurrent asthma, major epilepsy, and hard physical exercise of a purely physiological nature can be shown in some cases to have distinct inverse relations with recurrent articular gout. But it cannot be maintained that the increase of combustion is the sole salutary feature in pyrexia. I am arguing that exaggerated combustion operates by relieving the blood of its accumulated load of unoxidised or imperfectly oxidised carbonaceous material (hyper-pyrsemia). On this view any restriction of the carbonaceous income to the blood should also operate beneficially on gout. And it can be shown that many affections not usually associated with increased combustion but with diminished
-
JOHN DALEBROOK, M.A. Oxon., M.R.C.S. L.R.C.P. Lond. Seville, Nov. 25th, 1905.
Eng.,
TETANUS AND ANTITOXIN. To the Editors
of
THE LANCET.
ago I lost a brother from lockjaw ; I interest in the treatment of tetanus. In the Clinical Notes in THE LANCET of Dec. 2nd, I see reported" A Case of Tetanus Successfully Treated with I have read Antitoxin." the article most carefully but failed to find any improvement in the symptoms recorded until inhalations of chloroform were given, followed up by chloral and bromide of potassium. " The patient was fortunately able to swallow fluids during the whole illness," so the usual difficulty of administering suitable remedies by the mouth was absent. Having been in active practice for nearly half a century might I be allowed to ask you if there would be anything inconsistent with natural logic in suggesting that this patient got well from the rational treatmeitt by chloral and bromides in spite of the I am, Sirs, yours faithfully, antitoxin7 Dec. 4th, 1905. 73. H. H.
SIRS,-Many years naturally
therefore
take
"
-
A’.
T)
_..__
HAMMERSMITH
BOROUGH
COUNCIL
AND
THE
DIAGNOSIS OF DIPHTHERIA.—The public health committee of Hammersmith borough council reported recently that it had fully considered the advisability of providing the department with the necessary appliances for testing all doubtful cases of diphtheria before the patients are removed to the hospital. The committee was advised that the adoption of the proposal would involve considerable capital expenditure and heavy establishment expenses, and as an alternative it had gone into the advisability of making other arrangements whereby facilities could be given to medical men to obtain diagnoses at the council’s expense of suspected cases of diphtheria in the borough. The committee had ascertained that the pathological department of the West London Hospital would be prepared to undertake the bacteriological examination of specimens from the throats of persons suspected to be suffering from diphtheria at a fee of 5s. per The committee had resolved, subject to the usual case. sanction, to enter into an agreement with the West London Hospital authorities on the above basis for 12 months.
’
a
few hundred Members
con-
stituting this society who consider it their duty, in spite official discouragement, to keep, as it were, the by-pass
of of reform alight until the time comes, as it certainly will, when College affairs will once more require full illumination. In the opinion of some competent observers the one-portal system of admission to the profession is already in sight. If the London Colleges hope to constitute that portal they will have to adopt a more liberal attitude towards the profes ion at large. Privilege and oligarchies are now completely out of date. I am, Sirs, yours faithfully, W. G. DICKINSON. Dec. 4th, 1905.
THE ACTION OF THE EXTERNAL MUSCLES OF THE EYE, AND THE DIAGNOSIS OF OCULAR PARALYSIS. To the Editors
of
THE
LANCET.
SIRS,-May I draw Dr. D. M. Mackay’s attention to a paper which appeared in the Clin;cal Journal of March 27th, 1895, entitled
"The
Position
I
1729
income have clearly marked inverse relations with gout. Thus recurrent bilious attacks, migraine, and gastralgia associated with anorexia, even simple dyspepsia, have long been noted to alternate in many cases with attacks of articular gout. Hence, doubtless, the anorexia and dyspepsia associated with most pyrexias, together with the febrile regimen enjoined, are efficient reinforcements of the exaggerated combustion. At any rate, they would all conduce to the dispersion of hyper-pyrsemia. It is easy to see how pyrexia prevents for the time being the recurrence of the gouty paroxysm. But it is less easy to understand the permanent cessation of articular gout which sometimes succeeds an attack of some specific fever. Here, however, the permanence of the result can often be explained indirectly. It is recognised that the specific fevers often introduce a"change in the constitution." There may follow more or less chronic dyspepsia, recurrent bilious attacks, some of the paroxysmal neuroses such as migraine or asthma ; or patients previously lean may become obese through enhanced power of fat-formation. And any of these would tend to prevent the re-development of I am, Sirs, yours faithfully, articular gout. FRANCIS HARE. London, W.C., Dec. 4th, 1905.
and Rotation of the False
Image in Paralytic Diplopia represented Diagrammatically"? SEVILLE AS A WINTER RESORT. The diagram which I there published shows the following points : (1) Direction of action of the muscles of the eyeball ; To the Editors of THE LANCET. (2) primary deviation of the eye in paralytic squint ; (3) in of the false of the image SiRS,—Seville has been "boomed" lately as a winter position diplopia ; (4) quality diplopia ; and (5) rotation or torsion of the false image both resort, offering especial advantages to those suffering from for vertical and horizontal images. I venture to think rheumatic and rheumatoid diseases. It is the earnest wish that this diagram is as " concise and easily grasped " as the of both Dr. Karminsky, the German doctor resident here, one Dr. Mackay publishes. and myself, the English doctor here, that the profession and I am, Sirs, yours faithfully, the public should understand that the matter has not got R. BRUCE FERGUSON, M.D. Cantab. beyond the experimental stage. We shall be glad to give New Dec. 1905. Southgate, N.,
2nd
2nd,
1905.
statistics
have collected sufficient cases. I am, Sirs, yours faithfully,
so soon as we
z
THE INVERSE RELATIONS BETWEEN PYREXIA AND GOUT. To the Editors of THE LANCET. SIRs,-In his letter on this subject in THE LANCET of Dec. 2nd, p. 1643, Mr. Joseph Birt pertinently asks whether the inverse relationship between acute disease and gout is to be ascribed to the pyrexia alone, no matter from what disease the pyrexia may have arisen. It is improbable that the origin of the pyrexia has pe1’ se allY bearing on the result, for gout has been dispersed for shorter or longer periods by pyrexias having the most diverse origins. Thus tonsillitis, bronchitis, pneumonia, rheumatic and typhoid fevers, small-pox, vaccination, and various septic conditions, traumatic and other, have all proved effectual. On the other hand, the intensity and duration of the pyrexia appear to be of material importance. After an attack of acute sthenic gout which has been allowed to run its full course the patient is commonly free for a time from all gouty symptoms, articular and abarticular. But there is every gradation between acute and chronic articular gout. In these gradations inflammatory reaction and pyrexia are present in descending degrees. And, conformably, it is found that prolonged arthritis, articular deformity, continued ill health, and liability to subsequent attacks are present in ascending degrees. In chronic articular gout, indeed, the patient remains frankly cachectic. Hence possibly the pyrexia of pneumonia is a more efficient preventive of gout than the pyrexia of the most violent gouty arthritis. It seems clear, however, that the pyrexia is salutary mainly in virtue of the increase of combustion implied in the process. For apyrexial conditions associated with increase of combustion are also effectual. Thus recurrent asthma, major epilepsy, and hard physical exercise of a purely physiological nature can be shown in some cases to have distinct inverse relations with recurrent articular gout. But it cannot be maintained that the increase of combustion is the sole salutary feature in pyrexia. I am arguing that exaggerated combustion operates by relieving the blood of its accumulated load of unoxidised or imperfectly oxidised carbonaceous material (hyper-pyrsemia). On this view any restriction of the carbonaceous income to the blood should also operate beneficially on gout. And it can be shown that many affections not usually associated with increased combustion but with diminished
-
JOHN DALEBROOK, M.A. Oxon., M.R.C.S. L.R.C.P. Lond. Seville, Nov. 25th, 1905.
Eng.,
TETANUS AND ANTITOXIN. To the Editors
of
THE LANCET.
ago I lost a brother from lockjaw ; I interest in the treatment of tetanus. In the Clinical Notes in THE LANCET of Dec. 2nd, I see reported" A Case of Tetanus Successfully Treated with I have read Antitoxin." the article most carefully but failed to find any improvement in the symptoms recorded until inhalations of chloroform were given, followed up by chloral and bromide of potassium. " The patient was fortunately able to swallow fluids during the whole illness," so the usual difficulty of administering suitable remedies by the mouth was absent. Having been in active practice for nearly half a century might I be allowed to ask you if there would be anything inconsistent with natural logic in suggesting that this patient got well from the rational treatmeitt by chloral and bromides in spite of the I am, Sirs, yours faithfully, antitoxin7 Dec. 4th, 1905. 73. H. H.
SIRS,-Many years naturally
therefore
take
"
-
A’.
T)
_..__
HAMMERSMITH
BOROUGH
COUNCIL
AND
THE
DIAGNOSIS OF DIPHTHERIA.—The public health committee of Hammersmith borough council reported recently that it had fully considered the advisability of providing the department with the necessary appliances for testing all doubtful cases of diphtheria before the patients are removed to the hospital. The committee was advised that the adoption of the proposal would involve considerable capital expenditure and heavy establishment expenses, and as an alternative it had gone into the advisability of making other arrangements whereby facilities could be given to medical men to obtain diagnoses at the council’s expense of suspected cases of diphtheria in the borough. The committee had ascertained that the pathological department of the West London Hospital would be prepared to undertake the bacteriological examination of specimens from the throats of persons suspected to be suffering from diphtheria at a fee of 5s. per The committee had resolved, subject to the usual case. sanction, to enter into an agreement with the West London Hospital authorities on the above basis for 12 months.
’