- Email: [email protected]
THE LIBERTY OF THE SUBJECT.
300 and Siam,while an observer was sent by the United States of America. The conference is reported to have adopted a new agreement and final Act dealing with the prohibition of the retail of smoking opium through persons receiving commissions ; the definition of minors to whom smoking is forbidden ; penalties for inciting minors to smoke; and prohibiting the sale of prepared opium otherwise than for cash. The conference does not appear to have fixed a date from which the 15 years allowed by the Geneva convention for the gradual suppression of opium smoking was to commence. The representative of the United States demurred to the implied double standard whereby governments with Far Eastern possessions sanctioned opium smoking therein while proscribing it absolutely He likewise opposed a in the home countries. government monopoly system which was favoured by other members of the conference, and indeed he .contended " that there is but one real method by which to suppress the evil of opium smoking, and that .is complete statutory prohibition of the importation, manufacture, sale, possession, or use of prepared
- opium."
--
____
THE LIBERTY OF THE SUBJECT.
WHAT PROMOTES TUBERCULOSIS MOST?
IT is
pretty safe
to say that if
a score or
two of
.authorities on tuberculosis were asked this question, ,they would not agree over the answer. In other .--words, we are still to a certain extent in the dark - over the most important question that can be raised in this field. Dr. 0. Scheel,1 chief of a medical - service of the Ullevaal communal hospital of Oslo, ’has lately set out his view that the standard of living is far and away the most important factor in tuber-
culosis, and that the age at which infection occurs, the intensity of infection, recurrent super-infections, sanatorium treatment, and various other factors play
subsidiary, and perhaps even a negligible role. None of the elements of this thesis is new, and at the present time few would deny the importance of the general standard of living in relation to immunity to tuberculosis. The mass experiment in Germany during the late war is in this connexion unanswerable. But Dr. Scheel is greatly daring in this:that he brushes aside as unimportant all the other factors a
which
are
supposed
to
play a part
in
tuberculosis,
and which have determined the expenditure of enormous sums of money during the past half century.
Long
before the
discovery
of the tubercle bacillus
and the campaign against tuberculosis as an infectious .disease was started, the mortality from tuberculosis as well as the general mortality had begun to decline. And while it is thus impossible to correlate the decline in tuberculosis exclusively with the modern campaign against it as an infectious disease, it is possible to .establish an intimate association with this decline and the rise in the standard of living for which modern industry is responsible. It has been calculated that during the four centuries before 1880, the stature of the average
So far Dr. Scheel is on fairly safe ground. He becomes more interesting as he leaves this ground to skate on thin ice by challenging Newsholme’s verdict in 1906 that the principal cause of the decline in tuberculosis is the campaign waged against it as an infectious disease. In 1928 there were about 30,000 infectious cases of tuberculosis in Norway, with only 5300 beds set aside for them. In other words, Norway cannot expect to isolate more than some 18 per cent. of her infectious tuberculous cases. Complete isolation of all her infectious cases will, in Dr. Scheel’s opinion, never be feasible. Partial isolation merely has the effect of deferring the age of infection in a certain proportion of the population, nearly all of which, however, is tuberculin-positive at the age of 30. Does putting off the evil day, from infancy or childhood to adolescence or early adult life, matter much ? As far as girls are concerned, Dr. Scheel greatly doubts if it is better to be infected between the ages of 15 and 20 than at school age. He is also sceptical about the importance of the degree of infection, of super-infections, and of sanatoriums either as isolation or as therapeutic establishments.
living.
Norwegian
increased
by
4 cm. Between 1880 and 1926 it increased by 2-5 to 3 cm., if measurements of recruits during this latter period can be applied to the whole population.
Similar increases of stature have been observed in several other countries. Measurements in Norway of young adults belonging to different social classes have shown that the stature of the average man rises with his social status-another proof that stature is .determined, to a certain extent, by the standard of 1 Acta Med. Scand., 1931, Fasc. I.-III.
THE Medico-Legal Society’s discussion last week, like most other discussions on the Liberty of the Subject, covered a very wide field. Dr. L. A. Weatherly gave his views on the regulations under the Defence of the Realm Act, abortion, the legal position of alcoholics, and the segregation of mental defectives. As a veteran psychiatrist, he devoted a large portion of his address to the working of the Mental Treatment Act and criticised the Board of Control for what he described as a " bureaucratic attitude.’’ He also blamed many large municipalities for not establishing juvenile courts in connexion with their police-courts, and for not administering the Probation of Offenders Act in as full a measure as it could be administered. This accusation drew from Mr. Claud Mullins, the wellknown writer on law reform, an excellent defence of magistrates in general. Mr. Mullins, himself a magistrate, agreed completely with Dr. Weatherly on the stupidity of many of the minor regulations which had to be enforced in the police-court. He said that he wished that legislators, when passing new restrictive laws, would sometimes consider the question not only whether a certain state of affairs was desirable but whether the laws could be enforced, and whether the effort to enforce them was worth while. On the previous day, he said, he had spent an hour of his public time discussing whether a black-currant pastille was properly so-called when it contained no currant. His deliberations had been complicated by the fact that two learned analysts had sent him two independent and completely different reports on the composition of the pastilles in question. The number of regulations which he was expected to enforce was, he said, amazing, and they all meant a certain amount of interference with liberty and considerable expense to the public. On the subject of probation he uttered a muchneeded reminder that the probation of offenders was capable of serious misuse. It had, he said, been noised abroad that the effect of the Act was to allow every dog to haveone bite-a dangerous doctrine. It was constantly reported to him by policemen and missionaries that young offenders said, " Oh, the Beak will bind me over ; it’s a first offence," even when the offence was that of driving away an uninsured
301
Igenerally
motor-car by a boy unfitted to handle it. He wished believed that the liver plays an important that a method of restricting liberty existed half-way part in removing free haemoglobin from the circulation between probation and imprisonment. Finally, on when, for any reason, red cells have been broken up another matter, he made the pertinent inquiry in the blood, and it is something of a surprise to learit whether the State, now that it assumed responsibility from some recent work by Profs. R. Muir and for giving every life a chance, might not have some J. S. Young1 that this too is in doubt. When a single say in the question whether in a given case a life large dose of dissolved haemoglobin is injected intrashould ever exist. It was significant that every venously, none is excreted in the bile nor do the liver other speaker advocated some form of restriction cells show any evidence of hemoglobin or of an of liberty ; the consensus of opinion was that the iron-containing pigment. The cells of the convoluted nation was suffering, like Lucio’s friend in Measure tubules of the kidney, on the other hand, gave a For Measure, from "Liberty; too much liberty." diffuse reaction for iron which, after two or three days, Liberty demands a sense of responsibility, and only took on a granular form. The spleen was found normal those prepared to take responsibility can claim it. in all respects. When smaller doses were given over a longer period, a marked siderosis of the convoluted tubules of the kidneys was produced. It is known TUMOURS OF THE BILE-DUCTS. that haemoglobin free in the blood plasma passes. DURING the 20 years 1910-29 53 tumours of the through the glomeruli and it is, no doubt, by reabsorpbile-ducts were observed at the Mayo Clinic, all tion that it finds its way into the cells of the tubules.. except four of them being malignant. Dr. James M. This is apparently why a certain amount of haemoMarshall has collected and analysed these cases in a globinaemia may exist without any haemoglobinuria. recent papery Benign tumours of the extra-hepatic The liver, on the other hand, showed relatively slight ducts, of which H. D. Rolleston and J. W. McNee i or hardly any accumulation of iron, either in the liver cells themselves or in the Kupffer cells. And the’ found only ten cases on record in 1929, are authors are disinclined to believe that such increase or adenofibromatous. papillomatous, fibromatous, Two of Marshall’s cases were adenofibromata, one a i in the liver as they found really represents any active in haemoglobin. Both spleen and bone-marrow papilloma and one a congenital cyst of the cystic duct. showed more than the normal quantum of hsemoThe 49 malignant tumours were all examples of
usually
interest
primary carcinoma.
Operation
was
performed
in
45 cases, and in four the condition was found at autopsy. Three-fourths of the patients were over 50 years of age, the youngest being aged 23 years ; 31 were males, and 18 females. Gall-stones were .present in the gall-bladder or ducts or both in 21 cases (43 per cent.). The commonest sites of the tumours were the lower end of the common bile-duct and the ampulla of Vater. The usual clinical picture was that of obstructive jaundice, which was present in 44 cases, and varied in degree from slight to extreme. Marked loss of weight was seen in 45 patients and was the most striking manifestation after jaundice. Pain was absent in 15 cases throughout the entire course of the illness, and therefore the presence or absence of pain appears to be of little, if any, diagnostic significance. Pruritus was a prominent symptom in 25 cases, and in several it was the chief complaint. Spontaneous haemorrhages occurred in 16 cases. Of the 45 patients on whom operation was performed for carcinoma 19 (42-2 per cent.) died within 30 days, 26 survived for an average period of 17-3 months; of these three were still living, respectively, seven months, 20 months, and 34 months after the operation, and in six patients the results were unknown. The high operative mortality is attributed to the tendency to
hemorrhage and technical difficulties on the biliary tract.
of
operations
---
THE LIVER AND HÆMOGLOBIN. IT used to be supposed that it was the business of the liver to make bile-pigments out of the remains of red corpuscles. The haematoidin crystals in old haemorrhages showed that the manufacture of bilirubin was not the sole prerogative of the liver, but ’it has been left to recent experimental research to show that the tissues of the body generally have this capacity. The point which remains in doubt is whether the liver can do it at all ; the facts are consistent with the interpretation that its only share in the process is to pick up bile-pigment from the blood and pass it into the bile-ducts. But it has still been 1 Surg., Gyn.,
and
Obst., January, 1932.
siderin and presumably take their parts in of a haemoglobinaemia.
disposing
-
ANÆMIA WITH
DYSPHAGIA.
THE recrudescence of interest in secondary anaemia, last few years has brought into prominence what has been called the Plummer-Vinson syndrome. In 1922 Vinson associated the peculiar dysphagia, first described eight years previously by Plummer, with a severe secondary an2emia, and we now have records of many cases belonging to this group, a summary being published in 1928 by J. A. Munro Cameron.2 The main points in the syndrome are that the mucosa of the mouth, pharynx, and œsophagus shows inflammatory changes producing dysphagia, and that the patients exhibit severe an2emia of secondary type. It has been claimed that relief of the dysphagia, which can sometimes be brought about by the mere passage of a tube, will so improve the food intake that the anemia dis3 appears. Dr. George Graham and Dr. R. S. Johnson now report a series of cases in which they have observed that besides the syndrome as described, there is a definite increase in the fragility of the red blood corpuscles. They call attention to the colour of the skin, which is of a brownish-yellow tint rather than the so-called lemon-yellow of pernicious anaemia. Achlorhydria was present in all their cases, but the histamine test was not performed, and therefore they are unable to say whether the achlorhydria was absolute. On careful test of the fragility of the red corpuscles they found that usually haemolysis began in concentrations of normal saline higher than 0-50, and was always complete at 0-40. The distinction from acholuric jaundice was confirmed, apart from the dysphagia, by the absence of excess of bilirubin from the blood-serum, whilst the achlorhydria was further evidence. Graham and Johnson are unable to confirm the reported cure of such cases by the simple administration of a full ordinary diet, but found that the anemia rapidly improved when
during the
1 Jour. Path. and Bact., 1932, xxxv., 113. 2 Quart. Jour. Med., 1928, xxii., 43. 3
Ibid., January, 1932, p. 41.
- opium."
--
____
THE LIBERTY OF THE SUBJECT.
WHAT PROMOTES TUBERCULOSIS MOST?
IT is
pretty safe
to say that if
a score or
two of
.authorities on tuberculosis were asked this question, ,they would not agree over the answer. In other .--words, we are still to a certain extent in the dark - over the most important question that can be raised in this field. Dr. 0. Scheel,1 chief of a medical - service of the Ullevaal communal hospital of Oslo, ’has lately set out his view that the standard of living is far and away the most important factor in tuber-
culosis, and that the age at which infection occurs, the intensity of infection, recurrent super-infections, sanatorium treatment, and various other factors play
subsidiary, and perhaps even a negligible role. None of the elements of this thesis is new, and at the present time few would deny the importance of the general standard of living in relation to immunity to tuberculosis. The mass experiment in Germany during the late war is in this connexion unanswerable. But Dr. Scheel is greatly daring in this:that he brushes aside as unimportant all the other factors a
which
are
supposed
to
play a part
in
tuberculosis,
and which have determined the expenditure of enormous sums of money during the past half century.
Long
before the
discovery
of the tubercle bacillus
and the campaign against tuberculosis as an infectious .disease was started, the mortality from tuberculosis as well as the general mortality had begun to decline. And while it is thus impossible to correlate the decline in tuberculosis exclusively with the modern campaign against it as an infectious disease, it is possible to .establish an intimate association with this decline and the rise in the standard of living for which modern industry is responsible. It has been calculated that during the four centuries before 1880, the stature of the average
So far Dr. Scheel is on fairly safe ground. He becomes more interesting as he leaves this ground to skate on thin ice by challenging Newsholme’s verdict in 1906 that the principal cause of the decline in tuberculosis is the campaign waged against it as an infectious disease. In 1928 there were about 30,000 infectious cases of tuberculosis in Norway, with only 5300 beds set aside for them. In other words, Norway cannot expect to isolate more than some 18 per cent. of her infectious tuberculous cases. Complete isolation of all her infectious cases will, in Dr. Scheel’s opinion, never be feasible. Partial isolation merely has the effect of deferring the age of infection in a certain proportion of the population, nearly all of which, however, is tuberculin-positive at the age of 30. Does putting off the evil day, from infancy or childhood to adolescence or early adult life, matter much ? As far as girls are concerned, Dr. Scheel greatly doubts if it is better to be infected between the ages of 15 and 20 than at school age. He is also sceptical about the importance of the degree of infection, of super-infections, and of sanatoriums either as isolation or as therapeutic establishments.
living.
Norwegian
increased
by
4 cm. Between 1880 and 1926 it increased by 2-5 to 3 cm., if measurements of recruits during this latter period can be applied to the whole population.
Similar increases of stature have been observed in several other countries. Measurements in Norway of young adults belonging to different social classes have shown that the stature of the average man rises with his social status-another proof that stature is .determined, to a certain extent, by the standard of 1 Acta Med. Scand., 1931, Fasc. I.-III.
THE Medico-Legal Society’s discussion last week, like most other discussions on the Liberty of the Subject, covered a very wide field. Dr. L. A. Weatherly gave his views on the regulations under the Defence of the Realm Act, abortion, the legal position of alcoholics, and the segregation of mental defectives. As a veteran psychiatrist, he devoted a large portion of his address to the working of the Mental Treatment Act and criticised the Board of Control for what he described as a " bureaucratic attitude.’’ He also blamed many large municipalities for not establishing juvenile courts in connexion with their police-courts, and for not administering the Probation of Offenders Act in as full a measure as it could be administered. This accusation drew from Mr. Claud Mullins, the wellknown writer on law reform, an excellent defence of magistrates in general. Mr. Mullins, himself a magistrate, agreed completely with Dr. Weatherly on the stupidity of many of the minor regulations which had to be enforced in the police-court. He said that he wished that legislators, when passing new restrictive laws, would sometimes consider the question not only whether a certain state of affairs was desirable but whether the laws could be enforced, and whether the effort to enforce them was worth while. On the previous day, he said, he had spent an hour of his public time discussing whether a black-currant pastille was properly so-called when it contained no currant. His deliberations had been complicated by the fact that two learned analysts had sent him two independent and completely different reports on the composition of the pastilles in question. The number of regulations which he was expected to enforce was, he said, amazing, and they all meant a certain amount of interference with liberty and considerable expense to the public. On the subject of probation he uttered a muchneeded reminder that the probation of offenders was capable of serious misuse. It had, he said, been noised abroad that the effect of the Act was to allow every dog to haveone bite-a dangerous doctrine. It was constantly reported to him by policemen and missionaries that young offenders said, " Oh, the Beak will bind me over ; it’s a first offence," even when the offence was that of driving away an uninsured
301
Igenerally
motor-car by a boy unfitted to handle it. He wished believed that the liver plays an important that a method of restricting liberty existed half-way part in removing free haemoglobin from the circulation between probation and imprisonment. Finally, on when, for any reason, red cells have been broken up another matter, he made the pertinent inquiry in the blood, and it is something of a surprise to learit whether the State, now that it assumed responsibility from some recent work by Profs. R. Muir and for giving every life a chance, might not have some J. S. Young1 that this too is in doubt. When a single say in the question whether in a given case a life large dose of dissolved haemoglobin is injected intrashould ever exist. It was significant that every venously, none is excreted in the bile nor do the liver other speaker advocated some form of restriction cells show any evidence of hemoglobin or of an of liberty ; the consensus of opinion was that the iron-containing pigment. The cells of the convoluted nation was suffering, like Lucio’s friend in Measure tubules of the kidney, on the other hand, gave a For Measure, from "Liberty; too much liberty." diffuse reaction for iron which, after two or three days, Liberty demands a sense of responsibility, and only took on a granular form. The spleen was found normal those prepared to take responsibility can claim it. in all respects. When smaller doses were given over a longer period, a marked siderosis of the convoluted tubules of the kidneys was produced. It is known TUMOURS OF THE BILE-DUCTS. that haemoglobin free in the blood plasma passes. DURING the 20 years 1910-29 53 tumours of the through the glomeruli and it is, no doubt, by reabsorpbile-ducts were observed at the Mayo Clinic, all tion that it finds its way into the cells of the tubules.. except four of them being malignant. Dr. James M. This is apparently why a certain amount of haemoMarshall has collected and analysed these cases in a globinaemia may exist without any haemoglobinuria. recent papery Benign tumours of the extra-hepatic The liver, on the other hand, showed relatively slight ducts, of which H. D. Rolleston and J. W. McNee i or hardly any accumulation of iron, either in the liver cells themselves or in the Kupffer cells. And the’ found only ten cases on record in 1929, are authors are disinclined to believe that such increase or adenofibromatous. papillomatous, fibromatous, Two of Marshall’s cases were adenofibromata, one a i in the liver as they found really represents any active in haemoglobin. Both spleen and bone-marrow papilloma and one a congenital cyst of the cystic duct. showed more than the normal quantum of hsemoThe 49 malignant tumours were all examples of
usually
interest
primary carcinoma.
Operation
was
performed
in
45 cases, and in four the condition was found at autopsy. Three-fourths of the patients were over 50 years of age, the youngest being aged 23 years ; 31 were males, and 18 females. Gall-stones were .present in the gall-bladder or ducts or both in 21 cases (43 per cent.). The commonest sites of the tumours were the lower end of the common bile-duct and the ampulla of Vater. The usual clinical picture was that of obstructive jaundice, which was present in 44 cases, and varied in degree from slight to extreme. Marked loss of weight was seen in 45 patients and was the most striking manifestation after jaundice. Pain was absent in 15 cases throughout the entire course of the illness, and therefore the presence or absence of pain appears to be of little, if any, diagnostic significance. Pruritus was a prominent symptom in 25 cases, and in several it was the chief complaint. Spontaneous haemorrhages occurred in 16 cases. Of the 45 patients on whom operation was performed for carcinoma 19 (42-2 per cent.) died within 30 days, 26 survived for an average period of 17-3 months; of these three were still living, respectively, seven months, 20 months, and 34 months after the operation, and in six patients the results were unknown. The high operative mortality is attributed to the tendency to
hemorrhage and technical difficulties on the biliary tract.
of
operations
---
THE LIVER AND HÆMOGLOBIN. IT used to be supposed that it was the business of the liver to make bile-pigments out of the remains of red corpuscles. The haematoidin crystals in old haemorrhages showed that the manufacture of bilirubin was not the sole prerogative of the liver, but ’it has been left to recent experimental research to show that the tissues of the body generally have this capacity. The point which remains in doubt is whether the liver can do it at all ; the facts are consistent with the interpretation that its only share in the process is to pick up bile-pigment from the blood and pass it into the bile-ducts. But it has still been 1 Surg., Gyn.,
and
Obst., January, 1932.
siderin and presumably take their parts in of a haemoglobinaemia.
disposing
-
ANÆMIA WITH
DYSPHAGIA.
THE recrudescence of interest in secondary anaemia, last few years has brought into prominence what has been called the Plummer-Vinson syndrome. In 1922 Vinson associated the peculiar dysphagia, first described eight years previously by Plummer, with a severe secondary an2emia, and we now have records of many cases belonging to this group, a summary being published in 1928 by J. A. Munro Cameron.2 The main points in the syndrome are that the mucosa of the mouth, pharynx, and œsophagus shows inflammatory changes producing dysphagia, and that the patients exhibit severe an2emia of secondary type. It has been claimed that relief of the dysphagia, which can sometimes be brought about by the mere passage of a tube, will so improve the food intake that the anemia dis3 appears. Dr. George Graham and Dr. R. S. Johnson now report a series of cases in which they have observed that besides the syndrome as described, there is a definite increase in the fragility of the red blood corpuscles. They call attention to the colour of the skin, which is of a brownish-yellow tint rather than the so-called lemon-yellow of pernicious anaemia. Achlorhydria was present in all their cases, but the histamine test was not performed, and therefore they are unable to say whether the achlorhydria was absolute. On careful test of the fragility of the red corpuscles they found that usually haemolysis began in concentrations of normal saline higher than 0-50, and was always complete at 0-40. The distinction from acholuric jaundice was confirmed, apart from the dysphagia, by the absence of excess of bilirubin from the blood-serum, whilst the achlorhydria was further evidence. Graham and Johnson are unable to confirm the reported cure of such cases by the simple administration of a full ordinary diet, but found that the anemia rapidly improved when
during the
1 Jour. Path. and Bact., 1932, xxxv., 113. 2 Quart. Jour. Med., 1928, xxii., 43. 3
Ibid., January, 1932, p. 41.