THE RELATION BETWEEN THE VITAL CAPACITY AND THE ACTIVITY OF THE DISEASE IN PULMONARY TUBERCULOSIS

918 observations. In a series of 60 cases I determined the vital capacity, the extent of the disease as shown by the physical signs and the X ra,y findings, and the activity as judged by the sedimentation-rate of the erythrocytes. It is. generally accepted that the sedimentation-rate affords a very accurate guide to activity in pulmonary tuberculosis and also as to the progress of the disease, and my experience of this test in a large series of cases of tuberculosis entirely supports this view. The normal vital capacity in each case was calculated on five standards : standing height, sitting height, weight, chest circumference and surface area, in accordance with the tables given in Myers’s book.4> The mean of these five readings gives the percentage deviation of the patient’s vital capacity from the REFERENCES normal. The patient’s actual vital capacity was. 1. Beadles, C. F.: Brain, 1907, xxx., 285. 2. Fearnsides, E. G.: Ibid., 1916, xxxix., 249. determined by a Hutchinson spirometer. 3. Symonds, C. P.: Quart. Jour. Med., 1924, xviii., 93. In the accompanying Diagram the vital capacity 4. Adie, W. J.: Newcastle Med. Jour., 1927, vii., 249. 5. " : THE LANCET, 1930, ii., 237. readings are plotted along the abscissa and the 6. Symonds: Guy’s Hosp. Rep., 1923, lxxiii, 139. sedimentation-rates along the ordinate in each case. 7. Foggie, W. E.: Edin. Med. Jour., 1927, xxxiv., 649. 8. Gushing, H. : Guy’s Hosp. Rep., 1923, lxxiii., 159. The line drawn joins the points which are the mean of the individual readings. It will be seen that there is a definite relationship between the activity of the THE disease and the vital capacity, irrespective of ther RELATION BETWEEN THE VITAL CAPACITY amount of lung involved. If, on the other hand, the amount of lung involved by the tubefculous AND THE ACTIVITY OF THE DISEASE IN process is substituted for the sedimentation-rate, PULMONARY TUBERCULOSIS no such relationship can be demonstrated between BY G. E. BEAUMONT, D.M. OXF., F.R.C.P. LOND., vital capacity and extent of disease. Thus an early active localised lesion will usually lower the vital D.P.H. more than an extensive quiescent lesion. capacity PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES Cameron,5 in a careful study of vital capacity in OF THE CHEST, BROMPTON ; PHYSICIAN WITH CHARGE OF OUT-PATIENTS, THE MIDDLESEX HOSPITAL pulmonary tuberculosis in 198 adults during their treatment in a sanatorium, showed that there was no John Hutchinson/ in his pioneer work on vital definite relationship between the weight and vital’ capacity in pulmonary tuberculosis, noted in 1846 capacity, but that the vital capacity afforded an that in the early stages of phthisis the vital capacity estimation of the progress of the patient, and noted is on an average 78 per cent. of normal, and in the that the commonest cause of temporary depressions advanced stages it averages 38 per cent. of normal. in the vital capacity was a "cold." In view of the Dreyer and Burrellin 1920 observed that the vital relationship between the vital capacity and activity capacity in pulmonary tuberculosis affords an indica- of the disease, this suggests that the " cold " causes tion of the severity of the disease, and that serial a temporary increase in the activity of the disease. readings record the progress of an individual patient. I have further observed in patients who are improving,. Thus in active cases a low vital capacity was found, as, for example, after the establishment of a partial which rose or pneumothorax, that the vital fell according as the condicapacity rises tion improved before the sedior mentation-rate deteriorated. These authors shows the

likely unexpectedly to encounter one of these aneurysms, for they rarely produce symptoms unless there has been a leakage, and the aneurysmal sac itself rarely reaches a sufficient size before rupture to give symptomatic evidences of its presence." He goes on to mention that at a meeting of neurological surgeons only one had encountered an aneurysm in the course of intracranial operations, in this case a presumed tumour adjacent to the sella. I cannot help, however, being impressed by the fact that in my own experience I should have encountered several cases in which this diagnosis was clearly permissible, quite apart from rupture, as well as a number of other cases seen in former years in which I now think this diagnosis would have been justified. not

following

"

agreed, however,

improvement.

that

This is presumably due to a in diminution toxemia, as the,

the

capacity

vital was

also modified by the extent of the disease, the

greater

the

amount of

lung

pneumothorax has increased the amount of

involved the lower the vital

lung which if not functioning. In reading the

capacity. The

chart it should be remembered that there is a normal variation in the vital

prepon-

derating importance

activity

of the of the

disease,

as

the extent the lung involved, in determining the vital capacity is indicated by the

opposed

to of

capacity of

10

cent., and, further, some of per

Chart showing the relationship between the vital capacity in pulmonar3 tuberculosis and the activity of the disease, as judged by the sedimentation-rate of the red cells of the blood in 60 cases. The curve is plotted along the points which are means of In two instances, shown by the stars, the readings of the individual readings. two cases are identical.

the cases charted suffered from bronchitis or

919

emphysema, which of themselves lower the vital capacity. Despite these adverse factors a definite relationship between activity and vital capacity is

INCREASING numbers of cases of late rickets and osteomalacia are being reported from different parts of India, not only because of improved clinical recognition but in certain areas because of an actual increased incidence of the disease, due to changing economic factors adversely affecting the family dietary. The occurrence of late rickets and osteomalacia, due to deficient diet, among field workers obtaining adequate sunlight in the Kangra district of the Punjab in Northern India, has already been described.! Here large numbers of patients are concerned, and

financial considerations necessarily limit the choice of treatment. In the Palampur tahsil of the Kangra district, where the results of the osteomalacia inquiry carried out under the Indian Research Fund Association are being applied through the agency of the Punjab Red Cross, the public health and agricultural departments of Punjab, and the Canadian Medical Mission, the methods set out in the accompanying. Table have been followed in the effort to obtain practicable means of relief. It has already been shown that in order to obtain optimum results in treatment, in addition to vitamin D, adequate amounts of vitamins A and C and calcium phosphate salts are necessary,2 but in the Kangra Valley economic conditions do not permit the inclusion of the common sources of vitamins A and C in the diet in adequate amount. The summarised results of treatment show that the greatest clinical improvement is obtained from the use of cod-liver oil where, in addition to vitamin D, the patient benefits also from the use of vitamin A. Disadvantages are the relatively high cost of the imported oil, certain digestive disturbances, and the unsuitability of a fluid preparation for district work. The compound tablets t containing vitamin D (calciferol), together with calcium phosphate salts, undoubtedly have a place in treatment. They are cheap, cause no digestive upset, and are convenient for transport. It is unfortunate that it is not yet possible to include in them vitamin A also, at a low cost. Sun-irradiated yeast.-The attempts to produce in., India yeast suitable for irradiation have already been described.3 The results here given were obtained from the dried and powdered yeast waste obtained from vats, after the fermentation of molasses had been completed.t Facilities for irradiation by arti. ficial ultra-violet light not being available, irradiation by exposure to direct sunlight was utilised instead. The clinical results show that with sun-irradiated yeast improvement of symptoms, though very slow in comparison with cod-liver oil, was definite over a considerable period. The cost was very low, and in view of the large amounts of yeast taken digestive, disturbance was surprisingly small (only 10 out of 72 patients complaining of sickness). The material in its present form involved, however, considerable labour in dispensing. The services of a special nurse were utilised, covered by a grant from the Indian Red Cross. In view of the scanty information available as, to methods of direct sun-irradiation of yeast, the time

* A summary of recent work under the Indian Research Fund Association.

t Supplied by the British Drug Houses Ltd., London. t Supplied by the Amritsar Distillery, Punjab.

indicated. It has been

suggested

that the

of the

lowering

vital capacity in active pulmonary tuberculosis is due to a toxic weakening of the power of the expiratory muscles. Using a mercury manometer to determine the

following

results

expiratory

force I obtained the

:-

Active Cases.-10 males and 6 females

Average maximum expiratory force

64

mm.

Hg.

= 71

mm.

Hg.

=

Non-active Cases.-10 males and 6 females :

Average

maximum

expiratory force

The difference is too small to suggest that there is sufficient weakening of the expiratory muscles in active tuberculosis to cause a marked fall in the vital capacity. The lowered vital capacity possibly depends on some other factor, such as bronchiolar spasm, but of this there is no proof. These observations were carried out on private and hospital patients, and for help with the latter I wish to express my thanks to Dr. A. J. P. Alexander and Dr. A. J. W. Beard. REFERENCES 1. 2.

Hutchinson, J. : Med. Chir. Trans., 1846, xxix., 137. Dreyer, G., and Burrell, L. S. T. : THE LANCET, 1920, i. 1212 ; 1922, ii., 374. 3. Trail, R. R. : Ibid., 1933, i., 522. 4. Myers, J. A. : Vital Capacity of the Lungs, Baltimore, 1925. 5. Cameron, C. : Tubercle, 1922 iii., 353 and 385. RESULTS OF MASS TREATMENT OF

LATE RICKETS AND OSTEOMALACIA * BY DAGMAR CURJEL WILSON, M.D. GLASG., M.R.C.P. LOND., M.C.O.G., D.P.H. WOMEN’S

MEDICAL

SERVICE,

INDIA

(RETD.)

COMPARISON OF TREATMENTS FOR LATE RICKETS AND OSTEOMALACIA AT PALAMPUR, KANGRA DISTRICT, PUNJAB

living within 18 miles of Palampur, Kangra District. Sex.-Female, ages 10 to 55 years. C’
*

Classified

as

in previous papers ;

see

Diet.-Vegetarian, chiefly cereal, low fats. Sunlight.-Adequate (agricultural workers).

bibliography.’