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ÆTIOLOGY OF ACUTE RHEUMATISM
1240
CORRESPONDENCE MEDICAL REFEREES AND MINERS’ NYSTAGMUS To the Editor
of THE LANCET
Sm,-Probably many medical referees for ophthalmic cases in coal-mining areas have often felt the need for the help of a physician in dealing with cases of miners’ nystagmus. These cases are regarded by some as exceptionally difficult cases to decide. The chief objective symptom of the disease is ocular, so that these cases are rightly assigned to an ophthalmic medical referee for decision. But at the same time the actually disabling symptoms are frequently dizziness, headache, and nervous symptoms, which hardly come within the province of an ophthalmic surgeon to measure and assess. In elderly patients, for instance, who may still have some oscillations of the eyes, the dizziness is frequently due to arterio-sclerosis or other senile changes. In such a case the help of a physician’s examination and advice is most welcome. Although I had been a referee dealing with miners’ nystagmus cases since 1920, it was not until three or four years ago that I realised that facilities were already provided by the regulations for a medical referee to obtain " expert assistance " in cases where he required it. Since then I have repeatedly availed myself of the opportunity so afforded of obtaining a physician’s assistance in difficult or doubtful cases. Recently I discovered that my fellow referee, who was senior to me in length of service, was not aware of the existence of such facilities in the regulations. He agreed with me that in many cases of miners’ nystagmus a physician’s help would be most useful to the referee. Indeed, the proportion of such cases is so great that the question arises whether it would not be advantageous to have a physician associated with the ophthalmologist in every case of miners’
nystagmus. The present procedure
laid down in the regulations is for the medical referee to apply to the UnderSecretary of State at the Home Office for authorisation of such " expert assistance " in any case where he considers it necessary. This has never been refused in my experience. One reason why one does not ask for it perhaps more frequently is that it involves a delay of about a week before the case can be decided, and puts the workman, who often comes from a considerable distance, to the trouble of a second attendance. This objection could be obviated if the regulations could be amended by permission being given to the medical referee to obtain a physician’s assistance at once on his own discretion in any case where he considered it advisable. In one case recently where this was done without waiting for authorisation to be obtained, this action was approved by the Home Office under the circumstances. In some quarters there is at present considerable dissatisfaction with the working of the Workmen’s Compensation Act in cases of miners’ nystagmus. I am informed that the men would have more conndencc in decisions given in their cases if a physician were associated with the ophthalmic referee. Any step which may help to promote peace in this important industry deserves consideration. I am, Sheffield, JBIay 18th.
Sir, yours faithfully, HERBERT CAIGER.
ÆTIOLOGY OF ACUTE RHEUMATISM
To the Editor
of
THE LANCET
SIR,-The entirely new work by Drs. B. Schlesinger, A. G. Signy, and C. R. Amies is of the greatest interest. Such work, I venture to think, is not to be dealt with by facile criticism. At its best it will be one of those pioneer efforts which are leading us towards a new attitude to the problems of infection : at its worst it will infuse new blood into the pressing need for the study of rheumatism, a goal which many of us are only glad enough to have striven to reach. This may mean a new phase in the history of the study of rheumatic diseases, and, arising out of the useful summary of this paper in THE LANCET, p. 1162, I take this opportunity to ask you to allow me to do justice to myself and all who worked with me or assisted in those earlier days by correcting a general view often entertained of our work. We did much more for the reputation of this country than discover "the Micrococcus rheumaticus " which " was in all probability S. viridans." Guided by the work of former great clinicians I say without hesitation that we made the subject of juvenile rheumatism and some aspects of chronic rheumatism into tangible and attackable entities and revolutionised them for all time. Anyone who has honoured me" by glancing through " Researches on Rheumatism (1913) will know that neither the late A. Paine nor I believed in the " specific streptococcus, but we believed the disease to be as near "specific" as any disease in childhood. Heaven knows what " "
"
people imagine by a Again, although in 1899
specific " streptococcus.
I was the first to discover the essentials of what is now the Aschoff nodule I did not nor do I now believe in a " specific " lesion called the Aschoff nodule or body. There may be a specific necrosis. They may have realised from that book certain key points in the problem of rheumatism which must always have bearing and be met. For examples: A paper by Dr. G. F. Still and myself in 1899 showing that the most severe effects of the rheumatic poisons in a subcutaneous nodule were tiny areas of necrosis thus confirming earlier Scandinavian investigators. That is a key point. Is the necrosis or the Aschoff body the essential lesion ? I hold firmly the necrosis. Then, for the first time in this country came the isolation from rheumatic lesions and rheumatic living blood of a micrococcus that produced cardiac lesions, Those are key points, which medical arthritis, &c. historians will admit are key points in the history of heart disease and orthopaedics. Even if the explanation is at fault those facts for this country and for cardiologists are, to use a horrid term, epoch-making. Again in 1900 in that book we demonstrated for the first time in this country, as far as was then humanly possible, the local focus (the tonsil) in rheumatism. This is a key which has often been turned by physicians and surgeons, not always to the advantage of the rheumatic, but to the advantage of the users’ scientific reputations. That demonstration of the local focus is a key point : and indeed also a land mark. Again in part III. of that book there is a key point, the application of the scientific work to the human disease. It is the first essay ever written of that kind in England, and though I wrote it myself, I claim it is still hard to beat---but has to be beaten-as an explanation of juvenile rheumatism. Lastly there is one key point, at present rejected
1241 with indifference by almost all-one which I know my friend Dr. Schlesinger, kindly and long suffering though he is, cannot swallow even if a key point is swallowable. It is this, and I believe it to be the key point : malignant endocarditis often follows earlier cardiac rheumatism, and I maintain there is a rheumatic form owning the same streptococcal cause. A pathological child can find the micrococci in those vegetations and if there is a rheumatic malignant endocarditis then one cause of acute rheumatism is a streptococcal infection. The various types of streptococci found in laboratories do not worry me more than do the sugars that are fermented because my concern has been and is a horrible human disease. I will, however, disarm criticism by admitting all laboratory tests are "specific" and continue unmoved with the study of a disease. My determination is to fight the view that all my co-workers and I have spent nearly 40 years only to claim we have discovered a " specific " It is a slur on English Micrococcus rheumaticus. medicine because it is false, and a slur on those who have rescued rheumatism from solitary confinement in a pool of " acidity of the blood " or of radium containing water, or of a culture medium. I hope No one and trust this virus will take us further. knows yet where it may lead us, but all that matters on the scientific side is the truth-on the human side the rescue of rheumatic children. For my own part I will not have in any inevitable obituary notice this: " It is interesting that he claimed the ]j[icrococcus rheumaticus as thespecific ’ cause of juvenile rheumatism, but it was S. salivarius, or (still worse) S. faecalis." Such a notice would be too British for me even when dead. I am,
Sir,
yours
London, May 18th.
faithfully, F. JOHN POYNTON.
STIMULANTS OF METABOLISM
To the Editor
of THE LANCET
SiR,—May we call attention to a remark in Sir William Willcox’s annual oration before the Medical Society of London on May 13th (reported in your last issue) ? Referring to the use of dinitroin the treatment of and dinitro-o-cresol phenol that states Sir William they are such powerful obesity, and to the liver cells that their use kidney poisons should be avoided in clinical practice. Clinically the experimental evidence very definitely suggests that the danger of these compounds is solely that in large doses they may over-stimulate metabolism. The action of dinitro-phenol has been intensively investigated by Tainter and his colleagues in San Francisco, but they have been unable to demonstrate any renal lesion arising from its continued administration to rabbits although they used the most detailed methods, such as Addis’s urinary cell count and the excretion of phenolsulphonphthalein (Schulte, T. L., and Tainter, M. L. : Proc. Soc. Exp. Biol. and Mod., 1934, xxxi., 1163). We would also point out that the whole matter has been the subject of a very careful inquiry by the Council of Pharmacy for the American Medical Association, and dinitro-phenol is recognised by them as a useful therapeutic agent. Our experience with dinitro-o-cresol is very extensive, and we have never observed any change in renal or hepatic functions, even after administration for prolonged periods. As we have stated in previous publications the danger with this type of compound lies, not in its effect on the liver and kidneys, but in overstimulation of the metabolism from
over-
important point to be real risk arises from indiscriminate use of the drug. We have repeatedly pointed out that, provided a careful watch is kept on the patient and the basal metabolic rate is measured frequently, there is no danger in their use. From experimental work on animals it has been shown that the toxicity of these drugs is solely due to their power of raising the metabolism to such an extent that death supervenes. We are, Sir, yours faithfully, E. C. DODDS, J. D. ROBERTSON. The Courtauld Institute of Biochemistry, Middlesex Hospital, W., May 20th.
dosage. We feel that emphasised is that the
the
TREATMENT OF PITUITARY TUMOURS To the Editor of THE LANCET
SiR,—In your last issue Dr. Wilfred Harris states,
regard to sellar tumours, that " the only certain improvement, or chance of cure, is by operation and
in
the excision of the cyst and of its walls, or of the tumour, if not cystic." This assertion should not go unchallenged, ignoring as it does the effects of X ray therapy. As long ago as 1909 Beclere treated pituitary tumours by irradiation, one of his patients being alive twenty years later. In your issue of April llth, 1931 (p. 806), I described the remarkable recovery after irradiation of a patient who had suffered from severe headaches and failing vision and who was found to have a greatly enlarged sella and large bitemporal scotomata. This patient is still in excellent health nearly six years after treatment and is employed as a Similar cases have been window-cleaner. described by Nemenov and Jugenburg, Magnus, Hamann and others. In view of these results I consider that X ray therapy should be tried in all sellar tumours before they are submitted to the risks of operation. I am, Sir, yours faithfully, FF. ROBERTS. Cambridge, May 18th. SUPPLEMENTS TO THE DIET OF CHILDREN
To the Editor
SiR,-Dr. M. D.
of THE LANCET Wright’s letter in your
issue of llth advances two criticisms of our May paper, to which we should like to reply. Before dealing with the specific points that she raises, we wish to emphasise that they appear to be mutually destructive. It seems hardly justifiable to cast doubts on the accuracy of certain results and then to attempt to draw conclusions from them. Her first criticism is refuted by the experimental scheme employed. We specifically state that " every treatment follows every other treatment twice" in each age-group and for each sex. Thus, any effect of a particular supplement which persists into subsequent periods after that supplement has been withdrawn is compensated for. Our experiment does in fact conform to Dr. Magee’s conception of nutrition as a dynamic function, since we have assessed the nutritional state of our experimental children, not by their body-weight at any " one time, but by their " weight-increase duriibg a period of time. (We quote from Dr. Wright’s
letter.) The second criticism is, in our opinion, a piece of special pleading. Nowhere in our paper do we make the statement attributed to us by Dr. Wright, that balanced calories are of greater benefit than vitamins. It is surely axiomatic that these factors are complementary, as are the fuel and the spark in an internalcombustion engine. What we have strongly suggested
CORRESPONDENCE MEDICAL REFEREES AND MINERS’ NYSTAGMUS To the Editor
of THE LANCET
Sm,-Probably many medical referees for ophthalmic cases in coal-mining areas have often felt the need for the help of a physician in dealing with cases of miners’ nystagmus. These cases are regarded by some as exceptionally difficult cases to decide. The chief objective symptom of the disease is ocular, so that these cases are rightly assigned to an ophthalmic medical referee for decision. But at the same time the actually disabling symptoms are frequently dizziness, headache, and nervous symptoms, which hardly come within the province of an ophthalmic surgeon to measure and assess. In elderly patients, for instance, who may still have some oscillations of the eyes, the dizziness is frequently due to arterio-sclerosis or other senile changes. In such a case the help of a physician’s examination and advice is most welcome. Although I had been a referee dealing with miners’ nystagmus cases since 1920, it was not until three or four years ago that I realised that facilities were already provided by the regulations for a medical referee to obtain " expert assistance " in cases where he required it. Since then I have repeatedly availed myself of the opportunity so afforded of obtaining a physician’s assistance in difficult or doubtful cases. Recently I discovered that my fellow referee, who was senior to me in length of service, was not aware of the existence of such facilities in the regulations. He agreed with me that in many cases of miners’ nystagmus a physician’s help would be most useful to the referee. Indeed, the proportion of such cases is so great that the question arises whether it would not be advantageous to have a physician associated with the ophthalmologist in every case of miners’
nystagmus. The present procedure
laid down in the regulations is for the medical referee to apply to the UnderSecretary of State at the Home Office for authorisation of such " expert assistance " in any case where he considers it necessary. This has never been refused in my experience. One reason why one does not ask for it perhaps more frequently is that it involves a delay of about a week before the case can be decided, and puts the workman, who often comes from a considerable distance, to the trouble of a second attendance. This objection could be obviated if the regulations could be amended by permission being given to the medical referee to obtain a physician’s assistance at once on his own discretion in any case where he considered it advisable. In one case recently where this was done without waiting for authorisation to be obtained, this action was approved by the Home Office under the circumstances. In some quarters there is at present considerable dissatisfaction with the working of the Workmen’s Compensation Act in cases of miners’ nystagmus. I am informed that the men would have more conndencc in decisions given in their cases if a physician were associated with the ophthalmic referee. Any step which may help to promote peace in this important industry deserves consideration. I am, Sheffield, JBIay 18th.
Sir, yours faithfully, HERBERT CAIGER.
ÆTIOLOGY OF ACUTE RHEUMATISM
To the Editor
of
THE LANCET
SIR,-The entirely new work by Drs. B. Schlesinger, A. G. Signy, and C. R. Amies is of the greatest interest. Such work, I venture to think, is not to be dealt with by facile criticism. At its best it will be one of those pioneer efforts which are leading us towards a new attitude to the problems of infection : at its worst it will infuse new blood into the pressing need for the study of rheumatism, a goal which many of us are only glad enough to have striven to reach. This may mean a new phase in the history of the study of rheumatic diseases, and, arising out of the useful summary of this paper in THE LANCET, p. 1162, I take this opportunity to ask you to allow me to do justice to myself and all who worked with me or assisted in those earlier days by correcting a general view often entertained of our work. We did much more for the reputation of this country than discover "the Micrococcus rheumaticus " which " was in all probability S. viridans." Guided by the work of former great clinicians I say without hesitation that we made the subject of juvenile rheumatism and some aspects of chronic rheumatism into tangible and attackable entities and revolutionised them for all time. Anyone who has honoured me" by glancing through " Researches on Rheumatism (1913) will know that neither the late A. Paine nor I believed in the " specific streptococcus, but we believed the disease to be as near "specific" as any disease in childhood. Heaven knows what " "
"
people imagine by a Again, although in 1899
specific " streptococcus.
I was the first to discover the essentials of what is now the Aschoff nodule I did not nor do I now believe in a " specific " lesion called the Aschoff nodule or body. There may be a specific necrosis. They may have realised from that book certain key points in the problem of rheumatism which must always have bearing and be met. For examples: A paper by Dr. G. F. Still and myself in 1899 showing that the most severe effects of the rheumatic poisons in a subcutaneous nodule were tiny areas of necrosis thus confirming earlier Scandinavian investigators. That is a key point. Is the necrosis or the Aschoff body the essential lesion ? I hold firmly the necrosis. Then, for the first time in this country came the isolation from rheumatic lesions and rheumatic living blood of a micrococcus that produced cardiac lesions, Those are key points, which medical arthritis, &c. historians will admit are key points in the history of heart disease and orthopaedics. Even if the explanation is at fault those facts for this country and for cardiologists are, to use a horrid term, epoch-making. Again in 1900 in that book we demonstrated for the first time in this country, as far as was then humanly possible, the local focus (the tonsil) in rheumatism. This is a key which has often been turned by physicians and surgeons, not always to the advantage of the rheumatic, but to the advantage of the users’ scientific reputations. That demonstration of the local focus is a key point : and indeed also a land mark. Again in part III. of that book there is a key point, the application of the scientific work to the human disease. It is the first essay ever written of that kind in England, and though I wrote it myself, I claim it is still hard to beat---but has to be beaten-as an explanation of juvenile rheumatism. Lastly there is one key point, at present rejected
1241 with indifference by almost all-one which I know my friend Dr. Schlesinger, kindly and long suffering though he is, cannot swallow even if a key point is swallowable. It is this, and I believe it to be the key point : malignant endocarditis often follows earlier cardiac rheumatism, and I maintain there is a rheumatic form owning the same streptococcal cause. A pathological child can find the micrococci in those vegetations and if there is a rheumatic malignant endocarditis then one cause of acute rheumatism is a streptococcal infection. The various types of streptococci found in laboratories do not worry me more than do the sugars that are fermented because my concern has been and is a horrible human disease. I will, however, disarm criticism by admitting all laboratory tests are "specific" and continue unmoved with the study of a disease. My determination is to fight the view that all my co-workers and I have spent nearly 40 years only to claim we have discovered a " specific " It is a slur on English Micrococcus rheumaticus. medicine because it is false, and a slur on those who have rescued rheumatism from solitary confinement in a pool of " acidity of the blood " or of radium containing water, or of a culture medium. I hope No one and trust this virus will take us further. knows yet where it may lead us, but all that matters on the scientific side is the truth-on the human side the rescue of rheumatic children. For my own part I will not have in any inevitable obituary notice this: " It is interesting that he claimed the ]j[icrococcus rheumaticus as thespecific ’ cause of juvenile rheumatism, but it was S. salivarius, or (still worse) S. faecalis." Such a notice would be too British for me even when dead. I am,
Sir,
yours
London, May 18th.
faithfully, F. JOHN POYNTON.
STIMULANTS OF METABOLISM
To the Editor
of THE LANCET
SiR,—May we call attention to a remark in Sir William Willcox’s annual oration before the Medical Society of London on May 13th (reported in your last issue) ? Referring to the use of dinitroin the treatment of and dinitro-o-cresol phenol that states Sir William they are such powerful obesity, and to the liver cells that their use kidney poisons should be avoided in clinical practice. Clinically the experimental evidence very definitely suggests that the danger of these compounds is solely that in large doses they may over-stimulate metabolism. The action of dinitro-phenol has been intensively investigated by Tainter and his colleagues in San Francisco, but they have been unable to demonstrate any renal lesion arising from its continued administration to rabbits although they used the most detailed methods, such as Addis’s urinary cell count and the excretion of phenolsulphonphthalein (Schulte, T. L., and Tainter, M. L. : Proc. Soc. Exp. Biol. and Mod., 1934, xxxi., 1163). We would also point out that the whole matter has been the subject of a very careful inquiry by the Council of Pharmacy for the American Medical Association, and dinitro-phenol is recognised by them as a useful therapeutic agent. Our experience with dinitro-o-cresol is very extensive, and we have never observed any change in renal or hepatic functions, even after administration for prolonged periods. As we have stated in previous publications the danger with this type of compound lies, not in its effect on the liver and kidneys, but in overstimulation of the metabolism from
over-
important point to be real risk arises from indiscriminate use of the drug. We have repeatedly pointed out that, provided a careful watch is kept on the patient and the basal metabolic rate is measured frequently, there is no danger in their use. From experimental work on animals it has been shown that the toxicity of these drugs is solely due to their power of raising the metabolism to such an extent that death supervenes. We are, Sir, yours faithfully, E. C. DODDS, J. D. ROBERTSON. The Courtauld Institute of Biochemistry, Middlesex Hospital, W., May 20th.
dosage. We feel that emphasised is that the
the
TREATMENT OF PITUITARY TUMOURS To the Editor of THE LANCET
SiR,—In your last issue Dr. Wilfred Harris states,
regard to sellar tumours, that " the only certain improvement, or chance of cure, is by operation and
in
the excision of the cyst and of its walls, or of the tumour, if not cystic." This assertion should not go unchallenged, ignoring as it does the effects of X ray therapy. As long ago as 1909 Beclere treated pituitary tumours by irradiation, one of his patients being alive twenty years later. In your issue of April llth, 1931 (p. 806), I described the remarkable recovery after irradiation of a patient who had suffered from severe headaches and failing vision and who was found to have a greatly enlarged sella and large bitemporal scotomata. This patient is still in excellent health nearly six years after treatment and is employed as a Similar cases have been window-cleaner. described by Nemenov and Jugenburg, Magnus, Hamann and others. In view of these results I consider that X ray therapy should be tried in all sellar tumours before they are submitted to the risks of operation. I am, Sir, yours faithfully, FF. ROBERTS. Cambridge, May 18th. SUPPLEMENTS TO THE DIET OF CHILDREN
To the Editor
SiR,-Dr. M. D.
of THE LANCET Wright’s letter in your
issue of llth advances two criticisms of our May paper, to which we should like to reply. Before dealing with the specific points that she raises, we wish to emphasise that they appear to be mutually destructive. It seems hardly justifiable to cast doubts on the accuracy of certain results and then to attempt to draw conclusions from them. Her first criticism is refuted by the experimental scheme employed. We specifically state that " every treatment follows every other treatment twice" in each age-group and for each sex. Thus, any effect of a particular supplement which persists into subsequent periods after that supplement has been withdrawn is compensated for. Our experiment does in fact conform to Dr. Magee’s conception of nutrition as a dynamic function, since we have assessed the nutritional state of our experimental children, not by their body-weight at any " one time, but by their " weight-increase duriibg a period of time. (We quote from Dr. Wright’s
letter.) The second criticism is, in our opinion, a piece of special pleading. Nowhere in our paper do we make the statement attributed to us by Dr. Wright, that balanced calories are of greater benefit than vitamins. It is surely axiomatic that these factors are complementary, as are the fuel and the spark in an internalcombustion engine. What we have strongly suggested