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YELLOW FEVER AND LEPTOSPIRAL JAUNDICE
796 small lead hall with a hamlle is held on the skin at about the level of the foreign body while the X-ray tube is moved to and fro. If the foreign body and the ball are at the same distance from the screen their images will be displaced to the same extent. The ball is therefore moved round the limb until the shift of the two images is equal, when the position of the ball will indicate the depth of the foreign body. The same principle can be applied when an exploratory incision has been made, the tip of the surgeon’s forceps taking the place of the lead ball. It is not easy to judge the displacement of the shadows exactly, but Nogier says it can be done with practice. With his second method he guarantees immediate success. First the tube is arranged so that the shadow of the tip of the surgeon’s exploring forceps and the foreign body are superimposed at a point A on the screen which is carefully noted. The tube is then moved slightly to one side. If the forceps and the foreign body are at the same depth (distance from the screen) their shadow will be displaced an equal distance from A. If the shadow of the forceps moves further from A than that of the foreign body the forceps are too deep (i.e., too far from the screen) and vice versa. There are certain disadvantages in this method such as the difficulty in maintaining sterility, and, if many cases have to be examined, the danger of excessive X-ray exposure to both surgeon and radiologist, but it is sufficiently accurate for practical purposes, inexpensive and rapid to perform. For success, however, the surgeon and radiologist must know each other’s ways. YELLOW FEVER AND LEPTOSPIRAL JAUNDICE
BEFORE the modern spate of laboratory tests arose of an older generation were wont to place much reliance on what they termed a natural clinical flair. This flair was largely dependent on long and minute observation of a large number of patients. Actually, anyone who has seen many cases of for instance bubonic plague or exanthematic typhus has little difficulty in making an immediate clinical diagnosis. Nevertheless, one wonders whether clinical flair is always an entirely reliable guide. This doubt is increased by two recent papers which involve the differential diagnosis of yellow fever and leptospiral
physicians
jaundice. The last
epidemic of yellow fever in the United pointed out, is usually regarded
as
Bauerhas
so
that the correct
States, as having occurred in 1905 when Xew Orleans and Pensacola, Florida, were attacked. Several hundred people are known to have died in this epidemic which has alwaysbeen regarded as an almost classical outbreak. Sellards,3 however, has drawn attention to the careful pathological investigation of one of these patients by Stimsonin 1907 which showed that death was due not to yellow fever but to leptospiral jaundice, since in sections of the kidney prepared by the Cajal-Levaditi method spirochætes were demonstrated identical with those commonly termed Leptospira icterohœmorrhagiœ. Incidentally, Stimson called the organism which he described ( ? Spirochœta) interrogans
name
for the causnl agent of
leptospiral jaundice is not L. icterohœmorrhagiœ but Some years later Noguchi,4 investiL. interrogans. gating the aetiology of what were described as cases of yellow fever by highly competent physicians in South America, also isolated a spirochæte which he named 1. Bauer, J. H. (1940) Publ. Hlth Rep., Wash. 1940, 55, 362. 2. Sellards, A. W. Trans. R. Soc. trop. Med. Hyg. 1940, 33, 545. 3. Stimson, A. M. Publ. Hlth Rep., Wash. 1907, 22, 541. 4. Noguchi, H. J. exper. Med. 1919, 29, 565.
L. icteroides. There is now complete agreement that L. icteroides is identical with L. icterohcemorrhcugice and therefore with L. interrogans. It is thus obvious that in New Orleans in 1905 and in Guayaquil in 1919 cases of leptospiral jaundice were regarded as typical examples of yellow fever. This confusion is due to the fact that in both diseases there may be headache and backache, jaundice, albuminuria and bleeding. " Black vomit," though commoner in yellow fever, is
by no means unknown in leptospiral jaundice, while Faget’s sign of a constant pulse with a rising temperature or a falling pulse with a constant temperature is sometimes lacking in true yellow fever. Differentiation on purely clinical grounds is thus often difficult, if not impossible. White-cell counts should help, however, to separate the two diseases, for in yellow fever, after the first or second day, there is a leucopenia with relative lymphocytosis, while in leptospiral jaundice a polymorphonuclear leucocytosis is common. Today, on the other hand, highly specific laboratory tests both for leptospiral jaundice and for yellow fever leave little excuse for a confusion which undoubtedly existed in the past when reliance could only be placed on clinical flair. THE OSLO MEAL
IT is difficult to ignore the striking increase in rate growth in school-children fed on the cold Oslo meal as compared with those given the standard hot luncheon. Dr. Carl Schiotz of Oslo with his famous breakfast obtained a rise in weight 48 per cent. greater in boys and 140 per cent. greater in girls than that recorded previously with an orthodox diet, and his results have been corroborated by the London County Council in an experiment at ialile End. To those already familiar with the potency of protective foods but to most of us these results will not be they are astonishing. Apart from the difficulty which many would look for in persuading children to eat a meal consisting mainly of wholemeal bread and cheese with raw fruit or vegetables, there is an idea deeply imbued in the modern housewifethat a meal is more valuable when given hot than cold. It is, of more and more that foods vary course, appreciated enormously in their ability to promote growth. Normal growth, in fact, cannot take place unless the child is getting enough of the many discovered and undiscovered vitamins, the mineral salts, and not least animal protein. But it is not clear wherein the potency of this breakfast lies. As given in Oslo the meal consists of a third of a litre of unskimmed milk, an unlimited amount of kneippcracker or kneipp-bread with margarine and goat’s-milk cheese, half an orange, half an apple and a raw carrot. In London wholemeal bread was substituted for kneippcracker and kneipp-bread and Caerphilly for goat’s-milk cheese. Bread and cheese is no uncommon form of midday ’ meal among working-class folk and no startling results have been detected in children consuming this diet. The amount given in the Oslo meal is unlimited and this may mean that appreciably more is consumed than is usually taken to school, and the grain used in preparing the bread is whole and not mutilated by removal of the germ. The results are probably due to the presence of essential protective elements in all three sections of the meal-in the milk, in the bread and cheese and in the raw fruit or vegetable, but a more detailed study should be made to determine what constituent is most effective. It would be unjustifiable to attribute the effect mainly to vitamins, as has been suggested. It is at least possible that unlimited animal protein in the form of cheese is an equally potent factor. Further experiof
surprising,
BEFORE the modern spate of laboratory tests arose of an older generation were wont to place much reliance on what they termed a natural clinical flair. This flair was largely dependent on long and minute observation of a large number of patients. Actually, anyone who has seen many cases of for instance bubonic plague or exanthematic typhus has little difficulty in making an immediate clinical diagnosis. Nevertheless, one wonders whether clinical flair is always an entirely reliable guide. This doubt is increased by two recent papers which involve the differential diagnosis of yellow fever and leptospiral
physicians
jaundice. The last
epidemic of yellow fever in the United pointed out, is usually regarded
as
Bauerhas
so
that the correct
States, as having occurred in 1905 when Xew Orleans and Pensacola, Florida, were attacked. Several hundred people are known to have died in this epidemic which has alwaysbeen regarded as an almost classical outbreak. Sellards,3 however, has drawn attention to the careful pathological investigation of one of these patients by Stimsonin 1907 which showed that death was due not to yellow fever but to leptospiral jaundice, since in sections of the kidney prepared by the Cajal-Levaditi method spirochætes were demonstrated identical with those commonly termed Leptospira icterohœmorrhagiœ. Incidentally, Stimson called the organism which he described ( ? Spirochœta) interrogans
name
for the causnl agent of
leptospiral jaundice is not L. icterohœmorrhagiœ but Some years later Noguchi,4 investiL. interrogans. gating the aetiology of what were described as cases of yellow fever by highly competent physicians in South America, also isolated a spirochæte which he named 1. Bauer, J. H. (1940) Publ. Hlth Rep., Wash. 1940, 55, 362. 2. Sellards, A. W. Trans. R. Soc. trop. Med. Hyg. 1940, 33, 545. 3. Stimson, A. M. Publ. Hlth Rep., Wash. 1907, 22, 541. 4. Noguchi, H. J. exper. Med. 1919, 29, 565.
L. icteroides. There is now complete agreement that L. icteroides is identical with L. icterohcemorrhcugice and therefore with L. interrogans. It is thus obvious that in New Orleans in 1905 and in Guayaquil in 1919 cases of leptospiral jaundice were regarded as typical examples of yellow fever. This confusion is due to the fact that in both diseases there may be headache and backache, jaundice, albuminuria and bleeding. " Black vomit," though commoner in yellow fever, is
by no means unknown in leptospiral jaundice, while Faget’s sign of a constant pulse with a rising temperature or a falling pulse with a constant temperature is sometimes lacking in true yellow fever. Differentiation on purely clinical grounds is thus often difficult, if not impossible. White-cell counts should help, however, to separate the two diseases, for in yellow fever, after the first or second day, there is a leucopenia with relative lymphocytosis, while in leptospiral jaundice a polymorphonuclear leucocytosis is common. Today, on the other hand, highly specific laboratory tests both for leptospiral jaundice and for yellow fever leave little excuse for a confusion which undoubtedly existed in the past when reliance could only be placed on clinical flair. THE OSLO MEAL
IT is difficult to ignore the striking increase in rate growth in school-children fed on the cold Oslo meal as compared with those given the standard hot luncheon. Dr. Carl Schiotz of Oslo with his famous breakfast obtained a rise in weight 48 per cent. greater in boys and 140 per cent. greater in girls than that recorded previously with an orthodox diet, and his results have been corroborated by the London County Council in an experiment at ialile End. To those already familiar with the potency of protective foods but to most of us these results will not be they are astonishing. Apart from the difficulty which many would look for in persuading children to eat a meal consisting mainly of wholemeal bread and cheese with raw fruit or vegetables, there is an idea deeply imbued in the modern housewifethat a meal is more valuable when given hot than cold. It is, of more and more that foods vary course, appreciated enormously in their ability to promote growth. Normal growth, in fact, cannot take place unless the child is getting enough of the many discovered and undiscovered vitamins, the mineral salts, and not least animal protein. But it is not clear wherein the potency of this breakfast lies. As given in Oslo the meal consists of a third of a litre of unskimmed milk, an unlimited amount of kneippcracker or kneipp-bread with margarine and goat’s-milk cheese, half an orange, half an apple and a raw carrot. In London wholemeal bread was substituted for kneippcracker and kneipp-bread and Caerphilly for goat’s-milk cheese. Bread and cheese is no uncommon form of midday ’ meal among working-class folk and no startling results have been detected in children consuming this diet. The amount given in the Oslo meal is unlimited and this may mean that appreciably more is consumed than is usually taken to school, and the grain used in preparing the bread is whole and not mutilated by removal of the germ. The results are probably due to the presence of essential protective elements in all three sections of the meal-in the milk, in the bread and cheese and in the raw fruit or vegetable, but a more detailed study should be made to determine what constituent is most effective. It would be unjustifiable to attribute the effect mainly to vitamins, as has been suggested. It is at least possible that unlimited animal protein in the form of cheese is an equally potent factor. Further experiof
surprising,