+ All Categories
Home > Documents > A CARDIOVASCULAR SYMPOSIUM

A CARDIOVASCULAR SYMPOSIUM

Date post: 03-Jan-2017
Category:
Upload: dothuy
View: 213 times
Download: 1 times
Share this document with a friend
2
763 whether, in view of the financial commitments of the nation in respect of persons who through physical or mental deficiency become a charge upon public funds, a Royal Commission would be appointed to advise upon the restriction of procreation of children by unfit parents. While this country is not yet prepared for advanced eugenic legislation, it is interesting to note what legislatures are doing else- where. A recent volume of the Society of Comparative Legislation, containing summaries of the laws passed in different parts of the world during 1922, shows several examples of American enactments on this topic. The State of Nebraska, for instance, forbids the marriages of persons afflicted with venereal disease, and insists that no one adjudged afflicted with hereditary epilepsy or insanity shall marry unless first submitting to a sterilising operation ; applications for licences to marry must be accompanied by affidavits of freedom from venereal disease. Montana provides for the sterilising of inmates of what are euphemisti- cally called " custodial institutions," who are insane or feeble-minded or idiots or epileptics. An essential and certainly desirable feature of the Act is the insistence on adequate medical advice ; there is a hearing before a board with a right of appeal therefrom to a court of law. These American provisions are, of course, by no means the first of their kind. As long ago as 1895 Connecticut forbade the marriage of epileptic or feeble-minded persons under penalty of a minimum term of three years’ imprisonment. Ten years later the Act was attacked in the Supreme Court as being unconstitutional but was upheld, though it was subsequently modified. Wisconsin, Maine, and Delaware are other States which have passed similar legislation. The underlying principle I is the same, but the measures differ in that sometimes they actually make marriages void, sometimes they merely punish those who marry. Another American type of eugenic enactment is aimed not so much at preventing the birth of unfit children as at putting an end to sexual assaults by degenerates. Thus California in 1922 empowered the criminal courts to direct an " operation to prevent procreation " to be performed on persons convicted of carnal abuse of girls under ten years of age. Indiana, Iowa, and other States have passed similar Acts in the past, but the courts have sometimes held the laws to be contrary to the constitution ; in one case the operation was held not to be a " cruel " punishment, in another it was held " cruel and unusual," and therefore unconstitu- tional. This supervision of legislation by judges is always a little puzzling to us in this country where legislators are unhampered by a rigid written constitu- tion. We have not, however, hitherto heard much of eugenics at Westminster, unless we are to ascribe to a vague eugenic instinct the reluctance of certain legislators to pass such measures as the Deceased Wife’s Sister’s Bill. ____ THE RESULTS OF CONSERVATIVE TREATMENT OF POTT’S DISEASE. Now that the treatment of Pott’s disease is becoming operative, and Albee’s operation is exten- sively employed, it is most desirable that, for the purpose of comparison, information should be available as to the results obtained by more conservative measures. For it is obvious that there is no indica- tion for operative treatment, however good its results, if patients recover as often, as soon, and as permanently under less heroic measures. To provide such material for comparison, Dr. Santeri Leskinen,1 of Helingsfors, has collected the evidence obtainable in connexion with 241 cases of Pott’s disease treated at his hospital on conservative lines in the period 1895-1920. As many as 21 of these patients died in hospital, and of the remaining 220, only 137 could be traced. There were 126 males to 115 females, and 68 per cent. were between the ages 1 and 10. The cervical vertebrae were involved in 16-2 per cent., the thoracic Acta Chir. Scand., 1924, lvii., 193. vertebrae in 56-4 per cent., and the lumbar vertebrae in 27-4 per cent. Thus, the thoracic vertebrae were involved in more than half the total number of cases. But when the incidence of the disease in each vertebra was calculated, it was found that it was highest for the lumbar vertebras, each of which accounted for 13-2 per cent. of all the cases, whereas the corre- sponding figures for each thoracic and cervical vertebra were 11-3 per cent. and 5-5 per cent. respectively. In addition to the 21 patients dying in hospital, there were 43 who died after discharge. Thus, the mortality among the patients who could be traced was as high as 40-5 per cent. It was much higher for males than for females, the respective figures being 50 per cent. and 32 per cent. Tuberculosis or its sequels was the cause of 57 of the 64 deaths. The survivors who were traced were classified according as they were still ill, fairly well, or cured. The figures for these three classes were, in the order named, 12, 17-1, and 30-4 per cent. respectively. It will thus be seen that with a mortality of 40-5 per cent., and a complete recovery-rate of only 30-4 per cent., there was much room for improvement on the results of conservative treatment. The besr results were obtained in disease of the cervical vertebrae, only 26-3 per cent. of the patients having died, whereas 68-5 per cent. had completely recovered. Disease of the thoracic vertebrae responded least satisfactorily, the mortality being 46-3 per cent. and the recovery- rate 21’1 per cent. in this class. When the patients were classified according to their ages, it was found that the mortality was highest in the first two decades, in which it was 41 and 44-8 per cent. respectively. It was lowest in the third decade, in which it was 30-8 per cent. After the age of 40 the mortality became higher again. The average duration of treat- ment in hospital was eight months for the patients who were cured, six and a half months for the patients who remained fairly well, and seven and a half months for those who remained ill. It is sincerely to be hoped that operative treatment may give better results. A CARDIOVASCULAR SYMPOSIUM. ATTEMPTS to reconcile the rapid advance of know- ledge with the endeavour of the busy medical practi- tioner to make the best use of the scanty hours he can devote to study are always interesting. Such we believe is the objective of the editors of the symposium now being issued by the Medical Journal and Record of New York. The example we have recently received 1 deals with cardiovascular diseases, and we can readily believe that it will be welcome. It contains four articles which, without in any way attempting to provide a complete survey of the modern views on diseases of the heart and blood-vessels, give useful information on four big subjects which should be valuable to every practising physician who reads them. The opening article by Dr. T. Parsons-Smith perhaps errs on the side of complexity ; his subject is bradycardia, and whilst recognising the necessity for electro-cardiography in the differential diagnosis of many of the underlying causes of this condition, we feel that he may have laid undue emphasis on the interpretation of electro-cardiograms. The omission of references from his original article diminishes its value to the specialist. The other articles include a valuable dissertation on hyper- tension by Dr. Ernst P. Boas, and an excellent essay by Dr. S. Neuhof on the use of quinidine in private practice. This author finds that by giving 5 grains on the first day and three 5-grain doses on the second and third days, with careful examination by the family physician, the drug can be safely used in the patient’s own home. In all cases with tachy- cardia, a preliminary course of digitalis was given, and, in all cases, symptoms of idiosyncrasy, such as vomiting, diarrhoea, tachycardia, were carefully watched for. After the third day of quinidine, the 1 Cardiovascular Symposium. Medical Journal and Record. New York : A. R. Elliott Publishing Company. Sept. 3rd, 1924.
Transcript

763

whether, in view of the financial commitmentsof the nation in respect of persons who throughphysical or mental deficiency become a charge uponpublic funds, a Royal Commission would be appointedto advise upon the restriction of procreation of childrenby unfit parents. While this country is not yetprepared for advanced eugenic legislation, it isinteresting to note what legislatures are doing else-where. A recent volume of the Society of ComparativeLegislation, containing summaries of the laws passedin different parts of the world during 1922, showsseveral examples of American enactments on this

topic. The State of Nebraska, for instance, forbidsthe marriages of persons afflicted with venereal disease,and insists that no one adjudged afflicted withhereditary epilepsy or insanity shall marry unless first submitting to a sterilising operation ; applicationsfor licences to marry must be accompanied by affidavits of freedom from venereal disease. Montana providesfor the sterilising of inmates of what are euphemisti-cally called " custodial institutions," who are insaneor feeble-minded or idiots or epileptics. An essentialand certainly desirable feature of the Act is theinsistence on adequate medical advice ; there is ahearing before a board with a right of appeal therefromto a court of law. These American provisions are,of course, by no means the first of their kind. Aslong ago as 1895 Connecticut forbade the marriageof epileptic or feeble-minded persons under penaltyof a minimum term of three years’ imprisonment.Ten years later the Act was attacked in the SupremeCourt as being unconstitutional but was upheld,though it was subsequently modified. Wisconsin,Maine, and Delaware are other States which havepassed similar legislation. The underlying principle Iis the same, but the measures differ in that sometimesthey actually make marriages void, sometimes theymerely punish those who marry. Another Americantype of eugenic enactment is aimed not so much atpreventing the birth of unfit children as at puttingan end to sexual assaults by degenerates. ThusCalifornia in 1922 empowered the criminal courts todirect an " operation to prevent procreation " to beperformed on persons convicted of carnal abuse ofgirls under ten years of age. Indiana, Iowa, and otherStates have passed similar Acts in the past, but thecourts have sometimes held the laws to be contraryto the constitution ; in one case the operation was heldnot to be a " cruel " punishment, in another it washeld " cruel and unusual," and therefore unconstitu-tional. This supervision of legislation by judges isalways a little puzzling to us in this country wherelegislators are unhampered by a rigid written constitu-tion. We have not, however, hitherto heard much ofeugenics at Westminster, unless we are to ascribe toa vague eugenic instinct the reluctance of certainlegislators to pass such measures as the DeceasedWife’s Sister’s Bill.

____

THE RESULTS OF CONSERVATIVE TREATMENTOF POTT’S DISEASE.

Now that the treatment of Pott’s disease isbecoming operative, and Albee’s operation is exten-sively employed, it is most desirable that, for thepurpose of comparison, information should be availableas to the results obtained by more conservativemeasures. For it is obvious that there is no indica-tion for operative treatment, however good its results,if patients recover as often, as soon, and as permanentlyunder less heroic measures. To provide such materialfor comparison, Dr. Santeri Leskinen,1 of Helingsfors,has collected the evidence obtainable in connexionwith 241 cases of Pott’s disease treated at hishospital on conservative lines in the period 1895-1920.As many as 21 of these patients died in hospital,and of the remaining 220, only 137 could be traced.There were 126 males to 115 females, and 68 per cent.were between the ages 1 and 10. The cervicalvertebrae were involved in 16-2 per cent., the thoracic

Acta Chir. Scand., 1924, lvii., 193.

vertebrae in 56-4 per cent., and the lumbar vertebraein 27-4 per cent. Thus, the thoracic vertebrae wereinvolved in more than half the total number of cases.But when the incidence of the disease in each vertebrawas calculated, it was found that it was highestfor the lumbar vertebras, each of which accountedfor 13-2 per cent. of all the cases, whereas the corre-sponding figures for each thoracic and cervical vertebrawere 11-3 per cent. and 5-5 per cent. respectively.In addition to the 21 patients dying in hospital,there were 43 who died after discharge. Thus, themortality among the patients who could be tracedwas as high as 40-5 per cent. It was much higher formales than for females, the respective figures being50 per cent. and 32 per cent. Tuberculosis or itssequels was the cause of 57 of the 64 deaths. Thesurvivors who were traced were classified accordingas they were still ill, fairly well, or cured. The figuresfor these three classes were, in the order named,12, 17-1, and 30-4 per cent. respectively. It willthus be seen that with a mortality of 40-5 per cent.,and a complete recovery-rate of only 30-4 per cent.,there was much room for improvement on the resultsof conservative treatment. The besr results wereobtained in disease of the cervical vertebrae, only26-3 per cent. of the patients having died, whereas68-5 per cent. had completely recovered. Diseaseof the thoracic vertebrae responded least satisfactorily,the mortality being 46-3 per cent. and the recovery-rate 21’1 per cent. in this class. When the patientswere classified according to their ages, it was foundthat the mortality was highest in the first two decades,in which it was 41 and 44-8 per cent. respectively.It was lowest in the third decade, in which it was30-8 per cent. After the age of 40 the mortalitybecame higher again. The average duration of treat-ment in hospital was eight months for the patientswho were cured, six and a half months for the patientswho remained fairly well, and seven and a half monthsfor those who remained ill. It is sincerely to be hoped

that operative treatment may give better results.A CARDIOVASCULAR SYMPOSIUM.

ATTEMPTS to reconcile the rapid advance of know-ledge with the endeavour of the busy medical practi-tioner to make the best use of the scanty hours hecan devote to study are always interesting. Suchwe believe is the objective of the editors of thesymposium now being issued by the Medical Journaland Record of New York. The example we haverecently received 1 deals with cardiovascular diseases,and we can readily believe that it will be welcome.It contains four articles which, without in any wayattempting to provide a complete survey of the modernviews on diseases of the heart and blood-vessels,give useful information on four big subjects whichshould be valuable to every practising physicianwho reads them. The opening article by Dr. T.Parsons-Smith perhaps errs on the side of complexity ;his subject is bradycardia, and whilst recognisingthe necessity for electro-cardiography in the differentialdiagnosis of many of the underlying causes of thiscondition, we feel that he may have laid undueemphasis on the interpretation of electro-cardiograms.The omission of references from his original articlediminishes its value to the specialist. The otherarticles include a valuable dissertation on hyper-tension by Dr. Ernst P. Boas, and an excellent

essay by Dr. S. Neuhof on the use of quinidine inprivate practice. This author finds that by giving5 grains on the first day and three 5-grain doses onthe second and third days, with careful examinationby the family physician, the drug can be safely usedin the patient’s own home. In all cases with tachy-cardia, a preliminary course of digitalis was given,and, in all cases, symptoms of idiosyncrasy, suchas vomiting, diarrhoea, tachycardia, were carefullywatched for. After the third day of quinidine, the

1 Cardiovascular Symposium. Medical Journal and Record.New York : A. R. Elliott Publishing Company. Sept. 3rd,1924.

764

consultant again saw the patient and the nature offurther treatment was decided. Dr. Neuhof hasexperienced the same uncertainty of effect that hasbeen generally recognised ; but he reports no

untoward results from the treatment of privatepatients on the lines indicated, and his article is aneffective illustration of how the use of a valuable

Idrug may be extended without danger.

RETINITIS PIGMENTOSA.RETINITIS pigmentosa is one of those diseases the !

pathology of which is still a subject of keen debate.To recapitulate the main facts which any theory,to be tenable, has to explain: The disease is slowlyprogressive, intractable to treatment, and is liable tooccur in several members of a family. Its mosttypical ophthalmoscopic appearance is a passageforwards into the anterior layers of the retina of cellsbelonging to the hexagonal pigment layer which arenormally situated at the back of the retina immediatelyin front of the choroid-this phenomenon firstbecoming evident in the mid-peripheral region. Aconstant symptom, even in early cases, is night-blindness ; and the visual field nearly always showsa ring scotoma corresponding to the ring of abnormalpigment in the mid-peripheral zone. Two antagonistic theories have been and are still held to account forthese phenomena. On the one hand, the atrophyof the outer layers of the retina is supposed to be Isecondary to changes of a sclerosing character in the iIechoroidal blood-vessels on which their nutritiondepends. On the other hand, it is suggested that thedegeneration of the retinal elements is primary andthe sclerosis of the vessels of the choroid a secondaryphenomenon. Treacher Collins put the case for thisview five years ago in an important paper which wasmuch criticised at the time, but which has never beensatisfactorily answered.l In his view these cases areanalogous to those degenerations of tissue due todefective vitality to which the late Sir WilliamGowers gave the name

" abiotrophy." These diseasespresent characteristic features, says Collins, whereverthey occur, which differentiate them as a classfrom other affections. These features may besummarised as follows: 1. The tissue which isaffected is one that has attained mature developmentand which then retrogresses. 2. The condition is onewhich commonly involves several individuals of thesame family, either members of the same childship ormembers of different generations. 3. The partsaffected are usually bilateral and the extent of diseaseis limited by definite anatomical landmarks (as, forinstance, in the nervous system by a certain setof neurons). 4. The changes produced are progressiveso far as the anatomical limits of the tissue permit,and recovery does not take place. 5. The tissuesinvolved are those which have attained a high degreeof specialisation. In all these respects a typical case of retinitis pigmentosa appears to conform. Physio-logically the pigment in the hexagonal pigment cellsis possessed of the power of amoeboid movementwhich is exercised under the stimulus of light. Inthe normal retina, however, a barrier is formed by theexternal limiting membrane through which thepigment cannot pass. Atrophy of the rods and conescauses openings in this membrane through which thepigment is free to wander. According to this view,the sclerosis of the chorio-capillari4s which is so

often found is not the primary affection but issecondary to the retinal atrophy, and Collins supportshis argument by citing the fact that the pathologicalexamination of the eyes from four undoubted casesof retinitis pigmentosa in different stages of thedisease by independent observers, has shown that itmay occur without any discoverable sclerosis of thechoroidal vessels.With regard to the particular region of the retina

first affected in typical cases, the advocates of thechoroidal theory connect the ring scotoma and thedistribution of the pigment in the periphery with

1 Trans. Ophthalmological Society, 1919.

Ghe anatomy of the ciliary arteries, the diseasecommencing at a part where the supply of choroidalblood is least efficient.2 Collins finds the evidencefor this view insufficient and prefers to connect thedistribution of abnormal pigment and scotomatawith the fact that different regions of the retina aredeveloped at different periods of foetal life. " Itappears that the neuro-epithelium of the ultimatecentral area of the human retina is of later formationthan that of the parts around and that of the partimmediately around the central area is the first toattain its full development." It is this paracentralarea that is affected first in typical cases of retinitispigmentosa, whereas the central area which is thelast to be developed is usually the last to be involved.In the interval since this theory of " abiotrophy "

applied to retinitis pigmentosa was first put forward,we have had but little fresh light on the problem.Mr. M. L. Hepburn, in an article in the Septemberissue of the British Journal of Ophthalmology, supportsthe choroidal origin of the disease, and pertinentlyremarks in connexion with Collins’s paper that hecannot quite follow the argument that perfectlyhealthy pigment and pigment epithelial cells shouldwander away from their normal position, merelybecause their anatomical boundaries in front are

destroyed. The subject is complicated by the factthat there are certain cases of undoubted choroiditisin which the signs and symptoms are very similar tothose of typical retinitis pigmentosa. Occasionally,it is very difficult to make the distinction between thetwo. If the supporters of the choroidal theory areright, there is no distinction in kind but only in degree.On the other hand, if the theory of " abiotrophy " isultimately confirmed, the resemblance iskeeidental.

AN AD HOC RESEARCH.

Two members of the Harmsworth family havecontributed a sum of £25,000 to endow a research fundin memory of Mr. R. L. StJ. Harmsworth, who diedof infective endocarditis. The object of the fund isto investigate, and, if possible, to solve, the problemof this disease ; to this end the trustees of the fundwill be advised by a scientific committee consisting ofSir Thomas Lewis, Sir E. Cooper Perry, Sir ThomasHorder, and Dr. Mervyn H. Gordon. In the firstinstance the work to be undertaken by the fund willbe (1) the collation of facts as yet known concerningthe disease, (2) a close study of cases at present underobservation and treatment, and (3) research alongany hopeful lines suggested by members of thescientific committee. Grants may be made toindividual workers in this country or abroad, subsidiespaid to workers whose present efforts are directed inthe right direction, to others who undertake specialnew lines of research, and to those who contributestatistics, data, or results of private experiments.It is proposed to spend in this way the whole netincome of the fund each year and to close the fund atany time by the grant of the whole of the capital toa worker adjudged (to quote the terms of the award)to have finally disposed of the present obscurityoverlying our knowledge of the disease, and thusto give the profession

" control " over the disease.Sir Thomas Horder, in a report to the trustees, givesan account of a typical case of infective endocarditiswhich is sufficiently graphic to set out here in full.

B. J., a young man of 28 years, comes under observationbecause of some general malaise following a short febrileillness which was thought to be "influenza." The tempera-ture incident upon the latter disease does not subside, butpersists without any obvious reason. Careful examinationreveals no signs of any pulmonary disease, and the onlystructural change present is a valvular defect known to haveexisted since an attack of rheumatic fever at the age of18 years. This defect had caused no handicap hitherto andeven now there are no signs of any disability of the heart.Prior to the " influenza " the patient considered himselfquite fit, although inquiry elicits the fact that this illness wasnot of sudden onset but preceded by some sweating at night,2 Nettleship : Royal London Ophthalmic Hospital Reports,vol. xv., part iii., January, 1903.


Recommended