202

for less than a year, the longest period at work being46 years. The average mining life of the men was23 years.

All the men had worked in the suspected areas atone time or another ; in Colliery E 29 men, and inColliery F 13 men were actually working in the

suspected areas when cases of the disease were

occurring.SUMMARY AND CONCLUSIONS

The blood of 101 coal-miners exposed to the riskof infection with L. icterohaemorrhagiae was examinedfor the presence of immune bodies. In only 2 cases

were they present and both of these had presumablyhad severe Weil’s disease in the past. These resultsare at variance with those previously publishedrelating to sewer-workers and fish-workers. Thereseems to be no adequate explanation for this and wecan only conclude that the incidence of subclinicalWeil’s disease among coal-miners in the North Eastof England is less than might have been anticipated.

REFERENCES

Alston, J. M., and Brown, H. C. (1935) Brit. med. J. 2, 339.Smith, J., and Davidson, L. S. P. (1936) J. Hyg. 36, 438.Swan, W. G. A., and McKeon, J. A. (1935) Lancet, 2, 570.

MEDICAL SOCIETIESROYAL SOCIETY OF MEDICINE

SECTION OF MEDICINE

AT a meeting of this section held on Jan. 13th,with Prof. H. LETHEBY TIDY, the president, in thechair, a discussion on certain aspects of

The Asthma Problem

was opened by Dr. FRANCIS M. RACKEMANN (Boston).Asthma, he said, was obviously a symptom andusually depended upon allergy. It was very common,for 2 or 3 per cent. of the population had eitherasthma or hay-fever; and it was interesting as

depending more upon the reaction of the host thanupon the nature of the exciting agent. To under-stand the reason for asthma and its nature wouldbe a great step towards understanding immunity ingeneral.

Asthma, hay-fever, and eczema depended uponreactions of an immediate urticarial type, readilydemonstrable by a skin test. Some authoritiesbelieved that eczema was caused by a reaction inthe superficial and urticaria by one in the deeperlayers of the skin. These reactions occurred innormal as well as in allergic subjects, and could bereproduced in animals. A large dose of horse serumwould produce a positive skin test in most normalpersons. Patients recovering from pneumonia or

infested by a parasite would often give a positiveskin test to the specific pneumococcal carbohydrateor to an extract of the parasite. Delayed reactionsalso took place up to 48 hours after the exposure;a classical example was the reaction to tuberculin.The delayed and the immediate reaction could becorrelated to show that each played its part in thedevelopment of normal immunity. Dr. Rackemannquoted illustrative cases of patients sensitive to

lobster, wheat, and ragweed. Sensitiveness, he said,was exquisite, often multiple, and hereditary. The

symptoms associated with asthma were characteristic :low blood pressure, rapid pulse, quickness to tire,and an illness during the attack which suggestedsome hostile agent apart from the asthma itself.

Many persons would give a positive skin test whonever had an attack. The process seemed to bedifferent, but he did not know whether it were reallyso or merely a variation of the same phenomenon.The manner of production of the symptoms was a

fundamental problem. He doubted whether thelesion in asthma was an extension down the throatof the hay-fever reaction. He never saw laryngitisin either type of condition. Some patients with foodallergy had abdominal symptoms, and in othersthese symptoms might complicate a condition whichdepended upon dust. In a few patients migrainewas due to food or dust. All these symptoms must

depend on local tissue sensitiveness, but the offensiveagent was presumably carried in the blood. If theserum of an egg-sensitive patient were injected intoa normal person, a reaction would appear at the sitewhen an egg was eaten. The serum of a ragweed-sensitive patient would make a normal person reactpositively to a skin test with ragweed extract madeat another point. White of egg given to dogs appearedunchanged in the blood. Some of the remote symp-toms of allergy might be explained by assuming ablood-borne agent.Few patients died of asthma, but in one who had

died in an acute attack through suffocation, macro-scopic section showed the lungs studded with plugsof tough, sticky, tenacious mucus. Some workers

thought that the mucous glands in the walls of thebronchi were hypertrophied and over-active. This

appeared to be the real lesion. Fibrin was deposited,and eosinophils and small round cells multiplied.These obstructions would account for all the symp-toms. Dr. Rackemann doubted whether this hyper-trophy could be interpreted as an allergic response,and suspected it to be due to a peculiar nerve reflex.He was attracted by the theory that the hostile

agent was choline esterase, the ferment which brokedown acetylcholine. He declared that if English-speaking workers combined, they might producenoteworthy results.

Prof. L. J. WITTS described asthma as a verydiscouraging problem. The physician could, he said,establish a modus vivendi with many patients andpretend to benefit them by desensitisation, vaccines,or non-specific therapy. When they were followedup they were too often found to have relapsed, orto be reacting to another kind of agent or in anotherway. So much of the work done on allergy con-cerned the trigger and not the gun. None of theasthma remedies could be called a "real winner" "

in the sense of the recently discovered drugs whichcontrolled abnormalities of muscle and secretion.The most fundamental approach was, he thought,the search for a general bodily disturbance. Psychicfactors, though they were not the whole story, causedstriking variations, and physical exercises modifiedthe condition. The soil rather than the seed must bestudied.

Dr. E. R. BoLArrn regarded the difficulty of assess-ing results of treatment as in itself a criticism oftherapeutic efforts. Patients would produce everypermutation and combination of improvement shortof cure, but he gravely doubted whether objectiveevidence of real improvement existed, or, if it did,whether it was not a result of chance, lapse of time,or change of season. The history often belied a

patient’s optimism : he would claim to be better butreally be having just as many and as severe attacks.Improvement often went with a change in the actual

203

or psychological situation. Normal saline seemed tobe as effective as any drug with a specific action oras protein desensitisation. Remedial exercises werea more helpful addition to general treatment thanwere desensitisation or saline. Vaccine therapyshowed no particular promise. He advised closer

study of individual attacks and their causation.Better results would, he thought, be obtained fromdesensitisation if skin tests were more reliable. Pro-gress would be assisted by a common technique andstandardised preparations.The PRESIDENT recalled Osler’s observation that

the common end of urticaria patients was death fromnephritis and uraemia, and said that he had seenpatients die apparently from this cause without anyevidence of renal disease. A condition might existin which the brain imitated death from ursemiawithout any change in the kidney or the blood-urea. During a serum reaction the blood containedheterophil agglutinins-agglutinins and haemolysinsto sheep’s red cells. Only one other condition-glandular fever-produced this reaction. He drewno deductions from this striking fact.Dr. L. S. T. BURRELL related instances in which a

medical officer had an attack of asthma cut short

by a call to a dying relative, and a relapse on realisingits cessation ; and an elderly lady had completelyrecovered from asthma after a bad motor-car accident.A follow-up investigation undertaken at the BromptonHospital asthma clinic showed that three-quartersof young patients grew out of the disease spon-taneously, a fact which somewhat compromisedstatistics of treatment. Medical men did not knowhow to treat asthma and worked entirely in thedark.

’

Dr. W. F. H. COKE declined to be so pessimistic,and claimed value for adrenaline combined withdesensitisation, and for the new differential sedi-mentation tests which would distinguish betweenpatients of the allergic, the microbic, and the aspirin-sensitive types. Bacterial asthma was overshadowed

by allergy. The postnasal swab was most important,and even the aspirin-sensitive patient could be curedby suitable vaccines. Shock might produce an effectby liberating large quantities of adrenaline.

Dr. G. W. BRAY maintained that the mode ofabsorption of allergens was almost always lymphatic.He pointed to the results of investigating a numberof cold-sensitive children who developed angio-neurotic oedema on dipping the hand into cold water :a swelling of the glands was noted immediately, andquickly extended to the axilla. Some of them

developed an asthmatic attack, which could be pre-vented by applying a tourniquet to the arm. Otherexperiments had shown that egg-white given by thestomach could be found in the lymphatic ducts butnot in the portal vein. A similar condition of thelymphatic vessels might be present in glandularfever. The mucous glands were hypertrophied inadults only, not in children. If the asthma were dueto a spasm of the muscle, it ought to occlude theducts and prevent the large volumes of fibrinousmaterial from entering the glands during an attack.Hypertrophy with a damming back of the mucuswas a mechanical phenomenon rather than a primarycause.

Dr. RACKEMANN, in reply, said that children whooutgrew asthma were really cured through dis-

appearance of the underlying mechanism. Treat-ment was effective when the asthma depended on aspecific cause which was discovered. To be of valuethe history of a case must explain not only why the

asthma occurred but why it disappeared ; it mustaccount for all the time, and look for reasons ofremission. One of the major difficulties in under-standing the disease was lack of controls. Residencein hospital might itself be the treatment.

SECTION OF THERAPEUTICS ANDPHARMACOLOGY

A MEETING of this section was held on Jan. llth,Dr. J. W. TREVAN, the president, being in the chair.A discussion on

Nutritional Therapy in Pregnancywas opened by Dr. R. A. MCCANCE. He describedthe results of an analysis of the food eaten in

pregnancy by 116 women at different economic levels.About 50 were wives of unemployed miners inSouth Wales and Northumberland, 20 the wives ofemployed labourers in Bermondsey, London, 21were of the artisan class living in Camberwell,London, and 22 belonged to the professional classesand lived in various parts of the country. The womenhad been weighed and measured and in 77 the

haemoglobin had been determined by Haldane’smethod. The composition of the diets had beencalculated from analyses made at King’s CollegeHospital. The food eaten by each woman variedconsiderably in amount from day to day and it wasconsidered that a week was the shortest time in whicha reliable assessment of an individual’s diet couldbe made. The composition of the diets was affectedby at least two considerations-personal taste andincome. When classified according to the weeklyincome per head in the household (after deduction ofrent) there were 16 women with less than 6s., 23 with6s. to 9s., 19 with 9s. to 15s., 14 with 15s. to 25s.,13 with 25s. to 40s., and 22 with over 40s.The average intake of calories in the different

groups ranged from about 2100 to 2700 a day. Theintakes of calcium, phosphorus, and iron increasedfairly steadily in passing from the poorest to therichest groups and the differences in mineral intakewere attributable largely to the gradual increase in theconsumption of the so-called protective foods. Thusthe greater proportion of milk taken by the richergroups explained the increase in calcium and thegreater amount of brown bread eaten by the highestincome group accounted for some of their greateriron intake, but a steady rise in amounts of eggs,green vegetables, raw fruit, meat, and fish was alsopartly responsible. The consumption of breaddeclined with rising income. How did these differencesaffect health ? It was found that the women in the

poorer classes were on the average shorter than thewell-to-do, and the haemoglobin level also rose inpassing from the poorer to the richer groups, thedifferences between the first and last groups being inboth cases statistically significant. A significantcorrelation had also been found between the hmmo-globin levels of individual women and their ironintakes. It seemed then that those in the poorerclasses gave evidence of worse nutrition both at

present and in the past. Judged by the standards -set out by the technical committee of the Leagueof Nations however the diets of even the richestincome group were not entirely adequate. Inthese women the total calorie value must have beendictated by appetite and not by economic limitations,so that the committee’s 3000-3500 calories a day maybe in excess of that required by British women.The League’s recommendations for calcium, however,were presumably based on careful assessments of

204

calcium balance and if their figure of 1.60 g. per diemis correct the diets of all the women in this investiga-tion were deficient in calcium. The same line of

argument showed that the women were not eatingenough phosphorus. The cost of the League’srecommendations for protective foods was estimatedto be about 10s. 10d. a week. The analysis of the well-to-do women’s diets showed that many would findit really difficult to carry out the recommendationswithout radically altering their natural food habitsor greatly exceeding their chosen and probablyphysiological intake of calories. Practical remediesfor the deficiencies seemed to lie in teaching womenwhat articles of food to eat, in increasing the purchasingpower (for food) of the poor, in communal feeding,and in medicinal supplements. The complete solutionpossibly called for a mixture of all four methods.

Dr. MARGARET BALFOUR described observationson the effect of adding certain concentrated foodsubstances to the diet of pregnant women in SouthWales. She said that a nutritional scheme for assistingexpectant mothers in the special areas of England andWales had been organised by the National BirthdayTrust Fund in 1935 and had been gradually extendedby aid of a grant from the Commissioner for thespecial areas until in the year 1937-38 the provisionof foods for 12,000 expectant mothers had beenestimated for. Each mother whose income was

below a certain scale, irrespective of her physicalcondition, received per month 3 lb. of milky foods(Ostermilk, Ovaltine, or Colact) and 2 lb. of Marmite.These foods had been given during the last threemonths of pregnancy. There was some suspicionthat the mother shared the milky foods with herfamily, especially with the young children, but themarmite she was more likely to take herself as shedid not consider it so suitable for babies or the smallerchildren. The results up to June 30th, 1937, showedthat among 10,384 mothers who had received thefoods there had been a death-rate of 0.09 from

puerperal sepsis (one maternal death) and among18,854 mothers in the same areas who had notreceived the foods, there had been a death-rate of2.91 from puerperal sepsis (46 maternal deaths).Cases of septic abortion had been excluded from thecontrols by counting only the deaths in the lastthree months of pregnancy. Maternal deaths fromother causes had been rather less than half andinfant deaths and stillbirths had been rather morethan half those of the control series. The twoclasses of mothers might be considered fairly compar-able. It was true that the Birthday Trust mothersreceived the foods from the antenatal centres, so

they all had the advantage of antenatal care, whileonly some of the control series had this ; but under

present conditions it was not clear that antenatalcentres, when taken in large groups, would have alower rate of maternal mortality than other womenof the area, owing to the greater proportion ofabnormal cases and primiparse. The foods givendid not increase the proteins or calories of the dietto any great extent and the question arose whetherthe good result was due to a general improvement innutrition and the power of resistance to disease dueto the milky foods plus vitamins A, B, and D, orwhether it was due to some other element that had aparticularly beneficial effect on pregnancy and child-birth. Dr. Balfour suggested that the vitamin-B

complex might act in this way by means of its actionin increasing neuromuscular efficiency, in stimulatingdigestion and in preserving the integrity of themucous membranes, so rendering the uterine passagesmore impervious to germs. A research committee

composed of medical and scientific workers had

recently been appointed by the Joint Council of

Midwifery (of which the Birthday Trust Fund wasone of the components) to carry on the futureadministration of the scheme. It was obvious thatmuch more information was required to elucidatethe results. Antenatal clinical officers were beingasked to keep some records but it seemed desirablethat research workers should be called in to assistat the clinics..The PRESIDENT said he wished that Dr. Balfour

could have provided her controls from within herown group, even at the cost of denying the foodsto some of the women.

Dr. HELEN MACKAY thought, in view of the veryinteresting results obtained in the large-scale observa-tion, the work should now be taken up in a some-what different manner, by studying small groups ofpregnant women intensively. She thought that inany intensive study observations were best made bythe doctor or doctors responsible to the patientrather than by a separate observer. There was nodoubt that remarkable results could be obtained bymaking good deficiencies in children’s diets. It wastherefore reasonable to expect that large reductionsin the morbidity-rate of adults could be obtained inthis country by similar means.

Prof. JAMES YOUNG said that the investigation inthe depressed areas had been largely inspired byLady Williams, and that the work throughout hadbeen made possible through her enterprise and energy.It was difficult to explain the dramatic results com-pletely on any other basis than that which Dr. Balfourhad advanced. At the same time the reduction inthe death-rate had been so great that it seemedalmost too good to be true. The methods now inoperation for checking the cases individually would,however, enable the exclusion of any fallacies thatmight have crept in. This matter had engaged thecareful attention of the special committee of whichhe had recently been elected a member. Only1 death from sepsis in 10,000 women who had receivedspecial nourishment was a very striking figure. Atfirst sight it might almost suggest that, the com-plicated technical detail in antisepsis and asepsis,which had grown up within recent times and whichwas regarded as an essential part of the preventionof sepsis, was hardly worth while. At the same time,as an obstetrician, he felt that until the evidencewas overwhelming they could not assume thatsuch a complete protection was obtainable fromdietetic measures alone. There were many difficultieswhich might be quoted. In Rochdale it was knownthat the mortality had been reduced by 60 per cent.as the result of an intensive effort on behalf of the

community, in which doctors, midwives, and patientswere all concerned. This result was undoubtedlydue entirely to an improvement in the obstetricservice of the area and could not in any way beattributed to improvement in diet.Dr. JANET VAUGHAN, commenting on the high

incidence of anaemia in working-class women shownby Dr. McCance’s work, described a carefully con-trolled series of observations made in America.Half the women had been given iron during the lastfour weeks of pregnancy and the others none. Those

receiving iron had subsequently a haemoglobinvalue over 70 per cent., but 24 per cent. of thosewithout iron therapy had had a value below 70 percent., representing a considerable degree of anaemia.Possibly the haemopoietic effect of marmite mightbe a factor contributing to the results described byDr. Balfour. She thought the additions to diet

205

should be studied one at a time.-Mr. A. L.BACHARACH thought the Birthday Fund patientscould not be studied by making one addition at atime, since multiple deficiencies and an integrativeaction between more than one added factor were

likely to be responsible for the effects. If it were

possible to reduce the mortality and morbidity tonothing every effective addition to diet should bemade and the results analysed subsequently.-Prof. J.MARRACK regretted making up inadequate diets

merely by medicinal means.-Dr. PAYNE wonderedwhy milk should be such an essential article for theproviding of calcium in the diet of adults.

In reply, Dr. MCCANCE pointed out that manyanimals after weaning chewed and consumed bonesand the same was true of Eskimos. Herbivorousand indeed all mammals were liable to go into

negative calcium balance during pregnancy andlactation.-Dr. BALFOUR agreed that whole mealsmight be more satisfactory than special additionsto the diet, provided the necessary elements couldbe given in the meals at reasonable cost, and providedthe mothers could be induced to attend outsidecentres in large numbers.

WEST LONDON MEDICO-CHIRURGICALSOCIETY

AT a meeting of this society on Jan. 7th, with Dr.G. RICE-OXLEY, the president, in the chair, a dis-cussion took place on the causes and treatment of

Sterility or Infertile MarriageMr. EABDLEY HOLLAND described a routine that

he had often found successful. It began with aninvestigation of the history and a cursory gynoeco-logical examination, after which the woman was givena prescription of thyroid gland in graduated doses.This first stage included an examination of the

husband; Mr. Holland refused to have anythingto do with the case unless the husband cooperated.The second stage of treatment, after three monthson thyroid, began with a more complete examinationof the tubes, using Lipiodol injection, which wasmuch more reliable than insufflation of air. In aproportion of cases the lipiodol injection openedhitherto blocked tubes. The third stage of treatmentwas by means of hormones. In the large proportionof cases where there was genital hypoplasia consider-able doses of the follicular hormone (oestrin) might begiven.

Mr. KENNETH WALKER said that where a marriagewas childless it would usually be found that therewere adverse factors on the side both of the maleand of the female. The importance of such con-ditions as infection of the genital tract had beenexaggerated ; it was true that gonorrhoea could

produce absolute sterility but in most cases of child-lessness the condition found was merely impairmentof fertility. Ten years ago in such a discussion hewould have laid chief emphasis on local conditions ;to-day he would lay it on constitutional troubles.Endocrinology offered some hope, though not everycase was due to endocrine dysfunction.

Mr. V. B. GREEN-ARMYTAGE thought it importantthat medical officers and matrons of girls’ schoolsshould carefully observe the time of onset and typeof menstruation. Hypoplasia did not begin at theage of 25 when the woman came to the gynecologist ;it began in early youth, and if care were taken atthat period as to diet, exercise, and the giving of

cestrogenic substances when necessary, subsequentinfertility might be lessened. Mr. Green-Armytagewas convinced that contraceptive measures in the

early days of marriage were inimical to pregnancylater. Salpingography, he said, was carried out as aroutine on the Continent, and if practitioners realisedits ease and painlessness more cases of infertilitywould be investigated. It had the advantage overinsufflation that it gave information as to whetherboth tubes were patent or only one, and whetherthere was any abnormality of the uterus.

Mr. F. J. MCCANN spoke of the damage done tothe ductless glands in childhood by many of theexanthemata, the result being seen only after puberty.Irregularity of menstruation in the young girl shouldbe looked upon as a serious condition demandingtreatment, the treatment being first diet, secondlyexercise, and thirdly medication. Mr. McCann addedhis strong belief that birth control measures did

delay fertility for a considerable time, and mightcause sterility. Birth control was the greatest menaceto our race to-day, destroying the fertility of largenumbers of women and not a few men.

INTERNATIONAL OPHTHALMOLOGICALCONGRESS

THE fifteenth International Ophthalmological Con-gress was held in Cairo from Dec. 8th to 14th, 1937.The two main subjects discussed were, first, hyper-tension and retinal arterio-sclerosis, and, secondly,the relation of endocrinology to the eye.

Retinal HypertensionDr. H. P. WAGENER and Dr. NORMAN M. KEITH,

of the Mayo Clinic, jointly presented the openingpaper on retinal arterial hypertension. The ophthal-mologist, they said, because of his wider and moreintimate knowledge of the clinical details of retinalpathology, should be better equipped than the physi-cian to observe the reactions in the retina that areassociated with raised blood pressure and systemicvascular disease. If, as seems logical, the visiblereactions in the retinal vessels are similar, thoughat times disproportionate, to the invisible reactionstaking place in vessels of similar size throughout thebody, it is clear that an explanation of the mechanismof these reactions in the retina will go far toward

solving the mechanism of diffuse vascular disease.The responsibility of the ophthalmologist in the solu-tion of this problem is great, and his opportunitiesare wide, for he is able to see these vascular changesfrom their inception and to study their modes of

origin and progression.Arterial hypertension is evidently an expression

of a diffuse disease or abnormal condition of thearterioles throughout the body. The lesion of thearterioles results in an increase in the peripheralresistance in certain regions or in the whole of thearteriolar bed. The narrowing of the lumen of thearterioles, which is the apparent cause of the increasedresistance, is not structural in the earliest phases ofthe disease. It must be regarded as due to increasedtonicity of the vessel wall, to spastic constriction,or to a combination of the two. Whether the con-striction is due to the action of a pressor substancedirectly on the arteriolar wall or through the mediumof the sympathetic nerves, or simply to increasedvasomotor stimuli is not known. If the causativefactor of the arteriolar narrowing continues to operate,histological changes develop ultimately in various

parts of the arteriolar system, for example, in the