217CHRONIC RHEUMATIC DISEASES

insertion of a suprapubic drain. Dr. Leclercqjustified his hesitation in diagnosis by the fact thattenderness was most marked over the appendixarea, and that the gas bubble demonstrated in theX ray was so small that he thought it might havebeen caused by perforation of a gangrenous appendix.Curiously enough, Leclercq seems to have been

surprised to find the stomach full, although theretention of the stomach contents is one of the well-established facts in cases of perforation. Dr. Loutesaid that his practice amongst the miners in the

region of Charleroi had given him an extensiveexperience of perforation in patients coming to hospitalin poor physical condition. He considered that the

procedure described by Dr. Leclercq was a good one,and he had himself employed it. He was more andmore impressed with the number of cases permanentlycured by simple suture. Dr. Appelmans spokestrongly in favour of partial gastrectomy as theoperation of choice for perforation wherever thecondition of the patient justified it. Dr. Leclercqthought that too much weight ought not to be givento the statistics which showed greater success withgastrectomy than with suture. All the criticallyill patients were treated by suture, partial gastrectomybeing reserved for specially good risks.

CHRONIC RHEUMATIC DISEASES

WE welcomed the first report of the British Com-mittee on Chronic Rheumatic Diseases above all forits attempt to rouse more professional interest inchronic arthritis, and to feed that interest with suchgrains of wheat as can be winnowed from the chaffof a difficult field. The feeding process is continuedin the second annual volume,l and the winnowing iscareful. Prof. L. S. P. Davidson and Dr. Goldieopen it by presenting a reasoned case for regardingall rheumatoid arthritis as " chronic infectivearthritis." Their evidence is circumstantial-suchpoints as the more frequent occurrence of antecedentinfections and of infected foci in rheumatoid arthriticpatients than in controls, and the more frequentfindings of streptococcal antibodies in their blood-but it leads them to regard infection, along withsensitisation, and some constitutional predisposition,as the three factors together responsible for thedisease. Dr. W. S. C. Copeman presents a dozencases of his own, and quotes another dozen from theliterature, in support of the thesis that some casesof " rheumatoid " arthritis may be tuberculous in

origin ; in 11 of his 12 cases Prof. Loewenstein, ofVienna, found tubercle bacilli in blood cultures.A most interesting and valuable chapter is a reviewof recent American researches on diseases of jointsand related structures written by Dr. Philip Hench,of the Mayo Clinic, secretary of the American Com-mittee for the Control of Rheumatism ; it is a conciseand critical survey of the last three or four years,for which workers in this country should be mostgrateful. There are half a dozen shorter papers inthe volume, including a preliminary report by Dr.E. G. L. Bywaters of his researches in Prof. Dodds’slaboratory into the metabolism of joint cartilageand synovial membrane, and an account of an

attempt by Dr. Philip Ellman and Dr. SydneyMitchell to assess the psychological features of40 cases of rheumatoid arthritis and 40 osteo-arthritics." No cure for rheumatoid arthritis will ever come out

1 Reports on Chronic Rheumatic Diseases, being the AnnualReport of the British Committee on Chronic Rheumatic Diseasesappointed by the Royal College of Physicians. Edited by C. W.Buckley, M.D., F.R.C.P. Number Two. London: H. K. Lewisand Co., Ltd. 1936. Pp. 140. 12s. 6d.

of a committee room," Dr. Hench says, "but theefforts of an aggressive committee may well providethe future discoverer of a cure with the inspirationand assistance necessary to achieve his success."In that hope, we trust the efforts of the BritishCommittee will be continued and extended.

RADIUM FROM CANADA

THE isolation of radium from the streak of silver-radium ore near the Great Bear Lake in Canadahas been progressing rather rapidly. From an officialstatement recently issued by the Eldorado GoldMines Limited, who mine, carry, and refine the

pitchblende, it seems that unusual problems wereposed by the unparalleled richness of the ore inradium. The technical side of production has nowbeen solved by the Department of Mines with theassistance of Mr. L. Pochon who had worked atthe Curie laboratories in Paris. By October, 1936, theproduction of radium had reached two grammesmonthly, and the first ounce was completed on

Nov. 16th. The capacity of the refinery is expectedshortly to be trebled, and orders to the value ofmore than E800,000 are to be met in the coming year.It is stated that the market price of radium has beenhalved as a result of developments in Canada, andthere is welcome assurance that with increasingsuccess there is no intention of raising the Canadianprice to an exorbitant level.

THE BLOOD IN HODGKIN’S DISEASE

HaeMATOLOGISTS do not agree about the peripheralblood picture in Hodgkin’s disease, and it is usefulto have Wiseman’s account 1 of his findings in 31 caseswhich had not yet been treated by irradiation andin which the diagnosis was confirmed histologically.About half the patients, he says, had a normal totalwhite cell count, and the number did not exceed10,000 per c.mm. unless the illness was in an advancedstage-all but one of this group having much

enlarged abdominal or mediastinal glands. Theother cases showed a slightly subnormal count, andthere was a definite tendency to neutrophilia. Eosino-philia was sometimes found and Wiseman suggeststhat it is constant enough to be an aid to diagnosis,though it seemed to bear no relation to the activityof the disease. Approximately nine-tenths of thepatients had an absolute lymphocyte count below1500 per c.mm. (i.e., a lymphopenia), and in nonedid the number of lymphocytes exceed the normal.On the other hand nearly two-thirds had absolute

monocyte counts above 700. All cases sooner or

later developed a deficiency both of red cells and ofhaemoglobin, associated with an increase of reticulo-cytes. Wiseman concludes that a blood pictureshowing a lymphopenia with a high ratio of mono-cytes to lymphocytes, a neutrophilia, and normal totalwhite count should suggest a diagnosis of Hodgkin’sdisease. This cellular response, he believes, indicatesa non-pyogenic infectious agent as the cause of thedisease, and he regards it, perhaps rather dog-matically, as evidence against either a tumour

process or a virus. The pronounced lymphopenia inhis opinion negatives lymphoid hyperplasia, and heconsiders that the primitive reticulum cell and

monocyte are primarily affected. But his sug-gestion of an infectious agent of low virulence andnon-pyogenic origin, allied on the one hand to thetubercle bacillus and on the other hand to monocyticleuksemia, is not altogether easy to follow. Finally

1 Wiseman, B. K. (1936) J. Amer. med. Ass. 107, 2016.