1
1108 Annotations. VAQUEZ’S DISEASE. "No quid nimig." WHETmExt the different kinds of disease can be distinguished from one another on the same general principles by which the sorts of plants and animals are separated into species is a philosophical question of some nicety. If a disease is a specific response to a change in environment, it corresponds only to a Lamarekian conception of a species ; Darwinian and even Mendelian diseases there may be, but they are few and far between. The condition known as the " effort syndrome " seems to be just the extreme variant of the normal response to physical exertion ; in haemophilia there is no doubt a bit of a chromosome which is responsible. But most diseases as we know them are reactions to injury, and any lack of definition at their boundaries is the natural result of the variability in quantity, intensity, and time relations of the reagents. If the morbid systematist has to sink a certain number of newly described diseases as synonyms of what is already known, no one will question that the condition distinguished 30 years ago by Prof. Vaquez, by the association of poly- cythaemia, splenomegaly, and cyanosis, is a genuine and separate disease in any ordinary sense. It is a real pleasure that the author should visit London and take a survey of his child as Prof. Vaquez did last week at the Royal Society of Medicine. It must be admitted, as he frankly allowed, that no very definite progress has been made in the direction of cure. Radiotherapy and X rays will do something, and sometimes a good deal, by way of alleviation ; patients may be cured from their own point of view in the sense that they feel quite well, if only for a time. Bleeding is, as everyone has found, of temporary benefit only, but we are not sure that the disappoint- ment of having to do it again and again has not led to some neglect of the possibility of making a patient’s life relatively comfortable over a course of years by this simple procedure. In reaching an understanding of the nature of the condition there has been much more advance; indeed, the relative failure of therapeutics has helped to an appreciation of what the disease is. The primary anatomical error is the polycythsemia, the enlargement of the spleen being a secondary development, and the cyanosis due to the stagnation of the viscous blood in the surface vessels. The excess of red cells is due to over-action of the bone marrow, as Parkes Weber demonstrated when he studied the first cases identified in this country, and as is shown by the constant presence in the circulating blood of a few nucleated red cells. The only known cause of a persistent polycythaemia produced in this way by active growth of red cells is a defect somewhere in the chain of transference of oxygen from the air to the tissues. It may be that the air contains too little oxygen (as at high altitudes), or that some of the haemoglobin is inactive (as in chronic carbon monoxide poisoning), or that the rate of circulation is too slow (as in congenital pulmonary stenosis). No possible explanation of Vaquez poly- cythsemia can be found along these lines. It is evidently not compensatory and beneficial, but ,cryptogenetic and harmful. An overgrowth of any solid tissue which has these characters is grouped as a tumour, and the disease is best regarded as a benign tumour of red corpuscles just as leuk2emia is a malignant tumour of leucocytes ; pernicious anaemia is possibly its malignant analogue. In indicating these considerations Prof. Vaquez has illustrated to our advantage the benefits which the peripatetic physician may confer. Medicine is international, but not international enough ; each locality develops its own traditions and doctrines which is all to the good if they do not keep them too much to themselves and be content with that. And what is true of national views is true of our own schools among themselves. An interchange of teachers between the London schools would do much to promote true learning and a catholic medical education. DENTAL REGISTRATION. WE are informed by the Registrar of the Dental Board of the United Kingdom that the passage of time renders it desirable that those who wish to be registered or entered under the various sections in the Dentists Act, 1921, should now make application as quickly as possible. On the average a period of about two months elapses after an application is received before the registration is effected, and a person who is not registered when the Act comes into force, whether he has made application or not, will be prohibited from practising. It is thus important that those who desire to apply for registration and have not yet done so should immediately proceed with their applications. THE CHOICE OF CASES FOR TREATMENT BY ARTIFICIAL PNEUMOTHORAX. TEN years ago Dr. L. Colebrook and Dr. Parry Morgan showed that it was possible to maintain a pneumothorax simultaneously on both sides of the chest without causing the patient great embarrass- ment. Dr. Parry Morgan’s researches into the mechanism of the partial pneumothorax find striking snpport in a recent paper by Dr. N. Barlow and Dr. D. Kramer.1 The partial pneumothorax, single or bilateral, is, in their experience, far more effective than the complete unilateral pneumothorax which is so frequently associated with pleural effusions. Only in one out of 30 cases did a pyo-pneumothorax develop under their system of partial, low-pressure pneumothorax, which involves far less tension on pleural adhesions than the present high-pressure method. Nine of their 30 patients passed from their care into that of exponents of the complete pneumothorax school, and six of these nine developed pleural effusions. If these authors’ teachings prove sound, it would be no exaggeration to say that treat- ment by artificial pneumothorax promises to be revolutionised, and the time may come when bilateral pulmonary tuberculosis will be treated as a matter of course by a simultaneous, partial, bilateral pneumo- thorax. But this revolution has certainly not yet been made good, and stimulating as the authors’ paper is, it is not wholly convincing. There is not yet a consensus of opinion as to which cases are most suitable for artificial pneumothorax treatment, but those with an early unilateral apical lesion, or similar ones with an old arrested focus on the other side, would appear very favourable. In this connexion the case recorded in a recent number of the Bulletins et Mémoires de la Société des Hôpitaux de Paris (April 13th) is of interest. A boy, aged 14 years, showed signs of tuberculosis at the apex of the right lung, and had several slight ha moptyses. An artificial pneumothorax operation was performed on the right side about two months after the apparent onset of the disease. The left lung showed nothing abnormal on clinical examination, and the sputum contained no tubercle bacilli. The pneumothorax was maintained for three months, when signs of meningitis appeared, followed by death in 18 days. At the autopsy, in addition to the pathological changes due to the tuberculous meningitis and a slight degree of pericarditis, the lungs showed at the right apex a small cavity containing pus, but compressed and under- going fibrosis. At the apex of the left lung, however, there was a small caseous focus, and around it numerous old tuberculous lesions, some of which were calcified. It was considered that the tuberculous septicxmia resulted not from the recognised lesion at the right apex, for which the pneumothorax had been success- 1 American Review of Tuberculosis, April, 1922.

VAQUEZ'S DISEASE

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1108

Annotations.

VAQUEZ’S DISEASE.

"No quid nimig."

WHETmExt the different kinds of disease can bedistinguished from one another on the same generalprinciples by which the sorts of plants and animalsare separated into species is a philosophical questionof some nicety. If a disease is a specific response to achange in environment, it corresponds only to a

Lamarekian conception of a species ; Darwinian andeven Mendelian diseases there may be, but they arefew and far between. The condition known as the" effort syndrome " seems to be just the extremevariant of the normal response to physical exertion ;in haemophilia there is no doubt a bit of a chromosomewhich is responsible. But most diseases as we knowthem are reactions to injury, and any lack of definitionat their boundaries is the natural result of the

variability in quantity, intensity, and time relationsof the reagents. If the morbid systematist has tosink a certain number of newly described diseases assynonyms of what is already known, no one willquestion that the condition distinguished 30 yearsago by Prof. Vaquez, by the association of poly-cythaemia, splenomegaly, and cyanosis, is a

genuine and separate disease in any ordinary sense.It is a real pleasure that the author should visitLondon and take a survey of his child as Prof. Vaquezdid last week at the Royal Society of Medicine. Itmust be admitted, as he frankly allowed, that novery definite progress has been made in the directionof cure. Radiotherapy and X rays will do something,and sometimes a good deal, by way of alleviation ;patients may be cured from their own point of view inthe sense that they feel quite well, if only for a time.Bleeding is, as everyone has found, of temporarybenefit only, but we are not sure that the disappoint-ment of having to do it again and again has not ledto some neglect of the possibility of making a patient’slife relatively comfortable over a course of years bythis simple procedure. In reaching an understandingof the nature of the condition there has been muchmore advance; indeed, the relative failure oftherapeutics has helped to an appreciation of what thedisease is. The primary anatomical error is the

polycythsemia, the enlargement of the spleen beinga secondary development, and the cyanosis due tothe stagnation of the viscous blood in the surfacevessels. The excess of red cells is due to over-actionof the bone marrow, as Parkes Weber demonstratedwhen he studied the first cases identified in thiscountry, and as is shown by the constant presence inthe circulating blood of a few nucleated red cells.The only known cause of a persistent polycythaemiaproduced in this way by active growth of red cells is adefect somewhere in the chain of transference ofoxygen from the air to the tissues. It may be thatthe air contains too little oxygen (as at high altitudes),or that some of the haemoglobin is inactive (as inchronic carbon monoxide poisoning), or that the rateof circulation is too slow (as in congenital pulmonarystenosis). No possible explanation of Vaquez poly-cythsemia can be found along these lines. It isevidently not compensatory and beneficial, but,cryptogenetic and harmful. An overgrowth of anysolid tissue which has these characters is grouped as atumour, and the disease is best regarded as a benigntumour of red corpuscles just as leuk2emia is amalignant tumour of leucocytes ; pernicious anaemiais possibly its malignant analogue. In indicating theseconsiderations Prof. Vaquez has illustrated to ouradvantage the benefits which the peripateticphysician may confer. Medicine is international, butnot international enough ; each locality develops itsown traditions and doctrines which is all to the goodif they do not keep them too much to themselves andbe content with that. And what is true of national

views is true of our own schools among themselves. Aninterchange of teachers between the London schoolswould do much to promote true learning and a

catholic medical education.

DENTAL REGISTRATION.

WE are informed by the Registrar of the DentalBoard of the United Kingdom that the passage oftime renders it desirable that those who wish to beregistered or entered under the various sections in theDentists Act, 1921, should now make application asquickly as possible. On the average a period ofabout two months elapses after an application isreceived before the registration is effected, and a

person who is not registered when the Act comesinto force, whether he has made application or not,will be prohibited from practising. It is thusimportant that those who desire to apply forregistration and have not yet done so shouldimmediately proceed with their applications.

THE CHOICE OF CASES FOR TREATMENT BY

ARTIFICIAL PNEUMOTHORAX.

TEN years ago Dr. L. Colebrook and Dr. ParryMorgan showed that it was possible to maintain apneumothorax simultaneously on both sides of thechest without causing the patient great embarrass-ment. Dr. Parry Morgan’s researches into themechanism of the partial pneumothorax find strikingsnpport in a recent paper by Dr. N. Barlow andDr. D. Kramer.1 The partial pneumothorax, singleor bilateral, is, in their experience, far more effectivethan the complete unilateral pneumothorax whichis so frequently associated with pleural effusions.Only in one out of 30 cases did a pyo-pneumothoraxdevelop under their system of partial, low-pressurepneumothorax, which involves far less tension onpleural adhesions than the present high-pressuremethod. Nine of their 30 patients passed fromtheir care into that of exponents of the completepneumothorax school, and six of these nine developedpleural effusions. If these authors’ teachings provesound, it would be no exaggeration to say that treat-ment by artificial pneumothorax promises to berevolutionised, and the time may come when bilateralpulmonary tuberculosis will be treated as a matterof course by a simultaneous, partial, bilateral pneumo-thorax. But this revolution has certainly not yetbeen made good, and stimulating as the authors’paper is, it is not wholly convincing.

There is not yet a consensus of opinion as to whichcases are most suitable for artificial pneumothoraxtreatment, but those with an early unilateral apicallesion, or similar ones with an old arrested focus onthe other side, would appear very favourable. In thisconnexion the case recorded in a recent numberof the Bulletins et Mémoires de la Société des Hôpitauxde Paris (April 13th) is of interest. A boy, aged 14years, showed signs of tuberculosis at the apex of theright lung, and had several slight ha moptyses. Anartificial pneumothorax operation was performed onthe right side about two months after the apparentonset of the disease. The left lung showed nothingabnormal on clinical examination, and the sputumcontained no tubercle bacilli. The pneumothorax wasmaintained for three months, when signs of meningitisappeared, followed by death in 18 days. At theautopsy, in addition to the pathological changes dueto the tuberculous meningitis and a slight degree of

pericarditis, the lungs showed at the right apex a smallcavity containing pus, but compressed and under-going fibrosis. At the apex of the left lung, however,there was a small caseous focus, and around it numerousold tuberculous lesions, some of which were calcified.It was considered that the tuberculous septicxmiaresulted not from the recognised lesion at the rightapex, for which the pneumothorax had been success-

1 American Review of Tuberculosis, April, 1922.