THE "BURR" RED BLOOD-CELL
2
1185 standards. Dr. McCleary says of the sixpenny doctor : " Sometimes he was English ; not infrequently he was Scottish ; more rarely he was coloured ; often he spoke with an Irish accent. Usually he began with what was called a ‘ nucleus ’ and if successful he would develop his nucleus into a lucrative practice, which he would sell and with the proceeds buy a practice in a genteel suburb...." Sixpenny doctors worked exceedingly long hours, and at speed, doing their own dispensing from stock mixtures-for a bottle was a part of the bargain. Sometimes they gave Sacchar2cm Ust’urn, " a medicament which possesses in a high degree what Hippocrates laid down as the first essential of medicine-that it should do no harm." Dr. McCleary, who served as a locuin in several such practices, is cheerfully unrepentant about these bottles of burnt sugar. " When I think of the vast quantities of heart-depressing coal-tar drugs that are swallowed annually in self-medica- tion by an unreflecting public, I recall with satisfaction my dispensing of Saccharu7n Ustum with its reassuring colour and complete harmlessness of effect." Once he worked in a practice in North London where there were two waiting-rooms, one for the sixpenny patients and another for those who could afford to pay a shilling. The doctor saw two shilling" patients for every sixpenny patient, so the higher fee saved the patient a wait. The clientele in the two rooms varied according to the ready money at their disposal at the time ; there was no feeling of class distinction about it. Dr. McCleary would not have us think these doctors were inefficient or careless : ". Some of the men for whom I worked were skilled, conscientious, and laborious, who loved their work and did their best for their patients. They had developed a time- saving technique and a flair for distinguishing the important from the unimportant." He suggests that Flaubert might have made a classic of the life of one of these doctors. Some will recall a less ambitious work-Sixpenny Pieces, the modest tribute of Neil Lyons to Harry Roberts, in Stepney. ADRENOCORTICOTROPIC HORMONE AND HYPERSENSITIVE REACTIONS IT is sometimes forgotten that the symptoms of disease are produced not directly by the external or internal noxious agent which is acting but by the body’s reactions to that agent. Even when there is a definite bacterial or virus cause, the clinical picture-the malaise, fever, pain, and local inflammation-is that of the body’s attempt to combat the attacker. In some diseases, of which those called allergic are the most striking example, though they also include the rheumatic group, periarteritis nodosa,, and others-the body’s reaction is out of all proportion to the severity of the attack and is therefore called a " hypersensitive " reaction. In these, if the reaction can be abolished the " disease " is cured-at least for the time being. A few years ago Hughes 1 suggested that in acute rheumatism any " poison " which would abolish the body’s reactivity without doing any permanent harm would produce a cure : in his view this explained the action of salicylates in rheumatic fever. The same principle-of treating disease by moderating the body’s reaction-is behind the use of antipyretics in general, and of ’ Cryogenine ’ in particular ; and Dr. Geoffrey Bourne showed in these columns last week that reduction of temperature with this drug can improve the condition of patients with lymphadenoma, rheuma- toid arthritis, or tuberculosis. The vast amount of work being done in the U.S.A. with A.C.T.H. and" Cortisone ’ suggests that one impor- tant effect of these substances is to block hypersensitive 1. Hughes, W. Ann. rheum. Dis. 1942, 3, 89. reactions. This may explain the observations, made (though still unpublished) in a wide variety of diseases, that A.C.T.H. immediately abolishes the malaise asso- ciated with them ; it may also be the basis of the good results reported by Hench and his co-workers 2 in rheumatoid arthritis and acute rheumatic fever. More- over, Bordley and his colleagues 3 at Johns Hopkins have now reported remarkable results with A.C.T.H. in allergic diseases. The rapid recovery of a patient critically ill with exfoliative dermatitis due to iodine led them to try A.C.T.H. in a case of penicillin sensitivity of serum- disease type, in which the giant urticaria, joint pains, and fever disappeared within 24 hours. They then obtained equally rapid relief in five patients with severe chronic asthma which had not responded to adrenaline, theophylline and ethylenediamine, or rectal ether. In four of these the symptomatic improvement was accom- panied by the return of a pale cedematous polypoid naso- pharyngeal mucosa to an appearance not far from normal. In accordance with the experience in rheumatoid arthritis, the patients tended to relapse 2-3 weeks after their course of treatment. ’ . THE "BURR" RED BLOOD-CELL HaeMATOLOGISTS are familiar with the spherocyte, the round fat red cell of haemolytic anemia, and with the " target " cell, the thin red cell of Mediterranean anaemia, so thin that its sides clap together somewhere about the middle and make it look, in transmitted light, like a Scottish shield or target. Then there are the sickle-shaped cells associated with a familial anaemia in negroes, the oval cells which are also familial, and one or two other odd shapes of no particular diagnostic import have been described from time to time. The latest addition is the " burr " cell of Schwartz and Motto,4 which is said to be found only in patients with certain diseases, particularly where kidney function is impaired. The burr cell is a kind of, poikilocyte. It is a red cell of normal size with one or more spiny projections along its edge ; the projections are quite long, varying from about a sixth to half the diameter of the red cell, and photographs show that they are usually sharp and pointed. So it does vaguely resemble the burrs that stick to our clothes or the coats qf our dogs. Burr cells are not just crenated cells ; they are fairly evenly scattered over the blood-film, whereas crenated cells tend to accumulate in groups. The blunt-processed burr cell may well be difficult to distinguish from a crenated cell, so no cells should be counted as burr cells unless they are apart from crenated groups. Schwartz and Motto found burr cells in the blood particularly in cases of uraemia, carcinoma of the stomach, and bleeding peptic ulcer. Out of 75 uraemic patients 54 had burr cells in their blood smears ; out of 50 with carcinoma of the stomach 34 had burr cells ; and the cells were seen in 27 out of 50 patients with bleeding peptic ulcer. Two control series were studied ; the first comprised 100 consecutive blood- films from patients admitted to the medical wards for some condition other than a blood disease ; the second was made up of 100 patients who had some haematological abnormality. No burr cells at all were found in the first group, whereas 21 patients in the second group had them, and the only common factor in these 21 patients was renal impairment. What it is that causes red cells to throw out spinous processes has not yet been determined. Severity of the anaemia, duration of bleeding, degree of nitrogen reten- tion, dehydration, age, sex, and race, have all been 2. See Leading article, Lancet, July 23, p. 159. 3. Bordley, J. E., Carey, R. A., Harvey, A. McG., Howard, J. E., Kattus, A. A., Newman, E. V., Winkenwerder, W. L. Bull. Johns Hopk. Hosp. 1949, 85, 396. 4. Schwartz, S. O., Motto, S. A. Amer. J. med Sci. 1949, 218, 563.
Transcript of THE "BURR" RED BLOOD-CELL
1185
standards. Dr. McCleary says of the sixpennydoctor :
" Sometimes he was English ; not infrequently he wasScottish ; more rarely he was coloured ; often he spokewith an Irish accent. Usually he began with what wascalled a ‘ nucleus ’ and if successful he would develop hisnucleus into a lucrative practice, which he would sell andwith the proceeds buy a practice in a genteel suburb...."
Sixpenny doctors worked exceedingly long hours,and at speed, doing their own dispensing from stockmixtures-for a bottle was a part of the bargain.Sometimes they gave Sacchar2cm Ust’urn,
" a medicament
which possesses in a high degree what Hippocrateslaid down as the first essential of medicine-that it shoulddo no harm." Dr. McCleary, who served as a locuin inseveral such practices, is cheerfully unrepentant aboutthese bottles of burnt sugar.
" When I think of the vast quantities of heart-depressingcoal-tar drugs that are swallowed annually in self-medica-tion by an unreflecting public, I recall with satisfactionmy dispensing of Saccharu7n Ustum with its reassuringcolour and complete harmlessness of effect."
Once he worked in a practice in North London wherethere were two waiting-rooms, one for the sixpennypatients and another for those who could afford to paya shilling. The doctor saw two shilling" patients forevery sixpenny patient, so the higher fee saved the
patient a wait. The clientele in the two rooms varied
according to the ready money at their disposal at thetime ; there was no feeling of class distinction about it.
Dr. McCleary would not have us think these doctorswere inefficient or careless :
". Some of the men for whom I worked were skilled,conscientious, and laborious, who loved their work and didtheir best for their patients. They had developed a time-saving technique and a flair for distinguishing the importantfrom the unimportant."
He suggests that Flaubert might have made a classicof the life of one of these doctors. Some will recalla less ambitious work-Sixpenny Pieces, the modesttribute of Neil Lyons to Harry Roberts, in Stepney.
ADRENOCORTICOTROPIC HORMONE AND
HYPERSENSITIVE REACTIONS
IT is sometimes forgotten that the symptoms of diseaseare produced not directly by the external or internalnoxious agent which is acting but by the body’s reactionsto that agent. Even when there is a definite bacterial orvirus cause, the clinical picture-the malaise, fever, pain,and local inflammation-is that of the body’s attempt tocombat the attacker. In some diseases, of which thosecalled allergic are the most striking example, though theyalso include the rheumatic group, periarteritis nodosa,,and others-the body’s reaction is out of all proportionto the severity of the attack and is therefore called a"
hypersensitive " reaction. In these, if the reaction can
be abolished the " disease " is cured-at least for thetime being. A few years ago Hughes 1 suggested that inacute rheumatism any " poison " which would abolishthe body’s reactivity without doing any permanentharm would produce a cure : in his view this explainedthe action of salicylates in rheumatic fever.
The same principle-of treating disease by moderatingthe body’s reaction-is behind the use of antipyretics ingeneral, and of ’ Cryogenine ’ in particular ; and Dr.
Geoffrey Bourne showed in these columns last week thatreduction of temperature with this drug can improvethe condition of patients with lymphadenoma, rheuma-toid arthritis, or tuberculosis.The vast amount of work being done in the U.S.A.
with A.C.T.H. and" Cortisone ’ suggests that one impor-tant effect of these substances is to block hypersensitive
1. Hughes, W. Ann. rheum. Dis. 1942, 3, 89.
reactions. This may explain the observations, made(though still unpublished) in a wide variety of diseases,that A.C.T.H. immediately abolishes the malaise asso-
ciated with them ; it may also be the basis of the goodresults reported by Hench and his co-workers 2 inrheumatoid arthritis and acute rheumatic fever. More-
over, Bordley and his colleagues 3 at Johns Hopkins havenow reported remarkable results with A.C.T.H. in allergicdiseases. The rapid recovery of a patient critically illwith exfoliative dermatitis due to iodine led them totry A.C.T.H. in a case of penicillin sensitivity of serum-disease type, in which the giant urticaria, joint pains,and fever disappeared within 24 hours. They thenobtained equally rapid relief in five patients with severechronic asthma which had not responded to adrenaline,theophylline and ethylenediamine, or rectal ether. Infour of these the symptomatic improvement was accom-panied by the return of a pale cedematous polypoid naso-pharyngeal mucosa to an appearance not far from normal.In accordance with the experience in rheumatoid arthritis,the patients tended to relapse 2-3 weeks after theircourse of treatment. ’ .
THE "BURR" RED BLOOD-CELLHaeMATOLOGISTS are familiar with the spherocyte, the
round fat red cell of haemolytic anemia, and with the"
target " cell, the thin red cell of Mediterranean anaemia,so thin that its sides clap together somewhere about themiddle and make it look, in transmitted light, like aScottish shield or target. Then there are the sickle-shapedcells associated with a familial anaemia in negroes, theoval cells which are also familial, and one or two otherodd shapes of no particular diagnostic import have beendescribed from time to time. The latest addition is the" burr " cell of Schwartz and Motto,4 which is said to befound only in patients with certain diseases, particularlywhere kidney function is impaired.The burr cell is a kind of, poikilocyte. It is a red cell
of normal size with one or more spiny projections alongits edge ; the projections are quite long, varying fromabout a sixth to half the diameter of the red cell, andphotographs show that they are usually sharp andpointed. So it does vaguely resemble the burrs that stickto our clothes or the coats qf our dogs. Burr cells arenot just crenated cells ; they are fairly evenly scatteredover the blood-film, whereas crenated cells tend toaccumulate in groups. The blunt-processed burr cell maywell be difficult to distinguish from a crenated cell, sono cells should be counted as burr cells unless they areapart from crenated groups. Schwartz and Motto foundburr cells in the blood particularly in cases of uraemia,carcinoma of the stomach, and bleeding peptic ulcer. Outof 75 uraemic patients 54 had burr cells in their bloodsmears ; out of 50 with carcinoma of the stomach 34had burr cells ; and the cells were seen in 27 out of 50patients with bleeding peptic ulcer. Two control serieswere studied ; the first comprised 100 consecutive blood-films from patients admitted to the medical wards forsome condition other than a blood disease ; the secondwas made up of 100 patients who had some haematologicalabnormality. No burr cells at all were found in the firstgroup, whereas 21 patients in the second group had them,and the only common factor in these 21 patients wasrenal impairment.What it is that causes red cells to throw out spinous
processes has not yet been determined. Severity of theanaemia, duration of bleeding, degree of nitrogen reten-tion, dehydration, age, sex, and race, have all been
2. See Leading article, Lancet, July 23, p. 159.3. Bordley, J. E., Carey, R. A., Harvey, A. McG., Howard, J. E.,
Kattus, A. A., Newman, E. V., Winkenwerder, W. L. Bull.Johns Hopk. Hosp. 1949, 85, 396.
4. Schwartz, S. O., Motto, S. A. Amer. J. med Sci. 1949, 218,563.
1186
considered and rejected. Hypoproteinaemia and the
presence of blood in the intestinal tract may have some-thing to do with it. Schwartz and Motto think that burrcells can be valuable signposts in the study of the anaemias,though in their patients the diagnoses seem all to havebeen well-established. Still, it does not take very longto look for burr cells and no special technique is needed-so haematologists will be on the look out for them.
THE FOOD WE EAT
IN each of the past ten years, we are told, the averagecalorie value of the food going into consumption in thiscountry has been within 200 calories of the pre-wartotal of 3000 per head per day. This constancy is indeedremarkable ; but it also shows how deceptive averagescan be. For, as we all know, the effect of rationing, pricecontrol, and redistribution of incomes has been to spreadfood-supplies throughout the community more evenlythan ever before. And the sources from which the caloriesare obtained have also altered.
In a sequel to earlier accounts 1 the Ministry of Foodcarries the story of our food consumption forward toJune of this year.2 The report puts the average dailycalorie value of the food distributed in 1948 at 2890,and in 1948-49 at 2980. The Ministry’s estimate of theweighted average requirement in 1948, based on Americantables,3 is 2560 calories. This average, unlike the first, isfor food actually consumed. There’s many a slip ’twixtthe ship and the lip, and the Ministry’s figure for fooddistributed takes no account of waste at the retailer’sor in the household (apart from such obvious causes aspotato peeling). This waste may amount to as much as
10% of the total; so we have no surfeit.
Taking pre-war annual average as 100, the recentcivilian intake per head per day is as follows :
The following figures show, in percentages, the varioussources of calories :
Pre-war 1946 1947 1948 1948-49
By weight in lb. per head per aunum the averageconsumption has been computed as follows :
1948 !9-.<?ffe-MW 1946 1947 (provi- (provi-
siona]). sional)
1. See Lancet, 1944, i, 609; 1945, i, 157; 1945, ii, 718; 1947,ii, 403.
2. Food Consumption Levels in United Kingdom. Cmd. 7842.H.M. Stationery Office. Pp. 13. 4d.
3. United States National Research Council Recommended DietaryAllowances, 1945.
In 1948-49 the distribution of fats was nearly 20%above the level for 1946, and butter (12.5 lb. in the year)was at its highest level since the start of the war, thoughstill only half the pre-war total of 24-8 lb. Sugar (91.2 lb.)was also higher than at any time since the start of thewar, but was still substantially below the pre-war figureof 109-9 lb. Since 1946 consumption of liquid milk hasrisen by 7% ; compared with before the war it has risenby 55%, and consumption of dairy products as a wholeby 30%. In terms of
"
shell-egg equivalent," the amountdistributed in 1948-49 was only 8% below the 1934-38level.
ARMS AND DISEASE
Timor ntonts conturoat me, complamed -une poet..Whoever stops to consider the number and press of thedead is liable to this sinking feeling : it seems so dangerousto be alive. Prof. W. H. Wynn, who last Decemberbegan to recount the story of wars and epidemics, com-pleted it in his two final FitzPatrick lectures deliveredat the Royal College of Physicians this month. Warsare not great killers compared with plagues ; but so
vast has been the toll taken by both together that hisaudience may well have felt some pride in their fore-bears for surviving at all. They must have reflected,too, how very different our world-and even we ourselves- might have been but for sundry epidemics, timelyand untimely. Thus, when the Moslems set out to conquerthe world, not arms but pestilence kept them at bay.Pestilence defeated the Crusaders, thinned populationsthroughout Europe, led to vast massacres of Jews (whowere accused of spreading the Black Death), helped tolose France for England, made the Emperor Charles Vmaster of Italy, added to the horrors of the ThirtyYears War (which reduced the people to starvingdegraded animals), turned Charles I from the course
which might have saved him, almost defeated theFrench Revolution, broke the power of Napoleon at
Moscow, and gave birth to modern nursing. These arethe main and obvious effects of epidemics ; but theylead the mind to speculate on its unknown strokes-to wonder what potential princes, poets, saints, scientists,tyrants, and dictators it has brought down. No doubt
things might have been better, but then they might havebeen so much worse.
EDITORSHIP QF J.A.M.A.FEw, if any, doctors can be so well known to so many
people in so many countries as Dr. Morris Fishbein, editorof the Journal of the American Medical Association tillthe beginning of this month. He joined the journal,quite temporarily, in 1913 as assistant to Dr. George H.Simmons, and succeeded him in the chair in 1924. Aneditor in the dynamic American tradition, doing much toform as well as to express the policy of his association,he has also done much to raise the technical standardsof medical writing. His production of the QuarterlyCumulative Medical Index is in itself a major eontribu-tion to medicine. But at the same time he has madehimself one of the chief exponents of medicine to theAmerican public-through his editorship of Hygeia,and through books, lectures, and broadcasts. Many whodisagree with his opinions have come to feel aboutMorris Fishbein as Elliott Cutler did when he wrote:Of his intelligence I was long ago assured, but theconstant turmoil of this recent publication led me torespect his ideals, his generosity, his patience and hisability."
Dr. Austin E. Smith, director of the A.M.A.’s divi-sion of therapy and research, has now assumed editorialresponsibility for the journal.SIR HENRY COHEN, professor of medicine in the
University of Liverpool, has been appointed presidentelect of the British Medical Association in succession tothe late Prof. T. P. McMurray.
