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S” LIBRARIES
HEALTH SCIENCE
UNIVERSITY OF IOWA
| Wi li
-3 1858 021 45€
Digitized by Google
Digitized by Google
SEPT. 7, 1946
THE LANCET
A JOURNAL OF BRITISH AND FOREIGN MEDICINE, SURGERY, OBSTETRICS,
PHYSIOLOGY, PATHOLOGY, PHARMACOLOGY, PUBLIC HEALTH, AND NEWS
No. 6419
LONDON: SATURDAY, SEPTEMBER 7, 1946
CCLI
ORIGINAL ARTICLES
Epidemic Thrombophlebitis in the
East Africa Command (charts)
Lieut.-Colonel P. E. C.
MANSON-BAHR, M.R.C.P.,
D.T.M. & H., A. D. CHARTERS,
M.D., D.T.M. & H. ee ee takes
Nausea and Vomiting of Preg-
nancy: A Study in Psycho-
somatic and Social Medicine
G. GLADSTONE ROBERTSON,
BD se Se ots eS ee
Calf Plasma or
Transfusion
J. M. MASSONS, M.D.........
Typhoid Carriers Treated with
Penicillin and Sulphathiazole
C. H. COMERFORD, M.D.,
H. RicuHMonpD, M.B., W. W.
KAY, M.B. sack ei 6 oe aes
Pyridoxine (Vitamin B) in
Epilepsy : A Clinical Trial
J. TYLOR Fox, M.D., GLADYS
M. TULLIDGE, M.D..........
Primary Diphtheria of the Con-
junctiva .
A. R. MILLER, M.D., DOROTHY
E. BLOWER, M.B............
Peritoneal Nodules of Unknown
Ætiology (illus.)
HaSSAN IBRAHIM, M.B.......
SPECIAL ARTICLES
Fractional] Test-meals on Students
Awaiting Examination Results.
MICHAEL FLOYER, M.R.C.P.,
DENYS JENNINGS, BM,
DMR EPrcsutaieirareira prk
PUBLIC HEALTH
The World Health Organisation
and its Interim Commission
NEVILLE M. GOODMAN, M.D.
Paratyphoid at Coatbridge......
Infectious Disease in England
and Wales................4:
NEW INVENTIONS
Simple Apparatus for Micro-
sublimation. C. Lovell, m.p.
CLUB) E wd ann ded ne
333
336
341
343
345
346
348
CONTENTS
THE WHOLE OF THE LITERARY MATTER IN THE LANCET IS COPYRIGHT
LEADING ARTICLES
MEDICINE, POPULATION, AND
FOOD? 56d are Oe Ae hE OE Bee
ACTIVATION OF SKIN GRAFTS....
How To VACCINATE............
STANDARDS AND STAMPEDES....
ANNOTATIONS
An International Gathering.....
Hybrid Vigour in Sweet Corn....
Penicillin and Sulphathiazole in
Typhoid Fever..............
Death after Serum.............
A School for Diplegics..........
Tuberculous Endometritis and
COMIN sains ansen eai
Bovine Plasma Again..........
Curare in Neurologv............
For Auld Lang Syne............
- REVIEWS OF BOOKS
A Textbook of Forensic
Pharmacy. Thomas Dewar,
Basis of
Medical Practice. C. H. Best,
M.D., F.R.S., N. B. Taylor, M.D.
A Complete Outline of Fractures,
including Fractures of the
Skull. J. G. Bonnin, F.R.C.S....
‘Practical Anesthetics. Dr. J.
Ross Mackenzie..............
NOTES AND NEWS
The Dentist’s Income......... P
American Research into the
Common Cold..............
Treatment of Recurrent Herpes. .
University of Cambridge........
University of London..........
Society of Apothecaries.........
Merseyside Telephone Bureau....
Return to Practice..............
London Hospital..............
Royal Sanitary Institute........
Aslib Conference...............
Thiourea Derivatives in Thyro-
COMICOBIS ists Kd cure tinker shards
Births, Marriages, and Deaths...
Medical Diary—Appointments..
349
350
350
351
352
352
353
354
354
354
355
355
355
348
348
348
348
367
355
367
367
367
368
368
368
368
368
368
368
367
368
WITHDRAWS
LETTERS TO THE EDITOR
Treatment of Meningitis (Dr.
Stanley Banks, Dr. F. Marsh)
Water-supplies (Dr. E. W. Ainley-
Woalker) 33.2 06664539 neceg sees
Non-specific Epididymitis in
Industry (Dr. G. Whitwell)....
The Sister-technician (Miss Phyllis
L. Plumbridge)............. 3
Variation in the Female Pelvis
(Dr. J. Rabinowitch).........
“ Curarine ” (Dr. J. Trevan).....
Aid to Defzcation (Dr. Josiah
Oldfield, Dr. A. T. Todd)......
Circulation in the Kidney (Dr.
Brian Donnelly, D.M.R.E.).....
The London College of Osteopathy
(Dr. W. Hargrave-Wilson)....
Smallpox and Vaccination (Dr.
C. Killick Millard)............
Children who Spend too Long
in Bed (Dr. Catherine Storr). .
A Syndrome Simulating Acute
Abdominal Disease (Dr. S.
Oram). 4.5 dans oe eee Cases ae
Entertaining Allowance in the
Navy (Surgeon Rear-Admiral
Sir Cecil Wakeley, F.R.C.S.)....
Advertising Patent Medicines
(Dr. W. Lane Petter).........
Our Houses (Dr. A. T. Spoor)....
Appeal for Medical and Nursing
Journals (Dr. Neville Goodman)
Physiology of Convalescence (Dr.
S. C. LOwsen) «sce cise ene hoes
Desoxycortone and Arthritis
(Dr. Denys Jennings)
Splanchnic Block for Anuria (Dr.
M. A. M. Bigby, Dr. F. Avery
Jones, Mr. J.MacVine, F.R.C.S.E.)
IN ENGLAND NOW |
A Running Commentary by Peri-
patetic Correspondents.......
OBITUARY
Arthur Tudor Edwards, F.R.C.S.
(portrait) 4.000 Fs aoe wars cn Se
Harrie Leslie Hugo Schütze, M.D.
Otto May, F.R.C.P.... 0... eee ees
Surgeon-Commander W. T.
Gwynne-Jones, B.N........085
366
NEUROSIS AND THE MENTAL HEALTH SERVICES
By C. P. BLACKER, D.M., F.R.C.P.
With Foreword by Sir WILSON JAMESON, K.C.B.
“ With its array of facts and its well-built plan this report offers the argument and the means
for promoting the mental health services to their full range of opportunity. ’’"—THE LANCET
Pp. 240
20s. net
“OXFORD UNIVERSITY PRESS
AMEN HOUSE
WARWICK SQUARE
.
~
“ah v~ ` al, ™~
‘wall `
LONDON E.C.4
THE LaNceET] os THE DNE GENERAL ADVERTISER [SeErrT. 7, 1946
OXFORD MEDICAL PUBLICATIONS
jui Published i |
A New (Fifth) Edition of
THE NERVOUS CHILD
By HECTOR CHARLES CAMERON, M.D., F.R.C.P.
Consulting Physician to the Children’s Department, Guy’s Hospital
Contents include: Doctors, Mothers, and Children—Observations in the Nursery—Manage-
ment and Conduct—Want of Appetite and Indigestion—Want of Sleep—Some Other
Signs of Nervousness—Enuresis—Toys, Parks, and Amusements—Nervousness in Early
' Infancy—-Management in Later Childhood—Nervousness in Older Children—Nervousness
and Physique—Underlying Disturbances of Metabolism in the Nervous Child—The Nervous
Child in Sickness—Nervous Children and Education on Sexual Matters—The Nervous —
Child and School—Index. y
Pp. 260 -` | 8 Plates e 10s. 6d. net Į
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AMEN HOUSE WARWICK SQUARE LONDON E.C.4
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SD serr. 14, 1946
<
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aJ
THE LANCET
A JOURNAL OF BRITISH AND FOREIGN MEDICINE, SURGERY, OBSTETRICS,
PHYSIOLOGY, PATHOLOGY, PHARMACOLOGY, PUBLIC HEALTH, AND NEWS
No. 6420
LONDON: SATURDAY, SEPTEMBER 14,
1946
CCLI
ORIGINAL ARTICLES
Painful Feet in Prisoners-of-War
in the Far East (charts)
— E. K. CRUICKSHANK, M.B. ..
“Folie Acid in the Treatment of
_ ~~ Megaloblastic Anæmia
= Prof. L. S. P. Davipson,
rE F.R.c.P., R. H. Gmpwoop,
r F.R.C.P.E:
_ 2Confusion of Amoboma with
~^ Carcinoma (illus.) -
fy} MICHAEL J. SMYTH, F.R.C.S.
Gout in Leukemia
| L. M. SHORVON, M.B........
' Tuberculous Abscess following
— Intramuscular Penicillin
Z Denis EBRILL, FRCS.
STEPHEN D. ELEK, M.D.....
(ga
` ught-weight Oxygen Mask of
~- Plastic Material (ius.)
\; Basm 8. KENT, M.B., D.A.
3
aa
=
Cy
Gi
Picrotoxin in Barbiturate Over-
dosage
T. Naurs Misr, M.B.. 0.0.
SPECIAL ARTICLES
Length of Stay in Hospital
CES GARDNER, M.B.C.P.,
f. L. J. WITTS, F.B.0.P. |.
VA New Health Service: the
_~ Design in Southern Rhodesia
ts ‘Infectious Disease in England
x and Wales................06.
aos
7 MEDICAL SOCIETIES
^: Tuberculosis Association: Rela-
4J tionship between Primary and
“T= Adult Pulmonary Tuberculosis
! Association of Clinical Patho-
j logistS nisc oe ced eed e Sac es
ON ACTIVE SERVICE
Casualties
369
373
376
378
379
380
381
CONTENTS
THE WHOLE OF THE LITERARY MATTER IN THE LANCET IS COPYRIGHT
LEADING ARTICLES
B.C.G.: THE NEXT PHASE......
EXCISION OF THE HEAD OF THE
PANCREAS ..ccce ee ccc cece ees
EFFICACY OF THE PENICILLINS..
ANNOTATIONS
Twelve-and-Six a Head.........
Psychogenic Pain in Labour....
The Sick Famil
A Compassionate Release.......
Hokey-pokey Penny a Lump ...
REVIEWS OF BOOKS
Control of Pain in Childbirth.
Prof. ©. B. Lull, m.op.,
R. A. Hingson, M.D. ........
A Handbook of Social Psychology.
Prof. Kimball Young.........
Cardiovascular Disease in General
Practice. Terence East, F.R.c.P.
Howell’s Textbook of Physiology.
Editor: Prof. J. F. Fulton, M.D.
Experiments with Mammalian
Sarcoma Extracts in regard to
Cell-free Transmission and In-
duced Tumor Immunity. Carl
Krebs, Oskar Thordarson,
Johannes Harbo.............
NOTES AND NEWS
A Fund for the Tuberculous....
Intrathecal Sulphathiazole......
Down North.............0000-
University of London..........
Royal Faculty of Physicians and
Surgeons of Glasgow.........
Liverpool Medical Institution....
Wellcome Foundation ee ee
Royal Free Hospital............
Medical Women’s Federation. .
Lectures on Child Development. .
Iraq Appointment.............
THE LONDON AND COUNTIES
LETTERS TO THE EDITOR
Sir Almroth Wright and
Anti-typhoid Inoculation (Dr.
Leonard Colebrook, F.B.S.)....
Myth and Mumpsimus
(Dr. Christopher Howard, Dr.
George Day, Dr. R. J. T.
Woodland, Dr. J. Egan)......
Penicillin by Inhalation (Wing-
Commander D. Ferriman,
MRCP.) cece unse Gee eee ees
Suprapubic Prostatectomy
(Dr. T. J. D. Lane)..........
Funiculitis (Prof. Aldo Castellani,
F.R.C.P.
(E E DE EE EE EE E O E e e e E e E E E
Children Who Spend Too Long .
in Bed (Dr. G. F. Tripp, Dr.
J. A. McCluskie)..........06:
Favus in Devon (Dr. H. W. Allen)
Effect of Phosphate on Carbo-
hydrate Absorption in Sprue
(Prof. Brian Maegraith, M.B.)
Persistent Enuresis (Dr. H. Ucko)
Supplementary Food for Pre-
mature Infants (Dr. Helen
Mackay) ii isiicce vice see ease ie
A Syndrome Simulating Acute
Abdominal Disease (Dr. Philip
Evans) sick 63a Galt tenes eee
Nutritional Optic Neuropathy
(Dr. Jenner Wright)..........
Arsenical Chicken-pox (Dr. F.
Parkes Weber)..............
Dispensing of Drugs in Hospitals
(Mr. F. C. Wilson, M.P.S.)......
Peripatetic Error (Dr. W. R.
Snodgrass) ..........+-.0e05
IN ENGLAND NOW
A Running Commentary by Peri-
patetic Correspondents.......
OBITUARY
Alfred Charles Foster Turner,
M.D.
Medical Diary—Appointments—
Births, Marriages, and Deaths
MEDICAL PROTECTION SOCIETY, Ltd.
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SEPT. 21, 1946
THE LANCET
A JOURNAL OF BRITISH AND FOREIGN MEDICINE, SURGERY, OBSTETRICS,
PHYSIOLOGY, PATHOLOGY, PHARMACOLOGY, PUBLIC HEALTH, AND NEWS
No. 6421 LONDON: SATURDAY, SEPTEMBER 21, 1946 CCLI 4
i THE WHOLE OF THE LITERARY MATTER IN THE LANOET IS COPYRIGHT
ORIGINAL ARTICLES LEADING ARTICLES PUBLIC HEALTH
Penicillin in Wound Exudates OCCASION FOR THRIFT ....... .. 421 Typhoid at Aberystwyth....... 434
Lady FLOREY, M.B., E. C. SURGERY IN THE AGED ....... 422 Infectious Disease in England |
TURTON, M.B.C.P., E. S. and Wal6S iis scsn eds sce eae 434
DUTHIE, M.B.... ee cee eee oee 405 ANNOTATIONS NEWI ENTONG
Coronary Occlusion in Youn ; Dental Controversy............ 423 ;
Adults $ Perception ......sesseceseeese 424 Pneumoperitoneum-refill Needle.
MAURICE NEWMAN, M.R.C.P.. 409 Death after Curare............ 424 Joseph Smart, M.R.C.P. (illus.) 420
Defi Di Pri Penicillin in Wounds........... 424
eficiency Diseases in Prisoners- Test for Threatened Abortion.. 425 IN ENGLAND NOW
of-war at Changi, Singapore * Hospital Catering in Middlesex.. 425 A Running Commentary by Peri-
(charts) Testosterone and Angina Pectoris 426. patetic Correspondents...... 433
R. C. BURGESS, M.B., Silicosis and Aluminium Treat-
a Ge Berane Mideast hen AUN" MHON Hoes aedinconsn sas saan name 426 OBITUARY
BDS Oey ve Bone-marrow re Fate of the Nerve Homograft... 426 Karl Narbeshuber, M.D......... 429
. A. B. CATHIE, M.D........
LETTERS TO THE EDITOR NOTES AND NEWS
PECON SIRST TAN B.C.G.: the Next Phase (Dr. Crichton Royal Fellowships..... 43
Health Education : its Problems Philip Ellman).............. 435 Art for the Il...............4. 43
and Methods | Treatment of Meningitis (Surgeon Delinquency on the Screen...... 439
W. P. KENNEDY, L.R.C.P.E.. 427 Lieut.-Commander J. L.
= f l Fluker, M.R.0.P. 435 ; . ;
SPÉGIAL ARTICLES Effect of Phosphate e on Carbo- Ent e Pp o
A Visit to Finland hydrate “Absorption in Sprue Roval Colier Š o O eletr iC aas An d
W. P. Gurassa, M.B., F. L. (Dr. Hugh Stannus).......... 436 NERES T pitas a
JACKSON, M.B. .. eee eeeeee 431 apt en in the Kidney (Dr. Jaa Family Planning Association.... 439
. British-Swiss Medical Conference 430 Wisth an nee) cane (DiC. Travelling Fellowships.......... 439
Army Refresher Courses in Ger- WRI 2 oc es E eg er ae
many ..... ett G aia hae RIA Mi 432 Calf Serum for Transfusion (Mr. een Pree eee eee i yi
REVIEWS OF BOOKS L ae enone a E (Dr. 437 Middlesex Hospital............ 439
Technical Minutiæ of Extended A. P. Norman)... sss... 7 ae a oh A
Myomectomy and Ovarian Children Who Spend Too Long in Me aie as Dee y f th LCC? 440
Cystectomy. Victor Bonney, Bed (Dr. Catherine Storr, Dr. ee d S
FRCS eco eraea ts 420 Joan Brigden) .............. dee A E Medical
The 1945 Year Book of Neurology, Epidemic Thrombophlebitis (Mr. S agree E pe
Psychiatry and Endocrinology. A. C. Fisher, F.R.C.S., Dr. A. C. B na K a ae 440
Edited by Hans H. Reese and Lendrum) ........2.seeeeee- Be pais a Lo
Others... cece e eee e cree eee 420 Royal College of Physicians of aca Ea eh
A Practical Handbook of Mid- London (Dr. Charles Anderson S
wifery and Gynæcology. and others).......sesereess. 438 Medical Diary ................ 440
W. F. T. Haultain, F.R.C.0.G., Efficacy of the Penicillins (Glaxo Appointments ......sssesseese 440
Clifford Kennedy, F.R.C.0.G... 420 Laboratories Ltd.) .......... 438 Births, Marriages, and Deaths... 440
THE LONDON AND COUNTIES
MEDICAL PROTECTION SOCIETY, Ltd.
President: SIR ERNEST ROCK CARLING, F.R.C.P., F.R.C.S., F.F.R.
Members receive UNLIMITED INDEMNITY (subject to the
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Te Lancer] = THE LANCET GENERAL ADVERTISER [SEPT. 21, 1946
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2
SEPT. 28, 1946 ,
A JOURNAL OF BRITISH AND FOREIGN MEDICINE, SURGERY, OBSTETRICS,
PHYSIOLOGY, PATHOLOGY, PHARMACOLOGY, PUBLIC HEALTH, AND NEWS
No. 6422
LONDON: SATURDAY, SEPTEMBER 28, 1946
CCLI
ORIGINAL ARTICLES
Perforated Peptic Ulcer Treated MOTHERS IN JOBS ..........06. 457 Standardisation of Death-rates. .
Without Operation SALICYLATES IN ACUTE RHEU- Infectious Disease in England
HERMON TAYLOR, F.R.C.S. .. 441 MATISM ....ccccccccecccce - 458 and Wales..... TRANPE SEKE cians
araa aD SURGERY OF THE ŒsorPuaGus ... 459 MEDICINE AND THE LAW
Lieut.-Colonel W. J. ANNOTATIONS The Nature of a Charity........
O’Donovan, M.D., I. Kron- The Basle Meeting ............ 460
FAJN, M.D. ............:-- 444 Extraneous Causes of Uterine OBITUSRY
Treatment of Infantile Pellagra : Bleeding isos oot nsoles 460 Charles Ferrier Beevor, B.M. ....
Assessment of the Value of Snags in Protection of Practices 460 Harold Francis Lewis Hugo, M.B.
Protein Hydrolysates Megaloblastic Anemia in Children 461 Sir John Harris, M.D. ..........
THEODORE GILLMAN, M.B., Mechanism of Pain ............ 461
JOSEPH GILLMAN, M.B...... 446. Plague Vaccine ..............: 462 NOTES AND NEWS
Early Ovulation (illus.) The Basic Nursing Course ...... 462 Medical Students and the Bill...
SmoN SEVITT, M.R.C.P.I. : 448 LETTERS TO TUR EDITOR ee and Health Centres in
igi nel a eras 451 Discrepant Salaries (Dr. Cunning- Food Rations for the Germans...
: Ree eee ham Dax) ...........000008. 471 Dentists’ Fees under N.H.I......
Porfaration “OF: Ue: Aona SPY Relationship between Primary Blood-transfusions in Scotland. .
Swallowed Bones S and Adult Pulmonary Tuber- Home Production of Strepto-
Maanus HAINES, M.D....... 455 culosis (Dr. Walter Pagel).... 471 MYCIN woe cece e cece cece eeees
SPECIAL ARTICLES Goose-skin Reflex in Malnutrition Westminster Hospital and the `
World Problems of Nutrition È (Dr. Lucius Nicholls)......... 471 - Infants Hospital.............
FAO. Conference at Copen: Efiect of Phosphate on Carbo- Journals and Books Wanted
í a ‘ : 463 ae ese dat l a aa Bi k ee = . . A ists z R a
E SAA a ae ae a Shea ny rot. Brian Maegraith, M.B.). N. Sic ert taff...
EA Medical Conference “ia Patent — (Mr. S. Brook, re Scabies Film Revised ..........
Ce ee ae cee oye De E eA a A Sea a i
Aret Pn ae A see 1 467 Women in Medicine (Dr. Vivian University of Leeds ...........
“Chit d Be 208 “Rie: -PUOROrMA 467 Usborne) sasos preian ene eg 471 Society of Apothecaries ........
io a Se eS ees Pernicious Anemia and Carcinoma Middlesex Hospital and the New
` REVIEWS OF BOOKS of the Gsophagus (Dr. R. T. Service gic incea-w eiaceg sew a Dane
An Introduction to Clinical Cooke) .......-.00--00-. sere 472 “ Anesthesia” a.e... ESTEE
Neurology. Gordon Holmes, Psychoanalysis in the National. International Hamatological Con-
M.D., F.R.S. ccccccceecccecces 456 Health Service (Dr. Clifford forence ao Fs ak 38 TATE
Surgical Teaching of Abdominal SCOtb) sa see sau baa iaa 472 Irish Tuberculosis Society ......
Operations. Prof. J. L. Spivack, Death after Curare (Dr. E. Royal Sanitary Institute .......
Mei chaste eee ten, a hes 456 Asquith, Dr. Blair Gould).... 472 An Italian Medical Students’
Pediatric X-Ray Diagnosis. Prof. Sigmoidoscopy in Ameebic Dysen- Association ..... 0. ccc eee eeee
John Caffey, M.D. o.o... 456 tery (Lieut.-Colonel C. F. J. Divine Healing and General Medi-
Chemistry and Physiology of Hor- Cropper, M.R.C.P.E., I.M.S.).... 473 cal Practice ........ cece eee
mones. Editor: F. R. Moulton 456 Non-specific LEpididymitis (Dr. è Royal Medical Society .........
L’hypertonie de décérébration F. R. Bettley).............. 473 Fund for Research in Tropical
chez Phomme. - Prof. Pierre ` e T aa oa) Calciferol woke 3 geal ee
r. H. J. Wallace).......... t. Thomas’s Hospital..........
Mollaret, Tyan. Bertrand EE 456 New Words about Old Ago PAPI
IN ENGLAND NOW (Dr. H. St. H. Vertue)........ 473 Appointments .............. Pn
A Running Commentary by Peri- Technique of Prefrontal Leuco- Births, Marriages, and Deaths...
patetic Correspondents ...... 468 tomy (Dr. T. F. G. Mayer) ... 473 Medical Diary ................
CONTENTS
LEADING ARTICLES
THE WHOLE OF THE LITERARY MATTER IN THE LANCET IS COPYRIGHT
PUBLIC HEALTH
469
470
470
LIVINGSTONE or EDINBURGH Have PLEASURE
IN ANNOUNCING AN IMPORTANT NEW. WORK—IN ACTIVE PREPARATION
MEDICAL DISORDERS OF THE LOCOMOTOR SYSTEM,
INCLUDING THE RHEUMATIC DISEASES
By ERNEST T. D. FLETCHER, M.A., M.D. (Cantab.), M.R.C.P. (Lond.)
“The Rheumatic diseases are a social scourge, and their intriguing medical problem occupies a great part of this
new book, written by.a man who has devoted many years of intensive study to the subject of Rheumatism. It is
intended for all Medical Practitioners who come in daily contact with patients suffering from Rheumatism. One
of the great features of this book is that the study of Locomotor Disorders is carried through from the very
beginning, starting with the clinical examination of the patient and ending with the treatment of the disorder
which has been scientifically diagnosed. So far as we know this is the only book in the English language which
covers this field. It is illustrated with clinical pictures, X-rays and diagrammatic line drawings, about 500 pp.,
Royal 8vo.’’==_}Publishers’ Note. l
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Sa a aa a ae, ee ee GR ee
2
THE LANCET GENERAL ADVERTISER
469
\
[SEpr. 28, 1946
let
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SEE THE MANAGER OF
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The Res tricted Diet
Under normal conditions the restricted diet is the lot
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lack of variety tends to lead to lack of balance and
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THE MARMITE FOOD EXTRACT CO. LTD.
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ocr. 5, 1946
THE LANCET
A JOURNAL OF BRITISH AND FOREIGN MEDICINE, SURGERY, OBSTETRICS,
PHYSIOLOGY, PATHOLOGY, PHARMACOLOGY, PUBLIC HEALTH, AND NEWS
` No. 6423
LONDON: SATURDAY, OCTOBER 5,
1946
CCLI
- ORIGINAL ARTICLES
Conducing to the Cure: Social
Psychiatry in the Treatment
of Neurosyphilis by Induced
Malaria
MAEVE WHELEN, M.D., M. H.
BREE oreas mennee ea eaa 477
The Use of Reassurance
T. G. ARMSTRONG, M.R.c.P... 480
The Post-hepatitis Syndrome (illus.)
SHEILA SHERLOCK, M.R.C.P.,
VERYAN WALSHE, B.SC......
Pathology of Postanal Pilonidal
Sinus : its Bearing on Treatment
Davip H. PATEY, F.R.C.S.,
Prof. R. W. SCARFF, M.B.....
Nicotinamide Methochloride
Estimations in Sprue_ and
Ameebiasis (charts)
J. W. PAULLEY, M.R.C.P.,
G. J. AITKEN, F.R.F.P.S....
Relations of Steroid Hormones
and Anhydro-hydroxy-proges-
terone to Fibromatosis
RIGOBERTO IGLESIAS, M.D.,
Prof. ALEXANDER LIPSCHUTZ,
M Duran Los bueake yee: Kee
Remedial Correction of. Valgus
_ Foot Strain by Foot Pronation
Exercise (ilus.)
E. T. BAILEY, F.R&.c.s., B. S.
HARRENS (335086044 0 o4a% s 490
PRELIMINARY COMMUNICATION
“ Pellagragenic ” Activity of
Indole-3-acetic Acid in the Rat
E. KopicEk, M.D., K. J.
CARPENTER, B.A., LESLIE J.
484
486
488
HARRIS, SC.D. wc cee eee rece 491
SPECIAL ARTICLES
Children in Day Nurseries : with
Special Reference to the Child
under Two Years Old
Hapa F. MENZIES, M.D..... 499
International Medical Conference
in Londoh: seses ossis ossaa 501
Royal College of Obstetricians
and Gynecologists........... 503
Scotland: crs crnan ios as ces 504
CONTENTS
THE WHOLE OF THE LITERARY MATTER IN THE LANCET(3 COPYRIGHT
LEADING ARTICLES
PILONIDAL SINUS. neeese. E
ANNOTATIONS
World Medical Association......
Cardiovascular Changes in
Palpable Pedal Pulsations.......
Intensive Course in Psycho-
The Makings of a Medical School
Medical Research Council.......
Retirement of Mr. F. W. Martin..
LETTERS TO THE EDITOR
Military Service for Medical Stu-
dents (Dr. E. G. W. Hoffstaedt)
A Syndrome Simulating Acute
Abdominal Disease (Mr. B. W.
Goldstone, F.R.c.S.E., Dr. H. S.
Le Marquand)...............
Myth and Mumpsimus (Dr. R. M.
Fraseria eos aoe oka ales
Tuberculous Endometritis and
Sterility (Mr. Albert Sharman,
M.R.C.0.G., Mr. Arthur M.
Sutherland, M.R.C.O.G.)..
New Words About Old Age (Dr.
Gordon Irvine) ..............
Penicillin in Wound Exudates...
Arsenical Chickenpox (Dr. T. G.
FROG GS wie b:g se oe Oe as Rees
Desoxycortone and Arthritis
(Mr. D. G. Champernowne)....
Tuberculous Abscess following
Intramuscular Penicillin
(Dr. Frank Marsh)...........
Death after Curare (Dr.
Elam, Dr. J. D. P. Graham)
Amcboma and Carcinoma
(Mr. Philip Hawe, F.R.c.s.)....
Sign of Submerged Goitre
(Dr. H. S. Pemberton)........
Hospital Photographic Depart-
ment (Miss Sylvia Treadgold)
Christian Science (Mr. Colin R.
Fddison) . E E ee ye
496
496
497
498
506
507
507
REVIEWS OF BOOKS
Actions of Radiations on Living
Cells. D. E. Lea, PH.p........ 492
L’anémie infectieuse. G. Hem-
Molk Asie dag neces ey eee ee aS 492
The Outlook of Science. R. L.
Worrall, M.B..........0..000. 492
PUBLIC HEALTH
Prospects in Industrial Medicine 504
The General Register Office...... 504
Infectious Disease in England
and Wales...... Eee ekeewecie MOOS
IN ENGLAND NOW
A Running Commentary by Peri-
patetic Correspondents....... 505
OBITUARY
Thomas Watts Eden, F.R.C.P.
(POW OU) eect eas EEAS 509
Frank McCallum, M.B........... 510
NOTES AND NEWS
Traffic in Narcotic Drugs........ 510
Food Bulletins..... Sere ee 510
Midwives’ Progress............+ 510
Asphyxia and Anoxia.......... 511
Vital Statistics for June Quarter 511
Art Exhibition for the Hospitals 511
University of Sheffield.......... 511
Postgraduate Course at Leeds.... 511
Royal College of Physicians of
Londone sarerea eaii 511
Society of Medical Officers of
Cet O iia oa siarats ona ted, wie manai oll
British Institute of Philosophy.. 511
Central Council for Health
Education <. 46 6665 ive ne en 511
Medical Photographic Exhibition 511
West London Medico-Chirurgical
DOCIO ? sav eee sca bate Sawa » 611
Medical Defence Union......... 511
Local Responsibility for Hospitals 511
British Orthopedic Association.. 511
Centenary in Anesthesia........ 51]
Heberden Society.............. 512
Medical Diary—Appointments—
Births, Marriages, and Deaths 512 .
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This food is found to be of suitable composition for the great majority of normal infants,
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HALF CREAM
When foods other than breast milk are first introduced, some children require a reduced
fat intake. In a smaller number of cases it is advisable to continue with the lower fat
content for several months. The half cream food which contains the same vitamin and
iron supplements as the full cream variety, has this reduction of fat and addition
- of carbohydrate in the form of milk sugar.
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2
oor. 12, 1946
THE LANCET
A JOURNAL OF BRITISH AND FOREIGN MEDICINE, SURGERY, OBSTETRICS,
PHYSIOLOGY, PATHOLOGY, PHARMACOLOGY, PUBLIC HEALTH, AND NEWS
No. 6424- LONDON: SATURDAY, OCTOBER 12, 1946 CCLI
THE WHOLE OF THE LITERARY MATTER IN THE LANCET IS COPYRIGHT
ORIGINAL ARTICLES LEADING ARTICLES REVIEWS OF BOOKS
Sympathetic Control of Blood- NUREMBERG ........0-e es eeees 531 Abnormal Behaviour. R. G.
vessels of Human Skeletal Twenty YEARS OF TYPHUS Gordon, F.R.C.P. . 529
Muscle (ius.) RESEARCH ... ccc ccc cccccen 531 The Ship Captain’s Medical Guide 529
Prof. HENRY BARCROFT, M.D., ; Forensic Medicine. Douglas Kerr,
Prof. O. G. EDHOLM, M.B.... 513 Cues ro mme ANT ERE 532 PROP E S248 byes o00t bee ees 530
Psychoneuroses Treated with = © ETNI Food and Nutrition. Prof.
Electrical Convulsions ANNOTATIONS E. W. H. Cruickshank, M.B.c.Pp. 530
W. Lippert Miiican, M.D. 516 hree in One? 533 Sciatiques et lombalgies. Prof. .
Effect of Temperature on Sedi- Nicotinic Acid in Hypomenor- P “ie Raa are > : ee a, Ne
mentation-rate (charts) oo s34 Pathology of the Central Nervous
K. B. Rogers, M.B......... 520 The Hospital of the Future. se 534 Oe "590
Treatment of Yaws with Penicillin The Busy Nervous System...... 534 Borg tee ce eer) Sages on
K. R. Hox, ms. G. M. .. . Heparin in Infective Endocarditis 535 OBITUARY
FINDLAY, M.D., A. - Supplies of Artificial Radioactive Sir Wal Langdon-B
MACPHERSON, M.B. ........ 522 Substances ............+00.- 535 ae a < ee OR tOW n, Bae
The Uses of Plastics in Surger Anticoagulants in Coronary eee ee ae
Major GEORGE BLADE, ao o = Vhrohibosls, eo. 536 Sir Hassan Suhrawardy,F.R.c.s... 548
a en ee Sixth and Last ..............5. 536 NOES: AND NEWS
i ) wo... 549
Tuberculosis in Poland (charts) MEDICINE AND THE LAW On the Record........... TEETE
Marc DANIELS, M.D........ 537 Insanity Moral or Legal......... 541 = S A e aa anag arene a
. a : | arcoties Control........... see
E ydohey Society of Medical ey LETTERS TO THE EDITOR =| l
Town meets Country. OO o g40 Perforated Peptic Ulcer Treated University of London .......... 549
Infectious Disease in England and - without Operation (Mr. Harold Royal College of Physicians ..... 549
Wales ..... ; Tae ir be 541 Edwards, F.R.c.s., Mr. James Royal College of Surgeons....... 549
l l Gore, F.R.C.S., Prof. Eugene Royal College of Obstetricians
PARLIAMENT Rosenthal, M.D.)............. 544 ° ~and Gynecologists ........... - 549
The Bill in the Lords .......... 543 (Children in Day Nurseries . Faculty of Radiologists. ... kT . 549
(Dr. John Kershaw) ......... 544 Research Defence Society ....... 549
MEDICAL SOCIETIES Arsenical Chickenpox (Dr. A. L. Tuberculosis Course at Newcastle 549
Tuberculosis Association : Tuber- Craddock) 2 gcse ceaua skokt 545 College of Pharmaceutical Society 549
culosis of the Nervous System— Women in Medicine (Dr. Annis Hunterian Society............. 549
Treatment of Lupus Vulgaris— GUNG) erener renea Ge 545 Society of Apothecaries of London 550
Calciferol in Tuberculous Con- Use of Reassurance (Dr. M. B. Society for the Study of Addiction 550
ditions 24.65.66 r ae ee oe 528 Brody): otite rinra ees 545 Medical Society. for the Study of
Royal Medical Benevolent Fund Venereal Diseases. .... ETETEN 550
NEW INVENTIONS (Sir Arnold Lawson, F.R.C.S.).. 545 Food and Agriculture Organisa-
Needle and Cannula for Chest Megaloblastic Anzemia in Children — . tion 4 ete oes it har hawase. 550
Exploration. E. V. Medill, (Prof. L. J. Davis, F.R.C.P.).... 545 Centenary of Anesthesia GPa thats 550
M.B.C.S. (tllus.) oo. eee eee eee 530 Extraneous Causes of Uterine Middlesex Hospital Dinner ..... 550
Bleeding (Dr. Herbert Levy).. 546 —
IN ENGLAND NOW The National Loaf (Dr. I. Harris) 546 Appointments ................ 548
A Running Commentary by Peri- Children Who Spend Too Long in Births, Marriages, and Deaths... 548-
patetic Correspondents ....... 542 Bed (Dr. John McCluskie) ....° 546 550
THE LONDON AND COUNTIES.
Medical Diary..............2.-
MEDICAL PROTECTION SOCIETY, Ltd.
President: SIR ERNEST ROCK CARLING, F.R.C.P., F.R.C.S., F.F. R.
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These desiderata are to be found in ‘ Sulphamezathine,’
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[Ocr. 12, 1946
f
‘SULFATHALIDINE’
Hithalylaulphathszol
STAGE OF DISEASE
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DIENTAMGBA FRAGILIS
TOTAL NUMBER OF PATIENTS
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Nontoxicity, smaller dosage, effective bacteriostasis
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The compound is indicated in the treatment of ulcer-
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SHARP & DOHME LTD, HODDESDON, HERTS.
ocT. 19, 1946 —
THE LANCET
A JOURNAL OF BRITISH AND FOREIGN MEDICINE, SURGERY, OBSTETRICS,
PHYSIOLOGY, PATHOLOGY, PHARMACOLOGY, PUBLIC HEALTH, AND NEWS
No. 6425
LONDON: SATURDAY, OCTOBER 19, 1946
CCLI
a ORIGINAL ARTICLES
Carcinoma of Prostate Treated
with Cstrogens (illus.)
J. D. FERGUSSON, F.R.C.S. ..
Diagnosis of Schistosomiasis :
Intradermal Test Using a a Cer-
carial Antigen
WILLIAM ALVES, B.A., DYSON
JEAN L. BUCHANAN, M.B....
Observations on Fibrinolysis :
Plasminogen,. Plasmin, and
Antiplasmin Content of
Human Blood
- R. G. MACFARLANE,
J. PILING, B.80...........
Exercise and Cardiac Hyper-
trophy
> ef fp ee eseeaeeeeeeseee
- REVIEWS OF BOOKS
Atlas of Surgical. Approaches to |
Bones and Joints. Prof. Toufick
Nicola, F.A.0.8......ccceceee.
Carbohydrate Metabolism. Samuel
Soskin, Rachmiel Levine......
Symptomatic Diagnosis and Treat-
ment of Gynecological Dis-
orders. Margaret Moore White,
F.R.C.S. °
A Textbook of Surgery. Prof.
Frederick Christopher, F.A.C.s.
MEDICINE AND THE LAW
Alleged Cruelty to Cats........
IN ENGLAND NOW
A Running Commentary by Peri-
= patetic Correspondents.......
#@eoeaeveeeceseeveeeseeev eee ae
551
556
560
562
565
CONTENTS
THE WHOLE OF THE LITERARY MATTER IN THE LANCET IS COPYRIGHT
LEADING ARTICLES
CIRCULATORY EFFECTS OF OSTE-
ITIS DEFORMANS........e0008
THE CONVALESCENT HOME......
- ANNOTATIONS
Winter in Europe..............
Feetal Respiration.............
An American View of Rheumatism
Control of Ice-cream..........
Anti-midge Campaign..........
Cesarean Section..............
Medical Practice in New Zealand
Salute from the Bowler........
LETTERS TO THE EDITOR
Royal College of Physicians of
London (Dr. H. E. A. Boldero)
Children Who Spend Too Long in
Bed (Mrs. Ainsworth) ........
Bovine Plasma Again (Mr. R.
Arthur Hughes, F.R.c.s.)..
Tuberculous Glands and Calciferol
(Dr. T. Francis Jarman)......
Contraception with the Silver
Ring (Mrs. M. A. Pyke)......
Perforated Peptic Ulcer Treated
without Operation (Mr. H. I.
Deitch, F.R.C.S.)
Children in Day Nurseries (Mr.
E. R. Bransby, PH.D., Dr. H.
Edelston).....esessssesese.e
Sir Almroth Wright and Anti-
typhoid Inoculation (Mr.
Douglas Guthrie, F.R.C.S.E.)...
Splanchnic Block, Electrolyte Bal
ance, and Uremia (Dr. E. M.
Darmady j)er whe wineries:
Pilonidal Sinus (Mr. Edric Wilson,
568
569
572
580
581
581
F.R.C.S., Mr. R. L. Newell, F.R.0.8.) 582
Distribution of Disseminated
Sclerosis (Dr. W. Ritchie Russell)
Early Ovulation (Dr. W. P.
Hirsch, M.R.C.0.G.).......000-
582
582
PARLIAMENT
The Bill in the Lords: Party
Criticisms—Professional Criti-
cisms—The Second Day......
Question Time: Family Allow-
ances—Shortage of Medical
Textbooks—Flour Extraction
through - Bread-
OBITUARY
Stanley Wyard, F.R.c.P..
Arthur Norman Boycott, M. D..
Richard James Campbell
Thompson, M.D.....essssssss
Henry Beecher Jackson, M.R.C.S.
ON ACTIVE SERVICE
NOTES AND NEWS
Nursery Workers in Scotland.
For Children at Trogen.........
Medical and Dental Defence Union
of Scotland.............000%
` University of Cambridge....... =
University of Sheffield..........
Royal College: of Surgeons of
Bingland si 3s86 ea eoetast Rees
British Social Hygiene Council..
Scottish Universities By-election
Society for the Relief of Widows
and Orphans of Medical Men..
Empire Rheumatism Council... ;
Family Allowances...........-
Field Marshal Montgomery on
Morale
Biochemical Society............
Course on Diseases of the Chest
eeveeveeeeeteesensvrete @eeseet ee
Infectious Disease in England and
Waliss erehe Siete ba a ceernt es
, Medical Diary—Appointments..—
Births, Marriages, and Deaths...
573
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THE LANCET
A JOURNAL OF BRITISH AND FOREIGN MEDICINE, SURGERY, OBSTETRICS,
PHYSIOLOGY, PATHOLOGY, PHARMACOLOGY, PUBLIC HEALTH, AND NEWS
No. 6426
LONDON: SATURDAY, OCTOBER 26, 1946
CCLI
ORIGINAL ARTICLES `
CONTENTS
THE WHOLE OF THE LITERARY MATTER IN THE LANCET IS COPYRIGHT
LEADING ARTICLES
REVIEWS OF BOOKS
Coronary Disease A JOINT ENTERPRISE .......... 605 Child and Adolescent Life in
Sir MAURICE CASSIDY, THe BLEEDING Perrio Utcer .. 605 Health and Disease. Prof. W.S.
PROP. cess cece cece e eens 537 INFECTED FOOD ...........66- 607 aay deca dm S Prof 994
Serum-protein Level of Indian Vincent Arch zi AD ` 604
Soldiers (charts) ANNOTATIONS Tropical Nutrition and Dietetics.
Major MarTIN Hynes, Crisis and Consequences. ....... 608 Lucius Nicholls, M.D. .......- 604
M.R.O.P., Captain MOHAMMED Training in Child Welfare....... 608 Evolution of Plastic Surgery.
ISEA, L.3.M.¥., Sergeant 590 Rheumatism Research Centres.. 609 Maxwell Maltz, M.D.......... - 604
: ; : aad OP ence eae Sulphonamide Granulopenia in Pneumoperitoneum i Treatment.
irosis Canicola: a Case Children ....ceccccc ce ccceue 609 Prof. A. L. Banyai, M.D....... 604
Eos i Penicillin KE The Demobilised Specialist...... 610 PARLIAMENT
STUART ae ae 594 ‘-Encephalomeningitis of Virus a The Lords in Committee........ 619
i D AENEA S steh a E diss E E See's From the Press Gallery: When
aa Granuloma of the Nose Practical Nurses in Canada .... 610 is a Nurse Not a Nuro Tasis 621
. (Wus. .
Between Two Centuries..... 611
a NOTES AND NEWS
S. W. G. HARGROVE, Anesthesia in Retrospect....... 611 . - tags )
¥.B.0.8.E.. J. H. FODDEN, roid ae ae ee Xa Sn
M.D. A. J. RHODEs, Jouncil for the Care of Spastics
d LETTERS TO THE EDITOR er ’
PROP E cvs wter u eaa 596 Midwives’ Pay .........eceeees 614
Hae he Cx Exha Psychoneurosis Treated with Royal College of Surgeons of
eae eee u: Pinet iepel Convulsions England........... re 625
Major F. P. HALDANE ę a ae ea Oe Additions to Poisons List....... 625
MB. Captain J. L. J. Norman Glaister)......... 615 Uniwerite of Sheffield.......... 625
ROWLEY, M.B. ....--.----- 599 Morale of the Nation (Dr. James ` University of Manchester....... 625
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THE LANCET]
EPIDEMIC THROMBOPHLEBITIS
IN THE EAST AFRICA COMMAND
P. E. C. Manson-Baur A. D. CHARTERS
M.B. Camb., M.R.C.P., M.D. Camb.,
D.T.M. & H. D.T.M. & H.
LIEUT.-COLONEL R.A.M.C., LATE MEDICAL LATE MAJOR R.A.M.C.,
ADVISER TO EAST AFRICA COMMAND MEDICAL SPECIALIST
NON-SUPPURATIVE thrombophlebitis may be primary
or secondary. Secondary thrombophlebitis may be the
result of trauma, local infection, general debilitating
diseases, or fevers, such as typhoid, pneumonia, and .
influenza, or may follow operation or childbirth.
Primary. thrombophlebitis, or thrombophlebitis
migrans, is relatively uncommon. Its cause is unknown,
although Boyd (1938) regards it as a type of thrombo-
angiitis obliterans involving only the veins. Widely
separate regions of the body are affected. There is no
relation to pre-existing disease or trauma of the vessels.
Pulmgnary embolism often occurs, and complete recovery
is usual (Swirsky and Cassano 1943). Gelfand (1943)
describes a condition of thick leg among Africans of
Southern Rhodesia, the result of previous attacks of
thrombophlebitis of the femoral vein, which he states is
not uncommon.
A syndrome of recurrent thrombophlebitis accom-
panied by pyrexia, often relapsing and sometimes
associated with stiff neck, occurred among askaris of the
East Africa Command during 1944.
No previous record of such a condition has been
found. The outstanding nature of the disease is indicated
by the fact that the same clinical features have been
independently noted by several other medical officers:
Majors Campbell and Wright, and Captains L. E.
Burkeman, A. W. Pringle, S. M. Pruss, G. M. T. Tate,
M. Slade, J. C. Enterican, and E. Taube.
EPIDEMIOLOGY
Occasional sporadic cases of thrombophlebitis, involv-
ing one or more limbs, were observed in the command
during 1941 and 1942. In 1943 several patients were
admitted to hospital with cdema of unknown origin,
probably the result of phlebitis, but it was not until
January, 1944, that the disease began to assume epidemic
proportions.
The syndrome first appeared in a localised area of the
command among patients who had recently received
treatment at a special treatment centre for venereal
disease at Thika, near Nairobi. In April, 1944, ċases of
pyrexia with stiff neck were described by Captain A. W.
Pringle at Au Barre, in British Somaliland; in August
the disease broke out among patients who had been
treated at another special treatment centre for venereal
diseases, this time at Mandera, British Somaliland, some
1500 miles away from Thika. The outbreak reached its
peak during the third quarter of 1944 and then rapidly
declined. By the end of 1945 most of the recorded cases
were relapses.
The cases admitted to No. 1 (E.A.) General Hospital
and No. 3 (E.A.) General Hospital were as follows :
Quarter oe Quarter e A
Jan.—March, 1944.. 34 Jan.—March, 1945.. 69
April-June, 1944 .. 8l P Osea 1945 .. 40
July-Sept., 1944 .. 204 Ore ee. ~
Oct.—Dec., 1944 175 2
627
These two hospitals eventually received all the cases
occurring in Thika district. No accurate figures are
obtainable for the region of Mandera, British Somaliland,
but the peak figures coincided with those in Kenya.
6419
ORIGINAL ARTICLES |
oy
VARIETIES
The following account is drawn from the clinical
features of 145 cases among East African soldiers resident
in British Somaliland. and Kenya during the period
January, 1944—-June, 1945. Three varieties of the
syndrome were seen: (1) short-term fever with stiff
neck often followed by relapses; (2) thrombophlebitis
affecting one or more limbs, with a tendency to relapse ;
and (3) pyrexia, usually relapsing, without evident
phlebitis. The same patient might show one or more of
these varieties during the course of his disease. Thus a
bout of pyrexia with stiff neck might be followed by an
attack of thrombophlebitis, which in its turn might be
succeeded by pyrexia without evident phlebitis.
History of the Disease-——The vast majority of the
patients gave a history of having received treatment in
one or other of the two special treatment centres for
venereal diseases in the command. Of 83 cases in
British Somaliland 58 had been admitted for syphilis
and 4 for gonorrhea. The remaining 21 cases gave no
history of venereal disease and had not been resident in
a special treatment centre.
History of Previous Injections.—Most of the patients
had received a previous venepuncture for neoarsphen-
amine therapy, artificial pyrotherapy with typhoid-
paratyphoid vaccine (T.A.B.), or diagnostic purposes.
Of 143 cases questioned, 111 had been injected with
neoarsphenamine intravenously and bismuth intra-
muscularly, and 9 had received either intravenous T.A.B.
with intramuscular sulphapyridine or a diagnostic vene-
puncture. The remaining 23 gave no history of injection.
The interval between the last injection and the onset of ©
symptoms varied from three days to seven months. Of
100 cases receiving neoarsphenamine therapy, 79 devel-
oped symptoms within six weeks of the last injection.
The total dosage of arsenicals administered varied from
1-65 to 6-6 g., the average being 4:4 g.
SHORT-TERM FEVER WITH STIFF NECK
This form déveloped either as the first phase of the
syndrome or as a sequel to previous attacks of phlebitis.
The onset was
abrupt, though
there was usually
no rigor. Severe
pain in the neck
came on with the
general symptoms
of fever. On
examination the
patient had a
raised tempera-
ture with stiffness
of the neck (but
no head-retrac-
tion) and tender-
ness of one or
more muscles,
most commonly
the sternomastoid "™wscle. |
or the trapezius. If only one side was affected, torti-
collis was a common sign.
The duration of pyrexia varied from two to thirty
days, the usual course being about four days, and the
temperature falling by lysis (fig. 1). The fever was
commonly relapsing, the relapse being accompanied
either by another bout of stiff neck, or by an attack of
thrombophlebitis, or occasionally without either. Of 62
cases of short-term fever with muscle stiffness, the
sternomastoids were involved in 25, trapezius 21, infra-
hyoid muscles 3, posterior cervical 3, neck muscles
unspecified 5, erector spins 4 cases, and masseters 1 case.
No significant enlargement of the cervical glands was
noted ; neither was any evidence of cervical thrombo-
K
omastoid
omastoid
Onset of spasm of
left Stern
«
98
&
4
S
+
«
Q
4w
3
£
Q
right Stern
Uninterrupted recovery
1357 9 HH I 18 7
DAY OF DISEASE
Fig. I—Short-term fever with stiff neck, fol-
lowed by stiff neck involving a different
19 2I
334 ‘THE LANCET] LIEUT.-COLONEL MANSON-BABR, DR. CHARTERS : EPIDEMIC THROMBOPHLEBITIS [SEPT. 7, 1946
phlebitis detected. There was no sign of meningitis,
Kernig’s sign being invariably negative and cerebral
irritation consistently absent.
Laboratory Investigations.
Frequent examination of blood smears did not show either
spirochetes of relapsing fever or any other parasite.
Leucocyte counts were performed in 11 cases: the total
count was below 8000 per c.mm. in all cases, and a relative
lymphocytosis was found in 7 of them.
The cerebrospinal fluid was examined in 12 cases, in 3 of
which there was a cell-count of over 8 per c.mm. (all ‘lympho-
cytes), the remaining 9 showing no abnormality.
THROMBOPHLEBITIS AFFECTING ONE OR MORE LIMBS
This variety was usually acute, less commonly sub-
acute, and occasionally assumed unusual features.
(a) Acute Thrombophlebditis—Symptoms developed
either. as a sequel to an afebrile period following an
attack of stiff neck, or as the first incident in the course
of the disease. There was an acute onset of fever, with
severe pain in one limb over the site of a vein, and
examination revealed severe tenderness over the affected
vessel, the limb being held in protective flexion when
a popliteal or antecubital vein was affected. In the event
of a superficial vein being involved—e.g., the cephalic
or the internal saphenous vein—the vessel could be
palpated as a thickened tender cord throughout its
length, it being, not uncommonly, possible to palpate
a thrombosed internal saphenous vein for the whole of
its course from ankle to groin. Pitting edema was present
and was particularly severe when a deep vessel, such as
the femoral vein, was attacked. After an afebrile period
a relapse of fever often occurred, accompanied by
thrombophlebitis in another limb (fig. 2), or by stiff neck,
ext. saph. vein
Phiebitis of rt
int. saph.vein
ted recovery
u
&
(s
2
BS)
X
$
Q
ext. saphenous vein
ip
Phlebitis of left
Uninterru,
t 3 § 7 9 HH ISI 19 21 2 2 27 2 31 33 35
DAY OF DISEASE
Fig. 2—Pyrexia with phlebitis, followed by two relapses with fresh
phiebitis.
or without any localising signs. The thrombosed vein,
if superficial, sometimes persisted as a thickened hard
fibrosed cord for many months, and was still palpable
on discharge of the patient from the Army or the hospital.
Special Investigations
White-cell count was performed in 26 cases. In 22 the total
count was below 10,000 per c.mm., and in 4 higher. Most
showed a relative lymphocytosis.
Blood-culture was performed in 6 cases, in 5 of which
cultures were sterile. B. facalis alkaligenes was recovered
twice from one patient’s blood-culture but was almost
certainly a contaminant.
Biopsy of an affected vein was carried out on 6 occasions.
Some of the cases were acute and others chronic. On exposure
of the affected vein under local anzsthesia it was seen to be
greatly swollen, but not adherent to surrounding tissues. On
section, the vein was found to be completely thrombosed in
early cases; it was white and fibrous, sometimes with signs of
recanalisation, in later stages. On microscopical examination
no specific changes could be found. Examination of sections
in acute cases revealed a simple thrombus occupying the
vein, with no evidence of inflammation either of the vein wall
or of the surrounding tissues. In more chronic cases organi-
sation and recanalisation of the thrombus could be observed ;
one very chronic case showed foreign-body giant-cells in the
almost completely organised thrombus. Suppuration was
never observed; nor could any organisms be seen.
Culture of a vein at biopsy was performed on three ocea-
sions, a contaminant being grown in one case, the other two
being sterile.
In 99 cases the following veins were involved :
One internal saphenous .. a a | 15
Both saphenous .. s es i .. 4
One femoral T ga oe de .. 22
Both femorals__.. se, . aN as .. 2l
One popliteal Sf ; s za ser 2l
One superficial arm vein Ci .. 16
Superficial arm veins right and left .. . 4
? Portal vein a be AS as .. 2
105
Of these patients 6 had phlebitis of both arm and leg.
(b) Subacute Thrombophlebitis—Some patients ‘were
admitted with no other symptoms than cdema of one
or both legs, with irregular pyrexia, pain being often
absent and no thrombosed vein being palpable. The
urine was free from albumin, and blood examination did
not reveal anemia. Recovery often took place without
further complication, but in some cases a subsequent
attack of stiff neck or of acute thrombophlebitis indicated
the nature of the syndrome.
(c) Three unusual varieties may be mentioned : ®
(i) Chronic_—Two cases developed recurrent bouts of localised
venous‘ thrombosis every three weeks for five months.
During each attack, which was accompanied by two or
three days of pyrexia, a small tender nodule could be
palpated along the course of & superficial vein. One of
the patients had a typical attack of pyrexia with stiff
neck, and the other developed an acute thrombophlebitis
of his popliteal vein during the course of the disease.
Biopsy of a nodule in each case showed an organising
thrombus in a vein.
(ii) Portal Vein Involvement (probable).—Two patients devel-
oped ascites within a month of the termination of a
course of neoarsphenamine and bismuth. Fluid thrill
and shifting dullness were elicited. Œdema of the lumbar
spine and legs was present in one case. There was no
jaundice or albuminuria. No ova were found in stools
or urine. The blood-pressure was normal. No hepatic
abnormality could be discovered clinically. The ascites
disappeared completely in both cases, within three months
and one month. Both patients completely recovered and
returned to their units fit for duty. Neither of these
patients had stiff neck or thrombophlebitis of the limbs.
(iii) Association with Arteritis.—Two patients, admitted to
hospital with phlebitis, developed thrombosis of their
femoral arteries, with resultant foot gangrene. Each case
required amputation of the leg above the knee, after
which recovery took place.
(d) Complications and Sequele.—A notable feature
was the complete absence of embolism. A common
sequela was persistent œdema of one leg; because of
this many patients had to be invalided out of the Army.
No death resulted from this disease in these 145 cases.
PYREXIA, USUALLY RELAPSING, WITHOUT EVIDENT
PHLEBITIS
This variety was characterised by irregular pyrexia
lasting from three days to three weeks, without evident
phlebitis. In some cases the pyrexia ensued as a sequel
to an attack of stiff neck or phlebitis; in other cases
one or other of these syndromes developed as a com-
plication after the termination of the fever. But many
cases displayed no localising signs, the diagnosis being
suggested by a history of recent antisyphilitic therapy,
and by the coexistence in the same area of more typical
cases of the disease.
DIFFERENTIAL DIAGNOSIS
Pyrexia with Stiff Neck.—The differential diagnosis
from relapsing fever, cerebrospinal meningitis, and
malaria was readily settled by the repeated absence of
spirochetes and malaria parasites from the blood, and
by the normal cerebrospinal fluid. Acute myalgia of
neck and shoulders in epidemic form has been described
by Beeson and Scott (1942), and cases of persistent
myalgia following sore throat have been recorded by
THE LANCET] LIEUT.-COLONEL MANSON-BAHR, DR. CHARTERS: EPIDEMIC THROMBOPHLEBITIS [SEPT. 7, 1946 335
Houghton and Jones (1942), but in neither instance
was any association with thrombophlebitis or injections
mentioned.
Thrombophlebitis.—The acute form had to be diagnosed
from pyomyositis, which was differentiated by the
more marked local swelling, the absence of signs over
the site of a vein, the absence of peripheral cedema,
and the tendency to pus formation.
Subacute bilateral thrombophlebitis of the legs had
to be distinguished from other causes of cedema, such as
nephritis, anemia, cardiac failure, vitamin-B, or protein
deficiency, and epidemic dropsy. The differentiation
from these diseases only arose in those cases where no
area of thrombophlebitis was evident. Examination
of urine, blood, and cardiovascular system readily
excluded renal, blood, and cardiac disease. Beriberi
was eliminated by the absence of neurological or of
cardiac abnormality, and protein deficiency was excluded
by the normal plasma-protein level (estimations in 3 cases
were 8-95 mg., 8-83 mg., and 8-36 mg. per 100 c.cm.).
The residual swelling was distinguished from filariasis
by the pitting character of the cdema.
Relapsing Pyrexia without Evident Phlebitis—When
of over two weeks’ duration this pyrexia had to be
distinguished from other long-term fevers, such as
typhoid, kala-azar, undulant fever, and miliary tuber-
culosis: Negative cultural and serological reactions,
negative sternal puncture, and normal chest radiograms
excluded these diseases. The history of recent treatment
at a special treatment centre for venereal diseases, the
coexistence of more typical cases of the disease in the
same area, and in some cases the supervention of an
attack of acute phlebitis’ or stiff neck clinched the
- diagnosis.
| DISCUSSION
It might be thought that the description which has
been given is not that of a syndrome, but of a mixture of
short-term fevers, unrelated cases of thrombophlebitis,
and long-term undiagnosed pyrexias. They have been
described together as a syndrome for the following
Teasons : l
(1) A sudden outbreak of thrombophlebitis, with subsequent
decline in numbers of cases, occurred in two widely
separated areas of the command. Previous cases could
scarcely have been missed, as reliable observers were
present before the outbreak in these areas.
(2) Several observers, who had had no previous information
on the subject, made simultaneously and independently
the observation of the association of the short-term fever
with stiff neck, often followed by relapses, with thrombo-
phlebitis affecting one or more limbs, and later with the
pyrexia without evident phlebitis.
(3) The association of these three manifestations is shown
below :
l Cases
Short-term fever with stiff neck alone ii aa ve. <8
Thrombophlebitis alone T es .. 23
Pyrexia without evident phlebitis alone |. a 3
Short-term fever with stiff neck and thrombophlebitis -. 13
Short-term fever with stiff neck and pyrexia w ROUT
evident phlebitis .. 5
Thrombophlebitis and pyrexia without evident phlebitis.. 3
7
Short-term fever with stift neck, prombepblebitls; and
pyrexia without evident phlebitis
62
In searching for the cause of this peculiar syndrome
three possibilities were entertained: (1) that it wasa
virus disease like infective hepatitis ; (2) that it was due
to the local effect of neoarsphenamine or other anti-
syphilitic drug on the vein; and (3) that it was allied
to marantic thrombosis.
Virus Disease.—The points in favour of a virus origin
are the relative lymphocytosis, the negative bacterio-
logical findings, and its possible etiological and epidemio-
logical relationship to infective hepatitis in this com-
mand. The admissions for infective hepatitis to two
general hospitals at the time of this outbreak are shown
in fig. 3. The similarity between the two curves will be
noted. Most of the cases of infective hepatitis were
so-called postarsphenamine jaundice in patients under-
going antisyphilitic treatment. That infective hepatitis
can be transmitted by syringes has strong support. Of
62 patients developing this syndrome, 5 had previously
had jaundice, and 2 developed thrombophlebitis while
still under-
going treat-
ment in hos-
pital for jaun-
dice. The
theory that
the present
syndrome
may be caused
by a virus
transmitted
chiefly by
needle punc-
ture, but also
by other
means, such as
droplet, urine,
or fæces, is
attractive.
Rift Valley ._
fever, a virus
disease, is en
NUMBER OF CASES
demic in East i=
Africa. The SS §F Fes S§
=~ SS å QA N A 8g
sera of two £& £ fF Fg LZ gb
patients, $ $ P § $ S S S
taken in each 1944 1945
case on the Fig. 3—Admissions to No. | and]No. 3 (E.A.) General
second and Hospitals of cases of jaundice and of thrombo-
twe njty-first phlebitis from January, 1944, to December, 1945.
days, were
examined by Dr. K. C. Smithburn, of the Yellow
Fever Research Institute, Entebbe, but no antibodies
to the virus of Rift Valley fever were found.
Local Effect of Drugs on Veins.—The prolonged course
of the pyrexia suggests that the cause of the phlebitis is
an infection rather than a chemical irritation of the
veins by antisyphilitic drugs. The predisposing effect
of arsenic or bismuth cannot be doubted. It is possible
that one or other of these drugs so damages the veins
as to make them susceptible to infection. It will, however,
have been noted that some of the patients had received
no previous antisyphilitic therapy.
Marantic Thrombosis.—Thrombosis of limb veins
occurs in severely malnourished persons, but most of
these patients were healthy African soldiers of category A,
who were better nourished than their civilian com- |
patriots, among whom thrombophlebitis is unusual.
SUMMARY |
A syndrome occurring in East African soldiers is des-
cribed. The main features were pyrexia associated with
stiff neck or thrombophlebitis, and usually accompanied |
by relative lymphocytosis. There is a great tendency
to relapse.
The association with antisyphilitic treatment is
emphasised.
The possible causes are discussed.
We are grateful to Brigadier R. P. Cormack, 0.3.2., director `
of medical services, East Africa Command, for permission
to publish this article, and to Major J. E. McClemont, R.4.M.0.,
for some of the pathological investigations,
REFERENCES
Beonon, d P. B., Scott, T. F. M. (1942) Proc. R. Soc. Med. 35, 733.
Boyd, el 938) A Text-book of Pathology, Philadelphia, p. 449.
Cana. M. (1943) The Sick African, Cape Town, p. 140.
Houghton, L. E., Jones. E. I. (1942) Lancet, i, 198.
Swirsky, M. Y., Cassano, OC. (1943) J. Lab. clin, Med. 28, 1812.
k 2
336
THE LANCET]
NAUSEA AND VOMITING OF PREGNANCY
A STUDY IN PSYCHOSOMATIC AND SOCIAL MEDICINE
G. GLADSTONE ROBERTSON
M.D. Glasg.
My interest in the nausea and vomiting of pregnancy
originated in some observations I made, in general
practice, on dyspepsia in non-pregnant women. I had
noted that a particular dyspeptic syndrome, usually
attributed by its sufferers to “a weak stomach,” was
not uncommon in married women who were sexually
frigid. A short account of this syndrome is as follows.
The symptoms usually began soon after marriage, or,
if later, with the cessation of sexual interest. In its
initial phases the syndrome usually appeared at times
of the day which could be related to the impending threat
of coitus—i.e., in the late evening—or at the week-end.
The earliest and most constant symptoms were
abdominal distension, eructation of wind and of small
quantities of gastric juice (usually termed “ acidity ”’),
and an increasing distaste for fats, with a decreased
ability to digest them. Attacks of nausea appeared
later, with or without vomiting, which was often
described as “ biliousness.’’ Pain was present only in
long-standing and severe cases, in which discomfort was
almost constantly present. The condition was liable
to persist indefinitely but with little or no deterioration
‘jn general health.
Some of the patients were known to me before marriage,
when there was nothing to indicate that they were
abnormal. As a whole they did not lean towards any
personality group—e.g., hysterical or obsessional—
or towards any special psychiatrical category, such as
anxiety state. On the other hand, if the illness had
lasted for years, it was the exception to find a patient
who did not exhibit signs of anxiety.
A study of the emotional state of these patients at
the time of the onset of symptoms revealed a common
feature—i.e., sexual relationship with the husband gave
rise to disgust. The digestive disorder appeared to: be
a physiological response to the repetitive effect of this
emotion. Further, most of the patients came to dread
coitus and to develop signs of anxiety. The sub-
sequent nervous element was as clearly a response to
fear as the digestive disorder was to disgust. Neither
disorder was causally related to a primary psycho-
neurosis.
- When I first recognised this syndrome in 1938 I named
it “rejection dyspepsia” (unpublished). During the
succeeding years I have confirmed the findings in many
hundreds of women. In doing so I noted that a high
proportion of them at marriage were unduly attached
to their mothers. The syndrome is common and includes,
almost without exception, married women labelled
as having visceroptosis and the great majority diagnosed
as cases of nervous dyspepsia. Towards the end of 1943
I became impressed with the observation that women
with this syndrome invariably had a history of protracted
or severe nausea and vomiting during their pregnancies.
These and other observations suggested the possibility
that the nausea and vomiting of pregnancy might also
be related to frigidity. Accordingly I began to investi-
gate my pregnant patients and the histories of their
past pregnancies from this point of view. It appeared
that frigidity in the strict sense—i.e., the experiencing
of coitus as an act undesired in itself and unaccompanied
by the attainment of orgasm—did not inevitably cause
nausea and vomiting during pregnancy; but severe or
long-continued vomiting in a frigid woman during
pregnancy was related directly to the frequency of
undesired and unappreciated coitus. A further character-
istic associated with nausea and vomiting was that the
woman was excessively attached to or dependent on her
mother. This personality trait appeared to be relevant
to nausea and vomiting even when the sexual function-
ing of the woman was “normal.” Another character-
istic which seemed to be etiologically associated was a
history of previous dyspepsia.
DR. ROBERTSON: NAUSEA AND VOMITING OF PREGNANCY
[SEPT. 7, 1946
Serial Investigation of Pregnant Women
To evaluate the relevance of previous dyspepsia,
excessive attachment to the mother, and disturbed
sexual functioning in the etiology of the nausea and
vomiting of pregnancy, I investigated 100 consecutive
pregnant women. The results are analysed in table I,
which shows that 57 had nausea or vomiting and 43 had
none. The latter group can therefore be regarded as
controls. The table shows that 6 out of 57 cases had a
history of previous dyspepsia, against none of the
controls ; 20 out of 57 cases showed undue mother attach-
ment, against 4 out of 43 controls; and 40 out of 57
cases showed -disturbed sexual functioning, against
4 out of 43 controls.
These findings confirmed that a history of previous
dyspepsia, mother attachment, and disturbed sexual
TABLE I—DETAILED ANALYSIS OF CONTROLS AND CASES
Disturbed
Mother
xual
Previous attachment aoe
— Cases dyspepsia functioning
1 | 2 |Total| 1 | 2 | Total
Controls 43 0 ajo| 4 |4/ 0] 4
Nausea and |
vomiting :
Minor big 31 5 6 | 0 6 |14 | 4 | 18
Moderate .. | 17 1 513 8 6 | 7 | 13
Severe .. 9 0 3 3 6 0 9 9
functioning were etiologically significant in the nausea
and vomiting of pregnancy. '
DEFINITION OF TERMS AND STANDARDS OF ASSESSMENT
Previous Dyspepsia.—This term refers to those patients
who had had recurrent attacks of dyspepsia for some
years before marriage. These comprise 6 cases only—
a number too small for further subdivision. The dis-
order in 3 of these was said to have dated from “ acidosis ”
in childhood. ‘ All 6 had nausea and vomiting in preg-
nancy.
Mother ‘Attachment.—The trend of development in the
growing girl is towards an increasing freedom from her
earlier dependence on the mother. On marriage, more
especially when she herself becomes a mother, a woman
should be able to behave as an independent adult mother.
In some women, however, the infantile and childish
relationship with the mother persists, and they remain
enclosed within the orbit of the mother’s influence,
injunctions, and prohibitions. In other women the
extreme devotion expressed for the mother is (to the
appreciative observer) seen to be a compensation for
repressed aggressive tendencies directed against her.
Such tendencies are often found in a woman who is forced
by circumstances to care for an invalid mother besides
attending to her own household duties during the early
years of marriage. If the young married woman has
to live with her mother or a mother substitute—e.g.,
mother-in-law—the conflict between outward duty
(devotion) and inward resentment (hate) is exaggerated
as a result of propinquity.
Mother attachment varies from woman to woman,
varies in its predisposing conditions, and varies in the
same woman at different times. Its importance in the
nausea and vomiting of pregnancy is usually greatest
during the earlier pregnancies. With the passage of
years it tends to wear off and its etiological influence
tends to decrease. l
For the purpose of this inquiry I have used the numerals
l and 2 to indicate the degrees of undue mother attach-
ment estimated to prevail at and immediately before
onset of the pregnancies studied. Thus, if after marriage
the woman continues to visit her mother daily and
THE LANCET]
indicates her dependence on her by making no decision
of importance without consulting her the degree of
mother attachment was assessed as 1. When dependence
in this sense is very pronounced, or when the patient
described her interest in her mother as being greater
than her interest in her husband, the degree of mother
attachment was assessed as 2.
Why should undue mother attachment be the equi-
valent of a disgust factor in the subconscious? A
psychiatrical interpretation might infer that the first
aggressive feelings of the baby are directed towards the
mother and are associated with anal activity. When
in later life, as a result ‘of cultural influences, bodily
excretions become linked to dirtiness and filth, any
aggressive feeling towards the mother becomes. like-
wise associated with filth. The psychiatrist tells us that
over-devotion to the mother is a disguise or compensation
for aggressive tendencies.
Another and less complex explanation may be given
which has the advantage of being more easily grasped
by the patient. At various periods in the growth of the
normal] child he takes or steals what he desires, lies: to
escape punishment, and later becomes interested in his
body and genital functions. These impulses are con-
trolled and corrected chiefly by the mother, and as he
acquires cultural education he tends to become ashamed
of his past behaviour. This is shown by the inability
of the average person, of any age, to discuss without
embarrassment certain subjects, particularly of a sexual
nature, in the mother’s presence. It can even be said
that for the remainder of his life the very sight of his
mother induces in him subconscious shame.
Disturbed Sexual Functioning.—An obvious form of
disturbed sexual functioning is frigidity in the sense
that the woman has no interest in coitus, never experi-
ences orgasm, and may have vaginismus. My own
observations indicate that about 10% of married women
fall into this category of complete frigidity throughout
the whole of their married lives, and that many others,
especially overworked women with large families, ulti-
mately reach such a state. Most women with this
characteristic were noted to have undue mother attach-
ment before and during the early years of marriage.
It seems that well-marked emotional entanglement with
the mother tends to inhibit the normal expression of the
woman’s love for her husband. That the public mind
is aware of the discomfiture experienced by the husband
through undue interest on the part of his wife in her
mother is shown by the popularity of mother-in-law
jokes (invariably the wife’s mother). Other forms of
disturbed sexual functioning related ztiologically to the
nausea and vomiting of pregnancy are continuous loss
of sexual interest and inability to attain orgasm. Among
the factors associated with and precipitating these are
(on the part of the woman) ill-health, frequent child-
bearing, and fear of pregnancy.
Understanding of these conditions is, however, incom-
plete unless account is also taken of the sexual
functioning of the husband, which may show either
inexpertness or disturbance. For example, excessive
-= coital demands made by the husband may, if long
repeated, induce in the woman feelings of revolt and
disgust, attended by loss of sexual interest. Infrequent
intercourse, on the other hand, is not so likely to build
up a massive reaction of disgust. This is illustrated
by the absence of sickness in the strictly frigid married
woman who has intercourse on relatively infrequent
occasions and in the unmarried woman who has inter-
course only once or twice in the absence of orgasm and
even in the presence of painful discomfort. Continued
ejaculatio precox in the husband during early married
life may also lead to the growth of disgust in connexion
with coitus, because it prevents the wife from realising
completed orgasm and the sexual act becomes associated
with mere messiness. The inability of the woman to
attain orgasm may also be determined by the repeated
practice of coitus interruptus.
DR. ROBERTSON: NAUSEA AND VOMITING OF PREGNANCY
[SEPT. 7, 1946 337
Inquiry was also made into the proportion of coital
acts undesired by the wife and the proportion of coital
acts in which she did not attain orgasm during the
months preceding conception. Sexual functioning was
regarded as reasonably normal when the proportion of
undesired coitus and absence of orgasm did not exceed
20%. When either proportion exceeded 20% but was less
than 60%, the disturbance of sexual functioning was `
assessed as 1; when the proportion exceeded 60%,
the disturbance was assessed as 2.
Coital Infrequency.—As the theme of this discourse
implies that pregnancy sickness is caused by a massive
“ disgust ” factor in the subconscious, some method had
to be devised to exclude from the disturbed sexual
_ functioning category those patients who had experienced
coitus on relatively infrequent occasions. Accordingly, ,
no patient was included in this category in table 1 if
coitus took place less frequently than once a month or
six times in all.
Thus, disturbed sexual functioning was not taken into
account in 6 controls, although all were frigid in the sense
of the definition given above : 2 were unmarried and had
experienced coitus on three and four occasions; 2 had
married soldiers towards the expiry of embarkation leave ;
and 2 had been married for some years but asserted
definitely that coitus had not taken place oftener than
eight or nine times a year.
Though undesired coitus during pregnancy might
`. well have a bearing on the severity of sickness, it was
found expedient to limit the inquiry to a period of a few
months before the beginning of pregnancy. Many of
the women had not experienced coitus during pregnancy,
notably the wives of men serving with H.M. Forces.
Degree of Nausea and Vomiting.—The cases were
divided into three groups: minor, moderate, and severe.
In the minor group nausea, retching, or vomiting lasted
less than six weeks ; in the severe group those symptoms
were prolonged beyond five months, or, if of shorter
duration, were of such severity as to be classified as
true hyperemesis gravidarum—i.e., the fluid output
exceeded fluid intake. The moderate group lay between
the minor and severe groups.
DETAILED ANALYSIS
Detailed analysis of controls and cases is given in
table 1 which shows that minor cases (31) were almost
twice as common as moderate cases (17), and these in turn
almost twice as common as severe cases (9). This table
also indicates clearly that the etiological significance
of mother attachment and disturbed sexual functioning
is higher in severe than in moderate cases; higher in
these than in minor cases, and higher in minor cases
than in controls. Thus the percentage with mother
attachment in controls was 9; in minor cases 19; in
moderate cases 47; and in severe cases 66. The per-
centage with disturbed sexual functioning in controls
was 9; in minor cases 58; in moderate cases 76; and `
in severe cases 100. The greater significance of both
mother attachment and disturbed sexual functioning in
severe than in minor cases is also indicated by the
progressive percentage increase in degree-2 cases com-
pared to degree-1 cases as we pass from the minor
through the moderate to the severe group.
Variations of Nausea and Vomiting in Successive
Pregnancies in the same Woman.—The series of 100
pregnant women comprised both primipare and multi-
pare. The multipareenumbered 63 and between them gave
a history of 175 previous pregnancies. The syndrome of
nausea and vomiting was not necessarily a constant feature
for successive pregnancies in the same woman. Some of
the controls in this series were “‘ cases ’’ in their previous
pregnancies, and vice versa. The presence or absence
of vomiting in any single sequence of pregnancies in the
same woman could usually be related to the life situation
prevailing before conception—e.g., the relationship to
838 THE LANCET]
the mother, the attitude towards the husband as a
person, and the behaviour of the husband as a lover.
An analysis of the 175 previous pregnancies gave results
which corresponded to those obtained in the present
series of 100 pregnancies.
Table 11 shows, in six illustrative cases, the sickness
variability in a succession of pregnancies in the same
‘woman and the significance of previous dyspepsia,
mother attachment, disturbed sexual functioning, and
coital infrequence. Though these cases were selected
they are typical of the entire series comprising 275
pregnancies.
CasE 1.—A sequence of five pregnancies free from nausea
or vomiting in the absence of the factors previous dyspepsia,
mother attachment, and disturbed sexual functioning. She
desired the first, was resigned to the following three, and
averse to the last. In no patient does conscious attitude to
pregnancy bear any relationship to sickness.
Case 2.—Occasional attacks of biliousness dating from
school days. When previous dyspepsia is the only factor,
the degree of sickness is usually constant in all progneneles
in the same woman.
Case 3.—Devoted to and nursed mother with pernicious
anemia. Mother died shortly after pregnancy 5. Disturbed
sexual functioning throughout the years of marriage was 25%.
CASE 4.—Lived next door to and assisted her mother, to
whom she was much attached until after pregnancy 3. On
removing to another district she became detached from her
mother. After pregnancy 4 her sex interest began to wane.
After pregnancy 5 she became completely frigid. ?
Cast 5.—This woman was completely frigid. Her husband,
like many married to such women, became @ drunkard and
TABLE II—SICKNESS VARIABILITY IN SUCCESSIVE PREGNANCIES
IN 6 TYPICAL CASES, SHOWING SIGNIFICANCE OF PERSON-
ALITY FAOTORS
Preg-| Age Total | Nausea
Case CAP | PD | MA] DSF | OI and
nancy | (year) points vomiting
1 1 20 D 0 0 0 — 0 0
2 21 R 0 0 0 — 0 0
3 24 | R 0 0 0 — 0 0
4 27 R 0 0 0 — 0 0
5 31 A 0 0 0 — .0 0
2 1 27 D 1 0 0 1 1
2 31 D 1 0 0 — 1 1
3 40 R 1 0 0 — 1 1
3 1 20 D 0 2 1 -— 3 3
2 22 D 0 2 1 — 3 3
3 24 D 0 2 1 — 3 3
4 26 D 0 2 1 — 8 3
5 28 D 0 2 1 — 3 3
6 33 A 0 0 1 — 1 0
4 1 18 D 0 1 0 — 1 1
2 19 D 0 1 0 — 1 1
3 21 A 0 1 0 — i: 1 1
4 23 A 0 0 0 — 0 0
5 25 A 0 0 1 — 1 1
6 27 A 0 0 2° — 2 3
7 28 A 0 0 2 — 2 3
5 1 20 D 0 0 2 — 2 1
2 22 D 0 0 2 — 2 a |
3 24 D 0 0 2 - 2 1
4 26 A 0 0 2 |- 2 1
§ 27 A 0 0 2 — 2 1
6 29 A 0 0 27 — 2 1
7 30 A 0 0 2 _ 2 1
8 39 A 0 0 2 + 0 0
9 40 A 0 0 2 + 0 0
10 43 A 0 0 2 + 0 0
11 44 A 0 0 2 + 0 0
6 1 31 D 0 2 2 — 4 3
2 34 D 0 2 2 — 4 3
3 36 D 0 2 2 4 3
The last pregnancy in each patient was one of the 100 consecutive
pregnancies.
CAP, conscious attitude to pregnancy: D, desire for the pregnancy ;
R, resigned to being pregnant; 4, averse to the pregnancy.
PD, previous dyspepsia.
MA, mother attachment.
DSF, disturbed sexual sur deere
cl, coital infrequency.
tor, when the DsF factor loses significance as an agent capable
of causing sickness.
Total points are obtained by adding together degrees of PD, MA, and
DSF. (DSF points not included if cr present.)
Degree of nausea and vomiting: or 1, moderate 2, severe 3.
DR. ROBERTSON: NAUSEA AND VOMITING OF PREGNANCY
A plus sign indicates the presence of this
[SEPT. 7, 1946
later unfaithful. He contracted syphilis after pregnancy 7,
and they separated. Before conceptions 8, 9, 10, and 11 he
broke into the house (on the evidence of a neighbour and
her own testimony) and intercourse took place on only one
occasjon before each pregnancy.
CasE 6.—She illustrates the effect of a combination of the.
factors mother attachment (to a marked degree) and complete
frigidity. All pregnancies were complicated by hyperemesis
gravidarum. The first two terminated in stillbirth at the
29th and 3lst week respectively. The third continued to
the 35th week with survival of the child.
Vomiting and Miscarriage in the Wives of Returned
Service Men.—Although as has been indicated the
nausea and vomiting of pregnancy may be etiologically
complex, the practical considerations become narrowed
down when a previous pregnancy was free from sickness.
During recent months, in the course of general practice,
I have encountered an unusually high proportion of mis-
carriages preceded by severe vomiting among the wives
of ex-Service men who had been absent for two or more
years. Many of the wives had undergone one or more
previous pregnancies without sickness. In such cases
one would expect, in view of the findings recorded in this
paper, that frequent undesired coitus had occurred
before the recent pregnancy ; inquiry showed that this
was SO.
Many men, returning home after an absence of years,
seem to be. unaware that their wives have adjusted
themselves to a different mode of life and may in fact
` have ceased to. be in love with them in the physical sense.
The vigour, physical fitness, and sexual hunger of these
men contrasts with the war-worn condition of the
harassed housewife. If regular coitus is not preceded
by a preliminary courtship there is grave danger not only
of severe vomiting during an ensuing pregnancy, with
an apparent increased risk of miscarriage, but also of
- alienation of the affection of the wife.
These and similar aspects of human contact and
relationship, with their unlimited potential for unhappi-
ness and ill-health are the true kernel of Social Medicine.
The inception of university chairs of social medicine led
one to believe that an endeavour was about to be made
to equip the doctor ôf the future to grapple with such
problems, but apparently the subjects for research are
to be well-worn topics like vital statistics, drainage, and
impurities in food and milk.
ADDITIONAL FINDINGS
The compilation of this series of patients began on
April 1, 1944, and was complete in ten weeks. With
the exception of three women who miscarried on the
occasion of the first attendance, every pregnant woman
treated in the course of practice was included in the
series. Whether the pregnancy was at an early or at a
late stage during this period, recorded data were avail-
able from the first examination, and the inquiry was not
finally concluded until after the delivery of the last
patient.
The blood-pressure curve tended to rise more steeply
in patients who suffered from severe and protracted
vomiting.
Four patients had pyelitis during some stage of the
pregnancy, and 2 had albuminuria. All 6 had nausea
and vomiting. In all these cases nausea and vomiting pre-
ceded the rise in blood-pressure, pyelitis, or albuminuria.
Most textbooks comment on the higher incidence of
pregnancy sickness among “nervous” or “ neurotic ”
women. Most of the 100 patients were known to me
during previous pregnancies and often before marriage.
Nervous or neurotic trends were apparent in some before
marriage, but in others not until some time after marriage.
The impression gathered was that the incidence of sick-
ness was definitely higher in the latter group. This
finding is consistent with the view that the sickness of
pregnancy is not due to “‘ nervousness.” .
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Ætiology
The ætiology of the nausea and vomiting of pregnancy
has received considerable attention, but no definite
conclusion has been reached. An excellent review of the
subject was provided by Hall (1943). No toxin has
been discovered. Willis et al. (1942) and Weinstein
et al. (1943) consider deficiency of components of the
vitamin-B complex, notably vitamin B,, to be a factor
of importance, whereas Kemp (1933), Bandstrup (1939),
and Kotz and Kaufman (1940) emphasise abnormal
changes in the maternal adrenal cortex. Shute (1941)
and Schoeneck (1942) observed changes in the quantity
of gonadotropic hormone in the urine and blood of
patients suffering from nausea and -vomiting. No
specific pathological lesion has been noted, and the
post-mortem findings (associated with hyperemesis
gravidarum) are consistent with what might be expected
as the end-result of protracted vomiting and lack of food
and fluid (Sheehan 1939). Psychological factors have also
been considered, and Weiss and English (1943) express
the following view :
“ A conscious or unconscious wish not to become
pregnant: if the unconscious aversion is masked by a
conscious desire to become pregnant, sickness is likely
to be severe: an unconscious belief that a sin has been
committed: childhood fantasies suggest that the preg-
nancy has taken place by way of the gastro-intestinal
tract and the unconscious desire to be rid of the foetus
conceives its expulsion in the same way.”
This opinion, however, was not borne out by statistical
analysis of the conscious wish to be pregnant or not
pregnant in my series of 100 patients ; nor does it explain
the sickness variation in a sequence of pregnancies in
‘the same woman. It savours more of armchair deduction
in the abstract than of clinical observation (see table 11).
A discussion of the etiology of the nausea and vomiting
of pregnancy may most conveniently be arranged in
terms of Halliday’s (1943) formulation of etiological
principles.
ETIOLOGY OF ONSET
The PersonWhat kind of woman on becoming
pregnant develops nausea and vomiting? Relevant
personality characteristics are disturbed coital function-
ing (acquired in adult life, often short-acting, may vary
from pregnancy to pregnancy); undue mother attach-
ment (usually acquired in adolescence, tends to decrease) ;
and, less often, previous dyspepsia (usually dates from
childhood and remains fixed).
Environment.—Why does a pregnant woman develop
vomiting when she does? Among relevant environmental
factors are the physical propinquity of the mother and
husband, the husband’s behaviour as a lover, and the
frequency of his coital demands.
Mechanism.—Why does a pregnant woman’s ailinent
take the form of nausea and vomiting? A psycho-
somatic approach suggests that the nausea and vomiting
may represent the physical expression of an emotional
constellation in which disgust is predominant. It also
suggests that the biochemical changes associated with
pregnancy probably lower the threshold of the physical
expression of a latent or subconscious disgust; hence,
when the ovum dies or the fœtus is removed, the thres-
hold to physical expression is again raised and vomiting
ceases. In other words, pregnancy serves as a trigger.
These suggestions are consistent with the absence of
any proved toxin, the probable change of hormonal
secretions accompanying subconscious emotional activity
(as well as pregnancy), and the absence of any specific
pathological lesion.
JZETIOLOGY OF NATURAL RECOVERY
Why does the patient recover without. treatment ?
Women with nausea and vomiting of pregnancy: may
recover spontaneously in a few weeks when the illness is
DR. ROBERTSON: NAUSEA AND VOMITING OF PREGNANCY
[SEPT. 7, 1946 339
mild. In more severe cases removal from the proximity
of the mother or the husband is often followed by rapid
improvement. A study of successive pregnancies in the
same woman shows how the presence or absence of
vomiting in the various pregnancies is usually governed
by the presence or absence of the operative environ-
mental factors already described.
ZTIOLOGICAL PRINCIPLE OF THE PREVALENCE
The theory that nausea and vomiting is an expression
of the emotional life, especially of a heightened sense
of disgust, covers the known facts in terms of person
and environment (biological stiology.), the known facts
in terms of the bodily organs and functions involved
(etiology of mechanism), and the known facts of the
ætiology of natural recovery. Further, it can be shown
that it does not conflict with the principle of “ pre-
valence,” which is that if the incidence of a disease does
not conform with what we have inferred concerning its
ætiology, then our inferences are faulty, partial, or
erroneous (Halliday 1943).
The published work shows that the incidence of the
syndrome is not primarily related to physical factors
of environment, such as climate or diet, but is clearly
associated with the psychosocial set-up sometimes called
western civilisation. Thus the incidence is low among
Eskimos and native African tribes (Dieckmann 1938).
In oriental countries, except industrialised Japan (Hall
1943), hyperemesis gravidarum is practically unknown.
It is common in modern capitalist industrial countries,
such as western Europe and America, and is more
prevalent in urban than in rural areas. Dieckmann,
investigating the incidence of hyperemesis in various
climates, also notes that it was relatively rare in Germany
during the war of 1914-18, but that a well-marked increase
took place in the following years. The etiology of this
change in prevalence is complex, but it could be attributed
to the different psychosocial environment prevailing
in the war years contrasted with the post-war years,
notably the separation of husband and wife during the
years of combat (see above).
A further interesting fact, remarked on by veterinary
surgeons and farmers, ‘is the absence of vomiting in preg-
nant animals. Though the physical accompaniments of
pregnancy in many animals closely parallel those in
woman, the female animal is free from a sense of shame
in the presence of the mother, nor does she submit to
coitus from-a sense of duty to the male.
Therapeutic Inferences
As in most illnesses, etiological insight emphasises the
importance of prevention rather than cure—e.g., the
need for more knowledgeable upbringing of the young,
reasons why a woman should marry in accordance with
her instincts rather than to attain social position, and the
necessity for marital education in the newly married.
Nevertheless the results of this inquiry into etiology
have definite therapeutic implications. Knowledge of
the stiological importance of mother attachment,
disturbed coital functioning, and the frequency of
undesired coitus enables the doctor to focus his inquiries
on those characteristics of the patient’s personality
and her life situation which are of ætiological relevance.
Patients with severe nausea and vomiting in pregnancy
have usually endured a good deal of mental anguish,
and, because of the delicacy of the problems involved,
rarely make confidants spontaneously. There are few
of them who cannot be materially helped by bringing
to light their particular difficulties.
When a history of previous dyspepsia was the only
factor present, the degree of sickness was usually a
constant in all pregnancies in the same woman. Though
it might persist for a few months, it was rarely severe.
On only two occasions, where the onset was traced to
events at the unusually late age of between 12 and 14
+
340
years, was I able to discover significant factors or to
influence the normal course of the illness. Where a
strong mother tie exists, this can easily be discussed
freely, provided a reasonable amount of tact is used.
Most women are not upset to learn that it is neither
virtuous nor wise to be bound indefinitely by their
mother’s apron-strings. Where previous undesired coitus
is realised to be a factor, this can be discussed with
both husband and wife, He is inevitably unaware of the
possible significance this may have in relation to the
sickness of his wife. —
Although many of these talks were instigated by me
in pursuance of an idea and to obtain statistical data,
the underlying and inspiring purpose was to bring about
cessation of sickness, and, through change of habit in
the life situation, to prevent sickness in future preg-
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nancies. Each patient should be studied as an indi-
vidual. Treatment in any particular case depends
on the particular findings: The approach must be
sympathetic, tactful, unrushed, and in privacy. If
success is to be achieved, the patient, besides replying
to question and unburdening herself of her affairs,
should receive an acceptable explanation capable of
convincing her that the factors discovered by inquiry
were really the cause of her vomiting. The second
interpretation given above on the significance of mother
attachment as a sickness-producing factor is much more
readily understood than the first. In my experience
no woman, however dull, has the slightest difficulty
in believing that the effect of frequent undesired inter-
course is cumulative in the subconscious and leads to
a personality change which manifests itself as an increased
tendency to vomit. It may be necessary to remove the
patient from the propinquity of the mother or husband.
She may be benefited by the knowledge that the question
is being taken up with her husband. As a general rule
several factors—e.g., mother attachment and frigidity—
are found in the more severe cases of vomiting.
After such discussions the improvement is often
dramatic, especially among recently married women.
An older woman, however, who has been frigid from the
beginning—e.g., a multipara, perhaps pregnant for the
twelfth time—may present more difficulty. In such
& woman the disgust may be so chronic and deep-seated
that it finds physical expression even between her preg-
nancies in the syndrome of ‘rejection dyspepsia,” as
already described.
It is not easy to detail statistically the results of
treatment in a condition so variable as the sickness of
pregnancy ; hence only 4 of the more severe cases will
be considered, 3 of them briefly. All 4 women were
completely frigid—i.e., at no time in their lives had
there been sex interest—and all showed also mother
attachment: 3 of.them of the second degree and 1
of the first degree. When first attended 2 of the patients,
besides being violently sick, were bleeding slightly from
the uterus and having mild pains. Both were between
seven and nine weeks’ pregnant, both improved much in
two days, and both stopped vomiting within two weeks.
One remained well, but the second, who was living with
her mother, had two severe recurrences, one accom-
panied by an attack of pyelitis, in the later months of
pregnancy. Each recurrence had followed a domestic
crisis which required further investigation and treat-
ment. The third (table 1r, case 6) continued to have
nausea and vomiting until she entered labour at the
35th week. Although vomiting appeared to diminish
in intensity, treatment was less successful than in any
other case in the series, and she was the only patient
in whom pregnancy did not reach full term. The fourth
patient, aged 27, in her second pregnancy (one of the 2
cases of albuminuria), is described in greater detail.
Her mother approached me through a neighbour whom
I had treated during pregnancy. The patient was in hospital
DR. ROBERTSON: NAUSEA AND VOMITING OF PREGNANCY
[SEPT. 7, 1946
with the diagnosis of toxsemia of pregnancy. Next day she
was conveyed home by ambulance against stern advice.
She was visited once only. Half an hour was occupied in
obtaining the following story and in making the psycho-
pathological interpretations and suggestions thought necessary.
- Infe Situation and Emotions.—Her husband served in the
merchant navy. The marriage took place during a period
of leave, eighteen months previously. Conception took
place during his fourth spell ashore. She was devoted to and
dependent on her mother, with whom she lived when her
husband was at sea and whom she visited, forenoon and
evening, during his periods of leave. She said she was very
fond of her husband but felt revolted and disgusted when
physical relationship took place, which was frequently when
he was at home. Each time he left her to resume his hazard-
ous duty she was filled with remorse and guilt because she
had so little of herself to give him and a sensation of horror
lest, as a result of a torpedo, she might never have another
chance of seeing him. About two weeks after conception,
and before she was aware of pregnancy, her doctor advised a
rest from her work in a munitions factory and certified her
as unfit owing to hyperthyroidism. Two weeks later vomiting
began. When three months’ pregnant, she was admitted to
the maternity hospital, in which she was detained for four
months. During this period there was daily vomiting,
intermittent albuminuria, and a moderate rise in blood-
pressure.
Progress.—After a discussion of the relevant problems,
vomiting ceased in 24 hours. Appetite returned. She was
out of bed in a few days, and out of doors a week later. When
the hospital almoner called at the end of the second week,
she was out shopping, having gained a stone in weight. When
the patient called at my consulting-rooms three weeks after
her homecoming, her urine was free from albumin and her
blood-pressure was 125/80, at which level it remained until
her uneventful delivery. |
“ Psychosomatic ” and ‘‘ Psychoneurotic ”’
The psychosomatic concept has been the subject of
much confused thinking, and perhaps in no field of
medicine is there a greater need for the “ integration
of medicine,” advocated with enviable artistry by Walshe
(1945). The psyche-soma interrelationship has been
influenced by Freudian beliefs and analogy, and indeed
many writers apply the same principles to “ psycho-
genic ” somatic disorders as were found useful in the
study of psychoneurosis. Briefly, these principles
suppose that it is determined either genetically or in
babyhood or in childhood how the patient will break down
in health, should his later life stresses be too great.
Adult difficulties are lumped together as “anxiety ”
and are regarded merely as the factors which precipitate
the breakdown in point of time. In other words, whether
the stress is caused by flying a bomber over enemy
territory or by marrying a frigid wife, the form taken
by the resulting illness will be the same unless experi-
ences before or shortly after birth determined other-
wise. Others again still speak of an illness as being either
physical or psychogenic. For them ‘“ psychosomatic ”
is a euphemism for psychoneurotic. Thus, though
they have come to use new words, they continue to
think in terms of the outmoded classification of functional
or organic.
Such views are alien to those expressed in this paper,
which postulate a psychosomatic disease or disorder
to be a specific physiological response to a particular
type of emotion capable of being incorporated into the
personality at any age. The persistence of the disorder
is determined by the intensity and frequency of the
causal emotion and the age when it is experienced.
For example :
(1) Coronary thrombosis has been called by some the
doctors’ disease. The high incidence of this disorder
' among doctors is surely not because they are the subject
of any special hereditary traits, or suffered from particular
psychological traumata in childhood, or because they feed
on an imperfect diet or live in damp houses, or because
their physical or even intellectual output is unduly high,
but rather because of the emotional accompaniments
THE LANCET]
of their duties—factors such as hurry and tension, undue
responsibility, and fear of a diagnostic error or unkindly
judgment, with possible repercussions on their means
of livelihood.
(2) Enlarged Prostate.—The prostate is normally
activated by erotic emotions mediated by endocrine,
notably gonadal, activity. Few would deny that some
form of over- or mal-activity is responsible for the
ultimate enlargement, a view supported by the freedom
of the eunuch from both the predominant emotion and
hormone and from enlarged prostate.
These two diseases, unquestionably physical, and
resulting from the repetitive effect of specific emotional
constellations in adult life, appear to fall into the psycho-
somatic category. Neither need be associated with
psychoneurosis.
It is certain that ‘‘ disgust-shame ” factors may find
their way into the subconscious through life experiences
other than those expressed by the conceptions “ previous
dyspepsia,” “‘ mother attachment,” and “disturbed
sexual functioning.” For instance, it is probable that
a woman who was an inhabitant of a besieged city and
was so unfortunate as to be reduced to a diet of cats,
rats, and mice, would suffer from vomiting if she became
pregnant soon afterwards. On the other hand, there
was no evidence of a rise in either the prevalence or the
severity of the nausea and vomiting of pregnancy
among the blitzed citizens of London and such intensely
bombed areas, although there was an increase in the |
incidence of psychoneurosis. Some of the most highly
neurotic women in the series were free from nausea and
vomiting, in the absence of the described causal factors.
The sickness of pregnancy can be defined as a psycho-
somatic reaction. This behaviour pattern is separate
and distinct from the emotional quality popularly con-
ceived by the expression ‘“‘ psychoneurotic.”
From a survey of a very much larger series than the
100 women who form the basis of this paper, other factors
appeared to be etiologically relevant in a small
percentage of cases. Thus, the syndrome developed in
women with strong aggressive feelings towards the father ;
in women born in humble circumstances whose life was
dominated by an attempt to compensate in appropriate
social aspirations ; in women whose early life had been
marred by lack of love and affection, and whose sexual
needs after marriage seemed insatiable ; and in women
with an inability to accept the animal functions of the
Henk including secretions and excretions, birth, love, and
eat
FINAL NOTE
Although the importance of sex as a factor in the
nausea and vomiting of pregnancy has hitherto escaped
the attention of clinical and scientific workers, it has been
sensed by non-medical observers. Two fictional works
written by well-known lady novelists were recently
brought to my notice. In the first (Seymour 1928)
the absence of sickness in a pregnancy following an
ideal love union was strongly emphasised, while in the
second (Ertz 1943) equal emphasis was laid on the
persistence of sickness throughout a pregnancy where
the wife was not in love with the husband.
Summary
A clinical and statistical investigation of the nausea
and vomiting of pregnancy shows that the syndrome
may be the physiological expression of an underlying
emotional state which may be equated with that of
disgust. This view has the merit of covering all the
known facts, including those relating to the prevalence
of the disorder.
Relevant xtiological characteristics of the personality
are disturbed coital functioning, undue mother attachment,
and, to a lesser extent, a history of previous dyspepsia.
Relevant factors in the life situation are the frequency
of undesired coitus and the physical propinquity of the
mother.
DR. MASSONS: CALF PLASMA OR SERUM FOR TRANSFUSION
{[serpT. 7, 1946 341
These conclusions have important implications for
therapy. They indicate the need to supplement physical
examination of the patient with investigation into her
emotions and life situation.
This investigation owes much ‘to the inspiration and
illumination provided by the papers of Dr. J. L. Halliday on-
psychosomatic medicine. During its preparation I was
personally indebted to Dr. G. R. Anderson for useful sugges-
tions and to Mr. J. M. Ross for inquiring into the incidence
of sickness in pregnant animals.
REFERENCES
Bandstrup, E. (1939) J. Obstet. Gynac. 46, 700
Dieckman W. J. (1938) Amer. J. Obstet. ‘Gynec. 36, 623.
a 943) Anass in the Skies, London.
all, Si, ere: ‘Amer. J. med. Sci. 2 05, 869.
Halli ay, J L. (1943) Brit. J. med. Psychol. 19, 367.
Kemp, W N. (1933) caran med. Ass. J. 28, 389.
Kotz, J., Ka ufman, M. S - (1940) Amer. V5. Obstet. ‘Gume. 39, 449.
Schoeneck, pr a (1942) Ibid, , 308.
K. (1 O goid Rides gat, Ponia:
Sheehan, E L. (1939) J . Obstet. Gynec. 46, 685.
E. (1941) Amer. J. Obstet irae ry 490.
Walshe, F. M. R. (1945) Brit. med. J. i, 723.
Weinstein, B. B., Mitoha G. J., S ainia., G. F. (1943) Amer. J.
83.
Paes O. S. (1943)
Philad Yelphis, p. 614
Willis, R. S. et al. (1942) Amer. J. Obstet. Gynec. 44, 265.
CALF PLASMA OR SERUM
FOR TRANSFUSION
J. M. Massons
M.D. Barcelona
From the Institute of Medical Research in Barcelona University
THE costly business of collecting human blood for
transfusion, the difficulties of storing whole blood, and
various disadvantages (such as time lost in grouping)
in blood-transfusion have led many researchers to
seek a substitute for blood. put all have had serious
drawbacks.
Various attempts have been ade to remove the
anaphylactogenic properties of animal plasma or serum
so as to make it safe for transfusion.
Rosenau and Anderson (1906) used heat and chemical
agents, and Doladilhe (1937) tried eliminating a globulin
fraction by dialysis. Brodin and Saint-Girens in 1918
successfully injected 500 c.cm. of horse serum into a man,
and later (Brodin and Saint-Girons 1939) suggested that
transfusion with horse serum might be useful. Kremen et al.
(1942) concluded after many attempts that the use of calf
plasma was contra-indicated. The use of blood of a lower
animal for transfusion in man goes back to 1662 (Lancet 1939).
I thought that formol might act on serum anaphylacto-
gens as it did on bacterial toxins and animal venoms,
and I found that horse serum treated with formol lost its
anaphylactogenic properties after being incubated for
some days at 40-45° C (104-113° F) or for a shorter
time at a higher temperature. Moreover, formol, in the
necessary concentration, at 80-100° C (176—212° F) acted
as an antiseptic.
Several workers had already reported the anti-anaphylactic
properties of formol. Kendall (cited by Re 1940) and others
had shown its inhibiting effect on uterine and intestinal
contractions with the Schultz-Dale technique.
The action of formol on amino-acids and proteins has long
been known, and Sörensen (1908), using the reaction described
by Schiff (1899, 1901)— l
R
Psychosomatic Medicine,
i |
|
CH.NH, + H.CHO=CH.N.CH, +H,0
‘OOH COOH
—was able to determine the amino-acids, reckoning on pH
deviation resulting from the neutralisation of the amino
groups. It is probably this reaction that is responsible for the
removal of the anaphylactogenic properties of the proteins,
although other substances—e.g., ketene (CH=C=0O)—which
react with the proteins and block the amino groups, destroy
the anaphylactogenic power of animal sera (Goldie and
Sandor 1937).
342 THE LANCET]
Likewise Zipf and Bartscher (cited by Otto et al.
1938) and Platonov (1940) believe that formol suppresses
anaphylaxis by neutralising the biogen amines, especially
histamine.
PREPARATION AND PROPERTIES OF CALF PLASMA
To the citrated bovine plasma separated by centrifuga-
tion—for large amounts I use a De Laval blood-separator
—formol is added until a concentration of 0:35% is
reached. Five minutes later, to correct the acid devia-
tion resulting from the neutralisation of the amino
groups, ammonia is added until a concentration of
0-01% is reached. To avoid further gelification, 0:9%
saline or 5% dextrose or doubly distilled water is added
until a concentration of proteins 3-7-4:0% is reached.
The plasma is then heated over steam and, when it
begins to boil at 100° C (212° F), is left to cool to 50° C
(122° F). It is filtered to get rid of little clots and small
fibrin particles and then put into glass ampoules and
tyndallised.
The plasma so treated undergoes slight discoloration
and acquires a certain opalescence when viewed against
a dark background.
This procedure causes a slight increase in the freezing-
point (from — 0:48 to —0-56° C) and an important
. Increase in the viscosity. No noteworthy variation is
found in the albumin-globulin ratio and in the non-
protein nitrogen.
- these apparently contradictory changes.
The plasma can be preserved indefinitely at ordinary
temperature ; already I have samples three years old.
It does not, agglutinate or hemolyse human red blood
corpuscles. I have never seen any toxic effects due to
an excess of formol, probably because part of it combines
with the proteins, part with ammonia, and part evapor-
ates on boiling.
The action of formol is the important factor in my
method; the heat is only a means to accelerate the
reaction and to ensure perfect sterilisation. The truth
of this seems to be supported by my above-mentioned
experience with the action of formol at 40-45° C and
by the fact,that in those cases in which the anaphylacto-
gens are destroyed by heat, as in the method of Lenggen-
hager (1940), new antigenic properties are acquired which
produce anaphylaxis in previously sensitised animals
according to Frimberger (cited by Lang and Schwiegk
1943).
The ammonia is not absolutely necessary; but, if
it is not added, the plasma becomes cloudy and its
injection is painful. Sodium hydroxide can be used
instead of ammonia.
The plasma must be free from hemoglobin, and
as far as possible from lipoids.
By this method the anaphylactogenic properties of
the calf plasma are destroyed by physicochemical means
whereby the antigens are altered without destroying the
physicochemical properties of the plasma.
Studies still unfinished suggest that the degree of destruc-
tion of the antigenic power varies according to the level of
temperature and the time the formol is acting. Thus at
80° C the formolated plasma changes its colour, as already
stated, but retains slight antigenic properties: when repeatedly
injected into a rabbit it induces a low titre of precipitins,
and it will kill a guineapig with an anaphylactic shock. On
the other hand, heated to 100° C, or better to 110° C, it will
no longer produce precipitins or anaphylaxis.
EXPERIMENTS
My experiments were done on 70 guineapigs, 40 rabbits,
and 2 dogs. I chose young males because Duran-
Reynals (1919), Lumiére (1933), and Moreira (1925)
have shown that pregnant females are resistant towards
experimental anaphylaxis.
In an attempt to sensitise the animals, preliminary
injections were given to the guineapigs subcutaneously
DR. “MASSONS: CALF PLASMA OR SERUM FOR TRANSFUSION
Studies are in progress to explain
[SEPT. 7, 1946
on three successive days or else on alternate days and the
test injection intraperitoneally on 10 guineapigs and
intracardially in the remaining 40. In the rabbits the
preliminary injections were given in the same way as
in the guineapigs in 10 cases, but in the remaining 20
I used Grove’s technique (Sanchez-Cuenca 1942):
first injection intravenous, second subcutaneous 4-5 days
later, and test injection intravenous 21 days after the
initial dose. i
To make sure that the prepared calf plasma (P.C.P.)
contained neither complete nor incomplete antigen I
carried out the following experiments.
In 40 guineapigs, 10 rabbits, and 2 dogs I gave peoa
injections of P.0o.P. followed by a test injection of P.c.P..
10 other guineapigs and 10 other rabbits I gave aa
injections of P.o.P. followed by a test injection of fresh plasma.
In neither of these sets of experiments was any anaphylaxis
observed. Therefore the P.c.P. contained no antigen.
I next gave 20 other guineapigs and 20 other rabbits
preliminary injections of fresh plasma, and in order to be sure
of their sensitisation state I produced in 2 animals a typical
anaphylactic shock by injecting them with fresh plasma.
The rest of the animals were treated with a test injection
of P.c.P.; no anaphylactic shock was observed.
In the next experiment I gave preliminary injections of
P.C.P. to 8 virgin doe guineapigs and perfused the uterus of
each. When pP.c.P. was added to the perfusing liquid, no
alteration of uterine contractions was observed; but, when
antigen was added, the uterus developed tetany.
My next step proved that P.o.p. 10-20 c.cm. injected intra-
aay in rabbits had no effect equivalent to that of protein
shock.
There followed the investigation of the supposed toxicity
of serum proteins by injecting rabbits and dogs, without any
harmful result, with quantities of P.c.P. equivalent to a trans-
fusion of 3-5 litres in an adult man weighing 65 kg. (about
143 Ib.).
To test how long P.c.P. remained in the circulation
I bled dogs and measured the blood-pressure (B.P.) and
the amount of hemoglobin, having first taken special
precautions to discount the contraction of liver and
spleen by which dogs (but not man) react to hemorrhage.
Obviously the injection of liquid into the circulation of
a dog with low B.P. will raise the B.P. and reduce the level
of hæmoglobin. Conversely, when such injected liquid
leaves the circulation, the B.P. will fall again and the
hemoglobin become more concentrated.
In contrast to an injection of saline, which produces
a merely temporary effect, an injection of P.c.P. main-
tained its effect for twelve hours in spite of long-
continued anesthesia and small repeated bleedings to
determine the amount of hemoglobin.
I was now ready to experiment on man. I began by
giving gradually increasing doses of P.c.P. intravenously
to 25 sick or convalescent typhus patients. The initial
dose was 10 c.cm., and subsequent doses were worked
up to 300 c.cm. In no case was there any pyrogenic
reaction or the slightest sign of intolerance. In a thousand
injections of 100-1000 c.cm., there was never any
suspicion of urticaria, which is the most constant sign
of serum sickness, appearing in 90% of patients sub-
mitted to large doses of serum given intravenously
(Sanchez-Cuenca 1942).
Further experiments led me to conclude that my
patients did not become sensitised to calf serum, a
matter of importance in obviating future allergy to
veal or beef as a food.
THERAPY WITH CALF PLASMA
P.C.P. is given intravenously, somewhat tepid, and
preferably slowly ; but there is no objection to giving it,
if necessary, in the same way as a blood-transfusion.
A few patients complained of transient pain in the vein
during the injection of the first 50 c.cm. or so. Apart
from that, the only thing to be feared is a rigor after
the injection (I had 30 cases in 1000 injections), but with
THE LANCET]
DR. COMERFORD, AND OTHERS : TYPHOID CARRIERS
[SEPT. 7, 1946 343
the improved technique which is being introduced even
that risk should disappear.
I treated these groups of cases :
l. Post-hemorrhagic anemia, shock from wounds or ileus—
i.o., cases of surgical urgency.
2. Hypoproteinemias—e. gZ., lipoid nephrosis, famine œdema,
hepatic cirrhosis.
3. Dehydrated infants, alimentary toxæmia, and wasting.
In about 200 cases of surgical urgency the results were
remarkably good, especially as a prophylactic against
shock. For hypoproteinæmia 8 cases of hepatic cirrhosis
have been treated with P.c.P. with results equal to those
obtained with human plasma. In the third group of
cases Professor Ramos and his co-workers have treated
100 cases of alimentary toxæmia and a few cases of
wasting with P.c.P. with excellent results.
k ADVANTAGES OF USING CALF PLASMA
The following are the chief advantages of using P.c.P.
as compared with human plasma :
(1) The preparation and storage are more sconpmnieal:
(2) The plasma can be stored for over a year without
deteriorating.
(3) There is no need for refrigeration or any other special
conditioning of the plasma.
(4) Ease of transport.
(5) P.c.P. can be stored in shops, or in regimental casualty
posts in war-time.
(6) No loss of time in grouping the blood of a wounded man.
(7) P.C.P. can be injected without any risk. Even in heart-
failure it can be given safely, provided that the rate of 2 g.
per kg. of body-weight per hour is not exceeded. The only
doubt may concern the content of sodium citrate used as an
anticoagulant ; but this danger has been exaggerated in the
past, and the greatest amount given in large doses of P. 0.P.
never exceeded 2 g.
(8) No specialist expert is required to give the transfusion.
Anybody who can give an intravenous injection can administer
P.C.P. . If intravenous injection is impracticable—e.g., in
obesity, peripheral vasoconstriction of shock, previous ampu-
tation, extensive burns, and in infants—the plasma can be
given by sternal puncture. The sternal marrow can easily
absorb large quantities of fluid. In infants the head of the
tibia can be used instead of the sternum. This plasma does
not harm bone-marrow. Thus, in a moribund infant it was
injected to test its effects, if any, on bone-marrow, and at the
autopsy a day later no alteration of the bone-marrow was
found at the site of injection.
(9) Its action most nearly approaches that of blood.
SUMMARY
A description is given of the preparation and properties
of calf plasma as a substitute for human plasma in
blood-transfusion.
Experiments are described which showed that calf
plasma so prepared contained no antigens, and that its
effect was not merely temporary like that of saline.
Prepared calf plasma has been used successfully in
the treatment of three types of case: haemorrhage and
shock, hypoproteinzmia, and dehydration.
I wish to thank Prof. F. Garcia-Valdecasas for his friendly
aid and helpful criticism during my research,
REFERENCES
Brodin, P., Saint-Girons, F. (1939) Bull. Soc. méd. Hôp. Paris,
55, :
Doladilhe, M. (1937) C.R. Acad. Sci., Paris, 204, 301.
Duran-Reynals, F. vem C.R. Soc. Biol. Paris, 82, 830.
Goldie, H., Sandor, G. (1937) Ibid, 126, ae
Kremen, A. J z all, , Koschnitzke, H . K., Stevens, B., Wangen-
, O. H. (1942) ‘Surgery, ii, 333.
Pan (1 039) ii, 792
Lang, K., Schwiegk, ve (1943) Wien. klin. Wschr. ii, 579.
Lenggenhager (1940) Zbl. Chir. 67, 1961.
Lumicre, A. (i988) Colloides et micelloides, Paris, p 367.
Moreira, M. d (1925) C.R. D Biol. Paris, 93, 513.
Otto R., Feliz, Sge Laibach, F. (1938) Chemie und Physiologie des
pi iweisses, Dresden, p 3,
Platonov (1940) Z. Mikrobiol. 119, 658.
Re, P. M. (1940) Acidos aminados, Buenos Aires.
Rosenau, M. J., ee J. F. (1906) Bull. Hyg. Lab. no. 29.
Sanchez-Cuenca, B. (1942) Anang zia y alergia, Madrid.
' Schiff, H. (1899 9) Ann. Chem. 310, 2: go hy, 319, 59 and 287.
Sörensen, S. P. L. (1908) Biochem. Z , 45.
TYPHOID CARRIERS
TREATED WITH PENICILLIN AND
SULPHATHIAZOLE
C. H. COMERFORD H. RICHMOND
M.D. Dubl., D.P.H., D.P.M. M.B. Birm.
DEPUTY MEDICAL ASSISTANT MEDICAL
SUPERINTENDENT OFFICER
BEXLEY L.C.C. HOSPITAL FOR NERVOUS AND MENTAL DISORDERS
W. W. KAY
M.B., M.Sc. Manc., F.R.I.C.
PATHOLOGIST, EPSOM PATHOLOGICAL LABORATORY, LONDON
COUNTY MENTAL HEALTH SERVICES
BIGGER,! in reporting his observations on the synergic
action of penicillin and sulphathiazole on Bact. typhosum
in vitro, made suggestions for treating typhoid fever
with these drugs.
In February, 1946, a patient in Bexley Hospital con-
tracted typhoid fever. Bact. typhosum, phage type D,,
was isolated from blood culture on the seventh day of
the disease. Sulphathiazole 1 g. four-hourly was ineffec-
tive. On the twenty-eighth day of the disease the patient’s
condition was critical; her temperature was 103-4° F
and her pulse-rate 110 per min. A limited amount of
penicillin was then available, and treatment with this
combined with sulphathiazole was begun. Sulphathiazole
1 g. orally, and about 16,000 units of penicillin intra-
muscularly, were given every four. hours, a total of
387,000 units of penicillin being given in four days. On-
the thirty-second day of the disease, when this treatment
ceased, the temperature had become normal, and
remained so except for rises to 99° F on three days.
The pulse-rate also fell. At no time was Bact. typhosum
isolated from the urine or feces. The impressive clinical
improvement coinciding with the administration of so
small an amount of penicillin decided us to try the full
doses suggested by Bigger, in the treatment of typhoid
carriers. An account is now given of the results obtained
in two well-established carriers, both of whom regularly
excreted Bact. typhosum, phage type D,, in their
fæces.
Dosage.—An initial dose of sulphathiazole 2 g. by
mouth was followed by 1 g. four-hourly. Penicillin, in
doses of approximately 500, 000 units dissolved in
10 c.cm. of sterile water, was given intramuscularly at.
the same time. Treatment continued for eight days in
the first case, and seven days in the second.
Bacteriological Investigations.—For a month before
treatment and ever since treatment, six samples of every
stool passed have been examined, usually one sample in
the Bexley laboratory and five at the Epsom Pathological
Laboratory. Direct plating was carried out on MacConkey
and Wilson and Blair plates, and portions of each sample
were passed through enrichment media, either brilliant
green in peptone water in three concentrations (1/145,000,
1/250,000, and 1/400,000) and _ tetrathionate broth
followed by plating on MacConkey, or selenite F followed
by plating on Wilson and Blair and desoxycholate
agar. Magnesium sulphate was given every second or |
third night to secure regular evacuations. Two samples
of a morning specimen of urine were examined by direct
plating, one in each laboratory.
Serological Investigations.—Agglutinations to typhoid
O and Vi were carried out before treatment and at
monthly intervals thereafter. `
CASE-RECORDS
CasE 1.—A woman, aged 50, admitted to Bexley Hospital
on May 17, 1932, had two prophylactic inoculations of T.A.B.
vaccine in December, 1940.
1. Bigger, J. W. Lancet, 1946, i, 81.
DR. COMERFORD AND OTHERS: TYPHOID CARRIERS
[SEPT. 7, 1946
TABLE I—TYPHOID-VI AGGLUTINATION TITRES -
344 THE LANCET] .
Case 1 (treatment ended April 23, 1946)
Date |
. 1/5 1/10 1/20 1/40 1/80
April4,1946...| ++2 | ++ | + | #& l-
May 2, ,, +++ +++ ++ + +
June 3, ,, t+ + + ++ + + -
July 4, ,, .. + + + - -
Aug. 8, ,, o + (+) - - oe
|
=æ, no agglutination.
In September, 1943, in the course of a survey for carriers,
her serum gave the following agglutinations (North-western
Group Laboratory, L.C.C.): Bact. typhosum H 1/320; Bact.
typhosum O 1/160; and Bact. typhosum Vi 1/40.
Typhoid bacilli were isolated from the fæces on four
occasions in September and October. Agglutination tests,
repeated in August, 1944,.gave the following results: Bact.
typhosum H 1/125; Bact. typhosum O 1/125; Bact. typhosum
Vi 1/2; and against her own organism 1/250. Bact. typhosum,
phage type D,, was isolated frequently in February, March,
April, and May, 1945. '
Cholecystectomy was performed in June, 1945, the patient
making a good recovery. Typhoid bacilli were grown from the
gall-bladder removed at operation, and after operation the
organism was again isolated from the fæces on six occasions in
June and July, with one negative result intervening.
During the month’s observation before treatment with
penicillin and sulphathiazole the patient ran an irregular
temperature ranging between 100° and 97° F. This subsided
- on the third day of treatment, since when the temperature
has remained normal. Typhoid bacilli were isolated from
the stools passed on thirteen occasions (March 18, 19, 20,
April 1, 2, 3, 4, 5, 8, 9, 11, 12, and 15), but not from
the five stools passed on March 21, 22, 25 (2 stools),
and April 10. Stools were not passed on the days not
mentioned. _ l
Treatment was started at 6 P.M. on April 15 and continued
for eight complete days, a total of 24,800,000 units of peni-
cillin and 49 g. of sulphathiazole being given. No local or
constitutional ill effects attended the treatment. After the
second day of treatment typhoid bacilli ceased to be isolated
from the stools, and for over 130 days bacteriological
examinations of both stools and urine for this organism have
been consistently negative.
CasE 2.—A woman, aged 69, admitted to Bexley Hospital
on transfer from Canterbury Mental Hospital in April, 1941,
had no history of typhoid infection or 1.4.B. inoculation,
but in April and May, 1945, she had a mild pyrexia for twenty-
eight days, which began seven days after being in contact
with case 1. In retrospect it now appears that this may have
been a mild attack of typhoid fever. On March 26, 1946,
on bacteriological examination of the fæces following a
serological survey, Bact. typhosum, phage type D,, was
isolated. l l
During the month’s observation before treatment Bact.
typhosum was isolated from the fæces passed òn twenty
occasions (March 31, April 1, 3, 4, 5, 9, 11, 12, 15, 16, 17,
18, 20, 23, 24, 25, 26, 27, 28, and 29). Stools were not passed
on the intervening days. Thus, every stool passed gave a
growth of Bact. typhosum. Bact. typhosum was not isolated
on any occasion from. the urine.
Treatment with penicillin and sulphathiazole was started
on April 29 and continued until the morning of the fifth day,
when sulphathiazole by mouth was stopped owing to persistent
vomiting and 1 g. of sulphapyridine was given intramus-
cularly for six successive doses. As the vomiting then ceased,
sulphathiazole was resumed orally without further ill effect.
A total of 21,420,000 units of penicillin, 36 g. of sulphathiazole,
and 6 g. of sulphapyridine were given.
Apart from the bout of vomiting, presumably due to
the sulphathiazole, the treatment had no constitutional ill
effect, nor was there any local irritation at the site of the
injections. Bact. typhosum was isolated from the fæces on
the second day of treatment, since when for over 116 days
intensive bacteriological examination of the morning
(+) +, +, +, ++, HH,
Case 2 (treatment ended May 6, 1946)
1/160 1/10 1/20 1/40 | 1/80 | 1/160
+++ | ++ | +2 | = |
+++ | tee | + | (+) -
+++ | ++ + - -
++ + - - -
+ + +, increasing degrees of agglutination.
urine and of every stool passed has failed to isolate the
organism. `;
Agglutination Reactions.—Neither patient showed an
fall in the agglutination titres for typhoid H and O, but
8—10 weeks after treatment both showed a definite reduc-
tion in typhoid-Vi agglutination titres and a further
reduction after another four weeks (see table 1).
DISCUSSION
It is noteworthy that, in both cases reported, Bact.
typhosum was not isolated from the feces after the
second day of treatment, with the same intensive bac-
teriological methods as gave positive results on almost
every stool before treatment. It seems reasonable to
infer that the synergic action of penicillin and sulpha-
thiazole has at least inhibited the growth of Bact. typhosum
in the alimentary tracts of both these patients, though
a much more extended period of observation is neces-
sary before a safe conclusion can be reached that their
carrier state has been cured. Case 1 continued to excrete
typhoid organisms after cholecystectomy, a not unusual
occurrence. |
The typhoid H and O agglutination titres after treat-
ment showed no reduction. A much longer interval,
‘however, is required before they can reasonably be
expected to show a diminution associated with the
disappearance of the typhoid organism from the body
of the patient. Nevertheless the reduction of the Vi
titre two months after treatment may be interpreted as
indicating that the activity of the organism has ceased
in these two patients.
In both cases the organism belonged to phage type
D,, a type not included in those investigated by Bigger.
TABLE APPEARANCE OF BROTH CULTURES OF Bact. typhosum,
PHAGE TYPE D,, AFTER 48 HOURS’ INCUBATION (STANDARD
INOCULUM) l
Penicillin Sulphathiazole
no. | (units per ml.) |(mg. per 100 mi.)| Case 1 Case 2
E ee a a r a E S ES
2 4 0 + +
3 2 0 + 4
i : 0 ++ ++
i : 0 ++ ++
6 8 10 aos
i g 10 (+) +
8 2 10 + a
9 1 | 10 + i
10 0 10 + +
11 0 5 + +
12 0 2°5 + +
73 0 1:25 $e ++
=, broth clear. (+), +, +, ++, + +, increasing degrees of
.. turbidity. Both tubes 6 remained clear after 96 hours’
incubation.
THE LANCET]
In the laboratory the organisms were tested for peni-
cilin and sulphathiazole sensitivity by the methods
described in Bigger’s paper, and the results are given
in table m.
It is evident, then, that our organisms of phage type
D, exhibit in-vitro sensitivity to sulphathiazole and
penicillin mixtures similar to those of Bigger’s series,
and it seems reasonable to infer that this sensitivity
is also found in the living patient in the two cases
investigated.
The bacteriological results obtained in these cases
raise the question of treating other bacillary infestations
of the alimentary tract by this method. Should the
synergic action of penicillin and sulphathiazole, or other
sulphonamide, be as effective in treating dysentery
carriers as it appears to be in typhoid carriers, the
problem of dysentery, in mental hospitals in particular,
should be brought much nearer to an adequate
solution.
Our experience with these patients shows that the
treatment can be carried out in relatively non-codperative
mental patients, even in those showing, as one of ours
did, much wasting besides profound mental deterioration.
SUMMARY
Two typhoid carriers, one of whom continued to
excrete Bact. typhosum after cholecystectomy, have
been treated with penicillin and sulphathiazole on the
lines suggested by Bigger ! for typhoid fever.
Intensive bacteriological examination of every stool
after treatment failed to reveal the presence of Bact.
typhosum in them for periods of over 130 days in the
one case, and over 116 in the other.
Two months after treatment both patients showed
reduced agglutination titres to typhoid-Vi antigen.
These results encourage the application of this method
of treatment in a larger number of typhoid carriers to
test its effectiveness.
We wish to thank Dr. R. Cruickshank for the early work
carried out at the North-western Group Laboratory ; Dr. A.
Felix for the phage typing; Prof. J. W. Bigger for much
helpful information; Surgeon Captain R. G. Henderson,
medical superintendent of the Southern Hospital, Dartford,
for supplying the penicillin; Dr. L. C. Cook, medical super-
intendent of Bexley Hospital, for his interest; and our
technical staffs, in particular Mr. C. R. Wright and Miss S.
Ball, for much painstaking coöperation.
PYRIDOXINE (VITAMIN B,) IN EPILEPSY
A CLINICAL TRIAL
GLADYS M. TULLIDGE
M.D. Lond., D.T.M. & H.
ASSISTANT MEDICAL OFFICER
J. TYLOR Fox
M.A., M.D. Camb., D.P.M.
MEDICAL SUPERINTENDENT
LINGFIELD EPILEPTIC COLONY, SURREY
Harriette Chick and her colleagues (1938) observed
that pigs deprived of pyridoxine (vitamin B,) developed
typical epileptic fits, and further (1940) that similar
fits occurred in rats which had been maintained for long
periods on a purified synthetic diet supplemented with
cod-liver oil, pure vitamin B,, riboflavine, and purified
yeast-filtrate factor. In either case the fits could be
prevented or stopped by the addition of pure pyridoxine
to the diet, and the authors concluded that they were
due to deprivation of this vitamin.
There seemed, therefore, to be some justification
for a clinical trial of pyridoxine in epilepsy. Eight
schoolboys, aged 14-15 years and living in the same home,
were selected: 2 of them had petit mal only; 2 had
petit mal with occasional grand mal; 2 petit mal with
more frequent grand mal; and 2 more numerous fits
of varying type. The cases were selected because of the
regularity of the fits, and previous anticonvulsant
DR. TYLOR FOX, DR. GLADYS TULLIDGE: PYRIDOXINE IN EPILEPSY
[SEPT. 7, 1946 345
medication, whether bromide, phenobarbitone, or
phenytoin, was continued throughout the experiment.
Our intention was to give one member of each pair
20 mg. of pyridoxine daily for eight weeks, and then the
second member of each pair a similar dose in the following
eight weeks. When, however, it became apparent that
there was no change in incidence of the fits, the daily
dose was increased to 100 mg. and the experiment
shortened. In the end, 4 boys had received 100 mg.
a day for three weeks, 2 had received 20 mg. a day for
four weeks and then 100 mg. a day for four weeks, and
2 only 20 mg. a day for eight weeks. There was no evi-
dence of increase or decrease of fits in any case, nor was
any other change, mental or physical, noted in any of
the boys. So far as this short series of cases is a guide,
it seems unlikely that pyridoxine, even in large doses,
would be of value in epilepsy.
We are grateful to Messrs. Vitamins Ltd. for supplying
us with large quantities of the vitamin, and to Dr. Audrey
Baker, of their research laboratory, for her coöperation and
suggestions.
-REFERENCES
Chick, H., Macrae, T. F., Martin, A. J. P., Martin, C. J. (1938)
Biochem. J. 32, 2207.
— El Sadr, M. "M., Worden, A. N. (1940), Ibid, 34, 595.
PRIMARY DIPHTHERIA OF THE
CONJUNCTIVA
REPORT OF TWO CASES
ARCHIBALD R. MILLER DorotHy E. BLOWER
M.D. Glasg., D.P.H. M.B. Lond.
DIVISIONAL MEDICAL OFFICER, GENERAL .
GLASGOW CORPORATION PRACTITIONER
Two cases of diphtheria affecting the eye only are
recorded here, not so much because of the rarity of the
condition (Medical Research Council 1930) as because
of the rarity of finding the disease being passed from one
person to another and affecting the same unusual site
in both.
Case 1.-—A girl, aged 3 years, sickened of what was at first
thought to be a cold, characterised by nasal discharge and
injection of the conjunctiva, When she was seen by the family
doctor four days later the nasal discharge still persisted,
and one eye was much inflamed, with very congested con-
junctiva, much swollen eyelids, especially the upper one,
and a profuse purulent discharge. The child did not appear
particularly ill apart from the loca] condition, and there was
no obvious toxicity.
At this stage she was referred to the outpatient department
of the Glasgow Eye Infirmary for advice, and there the tentative
diagnosis of a diphtheritic infection was made, a swab being
taken for bacteriological examination. This was subsequently
found to contain corynebacteria, and the child was admitted
to a fever hospital while further investigations of the organism
were undertaken. - These were eventually found to be
C. diphtheriae and to be virulent. Although a membrane was
reported as being present on the inner aspect of the upper
lid its presence was not demonstrated at the fever hospital.
The girl made an uneventful recovery, treatment consisting
of antidiphtheritic serum 4000 units and local applications
of ‘ Argyrol’ and saline. Repeated cultures from the nasal
discharge did not reveal any diphtheritic organisms.
Case 2.—Four days after the admission of case 1 her
brother, aged 5 years, developed a similar condition. The
mother, profiting by her previous experience, took him to
the doctor at once. The conjunctiva was congested, and the
lids were swollen, especially the upper one, but the discharge,
though copious, was watery and not purulent. There appeared
to be little or no general upset. There was no sign of any
discharge or infection elsewhere.
As a precaution, pending further investigation, 4000 units
of antidiphtheritic serum was given intramuscularly, and a
swab was taken from theeye. The boy was confined to bed.
Cultures from the swab revealed the presence of coryne-
bacteria. The patient’s local condition appeared now to be
improving and his general condition was good. As there
346
THE LANCET]
MR. IBRAHIM: PERITONEAL NODULES OF UNKNOWN ZTIOLOGY
[SEPT. 7, 1946
were no other children in the house, it was decided to keep
him at home. In due course the bacteriologist reported that
these organisms too were C. diphtherie and were virulent
on biological test. By. this time the eye had returned to
normal and the patient seemed well.
There seems to be little doubt that the second patient
was infected from his sister: There were no other
cases of diphtheria of any kind at that address,
and the patients did not attend any school or day-
nursery. There was remarkably little toxic absorption
from the conjunctiva. Neither child had any complica-
tions, and there was only a moderate rise in temperature.
In case 1 the temperature was 100-2° F on admission to
hospital and normal by the next day, and in case 2
no rise of temperature was found.
Harries and Mitman (1940) point out that the toxicity
of non-respiratory diphtheria, though variable, is
usually slight, and that diphtheria of the conjunctiva
may be followed by rapid destruction of the globe. .
No suggestion of this was seen in either of these cases,
but both were relatively quickly brought under treat-
ment. We have not been able to-find in the literature
any record of the disease spreading from one patient’s
eye to that of another. The Medical Research Council
(1923) reported that, though diphtheritic conjunctivitis
was formerly considered fairly common, most modern
writers agreed that conjunctivitis caused by true virulent
diphtheria bacilli was rare.
REFERENCES
Harries, E. H. R., Mitman, M. (1940) Clinical Practice in Infectious
Diseases, Edinburgh, p - 157.
Medical Research Counait *(1923) Diphtheria, London, p. 229;
(1930) A oo aking of pee eeHoloey in Relation to Medicine,
London, vol. v, p. 100. .
PERITONEAL NODULES OF UNKNOWN
a ÆTIOLOGY
Hassan IBRAHIM
M.B., M.Ch.
SURGICAL TUTOR, KASR EL AINI HOSPITAL, CAIRO
‘Mittary nodules of the peritoneum are sufficiently
rare to be worth recording.
A married woman, aged 29, with no children, had had
frequent attacks of tonsillitis up to the age of 8 years, once
complicated by quinsy. She had never had acute rheumatism,
chorea, or any other rheumatic manifestation. She had had
an attack of gastric pain accompanied by vomiting and
hematemesis, lasting twenty-four hours, at the age of 8 years,
and a similar but milder attack two years later. At the age
of 19 she had sciatica.
Two years ago she began to have epigastric pain, occasional
vomiting, constipation, and lassitude. She had periodic
exacerbations of the pain lasting 2—4 days, alternating with
periods of relative freedom. Continuous slight fever, ranging
from 99° F to 102° F, persisted throughout. The symptoms
were worse during the summer and tended to improve during
the winter. She had always been thin, and lost 8 kg. during
the illness.
Various conditions had been suspected and treated—e.g.,
gall-bladder disease, liver disease, renal colic, spastic colitis,
and appendicitis—but none hed been confirmed. In the
spring of 1943 she had two severe attacks of generalised
abdominal pain accompanied by high fever, up to 103° F,
and aching in the limbs.
On examination, the heart and lungs were normal. A
definite tenderness over McBurney’s point and over the whole
right iliac fossa led to a diagnosis of appendicitis and operation.
Operation.—The abdomen was opened through a low right
paramedian incision. The terminal coils of the ileum, especially
along its mesenteric attachment, were studded all over with
hundreds of white nodules, about 2 mm. in diameter. There
were also nodules on both aspects of the mesentery. The
condition stopped just short of the cæcum, which was normal.
The nodules were scattered singly and in bunches of 10 or
more, resembling collections of small pearls. Though sessile,
they were only slightly adherent to the intestine and could
steve
MG ang, Zi PEF Pe
: iy io Miss
ARA Se
Fig. I—Conglomerate mass of Sodales with vascdlkt fibrous tissue In
between. (Low power.)
easily be picked off with forceps leaving no bleeding points
behind. The parietal peritoneum appeared to be quite free
from nodules, and neither fluid nor congestion was present.
No other abnormality was found, and the stomach, duodenum,
gall-bladder, bile-ducts, and liver appeared normal. The
appendix was removed, and some of the nodules were taken
for biopsy.
Histological Hxamination.—The first sections showed con-
glomerate nodules of whorled fibrous tissue (fig. 1). One of
the larger nodules was fibrous, its centre consisting of hyaloid
fibroid tissue in concentric layers with empty fusiform spaces
between the fasciculi (fig. 2). The periphery of the nodule
consisted of fibrous tissue which was fairly vascular, some-
times hemorrhagic, and moderately cellular. A peripheral
round.-cell infiltration of chronic inflammatory type was also
seen (fig. 3). A single group of endothelioid cells, similar to
an Aschoff body, was present in the outer cortex of one
nodule, embedded in vascular fibrous tissue (fig. 4) and closely
‘related to blood-vessels. Smaller fibrous nodules were lying
close together, with delicate cellular fibrous tissue between
Fig. 2—Section of nodule, showing hyalold fibrous tissue In onean
layers near the centre, whereas the periphery is more cellular.
(Low power.)
dule, showing the more cellular fibrous tissue,
(High power.)
thera. The nodules were covered with a single layer of flat
serosa cells. Careful search failed to reveal any bilharzia ova
or remnants of ova in any of the many sections examined.
As a whole, the histological appearance suggested a chronic
non-pyogenic inflammatory condition.
DISCUSSION
Only scanty references to nodular lesions of the
peritoneum have been published. Haythorn (1933)
classifies nodular lesions of the peritoneum as:
(1) Tuberculous.
(2) Pseudotuberculous (due to various bacilli),
(3) Syphilitic.
(4) Due to fungus infections. :
(5) Foreign-body granulomas due to (a) animal parasites, such
as bilharzia, Entameba histolytica, or Oxyuris vermicu-
laris ; (b) extravasated blood ; (c) gelatinous substances,
including ruptured pseudomucinous cysts and extraneous
. substances ; (d) oils and free fats; (e) extruded gastric
and intestinal contents; (f) extraneous foreign bodies,
such as sutures, &c.
(6) Neoplasms, such as carcinoma, sarcoma, melanosarcoma,
Hodgkin’s disease, &c.
Fig. 5—-Section of bilharzial subperitoneal nodule of appendix, for
comparison, showing four bilharzia ova in the centre surrounded
by severai layers of endothelioid cells and a peripheral lymphocytic
and fibroblastic reaction.
MR. IBRAHIM: PERITONEAL NODULES OF UNKNOWN ÆTIOLOGY
(sirt 7, 1946 347
High power.)
Except bilharziasis, none of these conditions resembles
the present findings, either macroscopically or micro-
scopically. Even bilharziasis can probably be excluded.
Bilharzial nodules are usually firmly adherent and resist
stripping when picked up with the forceps. They affect
the large intestine rather than the small, and are accom-
panied by signs of bilharzial infection of the mucosa.
Bilharzial dysentery, with diarrhea, tenesmus, the
passage of blood and mucus, and with ova in the stools,
is usual in such cases, All these features were absent in
the present case.
The strongest evidence against bilharziasis is the fact
that no trace of ova or remnants of ova were found in
any of the serial sections examined. Remnants of ova
—i.e., the chitinous capsule and spine—are very persis-
tent and are always found in bilharzial lesions, however
old they may be (fig. 5). The Aschoff bodies found in
this case have never been seen in bilharzial conditions.
Bilharziasis is only accompanied by fever for a short
time after the initial stage of infection and never causes
continuous fever lasting for years. Careful inquiry failed
to reveal any exposure to bilharzial infection in this case.
The similarity of thes lesions to Aschofi’s nodules
suggested the possibility of a rheumatic etiology.
Rheumatic peritonitis has often been described, usually
in association with arthritis and carditis, and the subject
has recently been discussed by Berger (1945). In the
present case the absence of all other rheumatic manifes-
tations, the fact that the lesions were limited to the
peritoneum, and the doubtful interpretation of the
histological findings, do not justify the condition being
definitely designated as rheumatic.
SUMMARY
In a woman of 29 years with recurrent abdominal
pain and fever for two years operation revealed an
unusual miliary nodular condition of the peritoneum
especially over the terminal ileum.
The nodules consisted of whorls of fibrous tissue, and
some contained collections of endothelioid cells resembling
Aschoff bodies. No bilharzia ova were found.
The findings pointed to a chronic non-pyogenic
inflammatory condition, but no cause could be deter-
mined, |
I am indebted to Dr. M. Sorour, professor of pathology in
the Fouad lst University of Cairo, for his full report on the
histological sections ; Major G. D. Morgan, R.4.M.0©., for similar
assistance ; and Brigadier Evan Bedford for his guidance
in reporting the case.
REFERENCES
Berger, H. (1945) Ann. intern. Med. 22, 97.
Haythorn, S. R. (1933) Amer. J. Path. 9, 725.
348 THE LANCET]
REVIEWS OF BOOKS—NEW INVENTIONS
[SEPT. 7, 1946
Reviews of Books
A Textbook of Forensic Pharmacy
THOMAS DEWAR, PH.D., B.PHARM. Lond., PH.C., barrister-
at-law, examiner to the Pharmaceutical Society of Great
Britain. London: Edward Arnold. Pp. 253. 10s. 6d.
Suc# a book as this has for long been urgently needed,
for no-one could pretend that the laws controlling the
preparation, sale, and use of poisons are concise or readily
accessible. Yet the pharmaceutical chemist, the toxi-
cologist, and the barrister all need more detail than can
be obtained from the textbooks of forensic medicine or
pharmacy. In this book every conceivable detail has
been handled by an expert who knows its significance
in practice, and the text defies criticism in this respect.
The dullness which is inevitable in any long statement of
the law is leavened by such charming quotations as
these :
Here phials in nice discipline are set,
There galleypots are rang’d in alphabet,
In this place, magazines of pills you spy ;
In that, like forage, herbs in bundles lie.
GARTH, The Dispensary, Canto 1.
Don’t rely too much on labels,
For too often they are fables.
SPURGEON, Salt Cellars.
Extensive footnote references to law and free use of
practical examples make this a real yet easily handled
compendium of reference. Its field embraces the forensic
aspects of such widely diverse subjects as pure pharmacy,
institutional dispensing, the Shop Acts, the Food and
Drugs Act, and the Venereal Disease Act. Though
intended primarily for the pharmaceutical student, the
book is certain to have a wide circulation in both medical
and legal circles.
e
The Physiological Basis of Medical Practice
(4th ed.) C. H. BEST, C.B.E., M.D., D.SC., F.R.S.; N. B.
TAYLOR, M.D., University of Toronto. London: Bailliére.
Pp. 1169. 55s.
Tan doctor—whether houseman, practitioner, con-
sultant, or teacher—as well as the student, will continue
to be attracted by this magnificent work. Best and
Taylor has become a classic, providing a link between
the laboratory and the wards. The authors animate the
relatively dry bones of preclinical studies by emphasising .
their practical application to future clinical work; they
bridge the gap when the student enters the wards; and
for the houseman too, acutely aware of his lack of under-
standing, they explain the disorders of function which
are perplexing him. Even the teacher at the bedside
will find here a better way of giving the answer to many
an anticipated question, and the sections on morbid
physiology offer the basis for much intelligent research.
Clinically the book is accurate and up to date and
conforms to modern teaching. The extensive biblio-
graphy and the references are conveniently grouped under >
chapter headings at the end of the book. This edition
appears in new form: double columns are said not
only to save space but to make easier reading; but this
seems doubtful.
A Complete Outline of Fractures, including Fractures
of the Skull |
(2nd ed.) J..Grant Bonnin, M.B. Melb., F.r.c.s., late
first assistant to the Injury Clinic, West London Hos-
pital; recently surgeon in charge, fracture “ A ” centre,
E.M.S.; major R.A.M.c. London: W. Heinemann.
Pp. 658. 30s.
UNDER this promising title, Mr. Bonnin has really
written a comprehensive textbook of fracture surgery.
Almost 200 pages are given to general considerations,
and the remainder to descriptions of the fractures of the
various bones, including a brief but satisfactory chapter
on those of the face and jaw by Mr. J. H. Barron.
Writing primarily for students, Mr. Bonnin has selected
carefully the material needing specially detailed descrip-
tion, and so has been able—in his chapters on ankle
fractures, for instance—to expand and elaborate many
of the principles applicable to fractures in general.
Simple and complex methods of treatment are detailed,
and no examiner could cavil at the methods recom-
mended. Moreover, by indicating and giving the reasons
for his preferred methods, the author setsa personal
stamp on his work: the book is no ‘“‘ rehash ” of more
extensive works on the subject. He says in his intro-
duction that he writes with memories of the inadequacy
of his student textbooks. This book is certainly not
inadequate: in an age of dehydrated textbooks his full
description is refreshing, and the reasonable student will
not grudge the few extra hours its reading entails.
Dr. J. Ross Mackenzie’s little handbook, Practical
Anesthetics (2nd ed., Bailliére, Pp. 172, 10s. 6d.), for
students and hospital residents, has been revised through-
out. As in the first edition, teaching is primarily given in
the fundamentals of practical anzsthesia. Many matters of
no direct practical interest to the beginner are reviewed,
but junior anesthetists will find the book useful.
er a
New Inventions
‘SIMPLE APPARATUS FOR MICRO-SUBLIMATION
THE apparatus here described was introduced by us
in the chemical investigation of cases of toxsemia.
Developments of micro-chemistry, in which the unit is
a millionth of a gramme, suggested that it might be
possible to identify some of the toxins which are present
in such minute quantities that they have defied analysis.
Many such substances are adsorbed by fine activated
charcoal, and if this is given by the mouth and subse-
quently recovered the substances can be extracted from
the charcoal. But included with the toxins are various
alkaloidal and resinous substances, which the patient
may have taken medicinally. It is in the separation of
these fractions that this apparatus is so useful.
In general the micro-oven follows the form of the
apparatus of Kempf. It consists of a brass block (see
figure), which was a model engine casting. Two tubes
of copper were turned to a driving fit, and driven into
the cylinder cavities. At the suggestion of my assistant,
Mr. W. G. King, one tube was made to project three inches,
and was tapered in the part outside the brass block. This
part of the tube was marked off at half-inch intervals.
A thermometer is fitted in the second bore-hole. The
block was heated on an asbestos mat over a gas flame.
A graph was made showing the temperature at each
mark corresponding to standard temperatures of the
block—say 200°, 250°, and 300° C. The temperature
will decline from the block to the end of the long tube,
so that different parts of the tube will be at different
temperatures. The graph was made on half-inch paper,
and thus the graph corresponded to the three inches of
the tube.
A mixture to be separated is placed in a glass tube,
closed at one end, and this is inserted into the graduated
copper tube, so that the closed end of the glass tube is
at the middle of the block, and it is marked at the exit.
On heating, sublirnation will occur at intervals along the
glass tube; and by laying the tube on the graph the
approximate sublimation temperature can be found.
The fractions can then be separated by the scratch ‘and
hot wire method. A scratch is made on the glass tube
and the fracture is led round the tube by applying a hot
bent-iron wire. Each fraction, so cut off, is then examined
separately.
©. LOVELL, M.C., M.D. Lond.
Bethlem Royal Hospital.
THE LANCET]
THE LANCET
LONDON : SATURDAY, SEPT, 7, 1946
Medicine, Population, and Food
In the past, populations have been held in check
by disease, famine, and war, and to a lesser extent
by contraception and infanticide. Of these factors
disease has probably been the most important.
Pestilences, such as the plague of Justinian (of which
Procoptius ! has left so accurate a record), the Black
Death, cholera, and influenza have slain their millions ;
and of even greater importance have been the ever-
present diseases, such as pneumonia, gonorrhcea, and
malaria. There is evidence that the decline and fall
of Greece and Rome were accelerated, even if they
were not initiated, by malaria: the sequence of events
is familiar to everyone who has lived in the tropics—
deforestation by man and his goats, soil erosion,
swampy valleys, and mosquito breeding. Today, in
Africa, India, and the Far East, malaria rivals and
possibly outstrips malnutrition as a cause of mortality
among young children; while in adults it lowers
resistance to other infections: an estimate on the
conservative side suggests that every year at least
5 million persons are killed by the various species of
plasmodium. Pneumonia, too, is an important cause
of death among primitive peoples and especially
among negroes in Africa: it appears in epidemic
form almost every year, with the advent of the cooler
weather. Gonorrhea, by causing sterility in both
sexes, has been one of the primary causes of a low
birth-rate. Even in war, despite the growing deadli-
ness of offensive weapons and the increasing effective-
ness of preventive measures, deaths from disease have
always exceeded those from enemy action, while the
results of disease far outlast those of bullet and bomb.
Germany and the whole world are still suffering,
as ALDOUS HuxLEy? has pointed out, from the
disease and devastation wrought by the Thirty Years
War (1618-48). Only the atom bomb seems com-
parable in its lethal effects to that of pathogenic
parasites.
If we wish, we can now do much to decrease the
infections which have hindered increase of population.
For the first time in the world’s history we possess
remedies capable of reducing malaria, pneumonia,
and gonorrhea. In ‘ Paludrine,’ it is said, we have at
last a true causal prophylactic for both malignant
and benign tertian malaria, as well as a curative
agent in advance of any previously known: it
is cheap, easy to make in large quantities, and of
very low toxicity, and to the feminine half' of the '
world it offers the huge advantage of leaving the
complexion unaffected. , By means of penicillin and
the sulphonamides we can now reduce the death-rate
from pneumonia and can go far to prevent sterility
from gonorrhea. Even some of the most primitive
races are already asking for large supplies of
these remedies as a panacea, while the sulphon-
amides have become so popular in West Africa that
1. Procopius (A.D. 449-565). Historiae (ed. Dindorff 1833-38).
2. Huxley. A. Grav Eminence, London, 1941.
MEDICINE, POPULATION,
AND FOOD [SEPT. 7, 1946 349
a profitable trade has developed in substitute tablets
made from such unpromising materials as chalk,
clay, or plaster-of-paris. Penicillin has the additional
advantage that it is (in proper dosage) effective against
syphilis, yaws, and tropical ulcer; and even localised
causes of mortality, like typhus and trypanosomiasis,
can now be controlled, either by chemotherapy or
by using the newer insecticides. We still lack effective
remedies against virus diseases and tuberculosis, but
the progress of the last ten years encourages hope
for the next ten.
There remains, in the form of malnutrition, one
check to human life which could be even more deadly
in the future than it has been in the past. Before the
war we were already all too familiar in western
civilisation with the huge sprawling city which, in
the words of Lewis MUMFORD,’ had ceased to be
a metropolis and had become a megalopolis and a
parasitopolis: but most of us were less well aware
that in parts of China, India, and Africa population
was also, as in Europe, far in excess of indigenous
food. Though local famines were sometimes reported,
less was heard about the fact that even before the
war 90%, of people in the tropics were living on a diet
which, though it might be adequate in calories for
most of the year, was almost always deficient in
proteins and vitamins of the B complex, while for
some months, during what was euphemistically called
“the hungry season,” it was deficient in everything.
Over 1000 million people were getting, on the average,
less than 2250 calories daily.4 Today, nobody in
these islands is likely ‘to forget that the shadow of
a hungry season has spread from the tropics to the
whole of the old world. If all the peoples of the world
are to be properly fed, and if we add annually to
their number all those who would previously have
died from malaria, pneumonia, typhus, or trypano-
somiasis, and all those who would never have been
born if their parents had still been suffering from
gonorrheea or malnutrition, we shall need tremendous
increases in the production and transport of essential
foodstuffs. Such changes can be ensured only by
a world authority empowered, if need be, to adjust
national interests to international needs. Meanwhile,
would it not be well for working parties, each con-
sisting of a doctor, an agriculturist, a food techno-
logist, a nutritionist, and a welfare worker, to visit
not only the West Indies (as proposed by PLATT 5)
but every region in the world to report precisely
on the prevailing conditions? Even on the most
casual survey it is obvious that there are many
areas where new and useful crops might be cultivated
if only local governments and their agricultural
departments could be stimulated to turn official
memoranda into positive action. Similarly the example
of the “food-yeast” factory, established for the
benefit of the Caribbean zone, might be copied else-
where. The whole question, in fact, of the synthesis
of vitamins and essential amino-acids by laboratory
,methods on a manufacturing scale demands immediate
attention.
Sir JOHN ORR’s report to the conference which
opened at Copenhagen on Sept. 2 proposes the
establishment of a World Food Board. In the task
3. Mumford, L. City Development, London, 1946.
4. See Times, August 21, p. 2.
5. Platt, B. S. Report on Nutrition in the aah West Indies.
Colonial no. 195. H.M. Stationery Office. 194
K3
350 THE LANCET] -
of feeding people better, the limiting factor at present
is, he believes, not the physical capacity to produce
enough food but the ability of nations to bring about
the complex economic adjustments necessary to
make adequate production and distribution possible. 4
To this the board would devote its efforts; and,
given enough good will, the results might prove
astonishing within our lifetime.
Activation of Skin Grafts
MoDERN plastic surgery has firmly upheld
THIERSCH’s dictum that a skin graft takes better on
an active or “excited ’’ raw area than on one freshly
prepared from normal quiescent tissue. Freshly cut
tissue normally has to pass through a latent period
of several days before proliferation becomes really
active, and this latent period is eliminated when grafts
are transplanted to (for example) healthy granula-
tions. ‘‘ When a surgeon takes up his knife to cut
into normal tissues,” says Peyron Rouvus,! “ every-
thing has been prepared for operation except the
structures immediately concerned.” If graft beds
are the better for being in an active state, is it not
likely that the grafts themselves would benefit by
activation ?
- Rovs has investigated this problem. Clipped rabbits’
skin was painted with a mixture of turpentine and
acetone to induce epidermal proliferation ; and after
a few days the epidermis, normally one or two cell-
layers deep, had thickened five- or six-fold and was
vigorously dividing: Grafts so activated were com-
pared with those cut from normal quiescent skin,
by grafting both simultaneously in patchwork arrange-
ment to rather poorly vascular beds freshly cut down
to the deep corium of the skin in the lumbar region.
Histological analysis revealed the following credit
and debit accounts. Activated grafts are easier to cut
and handle and are less inclined to fold and contract.
When they heal, they do so more rapidly and securely
, than normal skin ; the donor areas are more quickly
resurfaced and, if need be, yield more promptly a
- second crop of grafts. But there are grave dis-
advantages. The demands of hyperplastic skin for
nourishment are naturally greater than those of normal
quiescent skin, and a number of hyperplastic grafts
promptly die when transplanted to poorly vascular
beds, while their normal neighbours quietly “ sit out
time.” Sometimes the hyperplasia itself is trouble-
some, since the deep follicle epithelium of an activated
graft sometimes creeps between graft and bed and
begins to infiltrate the underlying tissue.
Rovs’s observation of the necrosis of activated
grafts on poorly vascular beds is interesting in the
light of MEDAWAR’s guess ? that a really thick graft
should be deliberately deactivated, in order to lower
its metabolic demands during the critical stage of
vascularisation. The deactivation is simply a matter
of allowing the graft surface to remain at room tem-
perature instead of at body temperature, as when
thick gauze or cotton-wool pads are put over it to
maintain pressure. In plastic surgery uses may be
found for both activation and deactivation. The
former might fill the bill for pinch grafts transplanted
to highly active granulations, for pinch grafts are
J. exp. Med. 1946, 83, 383.
1. Rous, P.
Brit. med. Bull, 1945, 3, 79.
2. Medawar, P. B.
ACTIVATION OF SKIN GRAFTS—HOW TO VACCINATE
[SEPT. 7, 1946
never used unless speedy epithelial spread is needed.
Deactivation might be the rule when full thickness
grafts are to be transplanted to poorly vascular,
freshly cut, beds—for example, on the back of the
hand. But for the ordinary run of skin-grafting
there can be no question of adopting either activation
or deactivation as a routine.
How to Vaccinate
INFANT vaccination against smallpox will soon
become voluntary, and opinions are divided about
the probable result of this change. Some think
that the vaccination of about a third of the popula-
tion during the first year of life, achieved under the
existing laws, will be maintained or even increased
when medical services are extended under the new
Bill. Others hold that hardly any infants will be
vaccinated when compulsion is’ removed. Much
will depend on the approach to the parents. Officially
sponsored health education has already had consider-
able success with immunisation against diphtheria ;
but the case for vaccinating infants against small-
pox, though a good one, will be harder to present
attractively through the poster, the press, and the
cinema. Probably the family doctor will have to do
most of the persuasion.
The chief bugbears of vaccination are the bad arm
and postvaccinal encephalomyelitis, The latter, a
rare complication, seems very rare indeed when
primary vaccination is not performed at school-age
or during adolescence—a fact which forms a sub-
stantial though somewhat awkward argument in
favour of vaccination during infancy. The bad arm
is a different and in some ways more important
matter. A severe local reaction, with or without a _
mild general reaction, is fairly common, especially
in adults, and though its consequences are rarely
serious it can cause a good deal of pain and tem-
porary disability. Much parental opposition to
infant vaccination probably comes from a personal
experience of this sort, perhaps after joining the
Forces.
There is some reason to believe that the technique
of vaccination can influence the incidence and severity
of local reactions. In this country a single insertion,
through a scratch not more than a quarter of an inch
long, has been recommended 1 to public vaccinators
since 1930 for ordinary civilian vaccination ; and the
Service departments have mostly followed suit.
In the United States another. method known as
“multiple pressure” has been officially recom-
mended ? for over twenty years. In this method the
skin over an area about an eighth of an inch in diameter
is subjected merely to a number of “ pressures ” with
a horizontally held needle, and there is no scratch
nor even pricking of the skin as in another method
described by PEtRcE? in 1937. Intracutaneous or
subcutaneous injection of ordinary vaccine lymph
has never been advocated, but these methods of
insertion have been tried with bacteria-free suspensions
of vaccinia virus obtained by egg culture and other
means. When HENDERSON and McCLEaN ‘ inoculated
a suspension of the elementary bodies of vaccinia
1. Statutory Rules and Orders 1930, no. 2, p. 16.
2. Leake, J. P. Publ. Hlth Rep., Wash. 1927. 42, 221.
3. Peirce, E. R. Brit. med. J. 1937, i, 1066,
4. Henderson, R. G., McClean, D. J. Hyg., Camb. 1939, 39, 689.
THE LANOET]
subcutaneously and intradermally, using hollow
needles, they reached the interesting conclusion that
immunity to vaccinia resulted only when there was
a. local reaction which included the formation of a
vesicle, the latter being due presumably to back
leakage of the inoculum along the needle track.
Very little has been recorded in this country about
vaccination by multiple pressure or intracutaneous
prick, although both these methods are older than the
scratch technique, and one of them was probably
used by JENNER. Most of the published papers deal
with the vaccination or revaccination of adults, and
as regards infant vaccination there is but little in
print about any of the techniques. DupLEY ë found
that substitution of multiple pressure for the scratch
method reduced sickness and disability due to vaccina-
tion and revaccination among the adolescent entrants
to a naval school. PARISH, however, noted that when
it was used for the primary vaccination of a group of
adults nearly a quarter of them had severe local
reactions. It has been stated? that the results of
revaccination by intracutaneous prick are easier to
read because local reaction due to trauma does not
obscure the so-called immune and vaccinoid types of
response. Another advantage attributed to vaccina-
tion by prick or pressure instead of by scratch is that
no dressing is required ; . but this has not been the
experience of at least one observer.§
It is by no means certain that trauma of the skin
during insertion is the only cause, or indeed the chief
cause, of severe local reactions. Although the bacterial
content of vaccine lymph can be reduced to a low
level by proper methods of manufacture, it remains
a more or Jess unknown factor in any given vaccina-
tion; moreover observations with purified prepara-
tions of vaccinia virus suggest that local reactions still
occur when bacteria are absent. Other factors of
undetermined importance in this respect are the
concentration of virus in the lymph and the immunity
response of the individual. Touching on this there are
the remarks of CRAIGIE as quoted by TULLOCH’?
in 1934: “the magnitude and endurance of the
immunity response is primarily a question of the
individual and his capacity to respond—not of
vaccination technique. The amount of seed and the
area of skin involved would seeni to be of minor
importance as regards immunity, so that nothing is
to be gained by making either too great. If they
are reduced to a minimum the developing immunity
will be better able to overtake the proliferating virus,
thus minimising reaction and the risk of sequelz.”
This implies that minimal trauma during insertion |
may shorten the duration of the reaction and thus
lessen its severity.
It would be well worth making some practical
comparative studies of the three main methods of
vaccination—dermal scratch, multiple pressure, and
intracutaneous prick—on a scale big enough to give
the results ‘statistical significance. Teachers of
vaccination at the medical schools might be able to
undertake such studies in connexion with the vaccina-
tion of-infants. For an investigation of the vaccina-
tion .and revaccination of adults Service medical
dopar maon would be better placed.
Dudley, S.. F., May, P.M. P TIYO., ane 1932, 32, 25.
3 Parish, H J Brit. med.
: 19:
Tulloch, W.J, J, State itd 1934, "42, 683.
STANDARDS AND STAMPEDES
[SEPT. 7, 1946 351
Standards and Stampedes
THE victims of the housing shortage have reached
the stage of exasperation. Squatters are moving into
military camps in many parts of the country and taking
joyful possession. It will be hard for the authorities
to sort out those deserving priority, but the movement
as a whole must command sympathy and under- |
standing, in spite of the obvious embarrassments it
creates. There is one risk, however, which needs to
be watched with great care: that the shortage will
lead to a lowering of accepted standards in housing,
especially standards of amenity and hygiene. To
meet emergency conditions minimum sanitation may
do well enough for a time, but it is fatally easy to
slide downwards, by allowing the temporary to become
permanent and even to be slipshod about permanent
building. The London County Council have set
themselves high standards of amenity in the homes
they propose to build. They have determined to keep
abreast with modern developments in construction
and fittings. Other areas would do well to follow this
lead.
The question of accommodation is more serious
and difficult. Both the Dudley Report and the
Housing Manual of the Ministry of Health, while
urging local authorities to study the actual needs of
families in their areas, recommend that, for the time
being at least, they should continue to provide three-
bedroom houses as their main programme. Some
doubt has been cast on the wisdom of this policy.
Thus in the Times a correspondent asks, “Do we
want tens of thousands of three-bedroomed houses ?
A three-bedroomed house is too big for a newly
married couple ;”’ and he goes on to speak of the
“amount of waste space that is being built with
our hard-pressed building resources.” If we leave
aside the special requirements of single persons and
the aged, we can concentrate attention on the family.
It is estimated that about 80% of families have
no more than two children, and the “average ”’
three-child family is represented by about . 10%.
On the face of it the Times correspondent seems right
In saying that “ continued overproduction of standard-
sized houses is wasteful of resources,’ but he is on
less solid ground in adding that “ this must seriously
retard the economic possibilities of any increase in
the child population.” The suggestion that the
child population might be increased by reducing
the number of bedrooms in the family house might
be true, if family limitation were merely a matter
of economics, but it is possible that other factors,
including lack of bedrooms, act as a more direct brake
on size of family. At any rate houses with only one
or two bedrooms offer no encouragement to young
married couples to be fruitful and multiply. |
The story is not so simple as this. Indeed, it is
doubtful whether the talk about waste space is well
founded. Between 1919 and 1934 some 42% of the
houses built were within the range of workers’
incomes; a further 40% might, at some sacrifice,
have been bought by the better off artisans ; and
the remainder were beyond their reach. Between
1934 and 1939 only 41% of the houses built (apart
from slum clearance) were genuine working-class
houses. In other words, a great host of three-bed-
roomed houses built between the wars were not for
352 THE LANCET]
the workers, but for comparatively well-to-do families.
Further, just before the outbreak of the late war at
least 225,000 houses were needed to complete out-
standing slum-clearance schemes, quite apart from
the vastly greater number of substandard houses
which were sliding into slumhood in 1939. Nearly
300,000 houses were required to deal with over-
crowding schemes at the exceedingly low standard
set up for this purpose. About 150,000 houses were
damaged beyond repair by enemy action. At least
another 300,000 are needed to provide for the increase
in the number of families since 1939. Miss MARIAN
Bow Ley, PH.D.,! whose illuminating researches have
produced a wealth of figures on the housing
situation, estimates in addition that nearly
four million workers’ houses. built before the
1914-18 war are so far below the lean standard of
the three-bedroom, non-parlour house built by local
authorities between the wars that they. require
replacement.
All the available evidence points to the conclusion
that there is a great dearth of three-bedroom houses
within the income range of working people, but this
does not of itself prove that three-bedroom homes
are desirable for the majority of families. We are
confronted here with questions of opinion. In the
Housing Manual of 1944 the Ministry of Health
recommend the provision of three bedrooms of the
following dimensions : ‘first, 135-150 sq. ft.; second,
110-120; and third, 70-80. It is true that the young
married couple do not require two and a half bedrooms
until they have a child; but it is good for them to be
able to contemplate the possibility of having a child
without worrying about the accommodation, even for
the confinement. People who are aghast at the
thought of three bedrooms for working folk seem to
have no idea how small the space really is, or what a
blessing the little third room is for a variety of domestic
purposes. They forget that such families may want
visitors ; that, like the rest of us, they often have to
provide ‘for aged relatives; and that there is some-
times sickness in the family. If we really mean to
pursue a population policy, we ought to encourage
families to have children. It is mere humbug to
pretend that they will get larger houses when they
have three children. In matters of this kind the
_ stimulus should come before the event, and not as
a lollipop promised for good conduct. In building
houses to last sixty years we have no right to assume
that the downward trend in family size will continue ;
even if it were to do so, the present area of a three-
bedroomed house is nothing to be alarmed about—
800-900 sq. ft.! As Mumrorp? says: “It is a
false solution to build a dwelling so small that the
psychological harmony of family life is sacrificed
to economy of space.”
1. Bowley, M. Housing and the State, London, 1945.
2. Mumford, L. The Culture of Cities, London, 1938.
THE INDEX and title-page to Vol. I, 1946, which was
completed with THE LANCET of June 29, is published
with our present issue. A copy will be sent gratis
to subscribers on receipt of a postcard addressed to
the Manager of THE LANCET, 7, Adam Street, Adelphi,
W.C.2. Subscribers who have not already indicated
their desire to receive indexes regularly as published
should do so now.
HYBRID VIGOUR IN SWEET CORN
[SEPT. 7, 1946
Annotations
AN INTERNATIONAL GATHERING
Tus year’s conferences, after the lapse since 1939,
have all the savour of long-deferred family reunions.
The international meeting under the chairmanship of
Sir Hugh Lett, which, as announced in our news columns,
is to be held towards the end of this month in London,
will be attended with peculiar zest; for it is to be a
world-wide gathering. Invitations have been sent to
organisations in 42 nations, and the majority have
already accepted. The principal business will be con-
sideration of means to promote international liaison in
medicine. This has hitherto been the aim of the Associa- |
tion Professionnelle Internationale des Médecins; but
the A.P.I.M. has been concerned solely with professional
and social medicine. The time has come for a wider
range of international codperation.
It is especially to be hoped that the new organisation
foreshadowed in the agenda will sponsor an improved
exchange of information, particularly on medical research.
Rumour has it that several of the world’s leading
nuclear physicists are actively discouraging young men
of promise from pursuing their specialty because they
believe that the free exchange of information essential
to progress in this field will never be resumed. No similar
embargo threatens medicine ; but some of its branches
are rapidly becoming almost equally complex, demanding,
no less than nuclear physics, the benefit of world-wide
consultation. It is true that the main course of research
in other countries is known to most in the top flight of
their specialties; it is true also that the results of
research are more or less easily available to all countries,
through the medium of the Quarterly Cumulative Index
Medicus, published in the United States. But to
announce results is not enough: the time for the sharing
of information is before research is initiated. Many
forms of investigation must be planned and integrated |
globally if overlapping and needless reduplication are to
be reduced and if each country’s facilities and aptitudes
are to be used to the best advantage.
HYBRID VIGOUR IN SWEET CORN
In Britain the word “f corn” denotes all kinds of
cereal grains, whereas in America it refers exclusively
to Indian corn or maize. This often caused confusion
with our American friends during the war. Most people
in this country understand, however, what is meant by
the term ‘‘ sweet corn ’’—the type of Zea mays charac-
terised by a higher sugar content than the “ field ”
corn used for animal feeding. Before 1939 sweet corn
was not widely grown in this country, owing partly
to unfamiliarity with methods of preparation and partly
to the uncertainty of yield in our capricious climate ;
but interest was stimulated by the influx of American
soldiers during the war and the call for vegetables to
replace those normally imported. In the subsequent
search for early varieties that might ripen successfully
in this country, interest centred on the “ hybrid ” corns.
To most people a hybrid is a cross between two unlike
parents, whether of different species or of different
varieties; but with maize it has come to have the
restricted connotation of a controlled cross between
two or more inbred “‘ pure lines,” each with definite
characteristics. Prof. George Shull, of Princeton Univer-
sity, was the first’ to show that by the crossing of two
pure lines, each of which might be of very low yield, -
a hybrid of much greater vigour than either parent
could be produced ; he introduced the word ‘‘ heterosis ”
to define this phenomenon of hybrid vigour. He began
work as Jong ago as 1905, and by 1914 he had formulated
all the principles for the commercial production of
hybrid corns ; it was not until 1924 that these valuable
types began to be used in the United States, but by
THE LANCET]
1937 80% of the sweet corn for canning was grown
from hybrid seed.
Maize is a dicecious plant—that is, it produces male and
female flowers on the same plant. The male flowers,
or ** tassels,” at the top of the plant shed their pollen
in the slightest wind on to the stigmas or ‘ silks ” of
the female flowers lower down. By growing two inbred
pure lines side by side and removing the “ tassels ”
from one variety as soon as they appear, the fertilisation
of the cobs with pollen from the other variety is assured,
and a “‘single-cross”’ hybrid, with the characteristic
hybrid vigour, is obtained. If seed from self-fertilisation
by such a hybrid is grown, the next generation shows
segregation and loss of the hybrid vigour. To maintain
the vigour and uniformity of the cross, new hybrid
seed must be produced in the same way every year—
a costly process and one which can only be undertaken on
a large scale by commercial seed-growers. Nevertheless,
it pays the grower to purchase this seed rather than to
grow the ordinary varieties. Other types of hybrid
than the “ single-cross ’’ are now sometimes used, because
they can be produced more economically, without loss
of the hybrid vigour. Thus, ‘‘ top-cross’’ hybrids
(crosses between an inbred line and an ordinary variety),
“ double-crosses ” (two different single-crosses hybridised),
and ‘ three-way crosses ’’ (with the seed parent a single-
cross and the pollen parent a third inbred line) are now
in regular production. If only more of our food plants
were diccious, their cultivation might, with heterosis,
be revolutionised in the same way as.the American corn-
growing industry.
PENICILLIN AND SULPHATHIAZOLE
FEVER
IN TYPHOID
SINcE Bigger’s report! on the apparently synergic.
action of penicillin: and sulphathiazole on strains of
Bacterium typhosum in the test-tube, clinicians have been
interested in the possibility of using this combined
chemotherapy against an infection which regularly takes
its toll of 10 to 20 patients in every 100 cases, As
Bigger showed, penicillin in a concentration of 2 units
per ¢.cm, in vitro has an inhibitory but not bactericidal
action on some strains of the typhoid bacillus, and when
this level of penicillin is combined with 10 mg. of sulpha-
thiazole per 100 c.cm., most strains of Pact. typhosum
are killed or effectively inhibited. With the recom-
mended dosage of 2 mega units a day for the treatment
of typhoid cases a level of 2 units per c.cm. of penicillin
in the blood can usually be surpassed although levels of
10 mg. of sulphathiazole per c.cm. are rarely obtained
with the usual dosage of 6-8 g. per day. However,
Bact. typhosum in moderate numbers can be inhibited
in vitro by lower concentrations of sulphathiazole
(1-5 mg. per 100 c.cm) so that the combined therapy
should theoretically be effective. As a rule the best results
with chemotherapy are obtained in the early stages of an
infection, when the pathogen is actually multiplying in
the tissues, and on this basis the peniciilin-sulphathiazole
treatment of typhoid should be most successful before
the end of the first week when the organism is still
presumably proliferating in such foci as lymphoid tissue,
. bone-marrow, and the gall-bladder. ess striking
results would be expected with treatment begun after
the end of the second week, when typhoid toxemia and
ulceration of the bowel with its attendant risks
of hsmorrhage and perforation are the main features of
the disease. Unfortunately few cases of typhoid fever
are diagnosed in the first week of infection but penicillin-
sulphathiazole may be exhibited in the early stages
of the not infrequent relapses, while McSweeney 2 has
claimed good results in a few cases treated in the second
and third weeks.
a et ee E
1. Bigger, J. W. Lancet, 1916, i, 81.
2. McSweeney, C.J. Ibid, July 27, p. 114.
i it aera i aiaa
PENICILLIN AND SULPHATHIAZOLE IN TYPHOID FEVER
[SEPT. 7, 1946 353
When treatment is begun late useful objective criteria
of the severity of the disease may be a positive blood-
culture and low titre of O antibody. Blood should
therefore be taken immediately before treatment is
begun ; the clot is cultured in bile or bile-broth and the
serum examined for agglutinins. Besides its effect on
the clinical infection careful observations should be made
to find whether penicillin-sulphathiazole therapy will
eliminate the infecting organism and thus secure early
bacteriological cure. After an attack of typhoid fever,
patients may continue to excrete the organism for many
weeks in convalescence and it is estimated that some
2% of affected patients become chronic typhoid carriers,
In the convalescent stage the organism persists mainly
‘jn the gall-bladder and bone-marrow ; in the chronic
carrier the usual focus is the gall-bladder, although, as
the recent Aberystwyth outbreak exemplified, the
possibility of urinary carriage must not be forgotten.
Penicillin is concentrated in the bile as well as in urine
and with massive doses effective levels may be obtained.
McSweeney reported early negative fecal cultures in
3 of his 5 treated cases (he does not say whether selective
culture media were used) and in this issue (p, 343)
Comerford, Richmond, and Kay record apparent success
in the treatment of 2 typhoid carriers. In the past
medical treatment of the chronic typhoid carrier has been
uniformly disappointing, though cures have lately been
claimed in individual cases with sulphaguanidine and
succinyl sulphathiazole. In some of these cases chemo-
therapy has followed apparent failure of cholecystectomy
—as happened with one of the 2 carriers now reported—
and it is only fair to point out that cholecystectomy
rarely leads to bacteriological cure before several weeks
and occasionally months have elapsed after operation,
Because of the possibility of intermittency of excretion it
is wise also to continue laboratory examinations of fæces
and blood (for Vi antibody) for at least a year after
apparent cure. However, the results reported by
Comerford and his colleagues will encourage others to
try the effect of penicillin-sulphathiazole in chronic
typhoid carriers, many of whom are known and kept
under supervision.
A complicating factor that deserves attention when
large doses of penicillin are being used for the elimination
of relatively resistant organisms is that commercial
preparations may contain 3 or 4 different penicillins °
the activity of which vary in vitro and in vivo against
different bacteria.. Thus penicillin 11 (X) has been
shown ‘ to be more active than penicillin 11 (G) against
pneumococci, hemolytic streptococci, Bact. coli, and
possibly gonococci, although in the usual standardisa-
tion tests the two penicillins are equally active against
Staph. aureus. American workers ë have also found that
penicillin rv (K) although highly active in vitro against
Staph. aureus and also against Treponema pallidum is
relatively ineffective in the treatment of experimental
rabbit syphilis, a phenomenon that has been correlated
with its rapid disappearance from the blood. The poor
results, compared with early successes, that have lately
been reported ° in the ‘penicillin treatment of syphilis are
also blamed on the high content of penicillin 1v in
commercial penicillin. Whether the increasing use of
Penicillium chrysogenum and the deep tank aeration
methods of production favour a greater yield of this
biologically inert penicillin are matters for further
investigation. Meanwhile these disturbing findings may
largely invalidate the internationally accepted method
of penicillin standardisation, the full report 7 on which
was lately published as a special Bulletin of the Health
Organisation. Obviously the manufacturer must take
3. See Leading article, Zhid, 1946, i, 539.
4, Libby, R. L., Holmberg, N. L. Science, 1945, 102, 303.
5. Eagle, H., Musselman, A. Jbid, 1946, 103, 618.
6. J. Amer, med. Ass., 1946, 131, 265, 271.
7. Bull. Hlth Org. L. o. N., 1945-46, 12, no. 2.
354 THE LANCET]
steps to avoid producing penicillin with a high content
of penicillin rv: or alternatively must use methods for its
elimination from the finished product. Failing the
production of specific penicillins such as 11 or nt, it would
also seem desirable to supplement the in-vitro tests for
penicillin standardisation by methods that have more
direct relationship to therapeutic efficiency—e.g., the
determination of residual penicillin levels in the blood
of suitable animals. .
DEATH AFTER SERUM
- A DOMESTIC tragedy i in Ireland, lately reported in the
daily press, underlines the possible dangers of antitoxin,
which were discussed in these columns a few months
ago.) Having good reason to believe that one member of
a household had contracted diphtheria, a doctor decided
to protect the seven contacts by giving each a dose of
antitoxin. The last to receive the injection, a girl of 14,
complained a few minutes later that she had had an
attack of asthma. Administration of a cardiac stimulant
was of no avail, and the child died with acute heart-failure
soon afterwards. The extreme rarity of such occurrences
—perhaps 1 in 80,000 injections—is no reason for under-
rating their seriousness. Children are more liable than
adults ; crude serum is more likely than refined antitoxin
to cause disaster ; no intradermal or other test of sensi-
tivity is entirely reliable ; a history of asthma is a warning
of the gravest significance ; a bottle of adrenaline should
be at hand, ready for immediate use, whenever an
injection of serum is given. Such in brief is the extent
of our knowledge. The induction of passive immunity,
perhaps combined with active immunisation as suggested
by Fulton and his colleagues,? is not only justifiable but
also highly desirable on many occasions, but it must
never be forgotten that it carries a small but definite risk.
A SCHOOL FOR DIPLEGICS
Frew conditions give such a false impression to the
onlooker as cerebral palsy. A child moving with great
difficulty, his knees rubbing together or crossing, his
arms bent stiffly on his breast or sweeping about in
athetosis, his lips dribbling, makes a picture which to the
inexperienced means idiocy. Yet many such children
are normal mentally, two-thirds of them are educable,
and even those who reach colonies for mental defectives
are usually among the higher grades. They may achieve
much success in managing their disabilities, sometimes
with little training or encouragement ; it is remarkable
to see how a boy learning weaving, for example, will wait
for the exact moment when his athetosis will allow him
to throw the shuttle. In the United States, where there
are said to be some 200,000 cases, considerable advances
have been made by Dr. Phelps, of Baltimore, among
others, in the training and education of children with
cerebral palsy. Now, thanks to the generosity and
enthusiasm of Mr. Leslie Williams, who has subscribed
a large sum of money and given much of his time to
fostering the scheme, and of Colonel and Mrs. Garwood,
who have lent their house at Croydon rent-free for seven
years and contributed to the fund, a school for British
children with this disability is to be founded.
At a luncheon to launch the scheme, held at the
Trocadero Restaurant on August 26, Dr. Earl Carlson,’
himself a diplegic, spoke of the school he has established
in New York for 75 palsied children, aged from 2 years
upwards. - Of his staff of 30, 5 are trained teachers, and
others are being trained for this work. Calling cerebral
palsy. the most neglected condition of childhood, he
described the ¢ase of a young man who at 20 could not
read and could scarcely talk ; after 10 years of proper
teaching he was admitted to a university and took a
1. Lancet, 1946, i, 694.
2. Fulton; F., Taylor, J., Wells, A. Q., Wilson, G. S. Brit. med. J.
1941, ii, 759.
3. AS announced in these columns last week (p. 332) Dr. Carlson
is lecturing at the London School of Hygiene on Sept. 9, at 4 P.M.
A SCHOOL FOR DIPLEGICS
[SEPT. 7, 1946
PH.D. He is now head of the high-school department of
Dr. Carlson’s school., Children attending the school
for mental and physical training usually need stay only
a few months. Dr. Carlson can estimate their intelli-
gence, he finds, whatever their physical state, and can
judge whether any child over the age of 3 years is
educable. Some return to the school for a few months
at the age of 18 years before going on to a university.
St. Margaret’s, the new school at Croydon, will begin on
a small scale, but this short-stay plan will make it possible
to deal with relatively large numbers of children.- At first
preference will be given to children who can feed them-
selves, are not incontinent or mentally defective, and
who show a good promise of improvement.
The incidence of cerebral palsy is unknown—one esti-
mate is 5-6 per 100,000 population. The cause is still
doubtful, for though the theory of birth-injury long held
the field (and the mothers often give a history of difficult
labour), the pathological findings suggest rather a blight
falling on the brain earlier in fetal life, destroying some
developing cells and allowing others, perhaps more
mature, to escape ; in the light of recent work infective or
dietetic factors will no doubt be inquired into. Whether
the case is predominantly spastic, athetoid, or ataxic
depends on the sites of the damage. The Rh factor
probably has some part in the etiology, for half Dr.
Carlson’s patients give a history of jaundice in infancy.
The house at Croydon is already being adapted to its
new purpose. The board of management consists of
Mr. Williams, Prof. J. M. Mackintosh, Sir Ernest Cowell,
and Dr. William Moodie, and the medical advisers to the
school will include a neurologist-psdiatrician, an ortho-
pecdic surgeon, and a specialist i in physical medicine, all
of whom will also be on the staff of Queen Mary’s J..C.C.
Hospital for Children at Carshalton. The board are
‘looking for a hostel where the parents of those entering
the school can stay for a time to learn how to help their
children. Miss Kathleen Wood has been appointed
headmistress of the school. Two physiotherapists on
the staff have completed a three months’ course in Dr,
Phelps’s clinic, and an educational psychologist, sent
out by the Foundation for Educational Research, who has
studied the work being done in a large number of .the
clinics in America, will make St. Margaret’s her head-
quarters for research and for developments of the move-
ment. It is hoped that the school will be in operation
by the end of October.‘ The Ministries of Health and
Education, the Foundation for Educational Research,
the National Coyncil for the Care of Cripples, and
Parents’ Associations all favour this new development,
and it is planned to make St. Margaret’s the forerunner
of similar schools in different parts of the country,
giving education and care to such unfortunate children
within the means of all their parents.
TUBERCULOUS ENDOMETRITIS AND STERILITY
THE association between sterility and tuberculous
endometritis has been recognised only in the last few
years, but Halbrecht,® in reviewing 820 cases of sterility
in women who were subjected to curettage in Tel-Aviv,
has found that 45 had tuberculous endometritis. The
diagnosis was confirmed by positive culture in 4 cases
and by animal inoculation in 3. Unfortunately, no.
account is given of the histological criteria for the
diagnosis, but he suggests that the number of positive
findings would have been greater if all patients had been
submitted to a total curettage rather than to a partial
or diagnostic endometrial biopsy. As a corollary hg
investigated 54 women in whom salpingography showed
the tubes to he partially or completely blocked; the
findings on curettage demonstrated that 18 of these had
tuberculous endometritis.
4. In the meantime inquiries should be nddiescod to Miss Kathleen
Wood, Coombe House, Croydo
5. Halk recht, I. Sehirere. “med. wv schr. 1946,76, 708.
THE LANCET].
BOVINE PLASMA AGAIN
[spepr. 7, 1946 355
This poses a triple problem: first, the relationship
between sterility and tuberculous endometritis ; secondly,
the situation of the original tuberculous focus, which
may, or may not, have been genital; and thirdly, the
significance and prognosis of the uterine disease. In a
previous article 6 Halbrecht outlined the past history
of 18 cases of tuberculous endometritis ; of these, 2 had
had pleurisy in youth, 2 had had tuberculous peritonitis,
and 3 others showed signs of other tubercwous affections
—persistent pararectal fistula, tuberculous adenitis, or
hip disease. It therefore appears that the endometrium
provides a long-term sanctuary for the tubercle bacillus,
in the same way that the gall-bladder harbours the
typhoid bacillus. The sequence is probably this : primary
focus in lung or abdominal glands, systemic tuberculosis
or dissemination to the pelvic peritoneum, exosalpingitis
or endosalpingitis with tubal occlusion, and finally
residual tuberculous endometritis.
In a final word of reassurance, Halbrecht says that
apart from the endometritis his patients were all fit by
external standards, and that, except for obliterating
the tubes, the disease remained stationary and untrouble-
some. For treatment he advises absolute conservatism
with complete abstention from surgical intervention.
His conclusion that occult, subclinical tuberculous endo-
metritis is one of the cardinal causes of sterility in general
and of tubal occlusion in particular may have come as
something of a shock to English workers; and it will
be interesting to see whether, with further experience,
similar reports appear in this country.
BOVINE PLASMA AGAIN
DvuRinG the war there were several reports 7 8 on the
use of bovine plasma or serum, and bovine albumin,
as blood-volume-restoring agents in man; but none of
the authors felt justified in proposing their unrestricted
use,
Any protein-containing saette for human plasma
must obviously be non-antigenic, non-toxic, and free
from agglutinins, and it should have at least the same
osmotic pressure as human citrated plasma. None of the
workers who have reported so far have been willing to
state unequivocally that the first condition has been
fulfilled, while the solutions of highly purified ox-albumin
prepared in Cohn’s laboratory at Ilarvard and used by.
Heyl et al.8 alone appear to fulfil the second. Of the
bovine material used, the ox-albumin seems least open
to criticism, and publication of the final conclusions
drawn from its trials—if in fact trials have been continued
—will be very valuable. Meanwhile a report from
Barcelona on the preparation of bovine plasma and its
use in man is published on another page of this issue.
Dr. Massons has subjected his material to rigorous treat-
ment to make it sterile and non-antigenic, but before
the adoption of his bovine plasma can be recommended
his claims must be substantiated by careful repetition
of his work, followed by controlled clinical trial. It is
unlikely that the osmotic pressure of Massons’ material
is equivalent to that of human plasma; indeed it is
- probably much less. His method of preparation is
simple compared with Cohn’s elaborate and expensive
fractionation, but its extreme simplicity will itself
evoke criticism.
The chief TN of using a substitute for human
plasma are that it will remove the dan ger of transmitting
hepatitis, and will lighten the burden of the many blood-
donors who have given so faithfully. Unfortunately much
work still remains to be done before this can happen.
No protein-containing substitute for human plasma
can. be employed until it has been clearly shown to be
not only harmless but also as effective as human plasma.
6. Lancet, 1946, i 235;
ie Edwards, F. R. Brit. med. J. 1944, i, 73.
ee abs ana Gibson, J. G., Janeway, C. A. J. clin. Invest. 1943,
CURARE IN NEUROLOGY
APART from anesthesia, there are two outstanding
uses for curare in medicine which may deserve more atten-
tion. There is mounting evidence that it can be used
with reasonable safety by intravenous injection to
minimise the chances of fracture in convulsion therapy,
especially in the elderly. Palmer 2} has summarised the
technique required. What may finally prove to be a
much wider field is in spastic or dystonic neurological
conditions, where no radica] treatment is possible, “and
spasm limits the value of all forms of physiotherapy.
Results have been published, for example, in tetanus,
status epilepticus, infantile spastic paralysis of several
kinds, parkinsonism, paralysis agitans, and Hunting-
ton’s chorea. They have been dubious so far, for two
reasons. There have invariably been troublesome side
effeets—blurred vision, diplopia, general weakness, and
dizziness—and the effect has been transient, and- not
sufficiently definite in proportion to the severity of the
symptoms to justify its routine use. Schlesinger ? has
now introduced a new factor by injecting the curare
intramuscularly in a mixture of peanut oil and white
wax, and so obtaining slow absorption. He finds that its
action is thus prolonged up to three days, and that the
unpleasant side effects do not develop. Confirmation is
required, but it may be that this modification in tech-
nique will lead to welcome, although probably partial,
relief for many patients who at present live many months
functionally helpless. Jt should not be forgotten that
a number of drugs, such as quinine methochloride,
magnesium sulphate, and erythrine, are believed to have
pharmacological effects similar to curare. There might
be an advantage in achieving the same end with some
such physiological analogue.
FOR AULD LANG SYNE
THERE can be few who served in the Forces during the
_ war years who do not find some pleasure in the recollec-
tion. Perhaps memory is happily selective; perhaps,
again, the rigours of present-day civilian life lend fictitious
charm to any alternative. ‘Whatever the reason, the
tedium, the irritations, the occasional danger, and the
frustration that largely compounded the life of the
amateur soldier usually defer to happier memories.
The life, though physically dangerous, was otherwise
secure, with food and pay assured without special
endeavour; many had the chance to see countries
they would otherwise never have visited; and the
return to the schoolboy community way. of living fostered
friendships which, but for the common share of dis-
comfort and danger, would never have been sealed.
The value attached to these ties has been shown by
letters in our columns in the last few months: for the
Army, a medical society has been proposed, and an
airborne medical society is being formed. Mr. T. J.
Daly, a former major and quartermaster, R.A.M.C.,
now writes to suggest an Army medical association to
hold reunion dinners throughout the country ; he offers
fuller particulars of a tentative scheme to anyone writing
to 1, Lancashire Road, Bishopston, Bristol. Ideas of
this sort will be warmly supported by those who seek
to preserve the little good that has emerged from the
lost years.
1. Palmer, H. J. ment. Sci. 1946, 92, 411.
2. Schlesinger, E. B. Arch. Neurol. Psychiat. 1946, 55, 530.
SYSTEMATIC research into the common cold is to be under-
‘taken in the United States, as well as in Great Britain (see
Lancet,
‘be made by the National Institute of Health (the research
1946, i, 822). In America, the investigation will
division of the United States Public Health Service), directed
by Dr. R. E. Dyer. Like the British workers, Dr. Dyer
‘emphasises that it. may be five or more years before sub-
stantial progress can be recorded, even allowing for the
better understanding of viruses in the last decade.
te TO ee
356 THE LANCET]
FRACTIONAL TEST-MEALS ON STUDENTS
[SEPT. 7, 1946
Special Articles
FRACTIONAL TEST-MEALS ON STUDENTS
AWAITING EXAMINATION RESULTS
MICHAEL FLOYER DENYS JENNINGS .
M.B.Camb., M.R.C.P. B.M. Oxfd, D.M.R.E. Camb.
From the Medical Unit of the London Hospital
THE association between disturbance of the guts and
emotional. tension has been recognised since the begin-
nings of literature. Older authors attributed emotional
instability to weak guts. . The pendulum has now swung
over, and gastroduodenal and colonic disorders, both
functional and organic, are popularly ascribed either to
excessive mental strain or to a temperament badly
adjusted to normal strains.
Typical evidence for this change of view is the alleged ;
frequency of gut disorder following mental tension.
A good example is Stewart and Winser’s (1942) paper
on the increase in perforated peptic ulcer during air-
raid periods. There arè many other lines of evidence,
such as the undue frequency of certain temperamental
types among ulcer patients (Davies and Wilson 1937),
observations on the effect of emotion on quite a large
number of patients with gastric fistule, ranging from
reaffirmed the claims of his
Beaumont (1833) to Wolf and Wolff (1942), observations
on experimental animals with fistulz or with transparent
abdominal windows, X-ray observations on experimental
animals and on normal and psychotic human subjects,
and finally test-meal observations on mental patients and
on subjects suffering from emotional stress or in whom
stress is induced under hypnosis. Alvarez (1929) has
written a very readable review, and Dunbar (1946)
gives a modern bibliography.
Various mechanisms for the production of peptic
ulcers by emotion have been suggested. The idea that
interruption of normal impulses from the brain, or the
production of abnormal ones, may be responsible dates
back to Kammerer (1818), who tried to explain the
association between brain lesions and gastric ulcers.
The theory of hypothalamic stimulation in its modern
form was favoured by Stewart and Winser (1942) and
severely criticised by Jennings (1942). Selye (1943)
“alarm” reaction of
ischemia followed by dilatation of capillaries and stasis.
- Cannon’s (1909) view of stasis and fermentation of
food producing irritation, gastritis, and duodenitis is a
possibility, and so is the idea of retrograde intestinal
movements associated with colonic irritability.
As pointed out by Jennings (1942), the difficulty of
the theory of hypothalamic stimulation is that, with rare
RESULTS OF FRACTIONAL TEST-MEALS IN SIXTEEN STUDENTS WHO PASSED AND FOUR WHO FAILED IN THEIR
EXAMINATIONS (17-20)
A.— PASSED
Time relationship of samples -
to announcement of results
Fasting and
No.) initial samples
Final
Minutes before Minutes after
1
samples
A.—PASSED (continued)
Time relationship of samples
to announcement of results
Fasting and
initial samples
Final
Minutes before Minutes after | samples
—_.-
——— |a | ee ee, eee
F | 70 | 72 | 75 .. | 60 F 10 | 6 25
T |120 |114 |115 110 100 | .. | 82 T 42 | 27 50
S +| + . | + S -| + +
Bitrjitr; -= - _ act = B — | + +
2| F| 0] 20 | 25 48 52 | 48 F 18 | 12 45
T | 20 | 40]48] , 65 65 | 65 T 30 | 30 60
Sjitrj +| + +|- S -| + +
3 | F| 0 | 12 | 32 28 22 | 22 F 35 | 64 58 | ..
T | 10 | 30 | 52 42 38 | 38 T 58 | 82 80 | ..
Sj/-—-| +] + + tr | tr S +j + +j..
B —_ tr —_ == —_ Co B sfa ` bad se
4| F| 0| 0] 25 33 22 | 22 F 42 | 25 50
T |10 | 18 | 45 54 47 |43 T 67 | 48 28
S| =] +] + + - | = S -| + +
B a om = = = — B af- afe aaen
5 | F | 18] 12 | 36 17 30 | 15 F 60 | 38 .. | 48
T | 38 | 30 | 58 32 52 | 30 T 80 | 52 .. | 64
S/—-| +] + + +] - Ss | -| + - +
Bj=-{=-|/- = - | = B -| + ae
6| F 48 | 17 0 0| 0
ae 70 | 35 | 20 25 30 | 20 | Arithmetic mean of 37-6
7 t+ + t a a Standard error of 6-2
7| F 38 | 20 | 45 50 41 | 38 TERS . .
T 58 | 35 | 70 72 60 | 50
B = ee a al = =:
8 | F 0| 0| 22 10 | .. 12 17| F 0| 0] 22 0 | 0
T 8 | 24 | 40 27 | ies 28 T 8] 8| 40 25 20 | 15.
S ee afo + =— ee era S a =" + a =n zz
B =- | = | = = N = B =- | = - -| =
9| F 37 | 18 33 37 9 18| F 35 | 34 50 50 | 28
I .. | 70 | 52 65 61 30. T o: 4 65 65 | 48
+| + + + + -| =
B - | = - tr + B -| + + | +
10 | F 0} 0 25 35 32 19| F 32 | 48 : == ‘ 22 | .. | 22 | 36
me eh 15 | 17 48 52 40 T 50 | 68 . | 20 37 | .. | 42 | 55
S -| 4 + + + S -| + : + -|.. |] =|-
B = ee = = Erea B = = ° as TRIR e _ =
11 | F 40 | 48 50 55 52 20 | F 30 | 32 42 37 | .. | 25].
T 58 | 65 70 72 68 T 50 | 55 62 58 | .. | 40
S - | = + = - S -| + + =- |, =- j.,
B = = = — - B ode fe =e. ° ry = oe = °
F, free HC]; T, total acidity ; S, starch; B, bile.
THE LANCET]
exceptions (Hoelzel 1942), many workers support the |
idea that stress causes reduced secretion and delayed
emptying. Wolf and Wolff (1942), in their observations
on “Tom,” and Wolff and Mittelman (1942), in further
observations on cases of gastritis, duodenitis, and peptic
ulcer, distinguish between anxiety associated with
hostility, resentment, or aggression, which causes hyper-
function of
the stomach,
and anxiety
associated
with depres-
sion, which
causes hypo-
function.
They note
the parallel
between gas-
tric secretion
and salivary
secretion.
The mouth
dries up with
fear, but
people spit
with rage.
Hinds
Howell
(1941) found
that test-
meal curves
during air-raids were so irregular as to be useless, but unfor-
tunately details were not published. Since no unselected
samples could be found in the literature, it occurred to
one of us to do fractional test-meals on students awaiting
the results of the M.B. examination, to give the results
after the first hour and to follow the curves for a further
hour to see if passing or failing had any influence. Twenty
students volunteered, of whom sixteen passed and four
failed. The technique used was to draw off as much of
the fasting secretion as possible and then to give a gruel
meal. All the subjects either went without lunch or had
an early light carbohydrate meal. The tubes were passed
between 4 and 4.30 P.M., samples were removed at
20-min. intervals, and the examination results were
announced at 5.15 P.M.
The accompanying table and figure show the exact
time relationship of the samples to the announcement of
the results. There is no evidence of hypersecretion and
no significant departure from expectation. It might
be argued that the tension was not great enough. We
do not believe this is valid, as during the first hour there
was a definite tense atmosphere in the room, and it was
deliberately increased. by sending messengers out to
inquire if all the results were yet ready, and by consulting
sheets of foolscap. Possibly a larger sample might pick
out the occasional abnormal case, but evaluation would
then be difficult.
Vio HCl. per cent
3
SAMPLE
Graph showing mean free HCI of 16 students who
passed and 4 who failed in thelr examinations.
Shaded area gives range of mean +2 S.E. in the 16
who passed ; black line gives mean of 4 who failed;
vertical line gives time of announcement of
examination results.,: l ;
_ SUMMARY
Fractional test-meal curves on twenty normal medical
students for an hour preceding and an hour following the
declaration of examination results showed no abnormality
which could be ascribed to anxiety, depression, or
elation.
REFERENCES
Alvarez, W. (1929) J. Amer. med. Ass. 92, 1231.
Beaumont, W. (1833) Experiments and Observations on the Gastric
Juice, Plattsburgh. :
Cannon, W. B. (1909) Amer. J. med. Sci. 137, 480.
Davics, De Wilson, A..(1937) Lancet, ii, 1353.
Hinds Howell, C. A. (1941
252.
‘ inser, D. M. de R. (1942) Ibid, i, 259.
Wolf, S., Wolff, H. G. (1942) Human Gastric Function, London.
lff, H. G., Mittelman, B. (1942) Psychosomatic Med. 4 ,5.
IN ENGLAND NOW
[sePT. 7, 1946 357
In England ‘Now
A Running Commentary by Peripatetic Correspondents
ONE of your correspondents has urged a more careful
estimate of the results of surgery by following up the
later histories of patients. Then your leading article
_ of August 17 has drawn attention to the grisly state of
some of the chronic sick, as discovered by a survey
undertaken by the Institute of Almoners, and among
these ‘‘ chronic sick’’ were men and women dying of
carcinoma in varying degrees of misery. The surgery
of carcinoma has to some extent already been checked
by follow-up, and judging by the number of forms now
filled in about these patients the follow-up will be more
accurate and detailed and more widespread than hereto-
fore. I have however an uneasy feeling that the form of
the accepted carcinoma follow-up leads to surgery which
often adds to the unhappiness of our patients instead
of alleviating it.
The accepted criterion of success in the treatment of
carcinoma is the survival of the patient for an arbitrary
period of years. Whether the patient is happy and
comfortable or in misery and pain is not recorded:
his mere existence alive is regarded as proof of success.
Because ‘‘ survival ” is an unpleasant word, hinting that
life may be present but not necessarily very enjoyable,
it is not used in this connexion; the fallacious but
comforting word ‘‘ cure ” is used in its place. A surgeon
will blithely record in public the results of his treatment
of carcinomatous patients as a three, four, or five year
“ cure,” lumping together the remainder as ‘‘ recur-
rences ” and therefore failures. Yet the end of a patient
with a recurrence may be a good deal pleasanter than
that of a patient ‘‘ cured.” The comfort of the patient
has become obscured by the attempt to eradicate a.
disease, an attempt based on pathology and checked
by statistics, both of which ignore the happiness of the
sufferer who dies in a different institution from that
which treats him at first. The introduction of beds
for the chronic sick and dying in the same building
where primary treatment is undertaken will go some
way to humanising the statistics: till then it might be
a good idea to record the results of the treatment of
carcinoma as “ alive,’’ ‘‘ with or without recurrence,”
‘S comfortable or miserable.”
i * * *
Almost certainly I qualify by residence and occupation
to write as a practitioner in a Medically Overcrowded
Area (M.O.A.). There is in London one indubitable
M.O.A., the one near Cavendish Square; but in present
controversy it does not seem to count, and a substantial
park and famous wood separate mine from it. Mine
is not what it was. There are many more people to the
house and perhaps fewer doctors to the street than there
were, but I know of six G.P.s and as many dentists within
200 yards of me—there may be more; houses are not
thick on the ground so the proportion must be fairly high ;
and besides we have been ‘‘ spoken of,” mentioned in the
same breath with such hotbeds as Bournemouth.
And that brings me to the point. It is time, I think,
that someone in one of these strange places spoke up,
for nowhere does experience more belie repute; and
repute so readily assumes the voice of authority. The
whole country now knows our reputed habits. ‘‘ Where-
soever the carcass is there shall the vultures be gathered
together ” puts them in a nutshell. Spying from afar
the congregation of the wealthy we buy ourselves into
a practice on borrowed thousands and have then no
choice but to get our money back by prostituting our
science and art. Well may we yearn for a Charter of
Liberty to deliver us from this bondage! Well may the
country’s awakening social conscience move it to arise
and cleanse the Augean stable! And if Augean stables
have parasites, and parasites have socks, well may they
be compelled to pull them up and do a bit of honest
work elsewhere !
So much for repute. Now for experience. Twenty-
five years ago your present peripatetic—no, the third
person is impossible. Once upon a time I, being young,
eager, married and offspringing, but slightly mellowed by
over four years of war, looked about for somewhere to.
live. We had sampled the M.O.A. as a living-place and
358 THE LANCET]
liked it. It was a fit place for bringing up a family, not
too far from our own parents and from my hospital job,
and there was a house going reasonably cheap. There
were shoals of doctors about, so one more could matter
Ta to them; and just possibly I should make a
ving.
We bought the house. We let the top half to friends
and I put a plate on the door. I never sat there like a
hungry spider twitching the threads of the web. I
went out and did jobs—paid and unpaid, hospital, welfare-
centre, pensions-board, and the like—and slowly friendly
doctors put me in the way of making a practice. Some
of the friendly ones were consultants a few years my
senior living in or near the M.O.A. and needing a “ real
doctor ”? for their children ; others were ‘‘ real doctors ”’
themselves, living farther off. The patients were
almost always immigrants—almost never from that day
to this the ex-patients of a local fellow-vulture. They
were very often interesting and pleasant people, very
seldom rich.
The fellow-vultures, after surveying the new bird for
a suitable time, actually invited it to join the Vulturine
Society—a very friendly gesture when you think what
predatory brutes they must really be. ‘‘The Vul-
turine ?” meets monthly in the winter season in the
actual eyries of its members. The eyries turn out to be
quite ordinary nests, the hen-vultures who receive us
seem quiet, domesticated fowls enough; and where are
the tell-tale fragments of bone, fur, or feather that should
reveal to a quick eye the horrid hidden sources of their
daily meat? How inconspicuous are our host’s beak
and talons! One might almost believe that even he—
and if one almost did one would be right because of
course (to quit fooling) neither he nor the other members
of the ‘‘ Vulturine’’ are any more predatory than I
am myself. They are decent ordinary practising doctors,
not perhaps without certain qualities of mind and
outlook which have drawn them to practise in the
- -M.O.A., but quite obviously neither parasites, charlatans,
go-getters, nor prostitutors of their art and science.
. + * *
When I die I shall leave an annual prize to the graduate
who can give the most bizarre reason for ing up
medicine. I might have been a pretty good starter
myself. The week before I began at college I filled in a
curriculum form for some distance before I discovered
that it wasn’t the one for arts after all. Somewhere in
the college files there is a curriculum form for medicine
(1939-40) with a teeny tear at one edge to show how far
I got before it struck me that it might be a better stunt
after all; whereafter I went straight to a second-hand
book shop and bought a textbook of pathology by
Lazarus-Barlow (1902 edition) for ls. 6d. and read it!
The closest rival in my year would be the anatomy
medallist, who, during his school years, saw a woman
have hysterics in the street when a forearm and head
were thrown at her from the upper floors of the medical
school. This incident greatly impressed on him the
power of the healers over the laity and fired him with the
ambition to emulate this feat. Runner-up would be the
old sea captain who had been left a substantial legacy
on condition that he embarked on the study of medicine.
Since the legacy was to stop when he qualified, the old
boy spun out his course to 14 years until ‘he accidentally
gave three right answers running in his finals and was
passed. By the time he had decided to get himself
struck off the Register to be able to start again, he
found himself enjoying a country practice so much
that he bought it with the savings from his legacy
instead. l
Lest any of you should be tempted to overwork your
imaginations, I might add that I am still in my twenties
and that the prize, in any case, will be quite worthless.
% * *
“ Typhoid Outbreak in Scotland: An Ice-cream
‘Carrier’ ? ” says the Manchester Guardian. If an
ice-cream carrier is a person who harbours ice-cream in
his body without manifest symptoms (as Dorland’s
Dictionary would lead one to suppose) most of the
children in our part of London must come in that
category just now, for the Strand is only second to
pila aun anon in the number of ice-cream sellers per
sq. inch. z
THE WORLD HEALTH ORGANISATION
[SEPT. 7, 1946
Public Health
THE WORLD HEALTH ORGANISATION AND
ITS INTERIM COMMISSION
NEVILLE M. GOODMAN
M.D. Camb., D.P.H.
DIRECTOR OF HEALTH, EUROPEAN REGIONAL OFFICE, UNRRA
THe work of the International Health Conference
in New York? can now be reviewed in the light of the
documents signed at its conclusion. These documents
consist of (1) the constitution of the World Health
Organisation, (2) an Arrangement establishing an interim
commission, (3) a protocol concerning the International
Office of Public Health, Paris, and (4) the final act of the
conference. All four were signed by almost all the
representatives of the 51 member-states of the United
Nations and the 10 non-member representatives attending
as observers ; but the first and third were in most cases
signed subject to ratification. l
CONSTITUTION
The constitution, after an impressive preamble, defines
the objective of the World Health Organisation as
“the attainment by all peoples of the highest possible
level of health.” The first of the organisation’s functions
is to “ act as the directing and coördinating authority
on international health work.” Among the twenty-one
other functions are strengthening ‘health services ;
furnishing necessary aid in emergencies; providing
health services to special groups, such as trust terri-
tories; establishing epidemiological and statistical
services ; proposing conventions and regulations ;
promoting maternal and child health, mental health,
research, technical training, and health propaganda ;
adopting international standards for biological, pharma-
ceutical, and food products, and for diagnostic pro-
cedures, public health practices, the nomenclature
of diseases, and causes of death; and promoting the
improvement of nutrition and environmental hygiene.
Services will be rendered only at the request of govern-
ments, and coöperation with other agencies in the various
fields is enjoined. The scope is thus even wider than that
of the Health Organisation of the League of Nations,
the Paris Office, and the Health Division of UNRRA
combined, though obviously all these functions will not
be taken up from the beginning. Already alarm has been
expressed at the proposal to standardise diagnostic
procedures, but it seems that all that is intended is the
standardisation of laboratory techniques, such as that
of the serodiagnosis of syphilis, formerly pursued by
the League of Nations. |
Membership is open to all States. A simple majority
vote of the World Health Assembly will admit any
State not accepting membership by signing the con-
stitution as a member or observer at the International
World Conference (Spain, Germany, and Japan were the
only States not invited to the conference). Colonies
or other territories not responsible for their international
relations may become associate members on application
by the “mother” country; their representatives
“ should be chosen from the native population ’’—a
clause which may lead to embarrassment—and their
rights and obligations will be determined later.
DIVISION OF DUTIES
The work will be carried out by the World Health
Assembly, an executive board, and a sécretariat. Member-
states will be represented in the assembly by not more
than three delegates, with alternates and advisors ;
delegates ‘‘ should he chosen from among persons most
qualified by their technical competence in the field of-
1. See Lancet, 1946, i, 970; ii, 58, 99, 142.
THE LANCET]
PUBLIC HEALTH
[sepr. 7, 1946 359
health, preferably representing their national health
administrations.” The assembly will meet annually and
in special session and determine its own place of meeting
in advance. Among its functions is the authority to
adopt conventions or agreements by a two-thirds vote ;
members undertake to accept such conventions within
eighteen months or furnish reasons for non-adoption.
The assembly may also adopt regulations on quarantine
requirements and standardisation of nomenclatures,
diagnostic procedures, and biological and pharmaceutical
products (including their labelling and advertising) ;
and such regulations will come into force at a given date
unless specifically rejected by members. These are
new and important powers, designed to ensure uniformity
and obviate delay experienced in the past, but they
may excite opposition if too much is attempted too
quickly. |
The executive board is to consist of 18 persons desig-
nated by 18 delegates elected by the assembly, holding
office for three years and eligible for re-election. The
board will meet at least twice a year, act as the executive
organ of the assembly, and take emergency measures.
The director-general, who is nominated by the board
and appointed by the assembly, has direct access to
government departments and nominates his own staff,
the conditions of whose appointment are to conform
to those of other United Nations organisations.
The location of the headquarters is to be decided
by the assembly, and it seems likely that it will be in
Europe. Regional committees and offices may be set up.
As soon as possible the Pan-American Sanitary Bureau
is to be integrated—whatever that may mean—with the
World Health Organisation, by mutual consent. Annual,
epidemiological, and other reports are to be made by
member-states to the World Health Organisation. The
constitution, which may' be amended by a two-thirds
majority of the assembly, enters into force when 26
members of the United Nations have become parties to
it: it is hoped that this number will be reached before
June, 1947, when the first assembly is expected to meet.
INTERIM COMMISSION
The Arrangement provides for the immediate establish-
ment of an Interim Commission of 18 persons designated
by that number of States. Its duties are to convoke
the first session of the World Health Assembly within
six months of the constitution coming into force; to
provide, for the agenda of the meeting, proposals on
programmes and budget, the location of headquarters,
regional areas, and staff regulations ; to prepare an agree-
ment with the United Nations ; to take over the functions
of the Health Organisation of the League, the Paris
Office, and the Health Division of UNRRA relating to the
international sanitary conventions; to negotiate with
the Pan-American Sanitary Bureau and other inter-
national organisations ; to prepare for a revision of the
sanitary conventions and the lists of causes of death ;
to establish liaison with the commission on narcotic
drugs and other commissions of the Economic and
Social Council ; and to consider any urgent health problem
brought to its attention by governments. The Interim
Commission is to derive its funds from a loan by the
United Nations, and governments may make advances
to it against their future contributions to the World
Health Organisation.
The commission? met in New York immediately after
election by the International Health Conference and
elected Dr. Stampar (Yugoslavia) as chairman and
2. Mr. Tange (Atstralia), Dr. Paula Souza (Brazil), Dr. Routley
(Canada), Dr. Sze (China), Dr. Shousha Pasha (Egypt), Dr.
Leclainche (France), Dr. Lakshmanan (India), Dr. Togba
(Liberia), Dr. Mondragon (Mexico), Dr. van den’ Berg (Nether-
jands), Dr. Sandberg (Norway), Dr. Paz Soldan (Peru), Dr.
Medved (Ukrainian Sovict Socialist Republic), Dr. Krotkov
(Union of Soviet Socialist Republics), Dr. Melville Mackenzie
ane Kingdom), Dr. Parran (United States of America),
. Guzman (Venezuela), Dr. Stampar ( Yugoslavia’.
-
Dr. B. Chisholm, late deputy Minister of Health of
Canada, as executive secretary; it also set up com-
mittees on administration and finance, epidemiology
and quarantine, and relations with other bodies. It
is understood that its next meeting, which must be
held within four months, will be in Geneva early in
November. : |
=- Finally, in the protocol, the signatories agreed, as
between themselves, to hand over the duties of the Paris
Office to the Interim Commission or the World Health
Organisation on the entry into force of the protocol ;
and, if the Paris Office has not been dissolved by mutual
consent before Nov. 15, 1949, to denounce at that time
the Rome Agreement of 1907, thus finally terminating
the Office. The protocol comes into force when 20 govern-
ments which were signatories of the Rome Agreement
have become parties to it.
_ We may conclude that the United Nations have made
a good start in the field of health and that unification
is at least—and at last—in sight. The many tedious
hours spent by the delegates in the hot-house atmosphere
of New York have not been wasted.
Paratyphoid at Coatbridge
On August 22 a case of enteric fever was admitted
to the burgh infectious diseases hospital, Coatbridge,
Lanarkshire. ° Next day 3 more cases were admitted.
All were bacteriologically confirmed as paratyphoid B
fever. All had consumed ice-cream from a common
source. On August 24 the manufacture and the sale of
the ice-cream was stopped, and local practitioners were
informed of the outbreak. A bacteriological investigation
revealed that an employee who made and sold the ice-
cream was excreting Bact. paratyphosum B in his stools.
It was not possible to determine the total quantity of
ice-cream likely to have been infected, but it is estimated
that at least 1500 cones and wafers were sold on one
day. The ice-cream was hawked within a certain area
of the town, and the cases are confined to that area.
The total number of cases up to August 30 was 74,
the majority being in children. l
Infectious Disease in England and Wales
WEEK ENDED AUGUST 24
Notificalions.—Smallpox, 0; ` scarlet fever, 665;
whooping-cough, 2058 ; diphtheria, 285; paratyphoid,
66; typhoid, 36; measles (excluding rubella), 2140 ;
pneumonia (primary or influenzal), 299; cerebrospinal
fever, 39; poliomyelitis, 30; polio-encephalitis, 1;
encephalitis lethargica, 2; dysentery, 52; puerperal
pyrexia, 138; ophthalmia neonatorum, 82. No case
of cholera, plague, or typhus was notified during the
week.
Deaths.—In 126 great towns there were no deaths
from scarlet fever, 1 (0) from enteric fever, 2 (0) from
measles, 8 (0) from whooping-cough, 3 (0) from diph-
theria, 29 (2) from diarrhoea and enteritis under two
years, and 7 (2) from influenza. The figures in parentheses
are those for London itself.
Birmingham reported the death from an enteric fever.
The number of stillbirths notified during the week was
242 (corresponding to a rate of 28 per thousand total
births), including 30 in London.
“ . . There was another occasion during the [Hot Springs]
Conference when the delegates of the other nations appeared
to be deeply impressed by the clear indication of the trend of
thought on food and nutrition in Great Britain. It was when
an account was given of the war-time food policy we have
implemented here and of the various measures we have adopted
to distribute foods according to nutritional needs. After this
meeting Professor André Mayer, the distinguished French
physiologist, took me by the arm as we walked along one of
the long corridors and said in his characteristically charming
manner, ‘M. Drummond, Vous Anglais, vous faites toujours
les révolutions avec tant d’élégance !’ ”—Sir Jack DRUMMOND,
F.R.S., speaking at the Royal Institution on June 2.
360. THE LANCET]
NON-SPECIFIC EPIDIDYMITIS IN INDUSTRY
[SEPT. 7, 1946
Letters to the Editor
TREATMENT OF MENINGITIS
Srr,—There is much truth in Dr. Wilfrid Gaisford’s
remarks (August 17) against intrathecal penicillin and
in favour of intensive systemic therapy in “ non-
traumatic meningitis.” But his statement is an over-
simplification of the therapeutic problem, since he does not
draw any distinction between (1) the various bacterial
forms of purulent meningitis, and (2) the different
extent of penetration of the blood-brain barrier by
serum, sulphonamides, and penicillin in the presence of
acute meningitis. Neither of these factors can be ignored
in the treatment of meningitis.
Recent pronouncements appear to have given rise to
a widespread impression that intrathecal penicillin must
at once be given whenever spinal puncture reveals a
turbid fluid. ‘‘ Treatment by penicillin is indicated for
all meningococcal cases,’’ we are told. The “‘ introduction
at once of intrathecal penicillin if the lumbar tap is
turbid ” is recommended in addition to sulJphonamides
_and systemic penicillin.?
bit out of focus! Is it already forgotten that prompt
and adequate sulphonamide therapy is rapidly curative
in about 95% of meningococcal cases? Is there any
evidence so far that the cure of these can be hastened
by penicillin ? I do not think so, nor have I any reason
to believe that any considerable part of the other 5%
can be saved by penicillin either. i
Since the meningococcal form is the most common
form of bacterial meningitis, the recommendation for
intrathecal - penicillin on discovery of a turbid lumbar
tap results in much unnecessary intrathecal injection.
In the great bulk of such cases doubtless no harm will
come of it, but unless the technique is invariably meticu-
lous, which is a practical impossibility, the potential
danger is by no means negligible. It is not only that the
impurities of penicillin are irritating to the meninges and
may even be non-sterile, but the introduction of grave
extraneous infection—e.g., Streptococcus viridans, coli-
forms, or Pseudomonas pyocyanea—is more common
than is generally realised. :
In pneumococcal meningitis the balance of evidence at
present appears to be in favour of intrathecal and
systemic penicillin as well as large doses of sulphonamides.
But the evidence for intrathecal penicillin is not so strong
as to justify a rush to it without prior examination of
a smear from the spinal fluid.
When staphylococcus meningitis is suspected, intensive
therapy by all routes may be justified without delay,
but this is a rare condition and there is usually some
clinical guide to the diagnosis.
It was a great relief, a few years ago, to get rid of the
trauma and risks associated with routine intrathecal
injections in the treatment of meningitis. Before we
return to them let us consider well whether any real
advantage is to be gained.
London, S.E.13. H..STANLEY BANKS.
Sir,—In his letter of August 17 (p. 253) Dr. Gaisford
condemns—in no mild terms—the use of intrathecal
injections of penicillin for nontraumatic meningitis. He
states that meningitis is a systemic disease and intensive
systemic therapy is the best form of treatment. I think
most people a short while ago would have been in com-
_ plete agreement with him ; the reason for the ‘‘ retrograde
step in therapy ” is surely that patients went downhill
steadily and even died when treated on the lines so ably
advocated. The observant medical attendants then
retraced their steps and tried intrathecal medication,
with the result that those patients not beyond recall
recovered.
There is a theoretical obstacle to systemic treatment ;
though not merely banausic it is often referred to as
the “ blood-brain barrier,” and though merely a theo-
retical obstacle for many of the sulphonamides (as Dr.
Gaisford argues with effect) it is a very real handicap
when the large molecule of penicillin has to be taken
into account.
Epping, Essex. .
1. Penicillin, London, 1946, p. 273.
2. Ibid, p. 276.
FRANK MARSH.
Surely the problem has got a —
WATER-SUPPLIES
Srr,—In the Times of August 10 I read that th
Cumberland County Council has been reviewing the
present and potential supplies of water to the county.
Presumably that fortunate county of lakes and mountains
has water enough available for all time. S i
But should not some authority at the highest level
be actively inquiring into the available water of the
whole country in view of .widespread housing schemes
which will entail the provision of large new water-supplies
in town and country alike? As regards the country,
cottagers in village or scattered country districts draw
their moderate water-supply from shallow wells (except
when these run dry) in quantities limited by habit, by
the labour of working buckets and windlass or pump,
and by what their well may yield at a given time. If
all these cottagers and all the new ones promised are
to have water by pipe and taps (hot and cold), baths and
bathrooms, and water-flushed sanitation, an enormous
, quantity of new water will be needed. Where is it to
be found ? Having knowledge of country life, I estimate
very roughly that a cottage family at present supplied
by a draw-well would, if afforded the ‘‘ amenities ”
proposed for baths, w.c.s, and kitchen taps, soon come
to use 10, 15, or 20 times the volume of water previously
used in daily life. A single lavatory flush runs off two
gallons. The total will amount to very large figures.
I am not enough of a geologist to know whether or
where this water can be found, but I read with apprehen-
sion from time to time of falling rivers and failing streams
whose dwindling flow is attributed to heavy pumping
from new deep wells for water undertakings or industry.
And it is well known that the water level over the clay
of the London basin, for example, has similarly been
a good deal lowered in recent years. |
Will it not be necessary to take very far-reaching steps
to conserve vastly more of the water that falls from the
skies, if we wish to use so much more? The question
may become one of urgency. Very few of us even conserve
the rain that falls on our houses. And from streets, roads,
land drainage ditches, and the like we run it off to the sea
as fast as we can. ;
The Cumberland County Council had a comparatively
simple problem to deal with: but is it not clear that
we need a general survey of the present and potential
water-supplies of the whole country?
Upavon, Wilts. E. W. AINLEY-WALKER.
NON-SPECIFIC EPIDIDYMITIS IN INDUSTRY
Sık, —The recent articles and correspondence on non-
specific epididymo-orchitis (Lancet, 1946, i, 775, 779,
834, 870) raise questions of interest to industrial medicine.
It is not uncommon in my experience to see workmen
who develop mild epididymal pain after exertion. The
history is usually that, while lifting, pain is experienced
over one spermatic cord, and shortly afterwards in the
testicle on the same side. As the pain does not quickly
settle the workman soon reports to the works’ surgery.
On examination the epididymis is slightly swollen and
tender and there is a tenderness of the vas. In one case,
the body of the testicle was also slightly enlarged and
tender, and in yet another case the symptoms and
signs were bilateral. Examination of the urethra and a
centrifuged deposit of the urine reveals no abnormality.
A supporting bandage usually relieves these patients,
the symptoms - disappearing in a-few days. In two
cases, however, the question of workmen’s compensation
has arisen, owing to the loss of a few days’ working time.
In all the cases seen, the symptoms have been mild,
and the principal anxiety of the patient has been over
_ the possibility of hernia. No signs of this have been
discovered. .
Apart from these cases, where no obvious urinary
infection exists and where the symptoms are mild, I
have seen two severe cases of unilateral epididymo-
orchitis. These also had, as a precipitating cause,
exertion or sudden effort. One had a history of gonor-
rhoea six months previously, while the other case had
flakes in the urine, which contained a fair number of
pus cells but no organisms on direct examination.
The questions, both of urinary infection and exertion
(given as a precipitating cause), have obvious bearings
on these cases in industry. The possibility of bias,
THE LANCET |
induced by workmen’s compensation, in the history of
industrial cases, would be absent in those cases noted
after physical training or “strain” in the Services.
Slesinger ? noted these cases in Service personnel and
postulated the theory of a reflux of urine down the
vas during effort. However that mav be, it may be
important that the réle of muscular exertion in causation
be more precisely defined in, at any rate, some of the
cases.
Oxford. G. WHITWELL.
THE SISTER-TECHNICIAN
Sıe,— With regard to the article on Democratic Nursing
in the issue of July 6, we feel it very necessary to protest
strongly against one of Mr. Cohen’s suggestions. This
is that married sisters working in health centres should
have a short training in the duties of a laboratory
technician. If sisters trained in this way are responsible
for the routine investigations the standard of the
laboratories in the health centres will not be a high one,
for the work of a technician is highly specialised and is
only acquired by many years of experience. In the
opinion of this committee, the laboratories should be
staffed with trained technicians to obtain a satisfactory
standard of work. PHYLLIS LANGAN PLUMBRIDGE
Secretary of the Committee.
London General Medical Branch, Association
of Scientific Workers.
VARIATION IN THE FEMALE PELVIS
Sir,—In connexion with the article by Dr. C. Nicholson
and Mr. H. Sandeman Allen (August 10), I should like to
comment on a few variations in the female pelvis which
we observed in the X-ray department of Shrodells
Hospital, Watford. The patients here are probably
representative of the London suburban population and
belong to all social strata, being referred for pelvimetric
analysis by private practitioners, obstetric specialists,
antenatal clinics, and maternity homes in the neighbour-
hood.
A striking feature is the comparative rarity of the
typical android pelvis, as described by Caldwell and
Moloy, with all its associated features—the acute
angle of the forepelvis, the short anterior transverse
diameter, the long and narrow sacro-sciatic notch, the
short posterior sagittal diameter, the deep symphysis
pubis, the narrow subpubic angle, the wide and straight
sacrum, and the deep true pelvis. The incidence of pelves
showing at least a few of these characteristics was not
more than 6-7 % of the total of 1200 pelves examined. In
a follow-up of the subsequent course of delivery we found
a surprisingly high need for interference and assistance
in this type. While the total need for interference in all
cases delivered at home by practitioners and in nursing
homes or hospitals was around 11%, the pelves with
android tendencies required assistance in 62 %.
To determine an android hind-pelvis we use a much
lower figure for the sagittal index than that given by
.Nicholson and Allen for their scutiform type. We do
not consider the arbitrary figure of 30 for the upper
level of the index as really indicative of a short post-
sagittal diameter if the index for the whole series of
307 cases is not higher thah 35:6. The figure which we
stipulate as the upper level for the index denoting a
narrow android hind-pelvis is 25. We feel that the
inclusion of pelves with indices above this figure would
lead to very slight variations of the round type being
considered among the android group. This would lead
to erroneous conclusions if an assessment of the course
of labour in relation to pelvic type is attempted.
Table vi of Nicholson and Allen, which gives the
mathematical basis for their conclusion that pelvic type
has no influence on the course of labour, shows however
—be it statistically significant or not—that the scutiform
pelvis required assistance in 46:5% of all pelves of this
type, while the narrow (anthropoid) only required inter-
ference in 32:3%, the flat in 37:5 %, and the round in
38-7 % in all cases of their respective types. I am con-
vinced that if a lower sagittal index were applied to
separate the scutiform group from the rest, and thus
all near-gynzcoid pelves be excluded, then the percentage
assistance rate in the first group would rise considerably.
1. Slesinger, E. G. Proc. R. Soc. Med. 36, 323.
VARIATION IN THE FEMALE PELVIS
[SEPT. 7, 1946 36]
The correlation coefficient between the sagittal index
and the ischial spine distance is very near the limit of
being statistically significant and would suggest that
with a low sagittal index occasionally an interspinous
narrowing could be expected, as is actually the case in
the funnelling of the true android type.
I do not think that any decisive conclusions can be
derived from consideration of the course of delivery
in about 30 cases of the scutiform type. This type
embodies only one feature of the android pelvis, and the
quantitative limits for inclusion in this type are drawn
too widely. From a radiological point of view I do not
feel it justifiable to diagnose an android pelvis from the
comparative relationship of two segments of one longi-
tudinal diameter in the inlet plane alone, as was done in
the case of the scutiform pelvis. I firmly believe that
consideration of all the other characteristics at different
levels of the pelvic cavity is at least as important, if
not more so, and enables one to arrive at a usable predic-
tion about the probable course of labour. If typical
android features are present in various parts of the pelvic
canal a prolonged and difficult labour is to be expected
in the majority of cases in which only the slightest dis-
proportion coexists.
Pinner. J. RABINOWITCH.
“ CURARINE ”’
Str,—Some confusion has arisen in the nomenclature
of alkaloids from curare which it is important to resolve
in view of the renewed interest shown in curarising drugs.
The word curarine was applied by Boehm in 1897
to an amorphous alkaloid which le isolated from gourd
(calabash) curare. From tube-curare he isolated a
chemically different amorphous alkaloid which he called
- tubocurarine, and King in 1935 described the isolation
and chemical structure of a highly active crystalline
alkaloid from tube-curare which he regarded as the
crystalline form of Boehm’s preparation and applied the
name d-tubocurarine chloride to it. Dutcher has recently
isolated the same d-tubocurarine chloride from native
curare prepared from Chondrodendron tomentosum. _
Ranyard West, whose work on the treatment of spastic
rigidity, Parkinsonism, and tetanus with curarising drugs
in 1932-36 and subsequent years aroused so much interest,
worked at first with crude native curares. Later he used
an amorphous alkaloid called ‘‘ curarine”’ which King
prepared from Strychnos toxifera, a liane known to be
used in the preparation of calabash curare in British
Guiana. West ran into the difficulty that cases of bron-
chospasm often occurred during treatment and has
rightly emphasised this danger. Recently, however,
reports have been published in this country of nearly
2000 cases of anzsthesia in which a preparation supplied
by Messrs. Burroughs Wellcome & Co., as ‘‘ curarine
chloride ”?” has been used without any cases of broncho-
spasm occurring. The discrepancy between this series
and Ranyard West’s reports is due to the fact that the
drugs used were different; the Wellcome ‘“ curarine
chloride ”’ is crystalline d-tubocurarine chloride derived
from tube-curare.
Messrs. Burroughs Wellcome & Co., in naming their
preparation “‘curarine chloride,” were actuated by a
desire to avoid a polysyllabic name. The term curarine
would be better dropped entirely, leaving new alkaloids
of this class to carry their appropriate adjectival prefixes,
a Messrs. Burroughs Wellcome & Co. now propose
O.
Wellcome Physiological Research Laboratories, J. TREVAN.
Beckenham, Kent.
AID TO DEFÆCATION
Str,— Your correspondent,.C. W. B. (August 10), advises
rubbing the lower back in order to secure an easy
defæcation. This is indeed a treatment of value, but it
is only successful in suitable cases. |
In every great cattle-market you will find wise farmers
testing the alimentary canal of a cow or steer they wish
to buy by scratching the sacral area of its spine with
their walking-stick. This commonly produces an
evacuation, and from this excrement the experienced
old farmer decides on whether to bid or to abstain.
This method is, however, of less efficacy in the case
of horses, and is practically valueless in the case of
constipated dogs. The nerve stimulus acting upon the
362 THE LANCET]
CIROULATION IN THE KIDNEY
[SEPT. 7, 1946
nerves of the intestinal muscles produces an immediate
reaction when the contents of the intestine are com-
paratively liquid; the nerves of the skeletal muscles,
which are called into play in the case of hard fæces, are
not affected. Cows therefore readily react, but the
habitually constipated human must not expect such a
result unless he regularly takes a daily meal of foods
like boiled beetroot, grated raw carrot, grated raw
turnip, or cabbage.
The same mechanism comes into operation when a
hay rake is applied to the sacral spine of a lazy bull;
in this way the muscles of the vas deferens are stimulated,
but not the skeletal muscles themselves.
London, W.1. JOSIAH OLDFIELD.
Pod
Srr,— Your correspondent may be interested to know
that this manœuvre was described in my Treatment of
Some Chronic and Incurable Diseases (Bristol, 1937,
p. 106), a second edition of which is in the press :
“ A wave of colon peristalsis can often be encouraged by
auto-massage of the muscles just above the left posterior
superior iliac spine. With the fingers of the left hand close
together, a circular clockwise pressure is made over an area
about the size of half a crown, the skin being fixed under the
fingers. This can be practised in the lavatory, if a motion
just fails to come.”
Incidentally this spot is.one to which the descending
colon sends out messages of discomfort or disease, when
it will be found to be very sensitive.
I learned of this trick twenty years ago from a patient
from tropical South America who had been taught the
method by anative doctorwith a hereditary ‘‘ degree” only.
Bristol. A. T. Topp.
CIRCULATION IN THE KIDNEY
Srr,—The report by Dr. Trueta and his colleagues
recalls four renal cases which I investigated radiologically
at a Service hospital in India.
The men were all referred for routine intravenous
pyelography, and each showed absence of function on
one side. The first two showed normal function on
both sides when the examination was repeated after
about 48 hours. In neither case was there evidence of
calculus formation or other abnormality.
The unilateral cessation of function prior to the first
` examination was thought to be due to restriction of
fluids combined with excessive sweating in the hot
climate. It was, however, difficult to understand why
this was complete rather than only partial and why
it was unilateral. Nevertheless, when further cases with
unilateral absence of function were found in which
there was no other abnormality, the examination was
again repeated within 48 hours, following a more liberal
intake of fluids; .and two then showed restoration of
normal function on both sides. There was no evidence
of calculus formation on the original films in either case,
and the minor calices, when visualised at the second
examination, were normal.
In the light of Dr. Trueta’s paper, I am inclined to
think that these 4 cases were examples of the device
whereby the cortex of a kidney is excluded from the
renal circulation, consequent upon diminished blood-
volume; in other words, the altered function was
simply the result of diminished fluid intake in otherwise
normal subjects in a hot climate.
Withington, Manchester. BRIAN DONNELLY.
THE LONDON COLLEGE OF OSTEOPATHY
Sır —Mr. W. E. Tucker (July 27, p. 145) entirely
discredits the theory of osteopathy, while accepting
. many of the manipulative. procedures introduced to
England by the osteopaths. His grounds for discrediting
the theory are the findings of a select committee of the
House of Lords. However august such a body may be,
it is hardly one which should be chosen to investigate,
clinically and theoretically, a form of therapy.
It is only too patent that while orthopedic surgeons
and physiotherapists have adopted some manipulative
methods, in large part these have been badly learned.
The College sets out to teach qualified medical practi-
tioners all that is best in osteopathy as taught and
practised in America. W. HARGRAVE-WILSON
London College of Osteopathy. Sub-Dean.
. days, when it proved to be too late.
SMALLPOX AND VACCINATION
Sık, —Dr. Boul and Dr. Corfield (August 24, p. 284)
are to be congratulated on the success with which the
outbreak of smallpox in Essex in the early part of this
year was controlled and a major epidemic prevented.
is is one more illustration of the efficacy of modern
measures for combating smallpox if efficiently carried
out, and it supports the view that smallpox, especially
the major variety, is, of all the epidemic diseases known
in this country, one of the most amenable to control.
This does not mean that all the measures adopted by
them were of equal value. Some no doubt would call
in question the value and advisability of the mass
vaccination campaign. We are told that 15,000 persons
were vaccinated in five days, but we are not told the
total number for the whole of the campaign. It is to be
noted that Dr. Boul and Dr. Corfield make no claim
that the mass vaccination campaign played any material
part in bringing the outbreak so satisfactorily to a close,
and in this I think they are wise. Results have some-
times been claimed for mass vaccination campaigns when
there was no real evidence to justify the claim. It is a
debatable point whether a mass vaccination campaign,
involving the vaccination of many thousands of persons,
with all the suffering from ‘‘ bad arms ’’—not to mention
more serious results—which such a measure necessarily
entails, is ever really called for until it is certain that
other and less drastic measures have failed. In addition
to the injury to health there is all the public scare and
upset which such campaigns inevitably engender. This
would matter less if there was any guarantee that a mass
vaccination campaign would cut short an outbreak,
but even with the most energetic campaign there will
always be plenty of people left unprotected to carry on
` the outbreak.
In the outbreak of smallpox in the neighbouring
county of Middlesex, reported -in the British Medical
Journal for August 10, 1946, equally satisfactory results -
were obtained without any recourse to mass vaccination
of the general population.
Other points in the article by Dr. Boul and Dr.
Corfield calling for comment are:
1. Of the 4 fatal cases, 2 were vaccinated and each
had four marks; so even “ efficient ” vaccination is no
guarantee against death from smallpox if too long an
interval has elapsed. In one of the cases the interval
was only 27 years. Of the 2 fatal cases which were
unvaccinated one (R. Pe.), a contact, might have escaped
death had he not foolishly refused vaccination for five
It is to be hoped
that when compulsory vaccination is repealed hostility
to vaccination, which compulsory vaccination undoubt-
edly engenders, will gradually disappear, and that no
close contacts will then refuse vaccination. There is
good reason to believe that vaccination during the
incubation period, if performed early enough, does
mitigate an attack even if it fails to completely protect.
2. One of the cases (Mr. Rd.) was the sanitary inspector
who arranged the disinfection of the houses and bedding.
He had been vaccinated but never re-vaccinated, and his
attack unfortunately proved fatal. Another case was
a nurse at the smallpox hospital who had an abortive —
attack. All members of a public-health staff who may
have to fight smallpox—doctors, nurses, sanitary inspec-
tors, &c.—should of course be protected by repeated
vaccinations as a matter of routine.
3. I agree with most of their ‘‘ Conclusions,” though
I am a little doubtful about no. 3, which deals with the
question of ‘‘ marks.” I am inclined to think that length
of interval since the last vaccination is of more importance
than the number of marks. I would rather make “ little
and often ” my slogan. I admit of course that in the
case of the general public frequent vaccination is quite
impracticable, but then I regard immunisation of the
general population as not the way to protect a community
against smallpox. The case of a public-health staff,
however, is quite different, and they should be vaccinated
every few years. Indeed, it might not be a bad plan to
make it an annual event for the whole staff, headed by
the medical officer of health. After the first vaccination
there would be practically no reaction, so no inconvenience
would be caused.
Leicester. C. KiILLick MILLARD.
THE LANCET]
A SYNDROME SIMULATING ACUTE ABDOMINAL DISEASE
[SEPT. 7, 1946 363
CHILDREN WHO SPEND TOO LONG IN BED
Sm,—I am not competent to question the accuracy
of the rules for sleep that Dr. McCluskie lays down in his
article of August 31 (p. 302), though I should like to know
how he obtained his results, and whether he is giving
average or mean figures: from my own very limited
experience of infants and children I should have said
that the individual variation covered a far greater range
than that of 30 minutes per 24 hours. It would also
be interesting to know if a significant proportion of
neurotic children have a history of having been kept too
long in bed. F
I particularly want to emphasise the impossibility of
following Dr. McCluskie’s rules when there is more than
one child in the family. It might be feasible, even for
the unassisted mother, who has cooking, shopping, and
housework to do, as well as looking after the baby, to
arrange her time-table so that an only child could be
released from its bed directly its 12 hours at night and
its 6 or 21/, in the day were up. But when there are two
or more children, one perhaps an infant on four-hourly
breast-feeds, the difficulty of getting Tommy up after
one hour’s sleep in the afternoon, of keeping John
happy from 7.0 a.m. to 7.0 P.M. without a break, of
feeding Mary at 6.0 A.M., 10.0 A.M., 2.0 P.M., 6.0 P.M., and
10.0 P.M. would send most mothers to the psychiatrist
on their own account, before their children were so much
as threatened with that modern bogyman. Dr.
McCluskie should remember that after the children have
been put to bed there is still their father’s dinner to cook,
and if that is to be followed by a round of ‘“‘ pottings ”’
and a 10.0 p.m. breast feed, can we blame the mother
who does not rise at 6.0 the next morning to feed
the infant and wake and dress the children who have
been !in bed since 6.30 or 7.0 the previous evening ?
I should also like to know how Dr. McCluskie deals with
the infant who is not old enough to sit or crawl and who,
when propped up in a pram with his toys around him
and enjoined to stay awake because this is his playtime,
proceeds to fall asleep in the most uncomfortable position
possible, in spite of having slept 14 hours the previous
night and 3 hours that same morning.
I feel strongly on this subject because it seems to me
this is another case of the academic approach being
used to a problem that is mainly human and domestic.
Too many overworked women are unnecessarily worried
if their babies’ meals are 15 minutes early or late, though
the baby may raise no objections. Don’t let us overload
their consciences further by threatening them with
neurotics or psychopaths for children if they treat them-
selves to a 7 or 8 hour night or an occasional half hour’s
rest in the afternoon. The neurotic mother, however
rigidly she adheres to a time-table, is not likely to bring
up the happiest or even the healthiest children.
London, W.11. CATHERINE STORR.
A SYNDROME SIMULATING ACUTE
ABDOMINAL DISEASE
Smr,—The paper by Mr. Goldstone and Dr. Le
Marquand in your issue of August 24, in which they
describe what they believe to be a new abdominal
syndrome occurring in European Servicemen in West
Africa, was most interesting to me as their description
very closely simulates. and indeed may be identical
with, a condition which can also occur in West Africans
and which I described last year (J. R. Army med. Cps,
1945, 84, 201).
Briefly, among 230 cases of infective hepatitis in
Nigerian troops seen over a period of two years, there
were 7 cases which were so striking clinically, and so
closely resembled each other, that I called the group
“ the acute abdominal syndrome ”’ and emphasised that
their importance lies in the fact that a surgeon with no
experience of such cases might easily feel it his duty
to explore the abdomen even in the presence of jaundice.
Could it be that the cases of Mr. Goldstone and Dr.
Le Marquand were in fact suffering from latent or sub-
clinical infective hepatitis? Although the urine was
tested in each of their cases, in subicteric patients bile-
salts are present only intermittently in the urine, and
several specimens at intervals should be examined. Or
could it be that my cases were suffering from this new
syndrome which presumably came on during the course
of infective hepatitis ? Whatever the answer the clinical
similarity of our cases is striking and the prognosis
without surgery excellent. In support of your con-
tributors’ theory of a staphylococcal origin, and for
what it is worth, staphylococcal infection (pyomyositis)
is very prevalent among West Africans. |
In over a year’s service with native Indian troops in
India no similar cases were encountered.
Stoneleigh, Surrey. S. ORAM.
ENTERTAINING ALLOWANCE IN THE NAVY
Sir,—Thbe recent Admiralty Fleet Orders (453-457)
set out the entertaining allowance for Executive Officers,
Royal Marine Officers, Wren Officers, Engineer Officers,
and Supply Officers (Paymaster Branch), but no mention
is made of the Medical Branch. For many years the
Medical Branch have felt that they have a very justifiable
grievance in that senior officers have no entertaining
allowance and yet are expected to give hospitality to
Admiralty visitors and anyone whom Parliament wishes
to be entertained at the hospital. During the war years
this was a very heavy item and numerous foreign and
allied officers were given hospitality on many occasions.
It seems that every branch of the Navy is given enter-
taining allowance except the Medical Branch, and this
surely should be put right.
London, W.1. CECIL P. G. WAKELEY.
ADVERTISING PATENT MEDICINES
Sm,—Dr. Thompson’s article of August 24 on the
advertising of patent medicines in the public press
“ provided ammunition ” in plenty for those who would
attack the more unscrupulous methods adopted by the
trade ; but he did not touch on an aspect of the subject
to which our own profession can give immediate remedy—
the trading on the gullibility of doctors in the medical
press. An all-wise Government now sees to it that only
a limited proportion of the morning mail contains
literature from the drug firms; but recollections of the
bad old days before the recent war teem with pamphlets,
all of them persuasive, most of them expensively got
up, some of them well-written, but few of them read and
almost none of them asked for.
I am well aware of the purpose and importance of this
form of literature, and I neither question the wisdom of
the drug firms in spending their money and their highly
qualified employees’ time on its production, nor the
usefulness of some of it to the medical practitioner.
Nor do I suggest that any of the medical journals should
be without their advertisement section, quite apart from
the financial side of the question. But when I look
through the advertisements composed for the notice of
the medical profession it seems to me that some take a
great many high sounding words to say very little;
others endeavour to blind the humble doctor with science,
or pseudoscience ; a few are frankly misleading. On the
other side of the coin are all.the arguments which could
be advanced by the advertisers, many of which are
readily admitted. The point, however, is this: that
doctors are themselves susceptible to the pressure of
advertisements, and to the salesmanship, as opposed to
the information therein contained, and are liable to
accept the over-simplification (of imperfect scientific
knowledge) which is designed to sell a product. They
thus contribute to the perversion (and consequent
increased cost) of advertising, which is usefully employed
in bringing genuine innovations to the notice of the
profession, but crosses the frontier between ethics and
mercenary expediency when it suggests that the opinion
of an anonymous authority, ‘or the testimony of some
thousands of medical practitioners, which favours a
particular product, however elegant, is a scientific fact.
W. LANE PETTER.
OUR HOUSES
Str,—Mr. Saward (August 24) is quite right. Of course
every house should have two w.c.s, and with hand-
washing basins. But when the waterworks company.
impose an annual tax of 10s. on each “extra” w.c.,
as they do here, people have to put up with minimum
essentials. Blame the waterworks, not the general public
Bristol. ARTHUR T. SPOOR.
Camberley, Surrey.
364 | THE LANCET]
‘ DESOXYCORTONE AND ARTHRITIS
[SEPT. 7, 1946
APPEAL FOR MEDICAL AND NURSING JOURNALS
Sir,—Reports and requests from UNRRA missions in
Europe make it abundantly clear that the greatest
expressed need of doctors in the liberated countries is
for medical literature covering the war years, so that
they may bring themselves up to date with advances
in unoccupied countries.
From time to time appeals for medical literature
for individual countries have appeared in the medical
press, and the British Council, the Ministry of Informa-
tion, the Royal Society of Medicine with its microfilm
scheme, and other bodies have done something to cope
with the problem, but, as a whole, the needs of Europe
have hardly begun to be met.
Even if UNRRA could spend its now scanty funds on
medical re-education—which it is authorised to do only
in the limited sense of informing doctors how to use |
` drugs and other medical supplies supplied by UNRRA
with which they may be unfamiliar—a special difficulty
arisés in the case of British medical and nursing literature
on account of the paper shortage.
I am, therefore, appealing for complete sets of general
and specialist medical and nursing journals covering
approximately the war years. They should be sent to
Dr: H. Hadaway, Room 1934, Health Division, UNRRA,
19, Portland Place, London, ‘W.1 (Telephone: Langham
3090/341), and carriage will be repaid if requested.
If it is felt that the sets cannot be given free of charge,
a price should be stated before the sets are forwarded
to us and we will try to obtain authority for their pur-
chase. A particular request which we have so far been
unable to meet is for a complete set of THE LANCET
(1989 to 1945 inclusive) for Hungary.
London, W?1. NEVILLE M. GOODMAN.
PHYSIOLOGY OF CONVALESCENCE
Sm,—I am sure your leading article of August 10 was
not meant to imply that convalescence is merely a matter
of protein administration. ‘Nevertheless this may be
an opportune moment to draw attention to other factors
influencing convalescence—namely, the patient’s person-
ality and emotional state, and his relationship with his .
doctor. l
Every surgeon is at times confronted by the case
where ‘‘ things will go wrong ”?” despite irreproachable
technique before, during, and after operation. In patients
who seem to be of equally good physical type the course
of convalescence after the same operation may differ
enormously. I suspect that it does not entirely depend
on postoperative feeding, and I wonder how much
attention was paid to emotional factors in the experi-
ments you describe. A surgeon with an indifferent
technique (there are some such about) may present
some surprisingly good end-results. I am led to believe
that personality as well as protein, character as well as
calories, play their part. Convalescence being a process
of psychic healing as well as tissue healing, it is worthy
of study by the psychiatrist as well as the biochemist.
Convalescence on the whole is better conducted by
the family doctor, who is more likely to understand
the mental make-up and requirements of his patient.
Even the specialist surgeon who attaches as much
importance to pre- and post-operative care as he does
to operative technique (no longer a rara avis) is as
likely as any other—perhaps indeed more likely—to
disregard his patient’s personality. Moreover not all
surgeons are equally suitable for all patients ; and just
as, with free selection, a patient gets the practitioner he
deserves, he should also have the surgeon whose person-
ality best fits his own. The family doctor’s choice of
surgeon is or should be infiuenced by the surgeon’s
personality as well as his ability with a scalpel. —
To a patient HIS operation is a major event in his life
—a milestone if not a tombstone, a turning-point,
ominous and fraught with danger. It may come as a
climax to a series of mounting fears, or as a devastating
bolt from the blue; in any case the trauma is psychic as
well as physical. Even after the operation, fears for the
future may remain; often a modification or radical change
in his life is necessary. These considerations need skilled
help, and his convalescence will be influenced accordingly.
Certain operations, moreover, have a special signifi-
cance to the patient. The loss of the uterus or a breast
in the female, prostatectomy or removal of a testicle
in the’male are examples of mutilating operations, with
particular effects on the psyche. In considering cancer,
the patient’s fear necessitates regard for personality as
well as postoperative prognosis. Psychic preparation,
suggestion, reassurance, and explanation are as necessary
as the choice of pre-anzsthetic or the Fowler position.
Here the psychiatrist may well be able to show the
influence of personality and reaction-type as well as of
neuroses and anxiety patterns in determining success.
Is it too much to hope that the nurse should help more
constructively in these problems? At present, and
through no fault of her own, her conversation consists
of useless if not harmful platitudes, interspersed with
blood-curdling reminiscences. Were she brought more
into the picture as an intelligent assistant to the team
her constant presence might be used to the mental as
well as physical benefit of the patient.
Convalescence depends in its final analysis upon the
total personality of the individual, and upon his mental
and physical make-up, and their reactions to trauma.
These should not be neglected in any study of convales-
cent problems. l
London, W.1. S. CHARLES LEWSEN.
DESOXYCORTONE AND ARTHRITIS
Str,—Dr. Harrison will always be in trouble with his
statistics until he cultivates the habit of defining his
symbols carefully. His recent calculation (Lancet,
August 10) differs from mine not because either of us is
incapable of arithmetic but because the P which he
calculates represents among other things the probability
of a number of dead rats not developing arthritis. Such
a probability is naturally much higher than my estimate
based on the behaviour of live rats.
My prolusion was purposely vague to spare Dr.
Harrison’s feelings. But now he tells us that he has
the support of a member of the Institute of Statistical
Analysis at Oxford. I trust for the good name of Oxford
statistics that I may assume that this adviser never read
the paper of Selye (1944) on which the arguments are
based. Serious discussion is difficult, because the logic
is almost entirely that of Lewis Carroll rather than of
Dodgson. This mysterious P, the meaning of which is
always changing, is calculated to two places of decimals
suggesting accuracy; but it is a matter of arithmetical
convenience how it is calculated and the answer depends
on the method. This is the sort of thing which Alice
found so trying and which made her head go. round.
The use made of P is just as startling as the methods
of calculating it. Statistics do not prove a hypothesis
directly ; but if good experimental design reduces
possible alternative explanations to two or three, statis-
tical methods may show that all except one are improb-
able. Dr. Harrison has to choose between Selye’s
hypothesis that adrenalectomy and thyroidectomy
. facilitate the production of desoxycortone arthritis and
his own hypothesis that their effect is negligible. There is
no question of Selye’s hypothesis being improbable. It
is Dr. Harrison’s which is on the borderline of being
eliminated. P stands for the maximum probability of
Dr. Harrison being right, and his argument can fairly
be summarised by saying that he considers that he has
afforded statistical proof of his rightness if he can show
that the odds against himself are less than 20: 1; whereas
Selye is wrong unless the odds are 20:1 in favour. No
doubt we shall hear from Dr. Harrison that this is a
‘* perfectly valid statistical procedure ” and an orthodox
application of the nul hypothesis, or another of those
numerous phrases with which specialties exert their
tyranny. If so, Selye is truly in an unfortunate position.
He never attempted to justify his statement statistically:
but relied on quantitative as well as qualitative differences
and on control series represented by a succession of
papers in previous years. He also gave a number of
subsidiary arguments which led up to his experiments.
All these points are unrepresented in the contingency
tables which are said to summarise his evidence. In
addition, the number of controls in the contingency
tables is so small that it is virtually impossible for
Dr. Harrison’s requirements to be fulfilled.
I must apologise to Dr. Harrison for the Pickwickian
vigour of this onslaught. The point at issue is quite
important. In medicine, we are always being. bullied
by the expert behind the scenes who threatens us with
oe eae eo a ae r Ait
LER. We oN 2 pe uiy EE
THE LANCET]
specialised profundities. If he really collaborated and
his name appeared at the head of an article, it would
not matter because he could be attacked by fellow
experts. Dr. Harrison’s paper is typical of hundreds
of others. His experimental work is excellent. The
arithmetic of his statistical adviser is beyond reproach.
But there is no logical cohesion between the two. He
and his adviser have unwittingly misled each other.
Neither is to blame. The fault lies in our cultural legacy
of science split up into water-tight compartments. What
is true of statistics is equally true of radiology, histology,
clinical laboratory reports, &c. I want to plead for
more whole-hearted collaboration. Experts must not
lose touch with general medicine, and general medicine
must learn from experts.
Royal Society of Medicine. DENYS JENNINGS.
SPLANCHNIC BLOCK FOR ANURIA
Smr,— Your leading article of August 17 on the recent
work of Trueta and his colleagues! refers to the need
for further trial of splanchnic block in anuria. The
interesting and attractive explanation of oliguria made
possible by their observations lends belief to the probable
benefit from splanchnic block. Nevertheless, caution is
needed in interpreting a diuresis which may follow this
method of treatment.
In the last two years, we have had 4 cases of severe
oliguria after abortion,-all treated conservatively without
hypertonic solutions, splanchnic block, or decapsulation,
and all had a spontaneous diuresis and recovered.
Detailed biochemical studies were made, and are being
reported elsewhere. If splanchnic block had been done
towards the climax of their desperate illness, doubtless
it would have been given the credit for their recovery.
CasE 1.—Single, aged 31. Abortion at 16th week, followed
by 10 days oliguria with secretion of only 262 c.cm. urine.
Blood-urea rose to 550 mg. per 100 c.em. Excellent diuresis
then occurred, and complete recovery. Well two years later.
_ CASE 2.—Single, aged 37. Abortion at 16th week, followed by
14 days severe oliguria with a total secretion of 2360 c.cm. urine.
Blood-urea rose to 350 mg. per 100 c.cm. Good diuresis then
began and blood-urea returned to normal. Well 22 months later.
CasE 3.—Married, aged 24. Two children. Incomplete
septic abortion at 16th week. Oliguria persisted for 13 days,
and during this time she passed only 1350 c.cm. urine. Like
the previous cases, she was extremely ill with vomiting and
hiccough, and she became cedematous. Blood-urea rose to
400 mg. and the serum potassium to 42:5 mg. per 100 c.cm.
The heart became completely irregular and the electrocardio-
gram showed very large T-waves and absent P-waves. Spon-
taneous diuresis then occurred, and, although colpotomy
was necessary for pelvic abscess, she made a satisfactory
recovery, and was well three months later.
CasE 4.—Single, aged 31. Admitted on account of blood-
stained vomitus, but found to have an incomplete abortion.
She had been losing for a week. The next five days a moder-
ately severe oliguria was noted. Blood-urea rose to 365 mg.
per 100 c.cm. A diuresis then began, and her blood chemistry
returned to normal within two weeks. She was quite well
18 months later.
As far as could be determined, these cases were not
due to incompatible blood-transfusion, sulphonamide
therapy, or abortifacients. They may have begun as a
reflex vascular spasm with cortical ischemia, and
possibly progressed to thrombosis and cortical necrosis.
In the obstetrical wards there has also been one fatal
case of anuria from cortical necrosis of the kidneys in
a girl of 16 admitted at term with severe accidental
concealed hzemorrhage. She was delivered of a stillborn
child and developed anuria and died on the third day.
A splanchnic block with amethocaine hydrochloride was
given on the second day, and repeated on the third day,
but without any effect.
About 1500 deliveries and 400 abortions are admitted
annually at this hospital. In view of our experience it
is surprising that only 19 cases of acute renal failure
after abortion, and only a total of 52 associated with
pregnancy, have so far been published.?
M. A. M. ee
F. AVERY JONES.
nee onder, woe eee = J. MacVine.
1. Boa Ja Barclay, A. E., Danicl, P., Franklin, K. J., Pritchard,
. M. Lancet, August 17, p. 237.
2. O'Sullivan, J. V., Spitzer, W. J. Obstet. Gynæc. 1946, 53, 158.
SPLANCHNIC BLOCK FOR ANURIA—OBITUARY
[SEPT. 7, 1946 365
Obituary
ARTHUR TUDOR EDWARDS
M.A., M.D., M.CHIR. CAMB., F.R.C.S.
Mr. A. Tudor Edwards, who died suddenly at St.
Enodoc’s, Cornwall, on August 25, won a world reputation
by his advancement of thoracic surgery.
Born in 1890, Arthur Tudor Edwards was educated
at Mill Hill School, at Cambridge University, and at
the Middlesex Hospital where he was awarded the
senior Broderip and university scholarships. From the
first it was clear that his bent was surgery. At the
Middlesex he worked under the late Sir John Bland-
Sutton and Mr. (now Sir) Gordon Gordon-Taylor; the
surgery of mangled limbs he learned from the mechanical
genius of Meurice Sinclair; and he gained a wide
experience of traumatic and general surgery during the
first world war, in which he served as a major with a
casualty clearing station. After demobilisation he acquired
an aptitude for treating the
aftermath of operations on
the gastro-intestinal tract that
must have been the envy of
his colleagues. The years of
waiting were ended by his
appointment to the Westmin-
ster Hospital and the Brompton
Hospital. His way was not
easy ; the attitude to thoracic
surgery was at that time one
of cautious, and indeed justi-
fied, reserve which was to be
overcome only by proof that
major procedures could be
undertaken with safety. In
his successes with the surgical
treatment of bronchiectasis,
bronchial and cesophageal car-
cinoma, and pulmonary tuber-
culosis, Tudor Edwards pro- ,
vided that proof; and to the ,
Brompton he attracted visitors of all nations, eager to
learn his methods.
His reputation was established through his pioneer
work in developing techniques which helped to advance
thoracic surgery from the occasional reluctant, and
always precarious, intervention to the status of an
acknowledged specialty ranking with abdominal and
other accepted branches of surgery. But he had further
claims to recognition: he was a great operator and a
teacher of distinction. Those that saw the easy grace
of his technique in the difficult procedures that had
previously defeated others realised that he was in the
front rank of great operators; his associates were
perhaps most impressed by the courage and foresight
with which he embarked on difficult cases, and by his
sound clinical judgment. Really great success in major
surgery comes not to the lone worker but to the man
who can organise and inspire his colleagues, assistants,
and nurses to form one harmonious unit, and in this
again he set a great example.
‘‘My first meeting with Tudor Edwards,’ writes
G. M., “ was in the early nineteen-twenties, when I
sought his help on behalf of a patient with bronchial
carcinoma. That first contact made an impression which
is still clear; for even at that time he showed the
characteristics which were to make him ‘a leader and a
pattern for the younger men in his specialty, both in
this country and abroad. His manner was grave and
courteous, he paid careful attention to my notes of history
and clinical findings, to the reports of bronchoscopist
and pathologist—and then he crosschecked them all!
Essential data must be verified if he did not know and
trust those who had recorded them. We were not offended,
for it was clear that his one object was the safety of
the patient, and this he ensured by every resource he
could command. Nothing second-rate would do. He
was an outstanding organiser of team-work. Surgeon,
physician, radiologist, pathologist, anzesthetist, physio-
therapist, nursing staff, surgical assistant—all knew
what was expected of them and gave of their best. The
patient also was made fully aware ofthe nature of the
Coster
366 THE LANCET]
OBITUARY
[SEPT. 7, 1946
operation planned, of its risks, and of any disabilities it
would entail. His full coöperation was obtained in a
carefully planned course of preoperative and post-
operative treatment. Tudor Edwards, or ‘‘ Tudor ” to
his friends, could act with the utmost decision and
despatch ; but action was quiet and seemingly unhurried.
His manner in the operating theatre was typical of the
man—decisive, but gentle and considerate. I never
heard him speak impatiently or unkindly to those who
were assisting him.”’
His published work gives some idea of his vast experi-
ence in the last twenty-five years. Thus his last important
paper, in the first number of Thorax, contains an analysis
of over a thousand cases of bronchial carcinoma, in 70 %
of which he had performed either pneumonectomy or
lobectomy. He was the first surgeon in this country to
perform with success lobectomy by dissection; and he
had already had many successes with tourniquet lobec-
tomy before its general introduction in 1931. He was
the first surgeon in this country to perform a pneumon-
ectomy; and he was among the first—if not actually
the first—to report successful resection of the carcino-
matous cesophagus. He is also known for his fundamental
contributions to the treatment of empyema. i
In 1936 the London Hospital invited him to organise
a department of thoracic surgery, and he resigned from
the Westminster Hospital to concentrate on his specialty.
As consultant thọracic surgeon to the L.C.C. he was
responsible fọr founding the successful unit at St. Mary
Abbot’s Hospital. He was also surgeon to King Edward
VII Sanatorium, Midhurst, and was attached to Queen
Alexandra’s Hospital, Millbank. The strain of these
many activities, along with that of a busy consultant
practice, inevitably took its toll. In 1938 he had a severe
illness, but made a good recovery. In the autumn of
1939, however, he again fell ill. Even this did not deter
him from once more throwing all his energies into work
during the second war. He was obliged to limit his
operating, but, as consultant adviser to the Ministry of
Health, took an active part in the founding of centres
for the reception of thoracic casualties throughout
Great Britain; these have proved so valuable that it
is difficult to see how they can be dissolved. As civilian
consultant to the R.A.F. he founded a special centre ;
_ he was also consultant thoracic surgeon to the War
Office, and served on many committees. In 1939 he was
awarded the honorary degree of M.D. by Grenoble
University, and in 1943 was appointed to the council
of the Royal Collegeof Surgeons. He wasa past president
of the Association of Thoracic Surgeons, and was recently
elected first president of the Association for the Study
of Diseases of the Chest, which owes its origin largely to
his inspiration and enthusiasm. Only this year the
degree of M.D. was conferred on him, honoris causa,
by the University of Oslo, which, during his last
sari sent him a gold ring. He is survived by his
widow.
G. G.-T. writes: ‘‘ Those who have been reckoned
great in surgery must of necessity be supremely skilled
in the craftsmanship of our profession; they must by
the initiation of some novel and successful system of
treatment or by the operative invasion of territories
hitherto unconquered have conferred untold blessing on
. mankind ; their work must have illumined the dark,
mysterious chasms in our knowledge of disease; but
they must also have trained and inspired a band of
surgical acolytes. Tudor fulfilled these criteria right
well; his operating theatre became a Mecca not only
for thoracic surgeons but for general surgeons from all
over the world.’’ ‘‘ Sincerity and directness of purpose,”
adds a colleague, ‘‘ were unmistakable in his character,
and one feels that he would ask no greater memorial
than the realisation of how much the chest surgery of
today owes to his efforts.”
Surgeon Commander W. T. GWYNNE-JONES, R.N.,
was one of the five occupants, all of whom lost their
lives, when a Royal Naval Air Ambulance crashed
on Mickeldore Crags, near Scafell, while carrying a
patient from Abbotsinch naval air station to
Warrington. Commander Gwynne-Jones, who was
oni poor of age, qualified at the London Hospital in
‘professional life.
HARRIE- LESLIE HUGO SCHUTZE
M.B. MELB., M.D. WURZBURG
Dr. Harrie Schütze, who died at Berne, in Switzerland,
on August 9, was born in Melbourne in 1882, the son
of a German father and an English mother. Educated
at Brackley and Cumloden, he graduated M.B. at the
University of Melbourne in 1905. Continuing his medical
education he took his M.D. at Würzburg two years later
and became assistant in the Institute of Hygiene in that
city. In 1912 he was elected to a Beit fellowship and in
the following year he was appointed to the staff of the
Lister Institute of Preventive Medicine in the bacterio-
logical department, where he remained throughout his
For many years towards the end of
his service Schiitze was in charge of the vaccine depart-
ment of the Institute, a position for which his natural
bent, training, and experience well fitted him.
One of his colleagues writes: ‘‘ A competent bacterio-
logist and a careful, thorough, and conscientious investi-
gator, he was so critical of his own work that his
results, though obtained in somewhat specialised fields,
stand today as he left them. His early work, largely of
an orientating character, stressed the importance and
reality of the different members of the salmonella group
of organisms and brought order into a field which was
becoming confused. Later he showed the importance
of the envelope of the plague bacillus in the antigenicity
of the vaccines made from it, and he also demonstrated
the essential differences between those otherwise closely
related micro-organisms, Pasteurella pestis and Past.
pseudotuberculosis.
‘ In 1913 Schütze married Henrietta Leslie, the novelist
and playwright. They shared common interests in
art, music, literature, and travel, and, apart from the
war when they lived at Radlett, they entertained their
friends, in a style and manner not soon to be forgotten,
in their charming house in Chelsea. Of a quiet, studious,
and retiring disposition, with a pleasant subdued voice
and a cultured, courteous manner, Schiitze’s feelings
often moved him more deeply than appeared on the
surface ; his concern for the persecuted and dispossessed
scholars of Europe was real, as were his efforts to relieve
their distress.”
OTTO MAY
M.A., M.D. CAMB., F.R.C.P..
Dr. Otto May, chairman of the British Social Hygiene
Council, died on August 15. As a former principal medical
officer of the Prudential Assurance Company he held
an established position in the insurance world, but his
brilliant academic career was unknown even to many of
his friends, while his modesty and concern with at one
time unpopular medico-sociological problems obscured
his professional ability and attractive personality. Born
in 1879, the second son of the late William May, he
was educated privately. Entering St. John’s College,
Cambridge, with a foundation scholarship he took a
first in both parts of the natural sciences tripos, and
after holding a demonstratorship in physiology at
Cambridge completed his medical education at-University
College Hospital. He qualified in 1907 and was awarded
the Atchison scholarship and the Liston medal. After
spending a year in house-appointments at U.O.H., he
became in 1908 medical registrar at the Middlesex
Hospital, and the following year physician to outpatients
at the Evelina Hospital for Children. To this period,
while he held a B.M.A. research scholarship and a Beit
fellowship, belong his papers on sensory disturbances
of heart disease, the mechanism of cardiac pain, and
posterior root section for the treatment of spasticity.
When he joined the Prudential Assurance Company in
1912 he thus brought to his new work a background ol
clinical experience and scientific training which quickly
won recognition. He served the Assurance Medica.
Society as secretary for many years, and in 1926 in hi:
presidential address, assessing the progress of lift
assurance medicine, he urged doctors to provide the
actuaries with data on which to base more accurat
assessments of mortality. Dr. May also discussed in ow
columns tuberculosis in relation to life assurance anc
the value of periodical medical examinations. He wa:
an honorary member of the Association of Life Assuranc:
Medical Directors of America.
THE LANCET]
BIRTHS, MARRIAGES, AND DEATHS—NOTES AND NEWS
[SEPT. 7, 1946 367
‘* Perhaps May’s many gifts,” writes D. C. N., ‘‘ were
displayed to the best advantage during the international
congress on Life Assurance Medicine in 1938, when he
acted as chairman of the organising committee. His
many live contacts with colleagues abroad and his
familiarity with their languages and special work and
interests, were invaluable in selecting speakers and
arranging the programme. His quiet humour and
never-failing courtesy went far to ensure the smooth
working of committees under his chairmanship. He
always had a smile and a kindly word for the younger
men trying to find their feet in this rather perplexing
no-man’s-land between the worlds of scientific medicine
and of shrewd business, and he combined most happily
the wisdom and caution of long experience of the effects
of morbid conditions on life expectation with an alert
interest in modern methods of research and treatment.”
Of his work for the British Social Hygiene Council
Sir Drummond Shiels writes: ‘‘ In the first world war,
May lent his full energies to Mrs. Neville Rolfe and to
the organisation she founded (afterwards the British
Social Hygiene Council) in the fight against the taboos
and prejudices—inside and outside the profession—
which hindered effective measures for the prevention
and treatment of the venereal diseases. Thereafter, in
writings and in speech, and often with little official
support, he continued his work for the council in the
long years between the two wars, and at his death he
was chairmdn of its executive committee. He also
rendered substantial service to the Central Council for
Health Education, when that body assumed responsibility
for V.D. propaganda. He lived not only to see the
venereal diseases take their appropriate place among
medical problems, but also to be cheered by new and
promising treatments. He had a very happy family
life and was always prepared to fight against forces or
conditions which prevented happy family life for others.
During the late war he returned to duty from his retire-
ment and led a team in long and strenuous days of
medical examination of recruits for the Services. In his
quiet but effective way he did something for public health
and for human happiness which his friends will remember
with pride and gratitude.”
Dr. May married Miss G. Mabel Rose and they had
two sons.
Births, Marriages, and Deaths
BIRTHS
BacsHaw.—On Aug. 29, in Liverpool, the wife of Mr. H. Bernard
Bagshaw, F.R.C.8.E.—twin daughter and son.
Brvks.—On Aug. 26, at Oldham, Dr. Margaret Binks (née Jackson),
the wife of Dr. Paul Binks—a son.
Brown.—On Aug. 21, the wife of Dr: John Brown, of Bedlington—
a son.
FRaANKLIN.—On Sept. 1, at Edgware, the wife of Dr. C. B. Franklin
—a son.
HuRMAN.—On Aug. 26, in London, the wife of Dr. J. Esmond
Hurman, R.A.F.V.R.—a son.
MacDONALD.—On Aug. 29, at Stanwix, Carlisle, the wife of Dr. Ian
onald—a son,
MacLaINE.—On Aug. 26, at Retford, the wife of Wing-Commander
F. V. Maclaine, M.B., R.A.F.—a 80n.
MOLAUGHLIN.—On July 19, in Dublin, the wife of Licut.-Colonel
F. E. McLaughlin, 1.M.8.—a daughter.
ROGERSON.—On Aug. 30, at Whitchurch, Shropshire, Dr. Evelyn
Rogerson, wife of Dr. Gerard Rogerson—a daughter.
ROSENBERG.—On Aug. 24, at Worthing, the wife of Dr. Henry
Rosenberg—a daughter.
SCUDAMORE.—On Aug. 26, at Macclesficld, the wife of Flight-
Lieutenant T. O. Scudamore, M.B.—a son.
SOLLEY.—On Aug. 25, in London, the wife of Dr. Rupert Solley—
& son.
TEaRE.—On Aug. 28, the wife of Dr. Douglas Teare, of Midhurst—
& son. :
WALKER.— On Aug. 30, at Kingston, the wife of Dr. G. D. Walker
—a son.
WaLsH.—On Aug. 29, at Milton, Suffolk, the wife of Dr. Rodney
Walsh—a daughter.
YotnGc.—On Aug. 24, at Nottingham, the wife of Dr. J. Horton
Young—a daughter.
MARRIAGES |
CaRLILE—BRYANT.—On Aug. 28, at Henbury, Bristol, Edward
Wilson Carlile, B.D., to Elizabeth Bryant, M.B.
CoopER—Cox.—On Aug. 22, at Watford, Keith E. Cooper, M.B., `
to Eileen Mary Cox.
DroRY—BELDAM.—On Aug. 24, in London,
Brownsword Drury, B.M., to Gillian Beldam.
PUXON—WEDDELL.—-On Aug. 29, at Colchester, Francois Edward
Mortimer Puxon to Margaret Weddell, M.R.C.0.G.
DEATHS
MiTcHELL.—On Aug. 26, at Ambleside, Thomas Houghton Mitchell,
M.D. Durh., aged 83.
Roger Anderson
Notes and News
THE DENTIST'S INCOME
THE Minister of Health and the Secretary of State for
Scotland have appointed a committee of nine members,
including four dentists, under the chairmanship of Sir Will
Spens, to recommend ‘“ what ought to be the range of total
professional income of a registered dental practitioner in any
publicly organised service of general dental practice.” The
Minister has further written to Sir Will Spens stressing that
the terms of reference do not bind the committee to base
their recommendations on what dentists have earned in the
past, but make it clear that the committee should state what
in their view the remuneration of dentists should be if the
proper social and economic status of general dental practice
is to be maintained in the future, and if the profession is to
attract suitable recruits.
TREATMENT OF RECURRENT HERPES
RECURRENT herpes is seldom a serious disease, but it
causes discomfort and disfigurement for days at a time and
as such may be a lifelong burden. The treatment consists in
finding a satisfactory local application. Dr. Arthur Whitfield
writes: ‘‘ The application of a drying powder, which is the
usual treatment, has, I think, very little effect ; and ointment
simply increases the sensation of heat and often leads to
suppuration. Attacks are generally preceded by premonitory
sensations of burning and itching. I found that tar solutions
applied at this stage help to abort the attack; and, after
several experiments, I settled finally on a water-soluble
varnish, ‘ Pellanthum,’ to which is added 10% of liquor
picis carbonis, made up by Messrs. Handford and Dawson,
Harrogate. This can be carried about and easily smeared over
the affected area, the resulting film being almost invisible.
There is no evidence that the treatment removes the tendency
to relapse, but it does at least ease the lot of those that suffer
from this tiresome disease.”
University of Cambridge
Dr. M. Hynes has been appointed reader in medicine, from
Oct. l next. Dr. C. L. G. Pratt has been appointed university
lecturer in mammalian physiology, and Dr. G. P. McCullagh,
university lecturer in pathology. Mr. A. L. Hodgkin, M.A.,
has been appointed temporary university lecturer in physio-
logy, and Dr. H. Butler temporary university demonstrator in
anatomy.
University of London
As already announced, the title of professor of clinical
pathology in the university has been conferred on Dr. R. J. V.
Pulvertaft, in respect of the post held by him at Westminster
Hospital medical school. .
Dr. Pulvertaft is 49. After leaving Westminster School he served
from 1915 to 1919 in the Royal Sussex Regiment, being seconded
to the Royal Flying Corps and R.A.F. as observer (Palestine)
and pilot (B.E.F.). At the end of the war he went up Trinity
College, Cambridge, where he had won a scholarship in classics,
and after taking the second part of the natural sciences tripos, in
Physiology, he went to St. Thomas’s Hospital as a university
scholar. Having qualified in 1923 he became assistant bacteriologist
in the vencreal diseascs department and was pathologist to the
medical and surgical units from 1923 to 1932, holding a Plimmer
research fellowship for part of this time. In 1932 he was appointed
director of the J. B. Carlill laboratories at Westminster Hospital,
and reader in pathology in the University of London. He became
M.R.C.P. in 1927, M.D. in 1933, and F.R.C.P. in 1938. During the
late war he served in the Army, chiefly in Egypt and Palestine,
and was for a time assistant director of pathology, Middle Kast
Forces. In 1944 he was appointed 0.B.E. His original observations
have been largely concerned with the behaviour of streptococcal
and other infections; before the war he made a special study
of aerosol disinfection, and of late he has worked on penicillin.
He was for several years editor of Discovery.
As already announced, the title of professor of physiology
has been conferred on Mr. W. P. Spurrell, r.R.c.s., in respect
of the post now held by him at Guy’s Hospital medical school.
Mr. Spurrell graduated B.sc. Lond., with first-class honours in
physiology, in 1921. He studied medicine at Guy’s Hospital,
qualifying M.R.0.8. in 1924, and M.B. Lond., with gold medal and
distinction in surgery and pathology, in 1925. The following
year he graduated M.S., and passed his final examination for the
F.R.c.8. At Guy’s Hospital he held appointments as outpatients
officer, house-surgeon, demonstrator in anatomy and physiology,
and surgical registrar; he was also awarded the Parsons research
fellowship. Subsequently, in the University of Leeds, he was
research assistant in the department of experimental pathology
from 1928 to 1930, and was demonstrator in physiology before
taking up his present appointment at Guy’s Hospital. He is the
author of numerous articles, and has taken a special interest in
the physiology of the alimentary tract.
368 THE LANCET]
Society of Apothecaries of London
At a court of assistants held on August 20 with Dr. H. F.
Powell, the master, in the chair, Dr. C. T. Parsons was elected
master for the ensuing year, and Dr. J. P. Hedley and Prof.
E. C. Dodds, F.R.s., wardens. Professor Dodds was appointed
representative at the British-Swiss Medical Congress at Bale,
and Sir Cecil Wakeley on the governing body of the British
Postgraduate Medical School and the proposed British Post-
graduate Medical Federation.
It was unanimously resolved to award the society’s gold
medal in therapeutics for 1946 to Sir Alexander Fleming,
F.R.S., and Sir Howard Florey, F.R.S., in recognition of their
discovery of penicillin.
The following were admitted to the freedom of the society :
By Fede Deon: Richard Clitherow, M.P. ; B. J. Frankenberg ;
Lord Amulree ; - Rook; C. W. F. McKean.
By Servitude: Q G. M. Woodwark.
The following were appointed examiners > pathology,
R. W. Scarff; midwifery (deputy examiner), Anthony
Charles; chemistry, Phyllis Sanderson. pee following
diplomas were granted :
D.I.H.—A. Anderson; K. Biden-Steele; M. P. Fitzsimons;
O. G. Bennett; G. F. K
Bailey ; a Walk or; G. LAR
J. M. j ones ; i . Gibbons ; R. N. Vann ; R. M. Michelmore ; ‘
Bg e B e cJ. Rich ; A. Culiner ; J. L. Struan-Marshall ;
London aa
From Oct. 16 to 19 a postgraduate course for former
students will be held at the hospital. Those who wish to
attend should notify the dean as soon as possible. The annual
dinner will take place on Thursday the 17th, at 7.30 P.M., at
Claridge’s Hotel, Brook Street, London, W.1, when Sir Henry
Bashford will be in the chair.
International Conference in London
An international medical conference is to be held at B.M.A.
House, Tavistock Square, from Sept. 25 to 27, to consider
the promotion of closer ties among the national medical
organisations in the different countries. The conference is
being convened by the British Medical Association in con-
junction with the Association Professionnelle Internationale
des Médecins. The languages will be English and French, and
an interpreter will be present.
Aslib Conference
Sir Reginald Stradling, F.R.S., president elect of the associa-
tion, will open the 1946 conference at the Polytechnic, 309,
Regent Street, London, W.1, on Saturday, Sept. 14, at
10.30 a.m. Further information may be had from As.
office, 52, Bloomsbury Street, W.C.1.
Royal Sanitary Institute
The institute will hold their 1947 Health Congress at
Torquay, from June 2 to 6, under the presidency of Earl
Fortescue.
London Scientific Film Society
During the coming session, beginning this month, the
society will show scientific and documentary films on Sunday
afternoons and evenings ; it also hopes to arrange for lectures
and the showing of research films on weekdays. Among other
proposed activities are the organisation of scientific films for
children, the publication of a quarterly journal, and the
production of experimental films. Inquiries should be directed
to the society at 34, Soho Square, London, W.1.
Merseyside Telephone Bureau
Doctors who have no-one at home to answer their telephones
have set up a central bureau in Rodney Street, Liverpool,
where urgent messages can be left. They will keep in touch
with the bureau while on their rounds and receive any messages
which have been sent during their absence. The Daily Express
(August 27) states that the new service, which is staffed
mainly by former medical orderlies and telephonists from the
Forces, will cost each doctor £20 a year.
17th London British General Hospital
A reunion dinner of this hospital] will be held at Oddenino’s
Restaurant, Piccadilly, London, W.1, on Oct. 25, 1946.
Tickets can be obtained from Dr. C. H. Atkinson, 53 Park
Street, W.1; Dr. D. Blatchley, 2 Chatsworth Road, W.4 ;
Dr. S. P. Rea, 84 Banstead Road, Carshalton, Surrey.
APPOINTMENTS—MEDICAL DIARY
Bhi P.R .
[SEPT. 7, 1946
Return to Practice
The Central Medical War Committee announces that the
following have resumed civilian practice :
Mr. re SEYMOUR PHILPS, F.R.C.S., 104, Harley Street, W.1.
Mr. A. H. M. SIDDONS, M.CH., F.R.O. 8., 140, Harley Street, W.1.
(AS from Sept. 29.)
THIOUREA DERIVATIVES IN THyYROTOXICOSIS.—Messrs.
Genatosan Ltd. point out that the American series of cases of
thyrotoxicosis, quoted in our annotation of August 10 (p. 207) as
showing an incidence of agranulocytosis of 0-594, was treated
_with thiouracil and not methyl thiouracil. Though methyl
thiouracil has been submitted to clinical trial in Great Britain,
‘Denmark, and Switzerland, there appear to be no published
reports of agranulocytosis with this drug. According to
Astwood and Vanderlaan (J. clin. Endocrin. 1945, 5, 424)
propyl thiouracil is even more satisfactory than the methy]
and ethyl homologues, and it is now undergoing clinical trial
in this country.
Major D. C. Bowl, 0.B.E., F.R.C.S.E., B.A.M.C., has been
mentioned in despatches in recognition of gallant and distin.
guished services in the defence of Hong-Kong in 1941.
Appointments
CAMPBELL, HARRY, M.B. St. And., D.P.H. : deputy M.O.H. and deputy
school M.O., Bath.
FİSHER, R. E. W. . M.B. Belf., D.P.H. : chief M.o., South Metropolitan
Gas Co., S.E.15.
Fox, P. J., M.B. N.U.I., D.P.H. : temp. asst. school M.o., Cornwall.
GOULD, Surgeon-Lieut. D. W., M.R.O.8. : M.O., Hong-Kong.
HYDE, W. D., M.B. Edin. : M.O.H., Enfield.
MORTON. ao M.D. Glasg. : : ” superintendent, Nottingham City
osp
Gloucestershire Royal Infirmary and Eye Institution :
BIRKS, M., M.B. Adelaide, F.R.C.8.E.: surgeon and urological
surgeon.
Evans, C. F., F.R.C.S., D.L.O. : asst. surgeon to E.N.T. dept.
. HAMILTON, H. A.. M. B. Camb., M.R.0.0.G. : gynæcological surgeon,
HUGHES, T. H., M.R.C.S., D.A. : anæsthetist,
HYDE, E. W., M.B. Camb., D.M.R. : radiologist.
JARRETT, R. F., M.B. Camb., M.R.C.P. : physician.
TOM, ARTHUR, M. R.C.S., D.A. : anesthetist.
WILED, W. J., M.B. Camb., F.R.C.S, : surgeon and radium officer.
Kent and Sussex H ospital :
ASHBY, P. T., M.B. Camb., D.A. : anresthetist.
EASTON, J. H., M.D. Camb., M.R.O.P. : physician.
JACOBY, N. M., M.D. Lond., M. R.C.P. : peediatrician.
‘SYMONS, H. M., M.B. Melb., D.0.M.8. : asst. ophthalmic surgeon.
Royal Sheffield Infirmary and Hospital:
DORNAN, ALFORD, M.B. Belf., F.R.O. 8.
GRAY, J. a M.B. Sheff., F.R.O.8.
Nov. 26).
HATHERLEY, EDITH, M.B. Sheff., D.O.M. 8. : ophthalmio surgeon.
JORDAN, ARTHUR, M.B. Lond., M.R. C.P. : biochemist.
LODGE, THOMAS, M.B. Shefi., F. F.R.: radiologist.
SNEDDON, I. B., M.B. Shefi., M.R.C.P. : dermatologist.
STUART- HARRIS, C. H., M. D. Lond., F.R.C.P. : physician.
WAYNE, E. J., M.D. Leeds, F.R.C.P. : physician.
Medical Diary
SEPT. 8 TO 14
: orthopeedic surgeon.
: surgeon, E.N.T. dept. (from
Monday, 9th
ROYAL COLLEGE OF SURGEONS, Lincoln’s Inn Fields, W.C.2
3.45 P.M. Prof. R. A. Willis: Invasive Spread of Tumours.
5 P.M. Dr. Michael Kremer: Cerebrospinal Fluid.
LONDON SCHOOL OF HYGIENE, Keppel Street, W.C.1
4 P.M. Dr. Earl Carlson: Cerebral Palsy in Children.
Tuesday, 10th l
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. R. A. Willis: Metastasis.
5 P.M. Dr. John McMichael: Circulatory Failure.
Wednesday, 11th She
ROYAL COLLEGE OF Sua eae ST
3.45 P.M. Prof. R. A. Willis:
` Primary Ones.
5 P.M. Dr. John McMichael:
UNIVERSITY OF GLASGOW
8 P.M. (Department of Ophthalmoloe
Irregular Dominance in Heredi
Thursday, 12th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. R. A. Willis: Spontaneous Tumours in Animals.
5P.M. Dr. R. G. Macfarlane: Heemostasis.
EDINBURGH POSTGRADUATE LECTURES
4.30 P.M. (Royal Infirmary.) Dr. I. GQ. W.
cardiogram in CHENUE Disease.
Friday, 13th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. R. A. Wilis:
Tumours.
5 P.M. Dr. R. G. Macfarlane:
é
Metastatic Growths simulating
Circulatory Failure.
.) Prof. W.J. B. Riddell:
ditary Nystagmus,
Hill: Electro-
Experimental Production of
Hemostasis.
THE LANCET] |
| PAINFUL FEET.
IN PRISONERS-OF-WAR IN THE FAR EAST
REVIEW OF 500 CASES
E. K. CRUICKSHANK
l M.B. Aberd.
From the Department of Medicine, University of Aberdeen.
THE symptom known as “ painful feet,” “ burning
feet,” ‘‘ aching feet,’ ‘sore feet,” and “‘ happy feet”
first appeared among prisoners-of-war in Changi Camp,
Singapore, at the end of July, 1942—.e., five and a half
months after their capture. Some of the Malayan doctors
present in the camp were already familiar with it, and
Landor and Pallister (1935) had described it in inmates
of the local jails who were on a diet deficient in vitamin B
_ and had noted that the pain disappeared when green
vegetables were added to the diet.
The following account is based on the records of 500
cases personally observed.
SYMPTOMS
Pain of two types. was felt in the feet :
(1) A dull ache was usually the earliest abnormality
and was felt below the heads of the metatarsals and in the
balls of the toes. At first it was present only at night
after a long day’s standing or walking, developing as
the patient was trying to sleep. As the days passed,
the ache became more pronounced, coming on in the early
morning and increasing when the patient retired to bed.
It was variously described as aching, burning, or
_ throbbing.
= (2) Sharp stabbing pains became superimposed on the
ache in 58-6% of the 500 cases. A single pain lasted
1/,-2 sec., shooting, parallel to the toes and soles of the
feet, into the heels, through the ankle-joints, and some-
_ times up the shins to the knees. In 6-4% there were
similar symptoms in the hands, but these usually developed -
only in long-standing cases 4-8 weeks after the onset
of symptoms in the feet.
As the condition progressed, the ache or burning sensa-
tion became constant, being present all day, getting worse
in the evening, when the shooting pains began to appear.
Both pains reached their maximum when the patients
went to bed, and often prevented sleep, at first for 1-2
hours, but later, in the severe cases, throughout the
night., Exercise relieved the pain considerably for a
time ; so many patients got up and walked around most
. of the night. Some put their feet in cold water or
massaged them, whereas others preferred warmth.
All these measures, however, gave very temporary relief ;
and, as time passed, the patients became worn out, red
eyed, and irritable from loss of sleep and constant pain.
At this stage, usually several weeks after the onset,
the appetite rapidly became poor in many of the men,
and these often showed pronounced lassitude and loss
of weight.
Nearly 80% of the patients gave a previous history of
a deficiency state of the vitamin-B, type—stomatitis,
glossitis, scrotitis, or defective vision.
SIGNS
General.—In the early case the general condition was
good unless there had been some recent debilitating
disease, such as severe dysentery or chronic malaria,
common precursors of the syndrome. In the established
chronic case there was evidence of rapid loss of weight.
The face had a strained worried look, with dark shadows
under the eyes, the result of constant pain and lack of
sleep. Some patients were nervous and jumpy, particu-
larly at any prospect of having their feet examined.
The incidence of associated deficiency conditions in
the 500 cases reviewed when they came under oer:
tion was as follows.
6420 |
ORIGINAL ARTICLES
[serr. 14, 1946
Vitamin-B, deficiency
Scrotitis .. -- 300%
Stomatitis (angular stomatitis, glossitis, lesions of
buccal mucosa, palatal erythema) -. 316%
Defective vision (the result of retrobulbar neuro-
pathy) 13-0%
Vitamin-B, nam (80%)
Œdema ai gi s4 T ia 6-2°%
Neuritic signs :
Absent or sluggish reflexes .. g eG sý 2:205
Hypalgesia of legs 1:89%
No associated deficiency disease 42:0%
Diarrhea was not an associated condition in the cases
reviewed, though 36% had a history of one or two attacks
of dysentery. Most of the patients were outpatients,
only severe cases being admitted to hospital. Cases
occurring in hospital patients with some other disease,
such as chronic dysentery or malaria, are excluded.
Feet and Legs.—No abnormality of the feet and legs
was seen in the great majority of cases. Some feet were
red, some pale, some somewhat bluish; but, when the
_ feet of 50 patients with painful feet were compared with
those of 50 persons without painful feet, an equal variety
of hue was found in the skins of the controls. There was
no evidence in the skin of vascular spasm or of trophic
changes. Most of the feet were warm, and the dorsalis
pedis and posterior tibial arteries were easily palpable.
The capillary circulation appeared normal, in that an
area blanched by pressure rapidly recovered its colour
on release of the pressure. Some patients had deformities `
of the feet—various degrees of flat-foot and hallux
valgus—but the proportion was no. higher than in a
group of controls.
sweated excessively, and, if they were dried, visible beads
of sweat again appeared in a few minutes. Some
patients in hospital adopted a characteristic attitude
in bed. They sat forwards in a half-squatting position,
gripping their toes in their hands. They were extremely
nervous of having their feet examined and withdrew the
foot rapidly if they were lightly touched. Hypersensitivity
to pinprick and light touch was present in about 22-2%,
but in most of these, if the feet were firmly gripped and
handled, there was no complaint of pain. Cramps and
muscle spasm were rare, and there was no muscular
tenderness.
Nervous System. -endon reflexes were exaggerated
in 23%, and in most of these cases the reflexes were
affected in the arms as well as legs, even when there were
no pains in the hands. In these patients the slightest tap
with a reflex hammer produced a very brisk response ;
in some cases 3-10 clonic movements of the ankles (and,
in a few, of the patella) were elicited when clonus was
tested for. The abdominal reflexes were present in all
cases and usually brisk. The plantar responses were
usually flexor, but in some cases an equivocal response
was repeatedly found; the feet in those cases were
extremely sensitive, and pronounced withdrawal was
associated with such responses. The exaggerated reflexes
developed gradually in the course of the disease, becoming
apparent on an average 3-6 weeks from the onset of
symptoms, though some cases showed this feature at the
first examination. Of the 51 cases which showed hyper-
tension (discussed below) 39 had exaggerated reflexes,
and 12 had reflexes within normal limits—i.e., 76% of
all cases with hypertension, as compared with 23% of
the whole series, showed increased reflexes.
The gait in severe cases was slow and hobbling because
of the pain but showed considerable individual variation.
In 2-2% the tendon reflexes were absent or very sluggish,
and in 1:8% hypalgesia of the feet and legs was found ;
these were regarded as cases of associated vitamin-B,
deficiency. No other sensory changes were present.
Cardiovascular System.—In 9 cases there was tachy-
cardia (pulse-rate 90 or more per min. after the patient
L
In a few of the severe cases the feet
THE LANCET}
370
RESULTS OF TREATMENT OF 500 CASES OF PAINFUL FEET WITH VITAMIN-B SUPPLEMENTS
DR. CRUICKSHANK: PAINFUL FEET IN PRISONERS-OF-WAR IN THE FAR EAST
[SEPT. 14, 1946
Approx. content of— Results of treatment
No. ‘Complete . Much No change
of | Treatment | Vitamin Ribo- aoe relie improved Improved or worse Remarks
avine SS oe eS OT
( ug.) (mg.) ees No.of| Average |No.of| Average |No.of| Average |No.of| Average
i g.) cases| time cases| time | cases| time cases| time
340 | 20 | During or | 62 | During or | 19 | During or! 18 Mostly outpatients
within a within a within a given rice polishings
few days of few days of; few days of 2 oz. daily after
injections injection injection injection injections (15 relapses
| | l within 1-2 weeks)
20 | Boiled green 750-1000 33 Cs 2 rae ety 11: | 19 days | 7 29 days 2 | 35 days All severe and
gram 8 oz. long-standing
daily hospital cases
323 ne polishings} 2500 | 0-25-0-5 |20-40 128 6 weeks | 51 6 weeks | 144 |6 weeks | Mostly outpatients
oz. daily 2
by mouth ; $
38 | Marmite 1 oz 233 1:03 33 a ; 21 .3 weeks 5 26 days 12 | 2 weeks! Mostly outpatients
had been lying down for half an hour). Of these, 1
had associated hypertension alone, 3 had hypertension
with exaggerated reflexes, 2 had hypertension with
absent reflexes, and 3 normal blood-pressures and normal
reflexes. None of the cases showed evidence of organic
heart disease.
Of 189 cases in which the blood-pressure was recorded,
51 gave readings that were considered hypertensive.*
(The upper limit of normality was arbitrarily placed at
’ 130/90 mm. Hg; the average reading for 500 subjects
without sore feet over the same period was 121/78.)
The average age of the patients with hypertension was
28 years (oldest 42, youngest 21). The average blood-
pressure in the hypertensive cases was 142/104 mm. Hg
(highest 200/ 142). The average reading for the other
138 cases in which blood-pressure was recorded was
118/76 mm. Hg.
In all the cases with hypertension the symptoms were
severe and of long standing. In this group the feet had
been painful for 1-5 months (average 21/, months) ; ; the
average loss of weight, during 6-18 months’ imprison-
ment, was 31/, st. (maximum 7 st. 4 lb., minimum 9 Ib.) ;
in all cases sleeplessness had lasted more than a month,
in some for as long as three months ; and in 49 out of the
51 the appetite had been poor for a month.
In 11 of the 51 patients hypertension developed under
observation. In the rest it was present when the first
blood-pressure reading was taken; these were usually
men who had been held on the lines as long as possible
and referred to hospital only when they became unfit
for duty.
No albumin was found in ‘the urine of any of these
cases.
TREATMENT
When the pains in the feet first appeared they were
assumed to be a result of a deficiency of vitamin-B
complex, in view of the findings of Landor and Pallister
(1935).
General.—All the patients were rested as far as possible.
Those with milder symptoms were taken off duties which
involved standing or walking. Those with more severe
symptoms were admitted to hospital and kept in bed,
except for bathing and going to the latrines. This was
very difficult to enforce, because of the temporary relief
obtained from exercise, and the men often slipped out of
bed and were found walking round and round the
buildings.
Diet.—The patients received the ordinary camp diet,
the calculated calorie value and food content of which
are shown in fig. 1. Available extra sources of vitamin-B
complex were as follows.
* Blood-pressure was not recorded in ‘the carlier cases, when the
possible association with hypertension had not yet been
recognised.,
has no.
Rice polishings.
Green gram (Phaseolus radiatus)—one of the pulses.
Extract of green leaves.
Ground-nuts (available in small quantities only).
Soya bean (available only after the major wave had
passed), `
‘ Marmite.’
‘ Nicamide °’ (B.w. co.) (nikethamide, the diethylamide of
nicotinic acid); 2 c.cm. is equivalent to 340 mg. of
nicotinic acid.
Synthetic crystalline vitamin B, (in small quantities).
RESULTS _
Crystalline Vitamin B,.—In 6 cases 2 mg. was given
daily intravenously for seven days, but no improvement
resulted. Owing to very limited supplies and to the
occurrence of frank beriberi in the camp no further
cases of painful feet were treated by this method.
Nicamide.—In preliminary experiments with this drug
it was found that no improvement resulted from admini-
stration by mouth. Intramuscular injection produced
improvement, but intravenous injection produced the
most rapid and satisfactory results. A daily dose of
1-7 ¢.cm. was given intravenously for 5-10 consecutive
days in 119 cases. These were divided into two groups.
(1) In 98 chronic cases (symptoms present for a
month or more) results were as follows :
(a) 10 patients obtained complete relief, except for occa-
sional aches, for two months. The symptoms gradually
disappeared, usually after the fourth or fifth injection. The
response did not occur immediately on injection. Nicamide
immediate peripheral vasodilator effect as has
nicotinic acid.
(b) 54 patients showed considerable improvement. They
were able to sleep, and the sharp shooting pains became
occasional or disappeared, Of these cases 12 relapsed within
a week of completing the injections in spite of 2 oz. of rice
polishings daily. (In groups (a) and (b), when possible, all
patients were given 2 oz. of rice polishings daily for one or two
months after the injections.) Of these 12 patients, 5 were as
bad as ever, and 7 were partially relieved. -
(c) 16 patients showed some improvement. The shooting
pains became less frequent, and they could get some sleep at
night.
ia) 18 patients showed no improvement.
(2) In 21 acute cases (treatment instituted within
three weeks of onset) results were as follows :
(a) 10 patients obtained complete relief except for ósana
aches, but 3 of them relapsed ten, seventeen, and twenty-two
days after the last injection.
(b) 8 patients showed considerable improvement.
(c) 3 patients were slightly improved.
To 10 patients, used as controls, 2 c.cm. of sterile
water was given intravenously daily for five days—2
said there was slight improvement.
Since the severity of the condition had to be gauged
to a considerable extent by the patient’s statements,
6
-= completely relieved ;
CALORIES
THE LANCET]
malingering and exaggeration of symptoms were difficult
to exclude. Only by careful observation and certain
tricks could these be detected, and there is no doubt
that some patients made the most of their symptoms to
avoid camp fatigues and heavy work.
Green Gram.—lIn 20 chronic cases 8 oz. of boiled green
gram was given daily for various periods. These cases
were all relatively severe and of long standing, and were
chosen because a considerable amount of weight had been
lost. The results were as follows:
(1) In 11 cases there was considerable improvement in an
average of nineteen days. Of these, 2 had had five nicamide
injections of 1-7 c.cm. intravenously before the green gram,
with slight improvement in 1 and none in the other. One
further patient, owing to his severe symptoms, was given a
course of five nicamide injections while receiving green gram,
but with no improvement.
(2) In 7 cases there was some improvement in an average
of twenty-nine days. Of these, l improved considerably when
nicamide was given, and 2 showed no improvement with
nicamide.
(3) In 2 cases there was no improvement in an average of
thirty-five days. Of these, 1 had had nicamide before the
green gram, with no improvement. The other was given
nicamide after thirty-one days on green gram and was con-
siderably improved.
Rice Polishings.—In 323 cases 3 oz. of rice polishings
was given daily. This dose was chosen because it was
the average maximum. amount that could be taken
by a patient in a day. In many cases a larger dose
produced diarrhcea and abdominal discomfort. It was
unpleasant material to take; and, since most of the
patients received their dosage as outpatients, it was
difficult to make sure that the full daily dose was taken ;
some patients were actually caught trying to dispose of it.
This must be taken into consideration in assessing results.
Of the 323 cases treated with rice polishings none was
128 (39-6%) showed considerable
improvement after an average of six weeks’ treatment, the
4000
Ol
©
o
(e)
H
L
N
TEINS (9.)
FAT (g.) a
—— 1942 ———— 19 45 —— ~ 1944 ——"—- 1945
Fig. I—Calories, carbohydrates, proteins, and fat in daily ration :
LH, heavy-duty ration ; L, light-duty ration ; N, no-duty ration.
DR. CRUICKSHANK: PAINFUL FEET IN PRISONERS-OF-WAR IN THE FAR EAST
[SEPT. 14, 1946 $371
Q
”
we 20
SS 15
ss 10
z 5
N
we o
= 8
YY
SÈ 6
SQ 4
OG
Sw 2
0
Wy
= `
ao
X P02
a ~
g 0
1942 —\— 19433 —-~— 1944 —-\_- 1945 —
Fig. 2—Incidence of fresh cases of painful feet per 1000 of population
compared with amounts of nicotinic acid and riboflavine per 1000
calories of diet. ; l
time varying from two to twelve weeks; 61 (15-8%)
showed some improvement in the same average period ;
144 (44-69%) were not improved or worse. In the first
two groups a few patients relapsed while still on rice
polishings.
Marmite.—To 38 patients 1 oz. of marmite was given
daily by mouth. None was completely relieved; 21
(55-39%) showed considerable improvement in three
weeks; 5 (13-2%) were considerably improved after an
average of twenty-six days; and 12 (31-5%) were not
improved after two weeks’ treatment.
The results of treatment are summarised in the
accompanying table. | |
‘ CONTROLS AND FOLLOW-UP
Unfortunately no true control group was kept in which
no treatment whatever was given, because the condition
was considered to be a vitamin-deficiency syndrome from
the first, and it was not regarded as justifiable to with-
hold treatment. However, cases occurred outside our
camp in isolated areas where no specific source of extra
vitamin B was available ; in these no considerable improve-
ment took place until better rations were supplied, when
the symptoms gradually became less severe and eventually
disappeared. |
It was impossible to follow up the cases indefinitely,
and a considerable number of the patients who had not
much improved left for other camps while under observa-
tion. The incidence graph (fig. 2) shows that there was
a sharp fall in the number of fresh cases at the end
of November, 1942, when Red-Cross supplies became
available, and thereafter there was a considerable general
improvement in the diet as the camp personnel began to
receive pay from the Japanese. It became possible to
supplement considerably the basic Japanese ration with
locally purchased foods, such as green gram and ground-
nuts. With this improvement in the diet the cases which
had not responded to specific treatment gradually
improved, and by July, 1943, the syndrome had almost
disappeared from the camp. Nor did a wave of fresh
cases occur thereafter.
= However, 6 patients seen three years after the onset
said that their feet had not quite returned to normal.
They complained of occasional aches in the feet at
night, with stabbing pains at times. The symptoms
were often worse in cold or wet weather.
The abnormal briskness of tendon reflexes, where
present, gradually became less as the pain disappeared,
but there was usually a lag of one or two months in those
cases where the disappearance of pain was rapid.
_ foot.
372 THE LANCET] DR. CRUICKSHANK: PAINFUL FEET IN PRISONERS-OF-WAR IN THE FAR EAST ` (SEPT. 14, 1946-
‘Cases with raised blood-pressure gave normal readings
from one to three weeks after considerable improvement
or disappearance of the symptoms.
| z DISOUSSION
The painful-feet syndrome developed among British
and Australian prisoners-of-war in Japanese hands six
months after they had been on a diet low in vitamin-B
complex and first-class protein but adequate in total
calories. Fresh cases ceased to appear in any number,
and the patients gradually recovered after a few months,
. when there was an all-round improvement in the diet,
with an increase in protein and the vitamin-B complex,
particularly vitamin B, and nicotinic acid. The syn-
drome had almost disappeared before there was any
increase in the riboflavine intake. The peak incidence
of painful feet occurred at a time when fresh cases of
recognised vitamin-B, deficiency were relatively few and
the vitamin-B, non-fat-calorie ratio was above the
critical level of 0-3 (Williams and Spies 1938).
Crystalline vitamin B, given intravenously in a few
cases produced no improvement.. The intravenous
administration of the diethylamide of nicotinic acid
brought about relief or much improvement in 68:8%
of cases in which it was used. This substance has no
pharmacological vasodilator effect, as has nicotinic
acid. No other pure vitamin of the B complex was
available for therapeutic trial. No definite conclusions
can be drawn from the results of treatment with marmite,
green gram, and rice polishings, as there were no adequate
controls ; the only controls were 9 patients who received
no treatment except two weeks’ rest, of whom 2 improved
considerably.
The beneficial effects of a diet or of dietary supplements
containing adequate amounts of vitamin-B complex
point to a B-complex deficiency. The nicamide observa-
tions suggest a deficiency of nicotinic acid as an important
factor. But, at a later date of imprisonment, when the
nicotinic-acid content of the diet again fell to, and
remained at a level as low as, that at which the initial
outbreak developed, there was no recurrence of these
cases in any great number. During this later period,
in contrast to the earlier, the riboflavine content of
the diet was adequate. A simultaneous deficiency of
nicotinic acid and riboflavine may therefore be necessary
for the production’ of the syndrome. The evidence
obtainable in the circumstances in which the
drome was observed does not justify any more definite
conclusion.
Pain.—The patients’ descriptions of the pain do
not throw much light on the mechanism of its production.
It differs distinctly from that of causalgia, pink disease,
intermittent claudication, erythromelalgia (Brown 1932,
Lewis 1936), pseudo-erythromelalgia (Craig and Horton
1938), and asthenia crurum dolorosa (Ekbom 1944).
The stabbing pains of the painful-feet syndrome are
reminiscent of tabetic lightning pains, but are felt as
longitudinal not as transverse stabs, and only below the
knees. There is a closer resemblance between the com-
bined aching and stabbing pains of the syndrome and the
pain of peripheral neuritis in its earlier irritative stages,
but in peripheral neuritis exercise and pressure usually
aggravate the pain, and muscular tenderness is present.
The closest resemblance is afforded by the immersion-
foot syndrome (Ungley et al. 1945), in the hyperemic
stage of which a diffuse severe burning or throbbing pain
is felt in feet and legs; about 7-10 days after rescue
shooting or stabbing pains are superadded, in bursts
like machine-gun fire and radiating from the centre of the
They are relieved by cold but aggravated by heat
and by exercise; and they are accompanied by circula-
tory changes and objective neurological signs not seen
in the painful-feet syndrome. The ‘excessive sweating
seen in some severe cases of painful feet resembles that
described in the later stages of immersion foot.
Syn-.
or two weeks.
persisted, it was still present after three years and was
' Craig, W.
Peripheral nerve damage is demonstrable clinically
and pathologically in immersion foot. The resemblance
between the pain of painful feet dnd of immersion foot
and peripheral neuritis suggests that the foot pain
may be produced by some dysfunction of peripheral
nerve-fibres or nerve-endings which does not progress
to a stage where clinical evidence of nerve damage is -
found. It seems unlikely that the pain is due to circula-
tory changes in the feet, since it does not resemble the
pain of known disorders of the blood-vessels, and there
was no clinical evidence of local vascular disturbance.
The mechanism by which the pain is produced is therefore
obscure; a metabolic disturbance of nerve-fibres or
nerve-endings, due to vitamin deficiency, is the most
attractive hypothesis.
Exaggerated Reflexes.—The significance of these is-
difficult ‘to assess. They developed in only 23% of the
cases. Their presence in the arms in many patients
whose pain was confined to the feet and legs argues
against any explanation based on hypersensitivity of
afferent nerve-endings. In the great majority of cases
they were not accompanied by any other sign of a
pyramidal-tract lesion ; the abdominal and cremasteric
reflexes, for example, were active, and the plantar
responses were flexor except in a few cases where the
feet were hypersensitive and equivocal responses were
obtained. It seems likely that the exaggeration
of reflexes, which developed mostly in the more severe
cases, may have been an effect of protracted pain and loss
of sleep. On the other hand, when the incidence of painful
feet was at its height, there occurred in the camp some
cases of frank spastic paraplegia and a few of quadriplegia
of obscure etiology. Some of these began as painful feet,
with exaggerated reflexes, and later developed clear-cut
signs of upper motor neurone damage. It is possible, there-
fore, that exaggerated reflexes in painful feet signify a .
minimal and reversible degree of damage to the central
nervous system, due presumably to dietary deficiency.
Hypertension.—There is no evidence to show whether
the hypertension observed in 51 out of 189 cases ade-
quately examined, is attributable to a specific disturbance
of blood-pressure regulation or is a general effect of the _
long-continued pain and sleeplessness with which it was
always associated. In all cases except one the blood-
pressure fell with recovery to within normal limits.
In cases where pain was promptly relieved by nicamide,
the fall was not abrupt but took place gradually in one
In the single case where hypertension
regarded as essential hypertension.
SUMMARY
A syndrome of which the chief features were aching
and stabbing pains in the feet was observed in prisoners-
of-war in Singapore at a time when their diet was deficient
in protein and the vitamin-B complex. Hypertension
and exaggerated tendon reflexes were added features in
some cases. Observations on 500 patients are recorded.
The diet records, and the beneficial effect of treatment
with nikethamide (the diethylamide of nicotinic acid),
point to a deficiency of nicotinic acid, perhaps in
conjunction with riboflavine deficiency, as a major —
factor in the production of the syndrome. |
I wish to thank General A. G. Biggam for permission to
publish this paper; Dr. R. C. Burgess, who was responsible
for the diet calculations; and Prof. R. S. Aitken for help
and criticism in the preparation of the article.
REFERENCES
Brown, G. E. (1932) Amer. J. med. Sci. 183, 468.
M., Horton, B. T. (1938) Surg. Clin. N. Amer. 18, 899.
Ekbom, K. A. (1944) Acta med. scand. 118, 197.
Landor, J. V., Pallister, R. A. (1935) Trans. R. Soc. trop. Med. Hyg. -
Lewis, T. (1936) Vascular Disorders of the Limbs, London.
Ungley, u C., Channell, G. D., Richards, R. L. (1945) Bri. J. Surg.
; R. R., Spies, T. D. (1938) Vitamin B, (Thiamin) and its
Use in Medicine, London and New York.
THE LANCET]
PROF. DAVIDSON, DR. GIRDWOOD: FOLIC ACID IN MEGALOBLASTIC ANEMIA
[SEPT. 14, 1946 373
FOLIC ACID IN THE TREATMENT OF
MEGALOBLASTIC ANAEMIA
L. S. P. DAVIDSON
B.A. Camb., M.D. Edin., F.R.C.P., F.R.C.P.E., F.R.S.E.
PROFESSOR OF MEDICINE i
R. H. Grrpwoop
M.B. Edin., F.R.C.P.E., M.R.C.P.
From the Department of Medicine, University of Edinburgh
Muca attention has been aroused by recent reports
by Spies (1946) and others on the use of folic acid in
megaloblastic anæmias of various types; the work has
been summarised in recent articles in this journal (Lancet
1946a and b). '
By courtesy of Dr. Spies and Messrs. Lederle Labora-
tories Inc. we have received a small quantity of synthetic
folic acid, and have treated nine patients suffering from
megaloblastic anemia. For this initial investigation we
chose six cases of classical addisonian pernicious anemia,
with typical megaloblastic bone-marrow and histamine-
. fast achlorhydria, but with no neurological signs and
no preceding history of diarrhcea or dietary deficiency.
These six patients were given folic acid in varying amounts
by mouth or by injection. The object of this part of the
investigation was to confirm the hemopoietic activity of
folic acid, as recorded by Spies (1946), and to assess
dosage. The other three cases were examples of refractory
megaloblastic anemia of the type described by Davis
and Davidson (1944) which failed to respond to parenteral
liver therapy but responded to proteolysed liver given
by mouth.
During the present investigation, our patients received
a normal ward diet, but no liver was included in the meals.
A similar diet has been given by us to many cases of
pernicious anzmia, and of refractory megaloblastic
anemia, without producing .any change in the blood
picture. In all cases, a control period of at least a fort-
night was instituted before the commencement of folic
acid therapy to ensure that spontaneous remission was
not taking place.
ADDISONIAN PERNICIOUS ANEMIA
Case 1.—A man, aged 72, with typical addisonian pernicious
anemia, under treatment for 4 years. He had responded
satisfactorily to ‘Anahemin,’ but some months before
admission his doctor had stopped treatment with parenteral
liver on account of general and local reactions. At the com-
mencement of folic acid therapy his ha:matological findings
were Hb 38%, (5:2 g. per 100 c.cm.); red cells 1,250,000 per
c.mm.; white cells 4400 per c.mm.; P.c.v. 17-5% ; M.c.v.
140-0 c. ; M.C.H.C. 29:7% ; reticulocytes <1% ; c.1. ‘1-5.
The patient was tested with folic acid and anahxmin
0-01 c.cm. intracutaneously. A marked local reaction occurred
at the site where the liver was injected, but no reaction
occurred from the folic acid. Accordingly folic acid 20 mg.
was given-intramuscularly on the lst and 2nd day of treat-
ment; no local or general reaction occurred. Folic acid
20 mg. was given by mouth daily from the 3rd to the 20th
day of treatment. Table r shows that there was a very
satisfactory rise in reticulocytes, red cells, and hemoglobin,
which was up to the standards demanded by the United
States Pharmacopoeia Anti-anemia Preparations Advisory
Board (hereafter referred to as the U.S.P. standard). After
folic acid treatment was stopped, the red cells and hemoglobin |
continued to rise for a further 21 days, without additional
therapy. Owing to the limited supply of folic acid, treat-
ment with anahemin was started on the 4lst day, after
preliminary desensitisation, and by the 8lst day the blood-
count and blood picture had been restored almost to normal.
Case 2.—A man, aged 37, with typical addisonian pernicious
anemia. He was first treated with liver injections 18 months
before the present investigation and improved greatly as a
result ; at that time he was in the Services overseas; he had
had no tropical disease. He was discharged from the Army
on account of ill health, and had had no anti-anemic therapy
for 9 months before he was referred to us. At the commence-
ment of folic acid therapy his hematological findings were :
Hb 52% (7-2 g. per 100 c.cm.); red cells 2,050,000 per c.mm. ;
white cells 3400 per c.mm.; P.c.v. 22:0%; M.c.v. 107:3 cu;
M.C.H.C. 32°7% ; reticulocytes <1% ; c.1. 1:3.
The patient was given folic acid 10 mg. by mouth daily
for 20 days. Table 1 shows that this resulted in a good hemato-
poietic response which, however, did not reach the U.S.P.
standard ; but by the 28th day the erythrocyte increase was
satisfactory on this basis. The red cells continued to increase -
for a further 23 davs after the cessation of folic acid therapy,
and no rise occurred during the ensuing 27 days. It is to be
noted that although the hemoglobin was 100%, the colour-
index was still above unity. |
CasE 3.—A man, aged 52, with typical addisonian perni-
cious anemia. He had suffered from weakness and breath-
lessness for a year, but these symptoms had become much
worse during the four months prior to admission to hospital.
He had never previously been treated with liver. At the
commencement of folic acid therapy his hematological
findings were Hb 50%; red cells 1,870,000 per c.mm. ;
P.C.V. 23:5% ; M.c.v. 125:7 c.u.; M.C.H.C. 29-4% ; reticulo-
cytes <1% ; c.r. 1-3. He was given folic acid 10 mg. daily
by mouth. From table 1 it will be seen that this produced
an increase of 1,270,000 red cells and 26% Hb in 14 days—
which is fully up to the U.S.P. standard. Owing to shortage
of beds, the patient was treated as an outpatient for the
first 7 days, and hence the peak of the reticulocyte rise was not
established.
CasE 4.—A man, aged 53, with typical addisonian pernicious
anemia. He had suffered from weakness and breathlessness
for 6 weeks before admission. No anti-anemic therapy had
been given before admission to hospital. At the commence-
ment of folic acid therapy his haematological findings were :
Hb 36% (5-0 g. per 100 c.cm.); red cells 1,270,000 per c.mm. ; ,
white cells 3800 per c.mm.; P.c.v. 14:5% ; M.c.v. 114-2c.p 3
M.C.H.C. 34:5% ; reticulocytes <1% ; C.I. 1-4.
The patient was given folic acid 5 mg. dailv by mouth for
68 days. Table x shows that he gained 36% Hb and 1,780,000
red cells per c.mm. in 21 days—a rise which conforms to the
U.S.P. standard. The reticulocyte rise and the rate of
regeneration over the first 14 days of treatment were, however,
below this standard. By the 57th day of treatment the
hæmoglobin had reached 100°¢, but the colour-index was still
above unity, and the m.c.v. was 102:4 c.u.
CasE 5.—A woman, aged 38, with typical addisonian per-
nicious anemia, who had never had liver therapy. She
had suffered from weakness and breathlessness for two years,
but these symptoms had become much more marked during
the two months prior to admission to hospital. Partial
thyroidectomy for thyrotoxicosis had been carried out six
years previously, with remission of all symptoms and signs
other than exophthalmos. At the commencement of folic
acid treatment her hematological findings were: Hb 28% ;
red cells 970,000 per c.mm.; white cells 1200 per c.mm. ;
P.C.V. 11-5% ; M.oc.v. 118-6 c.u; M.0.H.0. 33:9% ; reticulo-
cytes 2-4%; C.I. 1:44.
She was given folic acid 200 mg. intramuscularly in the
first twenty-four hours. Table r shows that this resulted in
a sharp rise of reticulocytes and an increase of more than
one million red cells and 20% hemoglobin in 11 days—a
result which fully satisfies the U.S.P. standard optimal rise.
The effect of this initial injection had finished by the 14th
day; so a second injection of 100 mg. was given. This
resulted in the reticulocytes rising to 16% on the 4th day after
injection, and a gain of half a million red cells and 14%
hemoglobin in six days.
CasE 6—A woman, aged 79, with typical addisonian perni-
cious anemia. She complained of increasing weakness and
breathlessness for six months. Two years previously she had
been treated for pernicious anemia, but had had no liver by
mouth or by injection for the past year. At the commence-
' ment of folic acid treatment her hzematological findings were :
Hb 26%; red cells 1,080,000 per c.mm.; white cells 2000
perc.mm.; reticulocytes <19% ; c.r. 1-2.
The patient was given a single dose of folic acid 400 mg.
by mouth. Table 1 shows that the response was truly
dramatic, particularly in view of the patient’s age. The
reticulocytes started to increase rapidly on the 3rd day, and
reached the high figure of 42°% on the 5th day. Fourteen
days after the administration of the single large dose of folic
374 THE LANCET] PROF. DAVIDSON, DR. GIRDWOOD: FOLIC ACID IN MEGALOBLASTIC ANZMIA [SEPT. 14, 1946
N
TABLE I—RESPONSE TO FOLIC ACID IN 6 PATIENTS WITH PERNICIOUS ANÆMIA
Reticulocytes Treatment
Red cells | Hb ° í i
Case A % E aa a
(millions/e.mm.) ° (Haldane)
In- | at | Day me aaa No. of days
itial | peak day) given
1 7 14 21 42 81 1 7 14 | 21 | 42 81 .. | <1-0} 40:0 20 20
1-25 1-40 0 3°78 | 4°74 38 | 42 | 56 | 72 | 80 96 - _ Also anahæmin 12 c.cm.
on days 41-80
2 1 7 14 0 26 4 70 14 | 20 | 26 43 | 70 \<1-0|10-0 10 20
. No treatment on days
20-70 °
10 25
5 81
7 200 im. | day 1
100 im. | day 14
5 400 by mouth,
6 1 -4 10 14 4 10 | 14 | 21 <1-0 | 42-0
1:08 | 1:20 | 2-04 | 3:02 | 3-18 26 | 34 | 50 | 68 | 66 | Single dose
Italic figures represeut day of blood examination. im. =intramuscularly.
° Folic acid 10 mg. was given daily by mouth from the 71st cay eae this produced a further rise of red-cell count to 5°05 million on.
e 91st day. .
acid, the red cells had increased by two million per c.mm., commencement of folic acid therapy he had been given 24 c.cm.
and the hemoglobin by 42%. No further rise occurred by the of anahemin. There was no response to this therapy; the
18th day, so folic acid 100 mg. was given by mouth on the blood figures continued to fall, and the bone -marrow remained
2lst day. Thered-cell increase reported above far exceeds the megaloblastic. The patient gave a 2 years’ history of weakness
U.S.P. standard. and breathlessness. He said that he suffered from hemor-
REFRACTORY MEGALOBLASTIC ANZMIA rhoids, which had bled intermittently during the preceding
Casz 7.—A woman, aged 37, first ddmitted to hospital in 6 years. No loss of blood was evident after admission to
` March, 1944, when she was 5 months pregnant. Her hemo- hospital, and the stool benzidine test was persistently
globin was then 56% and red cells 2,050,000 per c.mm. negative. The dietetic history was normal, and there was no
The bone-marrow was megaloblastic. A test-meal showed the diarrhæa. There were no abnormal neurological signs; the
presence of free hydrochloric acid. A diagnosis of pernicious liver and spleen were not palpable, and there was no abnormal
anemia of pregnancy was made. She failed entirely to res- 8landular enlargement. There was no history of hematemesis.
pond to 4 c.cm. of anahemin given intramuscularly, but and no visible enlargement of veins on the abdominal
responded to proteolysed liver, an increase of red cells of wall. There was no albuminuria. It is noteworthy that the
one million per c.mm. occurring in 20 days. The patient was patient’s daughter died in our wards a year ago with a severe
then discharged from hospital, but owing to difficulty in refractory megaloblastic anemia and was found at autopsy
obtaining proteolysed liver she did not continue ER, to have cirrhosis of the liver. In view of this family history,
She was readmitted in April, 1946, with a history òf weakness liver-function tests were performed on our patient. Tho
and of intermittent diarrhcea of a fatty type; a fat-balance test Serum bilirubin was 0:65 mg. per 100 c.cm. ; the blood choles-
carried out ‘according to the method of Cooke et al. (1946) terol was 167 mg. per 100 c.cm. ; and the cephalin cholesterol
showed the percentage absorption to be 75%. A test-meal test was negative. Serum alkaline phosphatase was 7 units
again showed the presence of free hydrochloric acid, and the Per 100 ml.; serum albumin 3:06 per 100'c.cm.; serum
patient was now thought to be suffering from idiopathic globulin 2-15 g. per 100 c.cm. The levulose-tolerance test
steatorrhcea. She had never been abroad, and the dietetic nd hippuric-acid test were both normal. .In short neither
history was normal. No anti-anemic treatment had been clinical examination nor laboratory tests demonstrated the
given for 18 months before the commencement of folic acid Presence of hepatic dysfunction. No adequate explanation
therapy as described below. During a control period of for the low serum albumin was found. At the commencement
14 days, the reticulocyte count ranged from 2% to 3-5%, but of folic acid therapy the blood figures were: Hb 28%
the erythrocyte and hemoglobin levels remained stationary. (3-9 g. per 100 c.cm.); red cells 950,000 per c.mm.; white
At the start of folic acid therapy her blood findings were as Cells 5200 per c.mm. ; P.c.v. 13:0% ; M.C.V. 136:8 cu; M.C.H.O.
follows: Hb 40% (5:5 g. per 100 c.cm.); red cells 1,370,000 30:0% ; reticulocytes 2:2% ; 0.1. 1-5.
per c.mm.; white cells 7800 per c.mm.; P.c.v. 19-0% ; This patient, who showed no response to a very large dosage
M.0.V. 138- T C.u; M.C.H.C. 28-9% ; reticulocytes 3-5% 3 or. 1-5. of anahzemin, a a to folic acid therapy with a reticulo-
The reticulocyte response and. the rise in red cells over a
therapeutic period of 14, 21, and 28 days reached the standards TABLE II—RESPONSE TO FOLIC ACID THERAPY IN CASE 7
demanded by the U.S.P. Board, although the patient was -— eens Neon a EN a ii e
suffering from idiopathic steatorrhcea and not from addisonian Day of Red cells Reticulocytes | pone-marrow
pernicious anemia (table m). Despite continued folic acid therapy TA (million/c.mm.) %)
therapy, 20 mg. daily, no further rise in red cells occurred 1 40 1:37 3.5 Megaloblastic
during the next 20 days. The m.c.H.c. on the 36th day was 4 Ši oona 17:5 Normoblastic
27-2% , and, in view of this evidence of iron deficiency, ferrous : 42 1:43 Pie .
sulphate was then added to the treatment. Ten days’ treat- 15 58 ` 9:93 Aa
ment with iron produced a small rise in the hemoglobin and 22 62 3-01 <1
no change in the red-cell count. Accordingly, intensive therapy ` ae i See =}
with anahzemin was begun, treatment with folic acid and iron 43 72 3.45 <1
being continued simultaneously. Seventeen days after the 48 78 3-64 <1
commencement of parenteral liver therapy the level of- as ie ree = '
hæmoglobin and red cells remained unchanged. Treatment 65 80 3.68 =
with proteolysed liver was then begun, 1 tablespoonful t.i.d. uf i je sy
‘OO
being given. An increase of one million red cells and 14% l
hæmoglobin occurred in 13 days, with the restoration of the ©=—————--
Therapy.—20 mg. folic acid by mouth on Ist to 10th days’
blood picture to normal. 10 mg. folic acid by mouth on 11th to 20th days; 10 mg. folic acid
Case 8.—A man aged 61. Six weeks before this patient Af Pie oa cea to got days: Fiona sulphate Reve on
: : O ays. nanemin c.cm. 1.m. On s oand, an
came under our charge he had been diagnosed as having 55th days. Proteolysed liver, one tablespoonful t.i.d. on 65th to
pernicious anemia, and during the month preceding the 78th days.
THE LANCET] PROF. DAVIDSON, DR. GIRDWOOD: FOLIC ACID IN MEGALOBLASTIC ANÆMIA ([SEPT. 14, 1946 375
cyte rise, an alteration of his bone-marrow from a megalo-
blastic to anormoblastic state, and a rise in erythrocytes which
was satisfactory for the first 8 days but thereafter failed to
improve with this therapy (table m1).
benzidine was negative, the M.c.H.c. was only 26-3°% on the
20th day. Accordingly ferrous sulphate was given for 14 days
without result. The patient was then given proteolysed liver
1 tablespoonful t.i.d. for 14 days. This resulted in an increase
of half a million red cells per c.mm. in 11 days, but thereafter
no further improvement took place.
CasE 9.—A man, aged 62, had been under treatment for
refractory megaloblastic anaemia since 1942. He showed no
nse to anahzemin, but on the recommendation of one of
us (L. S. P. D.) proteolysed liver was tried in January, 1945.
The results of this treatment were satisfactory, the bone-marrow
changing from a megaloblastic to a normoblastic state and
the red cells rising from 1-93 to 3-44 million over a period of
21 days, with a reticulocyte peak of 11:0%. The patient was
unable to obtain proteolysed liver after May, 1945, and had no
therapy other than iron and cod-liver oil up to the time of
his readmission to hospital in June, 1946. Clinical examina-
tion revealed that the liver was two finger-breadths enlarged
on palpation ; the spleen was not palpable, and no glandular
enlargement was found. The ankle reflexes could not be
elicited, the knee-jerks were weak, and there was an
extensor plantar response on the right side, the left being
doubtful. The patient was underweight ; there was no history
of diarrhoea, no evidence of glossitis, and the dietetic history
was satisfactory. A test-meal showed that there was hista-
mine-fast achlorhydria. At the beginning of the present
investigation the blood figures were: Hb 46% (6:3 g. per
100 c.cm.); red cells 1,700,000 per c.mm.; white cells 6200
per c.mm.; P.c.v. 22:0%; p.c.v. 129-4 C.u; M.C.H.C. 28:6% ;
reticulocytes 1%; c.1. 1-4..
This patient was first given 4 c.cm. of anahemin—twice
as much as our experience has shown to be adequate to
TABLE II—RESPONSE TO FOLIC ACID THERAPY IN CASE 8 .
Day of Red cells Reticulocytes
therapy (million/c.mm.) (%) Bone-marrow
1 0:95 2-2 Megaloblastic
5 1-10. 14:0 OR
6 «2 17-4 Normoblastic
7 f 18:2 (peak is
8 1:68 14:4
15 1°74 1-6
20 1:75 1:5
26. 2:02 2-4
30 2:07 <1
35 2:23 2:0
36 2-24 2-1
41 2-66 <1
47 2°77 <1
50 2:78 <l
Therapy.—20 mg. folic acid by mouth on Ist to 36th days.
Ferrous sulphate gr. vi t.i.d. on 21st to 35th days. Proteolysed
liver one tablespoonful t.i.d. on 36th to 50th days.
produce a maximal response in addisonian pernicious anemia.
This resulted in a slight rise in reticulocytes and an unsustained
rise in red cells. The bone-marrow, however, remained
megaloblastic. Folic acid therapy was then begun, and a
second submaximal rise in reticulocytes occurred (table Iv).
This was followed by a rapid red-cell rise and change in the
bone-marrow to the normoblastic state. Treatment with folic
acid for 28 days produced a gain of approximately two
million erythrocytes and 34% hæmoglobin. Continued treat-
ment, however, failed to increase the blood-count, and
the blood picture remained macrocytic. Treatment with
proteolysed liver is now being given. i
`
DISCUSSION
This short ‘series includes six cases of addisonian
pernicious anemia, of which four were treated with
folic acid daily by mouth in doses ranging from 5 mg. to
20 mg. ; two received a single large dose by the parenteral
and oral route respectively. Of the cases receiving daily
oral treatment, only case 1, who received 20 mg. daily,
had a reticulocyte response and red-cell rise completely
up to the standard demanded by the U.S.P. Board.
Cases 2 and 3, who received 10 mg. daily by mouth,
reached the standard at 28 days and 14 days respectively.
The reticulocyte rises, however, were suboptimal. With
Although the stool -
TABLE IV—RESPONSE TO FOLIO ACID THERAPY IN CASE 9
!
Day of Red cells Reticulocytes
therapy | (million/c.mm.) (%) Bone-marrow
1 1:70 <1 Megaloblastic
6 | 1-61 <1 a
7 ; = 4-2
8 | ia 5:3 (peak)
9 ! eax? 5-0
10 | 2-31 4-] one
11 oe 3°3 ee .
13 ai 2-2 Megaloblastic
14 | ‘98 1:3 i
16 1-99 <1 z
20 i 1-3
21 \ ; 6-0 (peak)
23 | 2-06 2-9
27 2-6 1-6 ay
29 Ls a Normoblastic
30 3-18 <1 Si
40 | 3-68 <1
45 | 3°85 <1
49 | 3-89 <1
Therapy.—1st day 2 c.cm. anahæmin, 2nd day 2 c.cm. anahæmin ;
20 mg. folic acid by mouth on 17th to 49th days.
regard to case 4, who received 5 mg. daily, the red-cell
rise over 21 days conformed to the U.S.P. standard,
but the reticulocyte rise was suboptimal. In all six
cases the bone-marrow was transformed from a megalo-
blastic to a normoblastic ‘state. The clinical state of the
patients improved coincidentally with the blood.
The variations in response of individual cases of
pernicious anemia, with similar blood levels, to parenteral
treatment with a standard amount of a potent prepara-
tion of liver is recognised by all hzematologists, and is
the principal factor in causing great. difficulty in the
assessment of potency and dosage. Hence it would be
unwise to define the optimal daily dose of folic acid
until a much larger series of cases has been treated.
Our observations suggest that the therapeutic daily
dose by mouth is between 5 mg. and 20 mg. At the time
of writing, it would be safer not to reduce the daily dose
below 20 mg. in the treatment of pernicious anemia—
an amount found to be satisfactory by Wilkinson et al.
(1946). |
Attention is drawn to the excellent response which
resulted from a single large dose of folic acid given by
mouth or parenterally. If results similar to those
produced in case 6, who received a single dose of 400 mg.
orally, can be obtained regularly, the simplest and most
effective method of treatment may prove to be an initial
large dose followed at weekly or fortnightly intervals by
doses of 50-100 mg. oo
Most reports have been of treatment with folic acid
over relatively short periods, presumably because of the |
small supply. Published accounts do not clearly indicate
that folic acid by itself can regularly restore the blood
picture to normal in pernicious anemia, but we have
had private reports from the United States that this has
been accomplished. The problem’ of maintenance
therapy has yet to be settled. oa
With regard to the three cases of refractory megalo-
blastic anæmia,. the following observations appear
to be justified.
1. Parenteral injection of a potent purified liver
extract was ineffective, while folic acid, in each case,
produced a rise in reticulocytes, red cells, and hzemo-
globin, and transformed the bone-marrow from the megalo-
blastic to the normoblastic state. In no instance,
however, was folic acid alone able to restore the blood
picture to normal. ,
2. Proteolysed liver by mouth was able to restore the
blood picture to normal in case 7, after the red-cell count
had ceased to rise with adequate administration of folic
acid. In case 8, proteolysed liver also caused a further
rise in red cells subsequent to folic acid therapy, but
did not restore the blood to normal. Treatment with
proteolysed liver has just been begun in case 9.
3876 THE LANCET]
It is of interest to note that cases 7 and 9 had previously
responded to proteolysed liver. Since megaloblastic
anzmias, refractory to anahemin, will respond to both
proteolysed liver and folic acid, it might be postulated
that folic acid is the active principle in proteolysed liver.
The data obtained in cases 7 and 8, however, indicate
that a refractory megaloblastic anemia can respond
to proteolysed liver after folic acid has ceased to be’
effective. This would suggest that in liver and proteo-
lysed liver there exists some as yet undiscovered anti-
anemic principle additional to the specific anti-anzemic
factor in anahzmin, and to folic acid.
SUMMARY
An account is given of the response of six cases of
addisonian pernicious anemia and three cases of refrac-
_ tory megaloblastic anemia to folic acid.
In all cases the bone-marrow was transformed from
a megaloblastic to a normoblastic state.
The effective daily dose of folic acid given by mouth
to cases of pernicious anzmia in the relapse stage varies
widely in different patients. The suggested dose is
20 mg. daily. ` :
Three cases of megaloblastic anemia refractory to
‘s Anahemin’ responded to folic acid which was, however,
unable to restore the blood to normal. l
The relationship of folic acid to proteolysed liver is
discussed.
REFERENCES
Cooke, W. T., Elkes, J. J., Frazer, A. C., Parker, J., Peeney, A. L. P.,
_ Sammons, H. G., Thomas, G. (1946) Quart. J. Med. 15, 141.
Davis, L. J., Davidson, L. S. P. (1944) Ibid, 13, 53.
Lancet (1946a) Annotation, i, 927.
— (1946b) Annotation, i, 969.
Spies, T. D. (1946) Lancet, 1, 225
Wilkinson, J. F., Israëls, M.
August 3, p. 156.
CONFUSION OF AMŒBOMA.
WITH CARCINOMA
MICHAEL J. SMYTH |
M.Ch. N.U.I., F.R.C.S. =
SURGEON, QUEEN MARY’S HOSPITAL, ROEHAMPTON
C. G., Fletcher, F. (1946) Ibid,
THE many abdominal cases admitted to Queen Mary’s
Hospital, Roehampton, during the later years of the
war 1939-45 included some in which left iliae colostomy
had been performed for no apparent reason. The
patients had not sustained any wounds affecting the
pelvic colon or the rectum. Digital examination of the
rectum, sigmoidoscopy, and barium enema did not reveal
any lesion which would have justified operation. In
some cases the operation had been advised for neoplasm
of the rectum, and in others a definite diagnosis of
carcinoma had been made, yet no trace of any new growth
could be found. At first I naturally thought that a mistake
had been made, that overwork, perhaps the heat and
burden of the desert, had been responsible for a ‘‘ phantom
tumour’’; .but, as other cases followed, and as the
operation had been advised, and in some instances carried
out, by well-known surgeons, it was clear that there must
have been some compelling reason for operation. The
answer was not far to seek, though at first it was not
obvious. 7 me
In tropical regions where amebiasis is endemic
Entameba histolytica may cause in the large intestine
a granulomatous condition which is often mistaken for
carcinoma. A good example is cited by Ogilvie (1945).
A factor common to the patients mentioned above was
that they had all had amebic dysentery, and all except
one had been treated with emetine. The logical con-
clusion was that the colostomy had been performed for
an “‘amceboma’”’ of the rectum or of the pelvic colon,
and that the operation, with or without emetine, had
brought about the disappearance of the tumour.
MR. SMYTH: CONFUSION OF AMŒBOMA WITH CARCINOMA
` diagnosis of carcinoma of rectum.
[SEPT. 14, 1946
‘Manson-Bahr (1945) has emphasised that amebiasis
is more widespread than is conimonly realised, and that
_ not only can it be contracted without causing pronounced
symptoms, but also it may lie dormant for years before
declaring itself. He has described (personal com-
munication) the case of an officer who contracted the
disease at the age of 2 years and developed a liver abscess
at the age of 28, with no symptoms during the inter-
vening years. -A similar case was seen by one of my col-
leagues, Dr. J. G. Willmore. Here, a retired warrant officer,
who ‘had contracted dysentery in the Burmese war in
1885, developed a large liver abscess in 1922, without any
signs of illness and without having left England during
the intervening years. .
= It is important that the prevalence of ameebiasis
should ‘be recognised, and that surgeons should be alive
to the possibility of amoebic granuloma simulating carci-
noma. I have no doubt that in amceboma of the rectum
colostomy is helpful rather than otherwise, but the danger
is that large-scale operations on the bowel may he
performed without any attempt at differential diagnosis.
Some even question the advisability of colostomy in
such cases and look upon the operation as unnecessary
and somewhat drastic. It is easy to be wise after the
event, when the nature of the tumour is realised, but the
man on the spot is often in the best position:to judge,
and the operation may have been the best for the patient
in the circumstances. One might go further and say
that, whatever the diagnosis, colostomy in the presence
of acute or subacute obstruction was the only correct
surgical procedure and, as a temporary expedient,
undoubtedly saved life. |
Radical surgery, such as resection of the colon or
excision of the rectum, is much more serious. In three
cases reported by Gunn and Howard (cited by Howells
1946) the preoperative diagnoses were carcinoma of
transverse colon, carcinoma. of cecum, and carcinoma
of colon. Two of the patients died as a direct result of
operation. Yeomans (cited by Howells 1946) emphasised
the almost invariably fatal outcome. of radical surgery
without anti-amebic. treatment. )
If a tumour of the colon or of the rectum is discovered
in a person who has served in the East, it would be wiser
to regard it as an amceboma rather than a carcinoma
until thorough pathological examination has proved
otherwise. In amceboma of the colon special care and
repeated examination of the stools may be necessary
before E. histolytica is demonstrated. With accessible
tumours, like those of the rectum, a biopsy should not be
omitted, for the specimen may not only help to dis-
tinguish a neoplasm from an inflammatory condition,
but also provide evidence of E. histolytica cysts. Failing
the services of a pathologist experienced in tropical
protozoology, a course of emetine should precede any
attempt at radical surgery. l
Occasionally amceboma and carcinoma may coexist.
Morgan (1946) reported the case of a young R.A.F.
officer with a swelling in the right iliac fossa. Investiga-
tion proved that he had contracted amebic dysentery,
and gppropriate treatment led to almost complete dis-
appearance of the tumour. The patient reported to
hospital later, when: it was found that the swelling had
recurred ; and, owing to the failure of further treatment,
operation was decided on. On removal of the cecum,
the tumour proved to be carcinomatous. ,
AMCEBIASIS OF SKIN AND SUBCUTANEOUS TISSUE
I wish to draw attention to a condition which may
affect the skin and underlying tissues and may readily |
develop after colostomy performed for such cases, when
amoebiasis is not suspected.
A colour-sergeant of the Royal Marines, aged 57, was
admitted to Queen Mary’s Hospital, Roehampton, with a
There was little docu-
THE LANCET]
MR. SMYTH: CONFUSION OF AMGSBOMA WITH CARCINOMA
[sepr. 14, 1946 377
mentary history, but he said that he had served all over the |
world but had never had dysentery. The beginning of the
illness he attributed to a ‘‘strain,’’ the result of lifting heavy
shells, which caused a ‘“‘lump”’ to appear in the left lower
abdomen. This was associated with diarrhoea, tenesmus,
and piles.
He was admitted to hospital, where his stools were examined
without anything being found to explain the diarrhea.
He was told
that he had
cancer of the
bowel, and
left iliac colos-
tomy was
performed,
presumably
' preparatory to
removal of the
“growth.”
After the
operation a
large infected
area developed
round the
colostomy,
and it was
only by dia-
thermy ex-
cision that
further spread
was pre-
vented.
The patient
had been dis-
charged from
the Service
and had been
sent to Queen
Mary’s Hospital for further investigation and treatment.
As it was less than six months since his operation and he
was anxious to go home to help with the harvest, he was
discharged and instructed to return later for closure of
colostomy.
He was later readmitted to Queen Mary’s Hospital, when
he was in good health. There was no blood or mucus in the
stools. For four days before operation he was given succinyl
sulphathiazole tablets to sterilise, as far as possible, the
contents of the large intestine.
At operation the colostomy was dissected free. In spite
of extensive scarring of the abdominal wall, the bowel was
mobilised without much difficulty and without the peritoneal
cavity being entered. Continuity of the bowel was re-
established, and the layers of the wound were drawn together
over a small drainage-tube.
The wound progressed well for three days but then became
acutely inflamed and broke down completely. The sutures
in the bowel also gave way, with re-establishment of the
colostomy.
During the next four weeks the infected area continued to
spread in spite of every form of treatment, local and general.
The inflamed area extended almost from the iliac crest to the
costal margin and consisted. of foul sloughing tissue (see
figure). The patient’s general condition was rapidly
deteriorating. l
Reviewing the case, the possibility of amoebiasis occurred
to me, even though examination of the stools elsewhere had
apparently proved negative. A fresh specimen was examined
Lg
Ameebiasis of skin following closure of colostomy
by Dr. Mackenzie Douglas, who reported the presence of —
numerous E. histolytice.
The further care of the patient was then undertaken by
Dr. J. G. Willmore, to whom I am indebted for an account of
his treatment. Intramuscular emetine gr. 1 was given daily
for twelve days, and ‘ Diodoquin’ 2 tablets by mouth
twice daily for ten days. The local area was kept as dry
as possible, and for this reason the bowel was not irrigated
with ‘Quinoxyl’; the sloughing wound was
heavily with a powder consisting
calcium penicillin and succinyl] sulphathiazole and covered
with tulle-gras.
The stools rapidly became clear of amceb, the man’s general
condition improved rapidly, and a striking feature was the
disappearance of the agonising pain in the wound and its
rapid healing. |
dusted
of equal parts of
DISCUSSION
This was one of our earlier cases and occurred before
I had come to consider that a colostomy without any
lesion to explain it was almost pathognomonic of
ameebiasis. It was thought advisable to publish the case
in view of the possibility of surgeons in different parts of
the country having to deal with ‘colostomies of this type—
i.e., where investigation proves negative and amcbe
are not found in the feces.
Amoobiasis of the skin was originally described in 1892
by. Nasse (cited by Manson-Bahr 1938), who recorded a
case of ruptured liver abscess with invasion of the skin.
Nasse recognised living entamcebz not only in the liver
pus but also in the skin. at the advancing edges of
ulceration.
Hsu (cited by Manson-Bahr 1938), in China in 1937,
described circum-anal ulcerations, fistule, and warts,
due to dysentery amcebe. He demonstrated the
organism in sections, in erosions of the cervix, and in
urethral ulcers in the male.
Manson-Bahr (1938) described a case similar to the
one recorded above, in which the parietes in the vicinity
of the colostomy and abdominal wall were involved.
He emphasises the fact that this peculiar gangrene,
with its colour, method of spread, and punched-out
margins of ulceration, cannot be forgotten or confused
with any other form of gangrene or ulceration of the skin.
He further emphasises the importance of microscopical
sections of the gangrenous skin, where the amæœbæ
will be found, even though they may not have been found
in the stools.
Gabriel (cited by Manson-Bahr 1938) reported a case
in an ex-soldier who had served in India fifteen years
previously. Though the patient had never had clinical
dysentery, E. histolytica cysts were present in the fæces.
The lower part of the rectum, the pelvic floor, and the
perineal tissues had been destroyed. Response to emetine
therapy was remarkable.
It may be as well to call attention to the converse of
the error described above—i.e., where patients with
carcinoma of the rectum have been treated for dysentery.
I have seen two such cases. In each the mistake was
due to the omission of digital examination of the rectum.
Both patients had been sigmoidoscoped and examined
with X rays and barium enema. In both the carcinoma
was situated low down in the rectum ; in one it involved
the side wall, and in the other the growth completely
encircled the bowel. In the first case the sigmoidoscope
was passed beyond the ulcer without suspicion, whereas
in the second it was evidently passed through and beyond
the growth before observation began. Both patients
had been treated elsewhere for amabic dysentery and
had been referred for operation for hemorrhoids.
The barium enema does not help much in the diagnosis
of neoplastic conditions of the rectum, particularly those
situated low down, for the delineation of a filling defect
with barium does not properly begin until the pelvi-
rectal junction is reached. It is equally possible to miss
a carcinoma of the rectum with the sigmoidoscope, and
this emphasises the fact that the first internal examina-
tion should always be with the finger. The patient should
be requested to strain down so that an ulcer, which at
first may not be palpable, may come within the ambit
of the examining finger.
I am indebted to Sir Walter Haward, D.M.S. Ministry
of Pensions, and Major-General Brooke Purdon, medical
superintendent, Queen Mary’s Hospital, Roehampton, for
permission to publish this article. |
REFERENCES
Howells, G. (1946) Brit. med. J. i, 161. `
Manson-Bahr, P. H. (1938) Trans. R. Soc. trop. Med. Hyg. 32, 223
— (1945) Manson’s Tropical Diseases, London,
Morgan, C. I. N. (1946) Proc. It. Soc. Med. (in the press).
Ogilvie, W. H. (1945) Lancet, ii, 585.
378 THE LANCET)
GOUT IN LEUKAMIA
REPORT OF A CASE.
L. M. SHoRVON
M.B. Lond., D.A., D.C.H., D.P.M., D.M.R., D.M.R.T.
SENIOR RADIOTHERAPIST, E.M.S. CENTRE, MOUNT VERNON
HOSPITAL, MIDDLESEX
Ir has long been a matter of great interest that, though
the uric-acid content of the blood is increased in
leukemia, gout hardly ever occurs in this condition.
Forkner (1938), in his exhaustive monograph, could only
cite Roberts and Rose Bradford (1907), Schultz (1931),
Brunner (1932), and Vining and Thomson (1934) as having
reported cases in which the two diseases coexisted,
Roberts and Rose Bradford, in their article on gout, state
that “in myeloid leukemia the quantity of uric acid produced
and voided in the urine is greatly increased, and it might
have been expected that persons so effected would exhibit
a strong proclivity to gout. This, however, does not appear
to be the case.” They only encountered one patient in whom
the two diseases were associated, and that patient had had
gout for many years before myelogenous leukemia arose. They
could find no case in which gout supervened as a result of
myeloid leukæmia.
Vining and Thomson, in reporting their case of gout and
aleukeemic leukæmia in a boy aged 5 years, also state that
they could find no case in the literature of gout supervening
on a leuksemia.
The present case is thus of special interest in that
acute gout developed for the first time in a patient
undergoing treatment for leukszemia.
CASE-RECORD
A man, aged 37, was admitted to Mount Vernon
Hospital under my care on May 16, 1945. He complained
that for the previous ten weeks he had been feeling
“ sluggish,” his abdomen had been getting prominent,
and he was dyspneic on exertion. He had no cough,
loss of weight, or pain, and bowels and micturition were
normal. There was no family history of gout or leukemia.
The personal history showed that he had had pleurisy
in 1931 and 1935. He had been to India but had not
contracted any illness there. `
On examination he was, of rather spare build, with slight
pallor of skin and conjunctive. Abdcmen enlarged ; no
petechiæ. Throat clean, tonsils moderately enlarged, no
gingivitis, teeth in good condition, Clinical examination of
lungs showed no abnormality except a slight pleural rub
audible at the level of the seventh rib in the left axillary
line, probably the result of previous pleurisy. Trachea central.
Heart showed no enlargement,no murmurs, and rhythm regular.
The abdomen was distended, practically the whole of it
being occupied by an enormous spleen, which formed a firm
OBSERVATIONS DURING TREATMENT
Deep Uric , Uric
Date X-ray | Hb| White | acid | Date | Hb | White| acid
1945 treat- |(%)| cells in. | 1945 |(%)| cells | in
ment blood ®
May 17 56 | 354,000 68 |58,000] ..
» 18 ga 64 |25,200/ ..
» 2j 54 |225,000 76 |29,000| 49
» 23 as ze 72 119,000] 5-1
» 24 54 | 244,000 78 |13,800| 5-2
5» 25 ae 18,800) 6-4
100 r
» 26 to 56 | 277,000 . |13,500| 6-4
spleen
» 28 60 |137,000 86 |18,600| 56
» 29 15,000| 6-0
» 30 4 a 92 111,700] 5:7
» 31 62 | 76,000; .. 96 ;11,400] 4-9
June 1 i TERE
* mg. per 100 c.cm.
DR. SHORVON : GOUT IN LEUKÆMIA
[SEPT. 14, 1946
smooth non-tender swelling which descended from under the
left costal margin right across the abdomen and down to the
right iliac fossa, with well-marked notches on the anterior
border. No enlargement of liver, no ascites, no palpable
glands, no sternal tenderness. Ophthalmoscopic examination
was normal.
Examination of the blood next day showed Hb 56% and
white cells 354,000 per c.mm. (polymorphs 42%, lymphocytes
3%, myelocytes 46%, and myeloblasts 9%).
The diagnosis of chronic myeloid leukemia was thus
definitely established, and it was decided to treat the patient
by deep X-ray therapy applied to the spleen. This was
started on the 18th. The factors used were kV 190, mA 6,
filter of 0-5 mm. Cu, focus skin distance 40 cm., size of field
10 x 15 cm. Each treatment consisted of 100r incident over
the spleen.
Three days later, May 21, the patient developed a typical
attack of acute gout. He.complained of sudden onset of
severe pain in the right toe. His temperature was 99-8° F.
‘The metatarsophalangeal joint of the right great toe was-
bluish red, somewhat swollen, and very tender. The site of
maximal tenderness was on the medial aspect of the joint.
The pain was aggravated by pressure and movement. No
other joint was affected.
Progress.—I treated the patient with colchicum and -
decided to continue the röntgen therapy. The affected joint
during the subsequent few days became more swollen, but
the pain was kept in check with colchicum. Ten days from
the onset of acute gout the swelling of the joint began
to subside and the temperature became normal, The
leukemia improved, and the spleen became materially smaller.
Irradiation was discontinued on June 1. The table
summarises blood examinations performed between May 17
and July 4.
The b patient left the hospital on July 5 feeling very fit.
DISCUSSION
~ Gout is commonly regarded as a disordered purine
metabolism characterised ‘by (1) recurring attacks of
acute arthritis, (2) an excess of uric acid in the blood—
i.e., hyperuricemia, and (3) deposition of urates in the
cartilages of the joints and in other structures. Of the
joints, the commonest to be affected is the metatarso-
phalangeal joint of the great toe, and this was the joint
involved in the present case.
The normal limits of the uric-acid content of the
blood are 0-7-3-7 mg. per 100 c.cm., with an average of
2 mg. per 100 c.cm. “In gout the uric-acid content of the
blood may be increased to an amount two or three times
as great as that in normal blood. Hyperuricæmia is not,
however, confined to gout and occurs in conditions in
which gout is almost unknown, notably in cases of renal
insufficiency, pneumonia, and leukæmia. It has been
stated that uric acid is the first nitrogenous constituent
to be retained in renal insufficiency, and in uremia the
uric-acid content of the blood may be very large. In
pneumonia and leukemia the increased amount of
uric acid in the blood is due to the considerable destruc-
tion of the nuclei of the leucocytes. In these diseases the
kidneys excrete large quantities of uric acid but cannot
eliminate the uric acid as rapidly as it is formed.
The way in which the increased amount of uric acid
in the blood is produced in leukzmia is briefly as follows.
The nucleoprotein of the nuclei of the leucocytes is
broken down by enzymes. It is first hydrolysed, protein
molecules being split off and nucleic acid liberated. The
latter consists of 4-nucleotides (H,PO, + base + carbo-
hydrate). The carbohydrate present is either a hexose
or a pentose. The bases are pyrimidines and purines,
the latter being adenine (6-aminopurine) and guanine
(2-amino-6-oxypurine). In the tissues, more especially
in the liver, adenine and guanine are deaminised to
hypoxanthine (6-oxypurine) and xanthine (2, 6-dioxy-
purine). Hypoxanthine is oxidised to xanthine and the
latter to uric acid (2, 6, 8-trioxypurine).
In gout the increase of uric acid in the blood is not
regarded as due to increased production as in leukzemia
but as probably due to diminished excretion by kidney
with normal production. Gout is not a primary renal
DR o
i a a a a ee
THE LANCET] MR. EBRILL, DR. ELEK : TUBERCULOUS ABSCESS AND INTRAMUSCULAR PENICILLIN [SEPT. 14,1946 379
defect but a metabolic disturbance, and it is thought
that in gout uric acid probably circulates in an abnormal-
form. ‘ This explains why the kidneys cannot eliminate
the uric acid, which consequently collects in the blood.
Uratosis, as opposed to hyperuricemia, is absolutely
confined to gout and is pathognomonic of it. Though
uratosis probably does not occur in the absence of hyper-
uriceemia, the latter may exist for prolonged periods
without inducing the occurrence of uratosis—i.e., gout.
It is thought that in gout the uric-acid salts which have
accumulated in the blood alter from a soluble to a less
soluble state, the blood becomes supersaturated, and
urates are suddenly deposited from the supersaturated
solution. Inflammation is excited mechanically by the
deposition of urate crystals in the affected tissues, and a
gouty paroxysm results. ‘ :
In the present case the attack of gout came on in a
patient who, except for age and sex, did not show the
usual predisposing factors cited in gout, such as heredity
and habitual excesses in food and drink. This case thus
differs from that reported by Vining and Thomson (1934),
in which there was a family history of gout. They
considered that the obvious explanation in their case
was that in the leukemic state there were present large
quantities of uric acid from the breakdown of immature
white cells which, in a subject carrying a latent tendency
to gout, led to uratosis. The attack of gout in my patient
was apparently produced as a direct result of the greatly
increased uric-acid content of the blood resulting from
the rapid destruction of white blood corpuscles. After
the first dose of 100 r the white-cell count was reduced ina
few days from 354,000 to 225,000 per c.mm., and it was
at this time that the attack of gout developed. It there-
fore seems that acute gout can, though apparently very
rarely, result purely from the increased amount of uric
acid in the blood which occurs in leukæmia.
REFERENCES
Brunner, H. (1932) Z. klin. Aled. 121, 700.
Forkner, C. E. (1938) Leukemia and Allied Disorders, New York.
Roberts, W., Bradford, J. R. (1907) In Allbutt and Rolleston’s
System cf Medicine, London, vol. 111, p. 123
Schultz, A. (1931) Virchows Arch. 280, 519.
Vining, C. W., Thomson, J. G. (1934) Arch. Dis. Childh. 9, 277.
TUBERCULOUS ABSCESS FOLLOWING
INTRAMUSCULAR PENICILLIN
‘REPORT OF A CASE
DENIS EBRILL STEPHEN D. ELEK
M.S. Lond., F.R.C.S.
RESIDENT ASSISTANT SURGEON ASSISTANT BACTERIOLOGIST
ST. GEORGE’S HOSPITAL, LONDON
So far as we know, tuberculous infection at the site of
penicillin injections has not been described. Abscesses
sterile on routine examination are not infrequent; but
they are not always examined for tubercle bacilli. We
have observed a case in which there is reason to believe
that penicillin administration was responsible for a
tuberculous abscess. Theoretically, direct inoculation
at the time of injection appears to be possible. If this is
so—and the case to be described appears to bear it out—
it is an indication for more stringent precautions in the
administration of penicillin.
A boy, aged 11 years, with no relevant previous medical
history, was admitted on July 24, 1945, with a large painful
abscess in the right axilla which had been present for about
a week. Two days after admission the abscess had become
soft and was opened. The pus gave a pure growth of Staph.
aureus. On the 30th a continuous intramuscular penicillin
drip was set up. The initial site of injection was the outer
aspect of the upper third of the left thigh. During the first
twenty-four hours patient complained of much discomfort
at the site of injection, whereupon the drip was discontinued
and a fresh one put up in a similar site in the right leg.’ The
penicillin was discontinued on August 3, by which time he had
bad 500,000 units. On the 22nd patient was discharged,
‘in two or three days.!
M.D. Lond., D.P.H., D.C.P. -
with his wound healed and no evidence of any residual
suppuration.
On Nov. 30—i.e., some three months later—he again
attended hospital, complaining of a painful swelling in the
left thigh near the site of his first penicillin injection. A
spherical fluctuant swelling, about 3 inches in diameter, was
found on the lateral aspect of the upper third of his left thigh.
There was no evidence of skin involvement, and the swelling
was only slightly tender. A chronic abscess seemed the most
likely diagnosis, infection by one of the common penicillin-
resistant contaminants being postulated. He was admitted
to hospital three days later, the swelling having increased in
size during this period. On Dec. 5 the abscess was explored
through a small incision and about 8 oz. of thin yellowish
fluid and some fibrinous clots were evacuated. The bacterio-
logical report on the pus was as follows: ‘‘ Routine cultures
sterile. Morphological Myco. tuberculosis present in large
numbers in the direct smear.” Later the acid-fast bacilli
were confirmed to be Myco. tuberculosis by culture and by
guineapig inoculation.
The abscess did not heal, and exuberant granulation tissue
appeared in the wound. Histological examination of this
showed typical tuberculous granulation tissue. Radiography
of his chest, spine, and legs showed no abnormality. At this —
time his Mantoux reaction was positive in 1] in 10,000 o.T.
On Jan. 7, 1946, an attempt was made to excise the tuber-
culous area completely. A Jarge diffuse area of necrotic tissue
was found extending superficial and deep to the fascia lata
and tracking in the intermuscular planes almost as far as the
shaft of the femur. At no point could the bone be felt to be
directly involved. The pathological tissue was excised.
The wound was closed completely, apart from a small drain
at its lower extremity, which was removed on the second day.
Complete healing was eventually obtained.
® DISCUSSION
The history of the case suggests that a hematoma
formed at the site of the first penicillin injection. This
would explain the severe pain noticed at the time. Human
blood is an excellent medium for the growth of tubercle
bacilli, and early evidence of growth can be observed
We have observed that the
addition of penicillin to laked human blood appears to
improve the growth of tubercle bacilli. One of us has
found in in-vitro experiments that this is especially
so when the concentration of penicillin in the blood is
low. The optimal concentration appears to be about
20 units per c.cm. When the concentration of penicillin
is very high, this adjuvant effect disappears. Furthermore,
by keeping the hematoma sterile, penicillin would
prevent it from being overgrown with contaminants
which would interfere with the growth of tubercle bacilli.
Regarding the source of the tuberculous infection, —
the most obvious and indeed the most likely solution is
that it was introduced at the time of the injection. Tubercle
bacilli might have gained access to the penicillin
powder, the diluted penicillin solution, or the apparatus
or needle used. The infection could have been conveyed
by one of the people dealing with these. The two house-
officers setting up the drip were radiographed with
negative results, but a further endeavour to pin-point
the source of infection after a lapse of months is likely
to be profitless.
The other, less likely, possibilities are as follows :
(1) Thata sterile hematoma formed at the site of the injection,
which was infected from a transient tuberculous bac-
terremia from some other source. This can be dismissed
as a practical possibility, as we have been unable to find
any evidence of tuberculosis elsewhere.
(2) That the injection activated a pre-existing localised focus
of tuberculosis, such as a lymph-gland or a bursa. We
regard this as equally unlikely, since no such structures
are described in this position. 7
(3) That the infection tracked as a cold abscess from some
distant source and was not connected with the penicillin
therapy. We have conducted an exhaustive search in an
endeavour to prove this happy solution, but clinically
and radiologically we have been unable to do so. At this
J. Path. Bact. 1941, 53, 327.
1. Pryce, D. M.
3880 THE LANCET]
stage it does not seem likely that such a hidden focus
would remain obscure.
On the assumption that the infection was jutsoanbed
at the time of the penicillin therapy, the incubation period,
until clinical manifestations appeared, was about four
months.
Our chief reason for publishing the case is to draw
attention to this serious complication of penicillin therapy.
We appreciate the fact that the probable solution lies
in some flaw in the aseptic technique used, though it is
possible that the infection gained access to the penicillin
during its manufacture. Penicillin is now used so exten-
sively that it is not unlikely that similar cases might
occur. Knowledge of the possibility of this happening
would lead, we hope, to added care in its administration.
It should at least lead to a routine examination of
post-penicillin abscesses with a view to excluding tuber-
culosis.
SUMMARY
A tuberculous abscess developed at the site of intra-
muscular injections of penicillin.
The infection took about four months to cause
symptoms.
The source of the infection was in all probability either
the penicillin or the apparatus for its administration.
Post-penicillin abscesses should be examined for
evidence of tuberculosis.
The importance of aseptic technique in the admini-
stration of penicillin is emphasised. |
Our thanks are due to Sir Claude Frankau, under whose care
the patient was admitted, for permission te publish this case.
LIGHT-WEIGHT OXYGEN MASK OF
PLASTIC MATERIAL
Bas S. KENT
M.B. Lond., D.A.
LATE SQUADRON-LEADER R.A.F.V.R.
From the R. A.F. Institute of Aviation Medicine, Farnborough,
Hants
Tark mask to be described was pasa designed as
a passengers’ disposable oxygen mask for altitude flying
in the Royal Air Force, but it should have a wide field
of utility in anzsthesia and oxygen therapy.
Various materials were tried, such as rubber, paper
(including paper impregnated with resins and plastics),
cardboards, papier mâché, fabrics (including plastic-coated
and doped fabrics), metals (notably aluminium), and
plastics. As a result of these investigations polythene was
considered to be the most suitable material.‘ Polyvinyl
chloride or cellulose acetate can be used but have some
disadvantages.
CHARACTERISTICS OF POLYTHENE
Polythene, an odourless vinyl-type resin and a simple
polymer of ethylene, was developed in this country by
Imperial Chemical Industries Ltd. and is sold under the
trade name of ‘ Alkathene.’ Itis a thermoplastic material
which readily lends itself to both compression and injec-
tion moulding. Despite its delicate appearance and the
thinness to which it can be moulded, it is very strong,
pliable, and resistant to tearing, though extremely
light. Owing to-the inert nature of polythene, a mask
made of it is virtually non-irritant and does not cause
dermatitis, as rubber mouldings sometimes do. Poly-
thene will burn, but less vigorously than rubber. It
costs about ls. 2d. per lb. Since a polythene face-piece
weighs about !/, OZ., the material for each will cost about
a Polythene is 100% reclaimable—..e., it can readily
be remoulded and used again.
THE MASK
The mask consists of a thin polythene face-piece to
cover the nose and mouth, incorporating a gauze-covered
DR. KENT: LIGHT-WEIGHT OXYGEN MASK OF PLASTIC MATERIAL
_ varies widely from subject to subject.
[SEPT. ‘14, 1946
Fig. I—Polythene mask and iatex reservoir bag.
ventilation orifice and slots for a single elastic strap; a
reservoir bag, into which oxygen is delivered through a
fine inlet tube, is attached (figs. 1 and 2). :
Face-piece.—The oronasal moulding has been designed
to fit on the face and not over the face. The necessity
for odd appendages has been eliminated, as the orifice
operating as both inlet and outlet valves, the slots for
the suspension strap, and the bevelled turret over which
the reservoir bag is slipped are incorporated in the one
moulding. The shape gives a reasonably curved and
tapered bearing surface round the periphery. In designing
a mask to fit the face, the measurement from the bridge
of the nose to the tip of the chin- (the nasion-menton)
is most important ; radiography shows (fig. 3) that in
this axis the bearing points of the face-piece are directly
over bone—-the nasal bone above, and the tip of the
mandible below—and that the face-piece has been
shaped to stand well clear of the nasal contour, which
A comfortable
visual field has been retained, and glasses may be worn
with the mask in position: A suitable dead space—about
75 c.cm. on an average face—has been achieved. The
orifice, housing, the suspension slots, and the most forward
point of the bevelled turret are in alignment, so facili-
tating packing and eliminating the projections which
easily catch in aircraft fittings, bed-clothes, &c. This
type of mask can be made in different sizes to suit
children or adults.
The face-piece is made by injection moulding, hot
liquid polythene being forced into a special mould under
high pressure. Advantages of this method are rapidity of
output by unskilled labour (about fifty times as fast as
rubber moulding), cheapness, uniformity of shape, and
a very low rejection-rate combined with economy of
material, since all trimmings and rejects are reclaimable.
Ventilation Orifice—A phosphor-bronze gauze (80-90
mesh) covering an orifice 11 mm. in diameter acts as
both an inhalation and an exhalation valve. The resistance
of this arrangement is so low as to be unnoticed even when
no gas is flowing. It will adequately cope with high
inspiratory and expiratory velocities. The position of
the orifice does not cause overdilution of the inspired
gases. Turbulence created by the gauze mesh is an
advantage at high inspiratory and expiratory flows.
THE LANCET]
Suspension.—A single light-weight and readily adjust-
able elastic band passing just below the lobes of the ears
(fig. 2) holds the mask in position. The simple ring-
and-hook fastening permits of rapid removal with one
hand (useful in cases of vomiting, &c.).
Reservoir Bag.—The thin latex bag is very similar to
the B.L.B. design. Its patency is ensured by the posi-
tion of the inlet tube, which holds its neck open (fig. 3).
A drainage plug is provided in the bottom of the bag
for the removal of excessive fluid due to condensation.
A conical bag made from thin (°/;900-8/1000 in.)
non-toxic polyvinyl chloride sheet and sealed by heat in
a high-frequency electric field may be used instead -of
the latex bag: The polyvinyl chloride bag is cheaper,
stores indefinitely, and is less vulnerable ; but the latex
bag is more elastic.
Inlet Tube.—This is made by extrusion of polyvinyl
chloride and has an internal diameter of !/,in. The narrow ~
bore and fine tube are an innovation which much reduces
weight,and bulk. |
ADVANTAGES
Since the mask incorporates the reservoir-bag partial-
rebreathing principle, it is economical in gas. In aviation
it is efficient up to an altitude of 30,000 ft. in warm air-
craft, maintaining a satisfactory oxygen saturation of
the blood with the user at rest and on minimal standard
oxygen flows.
Comfort.—The chief ventas in this mask lies in
its lightness, the
entire assem-
bly weighing
only l!/4 oz.
The great reduc-
tion in weight
adds enor-
mously to. the
wearer’s com-
fort, which is
further en-
hanced by the
smooth finish of
the mask and
the low resist-
‘ance to breath-
ing.
Plasticity .—
. xe SS
ASSN
D
XA:
polythene varies
imperceptibly
with large
changes of tem-
perature; in
this useful
characteristic
it is unlike
plastics of the
polyvinyl chlor-
ide group, which are renowned for variability of plasticity
with fluctuations of temperature.
Sterilisation and Cleanliness. —The extremely low cost
of the finished article enables it to be thrown away aftẹr
use, thus overcoming the usual difficulties and incon-
venience of sterilisatioù. This is particularly advan-
;
. 2
: (4,
7
oe “es
%
’ j hy
FA
YE
Gs
’ i"
2
me yg
oP a
A
Fig. 2—Mask and bag in position.
tageous in cases of phthisis and infectious diseases of all-
types. If it is desired to retain the mask, it can easily
be washed and treated with antiseptic solutions. Its
smooth finish facilitates removal of sweat, dirt, and
condensation.
Acoustics.—Because of the position of the ventilation
orifice, conversation is well heard through the mask.
APPLICATION IN MEDICINE
The equipment can be used for routine oxygen therapy
in the same manner as the well-established B.L.B. mask .
\
DR. MISIR : PICROTOXIN IN BARBITURATE OVERDOSAGE
The plasticity of-
[SEPT.
14, 1946 381
and with similar oxygen
flows and consumption.
For average cases the
flow can be adjusted so
that the bag remains a
little inflated at the end
of inspiration.
The mask is less con-
spicuous if the face-
piece is made flesh-
coloured or almost
transparent. Attractive
colours might be a boon
in the pediatric depart-
ment.
The advantages of so
light a mask on the face
of a patient in extremis
are obvious, the weight
being less than a sixth
of that of the standard
B.L.B. design.
A similar type of
transparent face-piece
for anesthetic purposes
would provide a mask
of less than a twelfth of
the weight of those in
current use. It would —
also enable the anæs-
thetist to observe through the mask itself whether the
patient was breathing through nose or mouth, the colour
of his lips, the squeezing and pinching of soft tissues,
the position of the airway, &c.
SUMMARY
A light-weight oxygen mask of new design, with a
plastic (polythene) face-piece, though designed for
aviation, could readily be applied to anesthesia and
oxygen therapy.
The complete assembly weighs only 1!/, oz. The
face-piece is so cheap that it can be thrown away
after use, is inconspicuous, and interferes little with
conversation.
I am indebted to the Director-General, Medical Branch,
Royal Air Force, for permission to publish this paper; to
the Director of the Institute of Aviation Medicine, Farn-
borough, where the development was carried out ; ‘and to
those colleagues who assisted, criticised, and . encouraged,
particularly Flight-Lieutenant A. J. Barwood and Flying
Officer J. D. Wilson.
PICROTOXIN IN BARBITURATE
OVERDOSAGE
T. NAUTH MISIR
M.B. Lond.
ASSISTANT MEDICAL OFFICER, OLDCHURCH COUNTY HOSPITAL,
ROMFORD
PICROTOXIN is now accepted as the drug of choice in
the treatment of barbiturate poisoning. It is a powerful
convulsant which acts mainly on the medullary centres,
stimulating in particular the respiratory centre.
Duff and Dille (1939) have proved by animal experi-
ments that picrotoxin rapidly disappears from the blood.
Very soon after injection the blood-picrotoxin level
falls and becomes steady in about 20min. After 2 hours
Fig. 3—Radiogram showing how the
mask bears directly on bony points
above and below, and how the inlet
tube keeps the neck of the bag
patent.
' the quantity in the blood is negligible as picrotoxin is
taken up by the tissues. For this reason the drug
should be given either intravenously or intramuscularly
in small doses and at short intervals—e.g., 15-30 min.
Only in this way can an effective concentration be
maintained in the blood.
Overdosage of picrotoxin manifests itself by con-
vulsions, which can be countered by the slow intravenous
382 THE LANCET]
TUBERCULOSIS ASSOCIATION
[sepr. 14, 1946
administration of a soluble barbiturate. In cases of bar-
biturate poisoning very large doses of picrotoxin have
been administered with success. Kohn et al. (1938)
report recovery after 671 mg. of picrotoxin had been
administered in four days, and Richards and Menaker
(1942) mention recovery after 1944 mg. The largest
amount given appears to be 2134 mg. rename 1938).
CASE-RECORD
A woman, aged 24, was admitted to hospital at 12. 30 1 A.M.
on April 6, 1945, completely unconscious and breathing
stertorously. The ‘pupils were of normal size, all the reflexes
were absent, and the patient was flaccid. Her mother believed
that the patient had taken about 50 pink tablets some 51/, hours
previously. The patient was last seen going to her room at -
7 P.M. and was found at 7.30 P.M. lying unconscious on the
floor. Part of a tablet was brought to hospital. It was
presumed to be ‘ Sonery] ’ and this was later confirmed. Each
tablet contained gr. 11/, of soneryl. The patient worked as a
packer at a nearby drug-manufacturing firm.
A stomach washout was immediately performed, but the
fluid returned was clear. Picrotoxin 10 mg. was injected
intravenously at once, but with no effect. A large amount of
an aqueous solution of picrotoxin was then made up, and about
2 hours after admission intramuscular injections of 5 mg. doses
were started. These were continued at 15-minute intervals
throughout the days of the 6th, 7th, 8th, and 9th, except
for a few short lapses of 2 hours each on the 8th and 9th.
Fresh amounts of picrotoxin solution were prepared daily.
At 11.15 P.m. on the 9th the patient became restless and
showed signs of returning consciousness. The picrotoxin
was therefore discontinued. She relapsed, however, into
unconsciousness, and the drug was started again 3 hours later.
It was finally discontinued at 5.15 A. M. on the 10th, when she
had definitely regained consciousness,
During her unconscious period she was fed nasally with
small glucose feeds. The head of the bed was raised. She
became febrile and chesty on the 8th. She was therefore put
on sulphathiazole in full pneumonia doses, but this had little
effect on the temperature, so it was discontinued after 3 days.
On her return to consciousness she was found to have a right
lower lobar pneumonia. This developed into an empyema.
Rib-resection was performed, the empyema cleared up, and
the right lung expanded fully. She then developed a left-
sided empyema, for which she also had a rib-resection.
The patient was discharged from hospital on Sept. 7, 1945,
but continued to attend the outpatient department for
dressings. She was finally discharged on Feb. 15, 1946.
Radiography on that date showed clear lung fields.
She had confessed to taking 100 tablets—i.e., gr. 150—
of sonery] on the night of her admission to hospital.
COMMENTS
This patient was unconscious for 4'/, days, during which
time 1745 mg. of picrotoxin was administered by intra-
muscular injections; except the first dose, which was
given intravenously. She appeared to tolerate the drug
well, and it did not seem to have any adverse side-effects.
The development ‘of the right-sided pneumonia must
have been a consequence of her “Jong period of unconscious-
ness. The left-sided pneumonia followed the operation
for the first rib-resection.
Lumbar puncture with withdrawal of cerebrospinal
fluid was not done deliberately, because I wanted to
gauge fully the effectiveness of picrotoxin.
POSTSCRIPT á
Since the above report was written, I have had to
treat another case of gross barbiturate poisoning.
A woman, aged 38, was admitted unconscious to hospital at
approximately 2 P.M. on June 17, 1946. The history suggested
an overdose of ‘ Luminal’ (phenobarbitone), and she after-
wards confessed to having taken 40 luminal tablets, 18
soneryl tablets, and 4 ‘ Nembutal’ capsules at about 10 P.M.
on the previous night. She had therefore been unconscious
_ for at least 14 hours before admission.
She was deeply comatose and flaccid, and all reflexes were
‘absent, including the pupillary light reflex and the corneal
reflex. She was given three ampoules of nikethamide (1°25 g.)
intramuscularly and later 10 mg. of picrotoxin intravenously,
but did not respond. Regular doses of picrotoxin—5 mg.
every fifteen minutes, intramuscularly—were commenced |
~
at 4.15 p.m. on June 17 and continued until 5 P.M. on the
20th except for short intervals when the patient seemed
to be regaining consciousness. On the evening of the 20th
she became very. restless and was almost fully conscious.
All her reflexes were present. Picrotoxin was therefore
discontinued. By next day she was fully conscious and was
able to speak rationally. Nasal feeding was then stopped.
On June 19, while she was still unconscious, she became
febrile and ‘ “chesty,’ ’ with bilateral basal crepitations. She
was put on sulphapyridine in full pneumonia doses by intra-
muscular injection. She responded well to this and it was
stopped on the 25th. Radiography of the chest on the 21st
suggested slight consolidation at both bases but on July 5 the
lung fields were clear. She was then discharged from hospital.
Throughout her period of unconsciousness she was nursed
with the head of the bed raised, and was fed by nasal tube.
In this case the patient was unconscious for about
14 hours before treatment was started, and received a
total of 1020 mg. picrotoxin in three days.
My thanks are due to Dr. E. Miles, medical superintendent, -
for permission to publish these cases, and to Mr. R. E. Frizzell,
the hospital pharmacist, for his help in making up the large
quantities of picrotoxin solution required.
REFERENCES
Duff, D. M., Dille, J. M. (1939) J. ola 67, 353.
Kona, R, Pia att, S. S., Saltman, S. Y. (1938) J. Amer. med. Ass.
Richards, R. ae Menaker, J. G. (1942) nem hesiclogy, 3, 37.
Rovenstine, E. A. (1938) Amer. J. med. Sci. , 46.
Medical Societies
TUBERCULOSIS ASSOCIATION |
On July 19, the second day of the association’s Oxford
meeting, with Dr. NORMAN TATTERSALL, the president,
in the chair, a discussion on the
Relationship between Primary ae Adult
Pulmonary Tuberculosis
was opened by Dr. Hans USTVEDT (Norway), who said
that the divergent views on the subject were due largely
to national variations in the epidemiological picture.
The dogma of universal childhood infection had been
killed by the agreement at the 1937 Lisbon conference
that primary infection now occurred chiefly during
puberty and early adult life. With good conditions for
observation it was found that about a third of primary
infections were accompanied by demonstrable signs.
Differences between children and adults were not great ;
though there was a malignant type, primary infection
often had a benign course. On the other hand, destructive
adult tuberculosis had had a characteristic maximum
between the ages 15 and 30, though this was apparently
being levelled off throughout adult years. Tuberculosis
dissociated from immediate primary infection originated
(apart from the probably few cases of superinfection)
in reactivated latent foci or in “ postprimary’’ meta-
stases from foci in lymph-glands or other organs. The
interval between primary and postprimary disease was
in most cases under 5 years, and was often only 1-2
years. Scandinavian figures, using erythema nodosum
as an index of the start of infection, showed that the
morbidity curve of serious disease had a high peak in the
first five years, and especially in the first year. Pleurisy
most often appeared within six months, and there was ,
a large concentration of disease in the years immediately
following the pleurisy. Norwegian statistics also showed
that the steep rise in the morbidity and mortality curves
nearly synchronised with the age-group at which the
number of new infections was greatest and the five-year
period thereafter.
Theoretically, destructive pulmonary panerealosis
could develop directly from the primary focus or its
immediate neighbourhood by breakdown, or it could
start from a new focus in another part of the lung.
Outside Norway much emphasis had been placed on
the latter method; MRadeker’s ‘ Frihinfiltrat,’’ which
was usually subclavicular, was not compatible with
the theories of development from tiny apical foci,
and his claim that it was due to superinfection was
not buttressed by adequate tuberculin testing, and
THE LANCET}
ASSOCIATION OF CLINICAL PATHOLOGISTS
[sepr. 14, 1946 383
there was much to suggest that the focus he described
arose from primary infection. As Scheel and Heimbeck
had emphasised in 1928, the problem must be solved
by repeated examination of individuals with primary
infections. In 1938 Malmros and Hedvall had claimed
that phthisis started in small or moderate-sized cloudy
spots, which were often multiple and might originate in
the supraclavicular region and/or in the first intercostal
space. In 1944 Frostad had shown that of 135 cases
of phthisis 48 had developed directly by breakdown from
the primary focus or its immediate vicinity ; in many
cases he had demonstrated cavitation in the primary
infection area. By a series of X-ray examinations, he
had also shown in 11 cases that the quiescent primary
focus was reactivated after a long interval, breaking down
into destructive pulmonary tuberculosis: in others
destructive pulmonary tuberculosis developed from an
entirely new infiltration at another site.
Dr. Ustvedt said that phthisis could develop in the
following ways: (1) direct from the primary lesion or
its neighbourhood; (2) by reactivation of latent primary
foci; (3) from metastatic foci of hematogenous, lympho-
genous, or bronchogenic origin; or (4) through new foci
of superinfection. It was thus important to detect
pri infection, and to observe it carefully for the
first few years.
Dr. S. ROODHOUSE GLOYNE (London) asked whether
individual morbidity was related to the typical mortality
curves. There was evidence that many primary infec-
tions occurred outside childhood. To recall Koch’s phe-
nomenon, the most significant part was the necrosis—
the cardinal sign of the reinfection—and this could be
produced with a large enough dose in the primarily
infected guineapig, in which the naturally progressive
disease was its own sensitising agent. But had the
phenomenon any relation to haphazard infection in
man ? There were two schools of thought. According
to one, man was infected only once in his lifetime and
subsequent tuberculous disease resulted from the main-
tenance of the original infection. The other held that
fresh infection was possible, but paid little heed to the
fate of the all-important original dose.
Precise knowledge of the time-sequence in the ‘‘ post-
primary ” phase was lacking. Perifocal satellite lesions
around .the primary focus spread to the lymphoid
follicles in the walls of the small bronchi. The disease
might then become indolent or quiescent or it might
progress until a small caseous lesion ulcerated into a.
bronchus; this marked the end of the postprimary
stage and the beginning of the chronic bronchogenic
excavating lesion of the adult, of which the outward sign
was sputum, On the whole, the evidence for the com-
plete healing of the primary complex in childhood was
not conclusive, though abdominal and, still more, cervical
primaries tended to heal.
Terplan had shown that age of onset did not neces-
sarily influence the anatomical appearances of primary
infection. He had also collated a series of post-mortem
records in which the first infection was represented by
a fully calcified complex whilst another complex of a
fresh infection was also present. He had, moreover,
recorded cases with primary foci and foci of true exo-
genous infection.
The most difficult.lesions to assess in the adult were
the three types of solitary spherical foci: (1) Assmann’s,
a caseous pneumonic infraclavicular lesion; (2) the
circular focus of Fraenkel confined to no special area of
lung; and (3) the pulmonary tuberculoma, probably
of similar structure to (2). As to the possible causes—
metastatic deposits, blocked bronchi, and unusual
primary foci—he had seen lesions which corroborated
the last two, but observation had not convinced him
that hematogenous metastasis was a valid explanation.
The terms ‘‘ endogenous ” and ‘ exogenous ” should,
he suggested, disappear. Along with the changing inci-
-dence of the disease and the age of onset, the pathological
picture also appeared to be aJtering. At least five types
of lesion could be identified : (1) the childhood primary
focus which heals; (2) the childhood focus which
smoulders until cavity formation in later life; (3) the
childhood lesion which progresses to bronchopneumonia
and death; (4) the primary focus in a previously tuber-
culin-negative adult ; and (5) the healed childhood lesion
=>
with adult reinfection of primary type, the latter either
also healing or progressing to destructive disease.
Dr. A. MARGARET MACPHERSON (London) described a
`~ follow-up of 729 children (over 600 for five or more years),
of whom only 7 had developed adult pulmonary tuber-
culosis. She had been impressed by the number of
adolescents with early adult infection, with either
a calcified primary lesion or a recent primary. focus. `
Characteristically these patients had no constitutional
disturbance, a normal B.S.R. and weight, and a negative
family history ; glandular enlargement seldom occurred
with the lesion, which was in the upper third of the lung
and tended to develop into typical pulmonary tuberculosis.
Dr. WALTER PAGEL (Middlesex) decried the importance
of exogenous infection. There were two main types of
phthisis, following either (1) immediately after the
primary complex, or (2) after an interval. His series
suggested that the former accounted for about 25%
of cases. On the other hand, he felt that small ‘post-
primary foci did not sterilise themselves as easily as
the lesions of the primary complex.
Prof. W. H. TYTLER (Wales) said that the question
would be clarified by large-scale statistical studies ; ex-
haustive pathological investigation restricted the number
of cases that could be tackled. The frequency with which
primary infection was delayed till young adult life was
increasing, but varied in different countries. It appeared
that at the Phipps Institute many tuberculin-positives
became negative, provided that their original infection
had resulted from ‘‘no known contact.” Did such
persons who had lost allergy retain some immunity ?
Dr. USTVEDT replied that morbid anatomy was not
the most reliable line of approach. The problem of the
negative reactor was important, but undoubtedly allergy
could be separated from immunity. The form of tubercu-
losis varied in different countries; in Britain the fre-
quency of calcareous shadows was an impressive feature.
ASSOCIATION OF CLINICAL PATHOLOGISTS
THE association’s summer meeting at Oxford on July-
26 and 27, under the chairmanship of Dr. S. C. DYKE
and Dr. A. H. T. RoBB-SMITH, was opened by Dr. R.
WINSTON EVANS (Manchester) with a paper on Observations
on Sickle-cell Anemia based on experience in West Africa.
Sternal marrow from 20 cases showed that specific changes
were not present in the early cells and only occasionally
in reticulocytes and normoblasts—i.e., sickling only took
place with ease after loss of the nucleus. Sealed, moist
preparations typically showed expansion, tenseness, and
filamentous extensions 6-8 hours before sickling, and
then an explosive onset. Among 600 fit soldiers sub-
jected to. routine testing there had been an overall
incidence of 19-°9%, with the highest—30%—in the
Gambians. The clinical findings varied, and might
include leg ulceration, which suggested that the sickling
was really not the primary lesion but merely superadded
to other diseases. Discussion showed general agreement
that oxidation-reduction was the important factor, pro-
ducing sickling in 10-15 minutes, whereas alteration in
pH alone had no influence. i
Dr. E. JACOBSEN (Copenhagen), discussing Reticulo-
cytes and their Humoral Regulation, said that if reticulo-
cytes were kept in saline at 40° C there was no drop in
their number in 6 hours, whereas when liver was added
the reticulocytes ripened very quickly. The liver
principle he divided into two parts—a thermolabile
fraction absorbed by florodin, and a thermostable
fraction not absorbed. The thermolabile portion was
a xanthine, of which folic acid was probably a part ;
stomach tissue also contained a good deal of the thermo-
labile fraction. Organs of different animals had
different amounts of ripening substance, those with few
reticulocytes having the highest ripening value while
those with many reticulocytes had a low value. He
suggested that increased reticulocytosis might therefore
not necessarily mean an increased output from the bone-.
marrow, but might indicate a decrease in the ripening
factor.
Dr. S. Wray (Harrogate), in a paper on Acid Phospha-
tase based on 25 cases of prostatic carcinoma, explained
the method of estimation and its increase in prostatic
carcinoma ; it was probable that maintenance doses of
384 THE LANCET]
REVIEWS OF BOOKS
[SEPT. 14, 1946
ee would be necessary for the rest of the patient’s
e.
In a discussion on the Reliability of Clinical Hæmo-
globinomeitry Dr. R. Q. MACFARLANE (Oxford) showed-
- how in a series of investigations a 20 % difference between
two examiners had occurred. Hight men and eight
women had been chosen—four trained and four untrained
men and the same in the women. MHeparinised blood
was tested by sixteen methods on sixteen samples by
sixteen observers. The results showed no real agreement
between the different methods and the base line of the
National. Physical Laboratory, in which iron is estimated
by King’s method. The conclusions on the significant
` errors were that differences of 4% were significant with
any one observer and 5% with any two observers. Dr,
I. D. P. Woorron (London) showed that colorimetric
methods agreed more closely with iron estimations than
did gas analysis; it was suggested that grey wedges
should be used, calibrated directly in grammes of heemo-
globin. Dr. MACFARLANE suggested that the original
N.P.L. standard of 13°8 g. per cent. was too low and that
14-7 g. per cent. should be accepted as the standard 100 %
hæmoglobin.
Dr. JANET VAUGHAN (Oxford) spoke on the Incidence
of Homologous Serum Jaundice after Transfusion from
observations at the North-west London Transfusion
Depot. Of 2040 patients followed up five months after
transfusion, only 1084 could be included in the series ;
of these, 77 (7°3%) had developed jaundice. In a con-
trol group no cases of jaundice occurred. The incubation
period after transfusion was 50-150 days, with the
majority between 60 and 100 days. All cases were mild
in contrast to other centres, where several deaths had —
been reported. Fewer cases followed whole-blood trans-
fusion than plasma or serum, probably because this was
pooled. Serum for prophylactic purposes should not
be pooled, and for transfusion only the smallest pools
should be used; and all blood products should carry
an identification ' number, so that records could be
easily checked. z
a’
Reviews of Books
Control of Pain in Childbirth
(2nd ed.) Cuirrorp B. LULL, M.D., F.A.C.S., clinical
professor of obstetrics, Jefferson Medical College ;
Rosperr A. Hineson, M.D., surgeon U.S. Public
Health Service, director, postgraduate medical course,
Philadelphia lying-in . unit, Pennsylvania. London:
W. Heinemann. Pp. 348. 42s.
THIs book could be read with advantage by every
obstetrician in this country, and by every anesthetist
who attends obstetric cases. All practitioners who do
midwifery would find it helpful. We are a long way behind
the United States in obstetric analgesia and anssthesia,
and Professor Lull and Dr. Hingson stimulate us to
improve our own well-tried techniques, if not to expand
the scope of our obstetric analgesia. They have written
_a@ good and comprehensive section on anatomy and
physiology, and they review and assess all known
methods of anesthesia and analgesia, using clear and
attractive diagrams to illustrate the action of each drug
on the various systems. They have a proper bias towards
local and caudal anesthesia, and put in a strong plea for
the use of continuous spinal anzsthesia. These methods
have much to recommend them; but British obstet-
ricians have never liked them and so get disappointing
results. Let them read this book carefully and try again.
There are good chapters on analgesia in domiciliary
midwifery, neonatal resuscitation, and anzsthesia in
ceesarean section. We have no comparable volume by
British authors. i
A Handbook of Social Psychology
KIMBALL Youne, professor of sociology, Queen’s College,
New York. London: Kegan Paul, Trench, Trubner.
Pp. 578. 21s. —
NosBopy questions the importance of social psychology,
but many doubt whether it yet has independent scientific
status. Prof. Kimball Young’s exposition partly answers
such doubts, but contains too much discussion and too
little experiment to allay them wholly. In a field which
touches daily life so closely, a textbook must do more
than state, examine, illustrate, and organise matter
which is within everyone’s knowledge; and the well-
informed reader will require that it should enable him to
correct his erroneous beliefs, and to enlarge the stock of
facts and generalisations through which he can predict
the outcome of known circumstances. This the book
does insufficiently, in spite of the author’s wide range,
critical erudition, and lucid grasp. There are three main
divisions: the first deals with basic relations of person-
ality to society and culture, the second with human
conflict, and ‘the third with mass behaviour. In the first
there are chapters on animal behaviour, drives and
emotions, factors in learning, the mechanism of person-
ality, stereotypes, myths and ideologies, and dominance
and leadership. Prejudice, revolution, war, and morale
are expounded in the section on human conflict ; prob-
lems of crowd behaviour, fashion, public opinion,
| propesencs, and power make up the final division of the
book. z | .
Cardiovascular Disease in General Practice
(2nd ed.) TERENCE East, D.M. Oxfd, F.R.c.P., physician-
in-charge of cardiological department, King’s College
Hospital, London. London: H. K. Lewis. Pp. 198. 12s. 6d.
UNLIKE most of his fellow authors, Dr. East has
succeeded in bringing out a new edition of his book
which is actually shorter than the original. This. is
typical of his approach to his subject: he restricts him-
self to aspects of cardiology important to the man
in practice. No unnecessary words are used; indeed
at times the style is almost telegraphic. The teaching
is essentially sound, though many will deprecate the
choice of cesarean section for delivery of the mother
with heart-failure. Pruning of the section on anemia
and heart disease would have left room for fuller exposi-
tion of the important subject of heart disease in old age.
Howell’s Textbook of Physiology
(15th ed.) Editor: JomnN F. FULTON, M.D.,. Sterling pro-
fessor of physiology, Yale University. London: W. B.
Saunders. Pp. 1304. 40s.
THE editor of this edition of the well-known book
originated by Howell has delegated many sections to
different writers. In the main, it is a sound exposition
_of the subject with a strong physical bias; thus, there
are good chapters on hemodynamics, and on muscle-
nerve physiology and electrical changes in the heart.
The nervous system is also unusually well treated, and
the section on the circulation is full of fundamental
information. Many students will feel the book is worth
having for these sections, which occupy more than two-
thirds of it. The remainder is also good, but respiration,
metabolism, nutrition, excretion, and reproduction are
not dealt with in the same detail, and there is no separate
section for the endocrine organs. When as many as 40
pages are allotted to the electrocardiogram and its
interpretations, this seems parsimonious. In spite of these
criticisms, which are chiefly of imbalance—a defect
almost inseparable from multiple authorship—the book
reaches the status of a standard work.
Experiments with Mammalian Sarcoma Extracts
an regard to cell-free transmission and induced tumor
immunity. CARL . KREBS, OsKaR THORDARSON,
JOHANNES HARBO, from the Aarhus Kommune Hospitals
_ Röntgen and Lysklinik. Translated by Robert Fraser.
“Pp. 96. ,
THESE further studies of the Krebs, Rask-Nielsen,
Wagner sarcoma were undertaken to find out if this
tumour is produced by a virus and is capable of cell-free
transmission, and also in an attempt to increase the
resistance of mice against inoculation with tumour cells.
Neither object has so far been attained, but the value of
this work lies in the detailed description of the procedures
adopted. Cell-free transmission of mamunalian sarcomas
has on occasion been successful, but never repeatable at
will. It seems therefore that the crucial factor has been
some neglected trifle or totally unsuspected condition.
These authors record one experiment only in which
cell-free transmission may have occurred. They conclude
that they have no evidence to support the hypothesis
that mouse leukosis is caused by a virus.
THE LANCET] B.C.G.
THE LANCET
LONDON : SATURDAY, SEPT. 14, 1946
B.C.G.: the Next Phase
By his social experience through the centuries,
European man has acquired a fair resistance to
tuberculosis; but until the introduction of B.C.G.
vaccine the bacteriologist had failed to add one cubit
to its stature. From the “ brownish-clear fluid which
is durable in and for itself,” which Kocn called
tuberculin, to the bacillus which CALMETTE and
GUÉRIN isolated from “lait du Nocard,” the tale of
these vaccines is a long one, and it is written in the
textbooks for those to read who wish. But most of
these vaccines belong to the past; they are dead,
both metaphorically and literally, excepting only
B.C.G. `
Introduced by CALMETTE shortly after the first
world war as a means of protecting children born
in tuberculous households in Paris, B.c.c. vaccine
has passed through several critical phases. Oral
administration, which was first employed, was too
haphazard and came to a dramatic end under the
opprobrium of the Lübeck affair, for which it was
not in fact responsible. Subcutaneous and intra-
cutaneous inoculations followed, but caused many
cold abscesses at the site of inoculation. Quite recently
B.C.G. has successfully negotiated the trial of two
new transcutaneous methods—a scarification and a
multiple-puncture technique. As to its real efficacy,
many international discussions have raised the tem-
perature amongst the critics, and no useful purpose
would be served at this late stage by going over all
the arguments which concerned the experts in the
Health Organisation of the League of Nations. Four
facts, however, stand out from the mass of official
reports and protocols of experiments: (1) the Cal-
mette-Guérin bacillus is harmless to man; (2)
inoculation with it increases resistance to tubercu-
losis ; (3) the degree and duration of this immunity
have not yet been precisely determined; but (4), like
the immunity conferred by other bacterial vaccines,
it is not permanent.
An impressive array of information collected from '
various parts of the world has recently been set forth
by the European regional office of UnRRa* and in a
memorandum, prepared by Prof. W. H. TYTLER,?
which has been presented to health departments
jointly by various tuberculosis organisations.* These
bodies have made it clear that informed opinion is
now in favour of a clinical trial of B.c.c. in this
country, and they also advocate a single source of
supply under official control. Because of the earlier
bacteriological reports on the unstable virulence of
the bacillus, and because of the Lübeck incident,
stress has rightly been laid on the care with which
the vaccine should be prepared by the laboratories.
1. P: of Communicable Diseases and Medical Notes, 1946,
2. Memorandum on B.C.G. prepared for Tuberculosis Association,
Joint Tuberculosis Council, and National Association for the
Prevention of Tuberculosis, 1946;. see TANG; July 27, D. 138.
: Seo Lancet, July 27, p.125. :
:- THE NEXT PHASE
[SEPT. 14, 1946 385
When a vaccine is made of living micro-organisms,
almost as much concern, however, should be felt
about its care when it is no longer under the watchful
eye of the bacteriologist who has prepared it.
The subcutaneous and transcutaneous methods of
giving B.C.G. have been pioneered chiefly in Scandina-
via. The Norwegians began with tuberculin-negative
nurses and then went on to immunise groups of the
general population. Later B.C.G. was introduced for
the Norwegian forces in Britain, and‘ between 3500
and 4000 were inoculated. This group deserves
special mention because it is the only large body of
persons immunised while living in this country ; but
so far as we know the results have not yet been
published. It has been claimed that the vaccine
“ gives a standardised innocuous primary infection,”
but the Unrra bulletin emphasises what is regarded
as a contra-indication to its use—namely, a latent
allergy in the individual.. It points out that
“ In Scandinavia nurses undergoing B.C.G. vaccina-
tion are completely segregated; there is an ante-
vaccinal period of isolation, during which all the
requisite preliminary investigations are made, viz.,
tuberculin testing, radiography, ascertainment of
home conditions to eliminate the possibility of recent
infection. Thereafter the vaccination is carried out
and, one month. later, the individual is tuberculin
tested. Should the reaction prove negative, the
individual is segregated for another month and again
tuberculin tested.”
If these difficulties have been overcome in Norway,
there is no reason why they should not be tackled
here, but with the present shortage of staff they will
not be easily surmounted. The memorandum presented
to the health departments advocates a trial—purely
voluntary—with selected groups of people who are
exposed to unusual risks of tuberculous infection.
Those who work in hospital—medical students,
nurses, and domestics—come to mind at once; and
these groups certainly lend themselves to medical
supervision, though not all their members are
-` employed very long in one place. In the industries with
a high incidence of tuberculosis it might be less easy
to arrange appropriate trials; while children in
tuberculous households in this country do not in
general run such serious risks as they did in Paris
when the vaccine was introduced. The primary -
object of an inquiry should be to determine whether
B.C.G. vaccine will give in Britain the satisfactory
results claimed for it in Scandinavia, in Canada, and
in some other parts of the world. It should be borne
in mind that tests on a small scale in New York,
where the conditions more closely resemble those of
the large British cities, have not been strikingly `
favourable : moreover, the clinical picture of tubercu-
losis varies in different countries, racial resistance
differs, and neither social. circumstances nor anti-
tuberculosis measures are the same. Granted therefore
that the vaccine is efficacious, it will not necessarily
produce dramatic results in this country where
infection is already under fair control, and where
spontaneous arrest of the disease is very common: it
is more likely to do conspicuous good in the devastated
and hungry parts of Europe where ordinary pre-
cautions have broken down and cannot be restored
for a long time; or in the tropics. There are some,
indeed, who consider it mere wishful thinking to
suppose that prophylactic vaccination will hasten
386 THE LANOET]
the slow disappearance of tuberculosis from our
midst, and even fear that it may deflect us from more
fundamental efforts at eradication. As Prof. ARNOLD
Ric has pointed out, however, a disease which still
kills twice as many individuals as any other during
the productive period of life cannot. be regarded as
nearly defeated. There is as yet no easy way to
victory over so inveterate an enemy, but it is not
too much to hope that immunisation, if wisely
handled, will prove a useful weapon.
The clinical trial of B.c.¢. which we hope soon to
see in this country should be placed in the hands of
a body such as the Medical Research Council which
has the experience, equipment, and personnel for
work on a sufficient scale. Only the most carefully
compiled figures in significant quantity will satisfy
the statisticians.- The question also arises whether
it should be confined to B.c.a. The vole bacillus
discovered by A. Q. WELLS shortly before the war 4
is running the Calmette-Guérin organism very close,
and BirkHava’s latest experiments suggest that in
animals its immunising properties are as high.’
Excision of the Head of the Pancreas
Hopes of a radical treatment for carcinoma of the
pancreas were first raised in 1899 when HALSTED
excised a segment of the duodenum and part of the
pancreas for an ampullary growth; but progress
was sporadic until, in 1935, WHIPPLE, Parsons,
and Murns ê initiated a systematic study. Since
then reports of excision of the duodenum and pan-
creatic head for carcinoma have become almost
commonplace in America.
Apart from the rare islet-cell tumour, malignant
growths of the head of the pancreas may be classified
according to their site in two main varieties :- carci-
noma of the ampulla of Vater or its- immediate
tributaries grows slowly and gives rise to early
jaundice, whereas carcinoma of the head of the .
pancreas proper is more common, more malignant,
and gives rise to jaundice somewhat later. A radical
resection of either type necessitates removal not only
of the pancreatic head but also of the duodenum,
beeause the lymphatic and blood supplies of the
two organs are inseparable. So bold an extirpation
(involving as it does the division and repair of the
intestinal, biliary, and pancreatic tracts) would
scarcely be possible without the recent advances .
in chemotherapy, the discovery of vitamin K, and
the excellence of resuscitative and anzsthetic tech-
niques. The problems of the actual excision are
anatomical and are largely concerned with avoiding
damage to blood-vessels essential to life. The repair
which follows has its special difficulties. The thorniest
is the treatment of the pancreatic stump; this
continues to secrete the most powerful proteolytic
enzyme in the body, and mere closure of the cut
end has led, through sloughing and digestion of
damaged tissues and sutures, to external fistule
and—still worse—to internal leaking. What remains
of the pancreas must therefore be anastomosed to
the jejunum, into which it can secrete. The new
1.
e O., Parsons, W. B., PO C. R. Amn. Surg..
1935, 102, 763.
EXCISION OF THE HEAD OF THE PANCREAS
{[serr. 14, 1946
anastomoses of the biliary and pancreatic tracts to
the intestine have no sphincters, and their ostia must
therefore be kept away from the main stream of
digesting food; unless this is contrived, by admitting
bile and pancreatic juice to the jejunum proximal
to the gastric opening, ascending cholangitis and -
pancreatitis will result from reflux of food up the
respective channels and the proximal jejunum will
be denied the protection from the gastric juice
provided by an alkaline flow from above. Opinion
differs as to whether radical pancreatoduodenectomy
should be done in one or two stages. The advocates
of the one-stage operation argue that the double
risk of. two operations is avoided, that vascular
adhesions at the second and more difficult stage
are sidestepped, and that the patients, though deeply
jaundiced, can be carried safely through by sufficient
preparation, particularly with vitamin K. The two-
stage protagonists hold that these patients are too
ill to stand a major procedure without preliminary
biliary decompression; they do not find adhesions
a problem at the second stage if the gall-bladder
is anastomosed to the jejunum.
WHIPPLE,” doyen of pancreatic surgeons and
an advocate of the: one-stage operation, has lately
distilled his wisdom in a formula for the operation.
For an ampullary growth the abdomen is entered
through a right rectus incision from the costal margin
to the umbilicus. After a general survey, the peri-
toneum is incised to the right of the duodenum,
which is elevated to determine the mobility of the
pancreatic head, and the configuration of the uncinate
process is studied. If the growth appears operable,
the common bile-duct is divided behind the duodenum.
The stomach is transected proximal to the pylorus,
and the origin of the gastroduodenal artery from
the hepatic artery revealed, ligated, and cut. The
duodenum is divided proximal to the duodenojejunal
flexure (this stage must be modified if the uncinate
process encircles the superior mesenteric vessels) ;
and the inferior pancreaticoduodenal artery is secured.
The pancreas is cut across at the junction of the
head and the body, and the splenic vessels, portal
vein, and superior mesenteric vessels are dissected
off, drawing the pancreatic head to the right. The
pylorus, duodenum, lower end of common bile-duct,
and head of pancreas are now removed en bloc.
A loop of jejunum is brought up and anastomosed
to the stomach, pancreatic stump, and cut lower
end of bile-duct, from below upwards, so that the
gastric opening is the most distal in the jejunum.
It seems easier than might be supposed to insert a
small rubber tube into the pancreatic duct which is
dilated from obstruction, and to thrust the tube
through a small hole into the lumen of the jejunum ;
the cut edge of pancreas is then sutured to the jejunal
wall. A drain is inserted and the abdomen closed.
WHIPPLE attaches great importance to the use of
silk throughout the operation, because catgut is
readily digested by any escaping trypsin; and he
thinks that the gall-bladder should never be used ~
to anastomose the biliary tract to the intestine—
an unavoidable expedient in the two-stage operation.
What are the results ? WHIPPLE in 1945 è reported
that he had done 8 two-stage operations with an
. Whipple, A. O. Surg. Gynec. Obstet. 1945, 82, 623.
S Whipple, A. O. Ann, Surg. 1945, 121, 847.
| THE LANCET]
immediate case-mortality of 38%, and 19 one-stage |
operations with a mortality of 31%, 22 of the opera-
tions being for carcinoma and all deaths occurring
in this group.. CATTELL,? who favours a two-stage
technique for jaundiced patients, has reported 13
two-stage and 5 one-stage operations with 3 immediate
deaths—an overall mortality of 17%. It is too early
to assess the remote results, but, as might be expected,
patients with growths of the ampulla seem to do
better than those with growths of the pancreatic head.
_ At least these figures falsify the physician’s ancient
gibe that the only effect of surgery in pancreatic
carcinoma is to let the patient die a better colour.
It would be idle to pretend that American experience
of these operations is not greater than ours, but only a
perverse and foolish modesty would ignore the work of
British surgeons. JLLINGWorRTH,!° GORDON-TAYLOR,!!
Marcor,!2 and Watson !? have between them recorded
8 cases with 2 deaths, all the successes being with the
two-stage operation. This year D’Orray,'* in a
hitherto unpublished address to the Royal Society
of Medicine, described what appears to be the first
successful one-stage radical operation in this country,
as well as 2 other cases, one of whom died. D’OFFAY
emphasises the accuracy of Courvoisier’s law in
the differential diagnosis of carcinoma and stone,
provided that the law is applied after actual inspection
of the gall-bladder through a peritoneoscope rather
than by abdominal palpation. PANNETT?5 has
also reported 2 successful one-stage operations.
The history of the radical operation for pancreatic
carcinoma shows that bold thinking has once more
confounded those who contend that surgical technique
has reached its zenith.
Efficacy of the Penicillins
Ir has been known for some time 18 that there are
several chemically different penicillins whose struc-
tures have a common nucleus, but differ in the nature
of a side-chain R. So far five different penicillins have
been isolated in the crystalline state from culture
media of moulds. Four of these, which have been
studied in greater detail than the fifth, are now called
penicillins F, G, X, and K in the United States,
whereas in Britain they are known as penicillins 1,
n, O, and Iv, according to the historical sequence
of their discovery ; it is hoped that this confusing
nomenclature will soon be replaced by a more con-
gruous chemical terminology. The side-chains R of
the different penicillins have the following chemical
structures: _
For penicillin 1 (F) C,H, (2-pentenyl)
wm (G) C,H,CH, (benzyl)
mr (X) OH . C,H, . CH, (p-hydroxybenzy])
i, 5 1v (K) C,H,, (n-heptyl)
The four different penicillins affect the same range
of bacteria, but differ quantitatively in their anti-
bacterial power in vitro. Thus, if we assign a value of
100 to the antibacterial activity in vitro of penicillin
u (G), the relative values for penicillins 1 (F), 1 (G),
Tm (X), and tv (K) are 90, 100, 55, and 140 against the
$ Carel R. B. New Engl. J. med. 1945, 232, 521.
‘ lingworth, ©. F. W. f isdinb. med. J. 1939, 46, 331.
11. Gor a Taylor G. Brit. med. J. 1942, zi 119.
12. Maingot, R. Lancet, 1941, ii, 798.
J. Surg. 1944, 31, 368.
J. Address to Royal Society of Medicine,
15. Pannett, C. A. Brit. J. Surg. 1946, 34, 84.
16. See Leading Article, Lancet, 1946, i, 539.
99 99
.
99 99
EFFICACY OF THE PENICILLINS
[SEPT. 14, 1946 387
strain of Staphylococcus aureus used for routine assays
of penicillin (in international units per mg. the
figures are 1550, 1667, 900, and 2300); against a
strain of hemolytic streptococcus the values are 82,
100, 140, and 120, and against a cultured strain of
Spirocheta pallida Reiter 53, 100, 50, and 75.17. The
chemotherapeutic efficacy of the penicillins, however,
like that of all other chemotherapeutic agents, depends
not only on their activity in vitro but on a series of
other factors, such as absorption, excretion, destruc-
tion in the body, &c. It is therefore not possible to
predict their effectiveness in vivo solely on the basis
of the figures for their antibacterial activity in vitro.
Recent evidence shows that penicillin Iv (K), not-
withstanding its high antibacterial action in vitro,
is much less efficacious in vivo than penicillin m (G).
Thus, in the treatment of Streptococcus pyogenes
infections in mice, penicillin Iv (K) was only 1/11th
as effective as penicillin m (G) and‘only 1/30th as
effective as penicillin m (X), and in the treatment of
pnéumococcus type I infections in mice penicillin rv (K)
was only about 1/6th as effective as penicillin m(G)
and 1/8th as effective as penicillin mı (X).1" Similar
results were obtained in the treatment of experi-
mental syphilis in rabbits. Here various independent
investigators 18 found penicillin Iv (K) to be only
about 1/10th as effective as penicillin rr (G). The
explanation seems to be that penicillin Iv (K) is subject
to greater destruction in the body than the other
penicillins. This conclusion must be drawn from the
fact that after intravenous or intramuscular injection
the blood-levels with penicillin Iv (K) drop more
rapidly than with the other penicillins, while the
proportion of the injected penicillin that is recoverable
from the urine is much lower with Iv(K) than with
_ the other penicillins,” 1° the figures being about 30%
and 80%.
The finding that penicillin tv (K) is less emais
chemotherapeutically than the other penicillins is of
considerable practical importance since commercial
penicillin is a mixture of different penicillins with an -
undefined proportion of penicillin rv (K). The amounts
of the different penicillins in the commercial products
depend on the strain of mould used in production and
on the composition of the culture medium. Strains
used by manufacturers up to 1944 yielded predomi-
nantly penicillin 1 (G), but since 1944 a change has |
` taken place in the commercial penicillin preparations,
leading to a fall in their content of 11(G) and a rise
in Iv (K). Strain Q176, which is now used by most
penicillin manufacturers because it gives the highest
penicillin yield, is known to produce under certain
conditions a considerable proportion of rv(K). A
statistical comparison has shown that the results of
treatment in early syphilis with penicillin preparations
manufactured before 1944. were decidedly better
than those obtained with penicillin manufactured in
1944-46. There may be other causes for this than
simply a change in the proportion of penicillin 1v (K).
Since 1944 the purity of the commercial penicillin
preparations has increased considerably. DUNHAM
and RAKE?’ have produced evidence to show that
17. Eagle, H., Musselman, A. Science, 1946, 103, 618.
18. Committee on Medical Research, the U.S. Public Health Service,
AEE A Drug Administration. J. Amer, med., ASS.
19. TET i D., f Osterberg, A. E., Hazel, G. R. Science, 1946,
20. Dunham, W. B., Rake, G. Amer. J. Syph, 1945, 29, 214.
388 cHE LANCET]
' TWELVE-AND-SIX A HEAD
~ [smpr. 14, 1946
impure penicillin preparations are more efficacious
than crystalline preparations in the prophylaxis of
experimental syphilis. It is conceivable—though
by no means proved—that during the far-reaching
purification of penicillin now carried out. an impurity
is removed which exerts a synergistic effect on the
treponemicidal action of penicillin. In any case it is
desirable to keep down the proportion of penicillin
Iv (K). in commercial. preparations to a minimum.
Fortunately it appears to be possible to influence the
course of penicillin fermentation induced by the strain
Q176 in favour of the production of penicillin 1(G) by
the addition of specific precursors. In future, producers
will have to adopt more comprehensive methods of
assay, The usual biological method of assaying
penicillin preparations, based on their in-vitro activity
against Staph. aureus, is, in conjunction with toxicity
tests,. the only criterion now commonly -used for
their clinical value. This will have to be supplemented
by an analytical method which will reveal their
quantitative content of the different penicillins. `
Annotations’
` TWELVE-AND-SIX A HEAD
THE controversy between the Ministry of Health and
the Insurance Acts Committee over the current N.H.I.
capitation fee, on which we commented in our issue of
August: 3 (p. 166),- has been carried some important
steps farther. Despite repeated representations by the
committee, the. Minister has persisted in his view that
the adjustment of. the current capitation fee and the
assessment of the proper mode and amount of remunera-
tion in the new National Health Service are questions
which interlock so closely that they cannot be considered
separately. The committee, neither accepting this view
nor being empowered to take any part in negotiations for
the future service, found itself unable to meet. the
Minister for the discussions for which he asked, and, in
default of negotiation, the Minister has now made his
proposed award of an increase of 2s. in the capita-
tion fee, to 12s. 6d., with retrospective effect from
Jan. 1, 1946. This he announced in the public press on
August 24.
The Insurance Acts Committee met on Sept. 5 to
reconsider its position, and it has decided that it can
regard this award only as an interim payment and in no
way as a final settlement of the long-standing claim of
' the panel doctor for higher remuneration. It reaffirms
its view that the fee of 12s. 6d. is gravely inadequate, `
and regrets that the Minister is unwilling to implement
now the report of the Spens Committee, whose findings
it had been promised would be applicable to National
Health Insurance “‘ irrespective of the institution of any
National Health Service.” It believes further action
should be taken, but before doing anything more it has
decided to consult the panel committees, and through
them the individual panel doctors. ‘It has accordingly
submitted the following recommendation for immediate
consideration by the panel committees and their con-
stituents, and for subsequent discussion at the Panel
Conference due to be held late in October.
‚That, in view of the Minister's failure properly to apply
the report of the Spens Committee to the current capitation
fee—despite explicit Government promises that this would
' be done—and in view of the grave inadequacy of 12s. 6d.
as remuneration for assuming medical responsibility for an
insured person for a year, it be recommended to all insurance
practitioners in England and Wales, Scotland, and Northern
Ireland to place their resignations from the National Health
Insurance Service in the hands of the Insurance Acts Com-
mittee and to authorise that committee at its discretion to
put in such resignations to insurance committees unless
the Minister is willing fully to apply. the Spens Report to
the current capitation fee with effect at least from-Jan. 1,
1946, or, failing agreement, to refer to the Spens Committee
or a. representative section of that committee or other
agreed independent body the interpretation of the Spens
Committee Report in relation to the current capitation fee,
both parties agreeing in advance to accept the findings of
such body.
There is much justice in the contention of the Insurance
Acts Committee that the assessment of a just capitation
fee for the present service could and should be separately
undertaken now. The offer to submit to the judgment of
“ the Spens Committee or a representative section of that
committee or other agreed independent body” is an
offer free from intransigeance which makes an agreed
settlement still attainable. But even if the Minister still
will not favourably consider any of these proposals, the
frustration of this controversy must not be allowed to
delay or obscure decisions which are even more important,
Next month the National Health Bill may become law.
As soon as it does, the Minister will be empowered to
draft regulations of the gravest importance to the future
of medicine. The British Medical Association has
promised the doctors the opportunity of deciding by
plebiscite whether the profession, through its negotiators,
shall participate in the drafting of these regulations.
The time remaining for the effective taking of this
plebiscite grows short and must not be wasted.
PSYCHOGENIC PAIN IN LABOUR
In the early nineteen-thirties Grantly Dick Read 1 1
postulated that the pains of labour are caused by fear
and that the proper relaxation of’ the cervix is under
the control of the autonomic system, which is connected
with the thalamus—the seat of all primitive emotions,
and notably of fear. Corticothalamic impulses may
inhibit the cervix via the sympathetic nerves and set
up a state of primary uterine inertia. The uterus may
be regarded as a hollow viscus with a detrusor and a
sphincter muscle, and it may reasonably be supposed
that the action of these two muscles, though primarily
antagonistic, is in Jabour synergistic. The normal
polarity between the sphincter and detrusor muscle
may be disturbed by impulses from higher centres, and
every obstetrician knows that a nervous woman having
her first baby, surrounded by solicitous relatives, is a
candidate for primary uterine inertia. Read therefore
emphasises the importance of reassuring the expectant
mother and of engendering such a confidence in her
obstetrician, midwife, and institution that she faces
labour with a mind calm and relaxed and a body in which
the sympathetic nervous system has not got the upper
hand of the parasympathetic. Having been instructed
in the nature and function of labour she knows what
sensations to expect, and does not panic when, for
instance, the head distends the perineum. Many women
so fortified and instructed can complete their labours
without an anesthetic or with only a minimal amount
during the conclusion of the second stage. For such
a technique of psychological anesthesia to be effective
the woman must be schooled from her first antenatal
visit, and this, of course, demands time and patience
on the part of her obstetrician. Read advises that she
should be taught how to relax, and instructed to practise
relaxation every day. The woman is also shown, by
anatomical diagrams, exactly what happens in labour ;
discussion about the baby is encouraged and the woman’s
mind is focused on the child and away from herself. It
is impressed on her that labour is a great event and a
memorable occasion culminating in the lusty cry of a
healthy child which it is her great feminine eres
to have borne.
1. Read, G. D. Natural Childbirth, London, 1933; see pote Reve-
lation of Childbirth, London, 1943.
aoe SE LB
THE LANCET]
THE SICK FAMILY
nT :— “aac a a—a<mMmq <I i ( (I
1
-
(sepr. 14, 1946 389
While some obstetricians have hailed Read’s work as
a pioneering service to obstetrics, others have decried
it as a new flight of psychiatric fancy. His method has
‘been employed in the U.S.A. by Blackwell Sawyer,?
who personally delivered 168 women in a small general
hospital without the assistance of a resident. His material
consisted of 62 primiparze and 106 multipare. He had
1 foetal death (a premature infant dying twelve hours
after delivery) and he used forceps 9 times—for occipito-
posterior position and deep transverse arrest 4 times
and for a big head (low forceps) 5 times.
of twins, and 1 breech and 1 face presentation. In
other words, his obstetrical material was fairly repre-
sentative. The women with malpresentations suffered
the most pain, but of the 106 multipare, 90 said that
they were helped greatly by the method, that they had no
pain during the first stage, and that they concluded the
second stage in two to five expulsive efforts. They were
all offered ether as an anesthetic but only 4 accepted
it. There was no hysteria or uncontrollable crying or
screaming. They were prepared to go through their
labour again, conducted in the same manner; some of
the women were astonished at the smoothness of their
delivery. Of the 62 primipare, apart from malpresenta-
tions and forceps for big heads'there were 53 cases, of
whom 5 were frightened, groaning, and complaining
women all through their delivery and were written off
as complete failures. Among the remaining 48 little pain
was experienced. In 10 of these pethidine was used in
doses of 50-100 mg., one or at most two injections being
given; this “ took the edge off the pain ” and enabled
the patients to codperate. In all primipare the perineum
was injected with procaine and a small episiotomy >
performed. Patients with whom the technique was
successful were calm and cheerful.
Sawyer’s conclusion is that the method when carefully
applied is valuable in relieving the pain of normal
childbirth in 90% of cases. The extent of relief varies,
but it is a positive phenomenon, complete in some and
partial in others with whom the minimal use of analgesic
drugs as an adjuvant will have an added effect. The great
drawback to the method is that it is very time-consuming,
and -there cannot be many obstetricians in this under-
doctored country who will have time to apply it properly.
It is at least abundantly clear that fear should be
banished from the expectant mother, and that if she has
full confidence in her attendants and the arrangements
made for her confinement (and this confidence is the
natural corollary of decent and efficient antenatal super-
vision) then she will have an easier, safer, and speedier
labour. |
l THE SICK FAMILY
~ SOCIALLY troublesome families, such as a number of
medical officers of health have been investigating in
this country,* were recognised in Holland to be a social
problem during the period following the first world war.
In 1926 a compound or colony was created by the city
council of Amsterdam on a peninsula between two canals
at the edge of the city. It consisted of 52 bungalows
adequately equipped and associated with a kinder-
garten, clubroom, and other amenities. Social assistance
and supervision were arranged, and much effort was put
into the scheme. But in the course of years it became
evident that it had utterly failed to restore these families
to a satisfactory independent way of life: ‘‘ the village
became a collection of social curiosities and freaks ;
after the evacuation of the compound these families lived,
and live, in almost indescribable squalor in the poorer
quarters of the town.” Dr. Arie Querido,‘ who has
2. Sawyer, B. Amer. J. Obstet. Gamer. 1946, 51, 852,
3. Savage, S. W. Brit. med. J. 1946, i, 86. Brockington
Lancet, 1946, i, 933. Wofinden, R. C. Publ. Hlth ston, Tois,
57,136. Stallybrass, C. O. Med. Oir, 193 946, 75, 89. Martin,
A. E. oe Administration, 1944, 22
4, Querido, A: Med. Offr; 1946, 75, 193.
He had 1 set.
reported on the matter, draws the picture so familiar
in every description of such families—dirt, disorder,
fecklessness, neglect, and misery. ‘“‘ Whatever is the
prevailing social problem, these families express it in
its most acute form. In times of prosperity they are the
parasites and petty. criminals; when it is difficult to
obtain work, they are the first and longest out of a job;
when there is a shortage of houses, they are roofless ;
if there is a shortage of food, they are the first to go
hungry.”
‘Dr. Querido, in his capacity as director of the municipal
department of mental hygiene in Amsterdam, was asked
to look into this question because of the presumed
importance of mental abnormality as.a cause of the
social failure. He was able to classify the families into
three groups. In the first the social problem disappeared
if certain adverse conditions of health and work could
be remedied ; the second group of families could never
keep its head above water unless it had external help ;
but the third group was certain to fail no matter what
social assistance was provided in the hope of remedying ’
or averting its deterioration. Querido therefore came to
regard the severe “ social problem ” family as a diseased
biological unit, of which social deterioration was the chief
symptom ; he compares the measures that one takes
to treat an individual patient who has mental disorder
with those which are necessary for the disordered family,
and finds them very similar. He is opposed to any such
drastic solution as disrupting the family by withdrawai
of the children: he compares it to killing a patient and
then saying that the problem of his disease is solved.
When he calls the social problem family a unit, he
evidently means what he says.
To treat the family, two conditions, he insists, must
be fulfilled—there must be means of treatment, and
power to make these means effective. A.committee which
has considered the question has put before the Dutch
government proposals to this end. A person who is
apparently unable, by reason of mental disease or other.
mental failings, to fulfil his material and moral obliga-
tions towards himself and those who are dependent on.
him, can be placed under legal supervision by order of
a judge. When one or both parents are thus dealt with,
the supervisor (who is an expert in psychiatric or social
work) establishes contact with the family, who must
follow his instructions, He will be the guardian of their
children, the parents being reduced to the legal status
of minors. If attempts to improve the situation fail
then the family can be placed, on the supervisor’s recom-
mendation, in an institution or camp for a period of a
year (which can be prolonged by judicial decision).
So far as the means of treatment are concerned, in the
first instance the whole family would be placed in an
observation camp where thorough psychiatric, medical,
and social investigation would be carried out ; thereafter
the family would be placed in one of the “ education
camps,” providing for about 15 families. While living in
this camp the children would go to the ordinary school
in the neighbourhood, and the members of the family
would work in the ordinary farms and industries of the
locality.” Social assistance would be at hand for building
up the household again. After a successful stay in the
camp the family would return to its original locality,
but would remain under supervision until the court
brings it to an end.
These proposals are drastic and could only be war-
ranted if the problem family presented as serious a
menace to society as criminals or dangerous lunatics.
Querido maintains that it does: ‘‘ the course proposed
involves a serious infringement of personal liberty and
offers possibilities of abuse. On the other hand, the
problem family offers serious dangers, is an infectional
focus to society and presents an intolerable state of
human indignity, so that strong measures are justified.”
rE
THE LANCET]
390
WAR AND THE -PUBLIC HEALTH
Tus week the Ministry of Health published a report
by Sir Wilson Jameson, the chief medical officer, “ On
the State of the Public Health. During Six Yéars of
War.” 1 The enemies facing the public- health services—
epidemic disease, malnutrition, and mental stress—were,
as the history of 1918 suggested, potentially. more
menacing than the more usual hazards of battle. The
same standard of planning was required to face both
these threats to the nation’s welfare, and the medical
preparations for war were important threads in the
larger pattern of national defence. Traditionally this
country is supposed to ‘‘ muddle through ” its difficulties,
but there are no signs that this was the way at the
Ministry of Health. The menace of death in all its forms
was faced, an intelligent appreciation reached, and a
plan framed which was bold in conception, careful in
detail, and yet elastic enough to meet the changing needs
and fortunes of war. When it was put to the test there
were of course failures and mistakes, but all in all the
offensive-defensive campaigns waged by the Ministry
and its satellites in town and country were as successful
as those of the fighting Services.
It was soon realised that intelligence, in the military
sense, was a first essential. Even before September,
1939, an intelligence section was established at the
Ministry to provide information not only for the civil
population but also for the military Services. During
the war itself, field investigations on epidemic illness
and sample surveys of patients in the E.M.S. hospitals
and of minor sickness among the civil population kept
the Ministry staff well informed. Gloomy if reasoned
forecasts of casualties evoked a major effort in building up
the staff, equipment, and organisation of the Emergency
Medical Service. With the number of injured mercifully
less than had been anticipated, the switch of the service
to the less dramatic but none the less useful forms of:
medical care was rapid and effective. Experience in the
blitz with the nation-wide civilian defence casualty
organisation, and in particular the ambulance service,
showed the advantages of large-scale administration in
this field. Into the fight were called the auxiliary services
of the laboratory. Blood-transfusion was widely used, and,
as the report says, its practice ‘‘ has increased prodigiously
and will increase still further. Transfusion is a procedure
directed to the treatment of disorders of the circulation.
There is little in medicine on which the study of the
circulation does not impinge and it is for this reason
that the advances stimulated by the war in this field
have had, and are likely to have more, profound reper-
cussions in many fields of civilian medical practice.”
The Emergency Public Health Laboratory Service
spread a net of laboratories, well-staffed and adequately
equipped, over the whole country. These undertook
not only routine diagnostic and public-health work but
also valuable field researches on epidemic diseases. :
While the responsibility for feeding the people lay
elsewhere, the Ministry of Health busied itself with
surveys of the essential foods. Insufficient diet, par-
ticularly when combined with overwork and over-
crowding, brings in its train, the risk of an increasing
incidence of tuberculosis, and the preventive efforts of
local-government doctors were redoubled. The hardships
of war bear most heavily on expectant mothers and
young children; their defences were strengthened by
dietary supplements. The traditional association of Mars
and Venus brought a rising incidence of venereal diseases,
leading the Ministry to discard its last Victorian inhibi-
tions and to embark on a virile and aggressive publicity
campaign. Another enemy, insidious but disabling, was
the anxiety and fear engendered by the onslaught on
1. On the State of the Public Health During Six Years of War,
Minis H.M.
1939-45. try of Health. soba noneky Office,
1946. 52.
FOOD FROM THE SEA
[sEPT. 14, 1946 —
the civil population ; it was countered by the psycho-
logical selection tests and welfare work in industry, and
psychiatric treatment in special E.M.S. clinics.
What were the results of this campaign ? The ultimate .
arbiter must be the account of the nation’s health in
the vital statistics of the war years, for “ facts are-chiels .
that winna ding.’? The infant and child mortality-
rates are particularly sensitive indicators of social well-
being; despite the loss, by enemy ‘action, of the lives
of 7000 children under the age of 15, and an increase in-
accident deaths through war conditions, the mean annual
death-rates in the three five-year groups under 15 were
below the rates for any year before 1939. New records
for the second and third years of life were set up in 1942 ;
and new low levels for neonatal, infant, and child.
mortality in the first ten years of life were attained in
1944. The stillbirth-rate declined continuously through-
out the war, while successively lower records for maternal
mortality were established in 1940, 1942, 1943, and 1944.
Another index to national health is the tuberculosis
death-rate. After a disquieting rise in 1939-41, the
pre-war downward trend was resumed, to reach a new
low-level record in 1944. In the field of epidemic diseases,
the major triumph was the immunisation campaign
against diphtheria; in 1944, deaths were less than one-
third of the pre-war average, although this essentially
preventable disease still caused more deaths than enemy
bombs. Diseases such as typhoid fever, which might
have been expected to spread in the disturbances. and
dirt of bombed cities, were held in check, but there was
an increase in scabies, food poisoning, and dysentery,
due, no doubt, to the difficulties of personal and culinary
hygiene. Field research, stimulated by an awakening
of the community’s social conscience, uncovered the
importance, as causes of disability, of rheumatism,
ansmia, and accidents in the home; and the need for
special care for the aged. These are not new problems,
but their extent was highlighted by the statistics which
these studies produced.
The advantages of nation-wide organisation in preven-
tive medicine have been fully demonstrated. In the new
Health Service these advances can be consolidated if
administrative efficiency is tempered with humanity.
FOOD FROM THE SEA
IN normal times about thirteen million tons of fish
is removed from the oceans of the world every year.
Of this catch some is consumed directly, either fresh,
preserved, or canned ; but a large part goes to the making
of over a million tons of fish meal, which contributes
indirectly to human diet through the nourishment of
farm animals and poultry ; and the Antarctic whale-oil
industry produces upwards of half a million tons of fat,
of which a quarter of a million tons is converted for
eating. In the years before the war the average annual
consumption of fish in this country was 161/, lb. per head ;
this was two or three times the consumption in France,
Germany, or the U.S.A., but only half that in Japan,
and possibly a tenth that in Norway. Measured by labour,
fish are a cheap source of first-class protein. There is a
wide variety of edible species, all highly nutritive and
rich in minerals—the iodine content, for example, is
50-200 times as great as that in any other food, while
that of calcium and phosphorus is as high as in beef.
Moreover, fish are available all the year round, and new
techniques of freezing enable such fatty fish as the
herring, which vary with the seasons, to be distributed
at their best throughout the year. Perhaps we do not
benefit fully from the bounties of the sea. Certainly
long usage has clouded our appreciation of this unique
harvest for which no field must be ploughed or cultivated,
no seed sown, and no stocks tended.
As on land, animal life in the sea depends either
directly or indirectly on plant life. This is found mainly `
THE LANCET |
-in the plankton; of which there are three groups—
producers, consumers, and reducers. The producers
comprise largely the chlorophyll-bearing diatoms and
alge, which by solar energy build up organic matter
from inorganic nutrients in the water. The consumers
or zooplankton feed on the living or dead matter of this
phytoplankton or its metabolic products, and are in turn
consumed by such fish as herring, pilchards, sprats,
mackerel, and, curiously enough, one of the world’s
largest mammals—the rorqual whale. Much of the
dying or dead plankton falls to the sea floor, where it is
eaten by the bottom fauna, including worms and shell-
fish, which in their turn form the food of the bottom-
living fish. The amount of plankton is very large, being
especially rich in some Polar areas, but varies from one
region to another; it has been estimated that in the
English Channel alone the annual crop of phytoplankton
amounts to 3600 tons per square mile. Suggestions that
_ the plankton might be used directly as human food
were revived during the late war after a German report
that the zooplankton had a nutritive value equal to
that of the best meat, and the phytoplankton to that
of rye flour. Investigation showed, however, that
the probable yield from our seas did not warrant the
establishment of a special fishery. l
The reducers, the sea’s bacteria, are particularıy
important to the marine life-cycle. As ZoBell has
recently indicated,! only a very small part (0-1%) of
the primary production of organic matter in the world’s
oceans is removed each year in the form of fish, commer-
cial algæ, &c. ; the remaining residues and waste products
of plants and animals undergo bacterial decomposition
and return in mineralised forms to the sea and atmo-
sphere, where they supply the phytoplankton with the
elements, such as nitrogen, phosphorus, and carbon,
from which its cell substance is synthesised. Without
these bacteria the sea floor would soon be cluttered up
with a mass of dead plant and animal remains, and
plant life, denied its essential elements, would cease.
A further important function of aquatic bacteria is the
conversion of dissolved organic matter into particulate
organic matter (bacterial cell substance), which animals
can utilise. ZoBell himself has found that, given suitable
conditions, bacteria can. mineralise roughly 70% of the
organic content of sea water and convert 30% into
bacterial cell substance or intermediate products. It is
debatable, as he points out, whether bacteria are sufti-
_ ciently abundant in sea water to constitute an appreciable
' item in the diet of marine animals, but cumulatively
they are clearly important to the food cycles of both
animals and plants.
A COMPASSIONATE RELEASE
In July several newspapers reported the case of a
young officer of the Royal Army Medical Corps who
was released from the Service soon after the death of
his father, with whom he was in partnership. The press
reports made it appear that his release was.the result of
pressure by a Member of Parliament to whom 400
patients were said to have written; and the patients
seemed to have been actuated by a belief that this doctor
was the only man who understood a method of treatment
practised by his late father. As may well be supposed,
these newspaper reports have caused indignation,
especially among those whose tenure of one-man prac-
tices did not prevent their acceptance for service during
the war. We understand, however, that this officer
was not in fact released on the ground that he is profes-
sionally indispensable at home : indeed, the local medical
war committee, which judges such matters, decided that
.1. Marine Microbiology. Claude E. ZoBell, associate
professor of marine microbiology, Scripps Institute of Oceano-
graphy, University of California. Waltham, Mass.: Chronica
eer ri ee (in London from Wim. Dawson and Sons Ltd.).
Pp. 4 b $ e "
PH.D.,
”
. A COMPASSIONATE RELEASE
- other precautions.
[serr. 14, 1946 391
he was not. The War Office granted him compassionate
release, obtainable in extreme cases of individual hard- `
ship of financial or domestic nature. Although there has
been some relaxation since the end of the war in regard
to one-man businesses (and practices) the number of
Army medical officers granted compassionate release has
been very small—less than 40 out of a total of over
8000 releases. f |
HOKEY-POKEY PENNY A LUMP
Tne present outbreaks of enteric fever recall the
profession’s ancient quarrel with the uncontrolled sale
of ice-cream. It is 67 years since a Lancet commission
drew attention to the appallingly filthy conditions in
which ice-cream was made in the Italian quarter of
London.t Gone are the days of ‘‘ penny a lump,” but
“ hokey-pokey ” (the Cockney’s rendering of the Italian
ecco poco or ‘‘ here’s a bit”) and the outbreaks are still »
with us. In the interval ice-cream has been credited
with ptomaine poisoning, carbolic-acid poisoning, zinc
poisoning, and scarlet fever, as well as recurrent out-
breaks of enteric. An outbreak of unspecified diarrhwa
in Lancashire was traced to premises with ‘‘ two vessels
containing ice-cream in process of manufacture...
within a yard of a pail-closet; and the fine strainer
used for straining the milk and cornflour after boiling
was within about four inches of a dolly tub in which
were babies’ napkins soiled with diarrhceal excreta.’ 2
Advances in bacteriology served to underline the extent
of the scandal. Thus in 1894 the medical officer of
health for Islington found in specimens of ice-cream
“ almost uncountable colonies of Bact. coli’? 3; and in
1897 the m.o.H. of Liverpool was impressed with ‘“ the
marked similarity between plate cultivations of the ice-
creams ... and those of sewage.” 4 Only fourteen years
ago bacterial counts were found to range from 625,000
to 265,000,000 per c.cm.§
In the nineties some local authorities and the larger
manufacturers were pressing for regulation of manu-
facture and distribution, but it was not until the enact-
ment of the London County Council (General Powers)
Act of 1902 that the first specific control was imposed.
“Tt is difficult to believe that such categorical exposure
of a foul danger to public health should not have been
. followed by reform until more than twenty years have
passed.” 6 Jn 1927 the Ice-Cream Association of Great
Britain and Ireland invited the Minister of Health to
propose a legal definition of ice-cream and to enforce the
licensing by local authorities of all makers and vendors,
whose premises should be inspected’; but no action
was taken. Since then some authorities, and notably
Hove, which provisionally adopted the same standard
-as for pasteurised milk,* have shown themselves increas-
‘ingly alive to the risks.
Last year a Ministry of Food
order prohibited the admixture, except by licence, of
dried eggs, since these may contain salmonella organisms ;
under the licence makers must pasteurise the mix within
two hours of manufacture, and myst observe certain
Otherwise, ‘“‘it is only when con-
ditions of manufacture are grossly insanitary that the
Food and Drugs Act, 1938, is called in to protect the
public.” 9 Most of us will therefore agree wholeheartedly
with the resolution passed by the conference of sanitary
‘Inspectors at Westminster on Sept. 5 calling for the
compulsory registration of all ice-cream vendors. Until
this step is taken no comprehensive plan of control is
possible.
THE annual Harveian oration will be delivered at the
Royal College of Physicians by Sir Maurice Cassidy on
Tier Oct. 18, at 3 P.M. His subject will be Coronary
isease. :
1 Lancei,1879,ii,590. 2. Ibid, 1900, ii, 1149. 3. Ibid, 1894, ii, 862.
4. Ibid, 1897, ii, 1458. 5. Ibid, 1932, ii, 1230. 6. Lbid, 1902, ii, 998.
7. Ibid, 1927, ii, 896. 8. Ibid, 1938, ii, 1084. 9. Ibid, 1945, ii, 214.
392 THE LANCET] `
Special Articles
LENGTH OF STAY IN HOSPITAL
FRANCES GARDNER * L. J. Wrrts.
M.D. Lond., M.R.C.P. M.D. Manc., F.R.C.P.
From the Nuffield Department of Clinical Medicine, Radcliffe
Infirmary, Oxford
_ Ir has recently been suggested that the need for hos-
pital beds could be diminished by the provision of
better facilities for outpatients or by the building of
hostels for patients who require only one or two nights’
accommodation for investigation or other purposes
(Lancet 1943, Lister 1945, Morgan 1945, Nelson-Jones
1946). Others have urged the creation of special wards
or hospitals for illnesses which cannot be classed as
incurable but nevertheless require protracted or special-
ised treatment; rheumatoid arthritis, peptic ulcer,
ulcerative colitis, and nephritis have been put in this
category.
With these suggestions in mind, we have recently
analysed a year’s admissions to a medical ward of 21
beds, 10 male and 11 female. The ward is essentially
' a diagnostic and research unit. There was great pressure
on our beds during the year under review, as the Radcliffe
Infirmary, which serves a population of 250,000, had at
that time only 80 general medical beds, and there were
no other medical beds in the area except in cottage hos-
pitals or hospitals of the poor-law type. The ward was
protected from the full pressure of the competition for
beds by the fact that it was ‘“‘ on take ” on only one day
a week. In other words, though containing one-quarter
of the medical beds, it admitted only one-seventh of the
emergencies which came into the medical side of the
hospital. In spite of this, over 30% of the admissions
were emergencies. l
During the period under review 180 men and 175
women were admitted to the ward. Though the total
number of patients was 355, the total number of admis-
sions was 440, because 28 patients were readmitted on
one or more occasions during the year. The average
proportion of occupied beds was 19 out of 21;
(8%) of the available bed-days were wasted. This
wastage was partly due to temporary war-time conditions
—beds had to be kept empty and available for D-day
casualties—but it was also an inevitable result of the
system of emergency admissions. All emergency cases
must be admitted on the day of “ take.’ It therefore
behoves the house-officer to arrange the discharge of
patients so that some beds are empty on the appropriate
day, and it is impossible to estimate with accuracy the
number of beds required.
The average duration of stay in hospital was about
16 days, but the accompanying figure shows that this
average figure is somewhat misleading. The largest
fraction of patients stays the shortest time in hospital,
and the proportion of patients remaining in hospital
steadily declines as the period of treatment increases.
The length of stay in 26% of admissions was less than
six days, and in nearly 50% of cases the patient was dis-
charged within eleven days of entering hospital. At the
other extreme is the group of 24 patients who were in —
hospital for more than fifty days. They accounted for
1772 bed-days, which may be roughly expressed by
saying that 5% of the admissions accounted for 25%
of the bed-days. An analysis of the whole series of
patients will be published by us elsewhere, and we deal
below only with the two extremes of short and long
admissions. .
SHORT ADMISSIONS | ,
The reasons for inpatient treatment of the patients
who stayed less than six days are shown in table 1:
* With a grant from the Medical Research Council.
LENGTH OF STAY IN HOSPITAL
626.
‘With advances in diagnosis and treatment.
[sEPT. 14, 1946
66 patients in this group were responsible for 113 admis- —
sions ; 27 were admitted as emergencies for the treatment
of acute illness, and 10 of these died shortly after
admission, the remainder being either discharged or
transferred to other hospitals within a few days. All
the other patients were admitted from the waiting-list :
17 patients were admitted for follow-up examination,
coming ‘either from other areas or from remote parts
of the surrounding counties; 11 patients undergoing
treatment with thiouracil were repeatedly admitted
for estimation of basal metabolic rate, accounting
for 54 short admissions; 3 patients were respon-
sible for 5 admissions for blood-transfusions; and
the remaining 8 patients were admitted for specific
investigations. l
In all, 39 patients from the waiting-list were responsible
for 86 admissions and 151 (2%) of the bed-days. Short
stays in hospital of this kind undoubtedly give rise’ to
some administrative problems. They tend to disturb the
smooth routine in a busy medical ward. Most of the
patients are in fair health and often in full employment,
and they may resent the small restrictions which must be
imposed in a hospital ward. Moreover, the amount of —
nursing time devoted to them seems out of proportion
to their needs. These are the considerations which
have led to the suggestion that patients of this
type might equally well be treated in the outpatient
department.
It is possible to divide the short-stay patients admitted
from the waiting-list into two groups. The first are
30 :
x 25
Y 20
=
S 15
9
N LOA bes N BIRN
Q
x m
Riis REER Come SD R R DES E ;
23I
eS eggs gee
LENGTH OF STAY (DAYS)
Frequency histogram to show the percentage of admissions entailing
different lengths of stay in hospital. .
those who require a bed overnight, either because an |
examination, such as cholecystogram or basal metabolism,
is to be carried out fasting, or because the patient lives
too far away to travel to and from hospital in one day.
Admissions of this kind can be arranged to suit the
convenience of the patient and the hospital, and patients
should rarely need to stay more than, one night. The
other group is constituted by patients who come in for
a short treatment, such as transfusion or ‘paracentesis,
and require a bed for about twenty-four hours. These
admissions can also be planned ahead, though not so far
ahead as the first group, and the patients are more liable
to overstay the expected time because things go wrong.
The division is not hard and fast, for some investigations,
such as lumbar puncture and gastroscopy, entail a recovery
period. Follow-up patients come into both groups.
Indeed, it is only necessary to make an analysis of this
kind to realise that the antithesis between outpatients
and inpatients is false; rather should we think of the
key hospital as a centre for diagnosis and special treat-
ment, which may or may not require the patient’s `-
admission.
The need for short stays in hospital grows steadily
Periodic
transfusions for refractory anzmia, estimation of the-
metabolism of patients receiving thiouracil, and
desensitisation to liver of patients with pernicious
THE LANCET]
TABLE I—REASONS FOR ADMISSION OF PATIENTS WHO STAYED
IN HOSPITAL LESS THAN SIX DAYS
Reason for admission Patients | Admissions
Acute illness— |
For dinprcala aaa treatment . ae 17 | 17
Follow-up examination and investigation 17 | 18
Estimation of basal metabolic rate oe 11 54
Blood-transfusion . . 3 5
Gastroscopy 2 2
Sternal puncture .. h se 2
Lumbar puncture.. 1 1
Paracentesis of abdomen.. 1° 2
Radiography : 1 1
Miscellaneous ve | 1 1
Total . | _ 66 | 113
anemia are examples of recent additions to the list.
Transport tó and from hospital inevitably presents
considerable difficulties in a rural area, and often
investigations arranged for outpatients would be more
expeditiously and conveniently completed if a night’s
lodging could be provided. Far from using outpatient
facilities inadequately, we believe we are using them
to excess. It would be kinder to admit to hospital some
of the patients who now undergo tedious and exhausting
investigations as outpatients, but shortage of beds
has made it impossible. It is probably true that when
it is possible to consider the comfort of the patient more
closely the demand for short-term accommodation will
greatly increase.
LONG ADMISSIONS
The reasons for prolonged inpatient treatment in the
24 patients who were in hospital longer than fifty days
are shown in table 1. Many of them were gravely ill, and
6 of them had died by the time of the follow-up, from one
to two years later. The largest fraction was made up
of 14 patients who underwent surgical treatment after
medical investigation ; 2 patients were kept in hospital
because they were the subjects of research, and 2 others
because it was difficult to find accommodation for them
elsewhere—a woman needing special X-ray therapy,
and a boy dying of lymphosarcoma. The remaining
6 are a heterogeneous group who had in common only
TABLE II—REASONS FOR STAY IN HOSPITAL LONGER THAN
50 DAYS
Cases ; Cases
Surgical intervention .. l4 Long-term treatment
oparo ay . 3 Pituitary cachexia.. 1
Cholecystectomy 9 Puerperal fever’ .. 1
Nephrectomy 1 Rheumatoid arthritis 1
Miscellaneous 3 ; Subacute nephritis. . 1
Thyrotoxicosis 1
n oblaining insti-
aD eal 08 ne H A - Ulcerative colitis 1
Lymphosarcoma .. 1
Reticulosis .. .. 1 Research ge “Pee ia. 2
the fact that they required prolonged medical treat-
ment. In retrospect it appears that only 3, of these
24 patients (rheumatoid arthritis, nephritis, and ulcerative
colitis), accounting for 260 (less than 4%) of the available
bed-days, could have been referred to a long-stay hos-
pital, if such had been available. i
A different picture was obtained when we inquired into
the fate of some of the patients with chronic diseases who
stayed in hospital less than fifty days. In table 11
we have summarised the data for all cases of peptic ulcer,
rheumatoid arthritis, ulcerative colitis, and nephritis
in this group. Many of these patients had been
LENGTH OF STAY IN HOSPITAL
[serr. 14, 1946 393
incapacitated for more than a year before admission to
hospital. They remained in hospital only three weeks
on the average and then were discharged home, some-
times with a short interval in a convalescent home
_ or cottage hospital. The results of treatment have been
strikingly unsuccessful: 8 of the 12 patients have
required readmission, and only 6 of them are back at
work, from one to two years later. Therapeutic failure
' may be inherent in the nature of these diseases, though
one would not judge so from reading textbooks of medi-
cine and treatment. A more justifiable comment would
be that the diagnostic hospital is not adapted to the
treatment of subacute and chronic illness. Patients with
peptic ulcer and similar diseases are not admitted unless
there is some complication, such as vomiting, hæmor-
rhage, or intractable pain ; and, when they are admitted,
they are often discharged before treatment could be
effective. This is largely the result of shortage of beds,
but there are also reasons which must be included under
the heading of psychological attitudes and motivation.
Both diagnostic and teaching hospitals are driven to
regard themselves as sorting- and clearing-houses, and
the tempo is too swift for great interest to be taken in
. protracted therapeutic procedures.
DISCUSSION
Short-stay admissions are important because of their
increasing frequency, long-stay admissions because
they account for a relatively high proportion of occupied
beds. Both are of particular interest to the outpatient
physician, who has the hard task of selecting patients
TABLE III—ANALYSIS OF PATIENTS WITH CHRONIC ILLNESS
WHO STAYED IN HOSPITAL LESS THAN 50 DAYS
Average dura-
Average | tion of inca-
duration} pacity (months) Patients
Disease Patients u — Se read-
‘ mitted -
pital | Before | After
(days) dis- dis-
charge | charge
Peptic ulcer 7 18 24 12 4
Rheumatoid arthritis 3 22 14 13 2 7”
Ulcerative colitis .. 1 - 44 30 24 1
. Nephritis 1 18 None 22 1
- Total ace 12 ` 21 12* 14 8
_ * This figure represents the node or usual duration of incapacity, and
not the average, which is distorted by a few very chronic cases.,
for admission. We do not find that patients who could
be dealt with as outpatients are being admitted to
hospital unnecessarily. On the contrary, the work of the
outpatient department would be easier if some of the
patients now investigated there were admittod to hospital
for one or two nights. We therefore agree with Rock
Carling and Power (1943), who pointed out that the
existence of a highly organised and efficient outpatient
service is likely to increase rather than diminish the
demand for beds. Our main criticism of the present
arrangements for admission is that too much responsi-
bility is left with house-officers and administrative staff,
and that more care might still be taken in selecting
patients from the waiting. list and in correlating the out-
patient and inpatient work of the unit. The rival claims
of medical urgency, social stress, and efficient employ-
ment of the ward need balancing, and doctor, secretary,
and almoner should combine in the task. Whenever
a patient fails to enter hospital when written for, an
inquiry should be made by the almoner.
Our review has less bearing on the problem of long-
stay hospitals. There is little doubt that the potential
demand for accommodation for long-stay cases is very
394 THE LANCET]
great. It could be better assessed from an analysis of
the records of outpatient clinics and X-ray departments
than from a study of this kind. With the present short-
age of beds, the physician seeing outpatients rarely
attempts to secure admission for cases of peptic ulcera-
tion and rheumatoid arthritis; and, when such patients
are admitted, they are referred within a few, weeks
for treatment in convalescent hospitals, their own
homes, or the outpatient-department. All that we can '
say is that provision of hospitals for prolonged treat-
ment of these patients would not greatly relieve the
, pressure on beds required for purposes of diagnosis.
By the same logic it should not reduce the variety of
clinical material in the teaching hospitals. Any measure
which entirely removed chronic illness from the teaching
hospitals would have a lamentable effect on the training
of nurses and students and on the advancement of
knowledge.
= ', The present tendency to specialisation in medicine,
both by individuals and by departments, is continuously
raising obstacles to the communication of ideas and to the
integration of treatment. Sickness is not just a produc-
tion job which can be broken down into separate elements
and treated by the methods of modern mass manu- -
facture. It is a personal and individual problem, and the
operative proverb is “ too many cooks spoil the broth,”
and not ‘‘ many hands make light work.’’. In a previous
paper from this department, the need for continuity in
treatment was heavily underlined (Brown and Carling
1945). The community hospital has a corporate spirit,
which might be weakened by overelaboration of function
and loss of adaptability. What is required today is not
-a further specialisation of purpose but an internal
reconstruction. At present the medical beds in hospitals
in this country are usually divided into a series of separate
units or firms which work 'more or less independently
and whose chiefs have a great sense of pride and property
in their charge. This traditional arrangement is steadily
-becoming less adapted to the needs of.the patient and
the medical student. It is suggested that the time has
come for a division on more functional lines. l
If we think in terms of patients, we find that we have
to deal with emergency: admissions, usually of acutely-
ill patients; short-stay admissions from the waiting-
list of patients who are not ill and do not require much
nursing ;
we translate these demands into bricks and mortar,
we shall design a medical unit which consists of three
sections: (1) the diagnostic and treatment unit, which
‘would correspond very closely. with our present ward ;
(2) the short-stay ward or hostel, which would cost half
as much per bed-week; and (3) the long-stay ward,
where the emphasis would be on treatment and research.
All these -three adjoining sections would be the field
of work of one team of nurses, technicians, assistants, and -
physicians, whose outpatient department would be on the
same floor or at least connected by direct lift. The
optimal size of a unit of this kind would probably be
about 75 to 100 beds. With less beds than this the sub-
sections for the two sexes would become too small for
effective working, whereas a larger number of beds would
be too many for an integrated unit with a life and
personality of its own.
For several reasons we are opposed to the suggestion
that special hostels should be provided for short-term
admissions of every kind, and that these hostels should
be separate from the wards of the hospital. The clinical
field is already divided into too many separate compart-
ments, and we do not want to split it up further. Most
of our short-term patients enter for follow-up or for
special treatment, and they like to come back to the
ward where treatment was started and where they feel
that their case is understood. The introduction of
hostels would be only too likely to bring its own crop of
LENGTH OF STAY IN HOSPITAL
and medium- and long-stay admissions. If- . than from a study of this kind.
[SEPT. 14, 1946
psychological and administrative problems. Even now
the recurrent type of admission is sometimes inadequately
supervised, as the period of observation extends over
several generations of house-officers. Lack of careful
- supervision is obviously undesirable, and it may be
dangerous in protracted treatment with thiouracil or
sulphonamide drugs. Recurrent admissions are essentially
part of the follow-up work of the ward. Evidence of
the value of following up all patients who have been
admitted to hospital has been published from this depart-
ment (Brown and Carling 1945). We believe that the
follow-up should be separated from the diagnostic work —
of the outpatient,department, and that it should be carried
out in close proximity to the ward. The same team of
senior medical officer, secretary, and almoner should be
responsible not only for the selection of cases from the
waiting-list but also for the general follow-up and for the
supervision of recurrent admissions..
SUMMARY
We have analysed 440 consecutive admissions to a
medical ward which is essentially a diagnostic and
research unit. is |
Short-stay cases form a high proportion of the admis-
sions, but there is no evidence that the number could
have been reduced without detriment to the patients.
by provision of better outpatient facilities.
Patients who were in hospital for more than fifty days
account for only 5% of the admissions but 25% of the
bed-days. More than half of them were patients who
eventyally required surgical treatment. Only 3 patients
in this group, accounting for less than 4% of the bed-
days, could have been referred to a long-stay hospital
or a centre for special treatment.
Special accommodation for short-stay and long-stay
cases would have released only 6% of the bed-days, and
therefore would not have relieved to any great extent
pressure on the beds required for diagnostic purposes.
Patients who might be expected to need prolonged
treatment seem to have been admitted to hospital with
some reluctance owing to shortage of beds, and they
were often discharged prematurely. The results of
treatment in this group were strikingly unsuccessful.
The need for long-stay accommodation could be better
estimated from an analysis of outpatient and X-ray records
It is undoubtedly great.
~The common practice of splitting the medical beds in
a hospital into small autonomous units does not seem
ideal. They should be arranged in functional groupings
to meet the needs of the different types of admission.
We are indebted to Miss I. F. Beck for much help in tracing
patients and analysing the data. For suggestions for hospital
design we have obviously borrowed from the ideas of Sir E.
Rock Carling..
. à REFERENCES
Brown, M., Carling, F. C. (1945) Brit. med. J. i, 478.
Carling, E. R., Power, C. M. (1943) Lancet, ii, 619.
Lancet (1943) ii, 545.
Lister, W. A. (1945) Lancet, ii, 757.
Morgan, D. G. (1945) Jbid, p. 795.
Nelson-Jones, A. (1946) /bid, i, 70.
—_—— —— — a
‘‘ Medical schools are charged with the responsibility for
admitting not those who say, however earnestly, that they
want to study medicine, but those judged to have the moti-
vation, industry and ability for the pursuit of a profession
involving the health and the lives of the people who will
seek medical aid in the years to come. The admission of
students lacking the qualifications for a medical career is
wasteful and harmful no matter how much the student himself
thinks he would like such a career. The cost of failures in
‘medical school, in money and time and work and disappoint-
ment, is so great that extreme care must be exercised in
the selection of students, even if enrolments decrease. Fresh-
man enrolments in 1946 will exceed 5500 mainly because of
the many veterans admitted . . . about 60% will be in this
category. . . . About 12% are women.”—J. Amer. med.
Ass. August 17, p. 1355.
A
THE LANCET]
A NEW HEALTH SERVICE :
THE DESIGN IN SOUTHERN RHODESIA
‘‘Irksome and circuitous as the methods of democracy
may seem to harassed administrators, in the long run the
results are more stable and permanent. Progress in public
health must be built increasingly on the basis of an informed
public opinion and intelligent public coöperation. There
is in a democratic country no short cut.”
From this principle the commission which has been
inquiring into the health services of Southern Rhodesia !
goes on to affirm that the -colony has now passed the
pioneer stage and must therefore proceed by democratic
methods. In its recommendations it has sought to
retain freedom of action and choice for doctor and patient
alike; to free the citizen from the fear of financial
embarrassment through ill health, while yet leaving him
to shoulder some responsibility ; and to intervene to
provide services only where they are not already being
efficiently provided at a reasonable cost.
To introduce a national health service in Southern
Rhodesia may be at once more difficult and easier than
in this country, for in the colony there is already a govern-
ment medical service and all the European hospitals
except one are government hospitals. Some of the more
obvious administrative snags are thus absent. But
Southern Rhodesia has the heavy responsibility of a large
and impoverished African population, who will be able to
contribute only a small part of what must be spent on
them. The commission firmly opposes any attempt to
relate expenditure on African health to African revenue.
The commission is equally convinced that health prob-
lems are indivisible, and that, though methods of dealing
with each section of the population may vary, a national
service must cover everybody. It therefore proposes
that for all races hospital treatment, maternity and X-ray
treatment, and laboratory services should be provided by
the State. And though the individual is to be left to
pay for his general practitioner, his dentist, his surgical
appliance, and his drugs, his burden is to be adjusted to
his financial strength : the maximum he will be asked to
pay for these services in any one year will range from £2
(income of £100) to £55 (income £2000). All amounts
above this will be met from a national medical fund on
production of the doctor’s receipted account. The
maximum covers the doctor’s bill for a whole family,
which means that married men with children will probably
make heavier claims on the fund than bachelors or’
childless couples. . No contributions have to be paid,
apart of course from general taxation. Patients who do
not wish to accept the salaried consultant staff at the
hospitals must pay the full rates at the hospitals as well
as their private doctor’s fee. A medical committee of
control, on which laymen as well as doctors would be
represented, will be set up to investigate cases in which
excessive visiting or excessive prescribing is suspected.
The commission recommends the creation of a separate
department of health directly responsible to the minister
of health. It also proposes the establishment of a
national health board and the division of the colony into
five regions with further subdivisions of areas which
would approximate to the present native districts. The
board would have nine members, including representatives
of the regions, the secretaries for health and native
affairs, and two doctors. Its functions would be advisory
and policy-making and it would have the duty of drawing
- up a national health plan from the plans submitted by the
regions. Each of the regions would in turn have its
council, again an advisory and planning body, and in
each region and area there would be a medical officer of
health in charge of the State health services.
Assuming that right of private practice will be with-
drawn, the following salaries are suggested for doctors in
the new service : secretary for health, £2250 ; consultants,
£1500-£2500 ; directors of public health or research,
£1750-£2000 ; regional M.O.H.s, £1500-£1750; area
M.O.H.S, £750-£1500. The general scale for government
medical officers (£750—-£50-£1500) will, it is felt, not
only attract.doctors into the service but retain them in it.
1. Report of the Commission presented to the Legislative Assembly,
une, 1946. ree nea PERMORENY Otlice, Salisbury, Southern
Rhodesia, 1946. Pp.1
A NEW HEALTH SERVICE—ON ACTIVE SERVICE
measles, 9
\ Captain HENRY ALEXANDER
[serr. 14, 1946 395
The larger local authorities which are able and willing
to carry out environmental services should continue to
do so and should be given financial help to expand them.
But in general the smaller municipalities should look
towards further expansion of their health services as
integral parts of their areas. Similarly,, though -the
State will assume responsibility for the treatment and
prevention of venereal diseases and institutional maternity
work, municipalities and voluntary organisations will be
encouraged and helped to continue any clinics which they
are running. The mines and mission hospitals for
natives will also be subsidised. |
The commission also open the way to a great expansion
of the preventive services of the colony with proposals -
that a nutrition council and a research council should be
set up. The members included Prof. C. F. M. Saint, M.S.
(chairman), and Dr. T. G. Burnett. .
INFECTIOUS DISEASE IN ENGLAND AND WALES
WEEK ENDED AUGUST 31
Notifications.—Smallpox, 03; scarlet fever, 744;
whooping-cough, 1976; diphtheria, 262; paratyphoid,
44; typhoid, 27; measles (excluding rubella), 1565;
pneumonia (primary or influenzal), 279; cerebrospinal
fever, 41; poliomyelitis, 21; polio-encephalitis, 4 ;
encephalitis lethargica, 0; dysentery, 74; puerperal
pyrexia, 131; ophthalmia neonatorum, 98. No case
of cholera, plague, or typhus was notified during the
week.
The number of service and civilian sick in the Infectious Hospitals
of tho:-London County Council on August 28 was 854. During the ©
previous week the following cases were admitted: scarlet fever, 46;
diphtheria, 17; measles, 42 ; whooping-cough, 43. i
Deaths.—In 126 great towns there were no deaths
from scarlet fever, 1 (0) from enteric fever, 2 (0) from
(0) from whooping-cough, 5 (0) from. diph-
theria, 31 (5) from diarrhoea and enteritis under two-
years, and 6 (0) from influenza. The figures in parentheses
are those for London itself.
Halifax reported the fatal case of an enteric fever.
The number of stillbirths notified during the week was
277 (corresponding to a rate of 31 per thousand total
births), including 40 in London.
On Active Service
CASUALTIES
KILLED
ANDREW Captain
Lieut.-Colonel Joun VARLEY
ROBERT FAUSSET CLARKE, SCHOFIELD, M.B. Leeds,
M.C., M.B. Edin., R.A.M.C. R.A.M.C.
Major C. L. LEWIS, R.A.M.C. Lieutenant WILLIAM FRED-
Captain ROYLANCE LYNTON ERICK ; JAYNE WESTON, |
PARKINSON, M.R.C.S.,R.A.M.C.
Lieutenant GEOFFREY ROGERS,
M.R.C.S., R.A.M.C.
M.R.C.S., R.A.M.C,
PREVIOUSLY REPORTED PRISONER-OF-WAR,
_ REPORTED DIED AS P.O.W. i
Lieut.-Colonel CYRIL ArM- Captain ALFRED Reana
STRONG, M.B.E., M.D. Durh., EASTWOOD, M.R.C.S., R.A.M.C.
R.A.M.C. Captain BASIL FREDERICK
BENBOW GULLIVER, M.C.,
M.B. Lond., R.A.M.C.
NOW
DEVERELL,
R.A.M.C.
M.B. Edin.,
H DIED
Captain JAMES Lavineton Captain WILFRED KENDRICK
ASHLEY, M.B. Brist., R.A.M.C. LLOYD, M.B. Birm., R.A.M.C.
Captain James RayrMonp’ Captain M. M. LOUGHNAN,
DUNN, M.R.C.S., R.A.M.C. R.A.M.C.
Captain PauL VERRIER Major Ewen ARTHUR ELSON
Isaac, M.B. Lond., R.A.M.C. PALMER, M.B. Camb,,
Captain ARCHIBALD DAVID _ R.A.M.C. |
Morrison’ KING, M.B. Colonel MICHAEL ^ JAMES
Edin., R.A.M.C. WHELTON, M.D.N.U.i.,
Colonel SIDNEY JOHN LIDDON R.A.M.C,
LINDEMAN, 0.B.E., M.C, Major EpmMunpD Huan Lewis
M.R.C.S., R.A.M.C. WIGRAM, M.B. Camb.,
R.A.M.C.
WOUNDED
_ Captain J. K. A. BURN, M.B. Aberd., R.A.M.C.
396 THE LANCET]
In England Now
A Running Commentary by Peripatetic Correspondents |
“ OF course,” said the German Mayor, ‘‘ we quite
understand that at the end of an unexpectedly victorious
war you must be a little disorganised and that your
Military Government is a temporary affair, but when
is the real government coming out? > This was said
some four months after the end of the war. Nobody
would think of saying it now, I fancy, but with the
Dodo in Alice might talk about the Caucus-race.
You remember ? .
_ “ What is a Caucus-race?’’ said Alice. ‘‘ Why,” said
the Dodo, ‘‘ the best way to explain it is to do it.”
First it marked out a race-course in a sort of a circle ;
then the party were placed along the course here and
there. They began running when they liked, and left
off when they liked, so that it was not easy to know
when the race was over. ... Then the Dodo suddenly
called out ‘‘ The race is over, everybody has won, and
everybody must have prizes.” Unfortunately for us the
prizes on this occasion are given jointly by the British.
_ taxpayer and the German population.: Since the German
population is already subsidised by the taxpayer to the
tune of eighty million a year, our administration of
Germany bids well to become the most expensive that |
‘bureaucracy has ever succeeded in foisting on any
people. Not that there are not many well-qualified
and devoted administrators in the service; there are.
To them the restrictions inevitably imposed by the
- uncertainty of international affairs, limiting as it does
-their planning and organisation, must be irksome.
There are however far too many to whom the service
means a cushy job at a big salary without expenses.
To these must be added the large group of people,
unsettled by the non-recurring opportunities of the war,
who are unable to reseat themselves in normal civilian
life but find a -haven in the peculiar conditions that
obtain in Germany.
It is a little galling to find that .a Control Commission
driver gets (I do not say earns) a bigger salary than a
captain, R.A.M.c., and that an ex-corporal can return
to an almost non-existent job at a salary of eight to
ten pounds a week with negligible expenses.
There are welcome signs that Authority is not unaware
of all this and is taking steps to remedy the defects.
Much harm has already been done to our prestige over
here, and it is high time to restore it to the position
it held at the end of the fighting.
It is perhaps unfortunate that this period should
coincide with the arrival of the first families who will
absorb a great deal of accommodation sadly needed by '
the Germans themselves. This new influx is perhaps
the most unpopular measure that we have yet con-
ceived. Touching, as it does, only a fragment of the
army out here it is debatable whether the atmosphere
of artificial comfort provided for the families will do
anything but estrange both the Germans and a large
number of British as well. What we are seeing in Germany
is not what we mean by the “ British Way of Life.”
It is to be hoped that those wives who do come out will
realise how important it is that they should bring with
them the influences that go to make a British home.
The Control Commission has to face difficulties as‘
great as any that have faced our colonial administrations.
In the past, selection for the Colonial Services has been
stringent, and the results usually good. Should not the
same principle be applied to this, the newest of all our
administrative services ?
* * * ka
Mumpsimus, “a traditional custom obstinately
adhered to however unreasonable it may be.” Woe is
me ! My conscience pricks badly. Every day I meet a
myth ar a mumpsimus about the hospital and do nothing
about it: it does no harm, I murmur, and let it pass.
What of the nursing woman-hours wasted; what of
discomfort and indignity endured in vain ?
I speak here with added authority. Only last week
I myself was sigmoidoscoped. The appointment was for
11 a.m. At 5 A.M. I was rudely awakened by the clank
- of the loaded trolley and my opening eyes beheld a
gallon-measure full of soapy water and a large bucket
full of mackintoshes. The actual washout was only
IN ENGLAND NOW -
[SEPT. 14, 1946
slightly uncomfortable, the fluid gravitating in and out,
iù and out of my empty rectum without let orhindrance ;
when it was over I fell asleep again. At 8.30 I ate a hearty
breakfast, at 9 allowed my lower bowel to empty as ig
its wont, then wrote letters till my hour was come.
Now why, oh why that eerie ceremony at dawn ? -Do
the nursing staff feel they ought to prepare their patients
for parade ? Must the rectal mucosa have its wash-and-
brush-up, spit-and-polish ?: Should we not declare the
mumpsimus, reasoning that in six hours anything may
happen, and it doesn’t really matter if it does ?
Some griefs are med’cinable, quotes an advertisement,
discussing the ‘troubles which cause nervous indigestion
and the merits of a dietary product in its relief. All
very true, no doubt, but why press Cymbeline into ser-
vice? Medicinable means medicinal, capable of healing ;
and not medicable, capable of being healed. And what
possesses this power of healing? Clearly grief, or some
griefs. Grief is the healer, not the to-be-healed. Must
we wait for Belarius to make this abundantly clear ?
Great griefs, I see, medicine the less ; for Cloten -
Is quite forgot. (rv, ii, 244.)
But let Imogen speak for herself. On receiving her
husband’s letter, she exclaims :
You good gods,
Let what is here contain’d relish of love, Í
Of my lord’s health, of his content, —yet not
That we two are asunder ; (let that grieve him: .
Some griefs are med’cinable ; that is one of them,
For it does physic love)—of his content,
All but in that! (mı, ii, 28.) |
No other play has all these three: medicinable, and
the verbs to medicine and to physic. To medicine occurs
only once more, in Iago’s terrible boast : i
Not poppy, nor mandragora,
Nor all the’ drowsy syrups of the world,
Shall ever medicine thee to that sweet sleep
Which thou owedst yesterday. (mmx, iii, 330.)
Some griefs, we learn, are medicinable; Othello’s is
not one of them: i .
Fell sorrow’s tooth does never rankle more
Than when it bites, but lanceth not the sore.`
(Richard II, 1, iii, 297.)
à * x x
The psychiatrist went as a bicycle to the ship’s fancy-
dress dance, the surgeon as Ohm’s law, and I—well
everyone said that I, complete with stomacher and
periwig, looked the living image of Archimedes imme-
diately before attaining notoriety in the first M.B. That
is everyone except the capstan-minder’s mate, who for
some reason was judging the competition. r
He had not liked me from the day I had pointed out
to the captain that the sprockets were rusty. I should
_ here explain that the Sea Salt’s Code shows clearly and
simply the inevitable consequences’ of rusty sprockets.
_Just as Q.E.D. ends all theorems everywhere, whether
anything has been proved or not, so the rule that one
rusty sprocket equals three small keelhauls—‘ small ”’
indicating that the thin end of the boat be used for the
operation—holds on all ships, on all the ponds of the
earth. The capstan-minder’s mate, one might say, had
-out-sprocketed himself, in that not only were there
15 sprockets rusty, but 7 more were so sclerosed as to be
useless. I am surely not to blame because the wretched
fellow was under water for most of the time between the
equator and latitude 754. This should be no reason for
deliberately mistaking me for a hors-d’ceuvre varié,
and: giving the prize to the psychiatrist, whose tyres
were not even pumped up.
x *
It was Sunday morning and I had to visit an outlying
hospital. My daughter, aged eight, came along and as
she had become rather bored during the car ride I took
her in to see the children’s ward. While I stood talking
to sister one of the nurses showed her around. ‘‘... and
this little boy fell off a ladder... . This little girl has a very
bad cough.” And then my daughter, wanting to show
an intelligent interest, was heard to say: ‘‘ I wonder—
have any of them got v.p.?” I understand that the
poster showing a bereaved widow was withdrawn
because it depressed people. On my part, I should like
to raise an embarrassed voice to ask the Ministry of
Health to stop their poster. campaign !
THE LANCET]
3 Letters to the Editor
SIR ALMROTH WRIGHT AND ANTI-TYPHOID
INOCULATION
Sm,—Sir Almroth Wright has just passed his eighty-
fifth birthday and the Times has reminded us that this
year is also the fiftieth anniversary of the beginning of
his work on prophylactic inoculation against typhoid
fever. That work was an outstanding landmark in the
bistory of medicine, not only because of its immense
ractical results but because it demonstrated the possi-
ility of evaluating the changes in an inoculated person’s
blood which result from successful immunisation. From
that time immunisation ceased to be a hit-and-miss
procedure.
Wright himself, in his first paper on the subject, was
careful to point out that the idea of using prophylactic
immunisation against typhoid fever (and also the use of
a non-living vaccine for the purpose) had come to him
from Haffkine who had applied a similar procedure in
combating cholera in India. It is, however, beyond
doubt that the whole credit for working out anti-typhoid
immunisation, and for getting it adopted in the British
Army in spite of considerable opposition from some in
high places, belongs to Wright.
In view of this it is surprising to read in Dr. Guthrie’s
recent History of Medicine that
“ During the South African War of 1899-1902 typhoid `
fever was a more formidable foe than the enemy and
accounted for twice as many deaths as his weapons. In
the Great War typhoid fever was relatively rare and, even in
the most unhealthy centre, that of Gallipoli, the incidence
was very small, and the enormous improvement was
almost entirely due to the success of anti-typhoid inocula-
tion. This happy result may be traced to the labours of
one man—Sir William Boog Leishman (1865-1926), a-
medical graduate of Glasgow.3 ”
And, in a later sentence :
“ Along with Sir Almroth Wright, who preceded him as
Professor of Pathology in the Army Medical College at
Netley, and whose name is closely linked with the discovery
` of vaccine therapy, Leishman set himself to devise a system
of inoculation against typhoid... .”’
The reference given in the above quotation is to
. page 1058 of Sir Harold Scott’s History of Tropical
Medicine, but it is difficult to see how the relevant
sentence on that page can support Dr. Guthrie’s state-
ment. It reads as follows:
“ In 1897 he (Leishman) returned to England and was
posted to the Victoria Hospital, Netley, as Medical Officer.
Netley was at that time the headquarters of the Army
Medical School, later transferred to Millbank as the Royal
Army Medical College. Dr. (later Sir) Almroth Wright
was then Professor of Pathology and Leishman gained
experience under him and together they inaugurated
: inoculation against typhoid fever. He also assisted Wright
in his work on anti-typhoid inoculation in the South
African War and in opsonic investigations of the staphylo-
coccus and brucella melitensis.”
‘On another page Sir Harold Scott refers to ‘‘ Sir Almroth
Wright’s anti-typhoid vaccine.”
It is to be noted that Wright’s anti-typhoid work
began in the summer of 1896 (see Lancet of Sept. 19,
1896, p. 807); whereas, according to Sir Harold Scotts
statement, Leishman was posted to Netley in 1897 as
medical officer. It is also noteworthy that Leishman’s
name appears as joint author of only one of the series
of five important papers on anti-typhoid inoculation
published by Wright between 1897 and 1901, the one
appearing on Jan. 20, 1900, in the British Medical
Journal—that is, 3!/, years after the beginning of the work.
To check my memory (not at first hand) of these
events, I recently wrote to one who was a pupil of
Wright’s at Netley and himself took part in the early
work on anti-typhoid inoculation. He replied that, in
his view, ‘‘ Wright and Wright alone was the originator
of anti-typhoid inoculation with killed vaccine’; and
he adds that Leishman was. not even on the laboratory
staff at that time. ‘‘ He had nothing to do with the
` introduction of anti-typhoid vaccine.”
MYTH AND MUMPSIMUS
[SEPT. 14, 1946 397
It would seem, then, that Dr. Guthrie has in some way
been misinformed on this matter. I hope that, in honour
of the greatest figure in English bacteriology, this
mistaken attribution of credit may be put right before
it gets copied into other books.
Birmingham Accident Hospital.
MYTH AND MUMPSIMUS
Smr,—The author of your opening article of August 31
must surely be a young man who delights in pulling the
legs of the elderly, but even the presbyopic must see
that he is erecting Aunt Sallies for the simple pleasure
of knocking them down. On the high spirits and
harmless games of youth it would be ungracious to
frown, but some of his statements require modification.
1. Dr. Forbes lumps together phlebotomy and exorcism and
consigns them both to Limbo. But exorcism was surely
always a priestly performance, and phlebotomy properly
practised is as useful today as it was in the years before
its very success led to its disastrous excess.
2. He appears to approve of increasing the fluid intake if
large doses of sulphonamides are given, but he scorns any
other reason for promoting diuresis. Are there no other
drugs whose concentrated presence may damage the
kidneys ?
3. He scoffs at diaphoresis and hot baths, but has he never
known their benison after a long day in the saddle ?
Is there no physiological explanation for tired and stiff
muscles and have we not in steam a proper therapy ?
4. The next time he has to cope with an outbreak of gastro-
enteritis, I will wager my old Culpeper to his new
Martindale that he will achieve far quicker healing if he
will give his patients an ounce of castor oil before he
starts them on sulphaguanidine. He writes: “ horribile
dictu.” I reply: “ experto crede.”
5. Dr. Forbes’s fundamental conclusions about enemata and
his rejection of all solutions except normal saline may
appeal to the youth who has never known the agony of
rectal ballooning, but these conclusions will annoy the
clinician who has seen what relief a turpentine enema
can produce when all the normal saline in the ward has
failed to charm forth any scyballe. He states that
“the complete efficacy of normal saline was proved long
ago.” By whom and where and when ?
6. Dr. Forbes then pens the following sentence: “The
adolescent girl who is pale, who will not eat, and who
faints easily is in all probability working too hard at
school and pining with unrequited love for her form
mistress.” This he calls a psychological upset. Has he
never seen a case of chlorosis ?
7. He says, “ leeching and blistering which survived and were
universally practised for centuries and yet have now
been totally discarded.” Have they? If “’tis true
tis pity,” or so it would seem to those of us who have.
hatin the painful pericarditis or plourisy relieved by
eeches.
I am no laudator temporis acti but I wish to protest
emphatically against throwing away the baby with the
bath water. :
London, W.1.
SIR,—In his delightful paper Dr. Forbes makes an
earnest plea for definition of terms, with which many of
us must be in full sympathy. To show my appreciation
in a practical manner, I should like to set the ball rolling
towards elucidation of the (now fashionable) term
‘“ psychosomatic.” Others can then kick it about and
eventually it may reach its goal. Meanwhile a good
time will be had by all.
It is easier to give a concept of this term than actually
to pin it down by a definition. My own tentative con-
ception is that it is analogous to the term “ electro-
magnetic.” In an electromagnetic system it is impossible
to alter the flow of electricity without altering the mag-
netic field. Conversely any variation in the magnetic
field is at once reflected in the electrical potential. The
two are as inseparable as the heads and tails on a coin,
being merely different observable aspects of the same
phenomenon. In the same way every alteration in the
LEONARD COLEBROOK.
CHRISTOPHER HOWARD.
‘psyche affects the soma, and vice versa, because (and
this is the important and difficult point to grasp) they
are different but interdependent aspects of the same
398 THE LANCET]
phenomenon—a living individual. There is no question
of mind over matter or matter over mind. Mind and
body, psyche and soma, are as inseparable as inside
and outside..
It would therefore appear meaningless to refer to
. ‘psychosomatic disorders ” as though they were certain
recognisable diseases in a class of their own, distinct
Pa
from other diseases. The phrase ‘‘ psychosomatic
medicine ” does, however, suggest to me a certain
approach to disease: and health. It suggests investi-
gating the patient as a whole, accepting the idea that in
every condition of life both psyche and soma are affected,
and (in practice) treating whichever is handier.
There is nothing new in this. General practitioners
have been doing it for centuries. But with the advent
of every new specific drug, serum, vaccine, and operation, _
the emphasis is shifting more and more towards soma
and farther from psyche. General medicine (and sur-
gery in particular) is concerning itself increasingly with
ridding.a patient of the physical handicap of his illness
and getting him back to work. Sometimes this is rather
like performing highly skilled running repairs on the car,
when really it may be the driver who needs attention.
Psychosomatic medicine, studying the patient as a whole,
would seek to make it unnecessary for him to break down.
Such is my conception, and I am only too eager to
revise it if it be found wide of the mark by my betters.
Mundesley. GEORGE Day.
Sm,—May I congratulate Dr. J. R. Forbes on his
paper of August 31? With the possible exception of
those relating to fluid-intake, I:feel each one of his
remarks is most sane and timely. Of paramount
importance are his references to the medically induced
neurosis. The abysmal ignorance, exhibited by general
practitioners and general consultants alike, concerning
the etiology, prevention, and treatment (usually so
simple and straightforward) of the common neuroses is
one of the most depressing and deplorable aspects of
modern medicine. This lack of simple knowledge,
fostered and perpetuated as it is bya mental attitude
of derision, means that, for every patient cured by the
exhibition of one of medicine’s modern therapeutic
triumphs, at least one (probably more nearly half a dozen)
is allowed to sink irretrievably into chronic invalidism
and the misery of a ‘life of medically induced or
medically perpetuated neurosis.
Port Talbot. R. J. T. WOODLAND.
SIR, —Dr. Forbes has handled a very awkward subject
and presented it in a most acceptable and entertaining
manner. It has long been my ambition to write a paper
on the same subject.
During nine years in charge of the diphtheria wards
of a fever hospital I could never convince any of the.
sisters that lying flat on a hard mattress without a
pillow was most uncomfortable, and therefore not restful.
I was looked on with horror and told that every school
of nursing insisted on cases of diphtheria being kept
flat without a pillow for at least three weeks. They
simply would not accept the fact that the same absolute
rest could be attained more effectively if the patient had
a pillow for his head instead of rolling it from side to
side on a hard mattress. Yet all the sisters slept with a
_ pillow or two under their heads.
Manchester. | J. EGAN.
F . PENICILLIN BY INHALATION
_Srr,—The papers by Dr. Humphrey and Dr. Joules
(p. 221), and Dr. Southwell (p. 225) in your issue of
August 17, tempt me to record my own short series of
observations. |
I used a Collison’s inhaler and gave five minutes’
inhalation every hour from 6 A.M. to 10 P.M. of a solution
of penicillin containing 5000 units to the c.cm. Three
cases of postoperative bronchopneumonia and 4 of post-
operative bronchitis responded most satisfactorily. The
bronchopneumonia cases presented dullness and impaired
breath sounds with radiological opacities, but had not
progressed to-the stage of bronchial breathing and
bronchophony. A case of postoperative confluent
Staphylococcus aureus pneumonia did not respond at
all, though relieved promptly by parenteral penicillin.
I have not cared to try this form of therapy in any
x
PENICILLIN BY INHALATION
~
[SEPT. 14, 1946
other lobar or confluent bronchopneumonia. Four eases
of chronic bronchitis and à comparatively mild case of
bronchiectasis improved in- that the. sputum changed
from mucopurulent to mucoid and lessened in amount,
though an appreciable quantity remained. A case of
postinfluenzal bronchitis and one of a low-grade post-
influenzal bronchopneumonia with mucopurulent sputum
believed due to secondary bacterial infection responded
promptly and completely ; the latter had not responded
to parenteral penicillin. On the other hand, 2 cases of
atypical pneumonia considered of virus origin, with high
serum cold-agglutination titres and plentiful muco-
purulent sputum, improved hardly at all. I was
interested in Humphrey and Joules’ observation that
Bact. coli appeared during treatment, as the same thing
occurred in several of my cases.
I have formed the impression that penicillin inhalation
has a definite rôle to play in the treatment of accessible
bacterial infection with organisms susceptible to peni-
cillin, with or without underlying pathological conditions.
Underlying conditions such as chronic bronchitis,
bronchiectasis, or a still active virus disease remain
unaffected. I suspect that consolidated lung is inacces-
sible to penicillin by inhalation.
I am indebted to Air Vice-Marshal A. F. Rook, consultant
in medicine to the R.A.F.M.S., for encouragement and
assistance in this investigation.
Ely. D. FERRIMAN.
SUPRAPUBIC PROSTATECTOMY
Str,—In suprapubic prostatectomy with closure, as
commonly performed, a catheter is passed from the
external meatus, through the urethra, into the bladder,
and then fixed in place. It is a common experience .
that it often tends to stick in the cavity which has just
been occupied by the enucleated ‘‘ prostate.” Even an
-india-rubber coudé catheter may so stick. During the
last couple of weeks, by borrowing a tip from Ivan
McGill, we seem to have overcome this difficulty. Dr.
McGill’s intratracheal tubes were originally made by
himself from ordinary tubing and given their requisite
curve by storing the tubes in round tins. We understand
they are still so stored. By sterilising catheters, known
as whistle-tipped in England and as McCarthy electro-
tomes in America, in 2-0z. tobacco tins and leaving them
in the tins for a couple of days they acquire a curve
which seems to permit them to ride smoothly into the |
bladder. The 2-oz. tobacco tin can accommodate three
22F catheters.
This procedure is so simple that it is unlikely to be
original, but it has proved so useful that this note may
help those who have not heard of it.
Dublin. ' T. J. D. LANE.
FUNICULITIS
Sır, — With reference to Lieut.-Colonel Power’s interest-
ing paper on funiculitis in British troops in Ceylon
(April 20), may I draw his attention to a paper by myself
published in THe LANCET many years ago (August, 1908)
on the disease I called ‘‘ endemic funiculitis’’ ? A fairly
complete description of it with four illustrations may be
‘found in Castellani and Chalmers Manual of. Tropical
Medicine (8rd ed., p. 1939), in which, in addition to the
acute type, mention is made of a mild form with throm-
bosis of the veins, without suppuration. To this latter
type, I feel, belong Lieut.-Colonel Power’s cases.
What is the etiology of endemic funiculitis ? In all
my Ceylon cases I found a virulent streptococcus; in
some of them there was also a filarial infection. I now
believe that the streptococcus plays by far the more
important ztiological rôle, and that the condition may
arise also when there is no concomitant filarial infection.
At any rate even if the syndrome should be considered
of filarial origin, it is clinically so characteristic that it
deserves being given a full description and not dismissed
in a few words, as is done in so many books on tropical
medicine. It must be kept in mind that the acute type
is a very serious disease and is of great practical
importance, since often, if the correct diagnosis is not
made in time and the appropriate treatment not given
immediately, a general streptococcal infection develops
with grave risk to the patient’s life.
Sintra, Portugal. ' ALDO CASTELLANI.
THE LANCET]
CHILDREN WHO SPEND TOO LONG IN BED
Srmr,— Dr. McCluskie’s stimulating article of August 31
is a welcome addition to the growing body of common-
sense advice about infant and child care. Hardly a
single criticism he has made could not be illustrated from
many cases known to any G.P. Most illustrative,
perhaps, of a typically ‘‘ successful” parental domination
is the child of 3 that “lay from 6 a.m. until 8 A.M.
in a wet bed playing with the blankets.” It is this
determination to ‘‘ train’’ the unfortunate babe, from
the moment of its arrival, for the convenience of its
parents’ pre-existing habits that has such lamentable
psychological results. Instead of making an attempt
to compromise, the parents endeavour (fortunately often
without success) to mould the child hourly into their own
adult groove.
Thus, many modern maternity nurses teach mothers
to leave their baby to cry, whatever their maternal
instincts, between the rigidly set feeding times: how
much this, tends to destroy the rapport between mother
and child is clear to see. I have known mothers to sit
agonised, in obedience to this teaching, watching the
clock creep round from 5.15 to 5.30, 5.45, before guiltily
picking up the baby ten minutes early for its 6 o’clock
feed, for a little overdue mother-love. |
One could cite such things ad nauseam—the rigidly
measured feeds, to be taken each time, never an ounce
to be left, nor an ounce extra given; the agony of the
weekly weight figures if there is a week’s stasis; the
anxiety if an 18-monther soils his trousers. In brief, the
modern mother is invited to consider her baby as nothing
more than a machine, requiring mathematical precision
in treatment and nothing else.
A great deal of the fashionable ‘‘ training ’’’ seems to
aim essentially at ensuring the minimal disturbance of
that domestic routine which. existed before the arrival
of the first child, without due regard for the child itself.
Two main themes of our instruction to mothers should
surely be these: (1) A frank admission that parenthood
means unselfishness and
love and individual understanding ; at the least striking
a fair balance between needs of parent and child, and
rather erring on the side of ‘‘ putting the children first ”’
(an unfashionable phrase today) than dominating them
for parental convenience. (2) While setting out the
necessary feeding time-table, principles of child care and
management, &c., we should insist that the mother
recognises that they are only for guidance, and not to
be slavishly adhered to like a railway time-table or legal
code. Child psychologists would find their work lightened
if the parents could be educated to ignore the ‘‘ baby
is a machine ” school of management, and to rely on
their own instincts:and judgment in solving individual
problems. |
Greenbithe, Kent. G. F. TREPP.
SıR,—My article—which incidentally is quite unworthy
of the publicity it has received—does not describe a
“ time-table ”? for infants and toddlers but a ‘“‘ plan ”? on
which to base a time-table. It states quite plainly that
.“ each child as he develops will soon give his mother an
indication of how much day-sleep he requires ”? if the
plan is followed. Rigid time-tables create an obsessive
mind in both the mother and the child, and too much
emphasis cannot be laid on the part played by mother-
love in the successful handling of a child.
The individual variation suggested by me is not 30
minutes but an hour, or more, or less. (Approximately
30 minutes is the time named, but some mothers may
find it necessary to add ; others to subtract.) Neverthe-
less, having regard to Professor Bühler’s table of actual
observations, which were timed not to the nearest half-
hour but to the nearest second, this variation may be
too large. I understand some American physicians are
carrying out stop-watch nursery recordings and I await
their results with interest.
Between the fifth and the tenth months an infant
who sleeps too long in the mornings becomes cross in the
afternoons because he cannot sleep. It is easy for a
mother to prevent an infant sleeping too long in the
morning and so gain the benefit of the afternoon rest
and no crossness. :
From years of experience with children I find that the
healthy child of three years at home begins to prefer all
bd
~ noted.
“ giving out,’ especially of `
4
' /
EFFECT OF PHOSPHATE ON CARBOHYDRATE ABSORPTION IN SPRUE [SEPT. 14, 1946 399
his sleep in one dose. But there is no harm in routine
day-sleep above this age provided always (a) the length
of the day-sleep is related to and not in competition with
the night-sleep, and (b) that it is the child’s physiology
and not the teacher’s boredom that calls for it. Where
there are two or more children who can play outside,
day-sleeps can be tiring and exhausting for the mother,
because they involve undressing, re-dressing, and
remaking of beds. (The practice of putting children to
bed during the day with their clothes on is a bad ‘one
because it causes overheating of the skin and sometimes
sweating.) | |
“ Rounds of pottings,’? indeed! I have 3 children
under six years who have never had a routine ‘‘ round of
potting ” in their lives because they go to bed to sleep, |
not to be taught bad habits.
There is too little respect for genuine motherhood in
Britain and too much kow-towing to a nation-strangling
matriarchy. |
Westcliff-on-Sea. JoHN A. McCLUSKIE.
FAVUS IN DEVON
Smr,—Whether it be due to an influx from elsewhere
or to an indigenous source of infection, there is some
evidence of an outbreak of favus in North Devon.
Scutula are not always easy to find, nor are the nails .
often affected, but with Wood’s glass, a hand lens, and
a microscope the infected hairs on the scalp, tiny crusts
surrounding hairs, and incipient bald patches can be
Ringed ‘lesions, from which the crusts have
been removed by treatment, have led to the diagnosis
of ‘‘ ringworm ” of the glabrous skin. , |
Exeter. ` H. W. ALLEN.
EFFECT OF PHOSPHATE ON CARBOHYDRATE
ABSORPTION IN SPRUE
Srr.—In our preliminary communication (Lancet,
1945, ii, 635) we reported experimental evidence that in
active sprue there may be ‘‘ a failure of the phosphoryla-
tion of glucose at the time of its absorption.” It was
our intention to continue our researches and publish
the results in detail later, but unfortunately (or for-
tunately ?) the cases suitable for experiment have been
too few to provide anything more than indications of
the direction in which future research should be devel-
oped. For the benefit of others who are more favourably
placed for doing experimental work, it seems worth while
recording our results of the effects of adding phosphate
to carbohydrate solutions administered to cases of
active sprue.
In our first experiment a case of active sprue with
characteristic history of loss of weight, flatulent dyspepsia,
and glossitis was selected and placed on a simple milk
diet. An oral sucrose-tolerance test was carried out and
the usual flat glucose and normal fructose absorption
- curves obtained. To confirm that the flat glucose curve
' did not arise from hold up of the sugar in the stomach,
the test was repeated, the sugar solution being injected. -
by tube direct into the duodenum. The resulting glucose-
absorption curve was again flat and the fructose normal.
Glucose was next injected intravenously, and, as Fairley
has found in other cases of sprue, the curve of disappear-
ance of the sugar from the blood was within normal
limits. | | |
It was clear that in this case the flat glucose curve
was due neither to delayed stomach emptying nor to rapid
removal of the sugar from the blood, and was therefore
presumably due to failure of absorption. We decided to,
investigate this failure of absorption by studying the `
points at which the complicated process of phosphory-
lation might fail. The accessibility of the phosphate ion
was investigated first. We argued that if the phosphate
were unavailable because it was absent (which was
unlikely on a milk diet) or because it was present in
some inaccessible form, then phosphorylation should be
restored by the exhibition of the phosphate ion. We
therefore repeated the sucrose-tolerance test, admini-
stering the sugar (100 g.) direct into the duodenum
and adding to it 8 g. of a mixture of potassium acid
phosphate and disodium phosphate buffered at pH 7:0.
The result was startling. The glucose curve was now -
normal, the fructose curve remaining unchanged. A
week later the sucrose test was repeated without phosphate
400 THE LANCET]
and the resulting glucose curve was again characteris-
tically flat, the fructose remaining normal. Some
time later the sucrose test plus phosphate was repeated
by mouth and again a normal glucose curve was obtained.
The relevant figures obtained in these experiments are
given below : ES
DUODENAL ADMINISTRATION OF SUCROSE (100 G.)
. Dec. 12, 1945 (no phosphate) Dec. 19, 1945
8 g. phosphate mixture)
Glucose Fructose Glucose Fructose
Time — en”
(hr.) mg. per 100 c.om. mg. per 100 c.cm.
0 90 0 60 0
al 70 15-3 153 7:0
1 76 15-7. 114 10-0
1#/, 70 10-3 55 7-9
2 82 8-4 51 7-0
21/3 80 : 6:0 62 5-2
We have repeated these experiments in a modified
way on 3 other cases of sprue, none of which was, however,
in a very active stage of the disease. In 2 of these cases
the phosphate appeared to assist the absorption of
glucose ; in 1 it had no effect. vo
These results are offered in letter form because they
are so incomplete and because we are unable to goon
- with the work owing to lack of cases. I think the results
show that in some cases of sprue at any rate the failure
of absorption of glucose is connected with failure of
phosphorylation of the hexose arising from an apparent
inaccessibility of the phosphate ion. In other cases the
complicated mechanism of phosphorylation may have
broken down elsewhere.
In cases in which the absorption of glucose is restored
to normal in the presence of the phosphate ion, the latter
might prove a valuable therapeutic agent.
School of Tropical Medicine, BRIAN MAEGRAITH.
University of Liverpool.
PERSISTENT ENURESIS
Sm,—Neither Stalker and Band’s paper! nor your
annotation on it (August 17, p. 243) mentions the possi-
bility of endocrine treatment of enuresis, although
evidence is availdble that points to a definite influence
of the sex hormones on the urinary system and also, to
some extent, on disorders of micturition.
The close developmental and anatomical connexion
between the genital and the urinary system provides a
basis for understanding a possible action of the sex
hormones on the urinary tract. £strogens in large
doses have occasionally produced bladder distension and
hydronephrosis in male and female mice.2 There is
reason to assume that the ureteral dilatation which
frequently occurs in women during early pregnancy is
due to cestrogenic action and not to mechanical obstruc-
tion, for which no evidence exists. Urinary symptoms,
such as frequency, urgency, and incontinence, are often
encountered in menopausal women and respond remark-
ably well to cestrogen treatment.?
Androgens produce hypertrophy of the urethra in
males and females and possess nephrotrophic properties ;
testosterone produces a true parenchymatous hyper-
trophy, principally of the cells of the renal tubules. This
hormone has also been shown to increase the tonus of
the bladder. Intravesical pressure after introduction of
increasing amounts of fluid is higher after treatment ;
the maximal pressure which can be tolerated without
pain and the pressure at which desire to urinate is
experienced are increased.‘
androgens in the treatment of prostatism knows that,
though it is without influence on prostatic enlargement,
the distressing symptoms associated with micturition
improve. The size of the urinary stream increases, and
the tonus of the detrusor and probably of the sphincter
muscles is augmented (cf. Egger $). Greenblatt ® treated
34 women suffering from nocturia, frequency, and
incontinence with testosterone parenterally, by mouth,
. Stalker, H., Band, D. J. ment. Sci. 1946, 92, 324.
. Lacassagne, A. C.R. Soc. Biol. Paris, 1933, 113, 590.
. Salmon, U. J., Walters, R. I., Geist, S. H. Amer. J. Obstet.
Gynec. 1941, 42, 845.
S. R., Hamilton, J. B. J. Urol. 1944; 52, 139.
. Egger, K. Schweiz. med. IV schr. 1944, 74, 676.
: Greenblatt, R. B. Office Endocrinology, Springfield, Ill. 1944,
p. .
Doni UIO
cs
=
5
©
5
PERSISTENT ENURESIS
Everybody who has used
[SEPT. 14, 1946
and by pellet implantation. His results were good, even
in cases with fibroids where orthodox teaching tends to
attribute nocturia to mechanical pressure. Stalker and
Band have stressed the point that nocturnal and diurnal
frequency, urgency, and sometimes diurnal enuresis ma
be associated with enuresis nocturna.
Enuresis in children has been treated by Hoffmann ?
with urinary gonadotrophins, and he claimed successes.
Testosterone propionate was used by Zehn,® who injected
5 mg. for a short period daily, then every third or fourth
day, and claimed excellent results. Schlutz and Ander-
+
son ® treated 50 children, 36 boys and 14 girls, between
the ages of 3!/, and 14 years with daily injections (10—
25 mg.), inunction, or oral application of male hormone ;
54% were cured, 34% much improved, 12% remained
unaffected within 2 months. The authors think that
failures were partly due to irregular medication. In some
cases the effect was dramatic but one case required treat-
ment for a year. No undesirable effects were produced ;
relapses occurred but resumption of treatment was again
followed by response. Treatment was combined with
fluid restriction, high salt intake, and getting the child
up once in the early part.of the night. Most cases were
on this management for some time but did not improve
before hormone treatment was instituted.
I have treated a small number of cases with methyl
testosterone in doses of 5-10 mg. per day, some combined
with inunction of testosterone ointment on the lower
part of the abdomen. The number is too small to allow
conclusions but all seemed to respond. One boy of
14 years has been symptom-free for the last 9 months.
In all cases treatment had to be continued for several
months ; larger doses or parenteral application might
have produced results in a shorter time. No untoward
side-effects were encountered. It may be mentioned that
two of the children had radiological abnormalities of
the first sacral vertebra. `>
Without underrating the complexity of the problem
of enuresis, I believe that androgen treatment is rational
enough to be tried on a larger scale, and that, on the
strength of the published data and my own observations,
results may be expected in a certain proportion of cases.
To establish the value of this therapy definitely and to
eliminate psychological factors which may easily affect
the response to any treatment in enuresis, control cases .
will be needed who are treated with an inert substance.
London, W.1. H. Ucxo.
SUPPLEMENTARY FOOD FOR PREMATURE
INFANTS
Str,—Many will have read with interest the article
by Jorpes, Magnusson, and Wretlind (August 17), setting
forth the results they obtained by giving premature
infants breast milk supplemented with casein hydro-
lysate and glucose. I hope the writers will give us some
further details. For example, did the control babies
` who had breast milk only receive the same total calorie
intake as the ‘ treated ’’ infants, or was the aminosol-
glucose given as an extra? Have they evidence as to
the effect of giving hydrolysate on neonatal mortality,
or on the development of infants by, say, 6 months
of age ?
If I am correct in understanding that the aminosol-
glucose was an extra, it would seem that the controls,
on breast milk alone, received at first ‘‘ minimal food
requirements for life,” and later an average of 100
calories per kg. (45 calories per lb.), daily, whereas the ©
infants with the supplement received over and above
this allowance nearly 20 calories per kg. extra. If this
were so, might not the improved gains of babies receiving
the hydrolysate be due simply to their improved calorie
intake ? Since a casein supplement might be poorly
tolerated by a premature infant, the deficient increases
in weight in the group given casein would not disprove
this suggestion. The increases in weight of Professor
Magnusson’s controls, on breast milk alone, are lower
than those I am in the habit of seeing among premature
infants born and supervised in a maternity hospital,
and given a more liberal calorie intake (Arch. Dis. Childh. -
1941, 16, 166). These babies are fed on breast milk
7. Hoffmann, F. Arech. Gyndak. 1938, 166° 240.
8. Zehn, P. Dtsch. med. Wschr. 1939, 65, 1831.
9. Schlutz, F. W., Anderson, C. B. J. clin. Endocrin,'1943, 3,405.
THE LANCET]
when possible, supplemented as necessary, when this
falls short, with half-cream dried milk and sugar, or with
condensed milk. They usually gain weight at a rate
not inferior to their full-term fellows—i.e., about 5-7 oz.
weekly or 25 g. daily after the first week of life, which was
approximately the rate of gain of the babies given
aminosol.. There are undoubtedly wide differences of
opinion as to the level of calorie intake conducing to
the lowest mortality-rates among young premature
infants, but there is no doubt that gains are likely to be
relatively small if the daily calorie intake is kept as low
as 45 calories per lb. body-weight.
The Swedish workers comment that doses of hydro-
lysate larger than those they advocate often caused
vomiting or regurgitation of food—and I too have
encountered difficulties when giving casein hydrolysate—
so that it behoves those who try this supplement to use
it with caution. If it should turn out that the important
effect of the hydrolysate supplement was that it provided
more calories,
allowance may still prove preferable. Perhaps Professor
Magnusson can clear up some of these points and correct
me if I have misunderstood.
London, N.W.3. HELEN M. M. MacKay.
A SYNDROME SIMULATING -ACUTE
ABDOMINAL DISEASE
Srr,—When I read the interesting description of their
syndrome by Mr. Goldstone and Dr. Le Marquand
(August 24) I was puzzled by the omission of Bornholm
disease from the differential diagnosis. Neither does
Dr. Oram mention it in his letter of Sept. 7.
My attention was first drawn to this disease some years
ago by Dr. W. N. Pickles but I saw no examples of it
until I was posted to Naples last May. Reference to these
patients has been made in your columns by Reynell
(Lancet, 1946, i, 977) following Scadding’s description of
cases in the Middle East (Ibid, p. 763). “Meyer also wrote
about cases in C.M.F. (Ibid, p.. 902), while Martindale
described an outbreak on a frigate in the Indian ocean
(Ibid, p. 834).
Bo and Le Marquand ask three questions :
“ Why does it develop on the right side only?”
Epidemi diaphragmatic myalgia occurs on either side,
but the authors discuss the condition in reference to the
“acute abdomen,” and, as Scadding points out, abdo-
minal signs are predominantly right-sided. The pain
initially is often central or bilateral, but abdominal
tenderness is usually only found under the right costal
margin. Pressure there may produce in addition pain
in the shoulder or neck. Presumably the upward pressure
on the liver is transmitted to the diaphragm. Further-
more, on seeing a patient with pain on the left side, one’s
attentioh does not immediately descend to the appendix
and gall-bladder, as it naturally does when pain is on the
right. The picture with involvement of the left side
more resembles that of acute dry pleurisy, and does not
as readily attract surgical attention.
2. “ Why does it develop so often in West Africa,
so rarely in U.K. ? ” This is an epidemic condition.
One may wait for years without seeing it, in the U.K.,
in Italy, or in W. Africa, and then suddenly it is common.
3. “ Might the syndrome be due to an unusual type
of epidemic?” Speaking from the armchair, my
answer is “ =
The authors suggest that the cause may be perinephric
staphylococcal infection. Four of the thirteen patients
had had boils. Is this surprising in European Servicemen
in W. Africa ? Four had preliminary periods of malaise.
Is this unusual in patients admitted with other acute
illnesses ? One of the authors’ patients developed a right
perinephric abscess. One of mine had a right apical
tuberculous cavity but this does not make the rest
tuberculous.
Dr. Oram suggests that latent or subclinical infective
hepatitis may possibly produce such symptoms. I do
not think so, for I saw a lot of infective hepatitis in Africa
and Italy from 1942 to 1946, but did not see patients with
“the devil’s grip’’ until this year. There was none in
Milan while I was there ; a few days later I saw examples
in Naples; yet infective hepatitis was common in both
places.
Cuckfield, Sussex. PHILIP EVANS.
A SYNDROME SIMULATING ACUTE ABDOMINAL DISEASE
then an increase in the breast-milk-
[serr. 14, 1946 401
NUTRITIONAL OPTIC NEUROPATHY
Sır, —The article by Dr. Fitzgerald Moore in your issue
of August 17 is of such interest to me that I would like to
make some observations on it.
The first real recognition of the syndrome of epithelial
and nervous lesions complicated by nutritional optic
neuropathy was by H. Strachan,! in 1897; I referred to
his work in my privately printed paper ? which Moore
mentions.
Strachan in 1888 drew attention to a form of multiple
neuritis prevalent in the West Indies. By 1897 he was con-
vinced he was seeing an unrecorded form of neuritis, and stated
that its chief features were: ‘‘(1) A more or less widespread
neuritis, involving some of the nerves of special “sense,
especially the optic nerve. (2) The occurrence of trophic
changes in the skin along the distribution of the nerve
terminations, in the muscles, in the mucocutaneous lines,
and occasionally in the cornea. (3) The rare but still to be
noted occurrence of monoplegias. (4) The fact that the
disease may be very severe, lasting for many months or even
years. (5) The fact that recovery is the rule and a fatal
termination very rare. (6) That it attacks many hundreds
of persons, at least in Jamaica, the great majority of these
being black or coloured inhabitants, who constitute ,the
bulk of the population, though the white residents are not
exempt by any means.’
Strachan next detailed some of the most porani signs
and symptoms and described paræsthesias and gradually
increasing impairment of vision, but noted that recovery of
sight was the rule and optic atrophy never resulted. He
also referred to ‘‘the condition of the mucocutaneous
orifices ” and said: ‘‘ This demands some little notice as
redness and irritation of the eyelids and lips are often the
first signs noticed. It soon passes into a slight eczematous
condition, especially at the corners of the mouth and round the
margin of the nostrils, with fine branny desquamation. A
similar condition in the mucocutaneous line in the prepuce
is not uncommon. More rarely there is a similar condition
of vulva and anus. The lips and inside of the mouth are
hyperemic and there may be much loss of surface epithelium
on the tongue.”
It is of great interest that Strachan recorded pigmen-
tation of the palms of the hands and soles of the feet.
Sensation was blunted and in grave cases involvement of
the innervation of the heart and diaphragm led to death.
He saw mental involvement only in two or three cases
but said such cases could be found in asylums. There
is little doubt that he was seeing cases of beriberi and
pellagra as well as the syndrome under discussion, but
his treatment was nevertheless correct, and consisted
in rest in bed and nourishing food gradually increasing
in quantity and variety throughout the early and
acute stages. Medicinal treatment was given for the
malaria believed to be present, and iodides to promote
absorption of the inflammatory material in the affected
nerves.
Moore says the condition I described in 1928 ° was
identical with that described by Stannus. This is not
so. I found defective vision a cause of constant com-
plaint, whereas Stannus ‘ records finding only 5 patients
with defective vision out of a total of 131, which means
there is no conclusive evidence of defective vision in
his report. ' Moore still makes it appear that I first
attributed the Sierra Leone disease to avitaminosis in
1930 ; but it was in 1927 that I attributed it to A and B
deficiency > and it was then that I introduced the
“ active treatment ’’ with yeast and cod-liver oil.
Recently Hobbs and Forbes è referred to the prophy-
lactic value of first-class protein in nutritional visual
defects, and it is interesting to recall that Clark,? who
investigated the syndrome of epithelial and nervous
lesions-in Nigeria, concluded that cyanogenic tooda Nuts;
1. Strachan, H. Practitioner, 1897, 59, 477.
The A and B Avitaminosis of Sierra Tecna
2. Wright, E. J.
Leitch’s Dietetics in Warm Climates,
Reprinted from J. N.
London, 1930.
3. Wright, E. J. West Afr. med. J. 1928, 2, 127.
4. Stannus,H.S. Trans, R. Soc. trop. Med. Hyg. 1913, 7, 32.
5. Wright, E. J. ae Medical and Sanitary Report for Sierra
Leone, 1927, p. 29.
6. Hobbs, H. B., 'Forbes, F. A. Lancet, August 3, 1946, p.149.
7. Clark, A. J. trop. Med. Hyg. 1936, 39, 269.
402 THE LANCET] i
' OBITUARY
. [SsEPT. 14, 1946
such as cassava, maize, sugar-cane, millet, guinea-corn,
peas, and beans were a common factor in the diet of all
people suffering from pellagra and allied nutritional
diseases. As a result he postulated that these diseases
were all due to slow prussic-acid poisoning. Although
Moore says that in Sierra Leone manioc was largely
replaced by rice, the second staple food is still cassava
(manioc) and is consumed in varying amounts according
to the availability of rice, the first staple; so cassava
in some form or other is frequently eaten by a large
number of people in Sierra Leone.
. Sulphur is the antidote to chronic poisoning by
cyanogenic foodstuffs. The daily sulphur requirement
of the body is probably in the neighbourhood of one
gramme, and as the sulphur content of foods is approxi-
mately 1% of the total protein it is apparent that
100 g. of good-class protein is required to ensure an
adequacy of sulphur. In Sierra Leone the dietary is
deficient in protein and hence in sulphur.
In 1936 I described * the experimental treatment of -
the Sierra Leone syndrome with organic sulphur, using
‘Contramine’ parenterally in some cases and ichthyol
orally for others. Judicious sulphur therapy was of
great benefit to the patients and resulted in economy
in treatment. Although good clinical results have been
consistently obtained’ by combined sulphur and vitamin
therapy in Sierra Leone, I have seen no record of its
use in nutritional optic neuropathy. |
London, N.W.3. E. JENNER WRIGHT.
ARSENICAL CHICKEN-POX
Smr,—Now that it is generally recognised that an
eruption of varicella not so very rarely follows or accom-
panies herpes zoster, and that herpes zoster in an adult
has the power sometimes of infecting a child with
varicella—and so on—one comes across many reports
bearing on this relationship or identity of the infective
agents of herpes zoster and varicella. As it is also
believed that the herpes zoster sometimes excited by
taking arsenical medicines (Sir Jonathan Hutchinson)
is a true herpes zoster, one would expect to hear of
examples of (arsenical) varicella following or accom-
panying attacks of arsenical herpes zoster and of
patients with arsenical herpes zoster infecting children
in their neighbourhood with (arsenical) ‘varicella; but
such observations seem to be very rare. This rarity may
be partly due to arsenic being employed much less than
formerly in the treatment of cancer, Hodgkin’s disease,
and anzmias. .
_ Before there was any ordinary talk of a connexion
between herpes zoster and varicella (though not before
Bokay’s writing of 1892) I certainly remember a remark-
able mixture of herpes-zoster-like and generalised
vesicular eruptions in a young person under arsenical
treatment. This surely must have been arsenical varicella.
Moreover, in the International Clinics (1916, 3, 185,
case 1) I described the case of a man, aged 59 years,
who developed typical herpes zoster while under arsenical
treatment for leukæmia. The herpes zoster was followed
by a generalised eruption of varicella-like spots. A little
boy, aged 4 years, who was in a bed in the same ward
-= close to that patient, developed varicella ten days after
leaving the ward. An almost exactly similar happening
was recorded later by A. Dostrowsky (Derm. Wschr.
1931, 92, 685). A man under prolonged arsenical treat-
ment for lymphatic leukemia developed (gangrenous)
herpes zoster together with a generalised ‘vesicular
eruption. This man’s child developed varicella 25 days
after the zoster eruption appeared in his father. Probably
there are similar accounts unknown to me, but I think
that arsenical varicella has been rarely observed.
Perhaps in such cases the herpes zoster and the
varicella are to be regarded as examples of Milian’s
‘* biotropism,”’ the arsenic acting by stimulating the
pathogenic ‘‘ agent’’ of a latent disease (herpes zoster,
varicella) and so making it manifest its presence by an
eruption. That is, I think, the most accepted theory,
but it still remains almost incredible that arsenic can
‘* produce ” a common infectious disease such as chicken-
pox. 7
London, W.1. F. PARKES WEBER.
8. Wright, E. J. Brit. med. J. 1936, ii, 707.
DISPENSING OF DRUGS IN HOSPITALS
Sm,—The death of a hospital: patient through a
nurse misreading a prescription sign has led to the
suggestion that the traditional symbols of the apothecary
should now give way to the metric system. In fact
the metric system is coming into use and its further
employment depends on the extent to which physicians
choose to adopt it in writing prescriptions. How drugs
are measured is not, however, the real issue. It is as
easy to slip up over a decimal point as over a drachm
loop. The real issue is who measures them. In the case
in question a pharmacist would have realised that the
quantity was greatly in excess of the proper dose. The
law should forbid the dispensing of potent drugs in
hospitals except by or under the supervision of a
pharmacist. F. C. WILSON
Member of the Council of the Pharmaceutical
London, S.W.20. Society of Great Britain.
PERIPATETIC ERROR
_ SIR,—Respectful greetings to Peripatetic Correspon-
dent, no. 3 of August 31. Of your kindness, Sir, please
to inform him: (1) that ‘“ viva” is called “ oral” in
Scotland; (2) that only my astral body—admittedly a
sticky affair—has even contemplated examing south of
N.B. (as your correspondent might call us); and (3) that
I am just a clinician—so heaven help your correspondent
if he gets an “ oral ” in Glasgow University or even the
“ Triple.” l ,
Now, Sir, please protect me from retaliatory wise-
cracks out of Charles Dickens, or I mobilise the sixteen
POES in our local telephone directory, and march
south.
Glasgow. W. R. SNODGRASS.
Obituary
ALFRED CHARLES FOSTER TURNER
D.S.O., M.D. LOND., D.P.H. :
Dr. A. C. Turner, who has been in charge of Leicester’s
school medical services for the last ten years, died
on Sept. 5. Though he had no children of his own, he
devoted his life in the truest sense to their care, and `
many parents both in Leicester and in Rotherham,
,where he served for many years, are grateful for his
kindly and efficient ministrations. __ |
Dr. Turner qualified at St. Thomas’s Hospital in
1907 and his connexion with Leicester goes back as far
as 1911, when he was appointed the first assistant
school medical officer. There are many references in the
annual reports of those far off pioneer days to the value
of his work. On the outbreak of war in 1914 he joined
the North Midland field ambulance and served in France
with great distinction. He was wounded in action,
twice mentioned in despatches, and awarded the D.s.o.
It was characteristic of his humility that he kept the
news of this distinction in the background. In 1922
he went to Rotherham as school medical officer and
remained there until 1935, when he returned to Leicester
in charge of the school medical service, then under the
general direction of the medical officer of health. During
the late war he was the planner of the city casualty
service, and his thoroughness, precision, and attention
to detail made a valuable contribution to its efficiency.
He spent the last few months at his desk, in spite of
increasing ill health, writing a review of the service with
which he was connected for so many years, and his
record of the Leicester school medical service from 1905
to 1945 will long remain a classic. Such was his official
life, but he was much more than an official. He set
an outstanding example of unselfish public service in —
war as in peace. A reticent man, particularly about his
own achievements, he had a most lovable disposition,
and his unexcelled stoicism during his long illness was
typical of his dogged determination to see all things
through without flinching. E. K. M.
RoYAaL FREE HosPITAaAL.— Prof. Winifred Cullis, D.sc., will
give the inaugural address at the prize-giving of the London
School of‘ Medicine for Women to be held at B.M.A.
House, Tavistock Square, London, W.C.1, on Tuesday,
Oct. 1, at 3 P.M.
THE LANCET]
NOTES AND NEWS ;
[SErT. 14, 1946 403
Notes and News
A FUND FOR THE TUBERCULOUS
AT present some 7000 patients are said to be awaiting
admission to sanatoria for treatment. Deaths from
tubercle average 80 a day in Great Britain and Northern
Ireland, and 100 fresh cases are reported daily. Last year
Lady Chetwynd founded a fund in memory of her husband,
Sir Victor Chetwynd, who died of tuberculosis; she herself
was killed in an air crash on Sept. 4, soon after the successful
launching of the fund. The original aim was to help Service
men and women who had contracted tuberculosis ; but the
introduction of the National Health Service Bill made it
necessary to specify the purposes of the fund more clearly
so as to avoid overlapping. It was therefore decided, in the
spring of 1946, that the Victor Chetwynd Tuberculosis Fund
should provide reablement for such patients, and should also
acquire a sanatorium for the treatment of suitable cases.
Reablement schemes have been arranged at the village settle-
ments of Papworth, El Alameen, and Preston Hall, and the
fund is hoping to control a sanatorium for some 150 patients
in Switzerland.
Besides those in the fighting Services—among whom
prisoners-of-war have been specially liable to tuberculous
infection—the fund is extending help to members of the
Women’s Land Army and to the Merchant Navy.
of the nursing services, whether, civilian or attached to the
Forces, also deserve the sympathetic attention of this new
_ venture in reablement.
secretary, Victor Chetwynd Tuberculosis Fund, 60, South
Audley Street, London, W.1.
INTRATHECAL SULPHATHIAZOLE
AT the inquest on a 63-year-old woman who died in the
Taunton and Somerset Hospital on August 5, a house-physician
explained that this patient had been admitted with suspected
meningitis; ‘Thiazamide sodium’ (sodium sulphathiazole)
from an ampoule contained in a box had been injected intra-
thecally, but she had died next morning. A printed form inside
the box made no reference to intrathecal injections, but
another box of the same preparation which he had since seen
contained a warning against intrathecal or subcutaneous
injection. The pathologist who had done the autopsy said
the cause of death was tuberculoma involving the spinal
cord; in his opinion death would have in anv case occurred
within ten days, and it was impossible to say whether the
injection had accelerated death. The coroner, returning a
verdict of death due to tuberculoma, possibly accelerated by
the intratheeal injection of thiazamide sodium, said he would
call the makers’ attention to the facts, to ensure that all
future boxes were explicitly labelled.
DOWN NORTH
THe Grenfell Mission at Labrador have carried on through
the second world war, but now their overworked hospitals
and nursing stations need repairs and new equipment if the
work is to continue efficiently. The mission ask their friends
to help them again this vear by buying the attractive Christmas
cards, calendars, and postcards which may be obtained from
their offices at 66, Victoria Street, London, S.W.1.
TUBERCULOSIS IN CHINA
Dr. W. Santon Gilmour, Unrra’s tuberculosis specialist for
China, speaking at a press conference in London on Sept. 6,
said that China, which had been an urbanised country for
thousands of years, had had tuberculosis very much longer
than Britain. China was very short of doctors, nurses, and ‘
hospitals, and hundreds of small towns and thousands of
villages were without the ordinary basic sanitation that was
taken for granted in this country. Houses were very small ;
in the cold North, people kept together in a fug, but conditions
were equally dangerous in the tropical South.
time-honoured method of fertilisation by the use of human
excreta promoted the spread of typhoid and other water- and
fly-borne diseases. In some parts there was shortage of food,,
while in others there was plenty ; this unequal distribution
was due to the difficulty of transportation and communication.
Unfortunately, political instability, with continuing civil war,
hindered the initiation and the financial maintenance of any
social programme. The tuberculosis-rate was, he said, very
high; among schoolboys and university students it was
about four or five times as high as in young adults anywhere
else in the world. Before the war, except in Peking and
Shanghai, China had had practically no arrangements for
Members .-
Contributions should be sent to the .
Moreover, the.
dealing with tuberculosis; there were no sanatoria, clinics,
or regular medical officers and no preventive legislation.
Both the Nationalist Government and the Communists were
eager to improve conditions, but they lacked personnel and |
buildings. It was quite certain that the disease could not be
dealt with in China as it had been tackled in the West, since
this would demand immense resources in doctors and buildings.
It must rather be approached as a social disease, with the
emphasis on prevention. Some of the people were illiterate,
and the whole population must be educated, particularly in
the principles of personal hygiene and healthy living. In
Chungking and Nanking a start had been made with X-ray
surveys of young students, with a view to making them well
before they got really sick ; thus a part of this generation might
be saved to teach the healthy way of living. Among the
Chinese, the technically trained—doctors, engineers, and
scientists—were at one, irrespective of political views, in
wishing to serve China with their particular technical skill.
Real progress could not come until both political parties buried
the hatchet. But the great thing was the enthusiasm of the
technically trained and of the students; they would put up
with a great deal, and were united in their desire to do some-
thing for China.
University of London | |
Dr. Dorothy Russell has been appointed professor of
morbid anatomy and director of the Bernhard Baron Institute
of Pathology at the London Hospital in succession to Prof.
H. M. Turnbull, F.R.s., who retires at the end of this month.
Dr. Russell studied medicine at Cambridge and the London |
Hospital, qualifying M.n.c.s. in 1922’ and M.B. London in 1923.
After holding appointments as assistant in the medical outpatients’
departinent, the Hale clinical laboratory, and the pathology depart-
ment, she began research work at the Bernhard Baron Institute
first as a junior Beit fellow, and later with grants from the Medical
Research Council, whose scientific staff she joined in 1933. In 1928
she went, as a Rockefeller fellow, for a: year to America, where
she studied with Prof. F. B. Mallory at Boston and Dr. Wilder
Penfield, F.R.S., at Montreal. In 1930 she graduated M.D., winning
the university medal; and in 1934 she received the John Hunter
medal and triennial prize of the Royal College of Surgeons for
work on the morbid histology of kidney and brain. She received
the M.A. Oxford (by decree) in 1942, and so.n. Cambridge in 1943
when she also became M.R.c.P. On the outbreak of war she went
to Oxford to work with the Nuffield department of surgery and the
Military Hospital for Head Injuries; she returned to the Bernhard
Baron Institute in October, 1944. Dr. Russell is a member of the
medical advisory subcommittee of the University Grants Committee.
She has written extensively on the pathology of renal diseases,
with particular reference to the classification of nephritis, and on
lesions of the central nervous system. She is the first woman doctor
to be appointed to the senior medical staff of the London Hospital.
Royal Faculty of Physicians and Surgeons of Glasgow
At a recent meeting of the faculty the following ,were
admitted to the fellowship :.
Andrew Allison, M.B., Glasgow ; Charles Douglas Anderson, M.C.,
M.B., Glasgow; John Duke Olav Kerr, M.B., Glasgow ; Robert
Andrew Shanks, M.B., Barrbead, Renfrewshire; Edward Andrews
Chisholm, M.B., Clarkston, Renfrewshire; John Hutchison, M.B.,
Glasgow ; Archibald McDougall, M.B., Glasgow; James Miller
McInroy, M.B., Dundee; William Magauran, F.R.C.s., Lancaster ;
James Clark Walker, M.C., M.B., Newmilns, Ayrshire.
Liverpool Medical Institution |
On Oct. 19 honorary membership of the institution will be
conferred on the following : i
Dr. A. E. Barclay, Sir Allen Daley, Dame Louise MeIlroy,
Prof. Charles McNeil, Dr. Ivan Magill, Sir Alfred Webb-Johnson,
Wellcome Foundation
When Dr. N. Hamilton Fairley, F.R.S., takes up his appoint-
ment as Wellcome professor of tropical medicine in the
University of London, on Nov. 1, he will cease to be director
of the Wellcome Laboratories of Tropical Medicine, but will
become eonsultant in tropical medicine to the foundation.
Brigadier J. S. K. Boyd, at present director of pathology,
War Office, will become director of the laboratories.
London School of Dermatology
A course of lectures in skin diseases is to be held at this
hospital, 5, Lisle Street, Leicester Square, W.C.2, on Tuesdays
and Thursdays at 5 p.m., from Oct. I to Dec. 12.
| Chadwick Public Lectures
Sir Arthur MacNalty is to give an address at 26, Portland
Place, W.1, on Tuesday, Oct. 8, at 2.30 p.m. ; he will speak on
Sir Thomas More as Public Health Reformer. At 2.30 p.m.
on Tuesday, Nov. 5, at 42, Broadway, S.W.1, Mr. Asa Briggs
will lecture on Public Opinion and Public Health in the Age
of Chadwick. A lecture on the Prevention of Acute Diseases
of the Respiratory Tract, with particular reference to Influenza,
will be given by Prof. C. H. Stuart-Harris at St. Mary’s |
Hospital medical school on Thursday, Dec. 5, at 4.30 P.M.
A
404. THE LANCET] 3
Medical Women’s Federation
The London Association of the federation is to hold an
evening reception for the council and delegates of the Medical
- Women’s International Association, which is meeting in London
this month ; the reception will be held at the London School
of Medicine for Women, 8, Hunter Street, W.C.1, on Thursday,
Sept. 19, from 8 to 10 p.m. The London Association’ s annual
general meeting will be held at B.M.A. House, Tavistock
Square, W.C.1, on Tuesday, Sept. 24, at 8.30 P.™m.; Dr.
Henriette A. Lohr (Amsterdam) will ppeak on 'Medicine in
Holland under German Occupation.
Lectures on Child Development
© The Provisional National Council for Mental Health is
holding ten weekly lectures on this subject, beginning on
Wednesday, Oct. 9. The lectures are intended for school
medical officers; the first will be given by Dr. Kenneth
Soddy, director of the council, and the others by Miss R.
Thomas, educational psychologist. They will be held at
39, Queen Anne Street, London, W.1, and further particulars
may be had from the educational secretary of the council
at that address:
Iraq Appointment
Lieut.-Colonel W. R. M. Drew has been appointed professor
of medicine at the Royal College of Medicine, Bagdad, in
succession to Sir Harry Sinderson.
Lieut.-Colonel Drew, who is 38 years of age, graduated B.SO.
at Sydney in 1929 and M.B. in 1930. He joined the R.A.M.o. in
. 1931, and served in India from 1932 to 1937, except for a period as
house-physician at the British Postgraduate Medical School in 1935.
In 1938 he became a M.R.c.P., and in 1939 obtained the D.T.M. & H.
He returned to the Postgraduate Medical School as clinical tutor,
but on the outbreak of war joined the B.E.F., being awarded the
O.B.E. after the evacuation from Dunkirk. Since 1942 he has been
responsible for the teaching of tropical medicine at the Royal Army
Medical College, Millbank, and for the last two years he has been
joint hon. secretary (with Dr. N. Hamilton Fairley, F.R.S.) of the
Royal Society of Tropical Medicine and Hygiene. He was elected
F.R.C.P. in 1945. His published work includes studies of primary
atypical pneumonia, the toxicity of mepacrine, and sprue.
Royal Sanitary Institute
Dr. F. T. H. Wood, medical officer of health for Bootle,
has been elected chairman of the council of-the institute.
Births, Marriages, and Deaths
BIRTHS
AHERN.—On August 5, at Graz, Austria, the wife of Colonel T. M.
Ahern, 0.B.E., R.A.M.O.—a daughter.
BaRNSLEY.—On Sept. 1, at Shorncliffe, Kent, the wife of Dr. Alan
Barnsley—a son
CHILD.—On Sept. 5 5, at Oxford, the wife of Dr. J. P. Child—a son.
Dovz. aoe Sept. 3, at Liverpool, the wife of Dr. W. L. Dove—
a 80
Fak On Sept. 5, one wife of Dr. I. Harvey Flack—a son.
GOULSTON.—On Sept. 3 , in London, the wife of Dr. S. J. M. Goulston,
M.C., M.R.O.P., of Sydney—a daughter.
Marwan at es August 31, at Cardiff the wife of Dr. J. J. Hayward
—a daug
LEITrH.—On Sept. 1, the wife of Dr. W. F. Leith—a daughter.
MAOLURE.—On Sept. 4, at annie Sierra Leone, the wife of
Dr. H. L. Maclure—a so
NORMAN.—On Sept. 4, at Llandrindod Wells, the wife of Lieutenant
Thomas Norman, R.A.M.C.—a SON.
PARSONS-SMITH.—On August 31, at Caterham, the wife of Dr.
Gerald Parsons-Smith—a son.
PICKARD.—On August 31, the wife of Dr. H. M. Pickard, of Endsleigh
Court, London, W. C.1—a daughter.
SAUNDERS.— On August 30, at Barnstaple; the wife of Mr. K. G. W.
Saunders, 0.B.E., F.R.0.8.E.—8 SON.
ScoTT.—On Sept. 2, at Malvern, the wife of Dr. G. S. Scotta son.
STANLEY.—On Sept. 5, at Portsmouth, the wife of Mr. B. E. C.
Stanley, F.R.c.S.—a daughter.
WatTson.— On. Sept. 5, the wife of Dr. G. I. Watson, of Vachery
Shere—a son. z
MARRIAGES
BRAINES—STONE.—On August 26, in Camee: Frederick Morley
Braines, M.B. Lond., to Beryl Winifred S tone.
HODGKIN—CANDLER. —On Sept. 4, at Clyst St. George, Devon,
George Keith Hodgkin, B.M., to Rosemary Candler
MACALEVEY—ALLPORT.—On J uly 20, at Singapore, Gerald Esmond
MacAlevey, O.B.E., D.S.O., M.O., brigadier R.A.M.c., to Hilda
Mary Allport, Q. A.1.M.N.S.R.
TAYLOR—LYNE.—On Sept. 6, in” London, John Henry Taylor,
M.R.c.s., to Joyce Winefred Lyne.
Tow—CARROTT. —On Sept. 5, Peter Macdonald Tow,
Wickford, Essex, to Evelyn Mary Carrott.
Wrs0on—Ivor Evans.—On Sept. 4, at Swansea, Peter Remington
Wilson, M.R.0.8., to Joan Ivor Evans.
DEATHS
M.B., of
BENNETT.—On Sept. 2, in Manchester, Christopher Henry Went-
worth Bennett, = R.0.8., of Sandbach.
BEtTrs.—On Sept. 1, at Kingsdown, Deal, Alfred John Vernon
Betts, M.B. Lond., lieut.-colonel I.M.8., aged 72.
MacPHERSON.—On Sept. 5, at Oxford, ‘Alexander Hill Macpherson,
L.R.O.P.E.
BIRTHS, MARRIAGES, AND DEATHS——-APPOINTMENTS
[SEPT. 14, 1946
Medical. Diary
SEPT. 15 To 21
Monday, 16th ,
ROYAL COLLEGE OF SURGEONS, Lincoln’s Inn Fields, W.C.2
3.45 P.M. Prof. J. Kirk: Anterior Abdominal Wall.
5P.M. Dr. David Slome: Water Balance in Health and Disease.
Tuesday, 17th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. J: Kirk: Posterior Abdominal Wall.
5 P.M. Dr. David Slome: Water Balance in Health-and Disease.
Wednesday, 18th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. J. Kirk: Pelvic Wall.
5 P.M. Dr. E. P. Sharpey-Schafer : : Heemorrhage.
UNIVERSITY OF GLASGOW
8 P.M. (Department of Ophthalmology.) Dr. W. O
: Etiology and Treatment of Paralytic Squint.
Thursday, 19th
ROYAL COLLEGE OF SURGEONS `
3.45 P.M.. Prof. F. Davies: Conducting System of the Heart.
5 P.M. Prof. Samson Wright : ee Neuronography.
EDINBURGH POSTGRADUATE LECTUR
4.30 P.M. (Royal maarr D Dr. a. L. Wallace: Care of the
Small Premature Infant. ,
Friday, 20th
ROYAL COLLEGE OF SURGEONS-
3.45 pm: Prof. F. Wood Jones:
e Palate.
5 P.M. Pol Samson Wright : Physiological N euronography.
TUBERCULOSIS ASSOCIATION, 26 Portland Place, W.1
3.15 P.M. Dr. Honor Smith: Clinical and Pathological Aspects
of Tuberculosis of the C.N.S.
5 P.M. Dr. G. B. Dowling: Treatment of Lupus Vulgaris.
Dr. D. E. Macrae: Use of Calciferol in Tuberculous
Conditions.
. Q. Taylor:
Development and Structure of
Appointments
ADE IN G. E., M. B. Camb.: tuberculosis officer, Exeter Deia.
evon. à
DARLOW, A. R., M.R.0.8.: M.O., Uganda colon service).
Easton, Á. D., 0.B.E., M.B. Edin., F.R.C.P.E. specialist consulting
physician, Perth Royal Infirmary
HORNE, W. A., M.D. Glasg., D.P.H. ‘senior deputy M.O.H., Glasgow.
ROBERTS, LLYWELYN, M.D.(Hyg.) Lond., M.R.C.P., D.P.H.: deputy
M.O.H., Sheffield.
RUSSELL, P. M. G., M.B. Lond., F.R.C.S., M.R.C.0.G.: surgeon in
charge oe obstetric gynecological dept., Royal Devon and Exeter
osp
SEARLE, P. W. J., M.B. Brist. :
Glasgow Royal Infirmary :
BEATTIE, WILLIAM, M.B. Glasg., F.R.F.P.8.: asst. surgeon.
FLEMING, CHRISTIAN M., M.D. Glasg., F.R.F.P.S.: asst. physician.
IMRIE, A. H., M.B. Glasg., M.R.O.P., F.R.F.P. S.: asst. physician.
INNES, A. J., M.B. Edin., F.R.C.S. : asst. surgeon, orthopeedic dept.
JARVIE, J AMES, M.B. Glasg., F.R.F.P.8.: asst. surgeon.
MoD UGALL, AROHIBALD, M.B. Glasg., F.R.F.P.8.: asst. surgeon,
orthopeedic dept.
RAESIDE, DAVID, M.B. Glasg., D.M.R.: third asst. radiologist.
SHORT, D. W., M.B. Glasg.: asst. surgeon, orthopeedic dept.
YOUNG, STEPHEN, M.B. Glasg. : surgeon, E.N.T. dept.
Royal Infirmary, Bradford : f .
Fvll-time—
CAMPBELL, R. J. C., M.B. Edin., D .M.R. : radiologist.
CARR, R. J., M.D. Durh., D.M.R : radiologist.
KELLETT, H. S., M.B. Camb., D.C. P. pathologist.
LEwIs, R. I., M.D. Lond., D. M.R.E. : radiologist.
Visiting—
BENSON, JOHN, M.B. Leeds, F.R.0.S.E. : ophthalmologist.
DAVIDSON, C. L., M.D., B.CH.D. Leeds, M.R.C.P., D.C.H.: asst.
physician. .
DAVIDSON, J. S., M.B. Edin., F.R.C.8.E.: asst. surgeon.
DAWSON, J AMES, M.B. Glasg., F.R. o. 8.: surgeon.
Dick, I. L., M.D. Edin., F.R.C.S.E. : orthopædic surgeon.
LANGLEY, R. L., M.D. Edin., M.R.C.P. B.: pædiatrician,
LLOYD, R. I. T., M.B. Leeds, F.R.C.S. PPh baLn logine;
MARTIN, F. R. R., M.B. Camb., F.R.0.8. asst. surgeon.
NAYLOR, ARTHUR, CH.M. Sheff., F.R.C.8.: orthopsedic surgeon,
OTTY, J. H., M.B. Aberd., F.R. 0.8. Es D.L.O. : E.N.T. surgeon.
PRICE, J. A. M.D. Belf., M. R.C.P. : physician.
SMITH, L. W., M.B. Camb., M.R.C.P.: asst. physician.
WATSON, G. W., M.B. Edin., F.R.C.S.E, ! surgeon.
Examining Surgeons under Factories Act, 1937 :
BYRNE, P. S., M.B. Lpool: Milnthorpe, Westmorland.
CARAHER, F. A., L.R.C.P.I.: Carnforth, Lancaster.
M.O., Fiji (colonial service).
Heap, G. M., M. R. 0.S. : Rochdale, Lancaster.
WEBSTER, F. J. D., M.B. Leeds : Bridlington, York. '
WHITE, J. A., M.B. Glasg. : Saltcoats, Ayr. :
THe Central Medical War Committee announces that the
following have resumed civilian practice :
Mr. BRYAN .MURLESS, F.R.C.S., M.R.C.0.G., 808, Acutts Arcade.
Durban, S. Africa.
Mr. Br eal F.R.C.8., 53, Harley Street, W.1. (Tel. Langham
THE LANCET]
‘PENICILLIN IN WOUND EXUDATES
M. E. FLOREY E. C. TURTON >
M.B. Adelaide M.B. Lond., M.R.C.P.
RESEARCH CLINICAL ASSISTANT REGISTRAR `
RADCLIFFE PENICILLIN UNIT OF THE MEDICAL RESEARCH
_ COUNCIL
ae Eo =- E. S. DUTHIE *
M.B. Dubl.
' DEMONSTRATOR IN PATHOLOGY, UNIVERSITY OF OXFORD,
AT SIR WILLIAM DUNN SCHOOL OF PATHOLOGY
THE routine prophylactic use, in severe battle
casualties, of intramuscular doses of penicillin prompted
an investigation into the penicillin content of wound
exudates after 100,000 units, the recommended initial
dose. It was hoped to determine whether such a dose
would be followed by exudation of the drug into a wound,
and whether it would remain longer there than in the
blood-stream, thus exercising a protective effect during .
long periods in transit, in ” which no injections were
given. When this time-limit was found, the same
dose was placed locally in the wounds, and the duration
of a protective concentration in blood and wound exudate
following each method of administration was compared.
METHODS
‘Exudates: were first collected from 22 lacerated wounds
in airborne battle casualties at the first removal of
dressings in the Radcliffe Penicillin Unit, and at different
intervals following the immediate administration of
100,000 units of penicillin.
Owing to circumstances over which the Unit had no
control, the supply of fresh cases ceased after three
months, and so, as the experiments continued and the
same wounds had to be used, the age of the latter
increased until the last one was 67 days old. The
immediate effects of trauma, therefore, could only have
exerted an influence on the earlier results. Intramuscular
administration was investigated before local when -
conditions more nearly approached those for which this
method of prophylaxis had in fact been used.
Collection was usually by means of a Pasteur pipette,
‘but a rubber drainage-tube was used on one occasion
and a glass tube on five occasions. When collection took
more than a few minutes, the collecting vessel was
surrounded with ice.
Assays of blood and urine were also carried out to
ascertain if there was any correlation between penicillin
concentration in the three fluids.
The method of assay used for low concentrations either
in the blood-stream or wound exudate was Heatley’s
drop-on-slide method (Garrod and Heatley 1944). For
urine and wound exudate, when enough was collected
and when the presence of more than 0-1 unit per c.cm.
_eould be expected, the cylinder-plate method (Heatley
1944) was used. To make the test more delicate, the
. plates were seeded with a 1 : 1000 dilution of broth culture
of the test staphylococcus (N.C.T.C. no. 6571).
Controls were obtained for wound-exudate samples
by the addition of penicillinase or by using those collected
so long after the last administration that they were free
of penicillin.
Difficulties in Interpretation. —The reading of slide
tests was made difficult in centrifuged exudates by the
frequent presence of contaminating bacteria. To exclude
false readings from inhibition of the test staphylococcus
by the contaminants, a series of tests was set up in which
serum was inoculated with the test staphylococcus and
with one of six varieties of gram-negative bacteria
cultured from the wounds. Various dilutions of
suspensions of the contaminants were used for inocula-
tion. Though they prevented the typical appearance
* With a personal grant from the Nuffield Provincial Hospitals Trust.
6421
ORIGINAL ARTICLES
of discrete colonies, microscopical examination always
revealed a free though more diffuse growth of staphylo-
cocci in the presence of Ps. pyocyanea and Bact. coli.
In the presence of proteus, growth though less abundant
took place in every concentration used.
The greatest problem to be overcome, however, was
the presence of some inhibitory factor,*or factors, other
than penicillin in the exudate. Nine wound exudates
inhibited the test staphylococcus even when incubated
with penicillinase ; so their assays are excluded from the
tables. Considerable efforts were made to eliminate this
factor and to find its source. It was not produced by the
gram-negative bacteria infesting nearly all the wounds,
nor was it associated with rubber tubing or its preserva-
tive. Moreover, it appeared in a sterile serous exudate
after it had been incubated for three hours. `
Exiraction.—Eventually a method of extraction was
developed which ensured that penicillin alone was
assayed. It depended on the use of ammonium sulphate,
of high pH, to precipitate the globulins, and of amyl
acetate and phosphate buffer for the actual extraction.
To reduce penicillin loss, samples were kept, from the
time of collection till the final extraction, in a beaker
containing ice, only being removed when centrifuged or
shaken. “The method was as follows :
(1) The sanples were centrifuged until a comparatively dlei
supernatant fluid appeared.
(2) This was removed with a pipette and diluted if necessary
_ with saline, to make a minimum of 0:4 c.cm. `
(3) Ammonium sulphate, equal by weight in grammes to half
the volume in c.cm. of the sample from (2), was added
and the mixture well shaken.
(4) It was centrifuged at 4500 rev. per min. for about 20 min.
—1i.e., until there was a sufficiency of clear Pape
fluid to use in the next steps.
(5) A volume of amyl acetate equal to that of an aliquot, of the
supernatant fluid was added.
(6) During gradual acidification to pH 2-0 with N/3 HCl n
persistent shaking was carried out to prevent destruction
by the acid before extraction had taken place.
(7) The supernatant amyl acetate was separated and removed.
(8) An equal volume of M/15 sterile phosphate buffer at
pH 7 was added to the amyl acetate and shaken well.
(9) After centrifuging, the phosphate layer was removed =
penicillin assay.
When slide tests were used, twofold dilutions were
made with sterile serum. A fraction of serum was
added to the first undiluted drop, as staphylococci did
not grow in the phosphate buffer solution only. The
lowest reading was equivalent to a little over 0-02 unit
per c.cm. In the cylinder-plate test, undiluted buffer
solution’ and tenfold dilutions were set up, so that, with
the plates seeded with a 1/1000 dilution of the test culture,
the lowest reading obtainable was 0-1 unit.
PENICILLIN LEVELS FOLLOWING INTRAMUSCULAR
INJECTION OF 100,000 UNITS
All cases had received some kind of prophylactic
penicillin therapy in transit, but none had been given
any in the 24 hours preceding each experiment, nor
was the last dose greater than 50,000 units. In eight
instances the assays were done on patients within the
first week of wounding, but the wounds of the remainder
were considerably older.
The results in 11 cases are recorded in table 1 I. Though
cases whose wound-exudate controls did not conform to
the standard mentioned earlier are excluded, their blood
and urinary assays served to confirm: the findings in
those described. It will be seen that, irrespective of the
age, types of bacteria, or pH of the wound, in every case
there was a detectable amount of penicillin in the
exudate up to 8 hours after injection, which ranged,
at the end of this time, from 0-02-0- 32 unit per c.cm.
t An excess of phosphoric acid would probably have been better.
. M T
406 THE LANCET]
After 12 hours it was still present in 50% of the exudates
` tested, but beyond this time there was considerable
variability between results in different cases. It was noted
that, though there were greater variation and prolonga-
tion in the duration of demonstrable inhibition in the
blood-stream than has been commonly met with in cases
treated with this dose (compare Fleming et al. 1944,
McAdam et al. 1944, Child et al. 1945), there was a
‘definite correlation between concentrations in the two
fluids. Blood- and exudate-penicillin levels were similar
at the end of the first hour after injection, but after this
the blood-penicillin level fell more rapidly than the
exudate-penicillin level—apart from one exception
(case 1) there was no instance in which the blood-penicillin
level after this time was higher than the exudate-penicillin
level. Further, where an inhibitory concentration was
prolonged in the blood, it was also prolonged in the
exudate.
Urinary excretion of penicillin ranged from 30-50 units
pet c.cm. during the first 4 hours to Ọ-0-1-5 units per
c.cm. by the end of 24 hours. The 4-hour concentra-
tions were associated with penicillin levels of 0-04-0-08
unit per c.cm. in the blood-stream and 0-16—-0-32 unit
per c:cm. in the wound exudate. It therefore seems
that the penicillin disappears from body fluids after
intramuscular injection in the following chronological
order: blood, wound exudate, urine.
Possible Factors Influencing. Penicillin Assay.—These
are discussed here as they apply more particularly to the
intramuscular series, for spilling was a larger factor in
the local series than any other.
(1) Blood-urea estimations were made in each case within
24-48 hours of the assay experiment. In one case (case 2),
with a clostridial infection in which inhibition persisted for
24 hours in the. exudate and for 12 in the blood, the
reading was 360 mg. per 100 c.cm. In the only other case
(case 4) in the intramuscular series whose blood-urea could be
` considered high there was no prolongation of inhibition in the
wound beyond 8 hours or in the blood-stream beyond 4.
In this case, however, the blood-urea only reached 46 mg.
_ per 100 c.cm.. Reduced excretion, as indicated by retention `
of metabolic. products, may have played a part in retaining
LADY FLOREY AND OTHERS: PENICILLIN IN WOUND EXUDATES
- glide test.
[sEPT. 21, 1946
penicillin in these particular cases but does not appear to have
affected the others.
(2) The pH of the exudates was tested in foie of this series
and in nine of those treated by local instillation. In one of
these it was 8-0-8-4 (case 1). This was one of the only two
(cases 1 and 5) in which the serous character of the exudate
might have influenced the penicillin content (Bigger 1944).
Inhibition was recorded in the undiluted exudate alone after
8 hours in spite of the fact that the blood continued to show
inhibition at a dilution of 1 in 4 at this period. Thé remain-
ing exudates were mainly thin, turbid, and darkly stained with
blood, with various amounts of deposit, only two being
purulent, and the eleven tested were within a pH of 6-0-7-5.
Destruction of penicillin from this cause therefore . should
have been minimal.
(3) Bacteria were looked for in all the wounds. In the
intramuscular series gram-negative organisms were present
in eight and coliforms in five. Four exudates which contained
coliforms, besides proteus and clostridia, Staph. albus, and
non-hemolytic streptococci in one or another, were assayed
at various intervals after known amounts of penicillin had been
added to them in vitro. One, containing initially 1-0 unit per
c.cm. and assayed by the cylinder-plate test, sustained a
loss at room temperature of 0-25 unit per c.cm. in an hour and
At 37° C-
of the whole penicillin content after 9 hours.
the penicillin completely disappeared within 4 hours.: Two
others had lost more than 0-3 of their original 0-4 unit per
c.cm. within 15 min. at room temperature, and the fourth,
assayed by the slide test and containing initially 0-2 unit
per c.cm., within 2 hours had lost 0-03 unit per c.cm. at 4° C
and 0-16 unit per o.cm. at 37° C. Thus, these exudates, which
contained various organisms—the one in common being
Bact. coli—showed a considerable and rapid loss of penicillin.
As a control, a sterile serous wound exudate with a con-
centration of 0-02 unit per c.cm. was set up. It lost no
activity when kept for 24 hours at 4° C, but, on incubation
at 37° C without penicillin, it produced another BONY
factor thus vitiating the comparison.
(4) Effect of Extraction.—Eight experiments were ‘made,
either by adding known amounts of penicillin in vitro or by
injection into patients and comparing the assays of the merely
centrifuged and the extracted exudates by cylinder-plate or
They showed that little penicillin was lost during
the extraction, and that in some cases an extract would give
a value when the merely centrifuged exudate gave either an
erroneous one or none at all. |
TABLE I—PENICILLIN LEVELS AFTER INTRAMUSCULAR INJECTION OF 100,000 UNITS IN 11 WOUNDS
Bacteria in wound Wound exudate (slide tests) . Ur ane ANS borin
Sees, E Controls’ ; f oe
a es 3 o| 2 inhibi- Units per c.cm. at hours after injection we
= (22/181, /2 5 ; g ny |__tion pea
S jesis|S(e; 8! Sláa Sg
od! & © S (>) ro : ©
o =i S]|8] |8 E Aldo 33
= |g [$/8)els/ 21S) |29)88 p
< SIAI S ae es Ow | & . 2 : 5
l Als s| sig 22 PE 1* |2| 3 4 |5 6] 7 {| 8 | 12 20 | 24 |28 Ag
: Ay Rn aglas ~
aii
1(¢)/ 4ļ|-|-| -|-| —/-Jsao o| + + + lo-ael4! +| + Jo-oz/0 4 | 05
2 (C) 6| t+t|-|~j-; -|F 0 2-56 t) + + (+) + (0:32) +] +| + 10-02 0-027 ..
3 (C) 6/,%+|/—| =>. ~| Vir| + 0 0°32) +) + |032 016 + (0-32) + 10-08) .. j.. ee :
4 (C) 6 - = oc | Ca -m -= 0 $ , + + 0:02 efe + Ga 0-02 as ee rs ee. ee >1 >1
5(C) {7 7) ~|—| | —| Vir) + oi 0 |>0-64/+; + [0-164] + | +1016.. Ot -= E
6 (C) 8 |=| tjej +] — | +|7:50-02 0 + |+ >004| + i+) + | + | 0-16) 0-16) 0-08) 0:04, 0-025 25 0
7(C) | 20 | ? +=]; =]. 0 + (+ 0:32) + | +/0-16 Of = | = |0t sa :
8 (E)| 11 | +i +] +) —| — |] +600 T + |+ + + +) + | + (0-02/0-02/0 0 =- |>1 0:02; 0
9(E)| 40 | —| +) tirj =j- 0 + iF t + i+ +| + |0040 -|;=—-, =|} .. ee ..
10 (E) | 40 | +| —| +| + |NH| —/|.. /0 0 + +) + + (+,0-08) + | + (0°04/0-02) .. 10 os
10 (E) | 61 | +) +) +1 —| — | — {6-0 0:04'+ 0:64) + | +/0-16' . 0 = | = j = . ae
11 (œ) |32 |+| +| —| —|NH| =-|../0-02) 0 | + + 008| + afons. l | 14] + | 04
For ppurp ose of comparison with table n, inhibition is recorded in units on the assumption that complete inhibition in undiluted slide tests
2 unit per c.cm.
(C), exudate centrifuged only.
(E), exudate extracted.
Vir, viridans.
In tables 1 and II, + or - in assay columns Indicates the presumed presence or absence of inhibition.
NH, non-hemolytic.
s Samp les taken at any time within the first hour.
tO0Oat Hilution of i in 2
|
THE LANCET] LADY FLOREY AND OTHERS:
PENICILLIN IN WOUND EXUDATES
[SEPT. 21, 1946 407
TABLE II—PENICILLIN LEVELS ‘AFTER LOCAL INSTILLATION OF 100,000 UNTTS IN 8 WOUNDS
| Urine (cylinder-
: - | ‘Bacteria in wound | Wound exudate (cylinder-plate tests) plate tests) Blood
EN r ~~ n
3 EE. S |e |¢ ca i Control Baa
a lie a pH city Gt betore Units per c.cm. at hours after instillation sat
So of 4 é 3 = k wound! instilla- a oss
> a >; 318 )]41. {(c.cm.) tion 338
ele|s|° ay 18 | 24 | 48 Eas
5 = | oO c.cm.) ang
12 (E)| 9 =|) = +] =l.. ] 5 ‘'<6-5 |20,000| + + | 500
| 11 - NH -| = |58] 5 | .. $20,000} + + +
f J
13 (Œ) | 12 -'NH = 68! 3 33,000 Sc
113 TEETE le. 6t] 5 es 20,000 + + +
116 | Dasa de 5 | .. {20,0001 + + !
14 (C) | 17 į E bas oe 6 | o [16,600] + | 10
8 (E)/ 18 = -| =! ej 64]| 5 20,000 + ' 100 ..
19 PEP GR S | 20,000 | + + +
_ |23 EP a 20,000 -y
6 (E) | 22 -;=-jįj-|-les] 6 oi 16,600 | + 10
23 oot os | oo ee 6-2 ee |
1 {
9 (E) | 27 -! NH: NH; = |66| 5 /<0-5 |20,000| + + 1-5
|
15 (©) | 52 INH .. | Mes) .. | 3 33,300 | >1000! n
(E) | 56 = = a Mee] rs | 4 66,600 | + | >1000,>10
(E) | 67 -=| = | NH = |66| 1 0-25 | 66, 004 + + -
10 (E) | 68 = NH =| = 6 i |16, 600 | |
|
(E), exudate extracted.
(O, exudate centrifugod only.
NH, non-hæmolytic.
Mes, B. mesentericus.
PENICILLIN LEVELS AFTER LOCAL INSTILLATION OF
100,000 UNITS
Experiments were made on eight separate wounds,
none less than 9 days old, and seven infected with
Bact. coli. A mild pyrexia was present in five cases, all
had had previous courses of intramuscular penicillin, and:
those whose control exudates showed a small ring of
inhibition had had local applications 24-48 hours pre-
viously. The wound was first cleaned with saline, and
then a solution of penicillin was inserted, the amount
varying with the cubic capacity of the wound. Spilling
and leakage was inevitable in open wounds during the
subsequent period of observation, thus explaining varia-
tion in results in the same wound. Assays were made by
the cylinder-plate method (table 11). Theextraction method
was used in seven cases. Only one reading was taken
in each experiment, as the quantity of fluid required for
this test necessitated the emptying of the wound when
_ each sample was taken. A fresh instillation of penicillin
for each assay was consequently required. As it was-
known that the original content of the wound was of the
order of 25,000 units per c.cm., the cubic capacity of the
wounds being 6 c.cm. or less, it was not considered
necessary to make early assays. The duration of a
detectable concentration of penicillin was the’ main
point at issue, and it will be seen that in all cases this was
for the blood at least 4 hours, for the urine 24, and for the
exudate 48 hours. In 50% of cases tested the duration
was extended to 6, 48, and 60-72 hours respectively.
Thus, in this series, the inhibition in the wound out-
lasted that in the urine by about 24 hours. These results
were irrespective of the bacterial flora and the age of the
wound after 9 days; the pH should not have affected
the penicillin content ; and in no patient was the blood-
urea over 53 mg. per 100 c.cm. A comparison of the
duration of inhibitory levels of penicillin by the two
methods of administration are set out in table m1. It
is seen that, though there is very little difference in the
duration of a detectable amount of penicillin in the blood-
stream, the enormously higher local concentrations from
instillation into the wound led to a very much greater
duration of inhibition in both urine and wound exudate.
In an attempt to find the amount and frequency of.
dosage necessary to ensure continuous bacteriostasis
* Units per c.cm. before instillation.
t On another occasion inhibition present for 5 hours.
¢ Only 66,000 units retained in wound.
in the blood-stream, smaller. doses were placed in what
suitable wounds still remained to us. Even 33,000 units
_ produced a demonstrable though not necessarily complete
inhibitory level in the blood for 5-9 hours. Using this as
a basis it should be possible to maintain a constant
inhibitory level in the blood by regular instillations of :
33,000 units or more.
DISCUSSION AND CLINICAL APPLICATION
The study of these exudates demonstrates the difficulty
of reliable assay of penicillin in such fluids. The presence
of natural inhibitory factors in pus was demonstrated by
Wright et al. (1918). Inhibition has been found by us
also in infected pleural exudates and in one instance in
a sterile wound exudate after incubation, and by McAdam
et al. (1945) in cerebrospinal, peritoneal, and joint fluids.
Therefore, before an attempt is made to assay any type
' TABLE ITII—COMPARISON OF INHIBITION AFTER INTRAMUSCULAR
AND LOCAL ADMINISTRATION OF 100,000 UNITS OF
PENICILLIN
Minimal duration of detectable
penicillin (hr.) ;
Source of samples
; Intramuscular | Local
Blood a aUl Sapa Siig a : | :
Urine oe ate eee ee a | a
Wound {In all cases tosted .. $ | 48
exudate 30 % ry) ry) ae 12 | 60-72 g
Range of concentrations detected 2:56-0:02 + 2000-1:0°
}
in wound exudates (units per
©.cm.)
+ All at 18 hours or more from instillation,
of effusion or to estimate its content of penicillin, this
source of confusion must be excluded. Extraction pro-
vides the best method of doing this, but it lengthens the
process of assay considerably. Perhaps the most practic-
able method would be to control every assay of an exudate
by setting up another with penicillinase, and to adopt
the more tedious process only if the control shows
inhibition.
The most curious anomaly in dealing with these infected
exudates was the apparently rapid destruction of penicillin
408 THE LANCET]
when added to them in vitro and yet its long persistence
in the wounds. Possibly in the case of intramuscular
injection a continual leakage into the wound from the
surrounding tissues might explain its presence, whereas
the enormous concentrations used in local instillations
would not be significantly reduced by the destruction of
several units per hour. Further possibilities are that the
rate of. destruction varies with the concentration of
penicillin, or that adsorption takes place when penicillin
is first added to an exudate, with the result that its
presence is not demonstrated by the cylinder-plate test.
The fact that some penicillin persisted (as shown by the
controls) even after an intramuscular course, or the
usual local applications of 250 units per c.cm., had been
discontinued 24 hours previously, showed its. ability to
withstand total destruction. Whatever the explanation,
the assays appear to be an answer to the fears expressed
by some—e.g., Meleney et al. (1946)—that penicillinase-
producing bacteria would neutralise the effect of the
drug in a wound.
A concentration of 0-02 unit per c.cm. was adopted
as the lowest protective concentration; but, though
adequate against most staphylococcal and streptococcal
invasions, it might be low for clostridial infection. If,
however, as Ross (1946) has noted, inhibition of relatively
resistant strains depends on the size of the inoculum,
then, at an early stage after wounding, when multiplica-
tion of bacteria cannot have progressed far, such a con-
centration should have some effect, for, according to his
slide-cell tests, this concentration in circulating serum
led to partial inhibition of Ol. weélchii. Intramuscular
injections of 100,000 units produced higher concen-
trations and complete inhibition for 1!/,-3 hours,
depending on the strain used. It can therefore be
stated that intramuscular injection of 100,000 units
‘leads to the exudation of a useful level of penicillin
into the wound which is reabsorbed more slowly so
that protection lasts several hours longer than is
indicated by the level of circulating penicillin. Though
the results recorded here indicate that, with the dose
used, reliance could not be placed on a longer period of
inhibition than 8 hours, yet none of these cases was
examined during the first 24 hours of wounding, when
metabolic disturbances and diminished urinary excretion
following severe trauma would favour the retention of the
drug within the body. Case 2, with fractures of femur,
tibia, and fibula, with much laceration of muscles of the
leg and back, Cl. welchii in his wounds, a blood-urea of
360 mg. per 100 c.cm., and no excision of his leg wound
for 9 days, should have produced very favourable condi-
tions for the development of gas gangrene. Yet inhibition
and therefore protection in his case was more prolonged
` both in blood and wound than in any less severely injured
case.
Further application to therapeutic fields may be |
- permissible. If the prolonged presence of penicillin
in wound exudates indicates its presence in any. inflam-
matory tissue exudation, a ready explanation is found
of the remarkably good results obtained by a course
of once-daily injections of aqueous solutions in early
syphilis (Jones et al. 1946), and of twice-daily injections
in acute inflammatory conditions (Bedford 1946) and in —
gonorrhea (Cohen and Grover 1945). It may therefore
be feasible to treat purely focal infections by a reduced
number of injections per 24. hours—e.g., once or twice—
while increasing each individual dose to 100,000 units.
or more without recourse to vehicles, such as beeswax
and peanut-oil, which delay absorption (Romansky and
- Rittman 1945). Certainly the fears expressed by Ram-
melkamp and Kirby (1945) of the danger of this type of
treatment do not appear to have experimental foundation.
In wounds treated locally, not only the duration of
protection but also the concentrations of penicillin make
a striking contrast to those treated by intramuscular
LADY FLOREY AND OTHERS >` PENICILLIN IN WOUND EXUDATES
. [sEPr. 21, 1946
injection. It. might be argued that the assay of the
fluid in these wounds was not a true index of the con-
centration in the tissues of their walls ; but, as inhibitory
concentrations were detected in the circulating blood for |
as long as after intramuscular injection, and in the urine
for at least twice as long, clear proof was given that
absorption took place. The necessity of collecting a
sufficient amount of exudate for each assay impelled. the
use of a solution, but for practical purposes it is obvious
that, failing complete suture, full retention of a fluid
‘preparation would always be problematical. This dis- _
advantage can be largely overcome by using a solid —
The extraordinary solu- .
preparation—powder or tablet.
bility and absorbability of penicillin by body fluids
renders it an ideal local chemotherapeutic agent. Those |
who have used penicillin powder, unmingled with a- sul-
phonamide, in wounds know how rapidly it is dissolved
and absorbed, though some exudation invariably accom-
panies its insertion. . So small an area as 1 sq. in. will
absorb 1 g. within a few minutes. Wherever hæmo-
stasis can be secured, there is no question therefore that.
local implantation of the drug in a wound will afford
surer protection than any practicable intramuscular dose.
One other point of clinical application emerges from
this study. After intramuscular injection the disappear-
ance of penicillin from the urine succeeded its disappear-
ance from the exudate, but in the case of local applica-
tion it preceded it. Where wounds need to be enclosed
in plaster, tests of the urine will indicate the presence of
penicillin placed in the wounds, with a 24-hour margin of
safety. —
The recommendation of intramuscular treatment as
‘the routine method of administration of the drug to
battle casualties, together with the ample supplies of
penicillin available between D-day and the end of the war,
seems to have encouraged the idea among surgeons that
this is the route of choice for administration. The
discipline of troops has enabled this method of treatment
to be carried out effectively and often for a long time.
Though the findings in this paper or the use of vehicles
delaying absorption may enable fewer injections to be
used, and though oral administration may become practic-
able (Finland et al. 1945, Ross et al. 1945), yet. these
methods cannot produce concentrations of the drug
comparable with those of local administration at the
focus of infection. To those who have practised and
seen the results of local administration, only using the
intramuscular route when inaccessibility of the lesion
necessitates it, it has long been obvious that, used
advisedly and repeated at suitable intervals, it not only
avoids the very undesirable effects of discomfort or even
pain to the patient and disturbance of his rest, but that
it can accomplish the desired results, both local and
systemic, wherever a wound can be so sufficiently closed
either by suture or dressings as to retain ane drug.
SUMMARY
A method for preparing wound exudates for assay of
their penicillin content is described.
Sources of error from other inhibitory jator and from
contaminating bacteria are thereby eliminated.
A dose of 100,000 units given intramuscularly. to
severely injured battle. casualties whose wounds were
4-61 days old invariably produced inhibition for 8 hours
in the wounds tested, and for 12 hours in 50% of cases.
A dose of 100,000 units given locally into wounds. 9-67
days old invariably produced inhibition for 48 hours in
the wounds tested, and for 60-72 hours in 50% of cases.
These time-limits were irrespective of the age, bacteria]
flora, pH, or consistence of the wound exudates.
Blood and urine assays were correlated with these
findings and served to confirm them.
_ A possible application of these nee to the treat-
ment of focal infections is mentioned.
»
THE LANCET]
DR. NEWMAN: CORONARY OCCLUSION IN YOUNG ADULTS’
[sErT. 21, 1946 409
. The advantages of local over intramuscular administra-
tion in prophylaxis and treatment are also discussed.
We are particularly indebted to Dr. N. G. Heatley for
invaluable advice throughout and for carrying out some
_ experiments; Dr. J. Humphrey for suggesting the use of
ammonium sulphate in the process of extraction; Lieut.-
Colonel J. S. Jeffrey for allowing us to do the work on his
cases; Private P. Bowdery for technical assistance; and
Dr. R. W. N. L. Ross for some final blood assays.
REFERENCES
Bedford, P. D. (1946) Lancet, i. 977.
Bigger, he a hen) Out ii, 400.
R. F. Hughes, K. E. A., Evans, R. W. (1945) in Poe
ama hls ` ‘nd Control in 21 Anny Group, London, p 37
Cohen, D. L., G Sas M. L. (1945) J Urol. 53, 812.
Finland, M., Meads, M. , Ory, E. M. (1945) J. Amer. med: Ass. 129,315.
al om Ka ‘Young, M: Y., Suchet, J., Rowe, A. J. E. (1944) Lancet,
Garrod, L. P., Heatley, N. G. (1944) Brit. J. Surg. 32, 117.
Heatley N. a. (1944) Biochem. J. , 6l.
Jones, T. R. L., Allen, S. J., Paon E . M. (1946) Brit. med. J.
. W. (1944) Lancet, ii,
i, 567.
DELA I. W. J., Duguid, J. P., Challinor, S
— McCall, A. a Ibid, ii, 843.
Moloney, F. L., Johnson, B. A., Pulaski, E. J., Colonna, F. (1946)
‘Amer. med. Ass. 30, 121.
p, C. H., Kirby, W. M. M. (1945) Bull. N.Y. Acad. Med.
21, 656.
Romansky, M, J. J., Rittman, G. E. (1945) New Engl. J. Med. 233, 577.
L. (1946) J. Path. Bact. 58, 441.
Ross, S., Burke, F. G., McLendon, P. A. (1945) J. Amer. med. ASS.
Wright, "A. E., Fleming, A., Colebrook, L. (1918) Lancet, i, 831.
CORONARY OCCLUSION
ADULTS
REVIEW OF FIFTY CASES IN THE SERVICES
MAURICE NEWMAN
M.D. Lpool, M.R.C.P.
PRINCIPAL MEDIOAL OFFICER, MINISTRY OF PENSIONS
` ALTHOUGH the last twenty years have seen a rapid
development in the clinical diagnosis of coronary
occlusion, it is still considered to be very rare in young
adults. A considerable number of cases in patients
under the age of forty years have been recorded in the
literature, although most of the authors describe only
1 or.2 such cases individually.
Smith ‘and Bartels (1932), in reporting 2 cases in patients
aged thirty-five and thirty-six, state that they were able
to find in the literature up to 1932 only 20 proved cases of
coronary thrombosis affecting patients under forty years
of age. Since then many more cases have been recorded. .
Durant (1937) reports 7 cases in patients aged thirty- five
years or under observed in a clinic in four years. ©
The most extensive series of cases has been recorded by
Glendy et al. (1937), who reported 100 patients under forty
years of age, collected from several hospitals and clinics in three
years; of these only 8, however, were under thirty years of age.
French and Dock (1944) analysed the clinical and patho-
logical features of 80 cases of coronary disease in American
soldiers aged from twenty to thirty-six from data received
at the American Army Medical Museum since the beginning
of the recent war. The striking clinical feature was over-
weight (in 73- -cases), and in every, case erlenioscloreste was
the basic lesion. .
IN YOUNG
In. view therefore of the apparent rarity of coronary
thrombosis in young people, I have gone through the
records of the Service men and women who have been
invalided with, or died from, coronary occlusion or
thrombosis, and collected the records of those up to the
age of thirty-five for analysis. A careful attempt has
been made to select only those cases where the diagnosis
was beyond doubt—i.e., either proved by necropsy or
where the electrocardiogram shows the characteristic
changes of coronary occlusion in support of the clinical
diagnosis.. All doubtful cases have been excluded.
I have collected records of 50 such cases which occurred
during the recent war. The youngest patient was
aged twenty, and no less than 22 of the 50 patients
Dy amen ge
- males to 1 female.
-cardiogram simulating coronary thrombosis.
were in their twenties, although as shown below the
frequency increases with age, as in the older age-groups :
: | ae eee
pe 20 21 | 22| 23 | 24) 25 | 26 a7 | 28/29. ! 30 | 31 : 32 | 33 | 34:35
Gaa 1,2 3; 1; 3| 1 2 2 4 3| 6] 7| 1ji ys
Fee Ee ee Og oe ee ene
| 15 | 35
These figures show that coronary thrombosis in the
young is not so uncommon as was formerly thought,
and that it may occur at an early age. Of the 50 cases
of coronary thrombosis the diagnosis was established
clinically in 11 and by necropsy in 39.
SCOPE OF PRESENT STUDY
I have extracted from the Service documents all the
available data that might have a bearing on the etiology.
None of the cases have been seen by me personally.
Unfortunately all the information that one would have
appreciated—such as family history, ancestral longevity,
and habits, including tobacco consumption, &
recorded. On the other hand, every case was examined
on entry into the Service, and in many cases several times
subsequently ; hence we have a record in every case of
the subject’s physical condition before the onset of the
catastrophe. The occupation before entry into the
Service has also been noted. The past illnesses, if any,
and conditions of service are usually recorded ; and the
relation of physical stress to the onset can thus ‘be
deduced. The height and weight of the individual on
entry is also usually recorded ; hence the relation of body-
- build may also be considered.
CLINICAL FEATURES
Sex-incidence.—Coronary disease at the usual older
periods is recognised as being more common in
males ; in the young age-group of Glendy et al. (1937)
the proportion was 24 males to 1 female. In the present
series there was only 1 female—a Wren aged 28.
It must be remembered, however, that in the pool from
which these cases were drawn there were about 10-15
Even so, it appears that the disease
is more common in males than i in females i in this younger
age-group.
Body-build.—The striking feature was the good
physical development and nourishment of these young
adults. The recorded weight on entry into the Service in
43 of the 50 cases was over 126 lb. - The highest weight
was 193 1b., and many were over 150 Ib. In 21 of the
39 necropsies remarks such as ‘‘ well nourished,” “‘ power-
fully built,” and ‘‘obese’”? are made. The physical
fitness of the subjects is indicated by the fact that 45
of the 50 were graded fit, or I, on entry. Even in the
5 exceptions the lowering of the category was due to
some slight disability, such as flat-foot, defective vision,
&e., entirely unconnected with the general physical
development. The heart was recorded as normal in every
case, including those in the lower category.
Previous Infection.Rheumatic fever may cause
proliferation and fibrosis of the elastic tissue of the
coronary arteries, with necrosis resembling ‘arterio-
sclerosis (Karsner and Bayless 1934). Further, acute
rheumatic fever is known to cause changes in the electro-
In the
present series 3 persons gave a history of rheumatic
fever, 2 of them having had the attack only two years
before entry into the Service.
There were 2 cases with a history of scarlet fever, and
in 1 of them, in which we have a detailed account of
the necropsy findings, including histological examination,
it appears that the scarlet fever may have been a causal
'factor in the pathology.
410 AE LANCET]
It is now generally recognised that chronic suppuration
and infection extending over many years may lead to
atheroma. In 1 case in this series the man sustained
a gunshot wound of the arm, which necessitated pro-
longed hospital treatment owing -to the formation of
sequéstra and to low-grade infection. He was dis-
charged from the Service two years later with the wound
healed but with albuminuria, and it was stated that he
never felt well subsequently. He died two years after
discharge from the Service, and necropsy showed ‘a
striking degree of occlusion of one branch of the coronary
artery, due to high-grade atheroma, which at this age is
a gross abnormality.” . He was twenty-nine years of age.
_ It appears, then, that infection may be an etiological
factor in the production of coronary disease in young
people.
Physical Strain.—Of the 50 persons, 23, or nearly half,
were subjected to physical stress, the catastrophe occur-
Ting immediately after. the stress in 11 cases and within
a few days in the remainder, On the other hand, in
27 cases there was no evidence of any stress before the |
onset.
Pre-Service Occupation.—Only 8 of the 46 pre-Service
occupations recorded were sedentary. Of the non-
sedentary occupations about half may be considered
as heavy work,
Prognosis.—In the 50 cases there were 39 deaths, a
very high mortality.
young adults is that in 33 of the 39 deaths the persons were
found dead or died almost immediately after a collapse.
The longest survival period of the 6 exceptions was
nine months. In contrast to the high immediate
mortality in this series, Conner and Holt (1930) found
an immediate mortality of 16:2% in
ages. Boyd (1944) states that less than 25% of patients
die in the first attack. It is also noteworthy that
practically all the sudden deaths were in apparently fit
and healthy men who had previously carried out their
‘military duties without any signs of cardiac distress,
the disease being unsuspected during life and only
diagnosed at necropsy.
Of the 11 patients still living several have resumed
work, although pain on exertion and breathlessness are
complained of. As most of the survival cases are of
recent occurrence, the ultimate prognosis -cannot yet
be determined, but 1 patient has so far survived four
years since the first attack (syphilis may have been a
factor in this case). The only other patient with evidence
of syphilis in the series had also resumed work. It
` may appear, therefore, that the prognosis in syphilitic
cases treated appropriately is good, but in view of the
small number of cases this is doubtful. In none of the
39 fatal cases was there any evidence of syphilis either
clinically or at necropsy.
Necropsy Findings.—The left coronary artery is usually
considered as being more frequently affected than the
right. In the present series of 39 necropsies the right
coronary artery was affected in 5 cases, the left in 17,
and both were affected i in 16 (no record in the remaining
case).
Leary ( 1941) considers that in the younger age-group
of coronary thrombosis (from twenty-two to forty. five)
the pathological lesion is due to subendothelial- fibrosis,
with necrosis of the intima leading to thrombosis.
Calcification, he states, does not occur in this group.
In the older group (over forty-seven), on the other hand,
the fibrotic process is absent and calcification is well
marked ; thrombus formation is not so common as in the
younger group. The findings in this series of 39 necropsies
do not support this view. Only 2 of the cases appear
to conform to Leary’s younger group, showing the
fibrotic reaction without calcification. The remaining
37 appear to present the usual degenerative atheromatous
changes met with in coronary disease of older people.
` DR. NEWMAN : CORONARY OCCLUSION IN YOUNG ADULTS
What is equally striking in these
in 287 patients of all `
ee
v
[SEPT. 21, 1946
In several cases extensive calcification of the coronary
vessels is noted by: the pathologist. Again, in 29 of the
-39 cases no thrombus was found,
The heart was definitely stated to be enlarged in
20 cases. In 1 it was described as small. In 17 cases
myocardial infarction was found, either recent or long-
standing ; in 1 case some of the infarcts appeared to be
at least two years old. l |
DISCUSSION
This series of 50 cases of coronary disease in young
adults demonstrates that degenerative changes of a
remarkable degree can exist in the coronary arteries at
an early age, and that coronary disease is not so rare
as formerly thought. It is therefore no longer justifiable
to disregard the possibility of coronary occlusion in a
‘doubtful diagnosis owing to the youth. of the patient.
The individuals are usually in excellent health, of good
physical development, and capable of exertion without
any untoward effects. Clinical examination is usually
negative, and there may be no subjective symptoms
before the onset.
Whatever the etiological factors, they appear to. ‘be
more common in males. Body-build appears to be an
important factor, as most of the subjects were powerfully
built, robust, and often adipose. There is evidence that
in some cases infections, such as rheumatic fever, scarlet
fever, and chronic prolonged low-grade toxsmia, may
play a part in the production of the pathological process
in the coronary vessels, Atheromatous lesions have
been found in children after ‘acute infections. In the
present series there were 3 cases with a history of
rheumatic fever and 2 of scarlet fever; 1 case followed
prolonged suppuration of a gunshot wound. Syphilis
appears as infrequent a cause of coronary thrombosis
in young people as in the older age-groups, there being
only 2 cases in this series. Hypertension does not appear
to be so important a factor in this young group as in
later life. Only 3 cases showed any evidence of hyper-
tension.
-~ Only 8 of the 46 pre-Service occupations were > sedentary
and half of the subjects were doing heavy work. before
entry into the Service. One might deduce from these
figures that sedentary workers suddenly called on to
experience the stress of Service life were not more liable |
to coronary: disease than manual workers; but, until
the proportion of sedentary to manual workers in the
Seryices is known, any inferences are premature and
unsound.
The high mortality i in this series indicates that the
prognosis in the young is much worse than in the older
age-groups. The immediate mortality is extremely high
(33 cases of sudden death out of 39 fatal cases).
In view of the large proportion of sudden deaths
in apparently healthy individuals, the necropsy findings
are rather surprising. The absence of thrombus in
most cases is unexpected. Again, the fact that m most
cases the myocardial infarction was due to gradual
occlusion of the coronary vessels by advanced atheroma,
often with calcification, as occurs in the older age-
groups, and indicating that the pathological process
had been present for several years, is also surprising in
view of the youth of the subjects.
‘SUMMARY
A review is given of 50 cases of coronary Seclusion
in young adults in the Services, the youngest being
twenty years of age.
The subjects were of good physical development and
previously fit condition.
Previous infection might have been of sotiological
importance in only a few ¢ cases,
In more than half the cases there was no evidence of
physical strain.
Sudden death took place in 33 out of 39 fatal cases.
THE LANCET] DR. BURGESS:
At necropsy, 37 out of 39 cases showed the usual
degenerative atheromatous changes found in coronary
disease of older. subjects, and in 29 there was no thrombus.
I wish to thank Sir Walter Haward, Director-General
of Medical Services of the Ministry of Pensions, for his
permission to publish this paper.
| REFERENCES
Boyd, W. (1944) Fethology of Internal Diseases, A els p. 60.
Conner, . A., Ho . (1930) Amer. Heart J.
Durant, T. M. (1937) ae intern. Med. 10, or
French, A. J., Dock, W. rae Amer, med. Ass. 124, 1233.
Glendy, R. E., Levine, S. A., White, P. D. (1937) Ibid, 109, 1775.
Earner, T., Bayless (1934) Amer. Heart J. 9, 557.
Fasi ) Arch. A
SE A
, Bartels. E. C. ANS Amer, med. Ass. 98, 1072.
DEFICIENCY DISEASES
IN PRISONERS-OF-WAR AT CHANGI, SINGAPORE
FEBRUARY, 1942, TO AUGUST, 1945
R. C. BURGESS
M.B. St. And., D.P.H., D.T.M. & H.
MALAYAN MEDICAL SERVICE; LATELY MAJOR R.A.M.C.,
NUTRITION OFFICER IN THE CAMP
SINGAPORE capitulated to the Japanese forces on
Feb. 15, 1942. Of the troops captured, a proportion were
in an exhausted condition, having fought- through a
strenuous campaign, but the majority had undergone
relatively little hardship. In the week that followed
the capitulation about 52,000 troops marched out from
_ Singapore to Changi Camp—about sixteen miles—in
the heat of the day. An outbreak of bacillary dysentery
had begun at the time of capitulation, and the shortage
of water and latrine accommodation in the prisoner-of-
war camp rapidly resulted in an epidemic in which the
morbidity-rate was high, but fortunately the disease
was due to a mild Flexner infection and the mortality-
rate under the circumstances was low.
GENERAL CONDITIONS
. The prisoner-of-war camp was on Singapore Island,
in open country near the sea-coast. During the first two
years the area included in the perimeter wire was spacious
and allowed considerable movement, but in the last
eighteen months it was somewhat restricted. Throughout
the whole time the housing was inadequate and this: was
particularly so in the last eighteen months. The peace-
time civil prison was used for housing troops, and 4
men were made to occupy cells designed for 1 convict ;
this building, with its peace-time capacity of 600—700
prisoners, at times held 6000 men. There were never
enough permanent buildings, and a large number of the
troops were housed in leaf huts with earth floors. These
were dark, damp, and impossible to keep clean. |
The climate of Singapore is equatorial. The mean
temperature is about 80° F, the mean maximum and
minimum varying between 87° and 74° F, and the
rainfall is about 100 inches a year. The temperature
varies but little throughout the year and the rainfall
is fairly evenly distributed. The climate must to some
extent have offset the privations of the prisoners-of-war,
for even when the calorie intake was relatively high
they did not complain of the heat and during periods ‘of
low food intake they complained of the cold only when
it rained..
Clothing was extremely scarce, especially latterly, and
the men wore only a pair of shorts. They worked
the whole day in this half-naked state and became a
mahogany colour with sunburn.
During the first year the bacillary dysentery persisted,
and about 80% of the personnel had one or more attacks.
Throughout the remainder of the time the disease was
always present and a number of minor outbreaks occurred.
In the last year amebic dysentery became increasingly
common. In the first two years there was a relative
DEFICIENCY DISEASES IN PRISONERS-OF-WAR
[serT. 21, 1946 411
freedom from malaria, but in the last eighteen months
some 70°% of the total population had one or more
attacks.
THE DIET
The Japanese scale of rations for prisoners-of-war `
was as follows:
Fresh vegetables ..
Rice tale .. 500 g. 100 g.
Flour es se 50 g. Canned milk 15 g.
Sugar ; : 20 g. Salt.. 10 g.
Cooking fat 5g. Tea.. 5 g.
Meat or fish 50 g.
This scale was not maintained, as can be seen from
table 1. The details of the diets contained in this table
were obtained by averaging the daily issues over a
month. Where: major changes occurred during the
month they are shown.
For the first three years the daily issue of rice, or some
substitute, was always more than 400 g. per man. In
February, 1945, the first severe cut was made. Men on
light duty—i.e., those who were not working for the
Japanese or employed on hard work in the camp itself
—were given only 325 g. per man per day. This was
followed by further cuts, and in the last months of the
camp rice was issued in daily amounts of 270, 225,
and 180 g. to heavy-duty, light-duty, and no-duty —
personnel. Almost all the rice supplied was highly milled.
The second item in the Japanese scale, a bleached flour,
lasted only for the first seven months and did not
reappear. The third item, sugar, was maintained at about
the 20 g. level throughout the existence of the camp.
The amounts of meat and fish issued varied consider-
ably. Fish was supplied more often than meat. Fresh
fish was usually in the form of numerous species of small
fish which were exceedingly bony and from which rela-
tively little nourishment could be obtained. The dried
fish was in the form of dried sprats (Stolephorus spp.),
or partially dried and salted horse. mackerel (Oaranz
spp.), or, much less frequently, larger dried fish which
could not be identified.
Fresh vegetables were not supplied in the first few
months, but thereafter sweet potatoes, yams, pumpkin, -
and cucumber were supplied on a scale exceeding that
laid down. Green leaf vegetables in quantity appeared |
later.
The canned milk on the Japanese scale was supplied
only for a little over two months. The last item, cooking
fat, was supplied in much more generous amounts than
laid down in the scale, except for the first few months.
The diet supplied by the Japanese was supplemented
by various means throughout practically the whole
period, although the supplements were at times very
small. In the first six months or so canned goods, biscuits,.
&c., which had been brought into camp by our own
troops, were issued by the supply depots on a regular
scale, but these issues were so small that they were
of relatively little value. In October, 1942, Red Cross
supplies were brought into the camp and it was possible
to supplement the “diet very considerably over a period
of two and a half months (see table 11). In June, 1943,
a levy on all money coming into the camp was instituted
and the diet was supplemented by purchases of fhe
foodstuffs shown in table 1 under the heading “ Camp
Messing Fund.” |
Estimated Food Value of Diet.—The details are shown
in table 111. In these calculations no allowance has been
made for waste except in root vegetables, although
during the periods when food was plentiful there was some
waste of rice; in the lean periods waste was reduced to
an absolute minimum.
The daily calorie intake in March and April, 1942,
was about the 2100 level. It increased slowly, and by
August, 1942, had risen to 2500 calories. From then
till the end of the third year of imprisonment—i.e.,
February, 1945—it was usually above the 2500 level.
THE LANCET]
412
PER MONTH
—-— NN Q
n ono
PER 1000 POPULATION
o-
FRESH BERIBERI CASES
3.
oe.
aQS o0-
T
z Sf o4
= 32
2 os
>P o &
i x> rx KS >erRX RK SY SER HAH YSzeERKRE
Sey SeegcsS 8S esses stexese ess
BSERHSSPSRVHtEssPsRVgsess saggy
1943 ———’ 1944
Fig. I—Monthly incidence of beriberi com)
vitamin 8B, /non-fat-ca orie radio, of diet
eee the last six months it fell to 2000 in the heavy-
duty scale, 1700 in the light-duty scale, and 1500 in
the no-duty scale. Apart from the first few months and
the last six months, the calorie intake was not grossly
inadequate. The same might be said of the protein
content. The fat mtake was low for the first few months
but thereafter was usually above 50 g. per day. The
calcium and phosphorus intakes reached a satisfactory
level owing to the dried fish, which was mostly in the
form of sprats, and the green leaf vegetables in the diet.
Part of the daily ration of cooking-oil was red palm oil,
and this together with the green leaf vegetables supplied
a high vitamin-A intake. Green leaf vegetables and root
vegetables supplied adequate quantities of vitamin C.
The diet for long periods was inadequate in several
components of the vitamin-B complex. It has only been
possible to estimate the vitamin B,, riboflavine, and -
nicotinic acid contents, and in all of these there is some
‘deficiency. The position as assessed by estimating the
food value of the diet might be summarised as follows.
` For three out of the three and a half years the energy
intake was not grossly inadequate, but for the greater
part of the time there was an imbalance in vitamin-B
complex. In the last six months there was semi-starva-
tion, with the imbalance, especially of vitamin B,, still
persisting.
_ In estimating the beriberi-producing ‘potentialities of
‘the diets as prisoners-of-war the formula suggested by
Williams and Spies ( 1938) was used. This formula is
the ratio of vitamin B, in the diet to the non-fat calories.
The vitamin-B, values given by these writers have
been used in the estimations. In comparison with the
figures published more recently, these values are low,
but, as will be seen subsequently, this method of apprais-
ing diets by relating them to the production of beriberi
fitted the picture as it occurred in the camp and proved
a reliable means of forecasting the incidence of beriberi.
It is to be noted, however, that only when the values of
Williams and Spies are used can the vitamin B,/non-fat-
calorie ratio of 0:3 be considered as the level at which
clinical evidence of deficiency will appear.
The estimated levels of nicotinic acid and riboflavine
are shown in table 111. Since, with a variation in the
DR. BURGESS: DHFICIBNOY DISHASES IN PRISONERS-OF-WAR `
red with aioe total calories and
(sepr. 21, 1946
_ calorie value of the diet from 3000 to 1400
the absolute intakes of nicotinic acid
and riboflavine would be. misleading, it —
_ seemed advisable to relate the intakes. of
these vitamins to the total energy value ;
they are therefore also shown in -milli-
grammes per 1000 calories... The. content
- of these three vitamins has been calou-
lated from the tables compiled’ by. Plar
(1945).
BERIBERI
The number of fresh cases of beriberi
admitted to hospital per 1000 population
per month is shown in fig. 1, with the
.yitamin B,/non-fat-calorie ratio of Wil-
- liams and Spies (1938) and thé estimated
total calorie intake. It was clear from
the beginning of the camp that beriberi
must occur. The estimated daily intake of
vitamin B, for the first two months was
less than 0-4 mg. and the vitamin B,/non-
fat-calorie ratio was under 0-2 mg./1000.
No allowance was made for loss of the
vitamin in.the preparation ‘and cooking
of food, and in the first few weeks
probably 25% was lost: in this way,
bringing the daily intake down to.0-3 mg.
Steps were then taken to check this loss
of vitamin. Cases of peripheral neuritis -
ascribed to beriberi were admitted to
hospital within a month of the start of this imbalanced
diet. All the early cases were in men who had a recent
history of addiction to alcohol, but the neuritis appeared
in men with no such history within six weeks. -
At this time, as mentioned above, a dysentery epidemic
was in progress, and some of the patients severely. ill
D
Q
$
=
N
©
ov
with this disease developed the superior hzmorrhagic
encephalopathy of Wernicke. Treatment and Prophy lamig
with vitamin B, were eminently satisfactory. .
The outbreak of beriberi neuritis was: ended in
November, 1942, by improvement in the diet, and from
then until May, 1944, there was a relative freedom from
the disease. In the early part of 1944 the vitamin B,/
non-fat-calorie ratio began to drop and a: further ‘out-
break of beriberi was anticipated. In due course it
appeared (fig. 1), and it persisted until the camp ended.
This outbreak may be divided into two periods:
(1) from May, 1944, to March, 1945, and (2) from March,
1945, until the end. During the first period edema was
by far the most common manifestation and in a propor-
tion of cases was not accompanied by any of the other
recognised signs of beriberi. ‘The clinician, however,
was satisfied that this was beriberi, and the results of
treatment with the pure vitamin supported his view
(Cruickshank 1946). The dietary picture also indicates
that this was the diagnosis. In fig. 1 it will be seen that
at the end of the first period the calorie intake was about
2600 and the protein about 60 g. per day. Apart from
the chronic dysenterics, no emaciated men were seen
at this time, and a representative group of men showed
an average loss of only 14 lb. on their weight before
becoming prisoners. These men lost a further 15 Ib. in
the last six months but they still could not have been
grossly emaciated at the end of the third year. Again,
the man who got the “ beriberi °” was not the emaciated
chronic dysenteric but the man employed on the heavier
work who would seem relatively fit one day and be grossly
odematous the next. It can be presumed therefore ~
that during this period the symptoms were a manifesta-
tion of vitamin-B, deficiency.
In the second period—March, 1945, to August, 1945—
a new type of case appeared. The clinician recognised a
different clinical picture, occurring in the emaciated man
oN
“THE LANCET}
DR. BURGESS: DEFICIENCY DISEASES IN PRISONERS-OF-WAR
[sEPT. 21,
1946 413
and resistant to treatment with vitamin B,. As can be
seen from fig. 1 there was a considerable drop in the
calorie and protein intakes. During the last six months
the calorie intake remained around the 2000 level and
the protein around 40 g. The vitamin B,/non-fat-calorie
ratio during this period was still at the level at which
symptoms would be expected, and cases were still
occurring which were probably beriberi.
certain that, in the later stages of the camp, two factors
were producing deficiency symptoms—an inadequate
calorie and protein intake ; and an imbalance in vitamin
B,—and that while some individual cases appeared to
be due to one or other factor, in the majority both factors
played a part in producing symptoms.
To sum up, in the first three years vitamin-B, deficiency
manifested itself in the form of cdematous, cardiac,
and neuritic beriberi and as Wernicke’s encephalopathy,
and in the last six months, while fresh cases of beriberi
continued to occur, the picture was compieated by
famine cedema.
During the last few years much gepennt work
on the minimal and optimal requirements of vitamin B,
has been done and there is considerable divergence in
the estimates of these requirements. During the term of
imprisonment, the diet was so deficient in vitamin B,
that symptoms appeared; it then so improved that
fresh ‘cases practically ceased to arise ; ; and lastly it
again deteriorated and fresh cases appeared. This
experience might indicate which of the levels for minimal
intakes found by different workers in induced deficiency
are correct. But two criticisms might be levelled at this
evidence. The first is
that the vitamin B, is
estimated from food
tables and cannot be as
accurately known as in
‘an experimental study.
This error, however, is
not likely to be so great
that one cannot give a
sufficiently accurate
figure for the intake
which produced disease.
The second criterion is
no biochemical investiga-
tions have been possible
and the more crude |
criterion of clinical obser-
vation has had to be
used. On the other hand,
the number of experi-
mental subjects in this
study has averaged
12,000 over the three and ` 0
FRESH CASES PER 1000 POPULATION PER WEEK
a half years, and since 3
there is a wide individual es
variation in the utilisa- S &
tion of vitamin B, this _ 84
large number is probably Q
a considerable advantage 3 2
in deciding the minimal zÜ
intake. Although dysen- 2
tery was extremely com-
mon it was usually not
of-a severe type, and in
only 14% of cases in the
first outbreak were recent
attacks of this disease
associated. with beriberi.
In the later outbreak
malaria was common and
possibly precipitated
beriberi in some patients.
Again, the emotional
RIBOFLAVINE
(mg per 1000 CALS) MICOTINIC ACIO -
00000
O -NUA
It seemed.
state of the troops at the beginning might by raising their
metabolic rate have increased their need for vitamin B,.
All these factors may have affected the findings, but it
nevertheless seems profitable to draw conclusions as to
the level of vitamin-B, intake at which symptoms appear.
The vitamin B, content of the diet has been estimated
from two food-value tables—those of Williams and Spies
(1938) and of Platt (1945). The values given by Platt
for the different foodstuffs in question are on. the whole -
somewhat higher than those suggested by Williams and
Spies. In their figures Williams and Spies allowed for
loss in preparation and cooking, but after the. first
few. weeks the loss in the camp, if judged by present-day
views on the destructibility of vitamin B,, must have
been negligible, so estimations based on these data
probably give a low assessment of the vitamin B, in the
diet. Table m shows the vitamin-B, intake as estimated
from both tables.*
If the incidence of berber is related to the vitamin-B,
intake as estimated from the higher value tables, it will
be seen that the disease appeared in about six weeks
* In table i it will be Ags phat the total vitamin-B intake peoctee
1-6 and 1-3 mg. in October and November, 1944. his high
level was due to soya bean in the diet. Soya E unless
processed, are singularly indigestible, and in a prisoner-of-war
camp where was the only method of preparation they
apparently passed through the bowel unaltered. It seems
reasonable to assume that little of the vitamin B, was absorbed
and that these figures for the B, intake for two months were
too high. Again, in the last seven months the vitamin B,/non-
fat-calorie ratio estimated by the pener values will be seen to
be relatively high. ‘This is due to the high levels attributed
to green leaf vegetables, and clinical e rr Sea leads one to
belicve that these figures were again too
RETROBULBAR NEURITIS
=- :— KERATITIS |
sroveesees ~ PELLAGROID SKIN RASH:
SCROTAL DERMATITIS
ACHING FEET
ANGULAR STOMATITIS
& GLOSSITIS
$194.2. ——_—*+_ ___—_ 1943. ——_ + ___—__ 19444. —____-+»___ 1945 —_
Fig. 2—Weekly incidence of various deficiency “conditions compared with nicotinic acid and riboflavine
contents of diet.
414 THE since
on a daily intake of 0-2 mg. per 1000 non-fat calories:
(N.F.C.) or a total intake of 0-39 mg., and that fresh cases
ceased to occur when the daily intake rose to 0-5 mg.
per 1000 n.F.c. or a total of 1-2 mg.; a further outbreak
started when the daily intake fell to 0-36 mg. per 1000
N.F.C. or a total of 0-9 mg. If the levels are estimated
from the lower figures, the disease appeared in six weeks
on a daily intake of 0-18 mg. per 1000 N.F.c.; fresh .
- cases ceased to arise when the intake reached 0-47 mg.
per 1000 N.F.c.; a further outbreak occurred when the
intake dropped to 0-26 mg. ; and fresh cases kept appearing
as long as the intake was below 0-3 mg. and even when
it reached the higher level of 0-33 mg. per 1000 N.F.c.
In deciding whether a diet is beriberi-producing, a
vitamin-B, intake of 0-3 mg. per 1000 N.F.c. should be
regarded as an absolute minimum and if the higher values
of the more recent food tables are used 0-4 mg. is probably
the minimum. This experience suggests that the 0-37 mg.
per 1000 n.F.c. found to. be adequate for normal carbo-
hydrate metabolism in experimental conditions by
Keys and colleagues (1943) is inadequate to prevent
cases of disease appearing in a large group. There was
@ great individual variation in susceptibility to beriberi
which might be accounted for by variations in the
requirement of vitamin B, for carbohydrate metabolism
or possibly by varymg degrees of biosynthesis (Najjar
and Holt 1943). Whatever the reason, this experience
supports the views of Williams and colleagues (1943a),
who, on the evidence of induced deficiency, concluded
that the much more liberal allowance of 0-66 mg. per
1000 N.F.c. is a minimum intake to maintain normal
carbohydrate metabolism. |
DISEASE DUE TO DEFICIENCY OF VITAMIN B,
The tollowing disease conditions appeared in the camp: -
angular stomatitis, glossitis, palatal erythema, scrotal
dermatitis, pellagroid skin rash, aching feet, spastic
paraplegia, keratitis, retrobulbar neuritis, and nerve
deafness. The incidence of fresh cases of: six of these
conditions per 1000 susceptible population per week
is shown in fig. 2. The incidence of spastic paraplegia
and nerve deafness is not shown in graph form. Since
only about 40 cases of spastic paraplegia occurred in
the camp, all within the first eighteen “months, the
incidence per 1000 population was so low that it cannot
readily be shown in a graph. They occurred at a time
' when the incidence of other conditions, such as sore feet,
was as its highest. The incidence of nerve deafness was
high, but it was often not noticed by the sufferer until
his friends drew attention to it, so a record of the fresh
cases would not give a true picture of the outbreak. ,
It can be seen from fig. 2 that there were two periods
of fairly high incidence of these diseases, and during
the remainder of the time there was a relative freedom
from them. There were also two outbreaks of beriberi,
but the first was small and of short duration and occurred
early. The first outbreak of the diseases now under
discussion was large, extended over a long period, and
appeared later. The second outbreak of beriberi was
protracted and larger, while the later outbreak of the
other disease ‘conditions was of short duration and—for
some of them—of much smaller dimensions. It is clear
that there is little similarity between the trend of incidence
of beriberi and any of these other disease conditions.
The clinical picture of the commoner conditions answers
in the main to the descriptions given elsewhere. The
keratitis was the disease described by Métivier (1941)
as ‘“‘ corneal epithelial dystrophy.” |
Time Distribution.—There are some points of interest
in the relative times of appearance and of highest inci-
dence of these conditions. The first evidence of disease
appeared early in May, 1942—about two and a half
months after the capitulation and one and a half months
after the first cases of beriberi appeared. The glossitis
a
DR. BURGESS: DEFICIENCY DISEASES IN. PRISONERS-OF-WAR
po
r
[serr. 21, 1946
and angular stomatitis and scrotal dermatitis were
the first to appear ; next came aching feet at the end of
July, 1942, nearly three months later—iie., five and a half
months after the capitulation. Keratitis and retrobulbar
neuritis. appeared at. the middle and end of August
respectively. It will be seen that there is a tendency to
follow this trend throughout. In October and November,
1942, the incidence of mouth conditions and scrotal
. dermatitis showed a sharp decline ; the decline of aching
feet was slower. and less definite, and there was little
evidence of any change in the slowly rising incidence of
retrobulbar neuritis. In the subsequent increase in
January and February, 1943, this order. was again
followed, though not so definitely. At this time there
was a rapid increase in mouth conditions and a less
rapid increase in scrotal dermatitis. © Aching feet. and
keratitis showed a slowly increasing incidence but it
did not reach any height. In 1944 scrotal dermatitis
and mouth conditions again showed a.rapidly rising
incidence, starting at the end of May and beginning of
June, while keratitis began to increase in Angust.
Aching feet were not much in evidence.at this time, and,
though there.was a rise in the incidence of retrobulbar
neuritis, it began earlier and did not reach a high level.
There is then some evidence of a relationship between
all. these conditions as regards the beginning and end
of outbreaks and they appear to fall into three groups f :
1. Mouth condition and scrotal dermatitis.
2. Keratitis and aching feet.
3. Retrobulbar neuritis. -
There are, however, some features which do not fit into
this picture—the persistence of a high incidence of
scrotal dermatitis in March and April, 1943 ; the slowly
rising incidence of retrobulbar neuritis before other
disease conditions had appeared in 1944; and the
absence of.a clear-cut outbreak of aching feet at that.
time.
The high incidence of scrotal dermatitis might perhaps
be accounted for by the fact that when a deficiency state
exists the devitalised tissue is particularly susceptible
to the action of any irritant or to invasion by bacteria,
and in this case a particularly irritant soap or lack of
facilities for washing may have been responsible. No
explanation for these other phenomena springs to the
mind. ) PD
The other disease condition shown on the chart—
pellagroid skin rash—appeared twice during outbreaks
`of the diseases just discussed, but the largest outbreak
began in the early months of 1945 when these other.
deficiency conditions were almost absent.
Relation to Nicotinic-acid and Riboflavine Intake.—
Fig. 2 ¢ shows that all these conditions, except pellagroid
skin rash, were common when the riboflavine level was
low and outbreaks came to an end when it reached the
higher levels. On the other hand, only the pellagroid
skin rash bore any relationship to the estimated nicotinic-
acid content of the diet, its appearance coinciding with
a low intake of nicotinic acid, though it did not con-
sistently appear when the intake was low. This rash
was a mild one, appearing almost entirely in men working
in the sun, so it seems that frank clinical evidence of
disease only manifested itself under certain climatic
conditions with this degree of nicotinic-acid deficiency.
t Woodruff, M. (unpublished data), after correlating information
concerning associated conditions, concluded that deficiency
disease in the Changi Camp could be divided into two groups:
(1) a beriberi (B-deficiency) group, and (2) the remainder, the
B.-complex-deficiency group. He pointed out that 49% of the
cases of peripheral neuritis showed other evidence of beriberi,
while in only 5% of the disease conditions in group 2 was there
an association with beriberi. Of over 1000 cases of retrobulbar |`
neuritis, 35% had keratitis, 20 % aching feet, and 28 % stoma-
titis and glossitis, while only 1% had beriberi. Of nearly 700
cases of aching feet, 31 % had retrobulbar neuritis, 29% kera-
. titis, and 24% scrotal dermatitis, while 7% had an associated
beriberi.
t The scale in this figure is based on the relative requirements as
laid down by the National Research Council of America, 1942
ee D n a
a a tS
THE LANCET] DR. BURGESS: DEFICIENCY DISEASES IN PRISONERS-OF-WAR
[serr. 21, 1946 415
TABLE I-—DAILY ISSUE OF FOODSTUFFS
1943.
Foodstuff
March | April | May Sept. Oct. Nov. Dec. Jan. | Feb.
Rice (highly milled) .. pee 427 435 469 487 474 483 483 508 500
Flour (white) .. ae > ae 54 63 48 46 a zs sA 6 ps
hite) .. oe A ss 17 20 20 26 19 20 20 20 20
Biscuits (wholemeal) .. : Es 9 we 5> is b à a ie es
(whole ee . > ee ee 6 26 ee e«@ . o e. s o . o
Ground-nut meal ee ee . o 2 8 ee ee ee ia ee ee
Ground-nut ae ee ee ee ee 5 ee. ee ee 5 3 2
Beans ( ) e. o ee e * é 14 6 6 ee ee e.a ee ee . °.
Maizemeal oe ee ee oe ee 19 ee a@ ee ee ee
Potatoes (canned) ‘eck ie ee 3 si za A 7 es T b
kin and cucumber a S5 is ; 23 43 44 79 94 104 95.
Sweet potatoes .. ae ba a 3S ai a 68 109 61 124 | 160 161
Green leaf eck os ; A 2 at ; 25 11 4 4 28 18
Egg lant ee ee e e°@ ee e@° . Ă- 18 e o 18 ee ee ee
and radish ate é a si ss < es 15 9 kis a
Jam and fruit (canned) ` i i 7 4 3 sk 63 ie oe šis so
Meat and veg. and Irish stew. ` 7 26 17 1 a 4 ele Sae èk eas
Meat `.. ee ee . oe 26 23 39 45 37 35 26 . ee
Fish 10 ae oe oe es 7 17 44 4t
Cheese, butter and margarine (canned) 9 Da a PN a 17 one
Ghi aa oe ee 3 6 8 9 6 10 a 7 8
Evaporated milk ne ; : 26 26 4 : í ix N za i sie eve
Rice polishings .. ass ae ‘ ne ze ze ii ; 6 22 28 23 oan 14
tebait ae we ; 3 ; A 4 12 13 12 | ead ee |
Red palm oil .. ae i ! ve : oe 11 10 T 15 11
Coconut oil ae ss . ʻa ` Se a s 4 10 "13.
Atta fiour Moe it ene a eng 11 e E PA se
Kaffir corn meal (sorghum) s os ne š a dil a Zs cé ee os
Dried soup powder sis va es ee ote 11 ae cg ae aa ca as
Vitaminised caramel .. a oe | l a r 4 Pe es or a oe s
Soya bean F ee oe ee ee | | ee & ee ve 1 14 12
A 1943 1944
Foodstuff se ieee ete -
March | April May/June [July Aug. | Sept.! Oct.! Nov. Dec. Jan. Feb. March April May June |July| Aug. | Sept.
Rice.. - š š 440 440 |440| 440 |440| 440 | 444 |440; 487 | 350] 3301310] 316 | 270 |415) 500 |500| 495 | 460
Soya beans. ee . oe ee ee ea ee oe e ee oe 170 150 129 96 oe ee ee ee ee ee l
Ma e ee . > ee ee a oe se oe , ee ee e688 62 131 45 ee ee oe ee
Sugar si oy a4 20 17 20 19 9| 22 20 20) 20 20} 20] 23 18 18 20 18 | 17 20 20
Coconut oil.. ns oar 17 16 21 18 20 30 25 25 25 25; 23] 21 25 25 25 25 25 25 25
Fresh fish .. sé sà 30 43 62| 47 53} 84 73 30 56 77| SOT] .. ee wat 18 9 10] ... 11
Dried fish oe f ve "ae ee ee ee e'e ee ee ae 22 ee eo. ee 19 17. oe ee 44 45 39 . 32
Fresh meat.. =... te So i k S ik gad bea a efi ia s3 9| 44 53 71 | 56| 13)... nor ne
Pork is ss ee ee i Ss 2 ds os ae 4 4 4| 4 ae ae 2 a sP ža
Green leaf vegetable eee 6 5 6j .. ae sà es 90) 9o 89] 70| 42 36 64 50] 55 6017 72 | 180
Mask melons, pumpkins, &c. 38 4 80 95 44) 128 | 143 |170| 100 | 226] 1001186 40 oe ee here is su ee
Sweet potatoes, a a 198 199 70 | 114 851 200 | 200 (170; 200 | 200] 2001 200] 120 150 1125] 325 | 320] 260 | 165
Bananas... ee mn as fg nS ais E we en io ea sce 93 10 95 90 70 32 21
Coconut sn ee . AN ee ae as a = ate ia Su ae 5i = 3 20 7 5f.. | 16 ee A
Green gram a bag A S i Pat ie é 4 oe hs es oe re ae T a LR we 5-
Pineapple .. 67 5|.. bis als
Camp Messing ee
Rice polishings Di X 23 28 28| 28 | 28] 16 16 8 Be EST E E EE ia . ia z
Ground-nuts ey P 12 13 28! 28 j.. 18 28 14] .. 2] 30] 14 5 : vi eee | o
Green gram Je 13 40 45| 57 90 85 85 85] 85 85| 25] 85 76 15 31 4 11 12.
Soya bean ... sa 4 | 11 Olas ee a on : oe aes ‘ wig : cs 8 7 sa
Dried horse mackerel 18 17 14| .. a Es a 3 9 Dies Ks a Patan aero sa Se
Whitebait . ane ‘ 28! 57 47 28 28 14; 18 23 1 2 Pa Ds Si a oy a 22 4
Red. palm oil con 14 31l.. as a Ss 3 17 9 3 8 14 13] 16 20 22 10
Sweet potatoes : 78) 165 |145| 114 85 a is : au Ea sè Eâ ma a `
5 | !
1944 1945 . 1945
Foodstuff Feb. March Foodstuff April Foodstuff
Oct. | Nov. | Dec. | Jan. | ——_——- prs: i May | June! July
a 1-9 |10-28] 1-9 |10-21/21-31 ‘ | 1—22 123-30 Sa ea
Maize x ia ‘ty 5 a se Sa E 50 Rice .. | 220 | 250 | 300 | 277 | 277
Rice .. : 460 | 460 | 464 | 460 | 459 | 495 | 450 | 270 | 220 Maize .. 50 50 a 23 23
Sugar F ' 20 19 20 20 18 18 18 18 18 Sugar `.. 18 18 18 20 20
fl . j 25| 25 25 | 25 25 20 | 20 20 20 Oil ee 20 20 20 20 20 Oi
Soya bean . 59 48 Sa T <a eA ‘a za eh Fresh fish 10 10 7 6 n Fresh fish —
Fresh fish 9 ee oa 10 se 13 6 6 Dried fish 24 24 35 26 13 Dried fish
Dried fish 38 34 29 25 34 15 22 22 22 Vegetable
Vegetable (root) .. | 172 | 172 | 183 66 | 122
(root) .. | 136 | 112 | 163 | 195 | 208 60 24 | 178 | 178 Greens 87 | 187 | 297 | 256 | 298
Greens . 283 | 212 | 300 | 284 | 297 | 150 | 140 | 164 | 164 Fruit as ae ws 22 7 is
Fruit a 44 14 | 26 23 26 13 gs 7 Yoa -
7 . C.M. Fund
C.M. Fund | Oil dee 33 33 33 33 33
Green gram.. 10 1 15 15 15 13 12 12 12 Millet 12) .. eee ibs E
Palm oil es 5 10 | 13 18 18 18 18 18 33 Tap chips sa 12 12 12 10
Diets in April, May, and June, 1945, were supplemented with food
from Red Cross parcels. The amounts were very small—about
40 g. per man per day. of chocolate, jam, bully beef, &c. owing to lack of space.
C.M. Fund =Camp Messing Fund
_ Details of -the light-duty and no- -duty. scales introdaced in
February and April, 1945, Too pECY VELI: have been omitted
446 THE LANCET]
Since some of these conditions are probably manifes-
- tations of riboflavine deficiency the estimated levels of
intake at which symptoms appeared are worthy: of note.
On an estimated level of 0-21-0-25 mg. per 1000 calories,
symptoms appeared in two and a half months in 1942 ;
in 1944, on an intake of 0-33-0-28 mg. per. 1000 total
calories, this appeared in about the same time. It is not.
clear, on the hasis of our estimated levels, why the number
of cases should have fallen in October, November, and
December, 1942. The improvement was due to Red
TABLE II—RED CROSS SUPPLEMENTS ocr, 9 TO NOV. 30, AND
DEC. l To 27, 1942 `
\
Average Average
l daily diet (g.) daily diet (g.)
Foodstuff f oar el eas 3 Foodstuff er eee |
Cc e oa: Cc ry 9-
Nov eS: Noy, | De
30 1-27 30 | 1-27
eee cian tg l
Atta flour oo | 17 -. | Dried fruit... 2 ie
Dhall ki Sa 8 8 Cocoa T 8 i 8
Milk (canned) As 21 9 Barley l io..
M. & “ 39 39 | Cornfiour 2 |
Corned peet ee 71 32 Biscuits 9 ,
Ghee -. m 8 s Vitaminised i
Soupimix , ues 3 3 caramels Pii
Mabela .. 10 10 Jam 2
Vegetables and Sugar (white) . 17:
Lim ime juice... 2 |
tomatoes (uned) 23 23
Guava (canned) . 9 9
7
Cross supplies coming into camp. For purposes of
estimation, the diet during the period under discussion
was assumed to be in accordance with the advice given
on how the extra food should be consumed ; but, since it
was distributed to units and in some cases to individuals,
the extra food may in fact have been consumed more
rapidly with a resultant higher intake over a shorter period.
In fig. 2 it will be seen that a fresh outbreak of keratitis
occurred in October, November, and December, 1943,
at a time when the riboflavine values of the diet were
higher than they had been, and there is evidence of a
similar rise in the other conditions. In August the
Japanese began making a big aerodrome near the camp
and labour was drawn from the camp. Labouring in the
-heat of the day and in the full glare of the sun may have .
played some part in producing this increase.
In general the estimated intake of riboflavine corre-
sponds fairly closely with the incidence of disease, so
it seems worth while to compare the level at which
disease occurred with similar levels found by workers in
induced deficiency. Sebrell and colleagues (1941) pro-
duced deficiency disease which appeared between the
89th and 232nd days on a riboflavine intake of 0-21 mg.
per 1000 total calories. This is in line with experience
_in the camp where disease developed in 80 days on an
intake of 0:21—0-25 mg. per 1000 calories. Williams and
colleagues (1943b) found no deficiency disease on an intake
of 0-35 mg. per 1000 calories. In the camp disease per-
sisted on this level although it had begun on a lower
intake and on two occasions the outbreak of disease did
not end until the level reached 0-5 mg. per 1000 calories.
This would support the suggestion of Williams and
colleagues that 0-5 mg. per 1000 calories is an adequate
intake.
There were further experiences which have some
bearing on this point: In 1943 a party of 7000 men went
up country and 25% of them had vitamin-B, deficiency
in one or more of the forms which have just been discussed.
They went up to conditions of starvation, disease, and
appalling hardship, and at the end of nine months when
44% had already died they were returned to the Singapore
camp. Within a week or two of leaving the relative
comfort of the camp the minor manifestations of vita-
min-B,-deficiency disease disappeared and did not recur
as long as the conditions of hardship lasted. Little or
no retrogression in cases of retrobulbar neuritis could be
found on their return. The calorie intake during this
DR. BURGESS: DEFICIENCY DISEASES IN PRISONERS-OF-WAR
(SEPT. 21, 1946
expedition was at times as. low as 1200 per day and
although it was at other times above the 2000 level
rapid loss of weight occurred.
itself was the direct cause of a numberof deaths. The
diets consisted of rice and very little else, and the ribo-
flavine intake for long periods was about 0-2 mg. per
1000 calories ; for about a month in one camp it was as
low as 0-15 mg. per 1000 calories.
When a man is consuming his own tissues his needs _
for riboflavine may be less, and this idea led me to
investigate the relative incidence in different groups of —
men in “Changi Camp. In the kitchens and food stores the
men were better fed; hun men cannot be expected
to handle food all day without taking a certain amount
ofit. On the other hand the men working on thè Japanese
- aerodrome got only their bare rations and were called. on
for a greater. energy output. In the better fed group the
incidence of scrotal dermatitis during an outbreak was
34% and in the worse fed group it was only 18%. There
were several hundred men in each sample and unfortu-
: nately weights were not taken, but had they been there
is little doubt that there would have been a clear-cut
difference. The impression gained was that riboflavine
deficiency was essentially the disease of the man who was
maintaining or gaining weight. The pellagroid skin rash
on the other hand occurred essentially in emaciated men.
‘In some 60 men treated for skin rash in hospital the
average weight was 102 lb., while a group of fit men at —
the same period had an average weight of 125 Ib.
_ PREVENTION OF DEFICIENCY DISEASE
In the prevention of deficiency disease beriberi was
always regarded as being of primary importance, for it
is a killing disease. The vitamin-B,-deficiency diseases,
though they seemed likely to be responsible for a con- -
siderable amount of permanent incapacity, were unim-
portant as a cause of death. Steps taken to prevent
beriberi built up the diet to a greater or less extent in
components of the vitamin-B, complex and some
measures taken had both purposes in mind. It seems
advisable, however, to deal with each separately.
Beriberi.—The occurrence of beriberi was foreseen
some time before it actually appeared, and attempts
were made immediately to minimise the danger. The
best means of doing this was of coursé to enrich the diet,
and in March, 1942, the G.O.C. Prisoner-of-war Camp,
Changi, wrote to the H.Q. Imperial Japanese Army
pointing out that the diet was grossly deficient in certain
vitamins and asking for additional foodstuffs which were
known to be in Singapore in considerable quantity.
The Japanese did nothing, although the case was
presented again and again in the early months. _
-A measure which was adopted early and to which
considerable attention has been paid throughout was
the preparation and cooking of food so that none of its _
vitamin content was lost. This is particularly important
in the case of the rice. The ordinary highly milled rice
has about 0-5 ug. vitamin B, per g. in the pericarp dust
and fine layers of pericarp that may remain after milling.
- It is however readily soluble in water, and if it is washed
and the water discarded about half of it is lost, while
if it is boiled in excess of water which is afterwards
discarded there is a further loss. Seeing that at times the
total daily intake of vitamin B, was not more than 0-4 mg.,
and that 0-2 mg. came from rice, the importance of this
measure can be appreciated.
A measure which is widely advocated for preventing
beriberi is the growing of yeast, but unfortunately unless
yeast is grown on a medium rich in the vitamin-B
complex it has little capacity to synthesise this vitamin.
In fact recent work (Malm 1945) suggests that it does not
synthesise it at all but simply captures it from the
medium in which it is grown. Yeast was grown in the
The Japanese were
merciless in their demands for output of work, and this |
THE LANCET]
DR. BURGESS: DEFICLENCY DISEASES IN PRISONERS-OF-WAR
[sepr. 21, 1946 417
-early days of the camp but it proved of little value
in clinical use and was abandoned as a means of
prophylaxis.
For about eighteen months in the existence of the camp
—i.e., from November, 1942, until May, 1944—by pooling
money coming into the camp and by purchasing and
issuing foodstuffs rich in vitamin B, on a fixed scale
the diet was maintained above the beriberi level. In
table r under the heading *“‘ camp ” the details of food
purchased can be seen. In the last year the money for
purchasing foodstufis was less and the prices were
fantastically high, so little could be done to supplement
the imbalanced and latterly inadequate diet. When the
Japanese learnt of their country’s capitulation they
offered as much rice as was wanted. The consumption
of large quantities of rice at this time would have led to
very grave imbalance, resulting in severe beriberi. A
strong stand was taken in this matter, and after some
protest it was agreed to restrict the daily issues of rice
to a level which would not cause a serious imbalance.
Fortunately this period was short, and with the arrival
of relieving troops the prisoners-of-war went back to
a European diet.
Vitamin-B,-deficiency Disease—The minor manifesta-
tions in the syndrome referred to as vitamin-B,-deficiency
disease in this paper were believed to be due to a ribo-
flavine deficiency.’ There was a significant association
between disease conditions in this group, and no such
association could be found between them and beriberi.
In addition, the commencement, course, and cessation of
outbreaks led us to think that, excepting pellagroid skin
disease, they probably had a common etiological factor.
The policy in prevention was based on raising the
riboflavine value to the highest possible level. Some.
tables of riboflavine values were available in the camp,
but they were old and judged by the more recent tables
highly inaccurate. They did indicate however that, of.
the limited foods available, fresh green leaves and légumes
were the only ones which could be obtained in sufficient
quantity to be of value. This was the reason for the
main items in the supplementary foodstuffs purchased.§
§ The other foodstuffs were introduced for the following purposes:
(a) The rice polishings were to ensure the absence of beriberi
and also to raise the nicotinic-acid level. (b) The palm oil was
to increase the calorie intake and make the food more palatable.
(c) The dried fish, preferably sprats, was to maintain at a
reasonable helene the calcium and protein intake.
` TABLE III —ESTIMATED FOOD VALUE OF FOODSTUFFS
2 1942
m
1943
Á Orr oo
March | April | May | June | July | Aug. | Sept. | Oct. 1-9 |Oct. 9-31; Nov. | Dec. | Jan. | Feb. | March) April
tein, oer i 41 40) 45 50 47 43 48 50° 83 85 67 41 43 48 59
Non-fat cals. .. Š 1874 | 1911 2058| 2017| 2120| 2271| 2251 2075 2480 2452| 2259] 2173| 2181] 2062] 2243
Total cals ae ... | 2060 | 2060 | 2263] 2222] 2315) 2466] 2548 2260 2899 2973| 2659| 2340; 2330] 2313] 2568
Vitamin B,, ug. 390 405 593 732 551 488 ve 953 1191 1246; 1159 715 923| 1140| 1410
Riboflavine, ug. ° 498 434 470 566 517 484 555 559 905 890 824 557 570 586 699
Nicotinic acid, ug. 6809 | 7001 [11,097 |14,299 10,997 | 8489}11,194) 15,366 | 19,180 |20,782 |18,588 |11,142 |13,892 |17,118 |19,601
B, (mg.) per 1000 non-
fat cals. ie 0-21 | 0-21 0:29} 0°33} 026| 0-21] 0-30 0-46 0°48 0°51/ 0:51] 0°33) 0°42] 0°55! 0-63
Riboflavine (mg) per f
1000 total ca 0-24 | 0-21 0-21] 025| 0-22) 0:20! 0-22 0-25 0°31 0-30) O31} 0-24] 0-24} 0-25! 0-27
Nicotinic ia ' (mg.)
whens 1000 total cals.. 3°31 | 3-40 4°90| 6-44] 4°75] 3-44] 4-39 6-80 6-62 6:99! 6-99) 4-761 596| 7-40] 7-63
tliams and Spies : l ;
Vitamin B,.. a 316 341 526 587 424 393 559 842 1075 1161| 1053| 474 766| 1019| 1234
B, : non-fat cals. .. 0°17 | 0-18 0-26). 0:29} 0-20] 0-17| 0-25 0-40 0°43 0°47] 0°47) 0-22] 0-35] 0°49] 0°55 -
1943 1944
l
May | June | July | Aug. | Sept. | Oct. | Nov. | Dec. | Jan. | Feb. |March} April | May | June | July /Aug.
tein, g. 87 106 98 86 | 88 85 84 137 95 109 96 47 49 65 63| 56
Non-fat cals 2300 | 2612] 2632] 2583| 2472| 2419| 2579| 2542; 2099| 2239] 2259] 1788| 2161 2546 2485 |2366
Total cals. : 2867| 3049| 2911| 3057| 2854| 2800] 2942) 3295) 2834| 2862| 2891| 2411| 2691) 3039| 2928 |2943
Vitamin B,, ug. 1651| 1812] 1701| 1561] 1784] 1352| 1262] 3039) 2685| 2577] 2201] 1000 924 919} 887] 818
Riboflavine, ug.. ded 872| 1014| 1026| 1022| 1034] 1111] 1104] 1653] 1226; 1380| 1243 789 809 862 832| 773
Nicotinic acid, ug. .. |24,377 |25,990 |21,177 [21,189 |24,941 |16,892 15,012 |16,771 |17,346 |16,625 |14,259 (10,284 |10,818 11,477 |10,778 |9737
By ( (mg... Jl per 1000 non- ;
0-72) 0-69) 0-65] 0-60] 0°72} 0-56] 0:49! 1-20] 1°28] 1:15] 0:97} 0°56) 0-43] 0°36] 0-36)0-35
Rinaorine (mg.) per
1000 total ca 0:30; 0-33] 0°35] 0°33] 0-36) 0-40] 0°38} 0-50| 0:43! 0-48] 0-43] 0-33] 0-30! 028| 0:28|026
Nicotinic aaa ` (mg.)
per 100 talcals... 8-50} 852] 7-27) 693) 874| 603] 510| 509| 612) 5-81} 4-93) 4:27) 4:02] 3°78] 3-68/3-31
Wiliams and Spies: : aN a .
Vitamin B,. ee 1441} 1568} 1390| 1610) 1433] 1529| 1418] 1724| 1220| 1289) 1155 715 704 650 630 | 662
B,: non-fat ‘cals. .. 0-63} 0-601 0°53] 062] 0-58] 063| 0°55] 068] 0-58{ 0°58] 0°51 | 0°40} 0-33] 026| 0:25/0-28
| 1944 1945
— | | Feb. March April Aug
| Sept. | Oct. | Nov. | Dec. | Jan. l May | June | July | 1-15
1-9 |10-28| 1-9 | 10-21] 22-31] 1-22 | 23-30
Protein, g. `.. zi 54 80 79 62 62 69 49 48 42 43 50 51 63 50 40 55
Non-fat cals. .. .. | 2112 | 2259| 2144 | 2161) 2181| 2222| 2046 | 1824 | 1406 | 1390 | 1476 | 1587 | 1706 | 1456 |1435] 1480
Total cals 2493 2696 | 2600 2579| 2637| 2696] 2436 | 2205 | 1797 | 1799 | 2108 | 2219 | 2320 | 2051 | 1984| 2057
Vitamin B,, ve. or 823 | 1592| 1273 990 997| 1015| 645 554 636 711 818 802 861 | “728 | 619| 877-
Riboflavine, ug. oa 963 | 1398| 1092 | 1237] 1212| 1245) 744 671 734 774 878 887 | 1172 968 | 1026! 1126
Nicotinic acid, z. 9583 |11,664| 9834 |10,140 |10,289 |10,537 | 7999 | 7218 | 6700 | 6950 | 7704 | 7980 | 9266 | 7466 | 7220! 8375
B, (mg.) per 1000 ‘non-
LAE eal cals. 0-39 0:70 | 0°59 0:46; 0°46) 0-46] 0:32 | 0-30 | 0-45 | 0-55 | 0°55 | 0-51 | 0-50 | 0-50 | 0-43] 0:59
Riboflavine (mg.) per :
1000 total cals. . 0-39 0-52] 0-42 0-48' 0:46] 0-46] 0°31 | 0:30 | 0-44 | 0-43 | 0-42 | 0-40 | 0-51 | 0-47 | 0°52] 0°55
Nicotinic acid (mg. ) l l .
per 1000 total cals.. 3-84 4:33| 3°78 3°93| 3-90) 3°91| 3-28 | 3:27 | 3:73 | 3°86 | 3-65 | 3-60 | 3-99 | 3-64 | 3-64] 4-07
-Willtams and Spies: ;
Vitamin B ze 547 743| 602 595 590 |> 607; 421 360 490 490 523 514 494 412 | 442| 486
Bi: non-fat cals. .. 0°26 0:33] 0-28 0-28 0:27 0-27] O21 | 0:20.) 0-35 0:35 | 0°35 | 0°32 0-29 0-28 0°33
0-31
418 THE LANCET]
The amounts arrived at were as follows:
Rice peneninge ws 30 g.
Palm oil 30 c.cm. :
Green gram (Phaseolus radiatus) (100 g.
Ground-nut de i A
- Soya bean eek
Sprats or dried fish 50 g.
The camp food tables indicated that the green gram,
Phaseolus radiatus, had an unusually high riboflavine
content while that of soya bean was low. The more
‘recent tables show the reverse, but in view of our
information the green gram was always purchased in
preference to the other légumes. It will be seen from
‘fig. 2 that the riboflavine level of the diet did not reach
any great height until December, 1943, and from table I
it will be clear that the cessation of the outbreak of
vitamin-B,-deficiency disease was probably due to the
introduction by the Japanese of 170 g. of soya bean in
place of an equal amount of rice. 3
The importance of green leaf vegetables in the diet
was appreciated by the British administration in the
camp, but, for the first two years, the Japanese were
either indifferent or could not be made to understand
that much sickness could ‘be avoided if they would allow
. the proper cultivation of vegetable gardéns. At the end
of the second year a new Japanese commandant was
more intelligent about the matter and good vegetable
gardens were made. From September, 1944, until the
end of the camp these gardens were probably responsible
for our freedom from these diseases. In fig. 2 it will be
seen that the riboflavine content was higher in that
period.
Since no green leaf vegetables were available at the
time of our greatest need and légumes were not obtainable
in the required quantities, at the beginning of 1943 it
seemed worth while to try to extract the vitamins from
some of the non-edible plants and grasses growing round
the camp. Fortunately power was available and the
engineers built various ingenious devices for crushing
leaves so that their cellular structure was broken down.
They were then macerated with water and the extract
was drunk. As long as fresh rapidly growing structures
were available the results obtained from this extract
were excellent, but soon the area to which the prisoners-
' of-war had access was cleared of all such plants. Coarse
tropical grasses were then used and little benefit appeared
to be derived from the extract.
SUMMARY
An outline is given of the general living conditions in
the prisoner- -of-war. camp on Singapore Island. The
Japanese ration scale and the supplements that could
be procured are described.
Estimation, week by week, of the composition of the
diet showed that the energy and protein intakes were
` not grossly inadequate except in the last six months,
but there was throughout a deficiency of one or more
of the B vitamins.
There were two outbreaks of beriberi. The first, which
occurred early, was uncomplicated but in the second the
picture was confused by famine cedema.
Comparison is made between the minimal levels of
intake of vitamin B, to prevent disturbance of meta-
bolism, as defined by workers on induced deficiency,
and the estimated. levels at which beriberi appeared
or disappeared in the camp. It is concluded that the
higher limits proposed on the basis of experimentally
produced deficiency (0-66 mg. per 1000 non-fat calories
daily) are in best agreement with experience in the camp.
The order and times of appearance of disease conditions
attributed to deficiency of one or more components of
the vitamin-B, complex are compared with those of
beriberi and with the estimated riboflavine and nicotinic-
acid contents of the diet. They appeared and dis-
DR. CATHIE: BLOOD-GROUPS IN BONE-MARROW
[sepr. 21, 1946
appeared in a definite sequence, independent of beriberi.
and with an inverse correlation with the riboflavine
intake, except pellagroid skin rash which showed some
relationship to the intake of nicotinic acid..
The requirements of riboflavine as defined by workers
in induced deficiency are compared with the estimated
levels in the camp diet. The level required to. prevent
deficiency as suggested by the camp diet is similar to
the findings of somè experimental workers, and camp
experience again supports the higher suggested minimum
levels (0-5 mg. per 1000 total calories daily), -© —>
- Of 7000 men who left the camp to work up country,
more than a third had signs of vitamin-B, deficiency in
camp, and they subsequently suffered so severely from
starvation and disease that 44% died within nine
months ; yet under these conditions the signs of vitamin-
B, deficiency, except retrobulbar neuritis, disappeared.
Further, vitamin-B,-deficiency disease in camp was
commoner in the relatively well-fed men. Pellagroid
skin rash, on the other hand, was more often found in
the emaciated.
The means used in attempting to combat deficiency |
diseases in the camp are briefly described.
I wish to thank Lieut.-Colonel Kenneth Alford, rm.s.,
and Major R. Orr, a.a.m:c., for their coöperation in the
prisoner-of-war camp, and Dr. Isabel Leitch, Rowett Research
Institute, for her help- and criticism in o preparation of this
paper;
REFERENCES
Cruickshank, E. K. (1946) Proc. Nutrit. Soc. (in the ore:
Keys, A , Henschel, A. F., Mickelsen, O., Brozek, J. M. (1943)
l J. Nutrit. 26, 399
Malm, M. By anaie ‘kem. Tidskr. 57, 42.
Métivier, V . M, (1941) Amer. J. Ophthal. 24, 1265.
Najjar, vA Hol t, L. E. jun. (1943) J. . Amer. med. Ass. 1% 683°
Platt, B gion ‘Spec. Rep. Ser. med. Res. Coun., gone. n 253
Sebrell, wW H., Butler, R. É., Wooley, J. G., Isbell, H 1941) Publ.
Hlth Rep., Wash. 56, 510.
Williams, R. D., Mason, H. L., "Wilder, R. her even a ei 25,71.
— — Cusick, P. L., Wilder, R. M. (1943b) Ibid,
Williams, R. R., Spies, T. (1336) Vitamin B, (T iamin) yond its Use
dici ine, New
in Me or
‘Woodruff, M. (1942) Report on Deficiency Wiséaacs Admitted to the
Australian General Hospital,
(unpublished).
BLOOD-GROUPS IN BONE-MARROW
I. A. B. CATHIE
M. D. Lond.
CLINICAL PATHOLOGIST, HOSPITAL FOR SICK CHILDREN,
GREAT ORMOND STREET, LONDON
Changi Prisoner-of-war Camp
“Tap fact of belonging to a definite E A is
a fixed character of every human being and can be altered
neither by the lapse of time nor by intercurrent disease ”
(Lattes 1932). This statement on the fixity of blood-
groups may be said to represent the present consensus
of opinion.
With the modern tendency to give repeated blood-
transfusions in various conditions, however, replace-
ment of the patient’s red cells with donor’s cells means
that part of the patient’s peripheral blood will evince the
characters of the donor’s cells. Should the donor’s cells
carry different hemagglutinogens from those. of the
recipient, anomalous results will be obtained when
attempting to establish the patient’s own group, and
cases are on record where all the patient’s cells had been
replaced and only the group of the donor could be
ascertained from the patient’s blood. In such a way
an apparent, though not real, change of blood-group
may be found. For example, the blood of case 11 of
Coombs et al. (1946) appears to have been entirely
replaced ; and case 4 of Wiener and Sonn (1946) was
an erythroblastotic infant whose Rh-positive cells were
entirely replaced by Rh-negative donor cells within
two days.
Hitherto, in establishing the true group of such cases,
there has been little option but to wait until the donor
cells have disappeared ; though, as the patient’s cells
start to reappear, the differential agglutination method
THE LANCET]
DR. CATHIE: BLOOD-GROUPS IN BONE-MARROW
[sepr. 21, 1946 419
of Dacie and Mollison (1943) may reveal the group while
donor cells are still present. There are times when
it is important to know the nature of a patient's cells,
when complete typing has not been carried out before the
institution of a line of treatment which has falsified the
true picture. Such a case was seen recently at this
hospital, and it was considered that investigation of the
bone-marrow red cells, which are not subject to the same
replacement by donor cells as are those of the peripheral
blood, might establish the true blood-group. As no
reference to the reliability of bone-marrow grouping could
be found in the available literature, normal children were
used as controls at the same time.
— INVESTIGATION
Marrow was obtained from twelve children who had
had no transfusions and in whom marrow puncture
was being undertaken for diagnostic purposes.
The first two marrow samples were taken from the
sternum with an ordinary Salah needle. As, however,
the yield of sternal marrow was rather- too small for the
purpose, particularly in small infants, and rendered
proper oxalating of the sample difficult, the later punc-
tures were made through the flat area of bone internal
and distal to the tibial tuberosity. Needles, used accord-
ing to the size of the patient, were those designed by
Gimson (1944) for marrow infusions.
‘Marrow was aspirated into a syringe, from which it was
immediately expelled into a small test-tube containing
double oxalate mixture (3 parts of ammonium to 2 parts
of potassium oxalate) which had been allowed to dry
and then moistened with a drop of normal saline just
before use. If the oxalate was used dry, various degrees
of agglutination jeopardised the chances of satisfactory
grouping. Only marrow discharged direct into the
oxalate was used, any adhering to the side of the tube
being carefully avoided.
Marrow suspensions so obtained were ABO- and Rh-
typed in small tubes in the ordinary way.
RESULTS
All twelve marrows showed the same ABO agglutino-
gens and agglutinins as those found in their corresponding
specimens of blood. Similarly, no difference was found
in the Rh genotypes of marrow and peripheral blood from
the same patient. The presence of nucleated red cells
and the myeloid series did not interfere with reading
the test. l
From these results it appeared that the true blood-
group and Rh genotype could be ascertained from the
marrow cells. Therefore marrow grouping was under-
taken at intervals on the patient whose peripheral
blood could not be grouped owing to repeated blood-
transfusions. The following hæmatological findings are
given in detail to illustrate how the divergent blood
and marrow pictures came into line again as the donor
cells were eliminated.
Baby X, with erythroblastosis fœtalis, was the second
child of healthy parents, whose first child was normal. Baby X
was born on Feb. 20, 1946, and became jaundiced on the
23rd. Blood-group A, ß in the serum, Rh-positive.
The mother, blood-group A, Rh- negative, had a low Rh
antibody titre at birth of the baby, and a titre of 1/64 on
March 2, 1946, and 1/256 on March 5, when some blood was
taken from her for preparing anti-Rh serum.
Between Feb. 24 and April 5 the baby received eight trans-
fusions of whole blood with group-O Rh-negative blood, the
rise in red-cell count after each transfusion being only transient.
In the meantime the mother’s blood had been processed by
Miss B. E. Dodd, who reported that it contained antibodies `
to the Rh factors C and D.
On April 5, to cross-check this finding, the baby’s blood was
now genotyped and found to be Rh-negative. Also, the
ABO group, which was put up as a routine, was O, with neither
æ nor B demonstrable in the serum.
Results were the same on April 7, except that weak B was
now present in the serum. This reversal of group with B
in the serum was also confirmed by Miss Dodd on April 8,
though at birth the baby had group-A Rh-positive blood.
From April 5 to 18 the baby slowly lost its red cells, the count
falling from 4,700,000 to 4,280,000 per c.mm. On the 18th
the peripheral blood-cells were group O, with 8 in the serum,
and there was a trace of agglutination with anti-D serum.
In the marrow, on the other hand, the cells were group A
and Rh genotype CDe, cde.
As marrow smears at this stage showed only 2-5°4 of primi-
tive red cells, it was apparent that the repeated transfysions
were producing a condition of red-cell hypoplasia, and further
transfusions were witbheld in the hope that the marrow would
be stimulated to make its own cells.
On April 25 the peripheral red cells were grouped as A,
with a good anti-D reaction but no agglutination with anti-C
serum. On the 27th the blood-count had fallen to 3,530,000
per c.mm., and the blood antigens were A CDe, cde, a formula
corresponding to that in the marrow.
These results are summarised in the accompany ing table.
Since then, the marrow has produced 129%, of normoblasts, and
the red-cell count is slowly rising. In the meantime the
father, group A, has been genotyped as CDe, cDE.
CHANGES IN THE BLOOD
Antigens present
Date
Blood Marrow
Feb. 25 ARh +
April 5 O cde, cde
April 6 O cde, cde . x
April 7 O cde, cde ws
” April 18 O cDe, cde A CDe, cde
April 25 A cDe, cde A CDe, cde
April 27 A CDe, cde A CDe, cde
DISCUSSION
It is clear from the twelve normal controls that the
bone-marrow red cells contain the same hemagglutino-
gens as do the peripheral cells. Also, the case illustrated
demonstrates that, where frequent transfusions have
been given, the marrow cells, being in a sense fixed, may
reveal the true antigens when the peripheral blood-group
is either obscured or altered by donor cells.
In the present case there was no indication at birth
to genotype the baby, which was merely recorded as
Rh-positive. As the father was CDe, cDE, and the
mother made anti-C and anti-D agglutinins, there cannot
be mych doubt that the infant was originally a CDe, cde,
a typing confirmed by the marrow and to which the peri-
pheral blood eventually reverted. As the father was not
available when the baby’s blood was giving an untrue
picture, the marrow reaction gave valuable corroborative
evidence about the type of agglutinins present in the
mother’s serum.
The behaviour of B suggests that the original antibody
was obtained from the mother, its disappearance and
reappearance coinciding with its obsolescence and the
-baby’s starting to manufacture its own 8.
The return of the antigens to the blood showed some
odd features. That the Rh antigen was detectable before
its ABO counterpart was probably due to the use of
higher titre anti-Rh sera; but why D should reappear
before C was demonstrable with high-titre serum is not
so clear, if the fixity of antigens is accepted, and may
be due to the fact that the factor D as a rule seems to be
more readily agglutinable than either C or E.
I am indebted to Dr. Donald Paterson for access to the
patient, to Miss B. E. Dodd for her help with the sera, and to
Mr. G. W. Cecil for much technical assistance,
REFERENCES
Coombs, R. R. A., Mourant, A. E., Race, B R. (1946) Lancet, i, 264.
Dacie, J. V., Mollison, P. L. 1943) Ibid, i, 550.
oes? J. D. (1944) Bril. med. J. i, 748.
Lattes, L . (1932) Individuality of the Blood, London
Wiener, A. S. Sonn, E. B. (1946) Amer. J. Dis. Child. 71, 25.
420 THE LANCET)
New Inventions
PNEUMOPERITONEUM-REFILL NEEDLE...
_TuH induction of a pneumoperitoneum is much more
difficult in most cases than that of an artificial pneumo-
thorax, because, owing to the softness of the abdominal
wall, it is extremely difficult to be certain when the point ..
of the needle is within the peritoneal cavity. Again,
in the pleura a good negative pressure is usually found,
except when the pleura is adherent, whereas in the peri-.
_ toneal cavity the pressures are often difficult to record
because: (1) they are not so great as in the pleural
cavity, and (2) a loop of intestine or a piece of omentum
may obstruct the hole in the. needle. E
The needle described was designed by Veress, in
Switzerland, to get over these difficulties. It is extremely
simple to use and very efficient. The point of the needle
is formed by a strong, hóllow, but blunt trochar running
within the needle, with an exit hole at one side, just
below the blunt end of the trochar.’ The distal end of
this trochar is fitted with a spring so that it projects
about 1 mm. beyond the point of the needle, but can be
withdrawn within the needle, being pushed out again
_by the spring when released. When the needle is pushed
through the tissues of the abdominal wall, the blunt
trochar is pushed back against the spring, and the cutting
‘edge of the needle, within which it runs, pierces the
tissues easily, the spring pushing the blunt trochar
forward as soon as the peritoneal space is reached,
displacing the gut or omentum in front of it, but not
damaging it, as the trochar is blunt. A, swing on the
manometer may or may not be recorded, but it is quite
` 4 or OS - i ani EE
PERI NASAL ENE WO E i nÊvmeaa andos amn : a Sot
. > . ` S E The
Above, the needle assembled for use. Middle, the cannula.
Below, the spring and trochar- ae?
safe to allow air to run in at this stage, at the end of
which the pressures will be easily recorded. | |
The technique in actual experience is helped by the
following suggestions. After anzsthetisation of the skin
and parietal peritoneum in the usual way, the needle is
inserted much more easily if a small nick is made in the
skin just medial to the lateral border of the rectus at
about the level of the umbilicus. As the needle is pushed
forward, the blunt trochar is pushed back against the
spring as it pierces the external fascial layer of the
sheath of the rectus abdominis, but springs forward as |
soon as this is pierced. As the needle is pushed forward
slowly, the blunt trochar is again pushed back as the
internal layer of the sheath of the rectus abdominis is
encountered, the trochar springing forward again when
this is pierced. These two movements are important
to observe and are much more easily detected if the
patient raises his head from the couch, thus contracting
the rectus abdominis while the needle is being inserted.
The original needle obtained from Switzerland is
somewhat large; so the size has been reduced by the
Genito-Urinary Manufacturing Co. Ltd., but the principle
is exactly the same. E
‘It is interesting to note that about 1925 G. Zorraquin,
of Buenos Aires, designed a needle which was almost
identical with this and was made by the Holborn Surgical
Instrument Co. Ltd. for the exploration of the chest in
cases of pleural effusion, so that fluid could be obtaine
without damaging the underlying lung. :
JOSEPH SMART, M.D.Camb., M.B.C.P.
Physician in charge of Outpatients,
aan London Chest Hospital.
NEW INVENTIONS—REVIEWS OF BOOKS
fa by
[sEPr. 21, 1946
gee Reviews of Books
Technical Minutiæ of. Extended Myomectomy and.
Ovarian Cystectomy _ l .
Victor BONNEY, M.S., M.D., F.B.0.8., consulting gynæco-
logical and obstetrical surgeon to the Middlesex Hospital
‘and consulting surgeon to Chelsea Hospital for Women.
London : Cassell. Pp. 282. 30s. =
Tus, the latest and probably the best book from the
pen of Mr. Victor Bonney, is the gospel of the apostle
of conservatism. In it, with the utmost simplicity of
language ‘and great clearness of detail, he explores
almost every. possible way of performing multiple
myomectomy. Mr. Bonney takes his reader and imagi-
nary pupil by the hand and leads him into the theatre.
and demonstrates each step in each type of operation.
The 241 illustrations, drawn by himself, are in the same
style as those of the famous Textbook of Gynecological
Surgery—little masterpieces of exposition. All gynsco-
logists and surgeons likely to perform myomectomy should
have this book. 7 . . |
The 1945 Year Book of Neurology, Psychiatry and
Endocrinology AE TE O
Edited by Hans H. REESE and MABEL Masten; NOLAN
D. C. Lewis;. and ELMER L. SEvrinenavs. Chicago:
Year Book Publishers. Pp. 720. 18s. — ie
SERVICEABLE and comprehensive, this triple volume
devotes four-fifths of its space to neurology and endo-
crinology (almost equally divided) and a fifth to
psychiatry: clearly the editors consider that.a high
proportion of the voluminous literature of psychiatry
adds nothing to our knowledge. It is consequently
regrettable that space is allotted to reflective or expository
articles, such as ‘‘ viewpoints on basic problems of
psychopathology,” ‘relationship of psychoanalysis to
psychiatry,” ‘‘ psychiatric problems in obstetrics and
' gynæcology,” which contain little that is new. In the
neurological section the editorial notes are frequent and
helpful ; special atténtion is drawn to the meningeal
responses to intrathecal medication, and the advantages
of giving penicillin otherwise than by this route for the
treatment of meningitis. The section on endocrinology
is the last which Professor Sevringhaus will edit; in a
prefatory note he compares the situation in 1934, when
he began the series, and now: great advances have been
made, but fundamental ‘relationships have not changed,
and there are still conspicuous gaps—for example, in
our detailed knowledge of the mechanism of the menstrual
cycle and of the hormones of the pituitary. This section
is, as ever, the most thickly packed, and bespeaks the
great if uneven activity in this field that prevails in
American laboratories and clinics, from which come most
of the papers abstracted. The value of the yearbook
would be enhanced if the index were more itemised.
A Practical Handbook of Midwifery and Gynsecology
(3rded.) W. F. T. HAULTAIN, M.B., F.R.C.0.G., obstetrician
and gynecologist to the Royal Infirmary, Edinburgh ;
CLIFFORD KENNEDY, M.B., F.B.C.0.G., assistant gyneco-
logist to the infirmary. Edinburgh :.E.’« S. Livingstone.
Pp. 388. 20s. er ee
THIs handy synopsis of obstetrics and gynecology
represents the teaching of the famous Edinburgh school
and it will therefore have a wide appeal north of the
Tweed, but English readers will find the book equally
acceptable to southern examiners. ‘Though primarily
written for the student about to qualify, it is also a useful
book of reference for the busy practitioner who wishes
to check up on some point quickly. The chapters on the
infant and on breast-feeding are particularly good and
the chapter on sexual disorders is useful and contains a
small section on contraception. Not all will agree with the
= . view that chloroform is the best anzsthetic when absolute
uterine relaxation is required for difficult rotation or
version, but the authors make the claim with various
laudable reservations. The Edinburgh school, to be
sure, are masters in .the administration of chloroform ;
but the English schools are not, and until its use is excluded
from obstetrics, some pregnant women will have their
lives endangered every year. There are other anæs-
thetics available which are safer and equally efficient. .
THE LANCET]
THE LANCET
LONDON: SATURDAY, SEPT. 21, 1946
Occasion for Thrift
Our Armed Forces, it is clear, are to be maintained
at a substantial strength in peace-time ; but though
Service claims must be met in peace as in war they
can no longer have exclusive priority.
of almost equal urgency lie ahead: the country’s
damaged economy must be repaired, and the Govern-
ment has pledged itself to improve the life and lot
of the people. If these purposes are to be fulfilled
our supply of skilled man-power must be carefully
husbanded and wisely allocated between the various
claimants. Thus the medical profession must meet
the higher peace-time requirements of the Services
while helping to man the new National Health Service,
which will ultimately call for more doctors than the
country now possesses. Plainly, more doctors must be
trained; the universities are alive to this fact,! but
they cannot promise any large increase within the
next few years. Meanwhile, the best use must be
made of existing resources. In these straits, an
authoritative body is needed to balance the claims of
civilian and military medical services and
itself that no doctor is wastefully engaged in either.
Since its establishment during the war, the Medical
Personnel (Priority) Committee has concerned itself
with exactly these questions. The committee’s
importance will be undiminished in the days of peace ;
indeed, its brief should be extended and its member-
ship enlarged to represent all interested parties.
Its duties should, as now, be advisory, and, like other
official committees that are in m making, it should
publish its findings.
There will be plenty of sone. for the committee.
It might first consider the proposal that medical
students shall continue to be called up for military
service, except when specially deferred, before starting
their medical course proper. The alternative system,
by which doctors would normally do their military
training after qualifying, would require close under-
standing between the Ministries of Labour, Education,
and Health, and the universities and Service depart-
ments ; and it could not be effected immediately since
the medical schools already have more candidates
than they can accept from the ranks of the demobilised.
But in a year or two the change should be practicable,
and it is not too early to plan for that time. Many
students would prefer that the break, if break there
must be, should come between school and university
rather than later; but will it not be more profitable
for both the community and the individual if the
doctor serves after qualifying, when he can help to
reduce Service demands on the country’s restricted
supply of medical men and can gain the knowledge of
Service medicine which he will need if ever he is
recalled to the Forces ? |
Then there is the step which many think inevitable
—the merging of the medical branches of the three
1. see Linca, August 41, p. 305.
OCCASION FOR THRIFT
men;
Other tasks
satisfy `
[SEPT. 21, 1946 421
Fighting Services into a single organisation, no longer
keeping itself aloof from civilian medicine but closely
linked to the National Health Service. This measure
would provide doctors in the Forces with an oppor-
tunity for widening their experience and might well
increase the efficiency of medical care for all fighting
but above all would be its saving in overlap
and hence the economy it would effect in hospitals,
equipment, and man-power. This step was advocated
early in the war by MEDICcUS, M.P.,? after a tour of the
B.E.F., and now, as then, the need is for a unifying
authority. The Personnel Committee would be well
constituted to study this scheme in detail and to advise
on its practicability.
There is a further aspect of economy that should not
be overlooked : time spent with the Forces should be
profitably occupied. And here again is an oppor-
tunity for the integration of military and civilian
medicine which we have already discussed in detail.?
The late war proved the eagerness of the young medical
' officer, even under difficult conditions, to enlarge his
experience. This thirst for further knowledge was
to some extent recognised and appeased by short
courses and clinical meetings in hospitals ; during the
last campaign in Europe one hospital (known, with
a levity that concealed respect, as the University of
Duffel) won a reputation for teaching that might be
the envy of established centres. In peace-time this
field can be more fully explored (see p. 432). It
may be found that some of the: best teachers have
returned to civilian life, and certainly much will
depend on the good will of civilian hospitals. The
Services, for their part, may look with favour on a
suggestion which is calculated to increase their appeal
and efficiency. The newly recruited medical officer
must first serve with a battalion or in a comparable
post with the other Services, for this work calls for a
special knack that is not learnt overnight. Moreover,
better than any other appointment, it teaches the
precise functions and effects of Service medical
practice ; indeed, many of those who joined the
Forces for the duration as specialists suffered. a per-
manent disability through not having held these
posts. But training should also include oppor-
tunities to work in military medical units, large and
small, and even in administrative offices. This
arrangement would not only benefit the Services by
instructing men in their operation but might also,
by providing first-hand experience of many branches
of medicine, enable junior graduates to return to
civilian life with a better idea of where their bent lay.
Service with the Forces should not be divorced
from, or delay advancement in, civilian work, but
should rather be a normal phase in a single career.
It may be that in the years to come the young doctor
will be able to count his time in the Forces towards
seniority in the National Health Service, and that
senior men will be free to return to the Services for
short periods without jeopardising their civilian
position ; they might, if specialists, thus help to make
good a deficit that will probably be felt even more
strongly in`the Services than in civilian practice.
Such a correlation may have to wait on more settled
days; but economy in the use of doctors cannot
wait.
2. Ibid, 1940, i, 987.
3. Ibid, 1945, ii, 531.
429 THE LANCET]
| Surgery in the Aged —
THE defeatism to surgical diseases in the aged is |
passing. The view of operation on the elderly as a
desperate expedient is still reflected in the undue
proportion of old people with acute surgical com--
plaints to be found in institutions for the chronic
sick; but the E.M.S., by sending doctors from
voluntary hospitals as emergency staff to these
institutions up and down the country, has influenced
surgical opinion on the illnesses of old people. Many
surgeons have returned to voluntary hospitals with
an increased respect for the tolerance of the elderly
for major operative procedures. The improved
expectation of life means inevitably that surgeons
will be increasingly occupied with patients over 60.
As TANNER ! remarks, the improved results are not
so much due to changes in technique as to better
pre- and post-operative care and a higher standard of
anesthesia. The old patient’s knowledge of dietetics
is rarely profound ; he is often faddy, practising self- `
imposed restrictions, especially on protein foods,
green vegetables, and fruit. Rationing difficulties and
poverty have usually added their burden. A prelimi-
nary period in hospital before operation, when
surgical circumstances permit, is well. spent;
WHIPPLE ? has pointed out the need for extra proteins
to increase the powers: of wound healing, and
STEVENSON, WHITTAKER, and KARK °? have found
powdered milk useful for this purpose. With syrup
flavourings it can be made into a palatable drink,
and should be given between meals, say at 10 A.M.
and 2.30 P.M., in 8 oz. feeds, and a further 16 oz. as a
milk-shake at 9 p.m. By this means 72 g. of protein
and 1100 calories can be added to the daily diet. It
seems unnecessary to give amino-acids. Extra
vitamin C is needed for the formation of collagen
. fibres, and many of these old patients bear the
stigmata of vitamin-B deficiency ; so vitamin supple-
ments in full doses should be added to the diet. The
hæmoglobin needs watching, for many of these old
people are anemic; this is best corrected with
iron, or if need be liver, for blood-transfusion requires
particular care, since their hearts will not tolerate
much overloading. Bed is a dangerous place for the
old man ; as often as not rest in bed, rather than the
surgeon, is responsible for a pulmonary embolus.
This is a complication ever to be feared in the aged,
and in some operations a preliminary double femoral
_ ligation, as is being increasingly practised in America,
might be advisable. Just before operation is not
the best time to change the habits of a life-time,
so enemas and purges are better avoided. Smoking
should be restricted for. 48 hours before operation,
but it will do no good to cut off the pipe after meals
and have the patient fumbling, restless, and miserable.
Morphine, when indicated for pain, should be given
in small doses. Harpy, WOLFF, and GOODELL 5
have shown that the maximum analgesic effect is
obtained with gr. !/ẹ and that a larger dose merely
depresses respiration. The patient who requires pre-
operative gastric lavage should have his washout
first thing in the morning and just before the evening
J. Tanner, N. C. Brit. med. J. 1943, i, 563.
2. Whipple, A. O. Ann. Surg. 1940, 112, 481.
. Stevenson, J. A. F., Whittaker, J., Kark, R. Brit.med.J.1946.ii,45.
. Hunt, A. H. Bril. J. Surg. 1941, 28, 436.
; HD D., Wolff, H. G., Goodell, H. Amer. J. Physiol. 1940,
» dtu.
Crum te
SURGERY IN THE AGED
[sEPT. 21, 1946
` meal; the usual practice of leaving the stomach
empty for the night robs the patient of the benefit
of the night’s absorption of food and fluid.
Of all the anesthetics for the aged, local injection,
with the patient preferably asleep (at any rate for the
Englishman), seems to be the most satisfactory ;
spinal anesthetics, especially high spinals, are. badly
tolerated by old people. Gas and oxygen is probably
the most dangerous, for any sustained cyanosis is
lethal. Light cyclopropane is almost certainly the
safest. The old patient should not be intubated as a
routine ; when the patient is light this leads to much
bronchial spasm, and, as Noswortuy ê has pointed
‘out, this may largely be responsible for subsequent
lung collapse. Postoperatively, intravenous drips are
better avoided ; with a small catheter at least 5 pints
of fluid a day can be administered by rectal drip.
Protracted gastric aspiration is badly tolerated, and
it is often maintained unnecessarily long after abdomi-
nal operations. ‘Although his tissues heal well, and
the peritoneal cavity does not seem to lose its power
of coping with any mild spilling, the old person’s
resistance to infection is always poor, penicillin,
preferably started before operation, is a valuable
weapon against wound sepsis, which may spread into
the peritoneal cavity and be responsible for the subse-
quent peritonitis. To avoid the unpleasantness of
repeated injections, penicillin may now be given
in 100,000-unit doses, and Dr. FiLor&y and her
colleagues demonstrate in this issue (p. 405) that such a
dose given thrice daily will maintain a bacteriostatic
concentration in the blood. Prophylactic sulphonamide
therapy TANNER thinks is of definite value against
pulmonary and peritoneal infection; he quotes a
series of 120 unselected partial gastrectomies with
one death, and attributes part of this success to
sulphonamides. Sulphamerazine may come to be
the drug of choice, for it has the advantage of requiring
only 8-hourly administration and its conjugated form
is relatively soluble in neutral and acid urine, thus
avoiding the risks of drug concretions and damage
to the renal parenchyma.’ Succiny] sulphathiazole
has proved its value in the preoperative preparation
of the patient for intestinal surgery ; in appendicitis,
so treacherous in the aged, it may be used as an added
safety factor. For diverticulitis, often seen in the
aged, phthalyl sulphathiazole, which requires but a
daily dose of 3-6 g., may be superior.
In the decision to operate on an old person the
surgeon should not be too much influenced by the
knowledge that the patient’s blood-pressure is high ;
even a history of coronary thrombosis is no absolute
contra-indication. Hypertension was present in 77%
of 341 “healthy ” Chelsea pensioners examined by
HowE tu.® “Give me preferably the old patient with
high blood-pressure,” GORDON-TAYLOR has remarked.
Fall of pressure in the aged is a bad prognostic sign,
and when “ systolic figures approach 110, the outlook
is grave.” 8 The surgeon should bear in mind that
hemoptysis, hematemesis, and profuse rectal bleeding
may result from hypertension rather than local
disease. Gastric surgery for ulceration is now being
increasingly performed with success in old people.
Gastric perforation is by no means rare in the higher
-an ee a m R == _ —e
6. Nosworthy, M. D. Quoted by Mimpriss, T. W., Etheridge, F. G.
ril. med. J. 1944, ii, 466. i
7. Henderson. J. Surg. Gynec. Obstet. : int. Abstr. Surg. 1946, 83.1.
8. Howell, T. H. Practitioner, 1946, 156, 444.
THE LANCET]
age-proups, and TANNER has seen it even at 91; it
seems certain that this diagnosis is often overlooked.
For the old patient with ulcer, gastrojejunostomy is
sufficient, for the mucosa is usually degenerative and
ulceration does not recur. The stomach growth, of
course, does require partial gastrectomy, and it is
amazing how well the aged withstand this procedure.
TANNER records a successful total gastrectomy in a
patient of 74, and WavucH and GIFFIN ® one in a
patient of 72. In such patients preliminary splanchnic
block may be dangerous, for, especially with the
anterior approach, pressure on the aorta may fracture
some of the atheromatous plaques usually present.
Resection of ceesophageal growths is now being success-
fully performed even in old patients, and the risks are
worth taking. The pharyngeal pouch quite common
in the aged is being dealt with under local anesthesia
by first transplanting the pouch to a higher level and
at a second operation coring out the mucosa. Growths
of the colon can be expeditiously dealt with by Paul’s
operation, and even if there are secondaries in the
liver an attempt should be made to remove the local
growth. Patients with secondaries in the liver often
live for two or three years.in fair comfort and removal
will spare them the misery and pain of the local
spread. The aged donot always need the full abdomino-
perineal resection; where the growth is at the
pelvirectal junction, or high in the rectum, the simpler
operation of leaving a distal blind rectal stump
(Hartman’s operation) is ample. CUTHBERT DUKEs,!°
and GLOVER and WavGu,!! have shown that distal
retrograde spread is slow, and that it only occurs in
1% of cases, and then usually only when the normal
upward channels have been blocked. Section of the
bowel an inch below the palpable edge of the lesion
will satisfy pathological requirements. The breast
carcinoma usually needs but a local amputation to
avoid the local ulcerating mass, and to remove what
the patient knows perfectly well is slowly whittling
away her life. Admittedly, such carcinomas are often
extremely slow growing, but, with the ever-extending
propaganda on cancer of the breast, no patient can
dismiss it lightly from her mind. Minor operations,
even circumcisions, are often necessary in old people
and should not be shirked. Hzemorrhoidectomy can
_ easily be performed under local anesthesia. The frail
old lady withstands well an operation for procidentia,
and it will give her comfort. As HowELL astutely
remarks, “ trifling matters often distress the aged
more than great ones.”
The possibility of a vascular catastrophe alway
hovers over the eld patient. Embolism of a mesenteric
or peripheral vessel is a condition amenable to
surgery, and has to be borne in mind. The peripheral
embolus is too often overlooked till too late for
surgery ; numbness and loss of power, rather than
pain, may be the chief symptoms. The limb with a
peripheral embolus, if operated on early (usually under
local anesthesia), does well. Arteriosclerotic gangrene
is now being treated by more conservative methods ;
gangrene of a single toe often ends with no more than
loss of the superficial skin. Reflex vasodilatation,
by heating the body or immersing the opposite limb
9. Waugh, J. M., Giffin, L. A. Proc. Mayo Clin, 1941, 16, 363.
10. Dukes, C. E. J. Path. Bact. 1940, 50, 527; Proe. R. Soc. Med,
1941, 34, 571.
11. Glover, R. P., Waugh, J. M. Surg. Gynec. Obslet. 1916, 82, 433.
12. Learmonth, J. R. Ldinb. med. J. 1943, 50, 140.
DENTAL CONTROVERSY
[sepr. 21, 1946 493
in water at 110° F, is probably the best way of
encouraging the collateral circulation; it does as
much as a sympathectomy and certainly more than
vasodilator drugs. For the frail patient, particularly
with spreading gangrene, amputation under ice
anesthesia has a place. The results of surgery in the
“old man’s illness ’’—prostatic obstruction—have
been much improved; Millin’s retropubic operation
has largely justified the original optimism. The other
old person’s disease, trigeminal neuralgia, is being
increasingly operated on early, and these patients
withstand the operation remarkably well. Fractured
neck of femur, which was the harbinger of death for
many of the aged in the past, is now almost routinely
treated with the trifin nail—a procedure which even
the very old withstand ‘well. Aseptic necrosis and
extrusion of the pin have rather damped initial hopes,
but a good result can usually be anticipated in at least
50°% of cases ; where this fails McMurray’s osteotomy
is extremely valuable. |
One example of the success being attained must
suffice. Carp /*has collected figures from a variety of
sources covering 2558 patients submitted to operation
at ages over 60; these show an average operative
mortality of 13:1%—a gratifying result. It does
indeed seem that the age of the “lean and slippered »
pantaloon ?” may become a less formidable problem
to the surgeon than that of the “fair round belly
with good capon lined.”
Annotations
DENTAL CONTROVERSY
TuE dispute between the dental profession and the
Minister of National Insurance raises an important
point of principle. Negotiations for a new scale of fees
for dental work done for insured persons began as long
ago as January of this year, when the Dental Benefit
Council set up a negotiating committee consisting of
three dentists, representatives of three approved societies,
and a number of Government members. This committee
issued a questionary to more than 1000 dentists engaged
in N.H.I. practice to ascertain (a) to what extent the cost
of running a practice had risen owing to the war, and
(b) what: were the private fees charged to non-insured
patients in the same walk of life as those treated under
N.H.I. The committee issued a unanimous report and
submitted a scale of fees which. represented an average
increase of about 100% over the pre-war scale. This scale
of fees has now been rejected by the Minister of National
Insurance. The dental profession. féels that having
exhausted what it regards as the normal negotiating
machinery it has no alternative but to abstain from
participating in the service. The dental profession fears
that if the present Minister is prepared to disregard
negotiating machinery in connexion with dental benefit
in this way, and to rate the value of a dentist’s services
so low, there can be- no hope of any better treatment in,
a scheme applying to the whole nation.
The scale which the Minister proposes to adopt from
Sept. 30 will yield an average net increase of 50% over
pre-war, according to the Ministry’s letter circulated
to dentists on Sept. 12, but the rise is not uniform.
Thus the fee for full upper and lower dentures,
which unfortunately is the form of treatment most
necessary for working-class patients, is £7 15s. When
the scheme started in 1926 this fee was £6; the present
fee is £6 7s. Gd.; and the dentists were prepared to
accept 9 guineas. The dentists contend that they cannot
—
13. Carp, L. Ann. Surg. 1946, 123, 110.
424 THE LANCET]
PENICILLIN IN WOUNDS
4
[sppr. 21, 1946
guarantee a satisfactory service for insured persons at
any scale below that which the Minister rejected, and
the Joint Advisory Dental Council recommends dentists
to. refuse to undertake N.H.I. work unless the higher
scale is adopted.
i PERCEPTION
THERE are many subjects of common interest to
philosophy and medicine: but if he is a physician the ©
Manson lecturer, required by the terms of his appoint-
ment to consider some such subject, may well doubt his
ability to reach the standard of subtle and recondite
profundity manifest in philosophical writings. Dr.
Russell Brain? has, however, succeeded in illuminating
a problem of basic importance for the philosopher—
the nature of perception, especially in its causal aspects.
Neurologists, he points out, usually adopt physiological
‘idealism as their epistemological theory : for them the
only independently necessary condition for the awareness
of sense-data is an event in the cerebral cortex. -But,
besides the familiar arguments against idealism, it is
possible to object to this, as Russell Brain does, that the
peculiar phenomena of cortical representation during
visual perception make simple “‘ projection ” of cerebral
events an inadequate explanation: ‘‘ when we perceive
a two-dimensional circle we do so by means of an activity
in the brain which is halved, reduplicated, transposed,
inverted, distorted and three-dimensional.”” But realism
too has its difficulties, implicit in Brain’s (probably
rhetorical) hope that a realist philosopher will give an
account of the ‘‘ ontological status of a black sense-datum
when it is not being perceived and, in particular, its
relationship to its non-existent substratum in the
physical world.”
By way of hallucinations and the phenomenon of
“ phantom limb,” which further illustrate this crux,
Brain passes to the rôle of the body in perception, and
instances & number of observations hard to reconcile
with any variety of critical realism. Awareness of
externality is clearly the cardinal problem: and spatial
relations, upon which this depends, are primarily per-
ceived in a somatocentric way. The body is well adapted
to the task of spatial discrimination, through its apparatus
for the integration of impulses conveyed from different
sense-organs to the cerebral cortex. Russell Brain holds
that the most likely explanation of the relationship
between sense-data and the nervous system is that a
sense-datum is a neural event which is conducted from
the surface of the body to the surface of the brain but
which carries with it some characteristic of the physical
stimulus which excited it. In his conclusion, which takes
account of the “ successiveness ” of the stimulus event,
he adopts a realist position in so far as he denies that
even secondary qualities are generated by our brains
or minds: “in sensing them we are perceiving the four-
dimensional texture of the external world.” This is a
thoughtful and stimulating essay which shows how
significant for the philosopher can be the observations
and reflections of the neurologist. | . |
DEATH AFTER CURARE
AN inquest was held at Hammersmith on Sept. 9
on a patient who died after an operation in which curare
was employed. A woman of 70 years had been admitted
to hospital two days after the onset of symptoms of
acute appendicitis. An hour after receiving morphine
gr. 1/, and atropine gr. 1/100, she was anesthetised with
*Pentothal’ 1 g. and was given ‘ Intocostrin’ 9 c.cm.
Oxygen was administered during the operation, which
revealed an acutely inflamed but unruptured appendix,
with much induration of the surrounding tissues and a
small adjacent collection of pus. The appendix was
removed, the pus mopped out, and the wound closed in
1, Neurological Approach to the Problem of Perception. Philosophy,
July, 1946, p. 133.
layers. The first alarming signs—cyanosis and shallow
respiration—appeared after the end of the operation,
which had taken 43 minutes. The patient recovered
somewhat with oxygen and carbon dioxide, but relapsed
and,. despite the injection of ‘Coramine’ 1 c.cm. and
‘Veritol’ 1 c.cm., died 35 minutes later. Necropsy
confirmed the presence of early peritonitis, which was
most pronounced in the right iliac fossa; there was
some dilatation of the terminal loops of the ileum,
suggesting early paralytic ileus. The left lung was almost
completely collapsed and there was considerable collapse
of the posterior halves of the right upper and lower lobes ;
there were one or two adhesions in both pleural cavities
and the lungs showed pronounced terminal congestion.
The heart muscle was a little friable, but only early
atheromatous changes were found, and there was no
valvular disease. Early toxic changes were seen in the
spleen and liver. The kidneys were remarkably healthy
for a patient of this age, although albumin had been
found in the urine before operation. The pathologist
considered that death was due to toxzemia and had been
accelerated by respiratory failure due to curare. A
verdict of death by misadventure was returned. `
PENICILLIN IN WOUNDS
THE topical application of sulphonamides to wounds
has proved a disappointment, and, though there is. not
unanimous opinion on this point, it is widely held that
the presence of a sulphonamide powder in a flesh wound
may actually delay healing. In sharp contrast to this,
there has never been a doubt that penicillin as a topical
application is of great value, for it has the advantages
over the sulphonamides that it acts in the presence of
pus, that its effect is not weakened by large numbers of
bacteria, that it is a much more powerful bacteriostatic
agent than any sulphonamide, and that it is very soluble
in tissue fluids. In the early stages of its use, penicillin
was recommended as a topical application because this
method was more economical than systemic adminis-
tration at a time when supplies were short ; and many
surgeons believed that, valuable as it was used thus, its
effects would be greater still when easement in the
supply position permitted free systemic administration.
‘This belief has not been borne out in practice, and the
paper by Florey, Turton, and Duthie in this issue gives
scientific foundation for the clinical impression that
locally applied penicillin is as effective in preventing
‘wound infection as it is when given parenterally.
Florey and her colleagues collected samples of wound
exudatés after penicillin had been given either by local
application or by injection. The difficulties they encoun-
tered in the assay of the penicillin content of these
exudates and the methods they used to overcome them
need not detain us here. It was shown that whereas
100,000 units of penicillin injected: intramuscularly
yielded for a minimum of 8 hours a wound exudate
which inhibited the test organism, a similar dose
implanted in the wound yielded exudates with inhibitory
concentrations for at least 48 hours. It might be argued
from this observation that locally implanted penicillin
remained in the wound cavity but might fail to reach
organisms lying in the wall, but this argument is defeated
by observations on the duration of inhibitory activity
in the blood and urine. There was little difference in the
time over which inhibitory levels were maintained in the
blood whether penicillin was given locally or parenterally,
but in the urine inhibition persisted in half the cases
for twice as long after local application as it did after
intramuscular injection. Penicillin is therefore readily
absorbed from wounds and must traverse the walls of
wounds (inhibiting meanwhile organisms lying in its
path) to gain access to the blood and urine. ?
All this is of great importance in its practical application
to wound treatment. Locally implanted penicillin is of
THE LANCET] |
greater value, unit for unit, than injected penicillin in
the control of wound infection—a conclusion which all
patients will welcome if it means that the 3-hourly
injection régime can be avoided. It is clear, also, that so
far we have not put nearly enough penicillin into the
wounds we have treated and have therefore had to waste
it by supplementary systemic administration. Some
practical points await elucidation. Can one put into a
wound a large enough dose of penicillin to sterilise it
with certainty at a single stroke? Do the tissues show
a marked resentinent to pure powdered penicillin in quan-
tity, and would healing be impeded by excessive exuda-
tion? If a single sterilising dose proves impracticable,
what is the best method of implanting penicillin into a
sutured wound at, for example, 24-hourly intervals ?
It seems that despite the vast experience of the past six
years, the last word on the best method of treating
wounds with penicillin has yet to be said.
TEST FOR THREATENED ABORTION
THE presence of pregnandiol in the urine can be deter-
mined qualitatively by a colour reaction which is neither
particularly involved nor time-consuming; and Guter-
man 1 now claims that this can be used as a diagnostic
test for pregnancy with an accuracy comparable to that
of the Friedman test. He suggests, moreover, that the
reaction is an accurate aid to prognosis in certain
complications of pregnancy, notably threatened abortion.
_ Pregnandiol is the excretion product of progesterone,
and it appears in the latter half of the cycle, ceasing one
to four days before the onset of menstruation. If
fertilisation occurs the corpus luteum persists and the
excretion of pregnandiol continues. In normal pregnancy
the excretion of pregnandiol follows a fairly well-defined
pattern. At first it is comparable to that in the latter
half of a normal menstrual cycle, but about the ninth
to twelfth week the excretion rises sharply to reach a
peak two wéeks before delivery ; it then drops sharply,
and pregnandiol has completely disappeared from the
urine twenty-four to forty-eight hours after delivery.
It is well known clinically that the corpus luteum begins
to degenerate . about the third month of pregnancy,
after which double odphorectomy can be carried out
without necessarily disturbing the pregnancy.
probable that the placenta assumes the function of
secreting progesterone from about the twelfth week
onwards; and the commonest time for abortion corre-
sponds to the stage at which the corpus luteum is
regressing and the “placenta is beginning to take over
its function. During this transitional period pregnandiol
excretion is liable to drop to a low level; and a drop
into the danger zone may well herald the onset of
threatened abortion. The test could thus forewarn the
clinician, who could take evasive action by ordering
rest, sedative drugs, and possibly progesterone by
injection.
Guterman’s colour reaction ? consists briefly in adding
concentrated sulphuric acid to the pregnandiol extracted
from the urine ; a positive reading is indicated by a deep
yellow or orange, which represents 0:4 mg. pregnandiol
per 100 c.cm. of urine, or roughly 6-10 mg. in twenty-four
hours—the normal amount in early pregnancy. He
studied 73 patients with threatened abortion; among
these the pregnandiol colour reaction with concentrated
sulphuric acid was persistently negative in 39, of whom
38 aborted. The reaction was persistently positive in
34, of whom 30 did not abort. Out of the 73 there were
5 wrong prognoses; but in 3 of the 4 positives that
aborted there was good reason for it—placenta pravia
in two and a large fibroid in the third. The test is most
useful up to the third month. Thereafter with the
excretion of Preeneucio! rising from 20 mg. to 50 mg.,
1. Guterman, H. S. J. Amer. ned. Ass. 1946, 131, 378.
2. J. clin. Dadon. 1944,
HOSPITAL CATERING IN MIDDLESEX
It is.
[SEPT. 21, 1946 425
a positive reading may persist for the first twenty-four
hours after foetal death. Guterman offers no explanation
of the pregnancy which continues despite a persistently
negative colour reaction. » The great advantage of the
method is its cheapness and speed; a result can be
obtained on the day that the specimen reaches the
laboratory. It is hoped that English workers will try
it out; if it is found to be as good as Guterman claims,
it should prove useful in the treatment and prognosis
l of threatened abortion.
HOSPITAL CATERING IN MIDDLESEX
By way of experiment, the Middlesex County Council
have decided to appoint a catering oflicer to one of their
hospitals.! The appointment is in the first instance to be
temporary, though not with any fixed limit of time,
and is to carry a salary of £750 a year, rising by annual
increments of £25 to £850. In a report to the public-
health committee, Dr. H. M. C. Macaulay, county
medical officer of health, notes that existing arrange-
ments present many of the drawbacks discussed by
King Edward’s Hospital Fund for London.2? Thus
hospital catering comes under the dual control of the
steward, who undertakes the buying and supervises
the porters who distribute the food to the wards, and the
matron, who supervises both the kitchen staff and
the nurses. The matron.may have the help of a house-
keeping sister, whose short course of training, ‘planned
in days when hospitals were smaller, is mainly adminis- .
trative, does not include cooking, and seldom covers
nutrition or the relation of food to health.
Dr. Macaulay found the matrons ready enough to
be relieved of the responsibility of catering; but the
stewards, though agreeing that it should be under one
person, were uneasy over the proposed appointment of a
catering officer. They feared the results of divided control
of staff, especially porters, and of stores, since food would
have to be separated from other goods; and they
concluded that the person responsible for catering
should either be the steward or else that the catering
officer should work under him.
It is doubtful whether this is the right arrangement.
As the King’s Fund point out, stewards have little
expert knowledge of food, cooking, and the science of
nutrition, and ‘their general administrative duties do
not leave them time to visit markets and interview
travellers. They have to depend on the long-term
contract, the written order, and the telephone in buying
food; Dr. Macaulay, in fact, noted that the contract
purchase was much too common. Yet a day-to-day
first-hand knowledge of markets is needed for clever
buying of seasonal foods, and a balanced diet can only .
be provided by a man or woman who understands nutri-
tion and is free to juggle with the commodities at his
disposal. Much, of course, must depend on the quality
of the caterer appointed; experienced caterers are
scarce, and until more have been found or trained it
may be well to go cautiously. In deciding to appoint
one catering manager, Middlesex County Council leave
themselves free to experiment with stores arrangements
and in other directions.
In addition, food service subcommittees are to be
appointed in all the council’s hospitals, made up of the
medical director, members of the medical staff, and
the officers responsible for hospital feeding, including the
matron, and the dietitian and caterer where these exist.
These committees will be able to reconcile the financial,
medical, nursing, dietetic, and administrative interests
concerned, and to deal with complaints about food. It
will be interesting to see whether they develop on the
lines set out by the King’s Fund, as technical and
1. Report of the Public Health Committee to Middlesex County
Council, July 31.
2. Second Memorandum on Hospital Diet, London, 1945.
426 THE LANCET],
professional committees, analogous to hospital medical
committees, advising their hospital boards, and regularly
consulted by them before any decisions are made to _
reduce expenditure on kitchen staff: or provisions.
Economies of these kinds can be expensive, whereas
increases in kitchen salaries have on occasion been more
than counterbalanced by savings on waste. The classic
example is that published by the King’s Fund in 1943
of a hospital which raised the total wages of kitchen
staff from £1000 to £2000, and enjoyed a fall in the total |
costs of catering from £20,000 to £14,000.
TESTOSTERONE AND ANGINA PECTORIS
MEDICAL propaganda is not without its riske, especially
in the hands of an enterprising journalist. Testosterone
for angina pectoris is an example of a comparatively |
untried treatment which has been prematurely popular-
ised in this way. Inthe U.S.A. many people with angina
are said to be either treating themselves with the drug or
urging their doctors to prescribe it. _ That its worth is
as yet unproved is confirmed by the latest report from
America. Levine and Sellers 1 gave 25 mg. of testosterone
propionate intramuscularly twice or thrice a week and
10-15 mg. of methyl testosterone sublingually every day
to 21 men with angina pectoris ; 11 showed no improve-
ment and only 2 showed ‘‘ marked improvement.” Of
the 10 patients who had male climacteric symptoms
(precordial discomfort) in addition to angina pectoris
6 reported that these symptoms were much improved.
-= Other workers? have reported similar results—failure
to relieve angina pectoris, but relief of chest symptoms
attributed to the so-called male climacteric. There
seems to be good reason for the conclusion of Riseman °’
that testosterone should be classed among agents of no
value in angina pectoris.
SILICOSIS AND ALUMINIUM TREATMENT
Last year we drew attention * to the patenting by
Canadian investigators of the aluminium treatment for
silicosis. It now appears that the patent does not apply
to Great Britain and that research-workers in this
country are free to experiment with the method. The
subject has been considered by the councils on industrial
health and on pharmacy and, chemistry of the American
Medical Association which in April issued the following
report 5°;
1. In E, A the prophylactic use of aluminium
inhibits the toxic action of relatively pure quartz.
2. In man, industrial dust exposures often involve mixtures
of various minerals in addition to quartz and other
environmental variables to which experimental animals
are not subject. Therefore human silicosis usually
develops more slowly and is often: modified in type.
Only prolonged unbiased observation, with adequate
control cases, will demonstrate whether the prophylactic
results obtained with animals are applicable to man.
3. Animal experiments have demonstrated that administra-
tion of high concentrations of .amorphous hydrated
alumina unfavourably influences resistance to tubercu-
losis. While this result has not yet been reported for
metallic aluminium, caution in the application of all
aluminium therapy to human beings is recommended.
4. The use of aluminium might appear as an easy short-cut
to healthful working conditions, thus saving large
expenditures for ventilation and other control methods.
Actually there is no substitute for the accepted methods
of dust control.
5. If industry indiscriminately treats all employees with
- aluminium dust there may be aggravation of tuberculosis
or other pulmonary conditions.
1. Levine, E. B., Sellers, A. L. Amer. J. med. Sci. 1946, 212, 7.
2. Goldman, S. F., Markham, M. J. J. clin. Endocrin, 1942, 2, 237.
-~ MeGavack, T. H. Ibid, 1943, 3, 71.
8. Riseman, J. E. F. New Engl. J. Med. 1943, 229, 670.
4
5
|, Lancet, 1945, i, 441.
. J. Amer, med. Ass. 1946, 130, 1223.
SILICOSIS AND ALUMINIUM TREATMENT
[serr . 21, 1946
6. The therapeutic use of aluminium in man appears to relieve
symptoms in a very small number of cases in which
silicosis develops rapidly. Experience in some groups is
more favourable than in others.
7. In view of these considerations it is recommended that the
general application of aluminium therapy in industry be
delayed until adequately and impartially controlled
clinical observation demonstrates its effectiveness in
preventing or alleviating silicosis in man. In the mean-
time, there should be no slackening i in the control measures
that have been found effective in reducing tho incidence i
of dust diseases in industry.
We agree heartily with this opinion and repeat that the
“ results of treatment and prevention of silicosis by the
aluminium method, while suggestive, are not yet con-
vincing, and much more work by independent and
untrammelled observers is needed to establish its efficacy.”
We hope too that the freedom of this country from the
effects of the Canadian patent will not result in the
indiscriminate establishment of aluminium inhalation
chambers at factories or other places where there is risk
of silicosis. The only established method of preventing
the disease is by seeing that workers do not breathe the
dust of free silica.
FATE OF THE NERVE HOMOGRAFT
- TRIALS by Seddon and Holmes! of nerve homografts
for bridging gaps in injured peripheral nerves indicate
that, despite its success in cats, rabbits, and monkeys,? the
method is ineffective in man. Barnes and his colleagues 3
have also made a careful investigation of homografts
in 8 cases of peripheral-nerve injury where the gap
between the divided ends of the nerve could not be
bridged by any other method ; in no case was there any
recovery of neural function. At varying intervals after
insertion, when it was apparent that no recovery was
occurring, the wound was explored and the graft
inspected. In 3 cases the graft was removed and studied
histologically 140, 355, and 904 days after insertion.
In all 3 cases regenerating nerve-fibres crossed the suture
line and penetrated the graft for varying distances, the
greatest being 25 mm. In the graft there was necrosis
of the fascicles and some fibrous replacement, the extent
of which appeared to depend on the time that the graft
had been in place; in the third case, examined at 904
days after insertion, there was dense fibrous tissue and
no evidence of the original graft elements.
Barnes and colleagues point out that the reaction to a
homograft differs fundamentally from. the reaction to an
autograft. The fibrous replacement of a homograft
appears to be due to a reaction of the host’s tissues ;
with an autograft the architectural characteristics of
the graft are maintained, and fibrosis results from the
proliferation of its connective-tissue elements. Why a
homograft undergoes necrosis and fibrous replacement
is still uncertain; Barnes and colleagues suggest that
it is the result of ‘‘ active acquired immunity ’’-—a view
originally expressed by Gibson and Medawar ‘ in relation
to skin homografts. Seddon and Holmes think that
where the gap is short, as in the rabbit, the tissue reaction
may not occur until outgrowing fibres have reached the
peripheral stump, and that in man, where the gap may
be long, the immune reaction attains its greatest inten-
sity long before the fibres have had time to. traverse
the gap.
Until more is known about the mechanism and control
of the host’s acquired immunity, the nerve homograft
will find no place in the surgery of peripheral-nerve
injuries.
1. Seddon, H. J., Holmes, W. Surg. Gynec. Obstet. 1944, 79, 1342.
2. Bentley, F. H., Hill, M. wie J. Surg. 1936, 24, 368. Sanders,
F. K., Young, J. Z. J. Anat., Lond. 1942, 76, 143. Bentley,
F. H., Hill, M. Brit. na J. 1940, ij, 352
3. Barnes, R., Bacsich, P., Wyburn, G. M» Kerr, A. S. Brit. J.
Surg . 1946, 34, 34.
4. Gibson, T Medawar, P. B. J. Anat., Tona: 1943, 77, 299.
THE. LANCET]
HEALTH EDUCATION
[SErT. 21, 1946 497
Reconstruction
+ HEALTH EDUCATION
ITS PROBLEMS AND METHODS *
l WALTER P. KENNEDY
Ph.D. Edin., L.R.C.P.E., F.R.S.E.
MEDICAL OREISEIN MINISTRY OF HEALTH
HEALTH education is a comparatively, new subject.
It has not yet been formulated in doctrine and pedagogic
methods, as hás been done with the older disciplines,
such as botany and chemistry. To say this is not to
disregard the work of those devoted medical men and
administrators, such as Heberden, Fothergill, Smellie,
.Snow,. and Chadwick and Simon, who laid the basis
of scientific hygiene and gave it practical expression in
public-health legislation.
The labours of the early iyrant involved convincing
the public so completely that their discoveries were
‘oorrect that the result was a general demand for
legislative action and an acceptance of the laws when
they were made. This meant instruction in the require-
ments for health, and it is the democratic method.
But a glance at the history of preventive medicine or
hygiene in modern times is enough to show us the main
grounds for the claim that health education is a new
- subject.
The preoccupation of hygiene is with the revani
of disease—and very properly so—while the preoccupa-
tion of the new health education is with the promotion
of health. The difference is that between a negative
and a-positive point of view. It is true that health
education could not have developed as an idea without
the prior creation of a firm foundation of preventive
medicine, but it is an extension from the older concepts
of the hygienists and sanitarians, and it has its separate
contribution to make to national welfare.
The time seems ripe to attempt at least: an elementary
analysis of the general concept and to formulate principles
for its further development. The following views are
presented as no more than a hypothesis upon which a
thesis may later be made. They are far from complete,
but their purpose will be accomplished if they only act
as catalysts to stimulate discussion among other workers
in the field.
DEFINITION
It is of first importance in any discussion to be definite
.- about the meaning of the terms used ; so we must make
a semantic examination of the word “‘ health.” This is
not easy, for health is a state of being and, as a biological
phenomenon, is in a continual condition of flux. Some
time ago I looked up the definition of health in all the
dictionaries and: textbooks at hand, and could not find
a single definition which satisfied the criteria laid down
in formal logic. -For example, to say that health is
wholeness or soundness of body and mind ” does
not really take one any further. At last it appeared
that the method of classical logic was inadequate to supply
the required answer. It was necessary to apply the logic
of the continuum as, for example, used by Bogoslovsky.
For the purposes of this dynamic logic we will postulate
that we can only consider health by also considering its
opposite, disease. This pair of contrasting concepts
may be regarded as opposite poles joined by a line along
which we can measure the distance of any point from
health at the one end, or from disease at the other.
Any scale of gradations can be chosen.’ This is what is
‘meant by a logical continuum. It is not a far step to see
that the ultimate of disease is death and (applying the
method of contrasting opposites) the ultimate meaning
ey ee re
* A Chadwick lecture given in London on Oct. 30,1945.
of health is life in the fullest and most complete and
perfect sense of the word.
But a complication must be added if the model is to
be adequate. Health and disease are not a simple pair
of contrasting opposites like heat and cold. They are
made up of immense numbers of components involving
the body, the mind, and the spirit. Thus the imaginary
line of the continuum becomes a rope of innumerable
strands. At first sight this may seem a tortuous and
perhaps pointless piece of speculation, but it does provide
.a basic model on which to found the reasoned structure
of the principles of health education. We cannot indeed
_escape the necessity for such a model, and it is surely
not contentious to hold that, if real advances in this
subject are to be made, the pragmatic méthod, which
has served its part, must be replaced by sound first
principles.
Health, then, is a state which can be measured. In
practice it is quite common to find approximate measure-
ments being made. The medical examination of Service
recruits, the much more exacting annual flying board for
pilots, the life-assurance examination, and mass nutri-
tional surveys are all examples of such approximations.
These would all appear crude if compared to the total
tests and measurements which modern medicine and
psychology could apply, were there sufficient time and
staff to do it. But they are enough for their especial
purposes.
If a population | large enough to give statistical
significance is examined by such methods, a norm or
average can be established which is a measure of the
so-called “normal” health of the group within the
limits of the measurements. But this is not to say that
such a normal is the best or even a proper state of health
for such a population. It is hardly necessary to point
out that any such standard norm for a group selected
from the British or any other people would fall far below
the norm which could possibly be attained by attention
to the rules of healthy living, good dentistry, complete
nutrition, individual education in place of conveyor-
belt methods, and so on. This is still true despite the
enormous betterment in national health and fitness,
expectation of life, stature, and the like, which have
been brought about by preventive medicine in recent
years—and which, we may well be proud to says
continued to improve during the war.
THE FIRST BASIC PRINCIPLE
It can be postulated, then, that such a norm of health
exists for any population, and any deviation below this
norm can be called negative, any deviation above,
positive. The validity of this concept is demonstrated _
further by applying to the measurements a Gaussian
curve, or indeed a frequency-distribution surface, although
I shall not here extend this argument. But in the doctrine
of positive health we have the first basic principle which
is the essence of the new attitude in health education.
It is that health is more than just the state of not -
being ill or of having no complaints or disabilities ;
Moreover “ ordinary ’’ health can be improved, though
preventive medicine alone is not enough. The idea
of positive health indeed points the way to constant
improvement. The fullest use and enjoyment of life
is only possible through the fullest use and enjoyment
of health. This is at once true of body, mind, and spirit,
which leads to the second basic Dey of sound
health education.
THE SECOND
This is the principle of holism, which I have found
best expounded in that most important book Holism
and Evolution, by General. Smuts. To put it in the |
simplest way, if we talk about man in the physical
sense, everyone will agree they understand what is
-meant ; but if we ask whether the term “ man ” includes
- fits.
428
his mind, or still more his soul, the argument starts.
Yet from the holistic point of view we must regard man
as a triad of body, mind, and spirit, just as psychologists
(of the classical school at least) treat the mind as a triad
of will, emotions, and intellect. But these are coexistent
and interdependent. They cannot be separated one
` from the other except for dialectic’: convenience. They
are not autarkic entities, for this would deny the
THE LANCET]
principle of solidarity. Similarly, a study of anatomy ©
without some physiology, especially neurophysiology,
would be completely meaningless ;
could not be studied at all without at least an elementary
knowledge of anatomy, for structure and function are-
inseparably related. Taking this circle method of
categorising one stage further, the life of man could be
described as a complex of the vegetative, motor, intellec-
tual, moral, and reproductive—and these merge at some
points. Part of the reproductive life of man is vegeta-
“tive, part of it is concerned with morals and so on.
The main point is that, while we admittedly section-
alise knowledge and observations, this is only a matter
of convenience, a sort of intellectual shorthand.
- “Separate ” sciences are really closely enmeshed together.
Advances in one produce alterations in the others, and
there is a fluid equilibrium between them. So, too, the
health of man is a whole thing and conterminous with
his life.
though commonly it is disregarded. ` For example, there
is the type of fallacy we may call unitarian, such as is
held by the faddist who has a diet cure for all ailments,
or the person who treats every ill as imaginary, the
so-called Christian Scientist.
It is necessary, then, for health education to be con-
cerned with more than the inculcation of habits of
= cleanliness, temperance, exercise, and the like. The
old saw “‘
“ corpus sanum in mente sana.”
- be remembered that the moral outlook is intimately
connected with the health of both body and mind.
THE THIRD —
The third principle of health education is not easy to
name satisfactorily, but for present purposes we may call
it the principle of motive or aim. It is designed to provide
Equally it must
the force or energy for carrying out whatever procedures |
may be necessary to obtain health. The principle shows
that in planning health education it is not sufficient to
instruct people how to improve their personal or com-
munity health. It is necessary at the same time to
convince them that it is really worth paying the price
in effort, time, and perhaps money to obtain these bene-
This may at first sight appear so obvious as to be
out of place in such a discussion, but unfortunately this
is not so. Ask anyone if they. want to be healthy, and
the unhesitating reply is that they do. If this question
is followed by a supplementary query about what they
are now doing to promote their health, the answer is
` seldom so prompt.
It is true that some people will reply that they brush
their teeth after meals and take open-air exercises when’
they can, and so on, and, in an occasional instance, if
one has chanced on a faddist such an inquiry may open
floodgates of enthusiasm. But only an insignificant
proportion of the population make any effort to improve
their physical and mental health and efficiency, unless
illness has brought home to them the handicaps of
disease.
Health education, then, must not only instruct but
also convince people that health is worth having. The
fact is obvious, as everyone will admit; but it is one
thing to accept the validity of a general statement
intellectually, and quite another to accept it emotionally
as well. If our instruction is to produce the best results,
it must create ‘converts to the idea and imbue them
HEALTH EDUCATION
while physiology
In studying it this should always be remembered, .
mens sana in corpore sano’’ has its corollary, .
a given activity than others).
` [SEPT. 21, 1946
with the fervour usually associated-with the phenomenon
of conversion. The formula then is:
(1) health is worth having,
(2) ordinary health can be improved by the exponditiire of .
effort, and |
(3) the expenditure of this effort pays real dividends.
I do not apologise for hammering at this point, obvious
though it may seem. It is a common enough experience
for people to be fired by the enthusiasm of a physical- —
culture expert on the radio, or perhaps a writer in a
women’s paper who promises beauty, charm, and a
handsome husband for, say, five minutes’ deep breathing
a day. The course of exercises or massage or whatever
it may be is started at once and kept up with fervour
for at least three days. How reminiscent this is of the
parapie of the seed that fell on stony g ground.
THE FOURTH
The fourth principle of health education is that of
use. We must use our faculties, or they gradually fade.
The Indian fakir may hold his arm above his head for
years, and the muscles atrophy and the joints ankylose
so that he cannot lower it even should he wish. A
small boy may attain some competence at the piano
in three or four years and then give it up, only to regret
as an adult that he is just able to pick out “ Swanee
River ’’ with one finger. These are examples ar atnophy
and disuse.
Few people develop and use their physical and mental
powers in the most efficient way, and improvement is
nearly always possible: The fact that athletes train
specially before a big event is evidence of this. One can
learn to walk a tightrope, or perform the difficult gyra-
tions of the ballet dancer, if one sets one’s mind to it.
This does not mean that everyone should practice
acrobatics or aspire to dance ‘* Petroushka.” It is
instanced as an example of how physical capacities can
be expanded (naturally, variations in physical and
mental endowments make some people more fitted for
It is equally true of
the mental faculties, whether one tackles the solution of
mathematical problems or the harder task of swaying
the House of Commons by impassioned eloquence. A
combination of application and practice will improve
one’s facilities for dealing with either contingency.
This principle can be taken a step further, for it
must be applied equally to the soul. Admittedly this
is an unsatisfactory terminology, but the point to be
made is that no person is completely healthy unless he
has a sound moral discipline. Whether this be entirely
from without, or from the wells of a man’s own conscience,
or a combination of the two, is irrelevant. The essence
of the matter is that this moral discipline must exist. It
has been remarked with surprise that during the war there
was a decrease in neuroses, and the anticipated incréase
of mental ill health did not develop. Though it is easy
to fall into the fallacy of post hoc, propter hoc, I am
convinced that this reduction sprang from the same
origin as did both the increase in the obvious unselfishness
of people, and the warmer spirit of neighbourliness which
was experienced especially in the bombed areas. The
stern necessities of the time imposed a stronger moral
discipline, and it is my opinion that this brought with it
a e OVa in mental and perhaps also physical
health
- An obvious example of the value of moral discipline
is in the realm of sex, where control is particularly
dificult because of the deep roots of the instinct, and
because of the repressions which have followed inevitably
from the development of our culture.
ence will deny that the sex aspects of life affect health
in many ways, and equally those experienced in dealing
with these problems will agree that the appeal to
expediency is inadequate to determine healthy sex
behaviour.
No-one of experi-
aE aE a
a ie ee *
THE LANCET]
~ OBITUARY
[sepr. 21, 1946 429
The rôle of moral discipline cannot be neglected ;
whether it is religious or strictly ethical is a matter for
the individual about which one has no right to be dog-
matic. It is, however, perfectly legitimate to insist
not only that it is important but also that it is essential.
_ METHODS OF PRESENTATION
Despite an extensive search I have been unable to
find any study which takes a comprehensive view of the
methods of health education.. The nearest is a book
by Williams and Shaw entitled Methods and Materials
of Health Education (New York, 1937), but it does not
go into the detail which seems desirable. We need
an evaluation of the relative effectiveness of the different .
methods of propaganda, from lectures to health weeks,
particularly in respect of their impact on different age-
groups or social groups and their applicability to the
type of message which has to be given. A study of this
nature is urgently needed. Techniques exist for carry-
ing out such an investigation and have been developed
widely in America in the field of merchandising research.
Some information of this kind has been collected in
relation to the Ministry of Health’s successful campaign
for diphtheria immunisation, but we need more general
research. .
A system of classification should be the first step in
planning a campaign of health education, whether it be
extensive or intensive. Different systems of classifica-
tion may be used; for example, we may divide the
problem into one of school and adult education. The
former falls into three subdivisions of infant, elementary,
and secondary, and university and technical college
groups. The adult -education would subdivide mto
general, comprising city- or nation-wide campaigns, and
special, covering the instruction of small groups such as
St. John ambulance detachments, Women’s Institutes,
or patients attending a maternity and child-welfare
centre. A second type of classification, parallel with
the first, categorises the methods of instruction: oral
(lectures, discussions, radio), visual (posters, advertise-
ments, pamphlets, cinema, and exhibitions), and a
comprehensive class of “health weeks.” One might
include in this list the provision of amenities, such as
swimming-baths, gymnasia, and sports grounds; but
the implications of this are wider than the strict field
of health education. A third system of classification,
which. would be useful in devising a scheme for health
education, would be to enumerate the people and organisa-
tions involved in conveying the message—doctors,
teachers, sanitarians, societies, and associations of
various kinds.}
In the absence of an analysis of actual observations an
opinion carries little authority ; but, if only to invite
contradiction, I say that the oral approach is more
effective in adult education than is the visual ; radio and
lectures appear more effective instruments than do
advertisements or posters. The success of Sir Wilson
Jameson and of Dr. Charles Hill on the air has been -
outstanding. The position of the cinema, however, is
anomalous, because it combines both types of instruction,
yet in this medium the visual element predominates over
the spoken. There are great potentialities in the develop-
ment of health-propaganda films, but the standard of
technical achievement in this field has not advanced so
quickly as it might well have done. Admittedly the
techniques are in the difficult stage of formulation, but
with two exceptions the standard of health films I have
seen is poor. The main reason appears to be that they
have been made for non-commercial purposes under the
direction of a committee of some society or association.
If the health film is to have an effective future, its
structure must be regarded far more as a matter for
professionals than has been the case in the past.
1. Seo Kennedy, W. P. Hlth Educ. J. 1945, 3, 60.
THREE LINES OF ACTION
There are three practical lines of action which are
essential for making the most of health education.
The first is the provision, especially in the small centres
of population, of more swimming-baths, gymnasia, and
sports facilities. These are the workshops of health.
In a recent visit to Germany I was impressed again by
the way in which small towns were supplied with these
amenities. Some hymn-writer once complained that it
was not right that the devil should have all the best
tunes. Equally we should not allow our fascist enemies
to be able to claim that in such ways they did more for
the people’s health than does the stronghold of democracy.
The second point is the necessity for training more
teachers in biological science and methods. Hygiene is
an obligatory course in American schools, and many
feel that this country lags deplorably in neglecting
this study. But, unless fully trained teachers with a
biological outlook are available, it is futile to introduce the
subject. More harm than good would result if the
ordinary teachers were given a Reader in Hygiene to
go through with their classes. Prof. Lancelot Hogben
has more than once put forward the demand that the
universities’ biological departments should review their
instruction and train more students in general biology.
The aim would be dual—to provide more biology teachers
for schools, and to give all university students some
knowledge of the science of life as an integral and essential
part of cultural education. The educationist who would
disagree with this proposal would be indeed a bold man.
` Finally, there is no doubt in my mind that the churches
should be codrdinated more closely, with the aims of
national health. It has been shown that, from the holistic
point of view, one must consider the moral aspect .of
human life with the physical and mental, and the point
needs no amplification. It need only be added that the
community group of the church congregation provides an
admirable nucleus for concerted action. People of like
conviction associate together easily, and the connexion
with the church is advantageous in many ways. -Within
the church and outside it many voices are growing
increasingly insistent that the church should pay a more
vital contribution to the nation’s life. Participation in
health education is not merely another way in which
this could be done. I submit that it is an essential duty
for the churches to interest themselves in this matter,
for life and health are a single whole, and no health
education can be complete unless it includes in its ambit
the physical, mental, and the moral activities of man.
Obituary
KARL NARBESHUBER
M.D.
Obermedizinalrat Karl Narbeshuber, who has died at
Gmunden, Austria, in his 79th year, was a former
president of the Austrian Medical Association. A true
Austrian and a friend of the British, he was no doubt
a marked man in the eyes of the Nazis, and no sooner
did the Anschluss come than they took their revenge,
treating him with cruelty and indignity. Hauled out of
his bed on the first night he was thrown into prison,
his life was threatened, his head and beard shaved, and
he was deprived of his civil rights, property, and practice,
and separated from his family. When Austria was freed
he returned to his native town of Gmunden and once
more devoted himself to his duties as Stadtarzt. But
age and the privations of war had affected his health
and he died on August 28. | )
A lovable man of wide learning and an exceptional
linguist Dr. Narbeshuber did much for the British
prisoners during the first world war. He often visited
London, and many English doctors have enjoyed his
agreeable hospitality in Austria.
, J. À. H. B.
430 THE LANCET] ©
BRITISH-SWISS MEDICAL CONFERENCE |
- x : a
A - 5 :
.
oo
| (sepr. 21, 1946.
=- Special Articles
BRITISH-SWISS MEDICAL CONFERENCE
Tue conference organised by the Swiss Academy
of Medical Sciences and the Royal Society of Medicine
- opened in the hall of the ethnological museum of the
University of Basle on Sept. 16. Of the 280 doctors
present. more than 150 had come from the United
Kingdom. Prof. A. GIGON, secretary-general of the
academy, who first proposed a conference of this kind,
introduced Prof. KARL WEGELIN, the academy’s presi-
dent, who said that the aim, as at last year’s Franco-
Swiss conference in Geneva, was to foster international
relations. Welcoming the British visitors he recalled the
ancient political and cultural bonds’ between the two
countries which had -remained unbroken since the
seventh century. For Switzerland he expressed satis-
faction at the end of the intellectual isolation enforced
by the war. Bundesrat ETTER, on behalf of the Swiss
Federal Council, paid a tribute to British tenacity
in the war and recalled what had beén done since then
to strengthen the links between his country and Britain.
He mentioned in particular Switzerland’s help in the
difficult post-war period—for example, she had invited
400 British children to stay in the country. ` Other
speakers at the opening meeting were Mr. T. M. SNow,
the British minister in Berne, Monsieur PAUL RUEGGER,
the Swiss minister in’ London, Prof. EDGAR BONJOUR,
rector of Basle University, Regierungsrat Dr. MIVILLE,
representing the authorities of Basle, and Lord AMULREE,
representing the Minister of Health, who recalled the
world’s debt to Switzerland for the International Red
Cross and for her fine conception of political liberty.
Prof. J. B. HUNTER, Prof. J. H. DIBLE, and Dr. ALAN
DRURY, F.R.S., of the British organising committee,
emphasised the need for collaboration between the two
countries and expressed thanks for Swiss hospitality. .
After the formal opening Sir Huen CAIRNS read a
paper in German on Investigations on Head Injuries
in Britain during the Second World War. Other papers
were given in English with a simultaneous translatio
into German. TA:
The afternoon session, under the chairmanship of
Sir LEONARD PARSONS, was opened by Prof. LuUZIUsS
RUEDI, who spoke on Acoustic Trauma, of which he
distinguished four types which could be classified
according to loss of function into two groups: the first
group comprised noise trauma, report trauma, and
certain blunt head injuries, and the second explosive
trauma. He went on te describe an ear defender which
he had designed, containing a resonator; its effect was
to damp down frequencies between 2000 and 7000 cycles
per second without seriously interfering with hearing.
Repeated experiments had proved the complete effi-
ciency of this defender which he suggested could be
usefully applied in industry.
CIRCULATORY FAILURE
Dr. JOHN McMICHAEL (London) said that the old `
“ back-pressure ’’ view of cardiac failure was based on
the mistaken idea that the veins are inert tubes. Thirty
years ago Starling showed, by means of his heart-lung
preparation in the dog, that the most important single
factor determining cardiac output is the venous inflow ;
up to a certain point elongation of the cardiac muscle
increases its capacity for work, but beyond that point
output falls. Harrison, in 1935, suggested that the output
of the heart might not be very much lowered in heart
failure, and in 1938 Dr. McMichael reached much the
same conclusion. In the early stages of failure the
resting output may not be significantly lowered, but the
capacity. to increase output is diminished. Only later
does the output fall, and then usually to not less than
half the normal resting value. The measurement of right
auricular pressure by a ureteric catheter, first practised
by Cournand in New York, has proved a safe and effective
means of estimating cardiac output and filling pressure,
and has been employed without mishap in over 500
cases by Dr. McMichael and his colleagues. .The new
method has confirmed that in the ordinary forms of
heart disease, from valvular defects or hypertension,
the resting output is. maintained and the first rise of
venous pressure takes place when the output is only
-slightly below the normal average. This rise is thus not |
the back-pressure effect of a falling output but a com-
pensatory mechanism to maintain the optimum output
as long as possible. In.the later stages of failure the
venous. pressure is considerably raised and the cardiac -
output reduced to about 3.litres a minute. In tho failing
heart digitalis reduces: the venous pressure and increases
the cardiac output, though in the normal heart the
reduction of venous pressure is accompanied by a fall
in output. In auricular fibrillation rate-reduction is not
of primary therapeutic importance; the major benefite -
of digitalis are achieved by reducing the venous pressure,,
and a mechanical reduction of -venous pressure will
produce as great an improvement as digitalis. . 34
_ Discussing the conditions in which a high cardiac |
output is required to oxygenate the tissues, Dr.
McMichael said that Sharpey-Schafer has shown that
when the hemoglobin falls below 30 % the cardiac output
may need to be doubled and this can be accomplished
only by a high.venous pressure and a simultaneous
increase of pulse-rate. At this stage the patient’s condi-
tion is precarious, and venous congestion and oedema
may be pronounced. Digitalis will lower venous pressure
and cardiac output, so reducing the supply of oxygen
to the tissues and making the patient worse ; transfusion,
on the other hand, will raise the right auricular pressure
but reduce the cardiac output, and this may result in
death from heart failure, owing to pulmonary cedema.
If transfusion is necessary to save such a patient’s life
it must be given slowly, possibly combined with digitalis.
The danger lies in raising the venous pressure, which is
set at the optimal level, so the anzmic patient should
be treated with liver or iron, as far as possible avoiding
transfusion. In cor pulmonale the output. is usually
high for a reason similar to that in ansemia—i.e., the
available oxygen in the arterial blood is considerably
reduced. Here digitalis is not only useless but dangerous.
High-output failure ‘has recently been observed with
generalised Paget’s disease, in a man of 66. The blood-
flow through the normal skeleton, measured by Prof.
O. G. Edholm with the plethysmograph, is about
100 c.cm. a minute, whereas in Paget’s disease the total
skeletal flow is between 3 and 4 litres a minute. The
circulatory state is thus a result of the enormous increase
in skeletal circulation. 7
The classical pre-war conception of shock has been
modified ; the view that blood is pooled or trapped in
some part of the vascular system has been discarded.
Heemorrhage is the major factor in war wounds; hsemo-
concentration does not occur except in burns and crush
injuries and some types of abdominal injury. Wallace
and Sharpey-Schafer have shown that, after the loss of
1000-1200 c.cm. of blood, full blood-dilution is not
attained for some 40 hours. SBlood-volume may
reduced in chronic anæmia, and this state is associated
with an increased cardiac output. In hemorrhage the
pressure falls in the great veins, the cardiac output
falls, the pulse-rate is accelerated, and the ee deen
resistance is increased. After this first phase there may
be a vasovagal reaction, owing to sudden vasodilatation
in the arterioles of the skeletal musculature, with reduc-
tion in pulse-rate and blood-pressure. Recovery from
this reaction, whose purpose is obscure, may be hastened
by .‘ Methedrine’? D. W. Richards has shown that in
the average case of shock the cardiac output seldom
falls below 3. litres a minute; the deep fall in blood-
pressure is due mostly to lack of vasoconstriction, for
which hitherto ill-defined factors in addition to the
vasovagal reaction may be responsible. Oxygen is
worthless as a means of overcoming the defects of
sluggish blood-flow in shock. Recent observations suggest
that in shock with overwhelming infections the regulation
of venomotor tone may be impaired and a suprarenal
cortical mechanism may be involved somewhere in the
chain of events. Other types of non-surgical shock—
e.g., the collapse of diabetic coma and coronary throm-
bosis—should be approached by the new methods.
THE LANCET]
Observation suggests that peripheral vasodilatation and
a high cardiac output are present in the early stages of
diabetic acidosis.
. (ESTROGENS IN CANCER
Prof. E. C."Dopps (London) recalled the steps which
led to the synthesis of stilbcestrol, hexcestrol, and
diencestrol as the result of collaboration between Sir
Robert Robinson and his colleagues in Oxford and
Professor Dodds’s own department at the Middlesex
Hospital. Animal experiments have shown that these
three substances can replace all the known activities of
the naturally occurring cestrogens. They have now
been widely used clinically for the treatment of meno-
pausal symptoms, amenorrhea, and dysmenorrhoea, and
for the termination of lactation. Their great advantage
lies in the fact that they are active by mouth and cheap
to produce. The possibility of using cestrogens in the
treatment of carcinoma of the prostate was first mooted
by Huggins and his colleagues in 1941. Castration for
the relief of prostatic carcinoma was originally advocated
by John Hunter, who observed that the gland would
shrink when the testes were removed. However, the
operation: had so many objections from the patient’s
point of view that it was rarely performed. In the
. four years from 1939 to 1943 Huggins treated 69 patients
with advanced carcinoma of the prostate by castration
combined with the administration of cestrogens. The
synthetic oestrogens were found to be perfectly suitable
for this purpose. (£strogens were administered to
patients who did not obtain a long remission of their
symptoms after castration and to those in which the
serum-level of acid phosphatase, though considerably
reduced, did not drop to normal. In most cases the
treatment relieved pain and frequency of micturition,
and improved the patient’s general condition; in some
cases there was a reduction in size of the primary tumour
and the secondary deposits. Other workers in Britain
and America have treated carcinoma of the prostate
with cestrogens alone and have confirmed Huggins’s
findings. About 95% of cases respond in some degree,
but the improvement is not always maintained and
many cases will have to be classed eventually as delayed
failures. No serious worker in this field would claim
that synthetic cestrogens will cure carcinoma of the
prostate, since if treatment is interrupted the disease
begins to progress again as before. But the treatment is
more than mere palliation; the benefit obtained, even if
only. temporary, constitutes a definite arrest if not a
regression of the disease. Side-effects reported from the
administration of cestrogens include swelling, tenderness,
or soreness of the breasts, nausea, vomiting, and occa-
sionally soreness of the testes. As a rule these effects
are not serious enough to require cessation of therapy
and they are generally far outweighed by the benefits.
obtained. The dosage of synthetic cestrogens is 1 to 5 mg.
per day. a ; ,
The exact mode of action of cestrogens in carcinoma
- of the prostate has still to be worked out. The changes |
in the serum-level of acid phosphatase indicate that the
metabolism of the malignant cells is interfered with.
This enzyme is present in large quantities as a secondary
sexual characteristic in the adult prostate, and its
presence depends on the activity of androgens. The
serum-level of acid phosphatase was shown in 1936 to
be abnormally increased in some men with metastatic
carcinoma of the prostate, and in 1941, Huggins demon-
strated that the level can be reduced either by orchi-
dectomy or by the administration of cestrogens. He also
pointed out that in many cases a malignant prostatic
tumour is due to hypertrophy of adult epithelial cells
which are acted on by androgens. He therefore deduced
that if the activity of androgens could be inhibited,
either by removal of the testes or by the administration
. of cestrogens, then the growth of these cells would be
interfered with and the tumour and possibly the secon-
daries would regress. A possible explanation for the
occasional failure of cestrogen therapy is that these
tumours may be due to the malignant development of
other cells over which androgens have no control. A
further explanation is the existence of an extragonadal
source of androgens, possibly in the adrenal cortex. It
is still doubtful whether, in addition to the inhibition of
androgens, the synthetic cestrogens exert some definite
v4
A VISIT TO FINLAND
~
[serT. 21, 1946 431 |
controlling influence on the malignant cells themselves.
Biopsies on cases before and after treatment with
stilbcestrol have revealed. characteristic changes in the
cells, different from those caused by irradiation.
Until the action of synthetic cestrogens in prostatic
carcinoma is explained it is impossible to forecast the
likelihood of success in carcinomas of other parts. Some
success has been obtained in carcinoma of the breast—
of 168 cases reported by various workers, 41 were
improved, and in 6 the improvement was ‘‘ spectacular”.
—and again the question arises whether the-improve-
ment is due to a change in the endocrine balance or to
the specific action of the drug on a certain type of cell..
A committee has been set up by the Royal Society of
Medicine and the British Empire Cancer Campaign to
investigate a large number of cases of carcinoma treated
with synthetic cestrogens and to follow them up over a
long period. The report of this committee cannot
appear for some years, but it is hoped that it will yield
valuable information on the type of case most likely to
be benefited and the reasons why such benefit is to be
ex pected. |
A VISIT TO FINLAND |
W. P. Gurassa' - = F. L: Jackson
M.B. Lond. - M.B. Lond.
WUILE on a visit to Stockholm, in March of this
year, we were assisted by the British Council to visit
Helsinki, so that we could see something of the medical
work there and meet some of the students and young
physicians. |
The journey across the Baltic was an entirely new
experience. The sea was frozen almost all the way
over, so that even with the assistance of icebreakers |
progress was slow. Several times the ship jammed in
the ice and we arrived at Abo many hours late. But
the weather was wonderful—cold and crisp with brilliant
sunshine, This, with the spectacle of myriads of tiny
islands, made the journey a delight. | |
The train journey to Helsinki from Abo was not so
pleasant. We left Abo early in the morning, without
any breakfast. Finnish restaurant food is bad. We
were offered some tiny scraps of rye bread with a little
fish roe on them, but could not face them, so we sustained
ourselves with some sugar which we had brought from
Sweden. Later, when the train stopped for a quarter
of an hour at a station we ate some potato, which in our `
. then famished state seemed extremely good. .
At Helsinki we were met by the assistant professor
of radiology from the General Hospital and two students,
.one of whom was a Swede who spoke fluent English
and acted as our guide during our short stay. We were
‘taken immediately to see Professor Holsti, the professor
of internal medicine, who entertained us generously,
both at the hospital-and at his home. He spoke
excellent English, having studied for some years in
America, and in true American fashion had prepared for
us a very full programme designed to show us as much
as possible. a |
At 8.30-on the first morning we attended the radiology
department, where we saw some films showing opacities
in the lungs of patients with typhus, early in the attack
before the appearance of the rash; these opacities
are fleeting, and should be sought specifically. Another
interesting film of the chest showed the characteristic
ground-glass appearance of asbestosis. We were impressed
by the quality of the work and the enthusiasm of the
staff, |
Next we were conducted round the Polyclinic by
Professor Holsti. We saw several cases of Buerger’s
disease, one in a patient of 17 years, and were told that
it is common in Finland, Another condition of which
we heard much was dibothriocephalus infestation,
and we were each presented with specimens of the
worms to bring back to England, This, however, was
probably unnecessary, since after eating some of the
432 THE LANCET]
fish obtainable in Finland—raw—we probably now
harbour sufficient of the parasites ourselves! The
morning concluded with visits to special departments
for the treatment of cancer, chiefly by radio-
therapy, and the newly formed allergy clinic under the
direction of Dr.’ Erikson-Lihr, the first-of its kind in,
Finland.
A national scourge in Finland is fahorculosia, the
annual mortality-rate being 17 per 10,000. Dr. Severi
Savonen,.who is in charge of the tuberculosis services
in Finland, told us that the war had brought a halt
to the previous decline in the mortality-rate. As elsewhere
in Scandinavia, B.C.G. inoculation is widely used, on a
voluntary basis. Infants are inoculated, where possible,
in the obstetric clinics soon after birth, and special homes .
are provided for the isolation of infants from open
cases. Savonen believes that inoculation produces
excellent results and does not give rise to ill effects.
At Christmas time, money for anti-tuberculosis work
is raised by the sale of coloured stamps which are stuck
on the letters in addition to postage stamps.
Later, Professor Holsti initiated us into the mysteries
of the Finnish steam bath (sauna), which is widely
acclaimed as responsible for the toughness of the Finns,
endowing them with a spirit of unbounded energy and
stubborn determination (sisu). Many people have their
own steam baths, and Professor Holsti’s was in a rough
wooden shack in his garden. In the corner burned a
fire, and water drawn from a near-by trough was cast
- on to it so that clouds of steam billowed into the room.
It is the custom to lie outstretched on wooden shelves
and perspire freely. From time to time one washes
with cold water, or beats oneself with a sheaf of leafy
twigs which have been dipped in cold water. Then
the heat increases. ‘When one feels sufficiently relaxed
one runs outside and rolls in the cold snow for a minute
or two. This closes the skin vessels and facilitates
drying. We dried without this severe preliminary act,
but watched amazed while the Proteeror s son and our
Swedish guide performed it.
‘Next morning we visited the niouropeyohiattic institute
at Lappvik, where we were conducted round the wards
by Dr. von Bagh who addressed us in French. This
institute is over 100 years old, but its construction is
_ good. The wards and corridors are light and airy, and,
as in most Scandinavian clinics, there are few patients
in each room (3-6).
sclerosis, and it was claimed that fairly good temporary
results were obtained. by pyretotherapy. Prefrontal
leucotomy has recently been introduced in Finland,
being used particularly for the treatment of chronic
obsessional states. We saw the first case so treated at
this hospital.
We learnt something of the poor food situation both
from personal experience and from accounts given to us
by medical men. Bread is of the poorest quality, dark,
coarse, and bitter, and is strictly rationed. Milk is
rationed to 600 c.cm. per person per week, butter to
500 grammes a month, and no other fat is obtainable,
Meat is rarely seen. The staple diet consists of potato,
bread, and fish. There is, however, a large black
market in food for those who can afford it. Most of the
people look thin and ill clad, and Helsinki, once proudly
called the ‘“ White City of the North,” shows signs of
neglect and dilapidation.
On our last evening we were entertained to dinner
by the Medical Association.. We gave them some
account of our medical studies in England, and many
of them expressed a desire to visit England later on.
We have brought back many pleasant memories of
Finnish hospitality.
The Finns look with confidence and determination
to the future—their ‘‘sisu’’ is no myth—and they
will strive hard to restore prosperity to their land.
ARMY REFRESHER COURSES IN GERMANY |
We saw many cases of disseminated
‘appreciated ;
lata 21, 1946
ARMY REFRESHER COURSES IN GERMANY
-~ AT the end of the late war the university clinic at
Göttingen, with its 2000 beds, was found to contain a
remarkable selection of clinical material. In the ensuing
months Major J. M. McFie and Major H. C. McLaren,
the medical and surgical specialists attached to a nearby
casualty clearing station, paid repeated visits. to the
clinic, with which they were so impressed that they.
suggested that refresher courses should be held. there
for medical officers, particularly those on general duty ;
such courses, they thought, might encourage post-
graduate study. The proposal was warmly supported
by the director of medical services, and the consulting
physician .and surgeon, 21 Army Group; and the first
course was held from Nov. 18 lo. 24, under the direction
of ae McLaren, who was later succeeded Py Captain
P. E. H. Jones.
CLINICAL TEACHING
The clinical teaching was given by the university
staff. Few of these spoke fluent English and most
officers had diffculty in following explanations in
German ; direct interpretation was tedious and some-
times misleading. A German-speaking specialist officer,
R.A.M.C., was therefore appointed chairman-interpreter. |
Case-notes were abstracted and translated into English,
and the translation was circulated with thė original
notes in German, which, with even slight knowledge of
the language, provided a good deal of information.
Cases were chosen with straightforward clinical signs
to ilustrate common disorders. In the medical and
surgical clinics each officer was allotted a long case, with
twenty minutes for examination, followed by five minutes
in which he summarised his findings before the whole
class, and .a further five minutes for the professor's
comments. Short cases were also shown. Midwifery
and gynecology were handled on much the same lines.
Post-mortem demonstrations were included ; and for a
short time each day the Germans demonstrated their
own recent advances. The morning break and a further
period at the end of the day were used for discussion;
time at the clinic was often saved. by deferment of
individual questions until these meetings.
The German method of teaching differs from the
British. With the British method interest is sustained by
the discussion of history,` symptoms and signs, and
differential diagnosis, and by the liability of anyone
suddenly to be asked a question. By the German method
the diagnosis is. often given first and followed by a
discourse in which the grounds for the diagnosis are
discussed. Much the same results are achieved in the
end by the two techniques. For the courses the British
method was used. |
OPEN LECTURES
The last afternoon was usually occupied with a lecture
or demonstration by either the consulting physician or
surgeon, or a medical officer with special knowledge - -
of some subject. These were open lectures which might
be attended by anyone, including sometimes nurses
from the clinic; as many as 150 have been present.
The arrangement that has proved most satisfactory
has been for the lecturer to speak slowly and clearly in
English, and for each listener to have a German trans-
lation in front of him. Experience has shown that
translation of German case-notes into English is best
undertaken by an Englishman, but that the German
version of a lecture to be given in English should be
made by a German.
Medical officers attending the clinic have had the
chance of seeing German methods and of obtaining clinica]
instruction in aspects of medicine which during their
service they had had little opportunity of studying
The reading of textbooks. which has been increasingly
practised since the end of the war, has been given added
impetus by these courses, which have been greatly
and the German staff has worked hard to
make them successful. Seven courses have been held at
Gottingen, and they are being continued at Hamburg,
which is. more readily accessible. In addition, courses
in midwifery are being held for nursing officers. It is
intended that these courses shall be retained as a
permanent feature of training in the B.A.O.R.
THE LANCET]
In England Now
A Running Commentary by Peripatetic Correspondents
DURING the war one had either to “stay put” or to
keep moving round the world at an enormous pace.
After nearly four vears of the former, I spent the later
part of the war in almost incessant travel. I gather that
we itinerants were generally spoken of as * swans ’’—1.e.,
creatures who flit aimlessly from place to place sticking
their long necks out. One’s journeys (*‘ really necessary ”’
or otherwise) were often brightened by unexpected
meetings with old friends. For instance, when T arrived
at a general hospital in North Africa the first officer I met
greeted me by my christian name—much to my surprise,
for I certainly did not recognise the prosperous, mature
individual who spoke. I discovered that we had been
new boys at the same prep. school together, and that he
had changed inwardly a good deal less than in outward
appearance. And the o.c. of the same hospital turned
out to be our own family physician, a territorial with
whom I had lost touch since his call-up in 1939.
Then there are the people one is always meeting.
One eminent medical major-general has done even more
“ swanning ” than I have. Within a period of eighteen
months our orbits have touched, quite without premedi-
tation, at Prestwick airport (he en route for the U.S.A. ;
I on my way home from Africa), London, Manchester,
Colombo, Melbourne, Delhi, and finally back in London
again. I am convinced that if I ever reach the North
Pole F shall find him squatting there. Then there are
the others that one just misses. I have been trying to
meet one scientist for years, and have been within
week of him in every continent of the globe. i
It is often impossible to avoid the use of such clichés
as “its a small world.” I remember meeting one
American major at a laboratory in the heart of the
Rockies. A month later we met again, this time at
Myitkyina, on the Irrawaddy, in Burma, after he had
crossed the Atlantic and I had crossed the Pacific.
* * * .
Yes, as I was saying when you cut me off.on Sept. 7,
the practitioner in the Medically Overcrowded Area
(M.O.A.) is perhaps less like a vulture than like that
aged man a-sitting on a gate, of whom the poet sang :
I shook him well from side to side
l Until his face was blue.
“ Come, tell me how you live,” I cried,
- “ And what it is you do.”
True, neither a Royal Commission nor anyone else has,
in so many words, asked him; but there can be no
doubt of the shaking. It continues with increasing
violence and perhaps can be taken to imply the question.
Anyhow by the time the cyanosis has reached ante-
mortem intensity it will be hard to give an articulate
and dispassionate reply. That hour is not far distant.
Better try now.
The essential feature of a M.o.A.—at least of mine—“is
that although it contains a fairly intimate mixture of
citizens of every social and economic class a good number
are what is called ‘‘ educated ’’; some have comfortable
incomes and some have inherited that sane and coinely
fashion of living which made Maurois call the English
gentleman ‘‘la type la plus sympathique du monde.”
The combination of all this with the famous medical
overcrowding has an almost wholly beneficent effect on
the quality of medical practice. Comparatively speaking
there is time for good work, rewards for doing it, and
effective penalties for not doing it. Our all-round com-
petence is, I am sure, less than that of many of our
colleagues in country towns, to whom I take my hat
right off; we are not their equals in resourcefulness, nor,
I suspect, in power of endurance; they would beat us
hands down at surgery, and I judge that they are better
at team-work—your typical M.o.A. doctor works alone—
but there are provinces of medicine in which I believe
we hold the field.
It is fashionable to assert that the whole profession
takes little or no interest in personal. preventive medi-
cine; it never sees the healthy patient and seldom even
the early symptom; its concern is solely with declared
disease. How different things will be when we have
IN ENGLAND NOW
!
[SEPT. 21, 1946 433
health centres! Perhaps they will, but in the meantime
all these things which the whole profession neglects to —
do it does in fact daily, hourly, and as a matter of course `
in the M.O.A.
To set aside half or three-quarters of an hour for
discussion of Susan’s aversion to food and Willie’s to
sleep, for the terminal or annual overhaul of three
children returning to school; to determine whether or
why Mr. Smith has grown thinner, or why Miss Jones
has been coughing for four weeks ; to give Mr. Brown the
once-over because he hasn’t seen a doctor for several
years—all the variations on these and kindred themes
make up, except in seasons of epidemic, a large proportion
of our daily work. | |
Now I am far from asserting that this is indeed the
medicine of the future. For. the practitioner it is
exacting, difficult, rather tedious, full of pitfalls, and not
very rewarding either in cash or in things discovered or
things prevented. It can never be a main fountain of
health, and for the patient it has potentialities for ill as
for good. But it is the medical reformer’s white-headed
‘boy, it is perhaps the chief characteristic product of the
M.O.A., and when the reformer has had his way with us
the M.O.A. and all its works will be gone. Forsooth, a
pretty paradox! But each man kills the thing he loves ;
and perhaps reformers are no exception. — ,
What else do we do? The doctor’s daily job, with
perhaps six hours over in the week to divide between
reading, writing, committees and societies, the family,
and the cultivation of a garden or an art. Six? Well,
perhaps eight, and, being on good terms with our profes-
sional neighbours, we get a yearly holiday without
importing alocum. What really attracts us to the spot ?
Not fortune-hunting, but, this excluded, it is anyone’s
guess. My own is that if we were examined the greatest
common factor in our make-up would be a certain slow-
ness—we are not quick thinkers or quick workers; we.
must have time. Unquestionably we are individualists,
with the qualities and defects of that species. Probably
most of us set rather a high value on the pleasant manners
and way of life to which most of us have been brought
up and prefer a small income in a place where our wives
and children can enjoy these things to a large one where
they cannot. We may believe, too, that we can do our
best work where we are; and we may be right. l
What of our patients—the citizens of the M.o.A. ?
Are they privileged ? I think they are; but not, as the
planners preach and possibly believe, by receiving some
costly drugs or magic treatments denied to others.
.They have, and exercise, free choice of the most genuine
sort; they reap the very real benefits of competition.
Each of us knows that if he lets his patient down that
patient can turn to his neighbour. It is very salutary
knowledge. They enjoy the almost priceless boon of
being able to ask for an appointment to discuss any
matter in which they think we can help them. To
extend this last benefit to ‘‘ insured persons ”’ without
much more encouragement than any government of the
last 35 years has given must seem to most people
impracticable. It seems so to me; but most men do not
readily divide themselves, no-one can stop the diffusion
of excellence, and there .can be no doubt that all the
citizens of the M.o.A. have some share in the refreshing
fruits of medical overcrowding. `
Nor, I think, can diffusion stop there. So long as there
is somewhere a standard of excellence, there will be a
tendency everywhere to attain it; destroy the standard
and the tendency must cease.
Perhaps our manner of practice in the M.O.A. has no
excellence, but if it has look your last on it, for it is
scheduled for demolition. The shaking or “ softening-
up” by gently persistent public detraction and by
alternate promises of sweets and smacks is well advanced.
On the Appointed. Day all our patients, I suppose,
become “ panel patients ’’ and we can take our choice.
We can try to maintain our standards under the familiar
conditions of government contract practice with this
egregious addition, that whereas it must clearly be both
illegal and wrong to take fees from our own patients it
will be legal and, in the eyes of authority, positively
meritorious to see other men’s patients behind their backs,
give them an ‘* independent opinion,” and lift a fee for it.
The whole foundation, in fact, economic and ethical, of
our manner of practice will on that day be bouleversé.
434 THE LANCET] PUBLIC
But we have a choice. We can reject the sweets, accept
the smacks, and take, bow in hand, to the merry green
wood, outlawed for sabotage. A grim choice.
But think of the m.vu.A.—the Medically Undercrowded
- Area. So I will; and I will think of their houses.
I am shocked at the inequality of housing. Some live `
in mansions, some in hovels; but I have a plan. On
an appointed day all who live in houses better or worse
an approved middle shall be housed in prefabs.
Then, all their dwellings being alike demolished, the
specially good brick, stone, timber, and tiles of the
mansions can ‘be used to fortify and increase the stock
' from which the approved middling houses in which all
shall hereafter live are to be built. When all. arè in
them, there being none better all will have the best.
What? You do not like my plan? You cannot
bear that a house architecturally good and beautiful
should be destroyed? You think it is part of our
common. inheritance,. that it has value as a pattern ?
You don’t think the bricks and stone of the mansions
will go very far? You think they will be scarcely
detectable ? Sentimental dreamer! Hide-bound Tory !
-~ Enemy of the People! Upholder of privilege! Fascist
reactionary 1 Bourgeois ! i
* * * f
As I was doing a locum near, I went on pilgrimage to
Selborne. I met the vicar, who told me a story of Gilbert
White (see portrait), who was a small and precise man.
When he was a subproctor at Oxford he found an under-
ss : graduate lying drunk and
naked in the street and
next morning he lectured
him but did not punish
him. because even in his
clothes neatly by his side.
I touched the limes White
‘planted to hide the carnage
of the butcher’s shop, I
trod reverently on his
grandfather’s grave in the
chancel. of the village
church, I admired the
window—except its garish
top—put up to his memory,
mosaiced with many birds,
and then went out to his
own grave in tbe church-
: yard. It was pleasantly
untended, hawkbit flowered on it and there were two.
thriving colonies of red ants. He would have liked that.
I let them sting me, striving at a molecular continuity and
kinship. May the peace that comes from the things of
the earth, which he got and gave—and gives—be with
him still. | ;
» k. *
I wonder how many people are making full use of the
results of war-time research to increase their comfort
when on holiday in Britain. Our biting insects and mites |
may not be the vectors of disease (and anyhow this
year’s weather has not encouraged cold-blooded creatures
to breed) but many a holiday has been ruined by
midges, gnats, or harvest-mites. D.M.P., or dimethyl
phthalate, was well known to the troops in south-east
Asia and elsewhere as an insect repellent, but how many -
have thought of it at home ? And many who have had
to go through the whole drill of smearing their clothes
with D.B.P. in_scrub-typhus areas have never thought
of doing anything like that when they are attacked by
harvest-mites. Yet one can protect oneself pretty
thoroughly from these creatures by smearing a couple
of c.cm. (or should we say ml. ?) of either benzyl benzoate
(any of the anti-scabies remedies containing it will do
equally well), or of dibutyl phthalate on one’s socks and
perhaps round one’s trouser bottoms. The remedy
remains effective for several washes, so one application
at the start of the harvest-mite season should do the trick.
Hosprrats Day.—This year hospitals day in London is to
be Oct. 8. All who can help are asked to write at once to the
appeal secretary of their local voluntary hospital, or to Lord
Luke, chairman of Hospitals Day, 36, Kingsway, London,
W.C.2.
HEALTH o i
‘smoothly.
- reaction to Bact.
cups he had folded his —
ps
kJ
—
[serr 21, 1946
Public Health - aie |
Typhoid at Aberystwyth |
THERE are now further details of the outbreak of
typhoid fever at Aberystwyth. Several people in the
town were taken ill on July 22, 23, and 24, with headache,
pyrexia, and cough; and on July 26 the first case of
typhoid was identified. During the next few days the
condition was diagnosed serologically in several further
people whose history appeared to incriminate ice-cream
sold by a particular vendor. A spot-chart kept at the
Public-health Department indicated clearly that, apart
from water, ice-cream sold by this. man was the only
foodstuff common to all patients admitted to hospital.
The milk-supply in the town is zoned ; and the fact that
all the patients happened to belong to different zones
was a great help in ruling out milk as the source -of —
infection. i S
The county medical officer of health arranged for the
isolation of all cases of typhoid, either in the ‘local
hospital or in hospitals in South Wales, and an ambulance
service was organised. These arrangements worked -
The sale of ice-cream by the suspected vendor, was
stopped on July 29; his blood gave. a positive Widal
typhosum (H) at a dilution of 1 in 320,
and to (O) at 1 in 80; it also reacted. to Vi at 1 in 80. |
Specimens of feces grew no enteric organisms, but.
Bact. typhosum was grown from the man’s urine and. was
later found to be of type C. He was admitted to an isola-
tion hospital for further investigation and treatment.
By this time Bact. typhosum had been isolated from the
other patients ; they were alloftypeC. | So
Cases of typhoid have since been identified in the
neighbouring district and elsewhere in the country in
people who had lately been to Aberystwyth and partaken `
of ice-cream, many of them naming the particular
seller. Altogether 76 cases have been notified in other
areas.
The course of the outbreak is illustrated by the weekly
notifications from Aberystwyth. |
Week ending’ .. -July Aug. Aug. Aug. Aug. Aug. Sept.
27 3 10 17 24 3i 7
Cases notified .. 1 43 29 18 10 1 3
So far only one case has been reported with an onset. .
more than 23 days after the sale of ice-cream by the
carrier was stopped. This patient was a contact. with
his wife who had been ill for some days before calling
in a doctor. Up to Sept.-8 only one other contact
appears to have contracted the infection.
The diagnosis of cases and the eons of carriers has
been much facilitated by the presence of an Emergency
Public-Health Laboratory in the local hospital. The
immense value of such a laboratory in remote areas has.
' been clearly demonstrated. _ 4
Infectious Disease in England and Wales
WEEK ENDED SEPT. 7 AO t
Notifications.—Smallpox, 0; scarlet fever, 668;
whooping-cough, 1824; diphtheria, 284; paratyphoid,
42; typhoid, 21; measles (excluding rubella), 1321 ;
pneumonia (primary or influenzal), 292; cerebrospinal
fever, 33; poliomyelitis, 19; -polio-encephalitis, 5;
encephalitis lethargica, 0;. dysentery, 86; puerperal
pyrexia, 136; ophthalmia neonatorum, 74. ` No case
of cholera, plague, or typhus was notified during the
week. an De
The number of service and civilian sick in the Infectious Hospitals
of the London County Council on Sept. 4 was 843. During the
previous week the following cases were admitted : scarlet fever, 42 ;
diphtheria, 38 ; measles, 17 ; whooping-cough, 27. E
Deaths.—In 126 great towns there were no deaths
from measles or scarlet fever, 2 (0) from enteric fevers,
6 (0) from whooping-cough, 2 (0) from diphtheria, 31 (0)
from diarrhoea and enteritis under two vears, and 6 (2)
from influenza. The figures in parentheses are those for
London itself. E |
Bradford reported the 2 fatal cases of an enteric fever.
The number of stillbirths notified during the week was
236 (corresponding to arate of 26 per thousand total
births), including 34 in London. n E
THE LANCET]
Letters to the Editor
we ee ae ee ee
B.C.G.: THE NEXT PHASE
Sir,— Your timely leader of Sept. 14 raises a number
of points of practical significance. As one who has
recently visited the Scandinavian countries,! where I
had a unique opportunity for seeing the work myself,
I may perhaps make a few preliminary observations.
I hope to publish my experiences more fully later.
I found the enthusiasm for B.c.G. in Norway, Sweden,
_ and Denmark widespread, and most people were con-
vinced of its efficacy as a valuable adjunct in the control
` of tuberculosis, although several public-health experts
emphasised that vaccination should in no way interfere
with -established anti-tuberculosis measures. I was
struck, too, with the little control work done on B.C.G.
in any of the three countries, and, while I can under-
stand and appreciate the difficulties encountered in this
connexion, I hope that in this country we shall have an
opportunity for remedying this defect in order to pro-
- duce reliable statistical evfdence of the value of immunisa-
tion. Such control work as I saw—admittedly the
figures were comparatively small—was convincing ;
but I agree with your statement that ‘‘ only the most
carefully compiled figures in significant quantity will
satisfy the statisticians.”
Although we rightly look to chemotherapy for striking
results in the future I think it is true that in this country
a somewhat neglected field of preventive medicine has
been protection against tuberculosis by active immunisa-
tion in tuberculin-negative subjects, more particularly
among persons in areas of high tuberculosis morbidity
and mortalitv—e.g., children of tuberculous families,
students, nurses, and other young employees in general
hospitals and sanatoria where exposure is great and
protection difficult.
Taking into account the difference in the clinical
features of tuberculosis in this country from those I
‘ noted in Scandinavia I felt that their work was highly
encouraging. : Few will question Heimbeck’s original
assertion—for which he deserves the highest credit—
that tuberculin-negative nurses show a higher incidence
of tuberculosis than those who are tuberculin-positive.
I was privileged to see with him in Oslo a further extension
of this work which more than corroborated his earlier
observations. |
Nothing that I saw impressed me more than the work
of Prof. Arvid Wallgren, now professor of pediatrics in
Stockholm, who has certainly been the pioneer of B.C.G.
vaccination in Sweden, having started his work in Gothen-
burg in 1926. His confidence in the clinical value of B.C.G. `.
remains undaunted although he recognises its limitation
and admits that it is not of use except in primary lung
tuberculosis. Unfortunately even Wallgren has, however,
had little opportunity for control work.
With regard to the respective merits of B.C.G. vaccine
and the vole-bacillus vaccine of Wells, which you rightly
suggest is running B.C.G. very close, Wallgren’s observa-
tions to me are not without interest. He urged, from
his own experience of vole vaccine, that it would be
of the greatest scientific interest and value if we in this
country were to use it. He gave me the impression that
it would eventually supersede B.c.a. I think there is
good evidence for the belief that both methods of
inoculation (a) are harmless to humans, (b) increase
resistance to tuberculosis, and (c) are of value only in
tuberculin-negative subjects. B.c.a. has stood the
test of time in many countries and its harmlessness has
been established by its practical application on a large
scale in many parts of the world. Nevertheless, there is
good evidence that the vole-bacillus vaccine has the
following advantages over B.C.G.: (a) it is apparently a
more potent immunising agent ; (b) its virulence is more
stable (the varying virulence of B.C.G. in Norway,
Denmark, and Sweden was noteworthy, and I was told
on more than one occasion that some of the strains were
losing their virulence); and (c) there is reason to believe
that tuberculin allergy following vaccination with it
1. My visit was sponsored by the public-health committee of the
~ county borough of East Ham, for whom I act as consulting
Ton gree for tuberculosis and diseases of the chest, and to whom
am greatly indebted.
TREATMENT OF MENINGITIS
[sePT. 21, 1946 435
was greater and occurred. earlier than that following
B.C.G.
Let me add a word about the method of administration
of the vaccine. Wherever I went in the three countries
the intracutaneous method devised by Wallgren was
regarded as the quickest, most reliable, and practical; _
and it afforded a more accurate measure of the dosage. .
All observers were emphatic that complications such as
significant abscesses never arose when the injection was .
truly an intradermal one but did arise when the technique
was bad and some of'the solution had been injected
subcutaneously. I was given, especially in Denmark,
an opportunity of assisting at the B.c.G. vaccine clinic
and I can corroborate this view from what I saw. Such
authorities as Herzberg in Oslo, Wallgren in Stockholm,
Anderson in Gothenburg, and Winge in Copenhagen
strongly favoured this method. The so-called trans-.
cutaneous method, either by scarification or multiple
puncture with the Birkhaug-Rosenthal instrument,
seemed to meet with little favour for a variety of reasons .
which -space will not permit me to deal with here, and
I had an excellent demonstration of ay by a great
authority. |
From these impressions I think one is justified in
urging that enthusiasm should be tempered with caution.
Wisely handled there is little doubt that immunisation
should prove a useful weapon. We have a unique
opportunity for starting afresh with adequate control `
experiments and filling in the gaps which Continental and
other workers, often through lack of opportunities and
no fault of their own, have omitted. We must furnish
sound statistical proof, beginning for preference with a
selected group of the population who are exposed to
unusual risks of tuberculous infection. May I, therefore,
strongly support your plea that the Ministry of Health
set up, as soon as practicable, an authoritative committee -
under the auspices of a body such as the Medical Research
Council to institute a clinical trial of what they regard
as the most effective method of tuberculosis vaccination ?
London, W.1, PHILIP ELLMAN,
TREATMENT “OF MENINGITIS
Sir,—Dr. Gaisford’s letter of August 17 should serve
as a useful corrective to over-enthusiasm. Whenever a
new remedy is discovered for any particular malady,
there seems to be a regrettable tendency to discard the
older and often well-tried remedies. Recent examples of
this appear to be syphilis and perhaps meningitis,
particularly cerebrospina] fever. In the latter, it: is
surely a retrograde step to employ intrathecal therapy
unnecessarily. What then are the indications ?
Possibly the greatest triumph of the sulphonamides
has been in the treatment of cerebrospinal fever, including
acute and chronic meningococcal septicemia, and the
great majority of cases—95% according to Dr. Banks
(Sept. 7)—respond excellently. With the exception of
cases of sulphonamide intolerance and those rare cases
of the ordinary types of the disease which fail to respond
to sulphonamides, there is no real indication for the use
of penicillin, at any rate intrathecally, in the non-
ting varieties of cerebrospinal fever. _
The fulminating varieties can be divided, perhaps a
little arbitrarily, into those cases which are often dead
within a few hours—Waterhouse-Friderichsen syndrome
—and ‘the type with well-marked meningitis which
progresses to a fatal termination in about twenty-four
hours. I have no experience of the use of penicillin in
the former type of case, but its efficacy by whatever
route it is administered (and it should certainly be given)
would seem doubtful. In the second type of fulminating
case, if after a few hours on combined sulphonamide
and systemic penicillin therapy the patient’s condition
is still rapidly deteriorating, then, in accordance with
the evidence so far available, intrathecal penicillin is
indicated. I have not had cause to regret this, and two
such injections are usually sufficient. It is important
to remember, however, that such cases comprise a very
small percentage of the total.
‘Similarly, penicillin is indicated in pneumococcal,
streptococcal, and staphylococcal meningitis; and, in
those cases which do not soon show improvement on
systemic administration of. the drug, the intrathecal
route is again indicated. I have successfully employed
THE LANCET]
436
CIRCULATION IN THE KIDNEY
[serr. 21, 1946
this method in pneumococcal meningitis when, despite
previous sulphonamide medication, the general condition
continued to deteriorate. Obviously, as few intrathecal
injections as possible should be given and one hopes that
heroic procedures such as trephining the skull for the
intraventricular injection of penicillin will not be
embarked on indiscriminately.
y
It seems then that the indications for intrathecal
_ penicillin are strictly limited and uncommon, and that
the mere fact of the cerebrospinal fluid being opalescent
or turbid or the cell-count increased. are no indications’
for such therapy. The immediate risks are obvious—
for example, the introduction of penicillin-resistant
-“ organisms—and the possibility of delayed sequel, such
\
as postmeningitic headache, should not be forgotten.
Clearly, much judgment and skill are required in deciding
when this route of administration is advisable. .
Royal Naval Auxiliary Hospital, ‘J. L. FLoKER.
Barrow Gurney, Bristol.
EFFECT OF PHOSPHATE ON CARBOHYDRATE
ABSORPTION IN SPRUE |
Srr,—Many will. learn with regret, on reading his
letter of Sept. 14, that Professor Maegraith has had to
abandon his experimental work on sprue. I take this
opportunity of making one comment. In both his
letter and the preliminary communication referred to}
he gives the impression that impaired phosphorylation
as a factor in the pathogenesis of sprue was an idea
emanating from himself, whereas the arguments support-
ing this belief were put forward by me four years ago,?
enone doubtless Professor Maegraith has overlooked the
point. |
London, W.1. Huen S. STANNUS.
CIRCULATION IN THE KIDNEY
Sır, —The preliminary communication by Trueta and
his colleagues in your issue of August 17 (p. 237), and
- their demonstration of a diverted renal circulation follow-
ing upon stimulation of afferent nerves, is at once
interesting and important. The investigators are to be
congratulated on their new technique, which has made
their observations possible, as much as on the results
` so far described, and it is to be hoped that the histological
investigations will be such as clearly to demonstrate,
in the rabbit, the presence and character (or absence)
of vasa recta and the other non-glomerular blood-channels
which have been described. |
It is indeed strange to read in your leading article
(p. 239) that ‘‘ the arrangement and functions of the
vasa recta ... have been relatively neglected,” when,
until this present claim of Trueta and his colleagues, it
has been generally agreed that the work of Huber
(1906-07), Gérard (1911), Traut (1923), and MacCallum
(1926) had disproved such non-glomerular medullary
supply described by Ludwig (1852), Virchow (1857),
and Golubew (1893)—just as the réntgenographic studies
of Katzenstein (1911), Liek (1915), and Gross (1917)
had disproved the existence of large arteries arching
o re pyramids, the arcuate arteries of von Ebner
In 1889 Bradford demonstrated vasoconstriction
within the kidney, and resulting shrinkage, on stimula-
. tion of the splanchnic nerves, and similar reflex contrac-
tion by central stimulation of the cut sciatic nerve and
vagus, and confirmed the earlier observations on the
relation of the splanchnics to the output of urine b
Claude Bernard (1859), and Cohnheim and Roy (1883).
Burton-Opitz and Lucas (1908) showed that section of
the splanchnics increases the blood-flow through the
kidneys, whereas stimulation decreases the flow; and
Burton-Opitz (1908) showed that the right and left
splanchnics were distriLuted to the right and left kidneys
respectively. In the frog, Bieter (1930), confirming the
work of Richards and Schmidt (1924-25) and Richards
(1925), recorded that stimulation of the sympathetic fibres
to the kidney, and of the central end of a cut sensory
nerve, such as the sciatic, produced great vasoconstriction
throughout the kidney: the majority of active glomeruli
stopped, showed stasis and gradual emptying of the
capillaries but no inflow of red cells, while ‘‘ The glomeruli
1. Lancet, 1945, ii, 635.
2. Trans. R. Soc. trop. Med. Hyg. 1942, 36, 124.
‘(sciatic or other) stimuli. .
which do not stop as a result of splanchnic stimulation
sometimes appear to show a flow at an increased speed,
as if a certain amount of arterial blood must get into
the kidney regardless of the number of glomeruli that
are open for flow.” Andrews (1927) noted anuria in dogs
following the release of tight ligatures from the leg,
and Bieter repeating this in the frog noted reduced
glomerular capillary . activity, an effect which was
removed by section of the splanchnics. Bieter (1935)
observed that “ it is likely that in the frog the vasomotor
control of the kidney vessels is not as highly developed
as it is in mammals and man, and consequently, ascending
the scale, the effects would possibly be more powerful.
When it is recalled that in human cases of severe renal A
cortical necrosis, in which even the columns of Bertini
are involved, the medulla is not necrotic and a great
many of the deep (juxtamedullary) glomerulj show no
stasis, that they and their wide efferents (which pass to
the medulla direct) are in fact functioning, it is not
ynnatural to conclude that this reduced or diverted
(medullary) circulation may well be maintained by these
glomerular efferents—without yequiring the existence of
vasa recta or of the corticomedullary arteriovenous shunts
described by Steinach (1884) and Spanner (1938) to
explain the viability of the pyramids and the anuria.
Like circumstances obtain in the rabbit in experimental
renal cortical necrosis. In the normal rabbit. kidney
5-7 % of the contained blood is present in the glomerular
capillaries where it is changed about 5 times pet second
and has a probable velocity of 1-2 mm. per second.
Thus if 85% of the glomeruli are involved in the necrotic
process of renal cortical necrosis, the remaining 15%
(large juxtamedullary glomeruli) can accommodate the
whole normal glomerular capillary volume, simply by
all of their capillary loops coming into play, should the
minute-volume remain unaltered (personal observations
on glomerular circulation). The circuit-time in ‘this
‘‘medulla-diverted ” circulation will be reduced too,
for the deep glomeruli ‘and their efferents are largest
and egress is free, resulting medullary blood-channels |
are short and wide vis-à-vis the cortical capillary rete.
In other words, from a consideration of the hemo-
dynamics of the renal circulation in the rabbit, it is
possible to suggest that the degree and character of the
altered renal circulation, as outlined by Dr. Trueta
and his colleagues, and the “ redistribution of blood-flow
within the kidney” discussed by Professor Maegraith
(p. 213), could be maintained by a circulation via the
deep (subcortical or juxtamedullary)-glomeruli only, the
cortex being relatively avascular, by vasoconstriction of
the peripheral arterial vessels in response to afferent.
But. vasa recta and their loops are described, and we
await with interest the first clear demonstration of these
vessels (in situ), and possibly also of other non-glomerular
supplies and shunts which from time to time have been
described. T
, REFERENCES
Andrews, E. (1927) Arch. intern. Med, 40, 548.
Bernard, C. (1859) in Schmidt’s Jahrbücher, vol. civ, p. 4 (quoted
by Bieter).
Bicter, R. N. (1930) Amer. J. Phys. 91, 436. ae :
(1935) in Berglund and Medes’s Kidney in Health and
Disease, Philadelphia, p. 126,
Bradford, J. R. (1889) J. Physiol. 10, 358.
Burton-Opitz, R. (1908) Plg. Arch. ges. Physiol. 125, 221,
Lucas, D. R. (1908) Jbid, 123, 553.
Cohnhcim, J.. Roy, C. S. (1883) Virchows Arch. 92, 424.
Gérard, M. (1911) J. Anat., Paris, 47, 169.
Golubew, W. Z. (1893) Int. Mschr. Anat. Physiol. 10, 541.
Gross, L. (1917) J. med. Res. 36, 327. l :
Huber, G. C. (1906-07) Amer. J. Anat. 6. 391.
Katzenstein, M. (1911) Berl. klin. Wschr. 2, 1651 (quoted by Gross).
beger
- Liek, E. (1915) Arch. klin. Chir. 106. 3 (quoted by Gross).
Ludwig, C. (1852) Lehrbuch der Physiologie des Menschen, Leipzig
and Heidelberg, vol. 1, p. 255.
MacCallum, D. B. (1926) Amer. J. Anat. 38, 153.
Richards, A. N. (1925) J. Urol. 13, 283: i
Schmidt, C. F. (1924-25) Amer. J. Physiol. 71, 178.
Spanner, R. (1938) Verh. anat. Ges. Jena, 45, 81..
Steinach, E. (1884) S.B. Akad. Wiss. Wien. Math.-Naturw, C]. 90,
171 (quoted by Shonyo, È. S., Mann, F. C. Arch. Path. 1944,
Traut, H. F. (1923) Carnegie Inst. Washington Publ. no. 332, vol. xv
p. 103. Contribn Embryol. no. 76.
Virchow, R. (1857) Virchows Arch. 12, 310.
von Ebner, V. (1899) in Kölliker’s Handbuch der Geweblehre des -
Menschens, vol. 111, part 1, Leipzig. !
J. F. HEGGIE.
l Department of Pathology, The University, Glasgow.
—
THE LANCET]
CALF SERUM FOR TRANSFUSION `
[SEPT. 21, 1946 437
- - MYTH AND MUMPSIMUS
SIR, —Many of us must be grateful to Dr. Forbes for
his destructive article in your issue of August 31. I
_ have often thought that destructive thought is a valuable
property. The vast accumulations of rubbish, many of
them monuments to the more foolish moments of great
men, need a great deal of shaking; and I do not think
Dr. Forbes has gone nearly far enough.
- He writes that there is only one criterion for the value
of any therapeutic procedure—does it work with
patients? Many theoretically sound treatments fail
because they work only if the patient is isolated in an
artificial environment. Take the magic bullets of Ehrlich
and their later modifications. In actual practice this
treatment sometimes failed, perhaps by the accidents of
treatment but often by default or irregular attendance
for the long and tedious courses of injections. Because
of these limitations the magic looked shabby in the
light of day. The failure.in many cases was due to the
fact that a man was primarily a lorry driver, a hotel
clerk, or a commercial traveller—in other words, a
human being—and only secondarily a patient with
syphilis. — . °
Any treatment that fails to recognise the human
animal as a whole and its place as a social unit tends to
partial success. The immobilisation of young children
for long periods seems a sorry sort of treatment for a
living creature ; it fails in that it treats a part by mal-
treating the whole. Activity is an essential part of
health, and far more care should be taken not to prescribe
unnecessarily restrictive measures; nor should a man
be taken off work without the most careful consideration.
He often does better if he stays at work.
The same applies to diets. A man should enjoy his
food because enjoyment is an essential part of good
digestion. Very few diets are enjoyable. Is it not a fact
that what we are really enduring in our ordinary dietary
is not lack of calories but unmitigated English cooking ?
Why does the gastric-ulcer patient have his meat minced ?
A more horrid food than minced meat cannot be
imagined, and given a reasonable set of teeth the
natural act of chewing suffices; chewing, moreover,
promotes digestion. : i
The trouble in gastric-ulcer diets is partly due to
simple-minded arguing from pathology. Here, we say,
is an ulcer in the stomach, it must not be irritated by
pips, fruit skins, stalks, meat extracts, alcohol, or tobacco.
But patients are often willing to experiment and some
find beer, as well as other supposed irritants, gives them
no discomfort. Many manage a practically normal diet
except for greasy foods. Arguing from pathology, well-
lubricated greasy foods should slide harmlessly over an _
ulcer. They apparently do not. Nevertheless, pathology
is a valuable corrective in medicine. Unfettered by it
Freud trampled on the fairy stories of Greece and raised
some extraordinary myths. Worse still, the psycho-
analytical school is becoming respectable—it even
appears in the Brains Trust !
It seems a pity to blow up some of these picturesque
ruins, but it may be necessary ; besides it gives healthful
pleasure to those who cannot stand bunk, especially
when buttressed by authority. i
Oxford.
; CALF SERUM FOR TRANSFUSION
Sır —No doubt war-time conditions prevented Dr.
Massons, of Barcelona, having access to my paper on
despeciated bovine serum (Brit. med. J. 1944, i, 73) to
which you refer in your annotation. A material some-
what similar to P.c.P. was produced in the department
of surgery, University of Liverpool, by the addition of
G. WHITWELL.
formalin and ammonia to bovine serum. The essential -
difference in the final production of the solution is, .
however, that in despeciated bovine serum the heating
process is taken to 72° C only, while in P.c.p. the solution
is heated to 100° C. Experiments which we did showed
that the agglutinins are destroyed at 72° C, associated
with changes in the globulin fraction. At this temperature
the changes in the albumin fraction are small and the
material still exerts an osmotic pressure of 120-160 mm.
of water compared to the figure of 150 mm. of water
found for pooled citrated plasma. Material heated
- above this temperature shows a steady decrease in the
osmotic pressure until at 100° C it has none at all. The
readings were taken by the micro-method of Krogh and
Nakazawa against mammalian Ringer solution. It is
thus difficult to see how P.C.P. can have any, more
beneficial effect than normal saline.
The original reason for the preparation of despeciated
bovine serum was to produce a substitute for human
plasma that would have been of value had the supplies
of human plasma not been sufficient to meet war-time
needs. When it was apparent that human material was
available in sufficient quantities, further production of
despeciated bovine serum was stopped. It was adminis-
tered safely, however, to over 200 patients by myself
and others in amounts of one pint or more, the largest
volume given to one patient being 16 pints. I would
reaffirm that despeciated bovine serum prepared by the
Liverpool method is non-toxic, non-antigenic, free from
antibodies, of an equivalent osmotic pressure to citrated
human plasma, retained in the circulation, and eventually
metabolised.
Liverpool. F. RoNALD EDWARDS.
LATENT PERIOD IN KALA-AZAR
Sir,—The following case well illustrates the fact,
pointed out by Armstrong, that there may be a long
latent period before kala-azar produces symptoms.
This seems to be fairly well known, but is nowhere else
emphasised in the published work. Manson-Bahr ?
suggests six months as the upper limit of the incubation
period, and Strong* and Scovel ‘ suggest four months
as the maximum; but none of these authors draws
attention to the further latent period which may occur
before symptoms appear. Manson-Bahr notes that the
disease may remain latent for many months in artificially
infected dogs, and Sweeney et al. describe a case with
a ‘‘ presumptive latent period of two years,’ as in the
present case. a
A private, aged 26, served from April, 1940, to December,
1943, in Eritrea, Egypt, Libya, Palestine, and Syria, and
from December, 1943, to February, 1944, in Italy. His
.disease probably originated before December, 1943, after
which date he was stationed north of Naples. j
In the summer of 1945 he noted that his belt seemed tight
on exercise, but otherwise he felt perfectly fit. In October,
1945, he was admitted to hospital with a history of coryza
for about a month, and of headache, shivering, and sweating
for several days. ; oe
He was thin and pale, with a yellowish tinge to the skin, and
had a swinging temperature rising to 100°-103° F every.
evening, accompanied by profuse sweats. A large tumour
was present in the left hypochondrium extending to below
the level of the umbilicus. The nature of this tumour remained
in doubt, it being considered to be either the spleen or the left
kidney. An intravenous pyelogram did not help, because no
dye was excreted on the left side ; and an attempt at ascend-
ing pyelography was unsuccessful. The liver was not palpable,
and no enlarged glands were felt.
Blood-count: red cells 2,030,000 per c.mm., Hb 48%
(14:5 g. per 100 c.cm.), colour-index 1-1; white cells 2650
per c.mm. (polymorphs 50%, lymphocytes 25%, monocytes
‘10%, eosinophils 1%; myelocytes 3%> myeloblasts 3%, l
unclassified 2%). Plasma protein 7:55 g. per 100 c.cm.
Sternal puncture gave a marrow count of polymorphs 8%,
myelocytes 40%, metamyelocytes 3%, lymphocytes 0,
monocytes 0, normoblasts 6%, premyelocytes 6%, myelo-
blasts 4%, erythroblasts 33%, megaloblasts 0. No Leishman-
Donovan bodies were seen. | . |
Other investigations all proved negative, and further blood-
counts and sternal punctures showed a similar picture,
Leishman-Donovan bodies still being absent from marrow
smears. Patient’s condition altered little, and the high
evening temperature and profuse sweats continued.
In view of the continued doubt in diagnosis, laparotomy
was done on Nov. 23, after: transfusion with packed cells,
The tumour was found to be a grossly enlarged spleen. No
other abnormality was found in the abdomen. Splenic puncture
. Armstrong, T. G. Brit. med. J. 1945, ii, 918.
: Manson Bune, P. H. Manson’s Tropical Diseases, London, 1945,
p. 156. l
. Strong, R. P.
` Tropical Diseases, Philadelphia, 1944. Doi
. Scovel, F. G. Ann intern. Med. 1944, 21, 607. a
. Sweeney, J. S., Friedlander, R. D., Queen, F. B. J. Amer. med.
Ass, 1945, 128, 1020. _ ;
Stitt’s Diagnosis, Prevention, and Treatment of
Om J D m
438 THE LANCET]
was done, but no Leishman-Donovan bodies were found either —
on direct examination of the biopsy specimen or on culture.
On Dec. 18, as there was no improvement, it was decided
- to treat the case as kala-azar, and a course of stilbamidine
0-075 g. followed by 0-15 g. daily to a total dosage of 2:25 g. was
given. The sweating began to decrease after six or seven
days, but the temperature did not respond till the thirteenth
day of the course, when it dropped suddenly and thereafter
remained low.
On Dec. 25 culture of marrow blood in Lache-dextrose
sloppy agar with defibrinated rabbit blood at 24° C grew
“ distinct leptomonas forms of Leishman-Donovan bodies,
fresh preparations showing characteristic motility.”
Progress was slow but excellent, the anzmia improving and
the spleen decreasing in size. In February, 1946, patient
was given a course of urea stilbamidine. In March his general
condition was most satisfactory, the spleen being just palpable
and the anemia clearing well. In April, 1946, he reported
numbness of forehead, cheeks, ane lips, but was otherwise
well.
The chief points of interest in this case are the lorie
latent period, the difficulty in diagnosis, and the dangers
of Vth nerve involvement when uaa Wes he is used.
P. NORMAN.
Hospital for Sick Chilaren, Great Ormond it London.
*,* L. E. Napier, writing in the British Encyclopedia
of. Medical Practice (London, 1938, vol. vil, p. 342),
mentions a patient who developed ‘symptoms of kala-
azar after being away from any endemic area for 18
months.—EbD. L.
CHILDREN WHO SPEND TOO LONG IN BED
Str,—Dr. McCluskie, in his letter of Sept. 14, replying
to my criticisms of his article, has so far retracted as
to say that the time of sleep required by a child may
vary by “ an hour, or more, or less’’: this period of an
hour was not mentioned in the original article. He
reaffirms his statement, with. which no-one will disagree,
‘behaviour.
that many children spend too long in bed: but he does
not explain how the mother with two or more small
children, and little or no domestic help, can follow the
‘ detailed directions” which
sleeping as well as feeding.
He has also failed to produce any evidence for the
dogmatic statements in his article that ‘‘ if a baby has
an hour too much sleep during the day it will certainly
cry during the night,” and “ variation by even 15-30
minutes from the amount of sleep each particular child
requires at each month f katona violent change of
” If “years of experience with children ”’
lead him to these conclusions: I can only assume that his
experience has been limited to dealmg with rather
unusual children. A perceptive mother recognises that
external factors such as the activities of the day, physical `
and mental, produce variations in the amount of sleep
required: and I think it a facile assumption that the
behaviour disorders which Dr. McCluskie describes can
be so directly related to lack or excess of sleep. In his
Contributions to Analytical Psychology Jung says that
“the neuroses of children are rather symptoms of the
aNd mental condition than a genuine disease of the
child.”’
I should be glad to know the signs and symptoms of
i nation-strangling matriarchy.”
London, W.11. CATHERINE STORR.
Sık, —Dr. McCluskie gives good advice concerning
hours of sleep for children. One cannot make a child
sleep to suit one’s convenience. I suggest that, if he
wakens early, the child might be encouraged to play
quietly with some toys, after being made comfortable,
until his mother is ready to dress him and give him his
breakfast.
months requires more sleep than Dr. McCluskie pre-
scribes. A baby wakened too long before his feed will
get tired and fretful. A contented baby soon learns to
adjust his own sleeping hours to his individual needs.
He will lie playing with his hands, and later practising
making new noises, and a busy mother will be unaware
when he wakened or fell asleep again. He should be as
happy in his pram as anywhere, though he will enjoy
a regular kicking time to exercise his limbs; this time
can be increased in length to correspond with his abilities.
Eastbourne. JOAN BRIGDEN.
CHILDREN WHO SPEND TOO LONG IN BED
-or vote at General Meetings of the Corporation.”
he thinks necessary for’
‘ active part in the management of the college.
to the desirability of ensuring that penicillin used
I consider that an average baby of a few |
-—d.e., if
å t
1
21,. 1946
[SEPT.
EPIDEMIC THROMBOPHLEBITIS
Sır, —There seems little doubt that the. condition —
described by Lieut.-Colonel Manson-Bahr and Dr.
` Charters (Sept. 7, p. 333) is the tropical primary phlebitis
described in 1941 by one of us ? as occurring in Northern ~
Rhodesia. Since then this disease has been studied
further, and our observations on 71 cases will shortly
be ready for publication. Manson-Bahr and Charters
state that they find no histological cause for the throm-
bosis. The histological appearances in the vein wall
described in 1941 were acknowledged then as obviously
abnormal (A. C. L.) but the interpretation of these and
of a subsequently observed chronic case with giant cells
(cf. Manson-Bahr’s case, p. 334) was at last made clear
by a recent opportunity to study what is certainly the -
essential lesion. It had come to be appreciated (A. à. F.)
that only a short stretch of the vein was primarily
involved, and microscopy of this zone has now revealed
a peculiar form of inflammation characterised by extreme
proliferation of young capillaries in the disrupted media
of the vein, and by the presence of phloxinephil intra-
cytoplasmic inclusions.
Luanshya, Northern Rhodesia,
and Department of' Pathology,
University of Glasgow..
ROYAL COLLEGE OF PHYSICIANS OF LONDON
Sm,—A letter in the British Medical Journal of
August 31 (p. 313) has focused attention once more on
the statutes, by-laws, and regulations of the Royal
College of Physicians and the justifiable discontent
which they arouse.
As is well known, the present regulations do not allow
members to take any part in the running of the college.
In fact, they are specifically debarred from doing so
under by-law 118, which says “. .. they shall not
be entitled to any share in the Government, or to attend
‘Surely
this state of affairs is quite out of date, and in view
of the great changes now taking place the time is ripe
for the college to broaden its representation with a view
to ensuring that members obtain a voice in its counsels
A. ©. FISEER.
A. ©. LENDRUM.
and deliberations on common-sense, democratic lines.
The college, instead of remaining a mere academic
institution, should become a living force, capable of
exercising a profound influence for good on various
medical, social, and educational problems confronting
us and pressing urgently for solution.
The first step in this desirable aim must surely be the
provision of facilities for adequate representation by
the members, who should be given every encouragement
to form their own standing committee, &c., and take an
Obviously
one of the important tasks of any newly elected com-
mittee should be to go into the question of the revision
of the existing pee eter concerning the election of
fellows.
C. ANDERSON.
S | M. N. PAt.
Sutton Emergenoy Hospital. D. Saaw.
EFFICACY OF THE PENICILLINS
Sır, — Your leading article of Sept. 14 directs attention
in
medicine shall, as far as practicable, consist only of
penicillin II (G). For some time past we have been:
fully conscious of this, and, by the choice of appropriate
media and precursors, together with the use of selective
extraction procedures, we have secured approximately
90% of. penicillin m (G) in our product. As a further
precaution, our vials are now filled so that, within the
limits imposed by existing assay procedures, we believe
them to contain the stated content of penicillin m (Q)
a vial is claimed to contain 100,000 units of
penicillin, it contains not less than that number of
units of penicillin 1 (G), and any small proportion of
penicillin Iv (K) which may be present is additional.
In this manner the practitioner is assured of the full
dosage of the penicillin on which he relies for therapeutic
efficacy. H. JEPHCOTT
l Managing Director,
Greenford, Middlesex. Glaxo Laboratories Ltd.
1. Fisher, A. C. S. Afr. med. J. 1941, 15, 131.
TBE LANCET]
Notes and News-
CRICHTON ROYAL FELLOWSHIPS
Topay some inside knowledge of the working of a modern
psychiatric hospital is essential for the consultant, and many
established specialists have been spending a busman’s holiday
visiting their colleagues at the Crichton Royal, Dumfries.
To fill this gap and to hasten the fuller training in psychiatry
lately recommended by the Royal College of Physicians, the
board of directors of the Crichton Royal have set up three
fellowships, in addition to the ordinary staff of the hospital.
The fellows will receive training in all branches of clinical
psychiatry, including fever treatment, prolonged narcosis,
electric convulsion therapy, insulin therapy, and leucotomy.
They will have opportunities to work in the outpatient and
child-guidance clinics, to join in the work of the psychiatric
social worker, and take part in home and follow-up visits.
Each fellow will be attached to one of the senior psychiatrists
who will be responsible for his instruction, and later patients
will be allotted to him. He will also attend all clinical staff
meetings and become familiar with the management of
different wards, the legal problems of psychiatry, and routine
psychological testing. The fellowships, which carry a salary
of £400 a year in addition to residential emoluments, will in
the first instance be tenable for one year from Feb. 1, 1947.
Forms of application may be obtained from the physician
intendent of the hospital and should be returned not
later than Dec. 16.
ART FOR THE ILL `
- Adrian Hill, an artist, had tuberculosis, and during his
long boring convalescence found how quickly he could make
the hands of the clock move by sketching in pencil or water-
colour. When he got up he shared this device for passing
the time with his fellow patients, and, partly no doubt owing
to his own ability to instruct and interest, found many who
could equal his pleasure in making pictures, if not his technical
skill. He has written a likeable book (Art versus Illness,
George Allen and Unwin, 10s. 6d.) about this small start in a
new type of occupational therapy and its considerable develop-
ments. He found a starved taste for pictures in many
unlikely quarters, and in others a bent for original work
which needed only opportunity to grow. His experiment
seems likely to become an accepted part of treatment in some
sanatoria and should be seriously considered in all. His
amusing and constructive little book, illustrated with many
of his own drawings and those of his patient-pupils, is well
worth reading with this idea in mind.
DELINQUENCY ON THE SCREEN
THe approved schools usually carry on their constructive
_ work without much publicity, but their achievements are so
notable that they should be widely understood. Children on
Trial, a Crown Film Production now showing at the Academy
Cinema, furthers this end and also adds to the high reputation
of British documentaries. |
young people are outlined without any emotional emphasis,
and the result is not only moving but intensely interesting
—far more so, indeed, than the average thriller. The delin-
quencies are not understated, the extenuating circumstances
kept in perspective, the approved school with its scope for
growth of mind, body, and spirit presented fairly. The cast
includes.only two professional actors, one of whom plays the
delinquent girl, the other the headmaster of the approved
schoo]. The other actors are taking their natural parts, the
-boys being played by Liverpool and Birmingham schoolboys.
The boy playing the main delinquent has a natural economy
of expression and gesture which could not be bettered.
Doctors should try to see this informative film. :
Family Planning Association
The association is holding a conference on Infertility, on
Sept. 21 and 22, at the National Institute for Medical
Research, Hampstead, N.W.3. At3 P.M. on Saturday, the 21st,
Dr. Mary Barton will speak on the Biology of the Cervix, and
Dr. G. I. M. Swyer on the Rôle of Hyaluronidase in Fertilisa-
tion. There will be-demonstrations at 5 P.M., and afterwards
Dr. Audrey Smith.and Mr. ‘A. S. Parkes, F.R.S., will read a
paper on Antigenic Properties of Spermatozoa. On Sunday,
the 22nd, at 11 a.m., Dr. Margaret Hadley Jackson and
Mrs. C. Harvey will speak on Experience with A.I.H., Dr.
Muriel Rose on the Prognostic Value of Semen Examination,
and Dr. Raymond Cross on Habitual Abortion. Further
particulars may be had from the secretary,- 69, Eccleston
Square London, S.W.1.
NOTES AND NEWS
The stories of three delinquent '
[serr. 21, 1946 439
University of Edinburgh
Mr. D. M. Douglas has been appointed lecturer in experi-
mental surgery in the university, and deputy director of
the Wilkie Surgical Research Laboratory. He has also been
elected to the staff of the Royal Infirmary as an associate
assistant surgeon.
University of Glasgow
Dr. Thomas Anderson, physician superintendent of Knights-
wood Hospital, Glasgow, has been appointed full-time lecturer
in infectious diseases in the university. The lectureship
which the university has set up after consultation with the
city corporation is the first full-time one in this country and
carries with it the title of visiting physician to Knightswood
Hospital, so that the holder may have adequate clinical
material for teaching and research. Dr. Anderson will also
become consultant in infectious diseases to the corporation.
ee salary scale of the lectureship is to be £1200—-£50-£1500.
r. Anderson, who graduated M.B. at the University of Glasgow
in 7528, held a resident appointment at the Western Infirmary and
later became deputy physician superintendent at Ruchill Fever
Hospital. He was elected F.R.O.P.E. in 1940, and obtained his M.D.
with honours last year. His published w ork includes papers on the
use of chemotherapeutics in infectious discases, particularly
pneumonia.
Royal College of Obstetricians and Gynzcologists
On Sept. 27 the honorary fellowship of the college will be
conferred on Mr. Victor Bonney in recognition of his services
to British gynecology.
Travelling Fellowships
The Medical Research Council have awarded Rockefeller
medical fellowships for 1946—47 to the following :
SHEILA T. E. CALLENDER, M.D. St. And., M.R.C.P., graduate assis-
tant, Nuffield Department of Clinical Medicine, Oxfor
C. E. DENT, M.B. Lond., M.R.C.P. roneacch assistant, “medical unit,
University College Hospital, London
A. M. JONES, M.B. Manc., M.R.C. bags Leverhulme research scholar
Royal College’ of Physicians), University and Royal Infirmary,
Tanchester.
A. M. MACDONALD, M.D. Edin., F.R.C.P.E., department of pathos
logy, Edinburgh University.
J. E. MORISON, M.D. Belf., lecturer in morbid anatomy, Queen’s
University, Belfast.
F. . PRUNTY, M.D. Camb., M.R.O.P., lecturer in chemical
pathology, St. Thomas’s Hospital medical school, London.
F. F. RUNDLE,:M.D. Sydney, F.R.O.S., surgical specialist, R.A\M.C.,
lately chief assistant and registrar Westminster Hospital, London.
JOHN SWINNEY, M.C., M.D., M.8. Durh., assistant surgeon, depart-
ment of urological surgery, Newcastle-on-Tyne Genera] Hospital.
The council have also awarded a Dorothy Temple Cross 7
research fellowship in tuberculosis to:
T. F. JARMAN, M.D. Durh., assistant tuberculosis physician, Welsh
National Memorial Association.
International Society of Medical Hydrology
This society is holding its first post-war meeting at Buxton
from Oct. 4 to 6. The speakers will include Dr. J. van Breemen
(Four Causal Factors of Rheumatic Disease in Connexion
with Medical Hydrology), Mr. R. Whittington (Plasma Vis-
cosity), Dr. Victor Ott (Present Swiss Concepts of Rheumatism
and Physical Medicine), Dr. Abraham Cohen (Physostigmine
in Rheumatoid Arthritis), and Dr. Louis T. Swaim (American
Concepts on Arthritis). Further particulars may be had from
Dr. Donald Wilson, 28, The Circus, Bath.
Service Prizes |
The R.A.M.C. Prize Funds Committee announce that the
following prizes are open for award in 1947 after a lapse of
some eight years due to the war:
Leishman Memorial Prize.—A silver medal and £30 for the best
work in any branch of medicine, surgery, or the allied sciences, or
in connexion with the general duties of the R.A.M.C. or of the
Army Dental Corps.
Alexander Memorial Prize.—A silver medal and £70 to the officer
who during the year has done most to promote the study and
improvement of military medicine, surgery, hygiene, or patholo,
Parkes Memorial Prize.—A silver-gilt medal and £60 to he
regular serving medical officer who has done most to promote the
study of naval or military hygiene.
The Alexander and Parkes prizes are not open to officers on the
stafis of the Royal Naval Medical School, the Royal Army Medical
College, or the Army Sthool of Hygiene. In making these two
awards first consideration will be given to original articles published
in a medical journal, and part authorship will not justify the recom-
mendation of an officer for these prizes.
Recommendations should be sent through the usual
channels, with copies of original articles and reports, to reach
the hon. secretary of the committee, R.A.M. College, iene
London, S.W.1, by Dec. 31.
Middlesex Hospital |
The annual dinner will be held at the Savoy Hotel, London,
= W.C.?, aa Oct. 4, at 7.30 P.M.
440 THE LANCET]
Nutrition Society ,
The society is holding a conference on The Work and Aims
of the Food and Agriculture Organisation on Saturday,
Sept. 21, at 10.30 a.m., at the London School of Hygiene,
Keppel Street, London, W.C.1.
Sir John Orr, F.R.s., director-general of F.A.O.; Mr. D.
Lubbock; Dr. P. Lamartine Yates; Dr. W. R. Aykroyd ;
and Miss E. Fautz. o
Medical Society of the L.C.C. S
There will be a clinical meeting of the society on Thursday,
Oct. 3, at 3 P.M., at Dulwich Hospital, S.E.22, when the staffs
of Dulwich and St. Olave’s Hospitals will demonstrate e cases.
Association of Industrial Medical Officers '
The annual general meeting of the association will be held
at the London School of Hygiene, Keppel Street, W.C.1,
on Friday, Oct. 18th, at 5 r.m., and will be followed by a dinner
at 7.30 P.M. On Saturday, the 19th, at 10.30 a.m., Dr. Donald
Hunter and Dr. R. S. F. Schilling will speak on Industrial
Medicine in the U.S.A. p 2
St. Thomas’s Hospital
Dr. A. L. Crockford has been appointed secretary of the
medical school in suceession to Dr. R. J. C. Thompson, who
has resigned. l a
Brazilian Honour
The Brazilian order of the Southern Cross has been conferred
on Sir Alexander Fleming, F.R.S., who presided over the Inter-
American medical congress which met in Rio de Janeiro this
month.
Return to Practice
_ The Central Medical War ‘Committee announces that
Dr. Kenneth O. Black, 27, Weymouth Street, W.1 menenen
3336), has resumed civilian practice.
Births, Marriages, and Deaths
BIRTHS
Durron.—On Sept. 10, in Manchester, the wife of Captain G. C. D.
Dutton, R.A.M.c.—a daughter.
HACKETT.—On Sept. 8, the wife of Dr. C. J. Hackett, of Wendover,
Bucks—a son.
HIBBERT.—On Sept. 13, in Liverpool, the wife of Dr. Geoffrey
Hibbert—a son.
HustTon.—On Sept. 7, the wife of Licut.-Coloncl John Huston,
R.A.M.C., of Edinburgh—a daughter. .
LILLICRAP.—On Sept. 12, at Lincoln, the wife of Dr. ‘Charles
Lillicrap—a son
Loaeir.—On Sept. 9, at Aberdeen, the wife of Mr. Norman Logie,
¥F.R.C.S.—a son.
MARRIOTT.—On Ria 11, in London, the wife of Dr. Ian Marriott—
' @ son.
heer.
YupDKIN.—On Sept. 7, the wife of Dr. Simon Yudkin—a daughter.
MARRIAGES
AMBROSE—CLAVERING.—On Sept. 11, in London, dordon Ambrose,
L.M.S.S.A4., to Sheila Clavering.
BENNETT— MELLING —On Sept. 7, at Baylham, Harold Stanley
Bennett, M.B., R.A.F.V.R., to Barbara Hunter Melling.
Rem—SwHarPe.—On August 31, in Calcutta, Grainger Wilson Reid,
lieut-colonel R.A.M.c., to R Ruth h Hilda Sharpe, Q.A.1.M.N.S./R.
WALKER—JONES.—On June 14, in Nairobi, D. O. Walker, major
R.A.M.C., to Mary Jones, Q.A.1.M.N.8./R. f K
DEATHS
BEEVOR.—On Sept. 15, at Burnham, Bucks, Charles Ferrier Beoyor,
M.A., B.M. Oxfd.
GOLDEN.—On Sept. 8, at ford, Michael Bruce Howard Golden,
M.R.C.S.
'Gray.—On Sept. 12, at Dalkeith, Midlothian, George Douglas
Gray, C.B.E., M.D. Edin., late lieut. -colonel R.A.M.C.
ILL.—On Sept. 8, at St. Mary Bourne, Hampshire, Alfred. Arthur
mail, M.D. Durh.
Howir.—-On Sept. 7, Mary Evelyn Howic, M.B. Durh., of Gosforth,
Newcastle-on-Tyne.
PaTON.—On Sept. 9, at St. Albans, Herts, Richard Reid Kirkwood
Paton, M.B. Glasg., D.P.H.
SLAYTER .—On August 22, in Madras. Edward Wheeler Slayter,
C.M.G., D.S.O., M.B. Edin., late colonel R.4.M.c., retd., of Halifax,
Nova ‘Scotia.
STREET.—On Sept. 8, at Crowborough, Ashton Street. M.B. Camb.,
F.R.C.8., lieut. -colonel I.M.8., aged 82.
WILSON. N. Ôn Sept. 10, in Cardiff, James William Albert Wilson,
M.D. Belf.
BIRTHS, MARRIAGES, AND DEATHS—APPOINTMENTS
The speakers will include `
ROYAL COLLEGE OF SURGEONS
{[sePT. 21, 1946 |
Medical Diary
SEPT. 22 To 28
Monday, 23rd
ROYAL COLLEGE OF SURGEONS. Lincoln’s Inn Fields, W.C.2
3.45 P.M. Pag R. A. Willis: Experimental Production of
Tum
5 P.M. Dr. NE F. Maclagan : Basal Metabolism.
Tuesday, 24th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. R. A. Willis: Statistical Study of Tumours.
5 P.M. Dr. L. E. Glynn: Nutritional Factors, Hepatoteiig Agents,
' and Liver Function.
MEDICAL WOMEN’S FEDERATION
8.30 P.M. (B.M.A. House, W.C.1.) Dr. Henriette Lohr: Medicine
in Holland under German Occupation.
Wednesday, 25th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. F. Wood Jones, F.R.S.:
ture of the Palate.
-5 P.M. Dr. L. E. Glynn: Nutritional Factors, Hepatotoxic Agente,
and Liver Function.
UNIVERSITY OF GLASGOW
. 8 P.M. (Department of Ophthalmology.) Dr. J. B. Gaylor : Elec-
troencephalography in Retinal Disease.
Thursday, 26th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Dr. > V. Davies: Development of Joints in General.
5 P.M. Prof. G. Barnard: Selection of Site and Specificity
of a Moi in Inflammation.
Friday, 27th
Development and Struc-
3.45 P.M. Prof. H. A. Harris: The N erve Plexnces of the Limbs.
5 P.M. Prof. G. Hadfield. The Reticuloses. _
BIOCHEMICAL SOCIETY
11 a.m. (University of Liverpool.) Short communications.
Appointments
BIOKFORD, B. J., M.B. Lond., F.R.C.S.: surgical registrar, eE
Chest Surgical Unit at Broadgreen Hospital.
GOLDMAN, H. P., M.B. Glasg., M.R.O.P.: physician, Bolton Royal
Infirmary. =
INGHAM, ARTHUR, M.B. Manc.: physician, Bolton Royal Infirmary
MOORE, THOMAS, M.D., M.S. Duth., F.R.O.8. surgeon, Duchess g of
York Hospital for Pa bies Manchester. |
PROBYN-WILLIAMS, R. C., B.M. Oxfd: examining factory surgeon,
Wotton-under-Edge, "Gloucester.
THEOBALD, G. W., M.D. Lond., F.R.0.0.G. : ` visiting obstetrician and
gyneccologist, Royal Infirmary, Bradford.
WARDLE, V. H., M.C., L.R.O.P.E. : examining factory surgeon,
Bishop Auckland, Durham.
Colonial Medical Service :
BAIRD, R. B., M.B. Edin. : M.O., Uganda. ;
BARNETT, Surgeon Lieut.-Commander A. M., M.R.O. S.: M.O.,
Tanganyika.
BARRETT, R. E., M.B. Lond., D.T.M. & H.: senior M.O., Uganda.
BaRTON, W. L., "M.B. Edin. : M.O. = Kenya.
BISLEY, oh Vana epee kad G.G., M. R.O.8. 2 M.O., ,
Buok, Major S. C., M.B. Camb.: M.O. ORAO Northern
Rhodesia.
BURKITT, Major D. P., M.B. Dubl., F.R.C.S.E.: M.O., Uganda;
CALVERT, MARY, M.B. Belf. : M.O., Nigeria. `
CANDLER, Lieut.-Colonel P; L., M.B. Camb. : M.O., Kenya.
CHEVERTON, R. L., M.R.C.S. A. D.M.S., Nigeria. i
CONNELLY, Wing- Commander J. R., L.R.C.P.E. : M.O., Kenya.
CONNOLLY, P. P. D., M.B. Belf. : senior M.O., p ongan yika;
- COOMBES, A. H. R., M.R.O.8. : M. o., Hong one
CUMMINGS, W. L., M.B. Edin. : district M.O., S Vincent, Wind-
ward Islands.
EVANS, Surgeon Lieutenant A. J.: M.0., N orthern Rhodesia.
FRANKS, Surgeon Lieutenant A. C., M.R.O.S.: M.O., Tanganyika.
GRIFFITHS, Major P. G., M.C., M.B. Manc. : M.O., Fiji. . l
GURD, C. H., M.B. Brist.: M.o., St. Helena.
HALL, C. L., B.M. Oxfd: M.O., Tanganyika.
'HETREED, V. W. J., B.M. Lond.: M.o., Nigeria.
HIRST, A. E. E., M.B. : M.O.H. (grade C), Trinidad.
HOLLOWAY, R., M.D.: M.O., Hong- Kong.
HOWELL, A. T., M.B Camb: A.D.M.S., Kenya.
HUGHES, M H., B.M. Oxfd : "M.O., Gold Coast.
KETER, MARY C., M.B. Glasg. : : M. o., Nigeria..
LEITCH, NELL, B.M. Oxfd : M.O., Nigeria.
McDONALD, J. H., M.B. Aberd. : : senior M.0., Tanganyika.
MoKENZIR, A., M.B. Lond.: A.D.M.8., Tanganyika.
NICKLIN, REGINALD, M.B. Birm. : senior M. o., Northern Rhodesia.
O’KANE, R., M.B.: M.O., Malaya.
PHILIP, C. R., 0.B.E., M.D. Aberd.: A.D.M.S., Kenya.
SANDERSON, N. D., M.B. Edin.: senior M.O., Northern Rhodesia.
SHEFFIELD, "WILLIAM, BM. B. Leeds: M.0., Northern Rhodesia.
THom, W. T., M.B. Edin.: M.O., Tangany ika.
WARNER, O. F., L.R.C.P.E. : M.O. (grade B), Trinidad.
WILLIS, J. y M.D. ; M.O., Hong-Kong.
Dr. E. H. van SOMEREN.—A footnote in a recent book of
memoirs states that Dr. van Someren, who practised in
Venice from 1898 to 1913, suffered from melancholia and
committed suicide in Venice. His obituary notices (see Lancet,
1913, i, 793; Brit. med. J. 1913, i, 589) make it clear that
he died at Syracuse after a short illness at the age of 41; he
_ was a diabetic and died in coma after contracting influenza.
THE LANCET]
PERFORATED PEPTIC ULCER
TREATED WITHOUT OPERATION *
. HERMON TAYLOR
M.A., M.D., M.Chir. Camb., F.R.C.S.
ASSISTANT SURGEON, LONDON HOSPITAL; SURGEON,
GEORGE HOSPITAL, ILFORD ; CONSULTING SURGEON,
ENFIELD WAR MEMORIAL HOSPITAL
Ir has long been a rule of surgical practice that
perforated peptic ulcer should be treated by immediate
operation to suture the perforation and drain the peri-
‘toneal cavity. It is, however, questionable whether all
cases of perforation should be lumped together indis-
criminately in this way. The gravity of the crisis depends
not so much on the fact of the perforation as on the
likelihood of a fatal peritonitis. But the factors which
determine this issue—the interval between perforation
and treatment, and the amount and character of the
leakage from the stomach—vary within the widest limits.
Automatic surgical intervention takes no account of
this variation, nor does it recognise the existence of the
natural defence mechanism within the peritoneal cavity.
It must not be forgotten that the peritoneum, with its
copious blood-supply and lymph drainage, its endothelial
cells and phagocytes, is specially adapted to overcome
infection. It can sterilise and absorb a considerable
quantity of infective fluid, provided the contamination is
not repeated before the peritoneum has had time to
recover from the damage suffered in the process. To
state this is to put the problem of perforated ulcer in its
proper perspective. Obviously if an infective peritonitis
is already established as the result of delayed treatment
or gross flooding of the peritoneal cavity there is no
alternative to the classical operation, since drainage is
essential. But if the contamination which has taken
place can be checked at the source without operation,
before it has overcome the peritoneal defence, no drainage
is necessary, and the patient will recover spontaneously.
A method of achieving this is described here, the effect
of which is to reduce the problem in any one case of
perforated ulcer to an assessment of the degree of leakage
that has taken place. The decision to interfere surgically
will depend on this assessment, but in the great majority
of cases it will not be necessary, as the present case-
reports show.
KING
DEVELOPMENT OF THE CONSERVATIVE METHOD
It will perhaps be useful to describe how I came to
make this departure from established practice.
In operating on early perforations in the usual way, I
repeatedly found that the peritoneal fluid was sterile on
culture, and therefore I began to dispense with the
drainage-tube more and more, without encountering any
case of delayed peritonitis as a result. But the crucial
experience was that from time to time there occurred
cases in which I opened the abdomen only to find the
perforation already sealed off by adhesion to a neigh-
bouring viscus, usually the under surface of the liver.
The firmness with which the adherent surfaces were
applied to each other, and the difficulty in separating
them to suture the perforation, suggested that this was
in fact unnecessary. When a similar case occurred later,
therefore, I left the sealed-off perforation undisturbed
without any untoward sequelx, but it was obvious that
I had performed a useless operation, having neither
drained the peritoneal cavity nor sutured the perforation.
I collected 8 cases of this nature and found that the
factor common to them all was that the patient’s last
meal had been eaten some time before the perforation—
j.e., the stomach was relatively empty at the time.
Consequently, not without trepidation, I tried to repro-
s Er Vane the Society of British Gastro-Enterologists, November,
6422
duce this condition in early cases by substituting gastric
aspiration for operation, relying on the peritoneum to
deal with the fluid that had already escaped, and on
local adhesion to seal off the dried-up perforation.
The results were satisfactory beyond my expectation.
Since January, 1945, 28° consecutive cases have been
treated in this way; 24 patients made an uneventful
recovery, 3 died from causes unconnected with the
treatment, and 1 died who might have been saved by
immediate operation, if I had had the experience at the
time to recognise the limits of applicability of the con-
servative method. With the experience that has been
gained and is now recorded, such an error in the selection
of treatment should be avoidable in future.
CLINICAL PROCEDURE
At King George Hospital, Ilford, when a case of
perforated ulcer is received, the decision whether to apply
conservative treatment or to operate is made in the
receiving-room (see below). If conservative treatment
is adopted, the patient receives morphine gr. !/, intra-
venously, repeated if necessary, and sucks a lozenge of
amethocaine gr. 1. When thereby his pain and anxiety
are dulled and his throat has become insensitive, his
stomach is emptied with a large stomach-tube attached
to a Senoran’s gastric-suction bottle. The tube is then
withdrawn, and the patient is sent to the ward. When he
has been made as comfortable as possible in bed, a small
stomach-tube is passed through the nose and fixed in
position, and the stomach is aspirated at half-hour
intervals with a 20 c.cm. syringe. The.quantity of fluid
withdrawn plus three pints in the twenty-four hours is
administered rectally, subcutaneously, or intravenously.
Small sips can be given, provided they are aspirated
out again at once; otherwise nothing is allowed by
mouth for the first day. Chemotherapeutic agents may be
given by injection if necessary. :
The treatment is continued during the second twenty-
four hours, but now hourly aspirations are followed by
drinks of 1 oz. of water. A mixture of milk and water is
substituted on the third day, and the tube is removed
when the fluid chart indicates that the amount taken by
mouth is passing into the intestine and is not collecting
in the stomach. Subsequent treatment is exactly as
for acute non-perforated ulcer, with graduated diet, oil,
powder, &c.
On this régime pain diminishes rapidly, and the patient
is generally comfortable within twelve hours or so. It is
interesting to observe the disappearance of the signs
progressively from the left lower abdomen towards the
epigastrium and right flank, where tenderness may
persist for some days. The indwelling tube is a source
of discomfort to the patient, but is usually gladly borne
when it is explained that the alternative is an operation. `
There is usually very little constitutional disturbance,
and the pulse-rate remains about normal. Ileus may be
expected in the not-so-early perforation, for which it
may be necessary to continue the aspiration longer than
usual. The limiting factor in the selection of cases is
implied in this consideration and will be discussed further.
If proper judgment has been exercised, a serious ileus
should not develop.
The treatment throws little more strain on the nurses
than if the patient had been operated on, but it does
require from them an appreciation of the fickleness of
stomach-tubes. A dry aspiration should never be
accepted as evidence of an empty stomach, unless a
small drink by mouth can ‘be immediately withdrawn
through the tube.
l CASE-RECORDS
The case-records include only unequivocal perforations
with full-scałe rigidity and tenderness, some being
confirmed by the radiological demonstration of gas under
N
442 THE LANCET]
MR. HERMON TAYLOR: PERFORATED PEPTIC ULCER
[serr. 28, 1946
the diaphragm.
limited leakage from an ulcer that occurred during the
period of the experiment are not included in the list.
There was one case of mistaken diagnosis during ghis time :
a man, aged 56, subject to dyspepsia, who had had a
sudden continuing pain four hours previously.
was generalised tenderness and rigidity of the abdomen,
and he was treated by aspiration on a diagnosis of per-
. forated ulcer. Persisting abdominal: signs and a steady
rise in pulse-rate, however, led to operation on the
second day, when a tense gall-bladder was found and
treated successfully by cholecystostomy. Two perfora-
tions in the series (case 6 and case 9) were also subjected
to operation on the second day because of persisting
generalised abdominal tenderness. In each of these
the perforation was found to be sealed, but collections of
sterile fluid in the pelvis and right flank were successfully
drained. It may or may not have been necessary to do
this, but the point to be made from these cases and that
of the acute cholecystitis is that, if an expectant attitude
is maintained in the management of the patients, no harm
need result from the delay in operation.
In the early cases of the series one was, naturally
perhaps, too ready to interfere and perform an inter-
current operation. Thus in case 3 one of my assistants
inserted a suprapubic drainage-tube, which unfortunately
gave rise to a fatal mechanical obstruction of the small
gut m the pelvis. Another patient died from a pulmonary
embolus on the fourth day of conservative treatment
_ (case 10). Necropsy showed a sealed perforation, and a
collection of sterile fluid in the right flank, besides the
fatal clot. A third fatality was a man, aged 65, admitted
twenty-four hours after perforating, too ill to be operated
on (case 15). He was treated by aspiration for eleven
hours in the vain hope that he would recover sufficiently
for operation. Necropsy showed a sealed lesser-curve
ulcer. None of these deaths was due to the treatment ;
indeed 'in case 3 the fatal issue must be attributed to the
substitution of operation and drainage, though this was
accidental. a
In case 16 the method was a tragic failure. The patient,
a huge unruly Irishman, had drunk two pints of beer
after his perforation and was quite uncontrollable in the
ward, drinking his mouth-wash and pulling out his
stomach-tube. Obviously he should have been operated
on, but this was put off till too late. He developed a
loculated peritonitis and a severe ileus, which proved
fatal on the fifth day. The case indicates the two chief
contra-indications to the conservative method of treat-
ment in an early case—inability of the patient to accept
the treatment quietly ; and the presumptive presence
of large quantities of fluid (in this case beer) in the peri-
toneal cavity. The same consideration would apply
when the stomach is dilated behind an obstruction, such
as a stenosing ulcer, unless treatment has been prompt.
Too much must not be asked of the peritoneal defence,
and a limit must be recognised to the applicability of the
treatment from this point of view. That this limit is
fairly wide is suggested by the fact that the 28 cases were
consecutive, though manifestly the sequence should have
been interrupted by one case for operation.
CASE-REPORTS
Case 1.—Man, aged 49; long history of duodenal ulcer ;
perforated 4 hours. Gastric aspiration for 10 hours. Pain and
tenderness diminished. Assistant (P. H.) operated “ to make
sure perforation was really sealed.” This was confirmed, and
10 oz. of sterile fluid was removed from peritoneal cavity.
Recovery. 7
CasE 2.—Man, aged 31, with 6 years’ history of duodenal
ulcer ; perforated 3 hours. Conservative treatment. Rigidity
and tenderness subsided in 2 days. Patient went home in
3 weeks. :
Case 3.—Man, aged 57, with 3 years’ history of duodenal
ulcer ; perforated 7 hours, 2 hours after a meal. Pain and
Three cases of doubtful. perforation or |
There |
tenderness: subsided with 48 hours’ aspiration, but abdomen
was rather distended. Pulse-rate 100-110. __
Assistant (R. E. R.) operated on diagnosis of ileus after 2 days.
Suprapubic incision only ; 2 oz. of sterile fluid removed. Drain
inserted. Patient improved for 2 days, then distension
increased, and patient looked worse. Pulse-rate slowly rose.
Patient improved with Miller Abbott tube but continued ill.
Operation (H. T.) after 7 days. Obstruction of small gut in
pelvis, dilated above and collapsed below an adherent kink
where suprapubic tube had been. This was freed, but patient
died 6 hours later. POS
At necropsy perforation was found to be securely sealed by
liver. No intraperitoneal collection of fluid. Death from
toxemia of intestinal obstruction due to the drainage-tube.
CasE 4.—Man, aged 52, with 10 years’ history of duodenal
“ulcer; perforated 3 hours, !/, hour after a meal. Pain dis-
appeared after 12 hours’ aspiration. Tenderness gone in 3 days.’
Home in 4 weeks. Uneventful recovery without operation.
CasB 5.—Man, aged 61, with 15 years’ history of duodenal
ulcer ; perforated 5 hours, soon after a meal. Poor physique,
chronic bronchitis and emphysema. Dyspnea on exertion.
Enlarged prostate and chronic retention.
Pain and tenderness subsided with 48 hours’ aspiration.
Distension amounting to ileus persisted 5 days and then
subsided. He recovered after some anxiety regarding the.
ileus. A very poor operation risk. | l
Twelve months later he was operated on for recurrence of
symptoms : duodenal ulcer with membranous adhesions to
liver. Gastro-enterostomy. Recovery.
CasE 6.—Man, aged 24, with 2 years’ history of dyspepsia ;
erforated 2 hours, having had a meal 2 hours before. Patient
improved with 18 hours’ aspiration, but tenderness and
rigidity remained diffuse. Operation (H. T.) therefore under-
taken as precaution. fPyloric region adherent by fibrin to
liver, not disturbed. Two ounces of peritoneal fluid—sterile.
No drain. Patient did well as regards abdomen. Post-
operative persistent fever and cough. Sputum contained
tubercle bacilli. Radiography showed tuberculosis of left apex.
Patient was last heard of in a north Irish sanatorium, doing
well. !
Case 7.—Man, aged 35, with 15 years’ history of duodenal
ulcer ; perforated 4 hours. Pain-free after 24 hours’ aspiration,
home in 2 weeks. Uneventful recovery. . |
CasE 8.—Man, aged 23, with 4 years’ history of duodenal
ulcer ; perforated 11/, hours. Pain-free after 24 hours’ aspira-
tion, abdomen soft in 48 hours. Uneventful recovery.
Subsequent recurrence of ulcer. Operation 4 months later.
Membranous adhesions between ulcerated duodenum and
liver. Gastro-enterostomy. Recovery.
CasE 9.—Man, aged 45, with 4 years’ history of duodenal
ulcer; perforated 31/, hours, 1 hour after a meal. Patient
improved after 28 hours’ aspiration. Persistent general
though diminished rigidity and rising pulse-rate indicated
operation (H. T.). Perforated duodenal ulcer found sealed off
by liver. Peeled off and sutured. Collections of fluid in
pelvis and right flank each drained with tube. Fluid sterile.
Patient did well. Operation was probably necessary to
drain the fluid. Nothing was lost by 28 hours’ delay. Fluid
was sterile, and ulcer sealed off.
CASE 10.—Man, aged 36, with 18 years’ history of duodenal
ulcer ; perforated 11/, hours, 3 hours after a meal. Pain
subsided in 6 hours. Tenderness persisted in right flank,
where a fullness indicated a fluid collection. This persisted
4 days, and loca] drainage was decided on. While being
prepared for operation, patient ‘“‘ went black” and died
instantly.
At necropsy pulmonary artery and right auricle were found
filled with curled up ante-mortem clot from. deep iliac and
inferior caval veins. Death from pulmonary embolism.
Sterile collection of clear yellow fluid in right subphrenic
space. No peritonitis. Duodenal perforation well sealed off
by liver.
Case 1].—Man, aged 36, with 1 year’s history of duodenal
ulcer ; perforated for 2 hours, 1 hour after a meal. Pain-free
after 6 hours’ aspiration. Tenderness gone in 2 days.
Uneventful recovery. g
CasE 12.—Man, aged 26, with 2 months’ history of dyspepsia ;
perforated for 3 hours, 1/, hour after a meal. Pain-free after
24 hours’ aspiration. Tenderness in right flank persisted 4
days. Given penicillin as temperature was 102°F. Uneventful
recovery. Radiography showed pyloric ulcer.
THE LANCET]
MR. HERMON TAYLOR: PERFORATED PEPTIC ULCER
[sEPT. 28, 1946 443
CasE 13.—Man, aged 67, with history of chronic bronchitis,
angina of effort, 10 years’ history of dyspepsia ; ulcer perforated
for 3 hours, 9 hours after a meal. Pain-free in 24 hours.
Tenderness gone in 3 days. An ill man on admission. Doubtful
if he would have survived operation. Steady recovery on
aspiration. i |
CasE 14.—Man, aged 47, with 18 months’ history of duo-
denal ulcer ; perforated for 2 hours, 4 hours after a meal. Pain
lasted 2 days on aspiration. Tenderness in right flank per-
sisted 6 days—subsided. Steady recovery, though slower
than usual.
CasE 15.—Man, admitted moribund, aged 65, with chronic
phthisis, chronic retention of urine, repeated melæna, 12
months’ history of failing health, 10 years’ history of dyspepsia ;
ulcer perforated for 24 hours.
It was intended to operate on this patient if he could be
improved sufficiently. Aspirated 11 hours until death. At
necropsy two ulcers were found, one on middle of lesser curve,
and one prepyloric, which had recently perforated and been
sealed off by liver. Thin peritoneal fluid, not cultured.
Tuberculous lungs, degenerate myocardium.
Case 16.—Man, aged 50, with 10 years’ history of dyspepsia ;
perforated 2!/, hours. Patient had drunk two pints of beer
to relieve pain. Pulse-rate 120. Uncontrollably restless,
fought the nurses, pulled out his stomach-tube, drank his
mouth-wash. Tenderness diminished under treatment, but
abdomen became distended and remained so. After enema
on third day patient had another sudden pain and condition
deteriorated. Re-perforation diagnosed.
Operation (C. A.) in extremis. Suprapubic drainage of
- pouch of pus. Patient died 3 hours later. Necropsy showed
anterior duodenal ulcer, not adherent. A ring of fibrin round
it and on the under surface of the liver suggested that the two
surfaces were adherent at one time and had separated again.
Dilated intestines. Loculations of pus in various parts of
abdomen. Death from peritonitis and ileus.
I should have operated on this man in view of the beer he
had drunk and his resistance to the treatment.
Case 17.—Man, aged 26, with 3 years’ history of duodenal
ulcer ; perforated for 4 hours, 2 hours after a meal. General
tenderness persisted 48 hours before resolving. Pulse-rate
112, slowly decreased. Residual tenderness in right flank
subsided after 6 days. Rather delayed resolution followed by
steady recovery.
CasE 18.—Man, aged 41, with 12 years’ history of duodenal
ulcer ; ulcer perforated 2 hours before admission, while patient
was atluncheon. General pain disappeared in 4 hours. Tender-
ness in right side lasted 24 hours. Uninterrupted recovery.
--CasE 19.—Man, aged 32, with 4 years’ history of duodenal
ulcer ; perforated for 1!/, hours, 3 hours after a meal. Pain
gone in 24 hours, tenderness gone in 48 hours. Uninterrupted
recovery.
CasE 20.—Man, aged 46, with 16 years’ history of duodenal
ulcer ; perforated 6 hours. Pain subsided in 24 hours, tender-
ness gone in 4 days. Uninterrupted recovery.
CasE 21.—Man, aged 63, with hyperpiesis, dyspnoea, and
cyanosis, and 2 years’ history of dyspepsia; perforated 41/,
hours. Pain subsided in 3 days. Patient nearly died of heart-
failure in first 3 days. Diagnosis of perforation proved by
gas under right dome of diaphragm ; patient could not have
survived operation. i
CasE 22.—Man, aged 65, with chronic bronchitis, dyspnea,
30 years’ history of duodenal ulcer; perforated 2 hours.
Tenderness subsided in 3 days. Uninterrupted recovery.
CasE 23.—Man, aged 28, with no history of previous dys-
pepsia ; perforated for 1 hour, 4 hours after a meal. Pain
subsided in 6 hours, tenderness gone in 2 days. Uninterrupted
recovery. Radiography showed duodenal ulcer.
CasE 24.—Man, aged 23, with 7 years’ history of duodenal
ulcer; perforated for 5 hours, ] hour after a meal. Smooth
rapid subsidence of pain. Uninterrupted recovery.
CASE 25.—Man, aged 31, with 10 years’ history of duodenal
ulcer; perforated for 1 hour, !/, hour after tea. Pain subsided
in 2 days. Tenderness persisted 3 days, with slight degree of
ileus. Slow but steady recovery.
CasE 26.—Man, aged 36, with 16 years’ history of duodenal
ulcer ; perforated for 3 hours, 6 hours after a meal. Pain gone
in 6 hours, no tenderness after 3 days. Uneventful recovery.
CasE 27.—Man, aged 50, with 10 years’ history of dyspepsia ;
perforated while visiting wife in hospital. Gas below
diaphragm. Pain gone in 24 hours, no tenderness after 4 days.
Uneventful recovery.
CasE 28.—Man, aged 65, with 20 years’ history of dyspepsia ;
perforated 8 hours, 1 hour after a meal. Low vitality ; cold
and collapsed. Pain subsided in 12 hours, tenderness in 3 days.
Uneventful recovery. Gastroscopy on 10th day showed a
healing lesser-curve ulcer at the incisura. Doubtful if he
would have survived operation. `
MORTALITY AND MORBIDITY
Several of the patients were- very poor surgical risks
indeed and would have stood little chance with operation.
Cases 5, 13, 15, 21, and probably 22 and 28 may be
placed in this category without postulating any post-
operative complications in the others.
Mr. Ian Soutar, my house-surgeon, investigated the
hospital results under the old régime to compare with
those we were obtaining, and to sustain our wavering
morale after the tragedy of case 16. He found that in
the preceding five-year period there were 77 perforated
ulcers of less than twenty-four hours’ duration, the
average time being five and a half hours. Of these
patients 14 died, a case-mortality of 18%. More than
half the deaths were due to heart-failure or to pneu-
monia, an interesting comment on the bad-risk cases
that were not operated on in my series. The postoperative
morbidity-rate among the survivors was 46%, half of
these being from pulmonary disease, and a quarter
being associated with wound infection, breakdown, or
subsequent hernia. It is obvious that there. is a great
deal to be gained by not operating if this can be achieved.
The 24 patients who recovered left hospital in 2--4
weeks. If it be conceded that the pulmonary embolus,
the intestinal obstruction, and the moribund patient may
be excluded from consideration of the mortality incurred
by the conservative method of treatment, the result is
1 death in 25 cases. As a first series, these figures are
promising, and they may be improved by further experi-
ence if a repetition of case 16 can be avoided. —
DISCUSSION
, If these early results are confirmed by further experi-
ence, it will seem that, in a district where the medical
organisation is good, most patients with perforated ulcer
admitted early to hospital need not be submitted to
operation. Surgical intervention should be reserved for
late cases, patients with pyloric stenosis and gastric
dilatation, and those who have ingested a large quantity
of fluid just before or after the perforation.
For sparsely populated district% ships at sea, or any
case where trained surgical help’ is not immediately
available, the treatment described above, or a modifica-
tion of it, may be given by a general practitioner or a
nurse, or on board ship possibly by an untrained person,
if a stomach-tube and syringe are available. Gastric
aspiration should certainly be used in any case of perfora-
tion that has to wait long for a surgeon.
In this series all the perforations except two were
duodenal ; it remains to be seen whether gastric perfora-
tions behave similarly.
SUMMARY
Early perforations will seal themselves if the stomach
is emptied and kept empty by aspiration.
Gastric contents in the peritoneal cavity will be
sterilised and absorbed if the leakage is not gross and
the contamination is not repeated. |
Of a consecutive series of 28 perforations treated by
gastric aspiration instead of operation, 24 patients
recovered. Of the 4 deaths, 3 were not related to the
conservative method of treatment. |
It is suggested that the technique described is worthy
of extended trial in early cases, operation being reserved
444 THE LANCET]
LIEUT.-COLONEL O’DONOVAN, DR. KLORFAJN: SENSITIVITY TO PENICILLIN
[sEPT. 28, 1946
for cases with gross flooding of the peritoneal cavity or
late cases with established peritonitis. | ‘
-~ The conservative method can be applied where surgical
help is not available. | .
My thanks are due to the nursing staff of King George
Hospital, Ilford, for their enthusiastic coöperation in this
work ; and to the resident surgical officers, Mr. R. E. Raynaud
and Mr. Charles Allen, to the surgical registrar, Mr. Philip
Hopkins, and to my house-surgeons, Mr. Ian Soutar and Mr.
M. J. Whelan, on whose clinical judgment and reports I largely
relied in the management of my cases.
SENSITIVITY TO PENICILLIN
ANAPHYLAXIS AND DESENSITISATION
W. J. O’DoNovAN I. KLORFAJN
O.B.E., M.D. Lond. M.D. Brux. _
LIEUT.-COLONEL B8.A.M.O, CIVILIAN MEDICAL
ADVISER IN DERMATOLOGY, ‘PRACTITIONER ATTACHED
MIDDLE EAST ' TO A MILITARY HOSPITAL,
PHYSICIAN, SKIN DEPARTMENT, MIDDLE EAST
LONDON HOSPITAL
ONLY a few cases of skin sensitisation to penicillin
have been reported up to now in the medical journals
available in the Middle East. Pyle and Rattner (1944)
reported one case of epidermal sensitivity, and Binkley
and Brockmole (1944) two cases. Silvers’ case (1944)
was in a chemist engaged in penicillin research. Criep
(1944) reported a case of acquired allergy to penicillin
after repeated intramuscular injections; generalised
urticaria developed on the resumption of injections after
an interval of ten days. Two patients who had been
treated with penicillin sprayings for skin affections
were admitted to a military hospital in the Middle East
because their skin condition had worsened while under
treatment. On examination they were found to be skin-
sensitive to penicillin.
One of them, the subject of this report, was given an
intramuscular injection of 15,000 Oxford units of
penicillin and responded with a violent anaphylactic
shock. He willingly submitted to experimental investiga-
tions and attempts to desensitise him with injections and
later by oral administration of penicillin. The second
patient was unwilling to undergo extensive experimental
investigations, and will not be referred to further.
Importance is attached to the first case not only because
desensitisation was successfully produced but also
because it was done by the oral administration of
penicillin.
CASE-RECORD
Bombardier A, aged 30, gave no history of serious general
diseases or accidents. gHe had always had a dry scalp and
thin hair. About 14 years ago he had a mild rash in his
groins for a few days. In England the summer sun regularly
caused some dryness and peeling of the skin of his face.
There was no history of asthma, hay-fever, eczema, or migraine
in him or his relations, nor of any idiosyncrasy. He had
spent six months in the M.E. before his admission to hospital.
The sun in the M.E. did not affect his skin more than it used
to in England. In June, 1944, some fissures appeared on the
webs of the left foot with irritation. When these had been
present for 3 weeks he showed them to the M.o. of his unit, who
ordered three-hourly sprays of penicillin 200 units pa C.cM., ;
this spraying was done five times daily for a week, without
noticeable benefit. The skin subsequently cleared with
bland ointments. | ;
In October, 1944, he had an abscess over the left jaw, and
penicillin sprays were again used for three days before incision.
Two weeks later a rash broke out on the lower part of his face
and on his left foot. He was admitted to the skin department
of this hospital, where he was treated for two weeks as for
seborrhea with ointments of zinc oxide, castor oil, olive oil,
and lime water, and the foot and face cleared. On Dec. 4,
1944, when on duty, his foot condition recurred and he was
admitted to the regimental sick-quarters for ten days, where
his foot was again sprayed five times daily. At the end of this
time the condition of his foot had worsened and an eruption
had broken out on his face. l
face swelled, reddened, and oozed all over.
« - CONDITION ON ADMISSION
On admission to the hospitalon Dec. 14 he was noted to be
an active, intelligent, fair-haired, and slightly bald man,
weighing 143 1b., B.P. 120/85 mm. Hg, with no discernible
visceral or nervous disease. The blood-count and urine were
normal. His face, forehead, and the front of his neck were
red. There was a mild cdema of the upper lip and round the
nose and eyebrows, and a vivid small papulomacular rash on
his cheeks and the front of the neck. The dorsa of the left
toes and foot were red, slightly swollen, and shiny.’ No fungi
were found microscopically in scrapings from the affected
skin areas. This history suggested an abnormal response of
his skin to penicillin applied externally. .
PATCH TEST
A solution of penicillin containing 200 units per c.cm.
was applied on scarified and unscarified areas on his back.
A fourfold pad of lint was soaked in penicillin and applied
five times daily at 3-hr. intervals through a windowed occlu-
ding square of ‘Elastoplast.’ As a control, on two other
areas the pads soaked in penicillin were left unchanged until
taken off. The scarified area where the pad was changed
three-hourly became red, mammillated, and moist—.e., positive
—after 21 hrs. All the others, changed or unchanged, became
equally positive 48 hrs. from the first application.
INTRADERMAL TESTS
An intradermal test was carried out with 0-2 c.cm. of saline
containing 4 units of sodium penicillin. This produced a.red
blush with a paler central weal after 3 hrs. The local
erythema persisted for over 2 weeks. The same amount
of normal saline injected intradermally into the other arm
produced an erythema which disappeared after 48 hrs. |
SPRAY TESTS
To confirm the diagnosis we sprayed the patient’s face
and foot with a solution of penicillin containing 200 units
per c.cm. three-hourly. After five sprayings his face became
vividly red, swollen, and covered with an oozing fragile
vesicular eruption. He complained of a severe local itching
and burning sensation. The foot reacted similarly but. not
so much.
ANAPHYLACTIC SHOCK
On the 17th the patient was given an intramuscular injec-
tion of 15,000 units of sodium penicillin (American manu-
facture) in a surgical ward. Aseptic precautions were observed,
and the solution was taken from a rubber-capped bottle which
was in use also for other patients. Just before the injection
his pulse-rate was 64 per min., temperature 97-4° F, and
white-cell count 8000 per c.mm. (polymorphs 71%, eosino-
phils 6%, lymphocytes 20%, and monocytes 3%). Fi
j s after the gluteal injection his pulse-rate rose ;
and he complained of a throbbing in his face; five minutes
later he complained of breathlessness, the pulse-rate became
very quick, and soon afterwards he was restless, very pale,
cold, and covered with a cold sweat, and then his bed was
shaken by a violent rigor; his teeth chattered, his breathing
was shallow, and his pulse thready and its rate uncountable ;
he slowly recovered, being tired and weak for a couple of days.
His white-cell count about 3 hrs. after the shock was 10,200
per c.mm. (polymorphs 58%, eosinophils 3%, lymphocytes
29%, and monocytes 10%). His temperature remained normal,
Six hours after this injection into the buttock, the patient’s
His right eye,
which was already showing mild conjunctivitis, became very
red and weeping, with some photophobia. |
SENSITIVITY AFTER SHOCK
A penicillin patch test was again applied as before to.
determine whether this notable unexpected anaphylactic
shock from the penicillin had desensitised him. The tested
areas were irritating and pink—i.e., moderately positive—
on the next day and became markedly positive on the third
day. On Jan. 17, 1945, a limited area of his face was again
sprayed at 3-hr. intervals with the 200-unit solution of
penicillin. This produced a severe local reaction, the skin
becoming red, swollen, and moist, a condition which “lasted
eleven days.
ACTINIC REACTIONS
On Jan. 10, 1945, Bdr. A casually exposed himself to the
M.E. winter sun. Approximately 2 hrs. later a moist
red rash appeared behind his ears. As an experiment,
squares of his back were exposed to the sun on the afternoon
of Jan. 11 through windowed black paper ; next day the sites
THE LANCET]
LIEUT.-COLONEL O'DONOVAN, DR. KLORFAJN: SENSITIVITY TO PENICILLIN [sEPT. 28, 1946 445
EE LT SSS Se Sse i UPSD
which had been exposed for '/, hr. were brown, 1l hr. pink,
and 2 hrs. red. A small area of the back exposed to an ultra-
violet lamp on Jan. 14 gave a mild erythematous reaction
after a '/;-min. exposure at a distance of 2 ft.; ‘an equally
blond patient did not react to twice this dosage. |
DESENSITISATION
Shock in penicillin therapy raises two questions: (1)
whether a penicillin-sensitive patient in immediate need
of injections of this drug, and having reacted with an
anaphylactic shock to a full injection dose, can be even
temporarily desensitised with injections of small and increas-
ing doses of penicillin at short intervals, given in the Bezredka
style to prevent serum shock, so that full-dose therapeutic
injections can-be started without delay; and (2) whether
a patient can be desensitised by continuous administration
of small doses of penicillin for a longer period.
In an attempt to find an answer to the first question 100
units of American sodium penicillin was injected under the
skin with the intention of repeating the injection a short
time later, intramuscularly, with increasing doses. After
25 min. the patient, Bdr. A, experienced shock similar to that
caused by the first injection of 15,000 units, but less intense
and less prolonged.
It is probable that starting with smaller doses we could
eventually inject a full dose without incident, but such a
technique would require a Jong time, many injections, and
much discomfort for the patient. The problem of urgency
could not be solved in this way. It remained to try the
oral route used by Lieut.-Colonel C. J. H. Little and Captain
G. Lumb, of the Central Pathological Laboratory, M.E. Their
communication (Little and Lumb 1945) was published after
our experiment had started with Lieut.-Colonel Little’s counsel.
Fifteen minutes before the administration of penicillin, 4 oz.
of milk mixed with one teaspoonful of sodium bicarbonate
was given to the patient to drink. Fifteen minutes later
American sodium penicillin 15,000 units in 2 oz. of milk,
beaten up with a raw egg and a little sugar added for flavour,
was given by mouth. |
On Feb, 23 the first dose of penicillin was given by mouth.
After 11/, hrs. the patient complained of a burning sensation
on the face. About 2!/, hrs. after the dose the face became
pink and later turned red. The redness gradually increased
in intensity and spread down the neck, and a mild edema
of the cheeks and eyelids appeared. The colour of the face
returned to normal 10 hours after the first dose, but the
skin of his rt. ear was irritating and discharging; during this
time the patient was in bed and out of the sun,
Next day, before having his second dose, the exuding
dermatitis round the rt. ear had increased, and the redness
of the whole face had’ reappeared, with more fine scaling as
compared with his condition before the treatment began.
The temperature and pulse-rate continued normal], and the
general feeling good. The blood-count did not vary. On
this 2nd day the patient had three doses orally of penicillin
15,000 units each at 3-hr. intervals. After each dose the same
akin reactions were noticed as after the first.
Two days after the beginning of the desensitisation treat-
ment, after four doses of 15,000 units in all, the face was very
sore and the rash had extended gradually to the whole of his
face. The area of exudative erythema increased, and there
was much more scaling of the forehead and scalp. The tempera-
ture and pulse still remained normal, but the white-cell count
rose to 16,000, with an unchanged differential count. In the
next 24 hrs. the patient received eight doses of 15,000 units at
3-hr. intervals. He then, Feb. 26, complained of general
malaise and was a little drowsy. The orbits, cheeks, ears,
and lips were very swollen and red. The ears and the angles
of his mouth were moist and fissured. The rest of the face,
neck, scalp, and upper part of the sternum were papular, red,
and scaling. The rt. foot, the one which was initially sprayed
with penicillin, was now red and moist. The groins and
scrotum were slightly red.
The daily doses were subsequently decreased to four given
at 3-hr. intervals as before and then gradually again increased
to eight as the symptoms subsided after ointments. On the
12th day of oral penicillin, March 3, the face, foot, and groin
were dry and peeling. The patient then had eight doses
of 16,000 units daily, without any other discomfort than a
transient mild diarrhoea and frequent micturition. He was
well enough to be up. The white-cell count gradually decreased
to remain about 9000, with a normal! differential count, until
the completion of desensitisation, Frequent analyses of the
urine showed no abnormality.
On the 13th day of treatment, March 7, the patient received a
subcutaneous injection of American penicillin 100 units without
showing or feeling any reaction. The next day he received
an intramuscular injection of 15,000 units without any general
effect. There was a slight soreness and an increase of peeling
on the face within 24 hrs. The 3-hourly full oral doses were
continued for another 5 days and then stopped. 7
To estimate progress, penicillin spray with the 200-unit
solution was again tried on the patient’s face on March 13.
After four applications the face became red, sore, and irrita-
ting. Although this reaction was much milder than before
desensitisation was started, the skin was still sensitive.
American penicillin 15,000 units was injected the next day,
to see if l | |
such a
dose could
still be
tolerated
without
anaphy -
lactic
shock. No
ill effect
was ob-
served.
Because ol
of ,the V2 1 tv2 +2 2V2: 3
partial i HOURS
S tato Bacteriostatic power of serum after oral administration
of skin of 15,000 units of penicillin. Curve | : three days after
decensiz start of desensitisation course. Curve2: sixteen days
; : later. Curve3: after completion of desensitisation
tisation, course. Curve 4: control.
oral peni-
cilin was resumed at the rate of six daily deses of 15,000
units each, at 3-hr. intervals, so as not to disturb the patient
in the night. This was continued for a further 11 days,
without producing any general or skin symptoms. The
desensitisation treatment had now lasted 30 days. The
penicillin sprays on Bdr. A’s face were repeated on March 16 -
and again were followed by puffiness of the eyelids, reddening
of the cheeks and neck, and exudation on a very small area
below the ear lobules.
On April 4 Bdr. A’s face was sprayed with a solution con-
taining 10 units of penicillin per c.cm. to ascertain the
degree of remaining sensitivity of the skin after 30 days of
desensitisation therapy. There was no reaction. ss
On April 9—i.e., 2 weeks after oral penicillin was stopped—
his face was again sprayed with the 200-unit solution five
times at 3-hr. intervals. Only a mild peeling and two small
areas, about '/, in. across, of dried-up exudate were noticed
under each ear lobule the following morning; so small a
reaction needed no treatment.
Walking in the sun for about 1 hr. next day provoked a
peeling and slight redness of the ears and round the nose.
Small squares of his back, exposed for '/, hr., 1 hr., and 2 hrs.
to the M.E. midday sun of April now gave the same reaction
as on a normal blond contro] patient. Experimental exposures
of small squares of his back to a quartz mercury-vapour
lamp gave a very faint erythema after !/,-min. exposure.
With continued exposures of his face. to the sun the intensity
of the actinic reaction gradually decreased, and on April 25
his face did not react to a 3-hr. exposure to the sun. :
PENICILLIN CONTENT OF BLOOD-SERUM
Estimations of the penicillin content of the blood-serum
were carried out for us. The first estimation was done in the
blood drawn off 3 days after the beginning of the desensitisa-
tion treatment. Bdr. A had already had thirteen doses of
15,000 units each of penicillin. ‘The estimation was repeated
on 3 consecutive days (see figure, curve 1). Another estimation
was made 16 days later, just before oral penicillin was stopped
and 5 days after the patient had been tested with an intra-
muscular injection of 15,000 units, without producing ana-
phylactic shock (see figure, curve 2). The final estimation was
made on April 13 after the last spray test on the face, 2 weeks
after the end of oral treatment with penicillin ; so, to make the —
conditions similar to those at the previous blood estimations,
Bdr. A was given another nine doses of sodium penicillin, |
15,000 units each, at 3-hr. intervals before the test (see
figure, curve 3). The control (see figure, curve 4) was also given
nine doses of sodium penicillin by mouth before the test.
These estimations were made for us by Lieut.-Colonel,
Little, R.A.M.c., on blood samples taken off 1/, hr., 1 hr.,
1'/, hrs., 2 hrs., and 3 hrs. after oral administration of the
N oOo èa A Q
SERUM DILUTIONS
446 THE LANCET]
drug. The slide-cell method was-used for estimations given
in curves l and 2, and the petri-dish cover-slip, substituted
for the ordinary slide-cell, for the estimations given in curves 3
and 4. The test organism was the Oxford Staph. aureus.
The following dilutions of serum were used : undiluted serum,
the 1:2 solution,.1: 4, and 1:8. When bacteriostasis was
complete in one dilution and distinctly partial, as compared
with the control, in the next highest, it was assumed that
` bacteriostasis would be complete in a dilution half-way
between the two.
‘DISCUSSION
The skin reactions to penicillin, however used, extern-
ally, intramuscularly, or orally, were limited to the areas
initially treated with penicillin—i.e., face, neck, and foot.
The rest of the skin remained clear throughout all the
investigations and desensitisation treatment, except for
the positive patch tests on the back and the intradermal
test on the arm. The fact that the face reacted much
less after the last test spray on April 9 with the 200-unit
solution than after the previous one on March 27 with a
solution of the same strength, although the patient had
no further desensitisation treatment by the mouth,
could perhaps be explained by abolition of the residual
sensitivity of the skin of the face by the two sprayings
before the last one—i.e., the antepenultimate with the
200 units per c.cm., and the penultimate with the
10. units on April 4.
Our aim in this case was primarily the desensitisation
of the allergic patient, yet this record may perhaps
contribute a little to the question of absorbability and
therapeutic effectiveness of penicillin when given by the
mouth, a special research on which work has since been
published (Little and Lumb 1945). We searched for
but failed to find microscopically any fungi, although
the foot lesions led us to suspect antecedent epidermo-
phytosis. We could not obtain trichopytin vaccine
to test this possibility. Jadassohn et al. (1937) thought
there was a common antigen in all the fungi present
besides the specific ones ; but Feinberg (1944) found that
persons clinically sensitive to penicillin spores did not
give a positive skin reaction to the penicillin drug. This
was confirmed by Criep (1944), whose patient with
penicillin urticaria gave a negative result to a patch
test with penicillin extract.
The curves shown in the accompanying figure can
probably be explained on the assumption that the anti-
body and antigen interact to form a compound which is
slowly eliminated from the body, a reaction which is
reversible, leading to disintegration of this compound.
Thus, the difference between curves 1 and 2, showing
the penicillin content of the blood-serum in progressive
stages of desensitisation three days and nineteen days
respectively after the start of desensitisation treatment,
can be explained in the following way. In curve l,
the sensitivity being still at its height, antigen-antibody
linkage and consequent bacteriostatic neutrality of the
compound in the serum are the predominant factors,
the reversible reaction, the disintegration of the compound
into its constituents, playing in this stage a secondary
rôle only. Curve 2 represents’ the total amount of
penicillin coming into circulation after absorption from
the intestinal tract as well as from disintegration of the
antigen-antibody compound.
Curve 3 represents the free penicillin content of the
blood at a later stage, when there was still a very mild
skin sensitivity after the treatment with penicillin had
stopped 2 weeks previously. This curve shows no free
penicillin present in the 4/,-hr. specimen ; it had been
taken up by the remaining antibody-antigen; but,
owing to the great dilution of this compound, and as
the antibodies at that stage were less numerous, it
immediately underwent disintegration, and the freed
penicillin gave, with the penicillin absorbed from the
intestines, the conspicuous peak shown in the l1-hr.
specimen. This curve is so much above the level of curve
4 given by the control patient that this additional
DRS. T, & J. GILLMAN! INFANTILE PELLAGRA
[SEPT. 28, 1946.
factor—i.e., the freeing of the penicillin administered
an hour previous y==must be taken into consideration.
~N
SUMMARY $
The case is recorded of a patient who’ became senaitive
to penicillin in the course of ordinary dermatological.
treatment with penicillin spray.
Anaphylactic shock followed an intramuscular a
of penicillin.
Oral administration of penicillin brought about com-
plete desensitisation, abolishing superficial skin hyper-
sensitivity and the shock effects of parenteral penicillin.
Actinic sensitivity developed and faded pari passu with
penicillin sensitivity.
An explanation is offered, in terms of antigen-antibody
theory, of the differences found in the penicillin content
of the blood during desensitisation and in a control.
A grateful note must be made of the assistance given
us in counsel and practice by Colonel M. T. Findlay,
A.M.S., and Major A. Kirshner, R.A.M.C., pathologist to
the hospital. l w a
: REFERENCES
Binkley, G. W., Brockmole, A. (1944) Arch. Derm. Syph., N.Y.
Criep, L H. (1944) J. Amer. med. Ass. 126, 429.
Feinberg, S. M. (1944) J. Allergy, 15, 271
Jadassohn, W., Schaaf, È., Wo ar, &. (1937) J. Immunol. 32, 203.
Little, C. H., Lumb, (1945) Tane i, 203.
J
Pyle, H. D., atin He (1944) J ‘Amer. med. Ass. 125, 903.
Silvers, S. H. (1944) dreh. Derm. SYPh., N. Y. 50, 328.
TREATMENT OF INFANTILE PELLAGRA
- ASSESSMENT OF THE VALUE OF PROTEIN
. HYDROLYSATES
THEODORE GILLMAN JOSEPH GILLMAN —
M.B., M.Sc. Witwatersrand M.B., D.Sc. Witwatersrand
From the Department of Anatomy, Medical School, University
of the Witwatersrand, Johannesburg
IN previous publications we drew attention to the
syndrome of malnutrition in African infants and children.
In its acute form this expresses itself as a characteristic
dermatosis, with varying grades of cdema, hypoprotein-
emia, steatorrhea, or diarrhea. The case-mortality
can be very high and this is related to the severity of the
fatty change in the liver which appears essentially in the
early stages of the disease. By carefully selecting com-
parable cases, on the criterion of the extent of the fatty
change in the liver, it became possible, by serial biopsies,
to assess the value of different forms of therapy on the
liver and on the course of the disease (Gillman and
Gillman 1945a, b, c, d).
In our hands gastric extract (‘ Ventriculin,’ P.D. CO.)
hag thus far proved to be the most satisfactory form of
treatment in this disease in which the case-mortality
may fluctuate between 40% and 60% over a number of
years. This finding has since been confirmed by Trowell
and Muwazi (1945) on a small series of cases. :
The lack of constant supplies of gastric extract made it
possible to treat only a limited number of cases at a time.
While waiting for further supplies we were constrained to
use other forms of therapy. As a consequence, groups of
cases were treated intermittently in different ways over
a period of three years. Protein hydrolysates only
became available to us about nine months ago. The
following i is a résumé of the various therapeutic measures
adopted in 161 infant pellagrins.
All cases received the standard dietaries recommended
for infants and children according to their age and
weight. Supplements were added as follows :
(a) Vitamins : Thiamine 60 mg.; nicotinic acid or amide
100 mg.; riboflavine 2 mg.; brewers’ yeast 4 g.; 15,000
units vitamin A and 1500 units of vitamin D as fish-liver oil.
(b) Liver extracts: By mouth, liquid extract of liver (B.D.H.)
By injection, 5 c.cm. crude liver extract (Lilly) intra-
muscularly twice daily.
(c) Dried stomach: Ventriculin 5 g. by mouth twice daily
for four to six days.
l
THE LANCET] DRS. T. & J. GILLMAN:
(d) Dried stomach+ vitamins: ‘Ventron’ (P.D. co.) two
capsules three times daily. Each capsule contains: ventri-
culin concentrate gr. 5 (equivalent to 1 g. original ventriculin) ;
thiamine 20 1.U.; riboflavine 5 Sherman units; and iron and
sodium citrate gr. 2 (0°13 g.).
(e) Details of the protein hydrolysates and the mode of
administration are mentioned in the text.
RESULTS
The results with the various forms of treatment used
are summarised in the table.
RESPONSE OF 16l INFANT PELLAGRINS TO VARIOUS FORMS
OF TREATMENT IN COMBINATION WITH A FULL DIET
Total
Treatment cascs Improved Died
% %
Diet alone Se ee T 10 6 (60) 4 (40)
Diet and vitamins SCs - 36 8 (22) 28 (78)
Liver extract (injection) a 10 7 (70) 3 (30)
Oral liver extract +vitamins .. 15 4 (27) 11 (73)
Protein hydrolysate 20 * 6 (30) 12 (60)
Dried stomach .. .. .. 50 47 (94) 3 (6)
Dried stomach +vitamins T 20 13 (65) 7 (35)
a a a i a
* Two of these cases deteriorated so rapidly that treatment was
changed.
s
Dried Stomach.—The case-mortality (6%) among the
50 cases receiving ventriculin is by far the lowest recorded
for this malnutritional syndrome. In the small number
of cases that die, even after ventriculin, the histological
appearances of the livers differ in some important
respects * from the most severely fatty livers of infants
previously described (Gillman and Gillman 1945a, b, c, d).
Ventriculin breaks the vicious cycle operating in
malnourished infants. This is evident from the sudden
diuresis and the gradual disappearance of fat from the
liver. Once this is achieved further treatment with
ventriculin is unnecessary and the infant is capable of
utilising effectively the constituents of a hospital diet.
Although gastric extracts have, thus far, proved
successful in our hands, it is very likely that the vicious
cycle may be broken by other methods, which remain to be
discovered.
Dried Stomach and Vitamins.—The addition of vitamin
concentrates and iron (thiamine and riboflavine) to
ventriculin, as in the preparation ventron, significantly
diminishes the effectiveness of the gastric extract, for the
case-mortality among the ventron-treated cases was
35%. This chance finding was virtually forced on us
by the fact that ventron, for a time, was the only form of
gastric extract available to us.
Inver Extract by Injection.—In the absence of ventri-
culin, liver extract by injection is the treatment of
choice. The case-mortality with this was 30% (see table).
Oral Liver Extract+ Vitamins.—When liver extract
is administered hy mouth in combination with vitamins
(thiamine, nicotinic acid, and cod-liver oil) the case-
mortality rises to 73%. In a group of children treated
with vitamins in conjunction with the hospital diet the
case-mortality rose to 78%, the highest yet recorded by
us for this syndrome. Most of these cases were treated
by other physicians attending at the hospital. They were
either unaware of the value of liver extracts and ventri-
culin or they were unable to obtain these products and
therefore persisted with large doses of vitamin con-
centrateés given orally and parenterally.
It may well be that the extremely high mortality,
was due to the massive doses of synthetic vitamins
administered to these malnourished infants (up to
* Description of these differences is beyond the scope of this note but
details will be made available in a monograph on malnutrition
now in preparation.
INFANTILE PELLAGRA
[SEPT. 28, 1946 447
120 mg. thiamine and 300 mg. nicotinic acid daily,
together with cod-liver oil). This we suspect from the
fact that vitamins, added to ventriculin or liver extracts,
were associated with an increased case-mortality (see
table).
Protein H E E —Our results with protein hydro-
lysates were most disappointing. Having read the
numerous reports eulogising the value of these hydro-
lysates we had hoped that our cases might have responded
to this new form of treatment.
The only reason for persisting with protein digests
in the face of such discouraging results is that, from time
to time, new preparations became available and it was
thought that one of these might ultimately prove useful.
Three different types of protein hydrolysates were used
_ in the following manner :
(a) A local casein digest :
(8 cases).
(b) ‘Pulvesco’: a whale-meat digest kindly supplied by
Dr. B. A. Dormer, chief tuberculosis officer for the Union.
As directed, the children received one teaspoonful of this
powder three times daily, together with ‘Casec’ feeds
(5 cases).
(c) ‘ Pronutrin’: an enzymatic digest of casein (7 cases).
Our patients received the recommended dose—2 g. of pronutrin
per kg. of body-weight per day. The dose was gradually
increased, as recommended, to 4g. per kg., which was given in
500-1000 c.cm. of 5% glucose saline. The total volume of
fluid was administered by intragastric drip, only 50—100 c.cm.
being allowed to enter the stomach in an hour. This small
amount of fluid was run in every alternate hour, day and night.
All the 8 patients treated with a locally prepared
casein hydrolysate died within three to five days. Our
experience with the last 3 cases of the series discouraged
us from further trial of this product. These were admitted
on the same day and were treated concurrently. For no
apparent reason 2 developed temperatures of 105° F
within 24 hours. No cause for this unusual pyrexia
could be discovered at autopsy. We were led to suspect
that the therapy, at least in part, was a contributing
factor, especially as a similar instance of hyperpyrexia
following the administration of protein hydrolysates
has recently been described (Curreri et al. 1945).
Five cases were treated with pulvesco. Slow recovery
was noted in 2 of these cases, while the remaining 3 died.
Pronutrin was also unsatisfactory in the 7 cases treated.
Two cases, initially considered mild, both on clinical
grounds and on the basis of the liver structure, deterio-
1 g. three times daily as a broth
rated so rapidly that after four to six days the treatment
was changed in the interest of the patients. Of the’
remaining 4, 1 recovered rapidly and the other 3 very
slowly ; 1 patient died.
The recent literature contains reports of the ineffective-
ness of the majority of protein hydrolysates in the treat-
ment of hypoproteinzmia in dogs (Madden et al. 1945).
Severe hypoproteinemia with odema and anæmia has `
even been produced in pigs by feeding casein digests in a
particular dietary setting (Cartwright et al. 1945). In
the light of these findings the 60% case- mortality in
our series of cases treated with protein digests is not
difficult to understand.
DISCUSSION, |
It is clear from our findings that the administration
of protein hydrolysates to infants with nutritional hypo-
proteinzmia, &c., fails to raise the plasma proteins, fails
to resolve the cedema, and in fact appears to increase the
mortality significantly above that observed in patients
treated by graded increases in the diet alone. Only
occasional cases appear to be capable of utilising these
digests of casein. In the majority, the administration
of these drugs appeared to aggravate the candition.
In this regard, the observations by Daft and collabo-
rators (1938) are pertinent. These workers reported
that ‘‘ overloading ’’ hypoproteinzemic dogs with plasma
resulted in toxic symptoms with the excretion of greater
448 THE LANCET|
quantities of nitrogen than could be accounted for by the
amounts of protein in the administered plasma. It
appears that ‘‘ overloading ’”’ is a purely relative term.
It may well be that our cases were incapable of utilising
hydrolysed casein by virtue of the extensive liver damage
present, and, more especially, because their metabolic
apparatus could not adjust itself sufficiently rapidly to
utilise these concentrates. If ‘‘overloading’’ ‘were
indeed responsible for the untoward results obtained
then it is clear that criteria are needed for determining
the dosage of protein hydrolysates to be administered to
each case. Until such time as these eriteria become
available we feel that the administration of protein
hydrolysates remains hazardous and is therefore
contra-indicated. _
Disease represents a particular homeostasis with its
own peculiar regulatory mechanism which may have no
counterpart in health. If the homceostasis in disease is
altered by tampering with any one mechanism without
understanding the basic character of the new homeceo-
stasis, then, quite clearly, such treatment can be expected
to be attended by disaster.
Thus a disease, initiated by malnutrition and showing
signs and symptoms regarded as vitamin deficiency, may
be aggravated by the administration of vitamins. This
is suggested from our results in the table. Similarly, the
hypoproteinemia observed in our cases may be an
expression of a new homeostasis emerging in chronic
malnutrition ; administration of hydrolysates in these
circumstances may also prove harmful. Treatment of
a single symptom or sign of a disease in which there
is widespread disorder of meravonst can often be
irrational.
The success of ventriculin, in our opinion, is not due
to the addition of a factor the absence of which from
the diet originally caused the disease. Ventriculin is
apparently able to cause such a radical alteration in the
entire homeostasis that the malnourished infant can
now take advantage of the essential constituents of a
good diet.
SUMMARY
The results obtained with various forms of therapy in
161 cases of infantile pellagra are recorded.
The effectiveness of ventriculin in the treatment of this
syndrome has been confirmed in 50 cases.
The addition of vitamin concentrates to ventriculin
significantly detracts from its effectiveness as a thera-
peutic agent.
Vitamin concentrates in combination with liver extracts
or ventriculin, or with a full diet, are contra-indicated in
the treatment of this form of chronic malnutrition.
Since the administration of protein hydrolysates may
result in toxic reactions, and very rarely promotes
recovery, we consider this form of therapy hazardous.
Until satisfactory criteria are established for determining
the dosage in each case, Such concentrates, in our opinion,
are contra-indicated in the treatment of the acute episodes
in the course of chronic malnutrition in African infants.
We wish to acknowledge our indebtedness to the Students
Medical Council of the University of the Witwatersrand
for a generous grant which made the continuance of this
work possible. Thanks are also due to Dr. Wunsh and Dr.
Kessel, resident medical officers, and to Sister Spikin for
assistance in the wards.
REFERENCES
Cartwright, G. E., Wintrobe, M: M., Buschke, W. H., Follis, R. H.,
Su ksta, aaa Humphreys, S (1945) J. clin. Invest, 24, 268.
cumi, A. ., Hirma, O. Vas Cohen, P. P. (1945) J. Amer. med. Ass.
28,
ses S., » Hobschelt-Robbins, F. S., Whipple, G. H. (1938) J. biol.
hen.
Gilman, T., Gillman, J. (1945a) Nature, Lond. 155, 634.
al 945b) Arch. intern. Med. 76, 63.
(1945c) J. Amer . med. Ass. 128, 12.
58 OD KON AE, n,
re us, Sak r, . Miller, L. L., Whipple,
qd 545) J. exp. Med. 82, 181. es
Trowail, H. C., Muwazi, E. M. K: "1946) Arch. Dis. Childh, 20, 170.
—_— oe
DR. SEVIIT: EARLY OVULATION
!
[SEPT. 28, 1946
a
EARLY OVULATION
SIMON SEVITT
M.D., M.Sc. Dubl., M.R.C.P.1., D.P.H.
THe theory of ovular menstruation supposes that
menstruation depends on ovulation and the formation of
the corpus luteum half-way through the normal menstrual
cycle of 24—35 days (Schroeder 1928). That menstruation
can take place without a preceding ovulation was
established for the macaque monkey by Corner and
Allen (1929), Bartlemez (1933), Sharman (1944), Sevitt
(1943), Rock (1939), and others. Therefore there are
probably both ovulatory and non-ovulatory menstrual
cycles. -
The question arises whether ovulation, when it takes
' place, always does so between the 14th and the 16th
days or can happen at any time during the normal
cycle. Teacher (1935), correlating the ages of very young
fertilised ova found accidentally at operation or at
necropsy with the previous menstrual history, concludes
that fertilisation, and therefore presumably ovulation,
can take place on any day of the cycle except during
menstruation. Evidence that ovulation can take place
on any day of the first fortnight of the menstrual cycle,
including the last days of menstruation, has been
obtained by correlating the menstrual dates and date of
operation with the state of the endometrial biopsy
material and of the removed ovaries.
The development of the endometrium during the early
part of the ovular menstrual cycle is under the influence
of the ostrogenic hormones (follicular hormone, cstrin),
secreted, at least in part, by the developing graafian
follicle. The endometrial changes following ovulation
and the formation of the corpus luteum are produced
by the luteal hormone, progesterone. These later changes
are characteristic histologically, and. their finding in a
uterine curetting or an endometrial ‘ punch ” from the
fundus uteri can be taken as strong circumstantial evi-
-= dence of the presence of a corpus luteum and therefore
of a recent ovulation. When the ovaries are also examined
and a corpus luteum is found, there can be no doubt
that ovulation has taken place.
ESTIMATION OF DAY’ OF OVULATION
——
Estimated age - |.
Dura-
Case | periodicity] fiom. of | Dax of | of secretory, lage | ovale
(days) (days)
3 |e | 6 | 9 | 1-3 6-8
4 28 ? | 9 | 2-4 5-7
5 28 4-5 | 13 ! 2-3 | 10-11
6 21 w | 6 |. 2 4
7 | s ? 5 | 1-2 3—~4
8 | 29 7 12 2 10
9 | 28 6 | 6 1 5
0; 28 ? 14 3-4 , | 10-11
|
* Since start of previous menstruation.
The terminology of the endometrial phases is confused,
and in this paper the simple classification of the histo-
logist is used (synonyms in parentheses) ;
Stage 1: menstruation. ae
Stage 2: non-secretory, early and late (regenerative,
follicular, interval).
Stage 3: secretory, early and late (luteal,
premenstrual, post-ovulatory, differentiative).
In the menstrual and case histories that follow, the
progravid,
“days are reckoned from the first day of the previous
menstruation.
In these ten cases there is evidence that ovulation
took place earlier than the mid-menstrual period. In
two (cases 1 and 2) the ovaries were available and
THE LANCET] DR. SEVITT :
EARLY OVULATION
[sepr. 28, 1946 449
corpora lutea were found. Correlation between the
estimated ages of the corpora lutea and the endometria
with the dates of operation and menstrual history showed
that ovulation took place on the 10th or llth day and
the 6th day of the respective cycles.
Case 1.—A multipara, aged 49, with menorrhagia.
Hysterectomy performed on the 14th day of 26-day cycle ;
menses 4 days.
Findings.—(1) Hemorrhagic, well-developed, cytologically
normal corpus luteum in the left ovary (1:5 cm. X 1 cm.).
(2) The endometrium presented long tortuous closely
packed glands, rather dilated and containing secretion.
The columnar-cell nuclei were basal, and the cytoplasm
contained secretory granules or vacuoles. Well-marked spiral
arterioles were present; and, though the stroma was dense
and spindle-eelled, it was evident that a developed secretory
stage was present (fig. 1).
In this case the corpus luteum was at least 3 or 4
days old, probably older, and ovulation must have taken
place at the latest on the 10th or llth day of the cycle.
CasE 2.—A 4-para, aged 27, with menorrhagia and pain
in the right iliac fossa. Curettage and right salpingo-
odphorectomy performed on the 7th day of 28-day cycle;
menses 4-5 days, heavy with clots.
Findings.—({1) A recently ruptured graafian follicle or
young corpus luteum in the ovary (1:5 cm. in diameter).
The stigma or point of rupture was still visible. Micro-
Fig. 1—Section of endometrium from case J, showing (1) long con-
voluted closely packed glands containing secretion ; (2) basal position
of nuclei and secretory activity of cytoplasm ; and (3) spiral arterioles
in spindle-ceiled stroma.
scopically, early infolding was present, with an early luteal-
cell development from a hyperplastic granulosa-cell layer
and theca interna (fig. 2).
(2) The curetting showed straight oval or round glands.
Cytologically the nuclei were placed basally, but there was
no more than a suspicion of secretory activity in the cytoplasm
(fig. 3). The stroma was round.-celled and oval-celled, con-
taining developed spiral arterioles.
In this patient, the absence of secretory activity in
the endometrium, together with a corpus luteum cer-
tainly no older than 24 hours, proves that ovulation
took place on the 6th day of the cycle, or 36 hours after
cessation of the menstrual flow. |
Circumstantial evidence of early ovulation was found
in-eight other cases. Correlation of the date of biopsy
and menstrual history was made with a conservative
estimate of the time since the secretory stage was initiated.
Ev en assuming that the endometrial change to secretory
activity takes place on the same day as follicular rupture,
which is doubtful (see case 2), it seems that the ovulations
had taken place between the 3rd and llth days of the
various cycles. The accompanying table shows how the
day of ovulation was estimated. The age of the secretory
stage was always estimated conservatively ; hence the
final column in the table is meant to give, not the actual
day of ovulation, but the latest day of the cycle on which
it could have occurred.
CASE 3.—An unmarried girl, aged 17, with dysmenorrhea
und menorrhagia. Curetted on 9th day of 28-day cycle;
menses 6 days.
Findings.—Early secretory, partially dilated and tortuous
glands, some of which contained secretion; mdematous
round-celled stroma; a few spiral arterioles.
CasE 4.—An unmarried woman, aged 33, with recent
hzemorrhage lasting 5 weeks. Curetted on 9th dav of present
cycle, her usual periodicity being 28 days.
Findings.—Secreting well-dilated tortuous glands, some
more differentiated, showing “‘ saw-teeth’”’ appearance and
containing secretion; basal nuclei in a columnar epithelium
with secretory granules; stroma shows early pseudodecidual
change, with numerous well-marked arterioles (fig. 4).
Fig. 3—Section of oval tubular endometrial gland, showing mitotic
figures in two cells (from case 2).
450 THE LANCET]
\
DR. SEVITT: EARLY OVULATION .
[sepr. 28, 1946
Fig. 4—Section of secreting endometrium, shawl convoluted glands
containing secretion (from case 4).
Casa 5.—A 3-para, aged 37, with excessive postmenstrual
leucorrheea. Piece from fundus removed on 13th day of
28-day cycle; menses 4-5 days.
Findings. —Glands mostly moderately dilated and some-
what tortuous, with eosinophil] granular vacuolated cyto-
plasm and basal nuclei. Some are smaller and are round
straight tubes not secreting. Stroma cells are in an early
pseudodeciduous condition ; spiral arterioles fairly numerous
and well developed.
CasE 6.—A 2-para, aged 28, with menorrhagia and vaginal
discharge. Piece from fundus removed on 6th day of 21-day
cycle; menses 10 days—i.e., while still bleeding.
Findings.—Most glands convoluted and contain secretion ;
cytoplasm secreting and nuclei basal—i.e., early secretory
stage. Some are non-secreting straight tubes. Stroma very
cedematous, and well-developed spiral arterioles seen (fig. 5).
CASE 7.—A 3-para, aged 28, with menorrhagia. Piece from
fundus removed on 5th day of 21 -day cycle.
Findings.—Most of the glands were moderately dilated,
some secreting and others not. Stroma cadematous in super-
ficial layers, but nuclei densely stained and round: some
thick-walled blood-vessels present, but most of the spiral
arterioles thin-walled and mainly in the spongy layer.
CasE 8,—A primipara, aged 38, with metrorrhagia. Last
period, heavy with clots, lasted T days. Piece from fundus
removed on 12th day; menses started 17 days later.
Findings.—Early secretory endometrium, with moderately
dilated and fairly tortuous glands ; basally placed nuclei
in secretory cytoplasm; stroma round-celled, with much
cedema;_ thick-walled spiral arterioles mainly in deeper
layers (fig. 6).
Fig. 5—Section of endometrium from case 6, showing most of the glands
in early secretory. phase. .
CasE 9.—A 2-para, aged 30, with yellow discharge since
miscarriage 2'/, years ago. Cervicalerosion present. Piece from
fundus removed on 6th day of 28-day cycle; menses 5-6
days—i.e., just ceased.
Findings —Mostly straight tubular glands, but cytoplasm
shows the secretory vacuolated change with basal nuclei
in a columnar epithelium. Some glands rather dilated, others
show early convolution. Stroma presented no luteal effects.
This is a very early secretory phase,
Case 10.—A 4-para, aged 38, with vaginal discharge.
Curetted on 14th day of 28-day cycle.
Findings.—Most glands are in the late secretory stage ;
some, however, are very convoluted but not secreting ; stroma
round-celled and cedematous ; ‘numerous spiral arterioles.
DISCUSSION
The ten cases cited were selected from sixty-two case-
specimens of routine biopsy and operation material for
which an accurate menstrual history and clinical details
were available. It appears, therefore, that ‘‘ premature ”
(or, more correctly, early) ovulation is not uncommon.
In two cases ovulation occurred towards the end of the
menstrual flow, when one would normally expect to find
a reparative non-secretory phase of activity in the
endometrium ; but, instead, a secretory and therefore
A yi > i 8 x s s A ce ( 9 aà DESI sa na
eae e et. x Ea — o SIERE
Fig. 6—Section of endometrial gland in vote pec phase from
case 8, showing (1) swollen stroma cells and (2) mitoses In gland cells.
presumably luteal stage is seen. In the other cases ovula-
tion took place on various days after cessation of the
menstrual flow. It follows that there is no “safe”
period in the first half of the menstrual cycle.
SUMMARY
Correlation between the menstrual history and day
of operation of ten patients with the findings of a
secretory and therefore presumably luteal endometrium,
during the first fourteen days of the menstrual cycle
(and the finding of corpora lutea in two of these cases),
supports the belief that ovulation can occur on any day
of the first half of the cycle.
My thanks are due to Prof. O’Donel Browne and. Dr. N.
Falkiner for supplying the operation and biopsy specimens ;
the late Mr. C. Hoppenkopper for preparing the sections;
Mr. W. Kampf for the photomicrographs; and Prof. J. T.
Wigham for his criticism and advice.
REFERENCES
Bartlemez, G. W. (1933) Contr. Embryol. Carneg. Insin, 142, 14.
Corner, G. A., Allen. W. M. (1929) ae te Physiol. 87, 326.
Roek, Jey Bartlett, M. K., Matson, D. D. (1939) Amer. J. Obstet.
ynec.
Schroeder, R. (1928) Ibid, 16, 135.
Sevitt, S. (1943) Irish J. med. Sci. February, p. 40.
Sharman, ts Sere J. Obstet. Gynec. 51, 85.
Deocier (1935) Manual of Obstetrical and Gynæocological
Soles London,
THE LANCET]
EMPIRICAL TESTS OF LIVER FUNCTION
MONTAGUE MAIZELS *
M.D. Lond., F.R.C.P.
CLINICAL PATHOLOGIST, UNIVERSITY COLLEGE HOSPITAL
APART from tests of specific liver functions, such as
the synthesis of hippuric acid, excretion of dyestuffs,
&c., certain empirical tests have been devised which all
depend mainly on excess of gamma globulin in serum
(Kabat et.al. 1943), though other minor factors may be
concerned, since the various tests do not always give
identical results. The object of the tests is threefold :
(1) to distinguish between jaundice of parenchymatous
origin and that due to obstruction of the bile-ducts ;
(2) to assist in the diagnosis of hepatitis without jaundice ;
and (3) to follow the course of toxic liver disease and aid
in its prognosis. The present paper attempts to assess
the relative value of some of these tests: Britton’s
(1945) modification of the Takata Ara tests ; the cephalin-
cholesterol flocculation test (Hanger 1939); the thymol
turbidity test (Maclagan 1944); and the colloidal- gold
test (Gray 1940).
Opinions about the value of these tests vary. Magath
(1940) reports that, though the Takata Ara test was
often positive in advanced cirrhosis, it was frequently
negative in early cases ; and, though many writers report
negative findings in jaundice due to duct obstruction,
others, including Magath, find a high proportion of
positives. Further, it is generally agreed that this test
may be positive in many conditions where the liver is
not involved, including in one series 27% of mental
cases (Ornstein 1937). It is therefore clear that the Takata
Ara test fulfils none of the objects set out above, and this
appears to be Magath’s view.
The cephalin-cholestero] flocculation test is more
satisfactory than the Takata Ara, though the reagent
varies greatly in sensitivity and probably in composition.
Thus, one sample may be unstable with the sera of
normals and cases of toxic jaundice, and stable with
bile-duct obstruction ; another may be stable in normals
and unstable in bile-duct obstruction (Pohle and Stewart
1941) ; and a third preparation may be stable in normals
and in duct jaundice and unstable in toxic jaundice, in
which case the typical flocculation as described by
Hanger (1939) and by Nadler and Butler (1942) are
obtained. The latter writers report that fresh cephalin-
cholesterol preparations gave numerous false positives,
and that typical results were only obtained with aged
material. On the other hand, Mateer et al. (1943) found
that fresh, preparations were alone reliable. | This vari-
ability constitutes the main drawback of the test, which
has been of. considerable value in the hands of some
workers.
The thymol turbidity test, according to Maclagan
(1944), gives a high proportion of positives in toxic
hepatitis and is usually negative in obstruction of the
bile-ducts. Unlike other tests it also permits of a quanti-
tative assessment of the strength of the reaction and
hence of prognosis and progress in cases of hepatitis.
According to Maclagan, thymol turbidity roughly
parallels the colloidal-gold test but is less likely to be
positive in infections and in rheumatoid arthritis. Col-
loidal gold was not used in the present work but a colloidal
suspension of Scharlach red, which is easier to prepare
and probably gives similar results. Details of these tests
are given in the appendix below. Responses to various
tests are shown in tables 1 and u, together with the
albumin-globulin ratios, which were often estimated in
parallel.
RESULTS
N ae ee ME flocculation (c.c.),
colloidal Scharlach red (c.R.), and thymol turbidity (T.T.)
* In receipt of a grant from the Graham Research Fund.
DR. MAIZELS: EMPIRICAL TESTS OF LIVER FUNCTION
[sepr. 28, 1946 451
were almost always negative or at most weakly positive.
Maclagan gives the range of T.T. as 0-4 units; in my
series 96% of normals were less than 3 units, with one
result of 4 and another of 5 units. The Takata Ara test
-(T.A.) gave so many false positives that according to
these data it has no positive value; possibilities of its
having a negative value will be considered later.
Parenchymatous Liver Damage.—This has been classi-
fied as follows. (1) Catarrhal jaundice, an acute infection
sometimes proceeding to subacute hepatitis. (2) Subacute
and chronic hepatitis, with little or no fever, but malaise,
persistent moderate jaundice, and sometimes ascites ;
death may result in a few weeks or months, or the
condition may proceed to cirrhosis. (3) Cirrhosis, which
may obviously follow the preceding, or the stage of
active hepatitis may be unobtrusive; cirrhosis then
appears to be primary, with gastritis, hematemesis, or
ascites as its salient features; jaundice, if present, is
not severe.
Table 1 shows that in catarrhal jaundice Houitive
findings are the rule, and the albumin-globulin (A./G.)
ratio was less than 1-5 in 11 of 18 cases. In 4 cases there
were negative or doubtful findings ; these patients were
already improving or began to improve during the
fortnight which followed the test. In one case alone all
TABLE I—SUMMARY OF FINDINGS WITH EMPIRICAL TESTS IN
VARIOUS CONDITIONS
No. of reactions graded as
Condition
(0) + + tet + +
Normals T.A. 50 | 34 | 11 4 1 0
ac. 50 45 4 1 0 0
T-T 50 49 1 0 0 . 0
C.R. 50 49 1 0 0 0
Catarrhal jaundice .. | T.A. 18 0 1 4 3 10
C.C. 18 4 1 1 2 10
T.T. 14 5 2 2 2 3
CR. 18 4 1. 2 3 8
A./Gd.| 18 7 3 5 2 1
Toxic hepatitis (sub- | T.A. 11 0 0 0 1 | 10
acute and chronic) | C.O. 1 0 0 1 3 7
T.T. 11 0 0 3 1 7
CR. ll 0 0 1: 3 7
A./Gd.| 11 0 1- 5 0 5
Cirrhosis T.A. 3 0 0 1 2 0
C.C. 3 0 0 2 1 0-
T.T. l 0 0 () 0 1
CR. 3 0 0 | 0 1 2
A./Gd.| .3 0 1 2 0 0
Jaundice due to duct | T.A. 28 10 | 3 5 7 3
obstruction C.C. 27 23 1 1 1 1
T.T. 19 18 1 0 0 0
CR. 28 21 | 1 1 Of 5
A./Gd.| 26 | 16 6 1 3 0
Acholuric family | T.A. 3 3 0 0. 0 0
jaundice C.C. 3 3 0 0 0 0
T.T. 3 3 (U 0 .- 0 0
OR. 3 3 0 0 0 0
l A./Gd. 3 3 Q 0 0 0
Nephritis with blood- | T.A. 3 1. 0 0 1 1
urea above 100 mg. | C.c. 3 2 1 0 0 0
per 100 ¢c.cm. T.T. 3 3 0 0. 0 0
O.R. 3 | 3 0 0 () 0
| A./ad. 3 2 1 0 0 0
Nephritis with blood- | T.A. 18 4 0 5- 5 4 `
urea below 100 mg. | ¢.c. 18 12 1 2 2 1
per 100 c.cm. T.T. 18 17 1- 0 0 0
. CR. | 18 | 12 | 0 1 5. 0
l A./Gd.| 18 10 7 1 0 0
Neoplasms without | T.A. 10 7 0 0 1 2
jaundice — C.C. 10 10 0 0 0 0
T.T. 10 10 0 0 0 0
GR. |, 10 | 8 | 0 0 2 0
Other conditions not | T.A: 30 17.1 4 8 | 1 0
listed above or in | Cc.c. 30 28 1 ,1 0 0.
table It T.T. 19 19 | 0 0 0 0
O.R. 30 27 1 be e 0 1
A. JG 1 1 0 Q
id.) 12 ioe |
T.T. . = thymol
A./Gd. =albumin-
T.a., = Takata Ara; c.c. = cephalin: cholesterol ;
turbidity ; C.R, = colloidal Scharlach red ;.
globulin ratio deficit.
For albumin- Ea Taro; O=1-:5 or more: '#=1°5-1:2; $=
1:2-10; ++ =1-0-0°8; + +=0-8 and less. The explana-
tion of the SSTULOIE Gr other tests is given in the appendix.
452 THE LANCET]
tests were consistently negative, though jaundice
remained intense for nine weeks and then gradually
faded. Pain was slight throughout, and the diagnosis
remains obscure. On the whole it seems probable that,
if signs have not begun to improve within a fortnight of
a negative result being obtained, the jaundice is due to
gross obstruction. In any case it will be apparent that
the tests may sometimes be negative at a time when
jaundice is ‘still severe, and, on the other hand, that
jaundice may improve while empirical tests remain
unaltered or even intensify.
‘In subacute and chronic hepatitis, well-marked positive
findings were invariable, and the a./c. ratio was below
1-2 in 10 of 11 cases. There were only 3 cases of cirrhosis,
and C.C., T.T., and C.R. were negative in 2, while the less
satisfactory T.A. was positive in all 3. Table 1 suggests
that in parenchymatous jaundice C.C. and C.R. are the
most satisfactory tests, with the much simpler T.T. a close
runner-up. It is worthy of note that Maclagan (1944)
reports 100% of positives for the colloidal-gold and T.T.
in 13 cases of cirrhosis, though in a later paper (1945)
he reports 2 negative cases. He classifies the parenchy-
matous group into infectious hepatitis and cirrhosis,
- and it is possible that a proportion of subacute cases is
included with cirrhosis, in which case a high proportion
of positives is to be expected. It would be unwise to draw
conclusions from 3 cases, but at least the possibility
exists that increase of gamma globulin together with
the resulting positive empirical tests is associated with
the activity of liver damage rather than with its extent.
Jaundice due to Obstruction of Bile-ducts or Hepatic
Ducts.—In two-thirds of the cases T.a. was positive ; it
therefore has no positive value in differential diagnosis.
On the other hand, it was positive in all cases of paren-
chymatous jaundice, and the tentative suggestion is
made that a dead negative T.A. by Britton’s method
(1945) indicates duct obstruction, more especially when
the associated jaundice does not clear within a fortnight
of the test. With regard to the other tests, positive
- findings with one or other were recorded in 7 of 28 cases.
Of 21 negatives one was a case of suppurative cholangitis ;
another had been severely jaundiced for eight weeks ;
while a third had been bronze-green for over a month.
It follows that long-standing intense jaundice does not
necessarily result in positive findings with C.C., T.T., and
C.R. tests. The findings in the 7 positive cases are shown
in table 1 (nos. 1-7). It will be seen that T.T. was low
‘in all, and this suggests that a reading of more than
10 units is strongly against obstruction of the ducts.
c.c. was positive in 3 and C.R. in 5 of the tabled cases,
and all these had serious complications. Therefore,
‘though negative tests do not exclude serious complica-
tions, positive findings suggest that such complications
may be present. Of 8 cases of carcinoma of the liver
with jaundice, T.a. was positive, and T.T. negative in all.
Hence, T.A. is useless in distinguishing between carcinoma
and hepatitis, whereas a positive T.T. makes carcinoma
of the liver unlikely, and a negative T.T. indicates that
hepatitis is probably absent. c.r. was positive in 4 cases,
2 being primary growths of the liver ‘and 2 secondary ;
c.c. was positive in only 2 cases, both secondary.
The findings of other observers in cases of duct obstruc-
tion vary. Hanger (1939) finds that c.c. is negative or at
most weakly positive in all cases. Nadler and Butler
(1942), using an aged reagent, had 20 negatives and 7
weak positives, whereas Mateer et al. (1943) found that
they could only rely on a relatively insensitive unripened
preparation, and that even so half their cases of gall-
stones gave positive findings. So, too, Pohle and Stewart
(1941) found, in 23 cases, 5 weak, 9 moderate, and 4
strong positives. With regard to T.T. and colloidal gold,
Maclagan (1944) found only 3 slight positives. Once again
it will be seen that Maclagan’s simple test, though not
infallible, is least likely to mislead in the differential
DR. MAIZELS: EMPIRICAL TESTS OF LIVER FUNCTION ©
[sErr. 28, 1946
diagnosis of jaundice. Hanger (1939) reports low A. ja.
ratios (less than 1-5) in 7 of 17 cases of duct obstruction ;
in the present series low ratios occurred in 10 of 26 cases.
In acholuric familial jaundice all tests were negative,
and it seems clear that empirical tests will help to dis-
tinguish between hepatitis and other conditions causing
jaundice, assuming that the obstructive jaundice is
not associated with some independent tease which
gives positive findings.
Nephritis.—It is clear from table 1 that T.A. gives many
positives; C.R. was less affected, and very strong reactions,
in contrast with what occurs in hepatitis, are not found.
C.C. gave fewer positives than C.R., and T.T. again proved
most satisfactory, giving only 1 weak positive in 20 cases.
The results of the tests were not correlated. with the
A./G. ratio or blood-urea level.
Neoplasms without Jaundice.—These were snotty
negative; 2 cases with metastases in the liver were
positive with T.A. and C.R., and negative with T.T. and 0.C.
(table 1).
Anemias.—Five severe cases of microcytic anæmia
were all negative. Most of the macrocytic anzmias gave
positive T.a. tests, but only 3 gave positives with C.R. and
C.C., and the reactions were weak. In these 3 cases macro-
cytosis was associated with hepatomegaly in one, with
nocturnal hemoglobinuria in another, and with. an
increase in the marrow plasma-cells (8%) in the third,
and liver damage may well have existed in all (table 11,
cases 17-24). T.T. was negative in 7 cases, and weakly
positive in 1 case. Maclagan (1944) reports 3 weak
positive 1.1.8, and 6, moderate or strong colloidal-gold
tests in 8 cases of pernicious ansmia.
Splenic Anemia.—One case had normal hippuric-
acid excretion ; a second patient had undergone splenec-
tomy, which had much decreased the incidence of
hgematemesis. Both cases gave positives with all four
tests (table 11, cases 15 and 16).
Poisons.—A case of early carcinoma of the parotid
poisoned with sulphonamides (table 11, case 25) had
agranulocytosis and slight hemolytic jaundice; except
for T.T., all the tests were positive, and perhaps this case
should have been included in the toxic-jaundice group ;
the same is probably true of case 26 receiving arsenicals
for syphilis. In still another case receiving arsenicals,
severe anemia and agranulocytosis were present and the
empirical tests were all negative.
Bacterial Infections.—Of 13 cases, 9 were positive to
T.A., 2 to C.C., and 4 to c.R.; 1 was rather weakly positive
to T.T. Maclagan (1944) gives 8 positive colloidal-gold
tests in 12 cases, and 4 weak positive T.T.s in 8 cases. In
table 11 cases 27-39 show that there is no correlation
between empirical tests, a./G.ratio, and sedimentation-rate.
Rheumatoid Arthritis.—This group is interesting because
of the frequency of positive findings recorded by
Maclagan (1944). In the present series (table 1, cases
40—44) T.A. was positive in 4, C.C. in 1, C.R. in 3, and T.T.
weakly positive in 1 of 5 cases. Here too there was no
correlation between these tests, 4./G. ratio, and sedimen-
tation-rate. i
Tuberculosis.—Apart from the T.A., other tests were
negative in this assorted group. In case 48 A./G. was very
low, and the sedimentation-rate very high, but C.C., T.T.,
and C.R. were negative (table II, cases 52-57).
Lymph-gland Involvement (table 11, cases 52-57).—
Apart from T.A., empirical tests were negative or weakly
positive in various conditions, including Hodgkin’s
disease and: lymphogranuloma inguinale. Case 64,
probably: lymphogranuloma inguinale, gave positive
tests. There were no cases of infectious mononucleosis
in my series, but Maclagan (1944) reports 3 strong
positive T.T. and colloidal-gold tests in 4 cases. It is
interesting to note the frequency of low A./G. ratios in
these glandular cases, due to increased globulin rather
than to low albumin. |
THE LANOET]
Sarcoids and Myelomata (table 11, cases 8—14).—The
liver was large in only 2 of 4 cases of sarcoid, and in no
case was there clinical evidence of hepatic deficiency.
But empirical tests were always positive and A./G. ratios
low. In myelomatosis, on the other hand, though 4./c.
was still low, empirical tests were negative in 2 cases,
whereas T.A. and C.R. were strongly positive in one.
Other Conditions (table 1).—These were mainly arterial
degeneration and non-malignant intestinal disorders ;
T.A. is often positive but hardly more so than in normals.
Other tests were largely negative. Included in the series
are 5 cases of hyperpiesia without nephritis, 1 each of
starvation, pulmonary embolus with ascites, Milkman’s
disease, and polycythxmia vera ; all these were negative.
An apparent neurotic gave weak positives with T.A., C.C.,
and c.R. Not included in table 1 are 3 cases of ulcerative
colitis, of which 2 gave negative tests and 1 gave con-
sistently positive tests and had an 4./G. ratio of 1/1.
There were no cases of cardiac failure in this series,
but Maclagan (1944) reports 3 weak positive T.T. and
5 positive colloidal-gold tests in 13 cases. He also
reports 6 negatives and 1 weak positive T.T. in 7 cases of
DR. MAIZELS: EMPIRICAL TESTS OF LIVER FUNCTION
[SEPT. 28, 1946 453
conditions in which empirical tests may be positive; the
implications of this are considered later.
DISCUSSION
In my ane Britton’s (1945) modification of the T.A.
proved too sensitive, giving slight or moderate positives
in non-hepatic conditions. Other modifications of the
T.A. give fewer positives in non-hepatic lesions but are
more often negative in frank hepatitis. On the whole,
therefore, the T.a. was not considered a satisfactory test.
C.R. was negative in about 80% of cases of jaundice due
to obstruction of the ducts ;° c.c. gave 8% of strong and
8% of weak positives; and T.T. gave only 5% of weak
positives. The A./G. ratio was usually low in hepatitis ;
a low ratio in duct obstruction usually indicated severe
infection or extensive metastasis ; it did not seem to be
induced by the remote effect of blockage on liver-cells,
even when this was prolonged. It therefore seems that
in uncomplicated cases C.C., T.T., C.R., and the 4./G. ratio
will usually help to distinguish between jaundice of
parenchymatous and duct origin. But the coexistence
of such complications as cardiac failure, nephritis,
rheumatoid arthritis, sarcoidosis, and lymphogranuloma
amyloidosis. It will thus be seen that there are various
TABLE II—DETAILS OF EMPIRICAL TESTS ON VARIOUS CASES
Case group Case | Clinical details T.A. C.C. nta C.R. A.G. Gin nT hr.)
1 { comatose +++ ma + + + 1-0 a
2 Carcinoma of ee extensive + + + O ie + + + T ia
3 secondary lung + O 0 O 2-2 ee
Obstructive jaundice 3a As 3, but six weeks later ++ + + 1 + 1-8 s
with positive tests 4 Suppurative cholangitis + + + + 3 + + + 1:2 Sa
5 Choleemia + + + + + 5 + + + 0:7 R
6 Gall-stones and fever + O 8 O 1-5 s.
7 Carcinoma of pancreas + + O 0 + 1-3 aye
8 | Liver large + + + ae + ats ‘
Sarcóids 9 Liver not large _ ++ + os +++ 1-1 ee
are oe ss 10 Liver large, bony rarcfactions - | +++ ++ 30 + 1-1 os
. 11 Sa l + + +++ 8 + + 0°9 a
12 (| ++ O 1 bt 0-24 TA
Multiple myelomatosis 13 Bence-Jones proteinuria í (0) O 1 O 0-28 za
14 O O 1 O 1:4 ie
15 Hippuric-acid synthesis normal + + + + 10 ++ + 1°7 sa
Splenic anæmia a { 16 Old splenectomy +++ + 8. + "15 Se
17 + + + + 3 + 0-96 è
} Refractory to liver and iron { + 0 1 0 2 i
Macrooytic anemia .. 20 ; ee
21 Refractory large liver, target cells + + + + s +- ss 2
i 22 + O 0 O 1:0 S4
23 Pernicious anemia + O 0 O 1:9 ais
24 + + 7 + + 2-0 è
25 Sulphonamide ; v.d. Bergh 2 units + + + + + 3 + 1-6 3
Poisoning ee oe { 26 ?N.A.B. ? toxic jaundice ttt) t+ 27. + + + 0-9: ba
27 Pneumonia +++) +++ 9 + + + 1-6 30
, ae Pneumonia, interlobar effusion z 3 2 a 21 50
| 30 Pneumonia { O O 0 + C 35
31 General peritonitis, high fever + O 1 O cy ws
32 Infective endocarditis, icterus + + + O za + + l'1- i%
Bacterial infections .. 33 Gangrene of chest wall + O 1 O 1:1
34 l ' Abortus fever + O 0 O ve 18
35 Appendix abscess + + 0 O ; sa
36 Bronchiectasis, urobilinuria + + O 1 + + ae
i Salpingitis, ulceration of cervix n 2 ‘ 5 1:8 as
39 \ Pyrexia ? cause | { O O 1 O 1-7 16 `
40 ae + + + O 3 + + + wae 26
l 41 ; + + + O 2 of A 28
Rheumatoid arthritis 42 i + O 0 O 1'9 50
43 ` + + 9 + + 1:1 35
44 re O O 3 O 1-2 36
45 O O ee O ee eo
46 Phthisis + O 2 O ss “a
| 43 Phthisis, enteriti ee O i O 0-5 39
i aisis, enteritis :
Tuberculosis .. =. 49 Phthisis, empyema O O 0 O ot 42
50 Peritonitis O O 0 (0) sa 20
51 Knee + + O 0 O 1-4 10
52 Spine and cervical glands + + + 3 O 1°5 36
53 ~ Lympbogranuloma inguinale + + 2. O 1-1 ia
Diaa P i a Sterile inguinal abscess, healed + H +| + So + ° + a + 1l sa
sorders o ymph- 5: i es
glands 56 X Lymphadonoma { + Ł 0 O 1-2 ši
57 Lymphatic leukemia - O O 1 O o. en
E.8.R. = Sedimentation of 100 mm. column in 60 minutes.
454 THE LANCET] .
inguinale might give confusing results. The complicating
malady, however, is not likely to cause much difficulty
since clinically it will be.fairly evident. But this is not
the case when jaundice due to duct obstruction is com-
plicated by cholecystitis, subphrenic abscess, empyema,
or poisoning by sulphonamides used in the treatment of
infection. In all these conditions T.A., C.C., and C.R. may
be strongly positive, though the high figures for T.T.
encountered in hepatitis (10 units or more) are not likely
to be met. There are no cases of hepatitis without
jaundice in the present series, but other data suggest
- that empirical tests could not do more than lend support
to a clinical diagnosis. :
As regards choice of tests, in so far as T.T. is much easier
than the others it is to be preferred, and it gives a simple
and quick pointer to the nature of obscure jaundice
and a quantitative measure of the degree and change
of liver-cell damage. There seems to be no special advan-
tage in using C.R., nor presumably in colloidal gold,
though both are superior to T.a. The difficulty with the
c.c. test lies in the preparation of a reagent of the right
sensitivity. When. this can be obtained, the test is
probably superior to T.T., but in my experience two of
three reagents prepared were too sensitive and rather —
unsatisfactory. . l
- With regard to the origin of the empirical tests, cata-
phoretic studies (Kabat et al. 1943) show that these
depend on increased gamma globulin. The cause of this
increase is less clear. According to Gray and Barron (1943)
the inability of the liver to form enough albumin is
compensated by increased production of beta and gamma
globulin or, if these fail, alpha globulin. It is, however,
difficult to understand how, when albumin formation
fails, the liver succeeds in producing greatly increased
quantities of globulin. On the other hand, Bing (1940)
has shown that hyperglobulinemia ‘occurs in many
different bacterial, virus, and protozoal infections which
all have in common much reticulo-endothelial or plasma-
cell reaction. Another possible source of gamma globulin
is the lymphocyte (Kass 1945). |
In the present series increase of serum-globulin above
the normal maximum of 3 g. per 100 c.cm. was observed
in several instances, including 2 cases of rheumatoid
arthritis with serum-globulins of 3-37 and 3-1; two cases
of sarcoidosis with globulins of 4:22 and 3-96; 2 cases
of Hodgkin’s disease with globulins of 3-0 and 3-53;
and 2 cases of lymphogranuloma with serum-globulins
of 3-39 and 3-17 g. per 100 c.cm. In none of these cases
was there evidence of liver involvement, and it seems
likely that the site of globulin formation was elsewhere.
This observation also applies to 2 cases of multiple
myelomatosis (in one, albumin was 2-29 g. and globulin
8-36 g. per 100 c.cm. ; in a second, albumin was 2:38 g.
and globulin 9-92 g. per 100 c.cm.).
figures suggest that albumin was reduced to a very low
level to compensate for the excessive production of
globulin. In 4 cases of hepatitis the a./c. ratios were
9-04/5:11, 3-46/4-34, 4-41/4-41, and 3-67/6-30. Here also
it is perhaps possible that part at least of the increase in
globulin is derived from an extrahepatic source and may
compensate for deficient production of serum-albumin
by the liver. If this compensation was osmotic, then,
owing to its larger molecule, a relatively larger amount
of globulin would be needed to compensate for the absence
of a given weight of albumin. In these circumstances
the total protein of a globulin-compensated serum would
be greater than that of normal serum, a finding which is
common in hepatitis and is illustrated in the 4 cases
mentioned above, where the total serum-protein was
7-15, 7-80, 8-82, and 9-97 g. per 100 c.cm.
SUMMARY
The rating of several empirical liver tests in order of
usefulness in the differential diagnosis of jaundice was :
thymol turbidity, cephalin-cholesterol flocculation, col-
| \
DR. MAIZELS: EMPIRICAL TESTS OF LIVER FUNCTION
In both, the
[SEPT. 28, 1946
loidal Scharlach red (or colloidal gold), and Takata Ara.
If a case diagnosed as toxic jaundice gives negative
empirical tests, it will probably begin to clear within a
fortnight. Failure so to improve, with persistence of
negative tests, suggests that the diagnosis is probably
incorrect. ~~
In obstruction of the hepatic ducts or bile-ducts the
colloidal red is negative in 80% of cases and the cephalin-
cholesterol flocculation in about 90%, whereas thymol
turbidity rarely exceeds 10 units, even when the jaundice
is long-standing and severe. When cases of duct obstruc-
tion give positive empirical tests, serious complications,
such as metastases and infection, are commonly present,
though extensive liver metastases may accompany
negative tests. l ar
Besides hepatitis, positive empirical tests may also be
given by myelomatosis, sarcoidosis, certain types of
adenitis, rheumatoid arthritis, sulphonamide poisoning,
and infections with certain bacteria, protozoa, and viruses.
If any of these maladies accompany simple duct obstruc-
tion, the positive tests may suggest that parenchymatous
damage is present. : |
APPENDIX ON METHODS
' Blood was collected in the morning, kept for three hours
at 37° C, and then at room temperature. In the afternoon,
serum was separated without hemolysis, and the tests were
put up immediately. i .
Takata Ara modified by Britton (1945).—Readings are
follows :
O =no change in any tube, or a cloud in tube 3, with or without
a fine amorphous precipitate. l
+ =sma})l gelatinous precipitate in tube 3 only.
+ = moderate or bulky precipitate in tube 3 only.
+ + =heavy flocculent precipitate in tube 3 ; some precipitation
in tube 2.
+ + + =heavy precipitate in tubes 2 and 3. (Though exceptionally
strong reactions sometimes occurred with precipitation
in tube 1, no special record was made of these.)
Cephalin-cholesterol Flocculation (Hanger 1939).—Recorded
as follows at 24 hours :
O =no change.
+ =fine granularity without precipitation.
+ =granularity with some precipitation.
+ + =granularity with heavy precipitation.
+ + + =complete precipitation with clear supernatant fluid.
Thymol Turbidity (Maclagan 1944).—Recorded in table 1
as follows :
O = 0- 4 arbitrary units.
+= 4- 8 units. + + =12-20 units.
+= 8-12 units. . + + + =20—40 units.
Colloidal Scharlach Red.—A saturated solution of the dye
in alcohol is kept at 37° C; 10 ml. of this in a clean conical
flask and 50 ml. water in a second flask are warmed to about
55° C and the water quickly added to the dye solution. The
mixture is then boiled first in the bath and then over gauze
till the final volume is about 20 ml. The volume is then made
up to 75 ml. and 0.35 ml. Evans blue (0:2%) is added. For
use, 0:5 ml. of the reagent is added to 0-5 ml. of serum diluted
to 1/2, 1/4, and 1/8 with saline (0-85%). Results are read next
day. If the serum is icteric, an identical control series may be
put up at the time of reading to facilitate identification of
colour changes. In the case of sera, readings are as follows :
Non-icleric sera
O=purple or violet .. we
+ = blue tinged with violet in
1 tube only... ve
+ =sky blue in 1 tube only
+= »» »9 2 tubes only » ”?
29 3 tubes ee <= 29 3 tubes.
Sedimentation-rate was observed after an hour in a 100 mm.
column of citrated blood. i
REFERENCES
Bing, J. (1940) Acta. med. scand. 103, 547.
Britton, C. J. C. (1945) Middlesex Hosp. J. 45, 29.
Gray, S. J. (1940) Arch. intern. Med. 65, 523.
Barron, E. S. G, (1943) J. clin. Invest, 22, 191.
Hanger, F. M. (1939) Ibid, 18, 261. .
Icteric sera
orange or dirty green.
dirty green in 1 tube only.
bottle-green in 1 tube only.
2 tubes only.
Il
Panna
—-
Kabat, E. A., Hanger, F. M., Moore, D. H., Landow, H. (1943)
Ibid, 22, 563.
Kass, E. H. (1945) Science, 101, 337.
- Maclagan, N. F. (1944) Brit. J. exp. ie 25, 234. |
(1945) Proc. Ass. clin. Path. 1, 2
= Magath T. B. (1940) J. Lab. clin. Med. 26, 156.
Mateer, J. G., Baltz, J. I., Marion, D. F., MacMillan, J. M. (1943)
J. Amer. med. Ass. 121, 723.
Nadler, S. B., Butler, M. F. (1942) Surgery, 11, 732.
Ornstein, I. (1937) C.R. Soc. Biol. Paris, 126, 519.
Pohle, F. J., Stewart, J. K. (1941) J. clin. Invest. 20, 241. \
+-
7 ee A T ee rr
THE LANCET]
DR. MAGNUS HAINES: PERFORATION OF THE AORTA
[SEPT. 28, 1946 455
PERFORATION OF THE AORTA
_ BY SWALLOWED BONES
Macnus HAINES
M.D. Lond.
ASSISTANT PATHOLOGIST, WESTMINSTER HOSPITAL
THE anatomical relations and infective contents of the
ceesophagus make its perforation often fatal. Most of the
cases, resulting from malignant ulceration, terminate
with mediastinitis. However, when a foreign body
becomes impacted in the wsophagus, usually at or just
below the tracheal bifurcation, there are three possible
sequelz ; (1) ulceration of the esophagus, leading later
to a ciéatricial stricture; (2) perforation of the cso-
phagus, with subsequent mediastinitis and/or pyo-
pneumothorax; and (3) perforation of the msophagus
and the aortic arch. The second of these sequelæ
may precede the third. The history and post-mortem
findings of two recent cases are reported here.
CASE-RECORDS
Case 1.—A well-built man, aged 22, on leave from the
Army, complained, after taking a mouthful of chicken on
Dec. 27, that something had stuck in his throat. He ate
no further dinner, and about 4 P.M. the same day sought
advice at his local hospital. The pharynx and larynx showed
no trace of a foreign body, and at the doctor’s suggestion
he swallowed a crust of bread without apparent difficulty.
Four hours later he reported again at the same hospital,
complaining of pain in the chest and of difficulty in breathing.
Further examination revealed no abnormal physical signs,
and the doctor advised him to return again in the morning
if he felt no better. He lay in bed all next day
(Dec. 28). Pain in the midline of the back,
localised to asmallarea over thesixth thoracic
vertebra, was first noted on this day, and he
was ‘“‘ unable to swallow anything.”
He returned to duty on the 29th and “went
sick.” He was admitted to hospital that
evening, when radiography of hischest showed
no abnormal shadow. Next day, his tempera-
ture being 100° F, he was œsophagoscoped.
After passing 23 cm. the instrument came
upon an cedematous swelling. No foreign
body was located, but it was considered
unwise to attempt passing the instrument
further, even if possible. A small hematoma
was encountered 2 cm, proximal to the area
of cedema.
A small hxematemesis took place on Jan.
2, and a further 6 oz. of bright red blood was
| i vomited at 12.30 a.m. on the 3rd. Three hours
later the patient said he was going to be sick
a DA A and tried to sit up, but fell back. The face
aorta by chicken blanched, severe air-hunger set in, and he
iE ara nee died within 5 minutes.
been opened At necropsy I found an irregular quadri-
from behind. lateral plate of chicken bone, whose sides
measured approximately 2, 2, 3, and
3 cm., firmly lodged in the oesophagus, just below the bifurca-
tion of the trachea (see figure). The anterior wall of the ceso-
was deeply congested and swollen. One angular corner of
the bone had made a rent 1-5 cm, long in the anterior wall, but
there was only slight inflammation in the circumeesophageal
tissues at this point. Another sharper corner of the bone
had pierced both the left posterolateral wall of the esophagus
and the contiguous aorta at the beginning of its descending
portion. The tearin it was 8 mm. long, and there was almost
no inflammation in the region. Clotted and fluid blood was
found in the stomach and intestine. Apart from exsanguina-
tion, other organs presented no abnormal features.
Case 2.—A housewife, aged 46, came to the hospital com-
plaining that she had just swallowed a fish bone. Laryngo-
scopy and pharyngoscopy showed no foreign body. Radio-
graphy of a barium-cotton-wool swallow was negative. Two
days later she was examined by the throat specialist, as the
pain in the chest and back persisted. Again no foreign body
was seen in the pharynx or anes and radiography again
showed nothing abnormal.
Six days after swallowing the bone she vomited, for the
first time, about half a pint of bright red partially clotted ,
blood. She then fainted and was found on the floor in a
collapsed state. On admission to hospital about two hours
after the hamatemesis she was pale and sweating. Examina-
tion by indirect laryngoscopy showed no foreign body.
During the evening, and on four subsequent occasions during
the next two days, she vomited more blood. : On the day
after admission cesophagoscopy was performed, but no
foreign body or ulceration was discovered. After a final
hemorrhage (about 20 oz. vomited) she died next evening.
At necropsy a small area of cedema and congestion was
found in the external aspect of the posterior wall of the cesoe
phagus extending upwards from the level of the tracheal
bifurcation. The mediastinal tissues immediately rolated
to the under surface of the bifurcation and along the right
bronchus showed early gangrene. Infection had tracked down
interstitially from above. On opening the csophagus from
behind there was seen a recent oval ulcer !/, in. long and !/, in
across, involving the entire thickness of the anterior wall of
the cesophagus. It was about 4 in. below the level of the
cricoid cartilage, though above the tracheal bifurcation.
The ulcer communicated directly with the adjacent aorta,
which had a tear in its wall !/, in. long and situated just below
the origin of the left subclavian artery. No foreign body
could be found in the cesophagus, lungs, or mediastinum. <A |
prolonged search was also made in the main branches of the
aorta without finding any foreign body. Blood was found
adhering to the ulcer and.in the cesophagus. The rest of the
alimentary tract contained large quantities of blood, both
fresh and altered.
DISCUSSION |
Several fatal cases have been reported, including
those by Grey Turner (1910), Watson-Williams (1937),
and Decoulx and Omez (1939). Many records can
also be found of successful removal of a foreign body,
in earlier years by cesophagotomy and nowadays by
cesophagoscope. In the fatal cases the minute size of the
foreign bodies, the length of time elapsing between the
accident and the patients’ coming under medical super-
vision, and the failure of radiography to demonstrate
the foreign body seem to be important considerations.
Grey Turner and Watson-Williams each report a case
in which the bone was not found at the autopsy. In my
case l radiography did not reveal the bone, and in case 2
the bone was never found. The time factor is very
variable ; commonly there is a 4-10 days’ interval between
the accident and a fatal aortic perforation. In Grey
Turner’s case the interval was 22 months.
The characteristic sign of injury to the aorta has been
vomiting of blood, which occurs at short intervals but in
increasing quantities until the final hemorrhage. Watson-
Williams believes that a prick perforation of the cso-
phagus leads to infection and necrosis of the arterial wall,
and rupture finally ensues from intra-aortic pressure,
This was a possible mechanism in one of his cases, where
the fatal hemorrhage closely followed the removal of the
bone through the wsophagoscope. In my case 1 it seems
that, owing to the size and sharp angle of the bone,
pressure from the pulsating aorta aided penetration.
There was no macroscopic inflammation in relation
to this perforation. Even if the bone had been seen
through the csophagoscope on Dec. 30, the chances of
removing it were almost nil. In case 2 it is considered
that the bone may have been vomited or swallowed at
any time after the aorta had been injured.
Decoulx and Omez report a very unusual case whose
course was aggravated by a second accident. A miner,
aged 37, continued at his work after swallowing a chicken
bone. Ten days had gone by when, at work, he received
a crush injury of the chest, which was followed by
vomiting of blood. He died two days later from further
haematemeses.
Diagnosis, without immediate endoscopy, presents
many difficulties in these cases. In some, radiography
will localise an opaque foreign body, but many foreign
bodies are not dense enough to be visible—e.g., fish bones. «
That a patient with a fairly large object impacted in the —
\
456 THE LANCET]
cesophagus can swallow solids is undoubted, and this
-fact cannot be too strongly emphasised. Many years
ago Grey Turner cited the cases of a woman who took her
ordinary food for three days despite the presence of a
plate of false teeth in her gullet, and that of a child who
had remained well nourished although a halfpenny was
lodged in the esophagus for one year and ten months.
During the course of a lifetime every practitioner
sees scores of patients who have swallowed various
articles, and many of these complain of pain in the chest.
It is generally believed that very few objects swallowed
in this way become impacted, and consequently cso-
phagoscopy is not often undertaken. But Chevalier
Jackson (1940) states that “in the College of Physicians
i REVIEWS OF BOOKS -
\
[SEPT. 28, 1946
of Philadelphia there are nearly 4000 objects, each of
which has been removed from the air and food p
of patients at the bronchoscopic clinics of Philadelphia.”
The cases reported here and others described in the
literature may serve to show why we should become more
“ esophagoscope conscious.”
My thanks are due to H.M. Coroners, North London and
West London, for permission to publish the cases, and to
_ Mr. E. Stanley Lee for his help in compiling the history in case 1.
REFERENCES
Decoulx, P., Omez, Y. (1939) Ann. Méd. lég. 19, 144. 5
Jackson, C., Jackson, C. L. (1940) The March of Medicine: New
York Academy of Medicine Lectures to the Laity, 1940, London.
Turner, G. G. (1910) Lancet, i, 1335. -
Watson-Williams, E. (1937) J. Laryng. 52, 264. È
Reviews of Books
An Introduction to Clinical Neurology
Gorpon HoLmeEs, M.D., F.R.S. Edinburgh: E. & S.
Livingstone. Pp. 183. 128. 6d. |
THE distinctive feature of the British tradition in
neurology is the intimate relationship between clini-
cal neurology and neurophysiology. Everywhere clinical
neurology is based upon neurophysiology, but nowhere
else has neurophysiology been so much enriched by the
work of clinicians. There is no more distinguished
E example of this than Dr. Gordon Holmes, whose work
has contributed so much to our knowledge of the physio-
logy of sensation, vision, and the cerebellum. Many,
therefore, will welcome this book in which he makes
available to a larger circle the teaching which generations
of students at the National Hospital have valued and
enjoyed. It is, as the title states, an introduction to
clinical neurology, based upon the interpretation of
neurological symptoms and signs in terms of anatomy
and physiology. The main functional divisions of the
nervous system are dealt with in turn, the motor system,
muscle tone, convulsions, sensation, the reflexes, the
visual system, speech, the sphincters, the autonomic
nervous system, and the mental state, to mention the
more important. The student beginning neurology will
find here the necessary foundations of the subject, and
the practising neurologist will enjoy the lucidity of the
exposition.
The Surgical Teaching of Abdominal Operations
(4th ed.) J. L. SPIVAOK, M.D., associate professor of
surgery, University of Illinois. Springfield, Ill.: Charles C.
Thomas. London: Bailliére. Pp. 710. 56s.
THis handsomely printed book has been considerably
revised, yet remains an encyclopedia rather than an
eclectic account of practical methods.. Even so, there
are omissions. Nine methods of gastropexy, an operation
of doubtful value, are described, yet there is no account
of the difficult dissection of the duodenum which is so
often called for. Professor Spivack’s ingenious methods
of cholecyst-gastrostomy and the formation of an
artificial anus are interesting. He is against aseptic
methods of anastomosis for the stomach. The book will
be read by experienced surgeons with much profit and
entertainment.
Pediatric X-Ray Diagnosis
JOHN CAFFEY, A.B., M.D., associate professor of pediatrics,
Columbia University, N.Y. Chicago: Year Book
Publishers. London: H. K. Lewis. Pp. 838. 75s.
THis is the first textbook in English on the use of
X rays in the diagnosis of children’s diseases and is an
elaboration of Dr. Caffey’s well-known section in Ross
Golden’s loose-leaf System of Radiology. The author was
clearly a pediatrician before becoming a radiologist, and
while some of the finer points of radiological technique
are missing, their loss is more than balanced by his
excellent clinical judgment. In every section of this book
the radiological appearances are assessed with the clinical
and pathological findings, and where one preponderates
suitable emphasis is laid on it. Rare diseases are but
briefly mentioned and most of the text and illustrations
deal with the common and important diagnostic prob-
lems. A striking commentary on the different values of
X-ray diagnosis in children and adults is that the gastro-
intestinal tract occupies only 60 pages while neurology
gets 160, the bones 200, and the chest 200. The illustra-
tions are well selected and enhanced by the addition of
beautiful anatomical and pathological drawings. The
book is the work of a practical man, demonstrating facts
as he found them in over twenty years’ experience in a
children’s hospital. It will be of great value to all radio-
logists, relatively few of whom have the opportunity to
work in a large children’s department. It should also
prove a revelation to the many pediatricians whose
radiological outlook, in this country at least, has been
limited by indifferent equipment. l
Chemistry and Physiology of Hormones
Editor: Forest Ray MouLrToN. Washington : American
Association for the Advancement of Science. Pp. 243.
THis book, to quote the foreword, grew out of a
research conference held at Gibson Island, Maryland,
in 1943. There are 18 authors, workers in the fields
in which they write. The policy has been to give
résumés of the well-established findings on the various
subjects, without excluding discussion of current work.
Whilst the publication should, be of value as a reference
book for endocrinologists and teachers—there are
some 1200 references—the more general reader, by
intelligent selection, can read it with profit and pleasure.
An index would have helped readers of both kinds. The
18 articles cover most of the known hormones and
endocrine glands and the relationships between them ;
but some account of the synthetic hormones of the
stilboestrol type might well have been included. Our
knowledge of the mode of action of insulin, conserva-
tively estimated by Lukens, has since been increased by
the observation of Price, Cori, and Colowick that insulin
and anterior-pituitary extract are antagonistic to hexo-
inase. W. T. Salter, writing on euthyroidism and
thyroid dysfunction, emphasises the clinical value of
ebay pe pais of the level of protein-bound iodine in
the blood.
L’hypertonie de décérébration chez homme
PIERRE MOLLARET, médecin des hôpitaux de Paris,
professeur agrégé à la Faculté de Médecine, chef de
service à l'Institut Pasteur ; Ivan BERTRAND, directeur
à l'École pratique des Hautes Etudes et de l’Institut de
Neurobiologie (Salpêtrière). Paris: Masson. Pp. 1565.
Fr. 180.
THis study of decerebrate rigidity (or, as the authors
prefer to call it, ‘‘ decerebrate hypertonia’’) is built
round the detailed observation of a single case, in a man
of 34 who fell a victim to Economo’s encephalitis at the
age of 17 and was nursed for the rest of his life in the
Salpétriére. During this long time he lay in a condition
of mutism and paralysis in extension, voluntary move-
ments being limited to the eyelids and upward movements
of the eyes. The strict localisation of the lesions of this
case to the substantia nigra, the commissure of Forel,
and the red and dentate nuclei, combined with this
clinical picture, leads the authors to argue in favour of
Sherrington’s original conception of decerebrate rigidity.
The historical background and physiology of the neuro-
logical condition are traced, in the course of which the
authors criticise the more recent attempts by British.
neurologists to amplify and, as they consider, confuse:
Sherrington’s conception. |
THE LANCET]
THE LANCET
LONDON: SATURDAY, SEPT. 28, 1946
Mothers in Jobs
“ An employer should not dismiss a woman simply
because she marries or because she is pregnant but only if,
for medical or other reasons, she is no longer fitted to her
job and if no alternative work can be offered her.”
P.E.P., in a somewhat optimistic broadsheet,}
support the right of the mother to go to work
if she wants to. Probably most British women
regard a job as something to fill the interval
between school and marriage, and accept as their
serious work the task of rearing their children
and looking after their homes; and if the State
looked on this work as comparable in value with any
other kind of work, the time and energy which
mothers devote to it would not be limited by the
earning capacity of the husband. Nevertheless if some
accessory services—such as day nurseries and help
in the home—were provided on an adequate scale,
mothers might be released to share in industrial work,
anyhow tor part of their time. The war brought some
changes on these lines. Family allowances recognise
the value of children and so, indirectly, of mothers ;
day nurseries gave mothers more freedom for work
when their services were acutely needed; and the
usual discovery was made that women have deft
fingers. In fact “there was found to be a greater
reserve of ability among the unskilled and semi-
skilled than had been imagined. This applied with
particular force to women workers—married or single
—who had in the past been confined mainly to the
unskilled occupations.” All the same, in an effort
to fulfil its two purposes of raising a new generation
and of providing labour and goods for this one, the
State makes conflicting demands on women. If there
is to be a labour shortage, as many women as possible
must be helped to share in industry; yet a long-
sighted policy would favour the bearing and rearing
of children, for this will automatically lessen man-
power shortage in the future. In this situation
P.E.P. advise that women who want to work outside
their homes must be allowed to do so, by the removal
of restrictions, occupational bars, and other impedi-
ments. If the principle of equal pay for equal work
is accepted, women will cease to be “ cheaper ” than
men and so may find their opportunities reduced in
some occupations ; in others they will no doubt hold
their own, or perhaps gain ground. P.E.P. are con-
cerned to reduce the conflict between motherhood and
employment, and to remove the economic necessity
_ which forces poorer mothers to remain at ill-paid
` work when they should, and would rather, be with
‘their children.
Experience in industry shows that most pregnant —
women give up work between the 26th and 28th
weeks, and comparatively few stay till the later
stages of pregnancy. Of 83 women followed up,
only 18 had returned to any sort of work 17 months
after confinement. In 1931 three-quarters of all
married women at work were in domestic service,
the textile industry, and the clothing, distributive,
1. Planning, no. 254, August 23, 1946. From P.E.P. (Political &
Economic Planning), 16, Queen Annc’s Gate, S.W.1.
MOTHERS IN JOBS
and catering tragles—all of which use much cheap
[serr. 28, 1946 457 .
—_——
rf
casual labour. And though the war gave all women
the chance of earning good pay, a return to normal
peace-time conditions will again drive expectant
mothers mainly into poorly paid and insecure jobs,
chiefly because the service they have to offer is-
uncertain. Yet it has been shown quite clearly that
properly safeguarded factory work is not harmful to
pregnant women, and indeed may be specially suited
to them because they can be supervised and trans-
ferred to appropriate types of work as need arises. |
Moreover, “‘ factory or office work may be less exacting
than looking after a house, attending to children, and
standing in queues ’’—though many women com-
bined both duties during the war. The main danger
to the working mother is this double burden of job
and housework, which may leave her no time to
seek proper antenatal care. Some firms, during the
war, arranged for antenatal care to be given in the
factory, and found that women reported their preg- —
nancies earlier to the factory nurse than they would
have done to an outside clinic. P.E.P. feel that when
the National Health Service is in action it would ‘be
better to encourage women to make full use of the
outside maternity service rather than to duplicate
such services inside factories. This can only be achieved
if the mother has no fear of dismissal when she
reports pregnancy, and if she is given time off to
attend the clinic. At present medical supervision of
mothers in direct relation to their work is unusual ;
yet it is essential, and can only be done properly
by a doctor who understands the kind of work she
is doing. The suggestion that the local antenatal
clinic should hold sessions in or near the factory
seems specially promising, and official food supple-
ments might well be issued at the factory.
Apart from care and supervision, the working
mother needs financial security and sufficient help
with her child and her housework. She is at present
entitled to the same maternity services as any other
mother (some free, some paid for at fixed rates), and
—under National Health Insurance—to free super-
vision by her panel doctor during pregnancy and after
lying in. She has no statutory period of leave, and no
maintenance allowance while she has to stay away
from work. Under the Factory and Public Health
Acts she may not be employed in industry during the
first four weeks after delivery, but this rule is difficult
to enforce and often ignored. She gets a single cash
benefit of £2 (£4 if her husband is also insured) under
the N.H.I. scheme ; and sickness benefit, though not
officially granted for pregnancy, is usually paid during
the lost six weeks if a claim is made. Under the
N.H.I. Acts, sickness benefit may not be paid “in
any circumstances whatever ” during the four weeks
after confinement. Some 20% of married and 30%
of unmarried mothers draw sickness benefit at some
time in the three months after childbirth. Benefit
rates are only a fraction of the amount needed for
full maintenance of mother and child, so the tempta-
tion is strong for the needy mother to work up to the
time of her confinement and to return to work as
soon as she gets up. The Washington Convention of
the International Labour Office in 1919 laid down
as a minimum 12 weeks’ maternity leave and cash
benefits sufficient for “ full and healthy maintenance
for mother and child”; but this ruling was never
ratified in Britain. In any case the periodyis much too
`~
| 458 THD LANOET]
short for the best interests of the child. The Royal
College of Obstetricians and Gynecologists have
suggested that the mother should be free from all
outside responsibilities for the first six months of
the child’s life—a view which is as strongly supported
by psychological as by physiological findings. The
‘introduction, under the National Insurance Act, of
a weekly maternity benefit of 36s. for 13 weeks, to be
paid on condition that the mother abstains from work,
will do something, but clearly not enough. P.E.P.
would like an extension of the period to be considered
at once. Moreover, for the mother who has no husband
to supplement it, the rate is too low, even when
family allowances are taken into consideration. A
National Assistance Service, to inquire into individual
cases, is thought to be the solution; but the word
“assistance ” in the title of an official body has
now an unpleasing sound in many ears. Public
Assistance, carrying on the old poor-law stigma, is
not always administered with tact and consideration.
A special children’s allowance to be paid to mothers
with no source of income but their own earnings
would meet the case better. The development of
nursery schools of the best type and the growth of
home-help services are also essential if mothers are
to take part in industry without detriment to their
- main career; for the old sneer about the woman’s
place being the home gains a different significance
once we realise that the output of the home compares
favourably with that of the workshop—that children,
in short, are more valuable than commodities. |
Salicylates in Acute Rheumatism
THE generally accepted view of the action of
salicylates in rheumatic fever is that they cause the
fever and the arthritis to subside but do not affect
the fundamental course of the disease or the develop-
ment of endocarditis and valve lesions. It is still
uncertain whether their febrifuge effect is merely
that of an antipyretic acting on the temperature-
regulating centre, or whether it is more complex
and in some way specific to rheumatic fever. Doubt
has also been expressed as to whether the joint effect
is anything more than analgesic, seeing that in the
natural course of the disease a given joint is swollen
and painful usually for only a few days. Recent work
in America has attacked these problems afresh, but
as yet no finality has been reached. `
In 1943 COBURN ! attracted considerable attention
for a claim that sufficiently high doses of salicylate
suppress the rheumatic inflammatory process and may
prevent lasting cardiac damage. With a new chemical
method he was able to determine salicyl radicle con-
centrations in blood. To maintain a plasma salicylate
level of 35 mg. per 100 c.cm. a daily dose of 10 grammes
or more of sodium salicylate is necessary, and . to
. reach that level quickly the early doses must be
given intravenously. Of 38 patients with rheumatic
fever so treated—young men from the American
Navy—all are said to have escaped valvular heart
disease, while of 63 similar cases treated with only
enough salicylate to relieve the symptoms 2] developed
valve lesions. Unfortunately the details, and especially
the duration, of subsequent observation are not
stated, and the conclusion must be accepted with
reserve. Yet the case-records, showing relief of —
1, Coburn, A. F. Bull. Johns Hopk, Hosp. 1943, 73, 435.
SALICYLATES IN ACUTH RHEUMATISM
. mild tinnitus.
[sEPT. 28, 1946 ;
symptoms in a few hours with intravenous salicylate,
the fall of temperature in 1-2 days, and the return
of blood-sedimentation rates almost to normal in a
week or two, are impressive. In some severe cases
salicylate levels of 60 mg. per 100 c.cm. were reached,
and except in one patient who developed a toxic
psychosis the only untoward effect mentioned was
At Johns Hopkins Hospital MURPHY ?
tested CoBURN’s claim by making a careful study of
12 patients with acute rheumatism receiving doses of
salicylate large enough to maintain plasma salicylate
levels of over 30 mg, per 100 c.cm. in nearly every case.
The diameters of 24 swollen joints were accurately
measured : 4 had decreased before salicylate therapy
was begun; 2 decreased within twenty-four hours, 3
in forty-eight hours, 6 in up to five days, 2 after five to
eight days, and 5 not at all in twenty-one days; 2 joints
became involved for the first time on the fifteenth day
of continuing salicylate therapy. Furthermore these
patients developed various fresh rheumatic lesions
during the intensive salicylate treatment, such as
nodules on tendon sheaths, pneumonitis, teno-
synovitis, and episcleral nodules; and some of these
were confirmed by histological study. MURPHY
concludes by doubting the accepted view that sali-
cylates promote the subsidence of rheumatic joint
inflammation. Wéarta and SmuLtu® compared 21
cases of rheumatic fever given salicylates in doses
that promptly established and maintained 35-50. mg. -
salicylate per 100 c.cm. blood, and 19 cases treated
with smaller doses. They could see no difference in
the duration of the attack or in the behaviour of the
sedimentation-rate of the two groups. Of toxic
reactions, in the “adequately treated ” group they
describe tinnitus and deafness as common; vomiting
as infrequent ; hyperpneea and tachycardia as occur-
ring at levels of blood salicylate over 50 g. per 100 c.cm.
MANCHESTER,*: from an American naval hospital,
accepts COBURN’s view of the effectiveness of sali-
cylates in suppressing inflammation and preventing
cardiac residua, and describes in greater detail the
toxic effects of continued high dosage. Hypopro-
thrombinzmia develops early, but is not severe and
does not progress. Delirium can be caused by rapid
intravenous infusion, raising the blood salicylate
level too quickly. Hyperpneea is due to acidosis and —
can be prevented by the simultaneous administration
of alkali. JAGER and ALWAY:5 report on 26 cases of
acute rheumatic infection treated with a long and
intensive course of salicylates. ‘Their results are not
uniformly favourable, since both raised sedimenta-
tion-rates and other evidences of rheumatic activity
persisted in many patients. Nor, as they say, is their
follow-up adequate. l
So far, then, the American evidence is conflicting.
The advocates of intensive salicylate therapy write
from naval hospitals, and it may be that rheumatic
fever behaves somewhat differently in picked young
‘men, so that results in them are not comparable with
those in mixed general hospital patients. There
seems no need as yet for doctors on this side of the
water to depart from their time-honoured practice of
giving salicylates by mouth in rheumatic fever, in
doses just large enough to-induce tinnitus, for at
least as long as the fever and the arthritis last, and of
2. Murphy, G. E. Ibid, 1945, 77, 1.
3. ia, R., Small, K. J. Amer. med. Ass. 1945, 129, 485.
` 4. Manchester, R. C. Ibid, 1946, 131, 209.
5. Jager, B. V., Alway, RY Amer. J. med. Sci. 1946, 241, 273.
THE LANCET].
hoping that rest and general measures will mitigate
the cardiac damage. It seems possible, however,
that succinate will replace salicylate. GUBNER and
Szucs® treated 65 cases with an average of 4-5 g. of
sodium salicylate daily, and compared these with
55 cases receiving a similar amount of the calcium
double salt of benzoic acid and succinic acid benzyl
ester together with ascorbic acid. The succinate
group showed a shorter clinica] course, a much lower
incidence of carditis (as shown, for example, by
prolongation of the P-R interval), and an apparently
lower incidence of valvular disease developing within
one to six months. Succinic acid acts as a catalyst
in some biological oxidations, and there is enough
evidence of derangement of tissue oxidations in
rheumatic fever to make its trial plausible on metabolic
grounds. The clinician will await further experience.
Surgery of the Œsophagus
THE widening scope of surgery in the treatment of
diseases of the cesophagus is illustrated by the spate
of technical modifications and the increasing size of
published series, compared with the isolated protocols
of a few years ago.
Malignant disease comes in for most attention, and
CiaGETT! now reports 54 operations for carcinoma
of the cardia of the stomach or lower cesophagus
using the thoracic approach. Of these growths, 24
were inoperable but no complications resulted from
the thoracotomy. In the other 30 the growth was
resected and continuity restored, with only 5 deaths.
It should be noted that only 3 of these were defined
as cesophageal carcinomata, the remaining 27 being
growths of the upper stomach. CLAGETT also records
2 resections for benign conditions. The virtue of this
route in the approach to high gastric lesions has been
clearly established. Lesions in the middle third of the
cesophagus lend themselves less readily to operation.
It has been shown that by mobilisation of the stomach
well up into the chest, after incision of the diaphragm,
an cesophago-gastrostomy as high as the arch of the
aorta is practicable.2 Most of these anastomoses
have been performed on the left side, though Ivor
Lewis? has had good results with a right-sided
thoracotomy and anastomosis after preliminary
abdominal mobilisation of the stomach.
Some benign strictures and high growths cannot be
dealt with in this way, and continuity between
pharynx and stomach can then be established only
by some form of extrathoracic gut or skin tube
method. With stricture, excision of the cesophagus
is unnecessary, and an artificial gullet is the method
of choice; the same applies to total removal of the
cesophagus after the Torek and pull-through types
of operation. The skin funnel operation has the dis-
_ advantages that the funnel is inert, and may become
lined with and clogged by hair. Jejunal or gut loops,
if properly constructed, convey food from the pharynx
to the stomach without artificial assistance, but their
length is limited by the distance to which the mesen-
teric blood-vessels will reach. YubIN * in a series of
80 cases used a skin tube in 6 instances and a jejunal
loop in 16; in the remaining 58 patients the two
6, Gubner, R., Szucs, M. New Engl. J, Med. 1945, 233, 652.
1. Clagett, O. T. Prot. Mayo Clin. 1945, 20, 506.
2. Garlock, J. H. Surg. Gynec. Obstet. 1944, 78, 23.
3. Lewis, I. Brit. J. Surg. 1946, 34,18.
4. Yudin, S. S. Surg. Gyner. Obstet. 1914, 78, 561,
SURGERY OF THE GSOPHAGUS
methods were combined.
[SEPT. 28, 1946 459
A recent modification
mainly applicable to strictures consists in using an
isolated jejunal loop as a free subcutaneous graft.
LONGMIRE and RavitcH 5 have shown that a long
segment of gut can be exteriorised and placed sub-
cutaneously, with its blood-supply initially left intact.
The gut is then in stages surrounded by skin flaps to
make a tube, and the mesenteric vessels are gradually
and increasingly constricted until the gut-skin tube
is viable. After division of its original blood-supply
the tube is moved, again in stages, to the front of
the sternum, where it is ultimately united to the
cervical cesophagus and stomach. This procedure
is tedious, involving many operations, but only the
initial abdominal operation need be regarded as a
major undertaking. The method ensures that an
adequate length of jejunum is available for the artificial -
esophagus ; and it overcomes the principal objection:
to the usual operation, in which the length of bowel
is determined by the mobility of the mesentery.
Localised strictures in the lower cesophagus are more
easily dealt with ; failing gradual dilatation, they can
usually be treated by a plastic operation on the lines
of a pyloroplasty. With severe or long narrowings,
an anastomosis between stomach and cesophagus
through a small diaphragmatic incision will by-pass
the stricture satisfactorily. CLARK and Apams ê have
practised one form of this operation in 5 cases; in
3 no known etiological factor was established, while
in another case the stricture appeared to be associated
with generalised scleroderma.
For the many young people with cesophageal stricture
or cardiospasm the chances of cure by radical surgery
should be carefully considered before the patient is
condemned to a life of dilatations or bougie swallowing.
Furthermore, the difficulty in differentiating between
carcinoma and some forms of stricture makes it impera-
tive to consider thoracotomy in any case of doubt.
5. Longmire, W. P., Ravitch, M. M. Ann. Surg. 1946, 123, 819.
6. Clark, D. E., Adams, W. E. Ibid, 1945, 122, 942.
MEDICAL STUDENTS AND THE BILL.—The British Medi-
cal Students’ Association sent a questionary on the National
Health Service Bill to 10,106 students in medical schools
in England, Wales, and Scotland. Of the 3801 (37:6%) who
replied, 17% were definitely opposed to the principle of a
comprehensive National Health Service, while over 80%
were in favour. As to whether the present Bill will improve
the medical services opinion was almost evenly divided.
A small majority preferred the hospitals to remain under
present administration, and a large majority disapproved of
the transfer of voluntary hospital endowments to a new
fund for redistribution.
Assuming that there is to be a service, opinion was strongly
in favour of practitioners and specialists being allowed to
conduct private practice along with their work in the service,
as is proposed by the Bill. The combination of salary and
capitation fees was approved (64%), though 18% favoured
capitation fees alone and about 12% salary alone. The
prohibition on the sale of N.H.S. practices (as proposed by
the Bill) was accepted by 53% to 40%, but the power of the
Medical Practices Committee to prohibit a doctor from
practising in a particular area was not approved (47% for,
50% against). Nearly 60% disagreed with the composition
of the local executive councils: where a reason was given
it was that the councils should include more professional
men.
Despite this disagreement about details, and uncertain
approval of the Bill as a whole, over 60% of the students
who answered the questionary expressed a willingness to work
in the new National Health Service, provided remuneration is
suitable and the regulations made by the Minister are
acceptable.
460 THE LANCET]
Annotations
THE BASLE MEETING
Last week’s British-Swiss medical conference (see
_ p. 464) was more than once likened to a peace conference ;
and, as at peace conferences, much of the most important
work was done outside the formal meetings. Workers
in both countries were eager to hear, at first hand, what
had been done in the long period of segregation, and
were often astonished at the parallel developments in
the war years. The papers themselves, to which the
Schweizerische medizinische Wochenschrift devoted a
special number in English, gave an excellent symposium
of recent advances in both countries. It may be hoped
that the visitors learnt something of the example by the
Swiss Academy of Medical Sciences in its preparations
for the meeting. The papers themselves were all read
in English with simultaneous translation, through
` earphones, into German—a device whose excellence has
been equalled, Sir Heneage Ogilvie remarked, only
at the Nuremberg trials. Delegates might perhaps have
found it easier to make contact with one another if
each had worn a rosette bearing his name; and it might
have been an advantage to discuss each paper after it
was read rather than at a single discussion in the evening.
But these are small points.
Swiss doctors are eager to hear more of British
medicine ; it was therefore disappointing to find that,
despite demand, the leading bookshops, though stocking
American works, had been unable to obtain British text-
books, and, in particular, textbooks of medicine. The
value of sending British publications to other countries
is not solely commercial ; and it is to be hoped that the
precedent of the British M edical Bulletin, which is readily
obtainable overseas, will. be applied to books before the
habit of buying those published elsewhere has become
too firmly established.
At the banquet given by the academy, Prof. Karl
Wégelin, the president, emphasised the strength of the
bonds between Switzerland and, Britain. Dr. Peter,
_president of the Basle council, spoke with eloquence of
the feeling in that city, so near the frontiers that the
sounds of war in both France and Germany had been
heard. The Swiss people had, he said, been sustained
by the spirit of the British, who had preserved democracy
for Europe and the world ; the best hope for the future
lay in closer personal relations, and it was such meetings
as the present that helped to foster international under-
_ standing. Professor Lutz, dean of the medical faculty at
Basle University, called for an objective approach -to
_ international affairs; and Dr. Leuch welcomed the
guests on behalf of the Swiss federation of doctors.
Sir Heneage Ogilvie, replying for the visitors, showed a
knowledge of Switzerland which gratified his countrymen
no less than their Swiss hosts.
EXTRANEOUS CAUSES OF UTERINE BLEEDING
WHEN faced with a case of menorrhagia or epimenor- |
rhea, the average clinician thinks of organic pelvic
disease, whose existence he proves or excludes by pelvic
examination. If he finds the genital tract clinically
normal, the condition is labelled as functional or endo-
crinopathic bleeding, and there the matter may rest.
It is important to realise that there are other causes of
bleeding and that organic disease, if present, may not
necessarily be the primary cause of the hemorrhage.}
Benign myometrial or adnexal lesions can hardly be
considered as primary factors in uterine hemorrhage,
though they may aggravate bleeding by interfering with
hormonal control or the dynamics of the pelvis. It is,
moreover, questionable whether it is fair to blame an
endocrinopathy for all or many of the uterine hemor-
rhages which are attributed to that cause. The influence
1. Frank, I. L. Amer, J, med. Sci. 1946, 210, 787,
SNAGS IN PROTECTION OF PRACTICES
[SEPT 28, 1946
of the central nervous system is well known : fright,
fatigue, sexual excess, change` of environment, or
emotional-shock often lead to irregularities in menstrual
function. The menstrual rhythm may also be disturbed
by physical agents, such as change of climate or of
weather, and the effects of high altitude ; thus waitresses
working on the Jungfrau-joch had to return to lower
levels because of severe menorrhagia. Not only the
pituitary and the ovary but other endocrine glands
affect menstruation. Hypothyroidism in 75% of cases
leads to menorrhagia, whereas hyperthyroidism as æ rule
results in hypomenorrhoea or even amenorrhma. Diabetic
women tend to suffer from ovarian degeneration, but
if stabilised with insulin menstrual function remains
normal. Infectious diseases and upper respiratory
infections such as the common cold, influenza, and
pheumonia may delay the onset of a period.
Blood dyscrasias must also be considered : more than
50% of women with idiopathic hypochromic anemia
have menorrhagia. Essential thrombocytopenic purpura
may be suggested by severe uterine bleeding at the
menarche. Secondary thrombocytopenia from such
causes as malignant disease, leukemia, septicemia,
arsenical poisoning, and X rays and radium must not
be forgotten ; pseudo-hemophilia is a further cause of
menorrhagia, and idiopathic hypoprothrombinemia and
hereditary telangiectases are among the rare—causes.
Deficiency of vitamins B, C, and K has often been
suggested as a possible cause of excessive uterine
bleeding ; and various types of heart disease and chronic
nephritis must not be overlooked. `
The gynecologist confronted with a case of menor-
rhagia should recall that he is not dealing with an
isolated region between the umbilicus and the perineum,
and that curettage and endocrine treatment are not the
final answer for every patient with functional bleeding.
SNAGS IN PROTECTION OF PRACTICES
A CORRESPONDENT complains that, being an insured
person, when his family doctor returns after 7 years in
the Forces he must give up his present doctor for at least
a year, whether he goes back.to. his old doctor or not.
This is quite true. Men who have served in the Forces
expect reinstatement in their jobs when they are released,
and the scheme for the protection of practices is an
attempt on the part of doctors to secure that those of
their colleagues who have been on national service can
return to their jobs on release. Schemes vary in detail,
but broadly speaking they provide that doctors who have
joined—and this covers the great majority of insurance
practitioners—will refuse to accept on their own hehalf
any patients of an absentee doctor until a year after the
absentee’s return or a year after the termination of the
emergency, whichever is earlier. They have agreed that
if a patient of an absentee doctor applies for treatment
they will tell the patient that they will attend only on the
absentee’s behalf. They are also required to display
in their surgery a printed notice intimating that during
the absence of a doctor on Service his patients will be
attended by a home doctor in the neighbourhood and on
the return of the absentee they will be expected to seek
any advice required from him.
If our correspondent has removed from the district
in which his old doctor practised he can transfer perma-
nently to the list of another doctor by using part “ B ”
of his medical card ; otherwise, if he wants to transfer
to another doctor he should ask his old doctor to sign
part “ C ” of his medical card consenting to an immediate
transfer. If the doctor signs—but he is not compelled to
do so—this will absolve other acting practitioners from
their pledge so far as that particular insured person
is concerned. The Medical Benefit Regulations provide
that an insured person may transfer at the end of a quarter
if, not later than the last day of February, May, August,
THE LANCET]
or November, he has given notice to the Insurance
Committee in writing of his desire to transfer, whereupon
he will be entitled to transfer as from the end of March,
June, September, or December next following. but such
transfer can be eftected only if the new doctor agrees to
accepthim. Jfourcorrespondent tries to take advantage of
this regulation, his present doctor will probably tell him that
he must wait until his old doctor has been back for a year.
The protection of practices scheme is supposed to
apply in exactly the same way to private patients, but
these do not hold medical cards and when applying for
treatment they often omit to explain that they are really
patients of an absentee doctor.
~MEGALOBLASTIC ANAMIA IN CHILDREN
AN M14 with high colour-index and large red-blood cells
does occur in infancy and childhood, but the frequencies
of its causes are quite different from those in adult
life. The commonest cause in childhood is nutritional
deficiency, either primary or secondary to ceeliac disease ;
Blackfan and Diamond ! have seen it in acute infections
in infants with temporary achlorhydria; hemolytic
syndromes, like erythroblastosis foetalis and familial
acholuric jaundice, and leukemias are not uncommon
causes. There has been much argument about the
incidence of true pernicious anemia before adult life
and the evidence has been reviewed by Peterson and
Dunn.? They point out that the following criteria are
essential for establishing the diagnosis of pernicious
anemia in childhood: macrocytic anemia, gastric
achlorhydria resistant to histamine stimulation, megalo-
blastic change in the bone-marrow, a specific response
to liver treatment, and the necessity for continued
treatment to prevent a relapse. Examined by this strict
standard, every case but two reported up to 1942 failed
to qualify ; not a few had free HCl in the gastric juice,
others showed no relapse after liver treatment was
stopped, some were clearly nutritional cases, and in
many the evidence was inadequate or rested primarily
on post-mortem changes.
Pohl 4 described the case of a girl of 13 years who was
studied for 4 years and presented all the features of.
pernicious anemia; Dedichen * reported a macrocytic
anæmia in a child of 13 months in whom repeated relapses
were Observed over a period of 3 years whenever liver
treatment was stopped. Peterson and Dunn describe
a case of their own, in a child of 13 months who was
admitted because of diarrhcea and pallor; the red-cell
count was 810,000 per c.mm., hæmoglobin 2 g. per
100 c.cm., colour-index 0-82, white cells 62,000 perc.mm.,
with 90% lymphocytes and 8% “ smudges,” and reticulo-
cytes 14%. It is not surprising that pernicious anæmia
did not figure in their original differential diagnosis ;
the child was transfused and not given liver until 3
months later, when it produced a surprisingly good effect.
The patient relapsed several times; during her fourth
relapse, 3!/, years later, the bone-marrow proved to be
megaloblastic; gastric achlorhydria had been noted
previously. It was found that the girl had an iron-
_ deficiency, and when this was remedied she improved
remarkably and the blood-count became normal. Nine
months later a mild normochromic anzmia was remedied
by increasing the dose of liver extract; the white cells
were then normal and with normal distribution. That
such an extraordinary case should be reported as per-
nicious ansmia emphasises the diagnostic difficulties
that arise in children; yet, apart from the absence of
macrocytosis and the curious lymphocytosis, the case
conformed to all the criteria given above, and the lack
of macrocytosis is attributed to the iron-deficiency.
1. Blackfan, K. D., Diamond, L. K. Atlas of the Blood in Children,
2 puondon, 1944. D Amer J; Di
» Peterson, unn is. Child. 1946, 71, 252.
3 Pon, C.” Mschr. a ieik. 1940, 8 , 192. j :
4. Dedichen, J. Acta med. scand. 1942, HL 90.
MECHANISM OF PAIN
[sepr. 28, 1946 461
Davis ë has described 3 cases of macrocytic anzemia
in children. The first was in an underdeveloped girl of
13 years who had a megaloblastic marrow and, at first,
free acid in the gastric Juice; she was treated, but 3
years later was seen in a relapse when she had achlor-
hydria and responded to a purified liver extract used
for treating pernicious anenia; it is clear that had she
been seen for the firat time at the age of 16 she would
have been regarded as a case of pernicious anemia. His
second patient was a boy of 14 years who had achlor-
hydria and megaloblastic marrow; a purified liver
extract was ineffective, but proteolysed liver by mouth
and a crude liver extract parenterally produced a
remission after which no further treatment was needed.
The third patient, a girl of 3 years, resembled the second,
but gastric acid secretion was present. Neither of these
patients would be classified as pernicious anzmia.
Recently Zuelzer and Ogden * in Detroit have drawn
attention to a macrocytic anæmia in infants aged up to
18 months that they found to be quite common, and
they give details of 25 cases. The bone-marrow, aspirated
from the femur, was typically megaloblastic, gastric
achlorhydria was present in some; the anæmia was
severe and clinically the patients had pallor, fever,
vomiting, diarrhoea, and sometimes petechis. All
except 5 of the infants responded rapidly to liver extract
or to folic acid, and so far these have not relapsed; the
5 exceptions died from complications, mostly infective.
From all this evidence it can be deduced that a macro-
cytic anxmia with megaloblastic change in the bone-
marrow is fairly common in infancy and childhood. It
should be distinguished from other forms of macrocytic
anzmia, since most of the patients respond to liver
extracts; ordinary crude extracts should be used and
not the purified extracts specially designed for thg
treatment of pernicious anzmia, like ‘ Anahæmin ’
Zuelzer and Ogden’s results suggest that it will be
worth while to try folic acid for these patients. It is
doubtful whether true relapsing “pernicious anzmia of
adult type does occur before puberty, and the outlook
for the children who seem to have the disease is relatively
good, since they nearly all show a lasting response to.
liver, and if they weather the original crisis they will
recover permanently. It seems reasonable that the name
“ megaloblastic anzmia,” which describes the main
diagnostic features of the disease without confusing it
with pernicious anæmia, should be adopted.
MECHANISM OF PAIN
In his founder’s lecture at the annual congress of the
Chartered Society of Physiotherapists on Sept. 14,
Prof. G. W. Pickering spoke of the pain mechanism in
man as consisting of three essential parts: the sensory
nerve-ending or receptor, the nerve-fibre or conductor, |
and the brain or cortical analyser. Receptors were very
numerous in the skin and liberally provided in the deep
fascial and muscular structures, but rather few in the
subcutaneous tissues. The parietal layers of the serous
membranes were well supplied, but the visceral layers
and the viscera themselves not at all, though perhaps
there was some evidence that the pains of angina and
peptic ulcer do arise directly in the organs concerned.
Periosteum and ligaments were sensitive, spongy bone
slightly so, compact bone and joint surfaces insensitive ;
arteries possessed more receptors than veins, and the
meninges were profusely studded with them, whereas
the brain itself had none.
The tissue changes which produced Bx ation of these
receptors might be physical, a deformation of surface
producing alteration in configuration and tension ;
or chemical, like the pain of claudication due to the
accumulation of metabolites in muscle-fibres, popug:
Davis, L. J. Arch. Dis. Childh. 1944, 19, 147.
` Zuelzer, W. W., Ogden, F. N. Amer. J. Bis, Child. 1946, 71, 211-
462 THE LANCET] |
ulcer pain from stimulation by acid, and the continued
pain of burns. It was the analyser’s function to receive
these impulses after transmission, to relate them to past
experiences, and to form an image for purposes of
description. Sir Thomas Lewis had shown that the
quality of pain arising in the skin surface was always
the same whether the stimulus was pinching, pulling,
or burning. With the skin anesthetised and the deeper
structures stimulated, the subject could always tell
that the pain was not arising in the skin though he could
not localise it to fascia or bone. Thus, from the point
of view of quality, there were only two kinds of pain—
one from the skin, and one from beneath the skin.
Visceral pain was not distinguished in quality from liga-
mentous or muscular pain, and any other “ qualities ”
were due only to mental associations and could be
excluded by eliminating visual and other factors. The
intensity of a~pain was largely determined by the
behaviour of the analyser. Hence the racial range of
susceptibility, the emotional influence which produced
the painless mutilations of religious ecstasy and the
exaltation of pain by apprehension, and the effects of
suggestion on the state of inhibition or excitation of the
cortical analyser. It was interesting to speculate how
much the beneficial results of physiotherapy were due
to such suggestion. One of the most fascinating problems
of pain was the phenomenon of reference. Skin pain
was accurately localised, while visceral pain was not. It
was to explain the fact that visceral pain did not corre-
spond closely to the organ of origin that James Mackenzie
introduced his conception of the viscero-sensory reflex
with enhanced excitability of the particular cord-seg-
ment involved. More recently, Kellgren’s! work on the
segmental reference of pain excited from the interspinous
ligaments had thrown further light on the whole subject.
In a sense, said Professor Pickering, it might be
more reasonable to ask why pain was so well localised
in the skin at all, rather than why visceral pain was
referred. The answer probably lay in the increasing
knowledge and experience gained by the cortical analyser
in development, an education associated with visual
knowledge of events in local areas of the body surface.
This educability of the analyser was well shown in the
fineness of touch acquired by the blind. With the
deeper structures such an education was obviously
impossible ; there was much less correlation with outside
influences, and the pain was felt over a wide area
determined by the segmental nerve-supply.
PLAGUE VACCINE
During the last half century over forty million doses
of plague vaccine have been issued by the Hafikine
Institute in Bombay. These have been used in different
parts of India whenever plague has appeared in epidemic
form and it is claimed that thereby several million lives
have been saved. The method of preparation of this
vaccine has varied from time to time, especially in the
last fifteen years, but during most of this period a broth
vaccine killed at 65° C, as first introduced by Haffkine,
was used ; later, lower temperatures were used for killing
the organisms.
The claim for the prophylactic valne of this vaccine
was based first on animal experiment, and then on the
extensive field experience in the plague-stricken areas in
India and elsewhere in the East. Statistics collected in
India indicated that the vaccine reduced the chances of
exposed persons becoming infected to a quarter and the
chance of dying of plague to an eighth of what they would
otherwise have been, whereas in Java it was claimed that
the infection-rate was reduced to a third or a half. In
1907 Strong, working in the Pbilippines, used living
avirulent vaccine with success, but he did not pursue
this line of work because of the practical disadvantages
1. Kellgren, J. H. Clin. Sci. 1939. 4. 35.
_ THE BASIC NURSING COURSE
(serer. 28, 1946
of such a vaccine, and nearly forty years later his opinion
on its impracticability on a large scale is unchanged.
The value of the Haffkine vaccine began to be questioned
iv the early 1930s. Figures from Madagascar, Central
Africa, and elsewhere seemed to indicate that the vaccine
was useless, and the methods of obtaining the data on
which the favourable claims had been based in India
were severely criticised by statisticians. This led to a
reinvestigation of the living avirulent vaccine, more
particularly by Girard and Robic in Madagascar in 1933
and in the following year by Otten in Java. Animal
experiments reveal a much higher protective value for
the living vaccine than is ever obtained by killed vaccine ;
ten million doses were given in the Dutch East Indies
up to 1941 without producing a single case of plague, _
and a tenfold reduction in the death-rate from plague
was reported in those vaccinated.
It is now generally agreed that the living avirulent
vaccine ig more efficacious than any killed vaccine, and
only the difficulties of its preparation and distribution
have prevented its general adoption. The dangers
inherent in the preparation of a living vaccine, especially
in tropical countries, are obvious. There is apparently
no danger that these avirulent organisms will regain
their virulence, but if the vaccine is kept too long it
loses its protecting property. The safe limits are between
the 5th and 15th day after preparation ; this is far too
short a period to allow distribution in a large country
such as India or among the far-flung fighting forces of
the United States in the late war, to take two examples.
The U.S. Services therefore used a killed vaccine, and
they chose one containing 2000 million organisms per ml.,
of which 0-5 ml. was given as the first dose followed by:
1-0 ml. a week to ten days later; ‘‘ booster’ doses of
1-0 ml. were given periodically when the ee from
infection was imminent.
THE BASIC NURSING COURSE
WE have often put the case for a two-year course
in practical nursing for all entrants to the nursing
profession, to be followed—for those who wish to apply
for senior posts or to specialise—by a much. stiffer
training, demanding a higher standard of theory than the
present curriculum. We believe this would have the
double advantage of reviving interest in nursing tech-
nique and research, and of developing to the full the
abilities of every type of student, whether her bent is
practical or academic or both.
It is encouraging to learn that the County Councils
Association have now endorsed this policy. The Public
Assistance Journal! announces that the association’s
executive council has accepted the following resolutions
previously passed by the Association a County Medical
Officers of Health :
1. There should be a basic training of two years for all
nurses, some of which period should be spent in nursing the
chronic sick. The training should be essentially practical.
. After that training and on passing their appropriate exa-
minations, the designation should be ‘‘Qu Nurse.”
.A substantial number of nurses should receive further
training in order to qualify them for positions of ward
sister and higher. The appropriate designations to be
settled later.
The proposal that every nurse should spend some time
with chronic patients is particularly valuable, for it is
precisely where the doctor and surgeon can do least
that the nurse can do most. She should be encouraged
to recognise and use her important oppor for
improving our care of such patients.
w N
Dr. T. WATTS EDEN, consulting obstetric physician
to Charing Cross Hospital, and consulting surgeon to
Queen Charlotte’s Hospital and the Chelsea Hospital for
Women, died on on Sept. 22 at the age of 83.
1. Sept. 6, p. 693. a
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Special Articles
WORLD PROBLEMS OF NUTRITION
F.A.O. CONFERENCE AT COPENHAGEN
FROM OUR CORRESPONDENT
Tue Food and Agriculture Organisation held its second
annual conference at Copenhagen from Sept. 2 to 13.
Its principal work was to consider the proposal of the
director-general, Sir John Boyd Orr, F.R.S., for the
establishment of a World Food Board. This board would
attempt to stabilise prices of agricultural commodities
in the world market, providing the necessary funds ;
to establish a world food reserve equipped for any
emergency that might arise through failure of crops in any
part of the world ; and to coédperate with organisations
concerned with international credits for industrial and
agricultural development and with trade and commodity
policy. The conference appointed a commission to sit at
once and draw up a detailed plan for the board. This is
to be submitted to an adjourned meeting of the conference
early next year.
The standing advisory committee on nutrition, whose
chairman is Lord Horder, in its first report to the director-
general recommended governments to keep a careful
watch on the food situation in their countries, for which
purpose, it says, diet surveys are of great value in assessing
dietary defects and formulating food-supply requirements.
F.A.O. should ask nutrition experts in the various
countries to study the methodology of diet surveys with
the ultimate aim of securing comparability of results
and perhaps evolving standard types of survey. On
school feeding the committee recommended that F.A.O.
should study school-feeding programmes in different
countries, covering all ages, with reference to the type of
food-supplies, organisation, cost, and effects on health.
Information about successful methods of school feeding
may assist governments to develop satisfactory pro-
grammes, particularly where school feeding has not been
organised. - ,
The committee laid stress on the need for studying
milling, processing, fortification, and preparation of
cereals in relation to nutrition. It suggested that F.A.O.
should study a number of staple cereals, such as wheat,
rice, maize, and rye, to ascertain the effect of these
operations on their nutritive value. The relation between
extraction-rates and vitamin-B, content of wheat calls
for investigation. The “ fortification ’’ of wheat-flour or
bread includes the addition of vitamins, calcium salts,
skim-milk, and other kinds of flour, such as soya-bean
flour. Information about the methods adopted by
different countries for conserving or enhancing the
nutritive value of wheat-flour would be of value to other
countries. Parallel problems of rice-processing should
also be examined. Highly milled raw rice is poor in
vitamins, notably B,, and investigation is needed to
decide which methods—e.g., under-milling, parboiling,
and enrichment—are likely to be most satisfactory in
the rice-eating countries. The effect of household
methods on the nutritive value of rice should likewise be
studied ; for instance, the washing of raw rice may remove
a considerable proportion of certain nutrients. There
seems to be a relation between the processing of maize
and the incidence of pellagra ; the F.A.O. nutrition pro-
gramme should therefore include a survey of the methods
of milling, processing, and preparing maize.
Perishable foods, such as milk, vegetables, and fruits,
also call for special attention if their nutritive value is to
be safeguarded ; and further study is required on the
utilisation of whole-fish meal and the inclusion in canned
meat of ground fresh bone.
EDUOATION IN NUTRITION
This subject has three main aspects: (1) the training
of specialised workers ; (2) the instruction of persons able
to help in the campaign for improving nutrition ; and (3)
the education of the people with the object of improving
their dietary habits. In studying and attacking nutrition
problems the lead must be taken by a “‘ core ” of speciali-
sed nutrition experts. To accelerate progress systematic
‘WORLD PROBLEMS OF NUTRITION
[sEPT. 28, 1946 463
instruction in food and nutrition, both theoretical and
practical, must also be given to inistrators, agri-
cultural experts, food technologists, teachers, nurses,
and social workers. The committee agreed unanimously
that the teaching of nutrition in various curricula,
especially medicine, is unsatisfactory. University
authorities and others concerned with higher education
should give nutrition a place in their curricula in
keeping with its importance. The position of the doctor,
the committee point out, is unique: his opportunities
of teaching and applying the principles of nutrition are
unequalled by those of any other member of the com-
munity. His training in nutrition should therefore be
thorough, and progress is not likely to be made here until
nutrition holds a conspicuous place in the medical curricu-
lum approved by the statutory bodies which control it
in the various countries. The principles of nutrition
should be inculcated in the child at home and at school,
and for the teaching of sound dietary habits to children
school feeding is useful. Similarly, the organised feeding
of workers is a valuable means of teaching adults. i
The education of housewives is of great importance,
and one means of providing it is through courses in
domestic science, which should be introduced in countries
where they do not exist. Voluntary groups, properly
guided, can do a good deal to spread a knowledge of
nutrition among the general public. Advertisements
educate the public, and therefore advertisement of the
nutritive value of food products should be controlled.
In countries deficient in food the emphasis in education
should be laid on the best means of utilising
available supplies ; in those with a surplus the need for
consuming diets of the highest standards should be
stressed. m
The war experience of countries with comprehensive
control plans—amounting almost to large-scale human
feeding experiments—contains valuable lessons.
NATIONAL COMMITTEES
At the outbreak of the war national nutrition com-
mittees or councils existed in over thirty countries, many
as a result of stimulus by the League of Nations. Only
a few of these are still effective. The committee recom- `
mended, therefore, that a comprehensive report should
be prepared on their present situation. Such committees
may be identical with the F.A.O. national committees,
but in many countries this is neither possible nor
desirable, though the two committees should be closely
associated. The nutrition committees must be guided
by trained nutrition workers, have adequate facilities
and financial support for research, and be able to influ-
ence their governments. They must have the coöperation
of governmental and other agencies—e.g., ministries,
labour unions, domestic science organisations, and
charitable societies—that are anxious to improve the
nutrition of the population and possess the necessary
means and personnel. Besides merely urging govern-
ments to establish committees F.A.O. should study
realistically the conditions necessary for their satisfactory
operation. . l
F.A.O. must know where to seek effective collaboration
from nutrition organisations and workers, and an index
of these throughout the world should be prepared. The
staff of the nutrition division should establish contact
with workers in various countries.
Nearly all practical nutrition problems will also
concern the World Health Organisation. The committee
recommends that a joint nutrition committee should
be set up between the two bodies, which should consult
together about the choice of their nutrition staff.
NUTRITIONAL STANDARDS
The nutrition committee of the conference, which has
some common membership with the standing advisory
committee, accepted its recommendations and suggested
certain directions in which they could be implemented.
It pointed out, for instance, that the expression of food
commodities in terms of nutrients requires the use of -
appropriate tables on food composition. This does not
mean a single international figure for each food, for there
are real differences in the nutritive value of foods in
different parts of the world. Nevertheless, the values
used by countries in preparing statistical material for
international consideration should be derived by com-
464 THE LANCET]
parable methods and represent the nutritive value of |
food at the same stage in the flow from the farm to the
mouth of the consumer. - Most of the data now available
= on the nutritive value of foods refer to products as brought
into the household (retail level) and provide information
on the proportion of inedible material and the moisture
content and nutritive value of the edible portion at this
. stage. The nutrient content of the edible portion may
‘be considerably higher than that of the same portion of
food “ as eaten,” because of waste and nutritive losses—
both visible and invisible—during household storage,
preparation, and serving of foods. Data on the composi- _
tion of food as eaten will ‘be increasingly necessary as
correlations are sought between the results of dietary
surveys and appraisals of the nutritional status of
individuals and population ‘groups. Accordingly the
nutrition committee recommended that F.A.O. should
arrange for joint consultation of experts in nutrition and
food statistics from various countries who should develop
the principles on which average food-composition figures
- used by individual countries should be based, and explore
the means whereby comparability of data for international
use can be attained, including, if necessary, the revision
of tables now used for this purpose.
UTILISATION OF CEREALS
In addition to the study of the preparation of cereals
recommended by the standing advisory committee, the
nutrition committee draws attention to a broader aspect
` of the question : the utilisation of cereals, cereal products,
and other plant products as human food or animal
feeding-stuffs in such a manner that the nutritional
needs of the population shall be best met. The best
method of utilisation will differ in various countries,
depending on the nutritive value of the cereals and
products in question, the efficiency of their conversion
by animals into human food, the relative cost of plant
and animal products and their acceptability to the
consumer, and the nutritive value of the diet of the
population, particularly of the low-income groups. The
committee accordingly recommended that F.A.O. should |
study the best utilisation of plant products for human
consumption, either directly or through the animal ;
and the most economical and satisfactory balance between
the production of meat and milk and between poultry-
meat and eggs. Such studies would assist governments
to plan their food policies so that food-production would
be adapted to the physiological requirements of the
people.
Rapid progress has been made in recent years in the
chemical and microbial synthesis of foods and nutrients,
such as yeast, fats, and vitamins. It is highly important
that synthetic processes which may contribute to the
improvement of nutrition and the alleviation of food
shortage and dietary deficiency should be investigated
and, if found advisable, their development stimulated.
The committee heard a report from a representative of
the forestry committee on the possibility of obtaining
food by the saccharification of wood, and considered
that the question of using saccharified wood for the
production of food yeast should be further explored.
The committee pointed out that the national nutrition
organisations recommended by the standing committee .
must be adapted to the governmental machinery of each
country. Countries which contain a number of com-
ponent units, such as federated states or self-governing
communities, are urged to establish a central repre-
sentative nutritional organisation. It recorded its
opinion that the scientific evidence at present available
does not indicate that, given similar environmental
conditions, the physiological requirements of food for
optimal growth, health, and physical efficiency are
different for the peoples in the various parts of the world.
It stressed the urgency of investigating food-supply
targets. |
The conference accepted both reports and passed them
to the secretariat for action. The immense amount of
correspondence, digestion, recording, and circulation
which they involve is only a fraction of the whole work
ofthe permanent staff of F.A.O.
THE OUTLOOK
An observer cannot help asking to what extent, when
these voluminous surveys and advisory documents come
BRITISH-SWISS MEDICAL CONFERENCE
[sePr. 28, 1946
into the hands of governments and other bodies in
various parts of the world, their precepts will be put into
practice, and how much of them will be neglected or
suppressed. Though some of the less controversial
advice may be followed, what weight will they. carry
when they conflict with political tendencies and com-
mercial or national interests ? Though the secretariat
has done wonders in a short time, this vast programme of
work must necessarily take years to execute. Even the
World Food Board, the urgent need for which is admitted
by all, cannot possibly under the most favourable
conditions come into activity before next summer, and
if the blue-print of the preparatory commission excites
substantial controversy, its establishment must be
correspondingly delayed. World events already move
with dreadful speed, and that speed is accelerating. The
obvious danger is that they will outstrip the organisa-
tion’s good intentions and heroic work. __ ao
BRITISH-SWISS MEDICAL CONFERENCE
(Concluded from p. 431) Ea
PHYSIOLOGY OF THE KIDNEY IN INFANCY
= Prof. R. A. McCance (Cambridge) said that before
birth the internal environment can be satisfactorily
regulated by the placenta; indeed babies, normally
developed in other ways, may be born with functionless
urinary tracts. Little is known about the function of
the kidney before birth ; but it has been proved that the
kidney of the newborn infant does not immediately
assume all the functions it will perform in later life.
The non-protein nitrogen of the blood may be higher
for a few days after birth than later, and the uric acid
in particular is raised. The serum shows signs of acidosis
and may contain very high concentrations of potassium.
In infants under 3 months, as in other young mammals,
water is excreted less freely than at a later age. After
the age of 1-2 years the urea-clearances of children are
of the same magnitude as those of adults. A baby’s urine
is never highly concentrated ; in the first few days of
life the specific gravity averages 1012-1015, and the
osmotic pressure 450 milli-osmols per litre, and in the
later weeks and months the urine is usually very dilute.
Even when an infant aged 14 days is deprived of water
and the urine volume falls, concentrated urine is not
normally produced; nor is the infant’s normal dilute
urine concentrated by injections of posterior pituitary
hormone. It has been demonstrated, however, that a
hypertonic urine is excreted, even by premature infants,
if the salt-intake is sufficiently increased ; these hyper-
tonic urines are not a sign of good renal function.
Infants respond to the intravenous injection of sodium
chloride (1 g. per kg. body-weight in 10% solution) and
the oral administration of urea (1-7 g. per kg. body-weight
with a minimum of water) by showing a moderate
diuresis, a rise in the urinary osmotic pressure, and
(despite this) a poor elimination of the test dose; the
responses are obviously complicated, but it is clear that
the normal infant’s kidney can be very. ineffective in
the early days of life. In babies the glomerular filtration-
rate is less than half that in adults; in the human
infant, as in some other mammals, the rate depends on
hydration, and quite mild dehydration may cause gross
abnormalities in the serum chemistry, so that renal
damage may then be erroneously diagnosed. Urea-
clearances of infants in the first 14 days of life are far
below those of adults when compared on the basis of
surface area; on the whole the clearances probably
vary with the minute volumes of the urine. The clearances
approach adult level towards the end of the first year.
These findings are supported histologically by the tall
columnar cells which cover the glomerular tuft in
foetal life; these cells prove an effective barrier to
ultrafiltration and are replaced by the thin pavement
epithelium found in adult life. The excretion of diodone
has recently been found to be very low in babies a few
days old, and the creatinine clearances to be no higher
than the inulin clearances. The ability to form and excrete
ammonia, however, seems to be fully developed at birth. |
Sodium, potassium, and chloride clearances are all
lower in the infant, and especially the premature infant,
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BRITISH-SWISS MEDICAL CONFERENCE
[sEPT. 28, 1946 465
than in the adult, which explains the premature infant’s
liability to cedema; thus the premature infant should
not be given much sodium chloride. The administration
of 0-9% saline as a source of fluid for a baby is bad
therapy, since it presents the kidney with the task of
excreting a hypertonic solution—a task it can perform
only if the serum has already become grossly abnormal.
HIGH ALTITUDE IN THE TREATMENT OF TUBERCULOSIS
Dr. J. E. WOLF (Davos) regretted that the develop-
ment of collapse therapy has led to a certain neglect of
climatic treatment at altitudes of 4000-6000 feet.
Climatic treatment can plainly never completely replace
surgical collapse therapy, particularly for the cavitating
form ; indeed high-altitude treatment increases the scope
of surgery, since the patient may be made fit for collapse
therapy by first having this conservative treatment.
Recent statistics have shown the advantages of continu-
ing both methods. Tuberculosis must be treated as a
general disease with local manifestations. The mechanism
by which high altitude helps to increase immunity is
not clear; a mountain climate, though it stimulates
body metabolism, also has a certain sedative action; it
has, moreover, a stimulating psychological effect.
Four climatic factors benefit the body’s biological
reactions: (1) diminution of atmospheric pressure ;
(2) ultraviolet radiation; (3) dryness of the air; and
(4) diminution of the cooling power. The metabolism
of respiration, circulation, and hemopoiesis are certainly
stimulated; but there is evidence that pathologically
increased metabolism—for example, in Graves’s disease
—is reduced at altitudes of 4000-6000 feet. Similarly
the increased basal metabolism sometimes associated
with tuberculosis is reduced at the same time as the
increased blood-sedimentation rate and blood-globulin
are lowered. it has also been shown that thyroxine
injected into animals at high altitudes has only a quarter
to a tenth of the effect that it has in the lowlands. The
influence of altered vitamin metabolism must also be
considered; at high altitudes the blood-cholesterol
increases, no doubt because of the intense ultraviolet
radiation. When the blood-cholesterol rises there is
an associated increase in the blood vitamin A. Both
vitamins influence tuberculosis; when vitamin A is
deficient, the incidence of infection rises. At Davos it
has been found in tuberculous patients that the blood
vitamin A is decreased, the diminution varying with the
gravity of the infection. It has also been shown that in
the first few weeks after the change to a high altitude
the vitamin A and D values increase together, even with
cavitating disease, provided there, is still a possibility
of reaction. Some of the benefit from high altitude
may be derived from its effect on the vegetative nervous
system and from its encouragement of blood acidosis,
in place of the alkalosis usually associated with
tuberculosis. | g
The clinical results of high-altitude treatment have
shown that it is strongly indicated in almost all forms
of surgical tuberculosis. With pulmonary tuberculosis
cases must be more carefully selected; the treatment
should not be adopted where the general condition is
grossly impaired or the lung-area greatly reduced. All
other forms and stages of pulmonary tuberculosis are,
generally speaking, suitable for the treatment; it is
sometimes contended that the exudative forms should not
be submitted to high altitudes, but in Dr. Wolf’s view
this is a mistake. ; |
CELLULAR ADAPTATION TO EFFORT, ALTITUDE, AND
- OXYGEN DEFICIENCY SRS
Prof. ALFREDO VANNOTTI (Lausanne) pointed out
that the effects of severe muscular effort’ and exposure
to high altitudes are, in most respects, the same. The
muscle persistently submitted to effort reacts by dilata-
tion of reserve capillaries, the formation of anastomoses,
and later possibly the formation of new capillaries ;
this capillary adaptation is probably related to effort-
acidosis. The myoglobin content in muscles submitted
to 2-3 weeks’ daily faradic stimulation is 10-35% more
than in control muscles. It is now held that cellular
respiration is regulated by two catalytic systems. One,
made up of pigments based on hzmins, activates the
arterial oxygen ; while the other is based on the activity
of hydrogen transporters, the deshydrases, and is largely
- below or above the knee.
(4) there is no redundant soft tissue ;
built up from the vitamins of the B group. With acute
effort the muscle-content of dissociated iron increases,
while with chronic effort there is a rise in muscle oxydase,
myoglobin, and cytochrome C. With acute effort there
is increased utilisation in the muscle of aneurine, ribo-
flavine, and nicotinic acid; but when hypertrophy
ensues from chronic effort, there is a rise in the muscle
content not only of myoglobin but of oxydase, cyto-
chrome, active iron, and vitamins of the B group.
Ascent to high altitudes results immediately in a
temporary increase in red blood corpuscles, attributed
by Barcroft to splenic contraction; then often the
number of red cells falls rapidly, apparently through
hemolysis. Regeneration follows, with reticulocytosis
and the formation of macrocytic red cells, rich in iron.
Hemoglobin and more especially myoglobin levels
continually rise; but whereas hemoglobin has been
observed to be formed with radioactive iron 6-8 days after
injection, myoglobin and cytochrome are not synthesised “
with it until after 3-4 weeks. The organism’s adaptation
to high altitudes is thus slow; the initial hemolysis
can be attributed to an attempt to mobilise iron for the
rapid synthesis of cellular hemins. With stay at high
altitudes the spleen enlarges and there is some hyper-
trophy of the adrenals, especially of the adrenal cortex. . :
. AMPUTATIONS |
Mr. GEORGE PERKINS (London) said that to satisfy
_ the needs of the limb-maker it may be necessary to
perform two operations—a provisional amputation
followed later by a definitive one. The provisional
amputation should be performed as low as possible,
since the wound will probably not heal without infection ;
there is no need to go above the level of existing infection.
The technique does not differ from that in the definitive: |
operation, except that the deep fascia and skin are not
sutured. Healing is quicker if the skin-edges are sewn
together for 2 cm. in the centre so as to cover the raw
end of the bone; but even this partial closure may not
be safe with recent infection. For the definitive amputa-
tion primary healing should, ideally, be assured; but
it may be necessary to accept the risk of infection from
a terminal ulcer. Experience from the first world war has
shown that end-bearing stumps do not last; the circula-
tion in long stumps, moreover, often becomes defective.
The sites of election now favoured by the Ministry of
Pensions’ surgeons are below or above the elbow, and
The short stump, though -
desirable, must be long enough to remain inside the
socket of the prosthesis when the joint above is —
placed at a right-angle, and long enough to contain
the insertion of the muscles that control the joint.. A
below-knee stump should measure 10-14 cm. from the
knee-joint to the end of the tibia, and an above-knee
stump 28 cm. from the top of the great trochanter to
the end of the femur. At Roehampton the Syme amputa-
tion has been condemned, owing to the difficulty of
fitting a comfortable prosthesis, which in any case is
unwieldy compared with that fitted after a below-knee
amputation. The optimum length for a below-elbow
stump is 18 cm., measured from the tip of the olecranon
to the end of the ulna, and for an above-elbow stump
20 cm., measured from the acromion process to the end
of the humerus. The technique for definitive amputation
is based on two considerations—the operation is per-
formed by all manner of surgeons, and the needs of the
limb-fitting surgeon must be met. The ideal criteria
for the stump are: (1) the scar is not exposed to pressure ;
(2) the scar is not adherent ; (3) the skin is not infolded ;
(5) there is no
projecting spur.of bone; (6) the stump is not tender ;
and (7) the wound heals by first intention. After the
operation the limb must be prepared ‘to receive the
prosthesis by shaping the stump, strengthening the
muscles, regaining movement at the joint above, and
reconnecting the brain to the stump. Finally, the
patient must be taught to use the prosthesis. .
CAROTID LIGATION IN INTRACRANIAL ANEURYSM |
Prof. H. KRAYENBUHL (Zürich) emphasised the
differences of opinion on the safety of carotid ligation.
He has undertaken the operation in 35 patients, ligating
in each case the common and internal carotid arteries,
with more or less extensive periarterial sympathectomy ;
466 THE LANCET]
BRITISH-SWISS MHDICAL CONFERENCE
[serr. 28, 1946
usually the artery has been compressed by hand for
20 minutes on the day before operation. Recurrent
subarachnoid hemorrhage has been the most common
indication for operation. The results with infra- and
supra-clinoid arteriovenous aneurysms have been uni-
formly good. Of 20 patients submitted to operation for
bleeding supraclinoid saccular aneurysm, 6 died ; amon
the 24 patients with saccular infra- and supra-clinoi
aneurysm, postoperative flaccid hemiparesis has occurred
in 4; but in 3 of these the disturbance has cleared
. almost completely.
PRIMITIVE TUBERCULOSIS, PRIMARY INFECTION, AND
‘6 PREMUNITION ”’ l
Prof. E. GRASSET (Geneva) recalled that tuberculosis
is seen in virgin stocks in its original uncomplicated
forms. Primitive stocks may be attacked by acute
infection at any age; indeed its spread may assume the
form of an epidemic. Usually this type of infection
results in early death. It may be spread by the lymphatic
system from a primary focus in the lung; or the lymph-
glands may be infected. In other patients the primary
focus in the lung is the principal lesion, resulting in
rapidly progressive pulmonary disease, and terminating in
caseous bronchopneumonia or secondarily disseminated
pneumonia. In some the spread of infection may be
temporarily checked in the tracheobronchial lymph-
glands. Pulmonary infection can be evaluated only by
radiography ; quite advanced lesions may be associated
with few symptoms and no signs on auscultation, a:
‘good general condition, and a negative sputum. The
lesion sometimes spreads through the lung in a compact
mass; but it may spread rapidly in wide zones of one
or more lobes. In children, and in some adults, the
tracheobronchial lymph-glands are greatly enlarged,
and the submaxillary and cervical glands may be grossly
swollen and tender; in other cases all lymphatic glands
are affected. After several weeks of this first phase,
the infection enters a new and dramatic stage, with a
gradual rise of temperature or sudden rigors and
profound toxemia. The picture becomes more clearly
one of pulmonary infection, with cough and increasing
expectoration; and a lobar or broncho-pneumonia
may be simulated by the profuse, often bloodstained
sputum, which, however, contains numerous tubercle
bacilli. With rapid spread and cavitation, the condition
deteriorates rapidly and the patient may die within 3
months, death often resulting from repeated or massive
hemoptysis and occasionally from meningitis. Necropsy
shows that the lesions are mainly exudative with little
or no fibrosis; in the same lung there may be different
forms, such as massive caseous pneumonia in one lobe
and fine nodules in the other. Elsewhere, as in the spleen,
similar caseating lesions are found; and the larynx,
pharynx, and intestinal tract may be ulcerated. This
process is to some extent comparable to the juvenile
type of infection seen after primary infection in some
European children. In Europe today the acute, rapidly
fatal, exudative type of lesion is unexpectedly common
among the war-stricken populations. The best hope of
control lies in ‘‘ premunition’’ with B.C.G. vaccine or
the vole-bacillus vaccine of Wells. ,
ARTERIAL INJURIES ~
Mr. J. J. MASON Brown (Edinburgh) divided arterial
injuries into those that arise indirectly from a missile
passing through nearby tissues, with arterial contusion
and traumatic arterial spasm ; and those in which the
vessel is wounded directly by the projectile. The purpose
of treatment is to restore the peripheral circulation, or,
if this is impossible, to promote the development of a
collateral circulation. Moreover, the limb must be so
placed as to minimise the effects of ischæmia while the
blood-supply is still depleted. The lumen may be restored
by vein grafts or artificial cannulæ, followed by heparini-
sation. For success the circulation must be restored
soon after the injury ; later restoration may result in ful-
minating toxæmia through the absorption of products of
disordered metabolism from the previously ischæmic limb.
It should be realised that, though the peripheral pulses
may be impalpable, there may still be sufficient flow of
blood through the injured vessel to maintain the limb’s
nutrition until collateral circulation has developed.
Primary surgery will abruptly interrupt the circulation ;
initial treatment should, wherever practicable, be con-
servative, to allow time for the development of collateral
circulation, though a traumatic aneurysm often develops.
The type of operation must depend on an assessment of
the condition discovered at the operation ; simultaneous
ligation of the accompanying vein should be undertaken
in primary surgery or in operations performed before
the collateral circulation is established. Sympathectomy
or sympathetic block, though of value in emergency
ligations, is unnecessary when the collateral circulation
is established. With false aneurysms hemorrhage at
operation should be controlled by a tourniquet; but in
operations on aneurysmal varices no tourniquet should
be used. When a tourniquet cannot be used it is impor-
tant to gain control of the artery above and below the
lesion. An intravenous drip should be set up before the
operation is begun, and fresh blood should bë at hand. —
Secondary hemorrhage, thanks to the sulphonamides
and penicillin, is now a rare complication. After operation
the limb should be placed about 6 in. below the heart-
level and constricting bandages should be avoided; a
sterile towel is a suitable covering. The limb can be
exposed to room temperature. Venous stasis can be
avoided by raising the head of the bed. Care of the skin
is essential. | |
EXPERIMENTAL DIABETES MELLITUS
Prof. F. G. YOUNG, D.sc. (London), said that the central
problem of the cause of diabetes remains unsolved. The
effects of pancreatectomy on carbohydrate metabolism
are much more pronounced in carnivorous than non-
carnivorous animals; the resultant diabetes can always
be controlled by insulin. The influence of the pituitary
gland is exerted largely by the secretions of its anterior
part; but the posterior lobe also exerts a significant,
though ill-defined, influence on carbohydrate metabolism.
It is possible that the posterior pituitary secretion acts
by influencing the secretions of the anterior part in the
same way as adrenaline affects the adrenal cortical
secretion. The diabetic condition in the dog during
continued administration of anterior pituitary extract
differs from that following pancreatectomy in that it
is extremely unresponsive to insulin and is associated
with increase in body-weight and nitrogen-retention ;
moreover, the liver glycogen is high rather than low.
There is experimental evidence of an antagonistic action
between insulin and anterior pituitary extract. In dogs
a permanent or so-called metahypophyseal diabetes has
- been produced by large amounts of anterior pituitary
hormone ; here irreparable damage is done to the insulin-
secreting mechanism of the islets of Langerhans owing
almost certainly to oyer-work under the influence of the
pituitary extract. The growth-promoting factor of the
anterior pituitary also inhibits carbohydrate oxidation.
Diabetes can be produced by the intravenous injection
of alloxan, which causes acute necrosis of the islets of
Langerhans, possibly through over-work exhaustion.
Dietetic experiments suggest that the major cause of
diabetic ketosis is a high-protein intake of meat rather
than fat. Anterior pituitary extract occasionally stimu-
lates regeneration of the insulin-secreting cells, but it is
not yet possible to apply this therapeutically. The effect
of cestrogen has been tried, in view of its known capacity
to depress the gonadotropic factors of the anterior
pituitary ; oestrogen is, in fact, effective in alleviating
postmenopausal diabetes, but there is no evidence that
it exerts a direct action or that the action is mediated
by the anterior pituitary. i
Human diabetes is not a single syndrome with one cause.
Some hold that the diabetic diathesis is inherited as a
recessive mendelian character, and that the incidence of
the condition has risen since the latent islet defect
was revealed, because of the opportunities for consistent
over-eating under conditions of modern civilisation. The
anterior pituitary is almost certainly concerned in the
origin of some cases; under certain conditions other
glands, including the adrenals and the thyroid, may be
implicated.
EXPERIMENTAL RADIOTHERAPEUTICS .
Dr. J. S. MITCHELL (Cambridge) ascribed recent addi-
tions to our knowledge of the therapeutic action of X and
gamma radiations largely to the influence of cytology
and cytochemistry, genetics, and radioactive tracer
methods. There is now a better understanding of the
+
of health workers.
THE LANCET]
significance of chromosome breakage and of the depen-
dence of the biological efficiency of different radiations
on specific ionisation. The therapeutic possibilities of
high-energy (20-50 Mev) beta and gamma radiations in
the treatment of cancer and related diseases should be
more closely examined. At present the 50 Mev betatron
appears to be the most suitable instrument for applica-
tion in radiotherapy as a source of high-energy gamma
radiation. The advances which led to the atomic bomb
provide a new way of preparing large amounts of radio-
active isotopes which should become widely used in
medicine as: (1) radioactive tracers for the study of
metabolic processes and in pharmacological investiga-
tions ; (2) artificial gamma-ray sources in radiotherapy ; `
and (3) agents such as P??? and I!!! with therapeutic
possibilities depending on the selective concentration
of the radioactivity of suitable isotopes in particular
cells and tissues. Hevesy, using radiophosphorus (P*?)
as a tracer, showed that the synthesis of thymonucleic
acid is inhibited by therapeutic doses of X irradiation,
thus providing convincing confirmation of previous
work using ultraviolet photomicrography, and the
Feulgen reaction. Great caution must be exercised
before any radioactive material is introduced into
patients on account of the possible risk of long-term
deleterious effects. The most promising substitute for
radium is‘now thought to be radiocobalt (Co*®), with
a half-life of 5:3 years. Of the selectively absorbed
radioactive isotopes, P?? and I}*! may prove the most
useful in therapeutics; interesting results have been
reported with P*? in the palliative treatment of chronic
myeloid and lymphatic leukemia and lymphosarcoma,
and in polycythemia. The value of fast neutron beam
therapy in cancer and allied diseases is still an open
question; evidence is accumulating to'‘indicate that
the biological action of fast neutrons differs in some
ways from that of X and gamma radiations.
NATIONAL HEALTH SERVICE
A SPEECH BY MR. BEVAN
AQDRESSING the Society of Medical Officers of Health
at their annual luncheon in London on Sept. 20, Mr.
ANEURIN BEVAN, Minister of Health, said that though
the armies were still arrayed on the battlefield of the
National Health Service Bill they were becoming, he
hoped, increasingly listless. All must unite to carry out
whatever Parliament finally decided ; any other course
was anarchy. When the Bill became law the main task
would begin—the administrative task, so much harder
than the legislative. It would be impossible to frame
regulations properly without the help of representatives
of the various branches of the medical profession. His
own purpose had been to follow with fidelity Lord
Dawson’s principle—to create an apparatus of medicine
and leave the profession to exercise it in freedom
and independence. „Parliament must create the
ring but it was for the profession to decide how to
use it.
By medical officers of health, Mr. Bevan continued,
the Bill had been criticised because it put hospital
midwifery under the regional hospital boards while
domiciliary midwifery remained under the local authority
—an arrangement described as dichotomy. But all the
serious difficulties of incodrdination in the past had arisen
because the hospitals had been owned by different
groups. Doctors would in future move quite freely
between hospitals and clinics. The M.O.H. and the
hospital doctor must in future join fully in their work,
having no occasion for jealousy. The unity of the scheme
was determined by the right of the individual citizen to
the use of all services of whatever kind, and the difficulties
raised, which were theoretical and slightly pedantic,
would in practice fall to the ground. ‘‘ We are now
facing,” said Mr. Bevan, ‘a very critical year,” and he
wanted to make all possible use of the great experience
One of the great dangers was over-
centralisation, and the more decentralisation could be
arranged, the better for the service.
In conclusion the Minister defied anyone to point to
any country more ambitiously striving to raise the
standards of life of the citizen. In every direction there
was in this country a renaissance. ‘‘I believe that we
shall win our way through, but there is a frightful shortage
-of every kind of worker.” This shortage made it essential
SCHOOLING FOR THE SUBNORMAL CHILD
[sepr. 28, 1946 467
to have complete coöperation between all engaged in the
same task, and he appealed to medical officers of health
as experts in that kind of coöperation.
Replying as president to Mr. Bevan’s toast of The
Society, Prof. J. JOHNSTONE JERVIS (Leeds) said that
the Bill was not perfect: no legal instrument was perfect.
Nevertheless it was incontestably the greatest thing
that had been done in social medicine in any age or
country. It should be given a fair chance to justify itself,
and nothing was to be gained by adopting a hostile
attitude. ‘‘ We and our colleagues may be relied upon
to play the part allotted to us in an earnest desire to
carry it to a successful issue.” On the eve of his retire-
ment, however, Prof. Johnstone Jervis wished to pay a
tribute to “a very great English institution ’’—local
government. And he could not but deplore the present
tendency of Government departments to encroach on
the province of local authorities, the latest example
being in the National Health Service Bill. If the health
services of this country had today attained a high degree
of perfection the credit was largely due to the inspiration,
enterprise, and hard work of local authorities. Local
government was the keystone of the arch of democracy.
However good and effective might be the new authorities
set up under the Bill, they could not replace the present
local authorities, and he prophesied that in the course
of years they would be replaced by local authorities
purged of their imperfections. If he might presume to
advise the Minister—head of what was once the Local
Government Board—it would be to expand, strengthen,
and maintain the powers of local government.
SCHOOLING FOR THE SUBNORMAL CHILD
WHAT CAN BE DONE
HANDICAPPED children need favourable conditions
if they are to develop their abilities to the full. Special
schools provide for children with serious disabilities,
but for others special arrangements must be made in
ordinary schools. In answer to the questions often
asked by authorities who have to make such arrange-
ments, the Ministry of Education have published a
useful pamphlet! explaining what kinds of children
need special educational treatment, how they should be
selected, the probable numbers, and the results to be
expected, besides giving advice on the arrangement
of classes and the qualifications of teachers.
PHYSICAL DEFECTS
Children who may need special treatment are the
blind (0-2—0-3 per 1000 pupils) or partly sighted (1 per
1000), the deaf (0-7-1 per 1000) or partly deaf (1 per
1000 upwards), the delicate (1-2%), the diabetic, the
educationally subnormal (10%), the epileptic (0°2 per
1000), the maladjusted (about 1%), the physically
handicapped (5-8 per 1000), and those with speech
defects (1:5-3 %).
At any time after the child is two years old the parents
may ask to have him examined to see whether he is going
to need special educational treatment; the authority
is bound to have this done, and to provide special
education if the child needs it and the parents wish it.
The child need not be attending any school when the
request is made. In some cases the earlier special treat-
ment or training is begun the better. Many blind and
deaf children between 2 and 5 are already in nursery
schools or departments for the blind or deaf, and the
decrease of crippling among children of school age is
largely due to orthopedic treatment given in the early .
years. Children seriously disabled by blindness, deafness,
epilepsy, aphasia, or physical handicaps can always be
given places in special schools. Partly sighted children,
if they can benefit from ordinary classes in primary or
secondary schools, or in open-air schools, should sit
at the front in a good light, and use extra-large paper
and soft black pencils. Experiments on lenses to magnify
ordinary print are now being made. Many partly deaf
children can be given a chance in ordinary schools
for six months to a year; if they fail to follow what
is said in ordinary school situations and if their own
enunciation is not clear and fails to improve they can
then go to a special school. Advice on their progress
should be sought from an educational clinic for the
1. Special Educational Treatment. Ministry of Education Pam-
phiet, no. 5. H.M Stationery Office. Pp. 36. 9d.
468 THE LANCET]
IN ENGLAND NOW
deaf, or from the nearest deaf school. The education
authority should provide courses in lip- ing, and if
necessary in speech improvement, for such children,
who may be collected for the purpose in groups of 5-10
for an hour twice weekly. Where no teacher can be found
for a class such children may perhaps be sent for a
term to a boarding-school for the partly deaf, to take
an intensive course in lip-reading. _ 2
Delicate children may ‘need to rest on a stretcher-bed
during the lunch-hour. Diabetic children, it is suggested,
should live in hostels, under medical and nursing super-
vision, where their diet can be regulated and they can
be taught the reasons for the restrictions placed on it; |
teachers could report at once to the hostel if a child
developed symptoms in school. Large authorities and
voluntary bodies are asked to establish such hostels.
Aphasic children are rare, but need special schooling ;
at present they usually have to go to deaf schools for
lack of a more suitable place. Children with speech
defects should attend classes twice a week, held by a
speech therapist working in the school health service.
THE BACKWARD
By far the largest problem is presented by educationally
subnormal children, who form 10 % of the school popula-
tion. Under the new Education Act it is not necessary
to.decide what has caused a child to be backward before
giving him educational treatment : that can be discovered
during the process of educating him. Children with an
intelligence quotient below 55 cannot be educated
at an ordinary school; and backward children who are
detrimental to the education of others in the class should
not be retained on sentimental grounds, but should
go to special schools. Thus a steady stable child with an
intelligence quotient of 70 may get on all right in the
ordinary class, while a nervous child of similar grade
might be better with the support of a special school.
If there are enough subnormal children in the school
they may be grouped in a class; or a class drawn from
a group of schools might be arranged, under a teacher who
believes in the value of the work.
The maladjusted child of normal intelligence needs
the help of the child-guidance team, and local authorities
should therefore make proper child-guidance arrange-
ments, or at all events employ an educational psychologist.
Sometimes a child can continue to go to his own school
while attending the child-guidance centre, or sometimes
he will profit by a fresh start in a neighbouring school.
Others, whose maladjustment arises in the home, may
need to be.boarded out with foster parents, or grouped in
hostels while still attending ordinary schools. Others
again may benefit most from a boarding-school for
maladjusted children. Day schools for such children
have been established in at least two areas, and have given
promising results.
Er o THE TEACHER
The. pamphlet ends with a clear-sighted note on the
qualities to be sought in teachers of children needing
special education. They must not undertake the work
to indulge their own maternal and compassionate
feelings. The life of the handicapped is hard, and these
children must be helped to be self-reliant, optimistic,
hard-working, and as far as possible skilled. Their
teachers must bring them emotional normality as a
pattern, and must be capable of making the most o
each child’s abilities. i
Mr. T. F. Drxon, ru.p., has been appointed professor of
biochemistry in the Royal College of Medicine, Bagdad.
MopELs OF THE Foor.—The Foot Health Educational
Bureau has prepared a series of models of healthy feet at all
ages from infancy to the adult, and is prepared to supply
casts of these at a reasonable cost. They are likely to be of
considerable value as visible standards of the normal to those
concerned with the preventive care of the feet—doctors and
nurses in child-welfare clinics and factory health services,
_ physiotherapists, physical training experts, and others to
whom the earliest stages of foot deformity are the most
important. The address of the bureau is 90, Ebury Street,
London, S.W.1.
In England Now
A Running Commentary by Peripatetic Correspondents
PERHAPS this business of German measles in the third
month of pregnancy being related to congenital defects
will open our eyes to a whole host of similar relations
which are common but fail to be obvious because of
the lapse of time between the initial and consequent
conditions. With a view to scooping a Nobel prize with
an original generalisation on these lines, I composed
myself for half an hour’s research in my armchair. It
was logical, I thought, to assume that the greater the
time interval, the more likely would. it be for a Great
Generalisation to be missed. So I began by looking for
adult disorders originating from events in infancy. I
chucked this line of thought when it dawned on me after
five minutes that much of the field had already been
despondency my courage returned. I would out-Freud
Freud. I would go further back still. E
Picture if you can añ ovum, a fresh and blooming
débutante making her one and only appearance in utero.
Alas, however, she differs from other protozoa in that
she cannot split in the middle on her own and can onl
achieve immortality by the sacrifice of her unicellularity.
Her chances of doing this are limited to the next forty-
eight hours or so. If she has no spermatozoic suitors in
that time, then she’s had it. Now picture if you can an
ovum in her forty-seventh hour. Her protoplasm is
pickled, her genes are jiggered, her mitochondria: are
moth-eaten, and her cell-membranes are slipping up.
Altogether, as far as ova go, she’s a hag. Then:suddenly
there is a lashing of tails in the middle distance and a
crowd of the boys come charging up the slope: She
gasps with relief. She shrieks with joy.. She grasps the
winner by the scruff of his neck before he can have a
chance to see what he’s landed with and change his
mind. Perhaps it is in such a union that originate those
placebos and excuses which are yet undeniable truths—
the ‘‘ constitutional weakness,” the ‘ constitutional
instability,” the ‘‘ constitutional predisposition.” ~
Yes—I suppose it is rather far-fetched. And anyway
—don’t you have to make a speech in German when
they give you a Nobel prize? Awful fag having to learn
German just for that. '
.* * *
The outstanding impression from last week’s conference
in Basle is the kindliness of our Swiss hosts, springing
from a keen sense of kinship. There are other memories :
a drive along the road, divided only by the Rhine, to
Rheinfelden, where Dr. Donald Hunter, somewhat
incongruously, spoke of industrial medicine ; the cleanli-
ness of Swiss towns;: the well-stocked shops; the
40-million-franc hospital, constructed during the war,
and containing gadgets enough to delight a schoolboy
mind for weeks ; and the food. To most, the meals,
after Britain’s austerity and unpolished cuisinerie, was
a natural attraction, though Switzerland, with two
meatless days a week and noticeable shortages in milk,
grain, and sugar, is not the land of superabundance which
some have painted. There is, moreover, no excess of
consumer goods, and those who plotted to carry off such
treasures as coloured china found their way barred. It
was pleasing to see in the shops many articles branded
“ Made in England,” even though many of them are still
unobtainable here. Visitors who did go shopping found
some difficulty in distinguishing the 5 and 10 centime
coins from the half-franc ; the difference in texture and
the serrated edge of the half-franc piece was little help to
the uninitiated.. Incidentally, why does Britain: alone
. still adhere to the vast penny for a piece of such small
denomination ? Despite the smallness of the country, the
dialect differs enormously between different places.
In Zürich diction is rapid and clipped, while in Berne, as
befits the centre of a large rural area, it is slow and sing-
song. In Basle the speech is noticeably more elegant,
and among the Swiss people the town has a reputation
for mordant wit of which other cities stand in awe. But
the canton spirit is strong, and the feeling is perhaps no
deeper than that between Liverpool and Manchester or
between Glasgow and Edinburgh. Certainly in Basle,
as elsewhere, the visitor finds nothing but friendliness.
[sepr. 28, 1946 -
_ scooped by a bloke called Freud. After a few seconds of —
~
THE LANCET] š
As, with regret, we turned our minds to packing for the
homeward journey, we discussed with nervous trepidation
the ways of British Customs officials. There were, we
found, two schools of thought : according to one, they
were wise men with all-seeing eyes, from which naught
could be hid ; the other contended that the Customs was
fair game, and that much could be concealed by the wary
traveller. As to which school I heeded—that concerns
only myself and my bank manager.
* * *
The Very Senior Medical Officer (V.S.M.0.) was annoyed.
One of the station medical officers under his jurisdiction
had sent in a submission that married female auxiliaries
were securing early release from the Service on the
grounds of pregnancy when it was impossible to confirm
or refute their claims on clinical grounds alone. The
station medical officer contended that the certificates
given by the private doctors of these women were
valueless so early in pregnancy unless backed by biological
tests, and that in any case such early discharge from the
Service was not justified at a time of acute woman-power
shortage. The v.s.m.o. did not agree; and he did not
like the station medical officer. Perhaps his annoyance
made him careless. He sent for the relevant orders and
after consulting them wrote a minute: ‘I think that
the provisions of Order xyz are adequate to deal with
these cases.” The papers passed to the next staff officer,
who took the trouble to verify the order reference and
then, with a gleam in his eye, wrote that so far as he
knew the apparatus mentioned in Order xyz had never
positively been implicated in these cases. When the
vV.S.M.O. received the papers back he sent again for the
orders to find that he should have written ‘‘ Order
xzy’’.and not ‘“‘ Order xyz,’’ which bore the full title
of Portable Aiming Teacher.
* * *
It was the twenty-third time that I had resolved to
take up the piano seriously, but the first such occasion
on which I realised why it is that concert pianists are
invariably / portrayed as highly strung, egocentric,
temperamental, and generally difficult individuals. It is
all a matter of hysterical dissociation. The essential of
pianoforte technique is that the falx cerebri should act as
an iron curtain, preventing one half of the brain knowing
or caring too much about what is going on at the other
side. My left hand knows all too well what my right
hand is doing—and vice versa. Nor are they satisfied
with each other’s performance. Each is continually
saying to the other, ‘‘ No. my dear! This is how you
should do it.” Hence the chord-salad. But take a
gross hysteric and put her at a piano. If she has the
rudiments then the rest comes just as easily and much
more pleasantly than automatic writing. Her bass and
treble selves enjoy a glorious independence but watch
each other sufficiently out of the corners of their eyes
to avoid the effect of a completely split personality.
_ Tschaikovsky had to conduct clutching his beard for
fear his head fell off. If I ever began to become at all
proficient at the pianoforte my main preoccupation would
be lest my cerebral hemispheres suddenly fell apart.
However, I can shelve that worry till the twenty-fourth
time. : |
: ; * * *
The labels on the exhibits at the Britain Can Make It
exhibition at the Victoria and Albert Museum omit the
final despairing cry of the plum-stone prophecy, though
they ‘still tantalise the would-be purchaser with their
degrees of availability—now, soon, later. All the same
it will be worth waiting to have a kitchen tap whose
washer can be changed without cutting off the water at
the main, or a pair of transparent plastic slippers that will
make Cinderella’s look like clogs, or an electric toaster
that even King Alfred could use. But life in the brave
new world will have its own complexities. The ingenious
combined stepladder, ironing board, and baby chair, for
instance, may set as many problems as it solves, and it
would take an experienced sleeper to attempt a night in
the air-conditioned bed of the future with its dashboard
for automatic temperature control. Twenty-four model
rooms show us the homes, schoolrooms and offices of the
future, and Mr. Nicolas Bentley’s sketches introduce us
to their inmates with such convincing detail that we find
PUBLIC HEALTH
. 1901 to 1939.
[SEPT. 28, 1946 469
ourselves congratulating the railway engineer (formerly in
the 8th Army and has a houseproud wife and five
children), the young doctor (newly set up in practice, but
studies social conditions and has a wife who likes outdoor
sports and photography), and the middle-aged storeroom
clerk (collects stamps, reads thrillers, and is a regular
picture-goer) on having solved their housing problems
so satisfactorily. |
* *
A radio speaker with a persistent cough can be
infuriating to his audience, but they can always switch-
him off. The situation is much worse for the speaker
himself ; when he feels a tickling sensation starting in
his throat he must go on speaking into the microphone,
keep at the correct speed which has been thoroughly
impressed on him at the rehearsal, follow his script, and
all the time wonder just when the explosion will come.
There is a switch on the table marked ‘‘ Censor ’’ which
puts the speaker off the air. I had always imagined it
was for interrupting anyone who transgressed the B.B.C.
code and inserted a bawdy remark, but I now discover
it is for the benefit of the cougher. He pauses at a
suitable spot, presses the key, clears his throat satis-
factorily, lets go the key, and proceeds hoping that the
public is none the wiser. I do not like this technique
myself, and having recently to broadcast with an
irritating and persistent cough I relied on ‘‘ syrup codein.
phosph.” This completely stopped the coughing and I
strongly recommend it to others who are too eens
to use the censor switch.
Public Health
Standardisation of Death-rates
THE issue of the civil tables! completes, with the
previous publication of the medical tables,” the Registrar-
General’s report on 1941. This was one of the most
depressing years of the war and some of its depression
is reflected in the figures: thus the birth-rate at 13-9
per 1000 was the lowest ever recorded, while the infant
mortality of 60 per 1000 related live births was higher
than any since 1933. To statisticians and medical officers
of health, however, perhaps the main interest of the
medical section lies in the introduction of the new method
of standardising death-rates.
It has been customary to standardise the crude death-
rate in order to take into account the change in the age- ©
structure of the population by applying the age-specific
death-rates in the year under review to the standard
population of England and Wales in 1901.: The use of
such a standard population ensured that, in a comparison
between two standardised death-rates, the differential
effect of ageing of the population on the crude death-rate
was neutralised ; the influence of other agencies, such
as epidemic and therapeutic innovations, on mortality
was thus readily isolated. Unfortunately there are some
residual difficulties even with this method. In long-range
comparisons, for example, the rate of decline in the stan-
dardised death-rate will depend upon the actual popula-
tion used as a standard: thus the decline in mortality
from 1901 to 1939 may appear either as 50% if 1901 is
used as a standard, or 38 % if 1939 is used as the standard
population. Similarly in comparing the mortality in
more recent years, say between 1938 and 1939, even
reversals of the trend of the standardised death-rate can
be produced by changing the standard population from
It would be more realistic therefore in
making such comparisons to use a modern population.
- To combine this realism with some balancing of the
divergent weighting effects of the population being
examined and this new standard, it is proposed to calcu-
late in future the comparative mortality index. The
last available stable modern population—that of 1938—
is used as one standard reference basis, the other being
the particular year under review. The new standard
population is made up by averaging, in each age and
sex group, the numbers in each of these two populations
so as to get a new standard midway between them. To
1. Registrar-Gencral’s Statistical Review of England and Wales
for the ver 1941. Tables. Part ır. Civil. H.M. Stationery
Office. 1s. i
2. Tables. Part r. Medical. H.M. Stationery Office. 5s.
470 THE LANCET]
this intermediate type of population are then applied
the death-rates at ages of (a) the given year, and (b) 1938,
to obtain by adding over the whole age scale the total
number of expected deaths in this new standard popula-
tion at these death-rates. The ratio of the expected
deaths in the standard population at the death-rates
of the given year to the similar total for the 1938 rates
gives the comparative mortality index. or cM... The
C.M.I. for any year can be compared with the previous
one by dividing the former by the latter to obtain a
‘‘mortality ratio.” Similarly a comparison between
‘the standardised mortality for males and females, based
on the average number of both exposed to risk, is given
by the ‘ male-female ratio.” In this and succeeding
reports these various indices and ratios will be given for
long series of years so that the trends in mortality can
be easily followed. |
There are good reasons for these innovations, though
they will doubtless cause acute headaches to D.P.H.
students. Their practical value should become evident
in future reports.
Infectious Disease in England and Wales
WEEK ENDED SEPT. 14
Notifications.—Smallpox, 0; scarlet fever, 791;
whooping-cough, 1744; diphtheria, 255; paratyphoid,
33; typhoid, 17; measles (excluding rubella), 1213;
pneumonia (primary or influenzal), 284; cerebrospinal
fever, 28; poliomyelitis, 22; polio-encephalitis, 1 ;
encephalitis lethargica, 1; dysentery, 68; puerperal
pyrexia, 100; ophthalmia neonatorum, 75. No case
of cholera, plague, or typhus was notified during the
week.
= The number of service and civilian sick in the Infectious Hospitals
of the London County Council on Sept. 11 was 861. During the
previous week the following cascs were : scarlet fever, 52;
diphtheria, 20 ; measles, 20 ; whooping-cough, 45.
Deaths.—In 126 great towns there were no deaths
from scarlet fever, 1 (0) from an enteric fever, 3 (1) from
measles, 10 (1) from whooping-cough, 5 (0) from diph-
theria, 54 (3) from diarrhoea and enteritis under two
years, and 2 (0) from influenza. The figures in paren-
theses are those for London itself.
Swindon reported the fatal case of an enteric fever. Liverpool had
3 deaths from whooping-cough and 7 from diarrhoea and enteritis.
The number of stillbirths notified during the week was
243 (corresponding to a rate of 26 per thousand total
births), including 37 in London.
Medicine and the Law
The Nature of a Charity
A LEGAL training undoubtedly helps judges to decide
an issue; but it may be a hindrance when they are
obliged first to agree on what they are there to decide.
In the case between the Commissioners of Inland Revenue
and the National Anti-Vivisection Society, now pub-
lished by the Research Defence Society,! it was agreed
at every hearing that the benefits to men and animals
of animal experiments have been great, and that the
suppression of such experiments would end medical and
scientific advances in many directions: but was this
relevant? The society had claimed exemption from
income-tax on the ground that they were a charitable
body; and the commissioners had refused the claim
on the ground that the society were not such a body.
A meeting of the Special Commissioners of Income
Tax was held in December, 1943, to hear evidence’
from both sides for the purpose of an appeal to the High
Court. Publications of the society were considered,
and evidence was given by their director, Dr. R. Fielding-
Ould. Testimony on the value of animal experiments
was then taken from Major-General L. T. Poole, Sir
Edward Mellanby, Dr. R. D. Lawrence, and half a dozen
other medical authorities. In their decision, the com-
missioners, after discussing the possible benefit to morals
and education from the society’s efforts to abolish
vivisection, declared that
“| if we conceived it to be our function to determine
the case on the footing of weighing against that assumed
benefit the evidence given before us, and of forming
1. The Fight Against Disease, 1946, 34, 1.
MEDICINE AND THE LAW /
{[szPr. 28, 1946
a conclusion whether, on balance, the object of the society
was for the public benefit, we should hold, on that evidence,
that any assumed public benefit in the direction of ‘the
advancement of morals and education was far outweighed
by the detriment to medical science and research and
consequently to the public health which would result
if the society succeeded in achieving its object, and that,
on balance, the object of the society, so far from being for
the public benefit, was gravely injurious thereto, with the
result that the society could not be regarded as a charity.”
But in 1895 two forerunners of the society were held
(In re Fovéaux) to be a charity within the legal definition
of the word, and this finding—by Mr. Justice Chitty,
as he was then—had never been overruled. The com-
missioners therefore decided that they were bound
by the authorities to hold that the society were a charit-
able body, and to allow their claim. .
When the case was heard in the High Court, however,
in July, 1945, Mr. Justice Macnaghten held that the
evidence proved that the society’s main object was the
total abolition of vivisection, and that “ attainment of
that object, so far from being beneficial, would be
gravely injurious to the community.” He therefore
allowed the appeal of the revenue authorities, where-
upon the society took the case to the Court of Appeal:
At the hearing in this court, in December, 1945,
the judges disagreed. The Master of the Rolls held, with
Mr. Justice Chitty in the case cited, that prevention
of cruelty to animals is a charitable object, and that the
society existed for the purpose of preventing a particular
form of cruelty, namely vivisection. í
“. . kindness and love towards animals,” he said, ‘‘ are
virtues the cultivation of which is conducive to the moral
advancement of humanity. I should be ashamed to hold
otherwise. The proposition is not made untrue by the
fact that human weakness or urgent human need persuades
or compels individuals or the community at large to sacrifice
the moral benefit. . . . I should not care to find myself
having to argue with anyone who regarded the practice of
operations on living animals as anything better than
a lamentable necessity.”
In short, the moral value does not disappear merely
because humanity has benefited by animal experiments,
or because the end is thought to justify the means.
He was for allowing the society’s appeal.
Lord Justice MacKinnon took the opposite view. He
felt that in 1895 Mr. Justice Chitty had failed to decide
the very issue before him—‘‘ Has it been proved to me,
by the evidence to which I have listened, that the
purposes of these [two anti-vivisection] societies are
beneficial to the community ? ” Though he held that
“ to be a charity there must be some publio purpose,
something tending to the benefit of the community,”
yet, when he came to give judgment, he said: ‘‘ The
intention [of these societies] is to benefit the community ;
whether, if .they achieved their object, the community
would in fact be benefited is a question on which I think
the Court is not required to express an opinion.” With
this Lord Justice MacKinnon could not agree. The
intentions of those who support such societies may
indeed be charitable : :
“ I readily assume that the motive which leads old women
to make bequests to this society is concern for the dear dogs.
As one who has more than once experienced the grief of
losing a beloved spaniel, I can respect and applaud that
motive: though I do not think my respect and applause
can be expected when it becomes a matter of the dear
guineapigs and the dear rats.” |
But the motive of those who provide the money is
immaterial, since the opinion of a donor that a gift is
for the public benefit does not make it so in law. He
felt that, on Mr. Justice Chitty’s reasoning, a society
secking to make the sale of rat-traps illegal, or a society
designed to prohibit the sale of insecticides, would
be equally charitable. He supported Mr. Justice
Macnaghten’s ruling, and thought the society’s appeal
should be dismissed with costs, a view with which
Lord Justice Tucker agreed. |
The appeal of the society was dismissed with costs,
but they were given leave to appeal to the House of
Lords. This final appeal has been lodged, but its date
has not yet been fixed.
‘
THE LANCET]
_ Letters to the Editor
DISCREPANT SALARIES
Str,—I read with amazement the five advertisements
from the Middlesex County Council in your issue of
Sept. 14. In the three for physicians and one for a surgeon
at general and tuberculosis hospitals the salary rose to
£1800 and then to £2200 as a special grade. The other
advertisement was for a deputy medical superintendent
in a mental hospital.and the maximum was £850: yet
the applicants for all the posts will be, or should be, of
about the same professional standing.
Every effort is now being made to unite psychiatry
and general medicine, but one of the essentials is an
enlightened outlook on the part of employing authorities.
When a county council which normally has a progressive
medical policy can only assess the value of the brain at
less than half that of the body surely something must be
very wrong ? E. CUNNINGHAM DAX.
Netherne Hospital, Coulsdon, Surrey.
RELATIONSHIP BETWEEN PRIMARY AND
ADULT PULMONARY TUBERCULOSIS
Sır, —The disparagement of morbid-anatomical find-
at the Tuberculosis Association’s meeting (Lancet,
Sept. 14, p. 382) cannot, I feel, be allowed to pass without
comment. While it is true that a few odd post-mortem
examinations, however carefully conducted, cannot solve
the problem of the origin of phthisis, it is by morbid-
anatomical research, and by it alone, that the actual
changes initiating phthisis, and their relationship to
preceding tuberculous changes, can be demonstrated.
pidemiological and radiological surveys consciously or
unconsciously refer to these changes and are of necessity
based on their study and knowledge. There can therefore
be no question of one method of approach being more
“ reliable ’’ than the other or superior to it because of :
the larger number of suitable cases.
are complementary.
Phthisis appears to develop from the primary lesion
either within a short interval, by direct bronchogenic
spread from a softening primary focus (‘ primary
cavity ’’), or from small ‘‘subprimary”’ (probably
- blood-borne) foci, or else, after a long interval, by recru-
descence. ,The former, more acute, development is
usually seen in young adults, whereas recrudescence is
observed in the elderly or middle-aged in whom a calcified
(primary or early postprimary) focus may be found in
a state of ‘ atheromatous liquefaction ’’ causing decom-
position of the calcified material and a break-through
into adjacent bronchi. It is the subsequent caseous
prone which in this type provides the ‘“‘ prephthisical ’’
ocus. |
Central Middlesex County Hospital,
London, N.W.10.
GOOSE-SKIN REFLEX IN MALNUTRITION
Sir,—When I visited the orthopedic hospital at
Siglap, Singapore, to study various signs of malnutrition,
Captain D. J. D. Bell, who was in charge of the hospital,
showed me a boy, aged about 10 years, in whom a goose-
skin reflex of the abdomen could be produced. The
boy had signs of ribofiavine deficiency (circumcomeal
proliferation of the capillaries and an enlarged magenta
tongue), muscular weakness, and other somewhat
indefinite signs of mild nerve degeneration, suggesting
early beriberi. The skin of the abdomen appeared normal
and felt smooth, and no enlarged glands could be seen
raised above the surface; but, when the blunt end of
a pencil or a finger-nail was drawn lightly over the skin,
within a second or two there was well-marked goose
skin. The glandular papules did not all appear at once
but came up, a few at a time, in two or three seconds.
In about half a minute the goose skin started to disappear,
` the papules fading away more or less in the order in
which they had appeared. The skin of the other parts
of the body did not show this phenomenon.
I have examined for this sign 111 hospital patients
with various diseases. Among them were 14 cases of
beriberi in men; in 3 of them the sign was positive.
These 3 were early cases ; all had mild paresis, and there
was pain on pressure of the calves in 2 of them. The
11 negative cases were in later stages of beriberi, and only
The two methods
WALTER PAGEL.
EFFECT OF PHOSPHATE ON CARBOHYDRATE ABSORPTION IN SPRUE
‘Guide (August 31, p. 307) are misleading.
[SEPT. 28, 1946 47]
1 of these had pain on pressure of the calves. I have
found the sign in only 1 other case among these patients,
a man with mild spastic paraplegia. This paraplegia
was of much the same type as lathyrism and therefore
probably of dietary origin due to deficiency of vitamins,
aggravated by some toxic substance in the food. In
support of this was the fact that his 9-year-old son was
lying in the next bed with a more advanced spastic
paraplegia. The son did not show the goose-skin reflex.
Of the 5 patients showing this sign, all had one or more
signs of deficiency of riboflavine, all had swollen fissured
magenta tongues indented by the teeth, 2 had patches of
superficial erosion of the tongue, and 3 had well-marked
circumcorneal injection. :
Beriberi is characterised by peripheral neuritis and
various degrees of degeneration of' other parts of the
nervous system. The goose-skin reflex must be due to
degeneration of the posterior part of the spinal cord ;
it cannot be due to peripheral neuritis.
The 3 adults with beriberi had patches of hyperkera-
tosis follicularis on the abdomen, but only a small
proportion of the glands were affected, and these papular
enlarged glands remained unaltered when the goose-skin
reflex was produced in the unaffected glands.
The only other patients with lesions of the nervous
system who have been examined for this sign were 2
with hemiplegia, but the reflex was not elicited.
Fulbourn, Cambs. ; Lucius NICHOLLS.
EFFECT OF PHOSPHATE ON CARBOHYDRATE
ABSORPTION IN SPRUE
Sir,—Dr. Stannus (Sept. 21, p. 436) has misinterpreted
our intentions. In our preliminary communication
(1945, ii, 635) we gave details of experimental results
which indicated that there was an upset in intestinal
phosphorylation in sprue. In such short communica-
tions reviews of the literature are out of place and only
essential references should be given. We referred to
Verzar, whose pioneer work on phosphorylation was the
basis of our research. The idea that intestinal phos-
phorylation might be retarded in sprue was not new when
Dr. Stannus published his interesting essay on the disease.
We found it already suggested in the extensive publica-
tions of Verzar and his colleagues’ and in the more
recent review on the etiology of sprue by Leitner.
All these works were published before Dr. Stannus’s paper.’
School of Tropical Medicine, BRIAN MAEGRAITH.
University of Liverpool.
PATENT MEDICINES
Sir,—Your leading article of August 24 discusses an
old yet ever topical subject. Few will dispute the reason-
ableness of most of Mr. Linstead’s ‘‘ indictments,” but
the remedies he offers are somewhat cumbersome. To
set up a new Whitehall machinery, with registers, boards,
fees, collectors, &c., would put new burdens on the
community without achieving the desired results. I
suggest that the first aim should be to confine the sale of
“ patent” medicines to qualified chemists. The phar-
macist is a trained person who knows when to refuse a
ready-made medicine and when to tell a customer to
seek a doctor’s advice. One of the main rules of the
Chemists’ Friends Association, which you mention, i?
that proprietary remedies of its manufacturer members
can be supplied only through qualified chemists. If the
medical profession would give a helpful hand to an
association such as this, only good could result—without
official interference. i
Gerrards Cross. S. BROOK.
WOMEN IN MEDICINE
Sm,—lIn regard to the proportion of women doctors
remaining in practice, the figures quoted in your Students’
i The survey by
the Medical Women’s Federation was taken in 1944, at
which time, I understood, all able-bodied women between
certain ages were obliged to work full-time (or part-time
if home ties were too great). Only those with full-time
home duties were exempt.
London, S.W.12. VIVIAN M. USBORNE.
1. Verzar, F., McDougall, E. J.
Absorption from the Intestine,
London, 1946; Verzar, F., Laszt, L. Biochem. Z. 1935,
278, 396 (for example).
2. Leitner, Z. A. Trop. Dis. Bull. 1942, 39, 497.
3. Trans. R. Soc. trop. Med. Hyg. 1942, 36, 123.
THE LANCET] J
472
PERNICIOUS ANÆMIA AND CARCINOMA OF
-= THE ŒSOPHAGUS
Str,—Nineteen years after the death sentence in
pernicious anæmia (P.A.) was commuted to “ liver for
life ” it is now becoming generally recognised that the
patient with P.A. is more liable to gastric carcinoma than
is his healthy neighbour.’ The best examples of this con-
currence seen here in the past few years were (1) a man
with P.A. diagnosed by blood-count, barium meal, test-
meal, &c., in July, 1938, who died, aged 37, in September,
1943, three months after laparotomy had revealed
inoperable gastric carcinoma; and (2) a woman, first
admitted to hospital with P.A. in October, 1933, who
died in September, 1942, at the age of 39, after a short
history of gastric upset; her neoplasm was proved by
necropsy and histology. These two patients were con-
siderably younger than in most of the recorded cases.
I have not been able to find any record of cesophageal
cancer in a patient with P.A., and the following presump-
tive case is reported in the hope that others may look out
for such cases.
A man, aged 49, was first sent to this department on
March 31, 1938, by Dr. H. T. Cank, of Leyland, for a blood-
count. He had had pneumonia in 1932 and 1933, and several
attacks of “ influenza ” since, the last being a few weeks ago
and attended by pain suggesting pleurisy. He had long been
easily tired, had lost weight, and had recently noted soreness
of the tip of his tongue.
His brother was known to the department as a case of P.A. 4
having attended regularly since August 1, 1935, when he was
.32 years old. Otherwise the family history was clear of
anzemia and cancer.
Apart from clinical anæmia, physical examination was
negative. Blood-count showed red cells 2,500,000 per c.mm.,
Hb 70% (Haldane), c.1. 1:4; white cells 7200 per c.mm.
(differential count normal). The mean red-cell diameter was
8-2 u (halometer).
After treatment with ‘ Campolon ’ the blood became normal
by April 27, 1938. On a dose of 2 c.cm. every three or four
weeks, blood-counts were normal in March and July, 1939.
Patient was seen once in 1940, thrice in 1941, and the figures
' were normal in four counts in 1942 and three counts in 1943,
when ‘ Anahemin ’ was being given. A test-meal in Novem-
ber, 1941, showed a histamine-fast achlorhydria. In January,
1943, patient was in hospital for four weeks with a left lobar
pneumonia. He left hospital 17 lb. heavier than on admission.
On Jan. 5, 1944, he was readmitted, complaining that for
three months he had been regurgitating food about an hour
after eating, and that for six weeks he had felt food stick at
about the level of the mid-length of the sternum. Despite a
good appetite he had lost much weight, and he had sternal
pain radiating to the right axilla.
He was wasted, and the right pupil was larger than the left.
Blood-count was normal. Radiography of barium swallow
showed cesophageal obstruction at the level of the lower edge
of the aortic arch (Dr. T. Harrison). Hoarseness had now
developed. <A Witzel’s gastrostomy was done on Jan. 26, but
patient died on Feb. 2. Permission for necropsy was refused.
I: wish to thank Dr. A. W. Baker and Dr. F. B. Smith
for permission to record this case.
R. T. COOKE.
Department of Pathology, Royal Infirmary, Preston.
PSYCHOANALYSIS IN THE NATIONAL HEALTH
SERVICE
SIR, —Clause 1 (1) of the National Health Service Bill
states: ‘‘ It shall be the -duty of the Minister .. . to
promote . . . a comprehensive health service designed to
secure improvement in the physical and mental health
of the people . .. and the prevention, diagnosis, and
treatment of illness...”
peutic, and especially psychoanalytic, treatment cannot
be generally provided since psychiatrists trained in
psychotherapeutic methods are only available in numbers
sufficient to cope with a minute proportion of the total
need. The number of patients being treated by psycho-
analysis is indeed small compared to the need, but the
number is not insignificant. Psychoanalysis is relatively
new, it is time-consuming, and it is costly. Its use in
treatment and in research cannot now be successfully
controverted. The situation after the passage of the
1. Leading article, Lancet, 1945, ii, 406.
DEATH AFTER CURARE
Nevertheless, psychothera-,
[SEPT. 28, 1 946
new Bill will be that a branch of the profession will be
able to cope with the psychoanalytic treatment of a
few hundred patients at one time, and the therapy is
one which is known to exist to many. Any Minister of
Health would be embarrassed at having to make regula-
tions designating priorities for treatment, and if the
selection is left to the individual. practitioner there is sure `
to be heartburning in his medical colleagues who refer
him patients. If psychoanalysis is not accepted as a
treatment to be provided under the Bill there will be
justified resentment among patients who are advised
such treatment. If psychoanalysis is accepted in any
degree the vast needs for training will become- apparent.
At present the official body organises training in
psychoanalysis and psychoanalytic treatment under the
auspices of a clinic at small fees or free, and arranges
publication and library facilities. The present endow-
ment and fees are such that slow development is likely to
continue to be possible without State aid. Under the new
Bill eventual organisation as a part, for example, of the
British Postgraduate Medical Federation, might become
possible. Under clause 16 (1) the Minister is able to aid
research, and perhaps eventually psychoanalytic research
might obtain State subsidy. Nevertheless, it seems to
be inevitable, though unfortunate, that psychoanalytic
therapy, training, and research will for a time run an
independent course.
London S.W.7. W. CLIFFORD M. Scorr.
DEATH AFTER CURARE
Sır, —With reference to your annotation of Sept. 21,
too much discredit is being thrown on a drug which was
not entirely responsible for this fatality. With a woman
aged 70 years, surely a dose of ‘ Pentothal’ of the
magnitude of 1 gramme was more than sufficient on its
own for the performance of an appendicectomy lasting
43 minutes; yet to this a dose of ‘ Intocostrin’ of
‘ 9 c.cm. (equivalent to 27 mg. of d-tubocurarine chloride)
was added.
Since pentothal and curare are synergic in action, it
seems strange that with these large doses no reference
was made to the necessity for controlled or assisted
respiration during the operation ; : reliance seems to have
been placed more on ‘ Coramine’ and ‘ Veritol’ than |
artificial ventilation of the lungs with oxygen when
cyanosis was first noted. Surely the cause of death was
prolonged hypoxia, with toxsemia as a secondary cause.
May I add a rider that in all cases of gross respiratory
depression an unobstructed airway must be ensured and
controlled respiration performed before resort is made to
respiratory stimulants.
London, S.W.I. E.
Sir,—Your report on this case raises many issues of
pee importance. At a time when anesthetists are
attempting to establish curare as a safe and useful drug
it is very tragic that such a case should occur. Yet many
useful lessons may be learnt from it. Apart from your
report the case is unknown to me, and I assume that the
facts as reported are correct. _
(1) The wisdom of using a new and experimental
drug (I am aware some may question the epithet) on
such a bad risk case appears to me doubtful in the
extreme. It would be very useful if the opinions of my
senior colleagues on this could be ventilated in your
columns. I use the term “ experimental ” deliberately,
for there is a drug still used by some of us, known as
ether, which has been employed as an anesthetic agent
for 100 years on many millions of cases. Any new drug
which has been in use for only a few years on a few
thousand cases must, by comparison, be termed * experi-
mental.”’
This appears to me to be an important principle to
establish. In an evening paper recently an anesthetist is
reported to have stated that in a certain fatal case curare _
was used as being the safest possible drug in the circum-
stances. Compared with ether, it is very doubtful if
curare could at present be correctly described as the
safest possible drug in any circumstances. Before the
value of any aneesthetic drug can be assessed it must
be used in hundreds of thousands of cases over a long
period. Some drugs have such obvious limitations that
their value, or lack of it, is soon discovered. Others,
of greater promise, require a longer trial. For example,
ASQUITH.
~
THE LANCET]
SIGMOIDOSCOPY IN AMŒBIC DYSENTERY
[sErr. 28, 1946 473
cyclopropane, which appeared at the outset to have such
great promise, required five years of trial before it could
be said to have passed the experimental stage. Curare,
which appears to be of even greater value than cyclo-
propane, will probably require an even longer trial. I
hope that, unlike ‘ Pentothal.’ it will not prove to be
a drug “‘ fatally easy ’’ to administer.
(2) When we examine the dosage of drugs used in
this case, it would appear that the coroner’s verdict was
charitable. An old lady of 70, suffering for two days
from an acute abdominal infection, and with early
peritonitis, was given morphine gr. 1/, and atropine
gr. */1o9- I would presume to say that the former drug
was superfluous. This was followed by 1 g. of pentothal.
In my opinion this was an excessive dose, even had
nitrous oxide been the only additional anesthetic to be
given. With curare in a fit subject in first-class condition
` I personally hesitate to give more than half this dosage.
Prescott, Organe, and Rowbotham (Lancet, July 20,
p. 80)- have pointed out the danger of giving two such
respiratory depressants together in full dosage. The
present case illustrates this danger. I am not surprised
that the patient required continuous oxygen.
This was followed by ‘ Intocostrin ’ 9 c.cm.—180 units.
Presumably this was given intravenously in a single dose.
So far as I am aware, 100 units of this drug is regarded
by authorities as a maximum single dose even in fit
subjects. any case, we are warned that in the very
young, or the very old, or in bad risk cases, this dose
must be considerably reduced. I hope that those who are
more competent than myself to express an opinion will
let us know in your columns whether this dosage should
be regarded as excessive.
I have the deepest sympathy with the anesthetist in
this case, of whose identity I am ignorant. ‘‘ There,
but for the grace of God, go I.” But I should like to
obtain the opinions of my colleagues on the following
four principles :
(1) New anesthetic drugs must be assessed in comparison
with ether.
(2) Final assessment cannot be made until many hundreds
of thousands of administrations have been recorded.
During this period of trial such drugs should be regarded
as experimental. |
(3) Such experimental drugs should not be given to bad
risk cases.
(4) The dosage of such experimental drugs should be care-
fully regulated according to the published recom-
mendations of senior anzesthetists.
It is oply with the object of establishing these prin-
ciples that, with humility and hesitation, I have
sought the hospitality of your columns at such length.
‘London, W.1. R. BLAIR GOULD.
SIGMOIDOSCOPY IN AMŒBIC DYSENTERY
SıR,—I should like to add a postscript to my article of
Oct. 13, 1945 (p. 460). Two points call for revision in
the light of subsequent experience.
The first of these concerns technique. I have since
found that the most satisfactory method of producing
a ‘‘clean’’ lower bowel, whether for the diagnostic
purpose of a sigmoidoscopy or for the therapeutic
purpose of a retention enema, is by the simple administra-
tion of a weak bicarbonate enema, after which a period
of 4-6 hours must be allowed to elapse. At the end of
this period, regardless of the taking of meals mean-
while, the lower eight inches of bowel are almost invari-
ably clean and ‘“‘ dry,’ in the sense that all traces of
enema fluid have been evacuated or absorbed. An
important point, and one often overlooked, is that the
evacuant enema must be of just that volume which will
produce an effective call to stool: this will be one
pint in some, considerably more or less in others. There
are still undesirable methods in use involving the exhibi-
tion of castor oil, &c., and I have known retention
enemata given within a few minutes of the evacuant
enema, thereby reducing the strength of the medicament
used to quite ineffectual proportions. Such errors in
technique not only defeat their object but often involve
a sore trial for the long-suffering patient.
Secondly, a point in diagnosis. Recently I have seen
a number of cases in which the ulcers are minute: with
the ordinary magnifying lens they catch the eye merely
as tiny points of extreme congestion. They are scattered
in small groups, and frequently only one such group can
be found. With a special magnifying attachment,
first shown me by Lieut.-Colonel A. M. Khan, R.A.M.c.,
it is possible to detect the actual tissue loss.
Keighley, Yorks. C. F. J. CROPPER.
NON-SPECIFIC EPIDIDYMITIS
Srr,—Dr. Whitwell’s letter of Sept. 7, recalling
Slesinger’s suggestion that non-specific epididymitis
may be due to stress reflux of normal urine, prompts
me to describe an experiment carried out at my sugges-
tion by Dr. G. L. Timms, pathologist to Kenya Govern-
ment Medical Service.
A rabbit was anzsthetised and 5 c.cm. of urine withdrawn
by vesical puncture. Of this, a part was cultured and proved
sterile. Of the remainder, 0-5 c.cm. was injected into the
previously exposed vas deferens on one side. As this was
done the epididymis could be felt to inflate with urine. The
animal remained clinically normal after this operation ; after
10 days the testis and epididymis on both sides were removed
and sectioned. They were all normal.
As Handley says (Lancet, 1946, i, 779), the reflux
theory does not seem very feasible ; and this experiment
appears to show that normal urine is not an irritant in
the epididymis, at least in the rabbit. 7
London, W.1. F. Ray BETTLEY.
TUBERCULOUS GLANDS AND CALCIFEROL
S1r,—With reference to the treatment of tuberculous
glands with high dosage of calciferol (July 20, p. 88), |
there seems to be some evidence that such treatment,
while helpful when sinus formation is present, has a
clinically adverse effect on glands which have not broken
down. In the absence of more detailed investigation
this is little more than an impression, but it would be in
keeping with the observation that in the early stages
of treatment of lupus vulgaris with calciferol there is
not infrequently a local exacerbation of the disease.
It would also be in keeping with similar observations
on the influence of tuberculin in.tuberculous lesions and
of arsenic in untreated syphilis. Until further evidence
is forthcoming it would appear advisable to use the
calciferol treatment with caution when lung tuberculosis
is present, since such a reaction in the lung might have
disastrous sequels. l l
London, W.1.
NEW WORDS ABOUT OLD AGE
Sır, —In your issue of August 10 (p. 214) Dr. Howell
discusses ‘‘ the nomenclature of old age.” It would be a
benefit to medicine if you would help to get the “‘ new
words ” fixed in correct form before it is too late.
From pais (stem paid-) a child, we have ‘“‘ peediatrics,”’
and from geron (stem geront-), an old person, we should
have ‘‘ gerontiatrics,’’ not ‘‘ geriatrics.” There is no
word geria in Greek, though there is eugeria, meaning a
good old age. Gerontiatrics therefore is the word for the
medical care of the aged and eugeria is its goal. |
Orpington, Kent. H. St. H. VERTUE.
TECHNIQUE OF PREFRONTAL LEUCOTOMY
Srr,—In order to avoid incision of the grey matter,
I suggest that prefrontal leucotomy might be performed
through an approach from the midline underneath the
angular gyrus by an incision of the corpus callosum in
the direction of its fibres. No doubt a special knife
would have to be designed and a new technique devised
for the new approach.
T. F. G. MAYER. |
Taunton.
*.* We are informed that section from this angle
would carry an appreciable risk of damage to the optic
nerves.—EbD. L
H. J. WALLACE.
Tur Medical Research Council have received from Sir
Leonard Rogers, F.R.S., a further addition to the endowment
for research in tropical medicine with which he entrusted
them in 1926. The capital value of this fund is now about
£15,000, and the income is applicable to special purposes .
within the general field of tropical medical research.
474 THE LANCET]
Obituary
CHARLES FERRIER BEEVOR
- - MOA, B.M. OXFD `
3
Mr. C. F. Beevor, surgeon to the ear and throat depart-
ment of the Royal Waterloo and Evelina Hospitals,
died on Sept. 15 at the age of 62. A son of Dr. C. E.
Beevor, the well-known neurologist, he was educated at
Charterhouse, and Magdalen College, Oxford, where he
graduated in 1906, taking honours in chemistry in the
final school of natural science. Continuing his medical
training at University College Hospital, he took his B.M.
in 1912, soon afterwards becoming house-physician to
Sir John Rose Bradford, and later a house-surgeon at
Charing Cross Hospital. À
Early in his career he became interested in otolaryngo-
logy, and worked in the special department at U.C.H.
until 1915, when he went to Egypt with a commission
in the R.A.M.C. as an otological specialist at one of the
clearing stations, where he remained until he was invalided
home in 1918. Not long after this he took up his work
again as a specialist and was appointed to the staffs of the
Royal Waterloo Hospital and the Evelina Hospital. His
successful practice included many friends and colleagues.
_ “ Essentially an individualist,” writes M. D., ‘‘ Charles
Beevor hated regimentation and resented interference
by red tape with his own individual methods of work.
It was, perhaps, largely this peculiarity which militated
against his chances of promotion in the academic world
of medicine, but his comparative freedom from such
commitments gave him more scope to develop his gifts
in his own way. His individualism inevitably resulted
in faults which sometimes showed themselves to his
disadvantage : but in his professional practice it expressed
itself as a great kindliness and in a disposition to spare
no trouble where his patient’s comfort was concerned,
and his friends loved him for his loyalty no less than for
his good fellowship.” l
Mr. Beevor leaves a widow and two daughters.
HAROLD FRANCIS LEWIS HUGO
M.C., M.B. LOND.
Dr. H. F. L. Hugo, who died at Crediton on Sept. 14
at the age of 60, had an unusually promising career as
a student which suggested that he might have made a
considerable reputation had .he wished to do so. He
elected, however, to become a general practitioner, and
for more than thirty years practised at Crediton, to its
great comfort and benefit. His work was interrupted
by the first world war, when he served with distinction
as medical officer to the Devon Yeomanry, by whom he
was greatly and rightly beloved. His kindness, firmness,
and courage did much to sustain the unit through bad
times in Gallipoli and elsewhere.
Like so many good men he was profoundly dissatisfied
with himself though infinitely forgiving to others. His
patience was inexhaustible, his humour abundant,
sometimes betraying his lively Gallic ancestry. As a
young man he was a “class’”’ soccer player, and- he
remained. a useful fastish bowler till well on in the
thirties. He was, moreover, a good bridge player,
though perhaps he got—and gave—as much fun out of
golf, which he was wise enough not to take seriously,
and billiards or snooker, in which he fluked outrageously.
His keen interest in natural history developed with the
years. The loss of both his sons in the recent war was
a blow from which he never recovered though he did not
murmur and continued to work as long as he could.
Many will mourn the passing of a handsome, blue-
eyed, shy but friendly, and extremely competent doctor
who always refused to make speeches but whose wise
guidance was invaluable ta the many committees to
which he was almost automatically elected. L. N.J. `
THe death is announced of Sir JOHN HARRIS, M.D.,
member of the Legislative Council of Victoria since 1920
and minister of public instruction and public health for
the State from 1935 to 1941. He graduated M.B. at the
University of Melbourne in 1890 and practised in his
native town of Rutherglen, in Victoria, till 1917, when he
served as medical officer to no. 1 Squadron, Australian
Flying Corps, in Palestine. He was appointed K.B.E.
in 1937.
OBITUARY—APPOINTMENTS—BIRTHS, MARRIAGES, AND DEATHS
[serr. 28, 1946
-` Appointments
CHALMERS, J. A., M.D. Edin., F.R.C.S.E., M.R.0.0.G.: gynescologist
and obstetrician in the North of Scotland and hon. charge |
gynecologist, Royal Northern Infirmary, Inverness.
CLEGG, J. W., M.R.C.8., D.c.P.: pathologist, Hospital for Consump-
tion and Diseases of the Chest, Brompton.
Day, F. M., M.R.C.8., D.P.H., D.T.M. : M.O.H., Hammersmith. .
DORE, J. C.,M.B.N.U.I., D.M.R.: junior asst. radiologist (diagnostic),
Middlesex Hospital, London. . :
FOWLER, ERIO, B.M. Oxfd: examining factory surgeon, Crow-
borough, Sussex. l .
Fox, P. P., M.B. Lpool, D.P.H.: M.0.H. for Chard, Crewkerne, and
Langport and asst. county M.O., Somerset. — -
GRIERSON, A. M. M., M.D. Edin. : deputy M.o.H., Manchester.
Hay, A. B., M.B. Aberd., M.R.0.0.G.: gynecologist and obstetrician
in the North of Scotland and hon. charge gynecologist, Royal
Northern , Inverness.
MITCHISON, D. A., M.B. Camb, : asst. to the pathologist, Hospital
for Consumption and Diseases of the Chest, Brompton.
MOREL, M. P., M.A. Camb., F.R.c.s.: surgeon, North Devon nfir-
mary, Barnstaple. ;
St. Bartholomew’s Hospital, E.C.1 :
Harrer, R. A. K., M.B, Edin., D.R. : director of X-ray diagnostic
dept. (whole-time). o
LOUGHBOROUGH, G. T., M.R.O.8., D.M.R.E. :
nostic dept. (part-time).
SIMON, GEORGE, M.D. Camb., D.N.R.E.: M.O., X-ray diagnostic
dept. (part-time). è
London Chest Hospital, E.2:
BaRLOW, DONALD, M.S. Lond., F.R.C.S. : asst. surgeon.
Brown, A. I. P., M.B. Lond., D.a.: aneesthetist. Ber cod
LINDAHL, J. W. S., M.CHIR. Camb., F.R.0.8.: asst. laryngologist
MOUNTFORD, L. O., M.B. Camb., D.A. : anæsthetist.
Pes ALICE C., M.B. N.Z., M.R.O.P., D.A. : aneesthetist.
Addenbrooke’s Hospital, Cambridge :
BERRIDGE, F. R., M.B. Camb., D.M.R.: radiologist.
LLOYD, OSWALD, M.D. Lond., F.R.C.8S., M.R.C.O.G. °
gynsecological and obstetrical depts. i
MARTIN, LAURENCE, M.D. Camb., M.R.C.P.: physician.
TRuscoTT, B. M., M.B.E., M.B. Lond., F.R.C.S.: surgeon,
WRIGHT, G. F., M.B. Camb., D.O.M.S. : ophthalmic surgeon.
Royal Liverpool United Hospital (Liverpool Royal Infirmary) :
BAMBER, G. W., M.D. Camb., F.R.C.P. : dermatologist. =
MACPHEE, G. G., M.D. Glasg., L.D.S. : dental surgeon. ~
SEATON, D. R., M.B. Camb., M.R.C.P., D.T.M. & H.: asst. physician
for tropical diseases.
WHITAKER, P. H., M.D. Lpool, D.M.R.E. :
Colonial Medical Service :
ANTONIO, R. F., M.B. Edin. : M.0., Gold Coast.
ASHE, GEOFFREY, M.B. Manc.: M.0., British Somaliland.
BALEAN, G. T., M.R.C.S.: M.O., Zanzibar.
BEST, A. M., M.R.C.S.: M.O., Uganda.
COOPER, P. R., B.M. Oxfd, D.T.M. : M.O., Nigeria.
EDINGTON, Major G. M., M.B. Glasg. : M.O., Gold Coast.
HANDFORTH, J. R., M.B. Camb. : M.0., Hong-Kong.
MACDONALD, Captain W. H., M.B. Lond.: M.o. (grade 11), Western
acific
PABLOT, P. J., M.B. Lond., D.T.M. & H.: M.O. (grade 1), Mauritius,
SMITH, Lieut.-Colonel G. G., M.R.O.8. : M.O., British Honduras.
STONES, P. B., M.B. Lond. : M.O., Nigeria.
WATERSTON, WILLIAM, L.R.C.P., L.D.S.: M.O., Kenya.
WEsT, J. H., M.R.O.8.: anæsthetist, Uganda.
The appointments to the Bradford Royal “Infirmary
announced in our issue of Sept. 14 were made under the
M.O., X-ray’ diag-
surgeon to
radiologist.
auspices of the Bradford Joint Hospitals Council and are-
not to the infirmary alone but to all the hospitals in the city.
Births, Marriages, and Deaths
BIRTHS
ASHFORD-BROWN.—On Sept. 14, in London, the wife of Dr. W. H.
Ashford-Brown—a son.
HEANLEY.—On Sept. 18, in London, the wife of Mr. Charles Heanley,
F.R.C.8.—a son,
MILLS.—On Sept. 17, in Birmingham, Dr. Margaret Mills, D.a.,
wife of Mr. W. G. Mills, F.R.c.s.—a daughter.
OLIVER.—On August 29, at Sheffield, the wife of Dr. G. B. Oliver
—a son. i
RUDLAND.—On Sept. 20, at Coventry, the wife of Surgeon Com-
mander R. S. Rudland, R.N.V.R.—a daughter.
MARRIAGES
LIGHT—BELL.—On Sept. 14, in London, Lovell Hillier. Benjamin
Light, M.R.C.S., to Colyeen Audrey Bell.
LONGLEY—DRURY.—On August 22, at Felpham, John Douglas
Brougham Longley, M.R.O.8., to Elizabeth Clara Dru Drury.
DEATHS
Boyrcotr.—On Sept. 17, at St. Albans, Arthur Norman Boycott,
M.D. Lond., aged 80.
Coox.—On Sept. 19, John Howard Cook, M.8. Lond., F.R.c.S.,
formerly of C.M.S. medical department, aged 75.
CoorER.—On Sept. 13, in Maine, U.S.A., Harold Merriman Cooper,
One: M.B. Lond., formerly of Hampton-on-Thames, Middlesex,
aged 74. .
GILBERT.—On Sept. 12, at Naini Tal, India, Leonard Erskine
Gilbert, C.I.E., M.D. Lond., lieut.-colonel 1.M.S., retd., aged 72.
HoLMES.—On Sept. 15, at Godalming, Richard Annesley Holmes,
M.R.C.8., aged 61.
Hvcco.—On Sept. 14, at Crediton, Devon, Harold Francis Lewis
Hugo, M.C., M.B. Lond., aged 60.
‘Watts EDEN.—On Sept. 22, Thomas Watts Eden, M.D. Edin.,
F.R.C.P., F..C.0.G., aged 83.
bes Sii
THE LANCET]
Notes and News
‘WESTMINSTER HOSPITAL AND THE INFANTS
HOSPITAL
THE governing bodies of Westminster Hospital and the
Infants Hospital, Vincent Square, have agreed to the merging
of their two institutions. The Infants Hospital, which has
been used during the war as a hospital for officers of the
United States Forces, will be reopened as soon as possible
as the ‘“‘ Westminster Children’s Hospital.” A good deal of
air-raid damage will have to be repaired before its services
can be fully developed, but the bed accommodation will
eventually be increased to 140.
The fusion of the two hospitals will make it possible to
concentrate all pediatric services and research at Vincent
Square, where Westminster Hospital students will have
exceptional opportunities for the study of children’s ailments.
is is one of several affiliations being negotiated by
Westminster Hospital following the recommendation made
in the report of the Ministry of Health survey. The hospital
has also recently taken over two convalescent homes with
160 beds situated in the country a short distance from London
for the reception of patients in an early state of convalescence
where after-treatment and industrial rehabilitation can be
conducted. |
JOURNALS AND BOOKS WANTED ABROAD
Dr. A. Tudor Hart tells us that the International Brigade
Association has had urgent requests from former medical officers
of the I.B. Medical Service in the Spanish War, now working
once more in their own countries, for current issues of medical
journals. ‘* Would some of your subscribers,” he asks, “‘ be
willing to forward their Lancet regularly for a year? If so,
will they please write to the secretary, International Brigade
Association, 14, Red Lion Square, London, W.C.1, who will
Jet them have a name and address. We have other former
colleagues still working in China to whom we should especially
like to forward recent and expensive surgical textbooks. May
we also appeal for some donations for this object ? They
should be sent to the same address marked ‘ Medical Text-
book Fund.’ ”
DENTISTS’ FEES UNDER N.H.I.
THE British Dental Association has approved the decision
of the General Advisory Dental Council to advise dentists to
refuse all dental benefit letters but to treat patients privately
at the scale of fees rejected by the Ministry of National
Insurance. The representatives of the association will not
take part in the work of the Dental Benefit Council until the
dispute is settled.
HOSPITALS AND HEALTH CENTRES IN U.S.A.
THE President of the United States has signed the Hospital
Survey and Construction Act, authorising Federal expenditure
of 375 million dollars during the next five years for the con-
struction of hospitals and health centres, and 3 million dollars
for the surveys which must precede such construction. Each
State is to develop its own programme for hospitals and health
centres, to be administered by State authorities under
standards specified by the U.S. Public Health Service. Any
State may initiate action by submitting a request to the
surgeon-general of this service for funds to carry out an
inventory of existing hospitals, and to prepare a plan for the
construction necessary to provide adequate care for all the
people. In defraying the survey expenses Federal funds
must be matched by. two to one. Allotments for actual
construction will not be made until the State plan based on
the survey findings has been approved. Construction allot-
ments to individual States will vary in amount: States with
a lower per-capita income, where there is relatively greater
need for medical facilities, will receive larger allotments per
head. Before any individual project is approved by the
surgeon-general, it must be shown that two-thirds of the
total cost of construction is available from other-than-Federal
sources, and that money can be found to maintain and operate
the institution after completion.
In the view of Dr. Thomas Parran, the surgeon-general,
“ this Act sets for the first time a national policy which makes
it clear that hospitals in the future must be planned, located,
and operated in relation to the overall health needs of the
people. . . . Adequate hospitals, health centres, and related
physical facilities are the essential workshops, without which
it is not possible to provide even a minimum of modern health
and medical services.”
NOTES AND NEWS
[SEPT. 28, 1946 475
. R.N. SICK BERTH STAFF |
Since 1933 the Central Council of the Royal Naval Sick
Berth Staff Associations have been helping the men of the
Royal Naval Sick Berth Staff to find posts as male nurses on
their return to civil life, and through their efforts attendants
with suitable qualifications are now registered as Service-
trained male nurses.
There are now vacancies on the council, and R.N. or
R.N.V.R. medical officers, active or retired, who would be
willing to help in this work are asked to write to Surgeon-
Captain M. H. Knapp, c/o Medical Department, Admiralty
64, St. James’s Street, London, S.W.1.
SCABIES FILM REVISED
THE M.O.I. film Scabies has been revised and is to be
reissued early in November by the Central Office of Informa-
tion under the title Scabies 1946. The latter half dealing with
treatment has been largely retaken, new shots being inserted,
and the commentary has been entirely rewritten.
Starting as before with good close-ups of the habits and
development of the mite, the film shows next the characteristic
sites of infestation; after this is inserted new material
showing the range of drugs available for treatment and their
relative efficiency, and then the film goes on as before to
show the method of applying benzyl benzoate emulsion. The
sequence on the relative merits of treating secondary infection
or the infestation first has again been glossed over, but more
emphasis is now laid on the importance of treating the whole
family rather than the individual.
This new version, which has been shortened to run for 24
min., is an improvement on the old even though some avoid-
able errors have been retained—for instance, the misleading
term ‘‘ microphotography ” where “‘ photomicrography ” is
intended. It will be screened again with benefit even to
those who saw the original version.
FOOD RATIONS FOR THE GERMANS
Ir was announced in Berlin last Monday that the basic
food ration in the British and American zones of Germany
will be raised again to 1550 calories daily for the normal
consumer from Oct. 14. The decision to increase the ration
at once, although there is no certainty of maintaining supplies
till next harvest, has been taken because of the urgency
of the situation as depicted in the June report of the tripartite
committee of investigation (Lancet, 1946, i, 896 ; July 6, p. 22).
This report said that for ordinary consumers the ration of
1550 calories achieved last wjnter, when supplemented with
unrationed foods, barely sufficed to maintain health.
BLOOD-TRANSFUSIONS IN SCOTLAND
In the quarter ended June 30, 1946, hospitals in Scotland
used 4136 pints of whole blood for transfusion, compared with
4094 pints in the previous quarter, and their demands for
liquid plasma rose from 839 to 1448 pints. The Scottish
National Blood Transfusion Association was able to meet
the increased need, 7888 pints of blood being obtained from
donors in the June quarter, a rise of 657 pints over the March
total.
HOME PRODUCTION OF STREPTOMYCIN
Four British firms are to codperate with the Ministry of
Supply, the Ministry of Health, and the Medical Research
Council in the pilot-scale production of streptomycin, and it
is hoped that preliminary clinical trials will begin before the
end of 1946. The firms concerned are Messrs. Boots, Glaxo
Laboratories, and the Distillers Company, who are all estab-
lished penicillin manufacturers, and the Heyden Chemical
Company, who are to instal a factory to make penicillin and
streptomycin at Ardrossan, Scotland.
Streptomycin will not be released for general medical use
until the conditions which respond to it have been clearly
established, and the clinical trials will take a considerable
time. Meanwhile plans will proceed for large-scale production `
to meet the demands of the medical profession as a whole.
The drug is already undergoing clinical trials in the United
States in all types of tuberculosis, dysentery, typhoid, and
paratyphoid fever, and certain infections of the urinary tract,
particularly those which do not respond to penicillin or
sulphonamides. Supplies in America are at present too small for
any substantial quantity to be made available for this country.
It seems likely that streptomycin will be more expensive
than penicillin on a per-case basis.
Major T. M. PEMBERTON, F.R.C.S., R.A.M.O., has been
appointed M.B.E. in recognition of gallant and distinguished
service while a prisoner-of-war. |
476
University of Leeds
The inaugural lecture of the faculty ‘of medicine will be
given at 3.30 P.M. on Monday, Oct. 14, when Lieut.-General
Sir William MacArthur, F.2.c.P , will speak on Insect-borne
Disease and English History.
Society of Apothecaries of London u
Diplomas in industrial health have been granted to the
following: A. Anderson, K. Biden-Steele, M. P. Fitzsimons,
G. B. Oliver, G. F. Keatinge. This list replaces that published
on Sept. 7 (p. 368).
Welsh National School of Medicine |
The opening address for the new session of this school is
to be given by Sir Wilson Jameson, chief medical officer of
the Ministry of Health, in the Institute of Physiology, Newport
Road, Cardiff, on Friday, Oct. 4.
Faculty of Homeopathy
Dr. C. E. Wheeler will deliver his presidential address to
the faculty at the London Homeopathic Hospital, Great
Ormond Street, London, W.C.1, on Thursday, Oct. 3, at
5 P.M. His subject is to be Looking Before and After.
Royal Medical Society
On Friday, Oct. 11, at 8 P.M., at 7, Melbourne Place, Edin-
burgh, Sir Henry Wade will give the inaugural address of the
210th session of this society. He is to speak on the Life of an
Edinburgh Medical Studént 300 Years Ago.
Irish Tuberculosis Society
At a meeting of the society to be held at Newcastle Sana-
torium, co. Wicklow, on Saturday, Oct. 19, at 2 p.m., Dr.
F. R. G. Heaf will read a paper on Recent Trends in Tubercu-
losis, Dr. Dorothy Price will discuss whether B.c.c. vaccination
is a practical proposition in Ireland, and Prof. F. J. Henry
will speak on Surgery in the Treatment of Tuberculosis.
St. Fhomas’s Hospital
The old students’ dinner will take place at Claridge’ s Hotel,
- Brook Street, London, W.1, on Nov. 1, at 7.30 p.m. Sir
Maurice Cassidy is to take the chair. The number of places
is limited to 250, and applications should be sent to the
aaa of the dinner committee, St. Thomas’s Hospital,
Royal Sanitary Institute
On Wednesday, Oct. 9, at 2.30 P.M., at 90, Buckingham
Palace Road, London, S.W.1, Dr. W. R. Martine, senior
assistant M.0.H. for Birmingha, and Mr. R. S. Cross, chief
sanitary inspector for Brighton, will open a discussion on the
Public Health Aspects of the Manufacture of Ice-cream.
** Anæsthesia ”
The first number of this quarterly journal, which Dr.
C. Langton Hewer is editing on behalf of the Association of
Anesthetists of Great Britain and Ireland, will appear on
Oct. 1. The publishers are George Pulman & Sons, Ltd.,
Thayer Street, London, W.1.
An Italian Medical Students’ Association
An Associazione Studentesca Internazionale has been
founded in the University of Padua and has taken the name
of the Digamma-Pi Association from Sinclair Lewis’s Doctor
Arrowsmith. It seeks to promote friendship and exchange of
information and opinions between medical students all over
the world, and would welcome inquiries addressed to it (in
any European language or Esperanto) at the Liviano Palace,
University of Padua, Italy.
Middlesex Hospital and the New Service
Mr. T. Money-Coutts, treasurer of the Middlesex Hospital,
speaking at a meeting of the court of governors reported in
the Times of Sept. 19, said he looked forward to the future of
the hospital under the new National Health Service with
, confidence and enthusiasm. It had been said that the new
Act would change the character of the voluntary hospitals,
but he believed that 200-year-old traditions such as theirs
had the strength not only to.survive but to thrive on changes
inherent in the development of our social system. The
character of an institution depended not on Acts of Parliament
but on the personality and -ideals of those who worked for it.
For those who had helped the voluntary hospitals in' the past
the new Act was not a signal for abdication but a challenge,
and the Middlesex would continue to depend on the interest of
their friends to maintain and improve their standards for
treating the sick.
He added that the medical school was flourishing, and that
women students will be admitted for the first time in October.
THE LANCET]
MEDICAL DIARY -
sake
[SEPT. 28, 1946
National Hospital, Queen Square |
On Monday, Sept. 30, at 4 p.m., Dr. Gordon Holmes, - F.R.S.,
will give the inaugural address of the first post-war course of
clinical neurology to be held at this hospital.
Return to Practice
The Central Medical War Committee announces that
Dr. W. Lindesay Neustatter has resumed civilian practice.
at 128, Harley Street, W.1 (Welbeck 3686).
Divine Healing and General Medical Practice
Dr. H. E. Collier will give the first of three monthly lectures
on this subject at Denison House, 296, Vauxhall Bridge Road,
London, S.W.1, on Wednesday, Oct. 16, at 7 P.m.. The
lectures are being given under the auspices of the Churches
Council of Healing founded by the late Archbishop Temple.
International Hematological Conference
The International Hematology and Rh Conference will
be held in Dallas, Texas, on Nov. 15. The guest speakers will
include : Dr. Philip Levine (Linden, New Jersey), Dr. R. R.
Race (London), Dr. William Dameshek (Boston), Dr. Ernest
Witebsky (Buffalo), Dr. I. Davidsohn (Chicago), Dr. Louis
K. Diamond (Boston), Dr. Ludwig Hirszfeld (Wroclaw,
Poland), Dr. Ignacio Gonzalez Guzman and Dr. E. Uribe
Guerola (Mexico City), and Dr. J. M. Hill (Dallas). The
secretary of the conference is Dr. Sol i aa Baylor
University Hospital, Dallas, Texas.
Messrs. Ward, Blenkinsop & Co. have moved from Liverpool
and their address is now 6, Henrietta Place, London, W.1
(Langham 3185).
A CORRESPONDENT points out that in our annotation of
Sept. 7 (p. 352) on hybrid corn, the word dicecious was used
when monccious was intended.
PENICILLIN IN BILE.—In our annotation on “penicillin and
sulphathiazole in typhoid fever (Sept. 7, p.. 353) the remark
that penicillin is concentrated in the bile should read:
‘‘Penicillin is excreted in the bile in concentrations similar
to, or even higher than, those attained in the blood” (see
Rammelkamf, C. H., Helm, J. D. Proc. Soc. exp. Biol., N.Y.
ROYAL SOOIETY OF MEDICINE
1943, 54, 31).
Medical Diary
SEPT. 29 TO OCT. 5
Tuesday, ist
ROYAL COLLEGE OF oe ae Lincoln’s Inn Fields, W.C.2
3.45 P.M. Prof. . Harris: Clinical Anatomy of the Lym-
phatic Bytes
5 P.M. Prof. Geoffrey Pepi we The Reticuloses.
ROYAL SOCIETY OF MEDICINE, 1 Wimpole Street, W.1
8.30 P.M. Orthopedics. Mr. V.H. Ellis: Injuries of the Cervical
Spine. OO a ee atial | address. )
LONDON SCHOOL OF DERMATOLOGY, 5, Lisle Street, W.C.2
5 P.M. Dr. J. E. M. Wigley: Eczema.
Wednesday, 2nd
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. H. A. Harris:
5§ P.M. Dr. Montague Maizels :
Growth of Bones.
Liver IKfficiency Tests.
2.30 P.M. History of Medicine. Sir Arthur MacNalty: Evolu-
tion of English Preventive Medicine. reece
address.)
UNIVERSITY OF GLASGOW
8 P.M. (Department of OF Switzerland. Mr. John Foster: An
Ophthalmic Tour of a
Thursday, 3rd
ROYAL COLLEGE OF SURGEONS Fa
3.45 P.M. Prof. H. A. Harris: Epiphysial Growth Cartilages.
5 P.M. Dr. Montague Maizels: Liver Efficiency Tests.
ROYAL SOCIETY OF MEDICINE
8 P.M. Neurology. Dr. Douglas McAlpine: Disseminated
Sclerosis. (Presidential address.)
LONDON SCHOOL OF DERMATOLOGY
5§ P.M. Dr. G. Bamber: Misuse of Antiseptics and other Medica-
. ments in Dermatology.
meee POSTGRADUATE LECTURE
4.30 P (Royal Infirmary.) Mr. J. R. Cameron :
Abnormalities of the Kidney.
Friday, 4th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. F. Wood Jones, F. R.S. : Anatomy of the Skin.
5 P.M. Prof. J. Z. Young, F.R.8. Nerve Injury and Nerve
Regeneration.
Saturday, 5th
INTERNATIONAL SOCIETY OF MEDICAL HYDROLOGY \
9 a.M. (Buxton.) Dr. J: Van Breemen: Four Causal Factors of
Rheumatic Disease
5.30 P.M. Mr. R. Whittington : Plasma Viscosity.
. Congenital
THE LANCET]
~ CONDUCING TO THE CURE
SOCIAL PSYCHIATRY IN THE TREATMENT OF
NEUROSYPHILIS BY INDUCED MALARIA
MAEVE WHELEN M. H. BREE
M.D. Lond., D.P.M. PSYCHIATRIC SOCIAL
MEDICAL OFFICER 1'C MALARIA THERAPY WORKER
CENTRE, HORTON EMERGENCY HOSPITAL
“ Life is short and Art is long; the Crisis is fleeting;
Experiment risky ; Decision difficult. Not only must the
physician be ready to do his duty, but the patient, the
attendants and external circumstances must conduce to
the cure.”
- Tais famous aphorism of Hippocrates expresses a
profound truth. Medicine originated as a social art.
Hospitals are the descendants of purely social agencies,
the . hospices of the early Christian era which gave
shelter not only to the sick but to the poor, the aged,
orphans, and travellers: later their functions were
separated and the hospital caring only for the. sick
appeared. Sickness was regarded as a social phenomenon,
as possession by the devil, as punishment for wrong-
doing, and so on. This gradually gave way to the
scientific approach to disease and the sick person hecame
an interesting pathological specimen rather than an
individual member of the community.. We are now
entering the era of the synthesis of these two outlooks
on sickness, and it is more and more widely recognised
that a patient is not only a carrier of a disease process
but is also an individual, a person living in a community
. who reacts upon and is reacted upon by that community.
Sir Arthur MacNalty (1943) expressed this well when
he said that one of the first steps in public-health reform
was the realisation that all forces—medical, environ-
mental, social, and individual—must be used to maintain
national health and combat disease. ,
The work of Canby Robinson at the Johns Hopkins
Hospital (Robinson 1939) is further evidence of the
need for the collaboration of medicine and social science.
He studied some hundreds of patients from the emotional
and social aspects and found that two-thirds of them had
adverse social conditions relating to their illness, and
in over half of these the adverse social conditions were
giving rise to emotional disturbances. He concluded
that the study of the patient as a whole and as a person
was essential to good medical practice, and that a
. knowledge of a patient’s difficulties would often throw
light on problems in public health and preventive
medicine.
. This paper is based upon a personal experience of
an attempt to link clinical medicine with practical
social science. The range of our experience is neces-
sarily limited by the nature of our work, but we feel
there are sufficient aspects of it to show the value of this
collaboration. |
PRACTICAL APPLICATION |
The starting-point of our work is the treatment
of neurosyphilis by induced malaria. We do not intend
to say anything about the strictly medical side of the
treatment—this has been done often and well—but to
confine ourselves to what might be called its social
aspect. . -
Before going any further we must say a few words
about the types of patients admitted for treatment.
. Since 1940 our range of patients has included a small
proportion of certified general paralytics and tabo-
paretics on leave of absence from their mental hospital
for the purposes of treatment ; a much larger proportion
of relatively early cases who do not require certification
to bring them under treatment; tabetics; cases of
syphilitic optic atrophy with or without other clinical |
. signs; asymptomatic cases without any clinical signs or
symptoms but. with cerebrospinal fluid (c.s.F.) positive —
6423
ORIGINAL ARTICLES VES, 7977 4Noloct. 5, 1946
on routine testing. Most of our patients have acquired
syphilis, but some have congenital syphilis and vary
from the gross mental defective to the asymptomatic
case. i
Illness, especially if it is prolonged and serious,
always engenders a situation fraught with anxiety, which
involves not only the sick person himself but also his
family and sometimes his friends. This anxiety, although
each case will have its specific factors, is based funda-
mentally on fear of the illness itself and what it may
betoken—actual or potential economic stress and uncer-
tainty about the future. Fear of the illness itself may be
aggravated if there is a feeling that there is something
mysterious about it and that it is not properly under- `
stood. A large proportion of our patients are admitted
with 11/,-2 years’ history of vague but progressive
symptoms; in some cases there have been repeated
visits to the doctor and various hospitals, only to be
told there is nothing wrong or to be given a week or
two’s sick-leave as a placebo. Finally they become so
ul that they have to be admitted to hospital, and a
thorough investigation reveals the cause of all the
trouble. Throughout this time there has been a gradually
increasing anxiety, which is often very greatly eased
as soon as a definite course of action is proposed.
Emotional reaction to the illness is absent in the grossly
psychotic or demented, but it is worth while to remember
that it may be present in a patient showing mental
symptoms. One of the worst cases of this sort of anxiety
we have seen was in a man with mild confusion and
severely impaired memory who was aware of his
disabilities and knew the nature of his illness. ` He
was a most pathetic object, and, owing to his mental
condition, very difficult to help. |
Sickness invariably raises economic problems for the
patient and his family, and unless these can be quickly
and satisfactorily settled they may give rise to a great
deal of unnecessary distress. This situation should
be dealt. with as expeditiously and sympathetically
as possible by the medicosocial worker. l
Lastly there is the question of the future. This involves
not only the outcome of the actual illness but, in many
cases, the patient’s ultimate re-establishment in the
community. It is often very difficult or impossible to
give a definite answer. The best one can do is to give
a simple and straightforward explanation, bearing in
mind the differing degrees of intelligence and under-
standing of those concerned. This has the added advan-
tage of enlisting their codperation in the follow-up
scheme. In this connexion the question of employment
is very important. It is probably true that any job is
better than no job, so long as it is within the patient’s
capacity—i.e., neither too hard nor too easy. In general,
the best type of work for a discharged patient is that to
which he is accustomed, since the resumption of habitual
activities helps to compensate to some extent for a
slight degree of deterioration. Unemployment leads to
boredom, but has the much more serious effect of making
. the individual feel unwanted and that he has no niche
_in society. The discussion of future plans with the patient
or his family is often very valuable and much appreciated ;
and if possible it is better to postpone discharge until
suitable arrangements have been made. In many cases,
of course, the patient has a job to go back to; but
where this is not so, it is sometimes possible to help
him to get suitable work or training. >` ica
.
. Mental symptoms, if present, may be the cause of a
- great deal of distress to the patient’s relatives. The
commonest reaction is, ‘‘ He isn’t mental, is he?” We
are quite sure the right way to handle this situation is
to explain simply but firmly that the patient is for the
time being mentally unbalanced, stressing the irresponsi- »
bility for his actions. It is often a help to try to-show the
kinship between physical and menial illness. There is a
6 or |
478 THE LANCET]
widespread belief among the lay public that mental
illness is incurable, and that admission to a mental
hospital means incarceration for life. It is often difficult
to convince people otherwise, but an attempt should be
made. If admission to a mental hospital becomes neces-
sary, permission is more easily given and anxiety allayed
if it is pointed out that today mental hospitals are
primarily hospitals and not places of detention, and that
it is possible to ask for and obtain a patient’s discharge.
If a patient shows much mental instability, it is impera-
tive to make an effort to keep him in hospital until
this has cleared up; occasionally it is impossible to do
this, and he has to be allowed to discharge himself
against advice, with the risk that he may prejudice
his future prospects by his unbalanced behaviour, even
though the prognosis of ultimate recovery is excellent.
If a patient is being discharged with some degree of
mental deterioration, it is as well to explain his limitations
carefully to a responsible relative and to give some idea
as to how to handle him.
What has been said so far, except for the section
on mental symptoms, is applicable to most types of-
serious illness, but in neurosyphilis there is the additional
factor of the syphilis with its moral implications. There
seems to be a very understandable disinclination among
doctors to tell patients or their responsible relatives
the nature of the illness. We feel that whenever possible
the patient should be told what is the matter; and, in
view of the risk of infection of other members of the
family and the consequent need of routine testing, it
is helpful if the patient can be persuaded to tell his
or her marital partner or allow the doctor to do so.
In cases where the patient is too ill, mentally or physically,
to give consent we usually tell the spouse on our own
responsibility. This does not mean that every patient
or relative concerned should be told everything; in
dealing with a disease like syphilis it is absolutely
essential to treat each case individually and to use the
utmost discretion. It is important to realise that
ignorance about venereal disease may be great, and the
implications of tabes, or general paralysis, or even
syphilis may be unappreciated. This can lead to diffi-
culties if information is unwittingly broadcast to relatives,
friends, or neighbours. We have met this catastrophe
more than once.
The knowledge that the disease is venereal, even
where there was previous’ suspicion, gives rise to con-
siderable emotional disturbance in both the patient and
his family, with which one must be prepared to deal.
The most pressing need is usually an opportunity to
“ get it off their chests ” ; this entails giving them a
chance to talk about the illness, to ask questions and so
on, apart from the time spent on taking a history.
There may be great anxiety lest other members of the
family are infected or may learn the nature of the
illness. It is essential to urge the necessity of doing
blood tests and, if necessary, lumbar punctures on all
relatives who have run the risk of infection. This in
itself may help to allay one type of anxiety. An early
reassurance that neurosyphilis is not contagious removes
a load of often unexpressed worry. We have known
cases where trained nurses have aroused this groundless
fear by isolating the patient or taking precautions to
protect themselves after learning the diagnosis. In
other cases the only thing that can be done is to reassure
about professional secrecy, but it must be borne in mind
that, although it is possible to guarantee that no member |
of the staff will give any information, the same cannot
be said for other patients and their relatives. We have
had several cases where either the patient or his family
has learnt the nature of the illness in this way.
The initial shock once over, the atmosphere is often ©
a good deal clearer, and one gets increased coöperation
in the treatment, a vital factor in a disease where treat-
DR. MAEVE WHELEN, MISS BREE: CONDUCING TO THE CURE
» 1943.
focr. 5, 1946
ment is long and tedious. Some time ago we had a
certified general paralytic whose wife had been an
inpatient with syphilitic ulceration of her legs. On
discharge she was advised to attend as an outpatient
for further treatment. She did so regularly until the
blitz made travelling difficult, when she lapsed. She
was seen in connexion with her husband’s illness and told
what was the matter. Her immediate response was,
“ Why ever wasn’t I told this before? Of course, if
I had only known it was so serious I should never have
left off going for treatment, however difficult it was to
get there.” If there is any contra-indication to explaining
the exact nature of the illness, a partial explanation may
prove useful, although this is not accepted at its face
value so easily since the Ministry of Health started
its campaign against venereal disease. People are now
rather apt to jump to the right conclusion ! l
A point that needs mentioning is the attitude of the
staff to v.p. Anyone who feels that it is a moral rather
than a medicosocial question should not work in the
department. The staff must be able to accept the patient
‘a8 a patient. This attitude of acceptance can be most
helpful, especially in cases where there is considerable
emotional reaction to the v.p. A patient of ours was
admitted in a great state of emotional upheaval because
of this. He was bitterly ashamed of his illness, terrified
that his family would get to know what was wrong,
and certain that anyone who knew what was the matter
would regard him as an outcast. The change in his
whole demeanour when he found that he was not looked
upon as a pariah but was accepted as a member of the
ward community was striking. He was converted
from a potentially very difficult patient into one who
was cooperative and helpful, and a possible full-blown
neurotic breakdown was averted.
The situation engendered by the illness with its
anxiety and stress may give rise to a superadded neurosis
in the patient or a potential or actual neurotic breakdown
in the family. The latter not. only produces another sick
person but will react adversely on the original patient
and still further complicate the family situation.
It is a direct benefit to the community for a sick
person to be restored to the best degree of health possible,
and every facility should be given for the reabsorption
' into employment of all the partially disabled, whether
physically or mentally handicapped, who are capable of
doing useful work. With this end in view it is essential
that the liaison between the hospitals and the employ-
ment exchanges should be strengthened and expanded.
Many adverse social conditions—e.g., the cost of treat-
ment just at the time when the income is lowered,
bad housing, congestion, lack of recreational facilities—
need to be radically altered for the whole community.
Efforts are made to help patients individually, but it
must be recognised that, unless these reforms are carried
out, any special priority given to one means, under
present conditions, that he receives it at the expense
of another, who may in his turn suffer through the
deprivation. 7
ILLUSTRATIVE CASES Da
CasE l.—Male, married, aged 32, was admitted in April, —
For the past three years he had been '*‘ making the
rounds of the hospitals,” feeling something was wrong with
him but getting no satisfaction. About six months before
admission he began to lose confidence in himself and became
afraid he would have an accident and injure his passengers
(he was a tram-driver). He found it difficult to convince
anyone that he was ill and unfit to drive, though he was
‘eventually transferred to point work, but. by then he felt
unfit to work at all. Finally his behaviour became so dis-
ordered that he was admitted to an observation ward and
then transferred to us. |
. On admission he was at times euphoric and mildly grandiose
and at others appreciated what was wrong and was anxious
to be treated. He was infected with malaria and had twelve
peaks of fever of 103°F or over. Immediately after treat-
\ FOR weeny |
THE LANCET]
DR. MAEVE WHELEN, MISS BREE:
CONDUCING TO THE CURE [ocT. 5, 1946 479
ment his mental symptoms became more pronounced, and
he was interfering, truculent, and emotionally unstable.
This abated pretty quickly and, although still rather uncertain,
he responded to a simple explanation about his illness and
treatment and agreed to go as a voluntary patient to a mental
hospital. The desirability of attending the follow-up clinic
after his discharge was also explained to him.
He stayed in the mental hospital from July, 1943, to
February, 1944. He was seen by us in November, 1943, at the
request of the mental hospital. He then appeared, in view
of his negligible degree of dementia and enhanced stability,
rather too well adjusted to hospital life; so we recommended
that an attempt should be made to find him suitable work or
training through the rehabilitation department. He was
therefore sent to an aftercare home in February, 1944, and
arrangements were being made to place him, when he walked
out leaying no address.
In April, 1944, he wrote saying it was nearly six months
since his last lumbar puncture, and he thought he was due for
another ; so could he have an appointment ? He turned up on
the appointed day showing a remarkable improvement. He
said that on leaving the aftercare home he had spent a
couple of days putting his affairs in order and had then
got a job helping on a crane. When last seen in September,
1946, he had maintained his improvement and was still
holding down the same job.
This patient’s codperation was enlisted by giving him
a simple individual explanation at a time when he was
able to appreciate that this was done in his own interests,
and that the situation demanded the coöperation that
we believed he could give. |
Case’: 2.—Male, married, aged 62, was admitted in
December, 1942. He was fairly well educated, and had
his own small business. He had had lightning pains for about
twelve years and had undergone a gradual change in per-
sonality during the last five or six years, becoming progres-
sively duller, mildly suspicious, and careless about his bills.
From February, 1942, he began to have frequent lapses of
memory, lost his business acumen, and made serious mistakes
in his estimates. His wife eventually became afraid of his
driving a car or handling financial matters and insisted
on his seeing a specialist.
On admission he was slow, dull, disorientated, and mildly
grandiose. He was infected with malaria, having 13 peaks
of fever of 103°F or over. After treatment his mental
svinptoms suddenly increased; he became acutely hallu-
cinated, confused, and restless. His wife’s consent was
obtained for his transfer to an observation’ ward ; but action
was deferred, as he began to show signs of improvement
and then rather suddenly became simple, childish, and
well-behaved.
His wife, who knew the nature of the illness and whose
od was negative, was faced with the problem of his business ;
if he was going to recover, then she wanted to keep it if
possible; if he was not going to be fit to direct it again, then
she wanted to dispose of it. The position was explained to her
as clearly as possible, and it was pointed out that it was
impossible to give a definite prognosis. She decided to try
to keep the business going for the time being.
When he finally settled down, his wife thought she could
look after him at home. Fortunately he was amenable to
suggestion and agreed not to touch any business affairs
for at Jeast six months but to rest and take things quietly.
Four months later, when he attended the follow-up clinic,
he showed a slight improvement. His wife reported that
he could make a satisfactory estimate, although he later
confused the jobs. He did not attempt to interfere in any
way, apparently as a part of his rest treatment.
He was seen again in April, 1944, when his wife reported
a steady improvement in business capacity and said they
had made a profit of £550 as against a steady loss while
he was in hospital. He still, however, showed signs of slight
residual deterioration—e.g., a slightly impaired memory
and a mild emotional instability. He was last seen in April,
1946, and had maintained his improvement.
This case illustrates the patient’s rehabilitation
through his family and the importance of suitable
employment. The ultimately comparatively successful
outcome was due not only to the treatment but also to
the able coöperation of his wife, which was enlisted
by giving her a good understanding of the situation.
Case 3.—Female, married, aged 45, a high-grade mental
defective, admitted December, 1942. On admission she
was emotionally unstable and slightly amnesic. She was
infected with malaria and had 12 peaks of fever of 103° F
or over. After treatment she became acutely psychotic,
declared she was Gracie Fields and broadcast every evening,
and was very confused and uncertain. This cleared up fairly
quickly, and when she was discharged she was childish and
mildly deteriorated but not very noticeably below her original
poor level. l l
Her husband was a thin anxious individual with a fair -
degree of intelligence. He had been brought up in an institution
and then gone into the Navy. He married soon after his
discharge, mainly to have a home. He had not known
his wife long and soon regretted the marriage. They had two
children (now aged 24 and 23) very soon after marriage.
About this time he contracted syphilis, had about two years’
treatment, and was told he was cured. Unfortunately he
infected his wife: she had some treatment and then lapsed.
As a result of all this he had a markedly ambivalent attitude
towards his wife, expressing remorse for his ‘‘ crime,” resent-
ment at his “ bad luck,” and anger with his wife for not
having continued her treatment, with the result that he had
worried for years over the possible later effects on her. Lately
he had felt numb on rising and had pain in the back of his
head. He and his daughters had tests which gave negative
results.
He was given a full and simple explanation about his
wife’s treatment and prognosis and had special interviews |
when visiting her and later when he brought her to the
follow-up clinic. He became better able to deal with his
remorse, resentment, and lack of affection for his wife. While
his wife was acutely psychotic he was asked to give his consent
to her certification. This produced an intense conflict, as
intellectually he could see the benefit to his wife, his daughters,
and himself; but his lack of affection and the realisation
of the difficulties he would have to shoulder if she came home
seemed to offer a method of self-punishment or expiation.
After his wife’s discharge he gradually settled down.
He clearly appreciated her innate limitations and shouldered
all the major responsibilities in the home, but without the
self-accusatory and self-punishing colouring which were so
much to the fore at first, and the physical symptoms of which
he complained while his wife was in hospital have disappeared.
This case illustrates the need to deal with an emotional
disturbance in a member of the patient’s family. If the
obligation to the husband had been limited to testing his
blood and cerebrospinal fluid, it is possible that his mental
conflict would have resulted in a neurotic breakdown,
which would have adversely affected his daughters and his
working capacity and would have made the patient’s
chance of adjustment outside an institution very unlikely.
DISCUSSION
Medicine for a long time has concerned itself mainly
with the curing of disease, but now its scope has been
enlarged to include the maintenance of health. This
entails the consideration of the patient as an individual
and not simply as a carrier of disease; Mr. A must be
Mr. A and not just a ‘‘ case of hæmorrhoids.” All factors
that are adversely affecting him must be considered
with a view to their elimination or mitigation, either by
enabling him to deal with them himself or by actually
removing or altering them by outside interference. In
future, not only must the physician be ready to use all
the medical knowledge and resources available to him
but he will accept, as part of his duty, the obligation to |
assist ‘‘ the patient, the attendants and external circum-
stances ” to “‘ conduce to the cure.”
“ Prevention is better than cure” is a popular and
true slogan. It will be more often achieved if all oppor-
tunities are utilised. For instance, if a close friend or
relation has been exposed to infection or to an emotional
situation with which he cannot cope, an attempt should
be made to arrest the trouble before it has had time
to develop. Case 3 is an example where this was done
successfully. -
The increasing complexity of medicine means that
the doctor can no longer work satisfactorily in isolation
i o2
480 THE LANCET]
but must be a member (albeit the responsible member)
of a team containing medical and non-medical personnel.
It is impossible for the doctor, even if he has the time,
to deal with all the social aspects of an illness, as he has
not the necessary training and knowledge. This side of
the illness is far better.dealt with by a trained medico-
social worker, working in the closest, collaboration with
the doctor.
Team-work and Slane the scope of clinical medicine
: will open up a great field of research, embracing mental
hygiene, prophylaxis, and social medicine.
CONCLUSIONS
The empha: should be shifted from the curing
of an illness to the wider conception of the promotion of
optimum health. This entails the recognition of each
patient as unique ; a particular individual, in a particular
family, in a particular environment.
The wider outlook means that the patient’s family
is included in the total picture, with the result that
incipient trouble in another member of the family
is more likely to be noticed and dealt with prophy-
lactically before it further aggravates the situation.
The criterion of successful treatment is the degree
of satisfactory functioning of .the patient in society.
. This entails cooperation between medicine and. social
science.
We wish to thank Dr. W. D. Nicol, medical superintendent
of Horton Emergency Hospital, for his interest and
coöperation.
REFERENCES
MacNalty, A. S. (1943) Practitioner, 151, 133.
Robinson, G. C. (1939). The Patient as a Person: a Study of the
Social Aspects of Illness. Commonwealth Fund, New York.
THE USE OF REASSURANCE
T. G. ARMSTRONG
M.D. Camb., M.R.C.P.
LATE LIEUT.-COLONEL R.A.M.C.; OFFICER I/C MEDICAL
DIVISION OF A GENERAL HOSPITAL
Ir is to be regretted that during the last fifty years
of scientific progress the management and handling of
patients has been neglected in the medical curriculum.
The personal, and often intimate, methods of the older
physicians are being replaced by highly specialised or
materialistic impersonal methods.
The management of patients, though not an exact
science, is, or should be, part of a discipline comprising
method and technique. It can be studied and improved
in the same way as other scientific disciplines. Train-
ing in this subject is necessarily more difficult than
the simple acquisition of facts. Much depends on the
' establishment of sympathetic contact with patients, and
perhaps yet more on experience. Our only training
has been in the hard school of experience over many
years. Much time could have been saved and long
periods of sickness avoided if the principles of personal
therapeutics had been taught in our medical schools.
Six years of military medicine have provided.a valuablé
lesson in the handling of young active patients whose
main desire is to get well, as opposed to older folk
who often “‘ enjoy ill health ” and in whom it can even
be a disservice to cure their imagined ailments.
Neurosis is just as common in the Services as it is among
civilians ; but, owing to this desire to get well, it is much
more easily treated. I intend here to show how this can
be done by reassuring the patient.
VALUE OF REASSURANCE
Reassurance (by which I mean the allaying of the
patient’s anxiety) is of great value not only in treating
neurosis but also in cases of organic disease. Fear of
an existing organic disease often produces greater dis-
t
- DR. ARMSTRONG: THE USE OFf REASSURANCE
[ocr. 5, 1946
ability than:does the disease itself. Silence, except in
the gravest maladies or with patients of the lowest
intelligence, is inconsiderate and even dangerous. Too
few patients are told the cause of their complaint ; . too
little is said of the probable duration of. treatment
and the ultimate outcome. I have been impressed by
the value to the happiness of my patients of a frank
explanation of their disease and its prognosis. I have
also been depressed by the frequency with which patients
who have been previously investigated have received
no indication of the nature of their malady. Curiously,
this neglect has been most noticeable when the findings
have been negative.
After making a diagnosis, whether of organic disease
or neurosis, some doctors overtreat patients by useless
methods. Lengthy treatment for incurable disabilities
is a potent cause of additional ill health. The oft-
repeated bottle of medicine, the continued application
of physiotherapy, and the weekly certificate are poor
substitutes for sympathetic explanation and encourage-
ment to keep at work and make the best of not too
bad a job. With young people simple explanation,
reassurance, and minor psychotherapy have been so
‘ often effective in forestalling serious invalidism and
curing existing disabilities that I have thought it worth
while to describe here the simple method used. . It must
be emphasised that simplicity is the keynote. The
approach has always been that of the general physician,
and no attempt has been made to treat major psycho-
neurotic illnesses; nor have en eae methods
at any time been used. |
METHOD OF REASSURANCE
The Doctor’s Diagnosis.—No patient can have full
confidence in his doctor if a complete examination has
not been carried out, and no doctor can confidently
reassure his patient without having carried out such an
examination. Organic disease should only be diagnosed
when there is reasonable proof that it is present. It is
better to attribute incorrectly a small percentage of organic
illnesses to functional causes than to condemn a large
number of healthy patients to the fear of a non-existent
disease. If a functional disturbance is diagnosed, the
doctor should appreciate his good fortune rather than
decide (as he too commonly does) that this is yet another
piece of medical junk to be thrown on the scrap-heap of
disinterest.
The Patient's Diagnosis .—What does the patient cop-
sider his malady to be? What organ does he think is
diseased ? What is his attitude to his condition ? What
does he fear? Does he fear a progressive illness leading
to total incapacity ? The answers to these questions are
of the greatest value. Without them no real reassurance
can be given to a patient with functional disease, for
unknown fears cannot be calmed. These questions are
as important as a full physical examination ; they must
be viewed ‘‘in daylight,” recognised, and frankly dis-
cussed. Occasionally the patient will spontaneously
voice his fears. More often he must be questioned. It
is best to ask a general question such as, ‘“ What do you
think is the matter with you ? ” But it may be necessary
to put it in specific terms: to a patient complaining of
left inframammary pain on exertion +‘ Do you fear mans
heart is affected ? ”
A healthy soldier, aged 23, who had been ended to
category B for etfort syndrome following diphtheria, continued
to complain of dyspnæa, precordial pain, and palpitation
on the least exertion. Asked his opinion of the cause, he
said that he thought he had permanently injured his heart.
Early in the first siege of Tobruk he had been admitted to
hospital with faucial diphtheria and told that he must remain
at complete rest in bed, as otherwise his heart might be
damaged. Unfortunately, owing to extreme pressure on the
orderlies, he had to get up to obtain food and to visit the
latrines. He was later evacuated to the base and kept at
` THE LANCET]
complete rest for six weeks ;- but he believed that irreparable
damage had been done during the first week in Tobruk. |
After specific reassurance his symptoms disappeared and
to his great satisfaction he was regraded to category Al.
Other Doctors’ Diagnoses.—It is always worth while in
complaints of functional origin, especially those referred
to the heart, to ask if any doctor has ever told the patient
the nature of his illness. Opinions given by doctors
always carry great weight with patients and heavily
influence their opinion about themselves. A patient
who has been told that he has a ‘“‘ strained heart” or
“a little weakness of the heart ’’ will be.convinced that
he has some form of heart disease. His belief will at
least modify his attitude to exercise, and at the most will
produce a fear—not readily expressed—of sudden death.
Previous positive diagnoses are often reported by patients
with heart-consciousness or effort syndrome. If such a
diagnosis of organic disease remains fixed in the patient’s
mind and is not discussed, reassurance by a second doctor
is clearly useless. Conviction of the absence of organic
-' disease is an absolute essential for reassurance and
.recovery, and can only be achieved if the final opinion is
completely accepted and the original opinion of organic
disease rejected. Often the first opinion will be found
to have been correct and reasonable, but to have been
misinterpreted by the patient ; frank discussion, and a
statement that the disease which had been present at
the time of the previous opinion has cleared meanwhile,
will often reassure the patient. |
A healthy soldier, aged 23, complained of precordial pain,
‘palpitation, and dyspncea on exertion. There were no
abnormal signs. His regimental medical officer had told him
that he had mitral stenosis and should be invalided home.
He was reassured but did not get well. On direct questioning,
he admitted disagreement with my reassurance ; he felt that
his own medical officer, who had watched him for a long time,
knew his case well. He believed that his medical officer’s
opinion was correct and mine wrong. He refused to accept
my reassurance and retained his symptoms.
Emotional Upset.—It is useful to inquire for emotional
upset at or before the onset of illness. Occasionally
there has been a severe mental trauma; more often a
succession of minor disturbances have exerted a cumula-
tive effect. The following case-record from civil practice
is an example of a single mental trauma.
A young man, aged 19, a factory messenger, complained
of three months’ left inframammary pain, palpitation, and
dyspneea on exertion. These had been so severe that for the
last two months his doctor had kept him off duty.
On examination he had no physical signs. He was asked if
anything notable had happened to him about the time of the
onset of his illness. He replied, “ No, I don’t think so.
Nothing much, except that my girl friend broke off her
engagement to me.” He was asked casually if he was suffer-
ing from a broken heart. He burst into emotional laughter
lasting several minutes.
The situation was explained to him, and he was assured
that he had no organic disease, His pain on exertion ceased
abruptly after the interview. He was given a week’s graduated
exercises to restore his confidence, after which he returned to
work, and six months later he was still at work and had no
symptoms. 5 o
His illness and two months’ incapacity for work could have
been prevented by prompt reassurance at the onset.
Such cases are unusual; more often a succession of
annoyances have impaired morale and rendered tha
patient conscious of minor disabilities which would not
normally trouble him or induce him to report sick.
Explanation.—If organic disease has been excluded,
this must be carefully explained to the patient. It is
especially necessary at the outset to gain the patient's
coöperation and confidence. The doctor must tell him
clearly that he. does not believe him to be a “ lead-
swinger ° and must explain to him the nature of
functional ‘disease. It is useless to try to reassure a
patient by telling him that there is nothing wrong with
DR. ARMSTRONG: THE USE OF REASSURANCE f
[ocr. 5, 1946 481
him. He knows that he is il; his symptoms tell him
so. It is equally unprofitable to tell him that he is
imagining his complaint ; this will injure his self-respect,
suggest that he is malingering, and destroy his confidence
in the doctor. The doctor must openly admit that the
patient’s symptoms are genuine, and must explain the
reasons for the symptoms. On his ability to satisfy
the patient by explanation will: depend the success of
treatment. ' l
Men who have had a minor organic illness—e.g.,
fibrositis of the back—may, ‘under the stress of emotional
or environmental factors, persist in complaining of pain
after all signs of active disease have disappeared ; the pain
has become a habit. Sometimes such pains are partly
fostered by the continued adoption of a faulty posture
originally due to attempts to ease a real pain. The
explanation of such a case, followed by a short course
(not more than fourteen days) of re-educative exercise,
will relieve the patient’s symptoms without causing
him any loss of self-respect. It must be emphasised
that there is no longer any organic disease, and that
the treatment prescribed is merely re-educative. The
patient should be led to believe that his symptoms are
due to lack of confidence in his body, and that he is
simply being taught how to cure himself. T
In suitable cases, particularly in functional disturb-
ances of the gastro-intestinal tract and of the cardio-
vascular system, the mechanism of emotional reaction
should be simply explained. The patient should be told
how emotion can alter the working of an organ and 80
cause real discomfort and pain. Examples should be
given. It should be pointed out that everyone knows
that sudden fear occasioned by a nearby explosion will
cause a rise in pulse-rate in normal people. It is common
for normal men in the emotional strain of waiting for
an examination to experience frequency of micturition.
Such examples may be given to illustrate the reaction of
emotion. Stomach disorders are more complicated ;
but, besides mentioning the indigestion that may follow
fear and the anorexia that may accompany love, it 18
useful to explain that direct visual observation of the
interior of the stomach has established that its lining
membrane becomes congested or inflamed under the
influence of severe emotional stress.
In some cases it may be necessary to explain to the
patient that a*person who believes he has a disease-
unconsciously focuses his attention on the incriminated
organ and becomes, for example, heart-conscious Or.
stomach-conscious. In other words, he becomes unduly —
sensitive to normal reactions in those organs. n
Final Reassurance.—In pure functional disorders it
should be stated, emphatically and without any “ hedg-
ing” or the expression of any doubt, that no organic
disease exists. There must be no room in the patient's
mind for any doubt about the doctor’s opinion. The
doctor should also find out if the patient has accepted his
opinion. If the patient has not done so, further explana-
tion may be necessary. If, in spite of this, the patient still
refuses to accept the doctor’s opinion and makes some
such remark as “ But why do I get this pain?” the
prognosis is bad.
OTHER TREATMENT
As a rule, in the absence of organic disease, specific
treatments should not be ordered. But in some cases
such treatment is useful for saving self-respect, restoring
confidence, and maintaining coöperation. In such cases
the adjuvant treatment should aim at progress and
not rest. Rest in bed is recommended too often and
for too long; it fosters the belief in a serious disease.
It.should be made clear to the patient that the treatment
is not meant to counteract a disease but to assist his
natural resources. To a man with functional backache
graduated exercises are important ; being out of training
he must readjust himself gradually, and if he does too
THE LANCET]
482
much he will become stiff. Barbiturates are invaluable
took place 2-24 months previously.
for inducing sleep in anxious and nervous patients.
The treatment should be short, rarely more than two
or three weeks. If no progress has been made at the
end pf this time it never will be, and continuance of
treatment will merely foster belief in its e
SUMMARY
Reassurance, or the allaying of the pat ae anxiety,
is of great value not only in neurosis but also in organic
_ disease by removing ill-founded fears.
For reassurance to take effect, the patient must have
complete confidence in the doctor, and the doctor com-
plete confidence in his diagnosis. This is best done, in
psychogenic cases, by explaining to the patient the
mechanism involved.
Adjuvant therapy must be short, i avoid suggesting
to the patient that he has a serious disease ; and it must
be aimed at re-education of the patient.
_ My thanks are due to Prof. J. A. Ryle zor much helpful
criticism and advice.
THE POST-HEPATITIS SYNDROME
SHEILA SHERLOCK, M.D. Edin., M.R.C.P. -
BEIT MEMORIAL RESEARCH FELLOW
VERYAN WALSHE,* B.Sc. Lond.
From the Department of Medicine, British Postgraduate Medical
T School, London
eatavats (1944) has described cases of persistent
disability following postvaccinial (yellow fever) hepatitis
and has designated the condition the ‘“‘ post-hepatitis
syndrome.”
Benjamin and Hoyt (1945) report a similar series, and
during the past two years we have studied a group of
soldiers in whom symptoms and usualy an enlarged
liver have remained after clinical recovery from acute
hepatitis. Besides studying the clinical features and
making biochemical investigations, we have used the
aspiration technique of liver biopsy to study hepatic
histology. At the present time, when so many men
who have had hepatitis are returning to civilian life, it
seems important to report the findings.
Our 20 patients were soldiers of the British, Canadian,
and Czechoslovak Armies. All were grade A before
contracting acute hepatitis. In 18 the hepatitis was
of the simple “infective”? type; in 2 it had followed
_arsenotherapy for syphilis.
The laboratory methods used were the estimation
of serum-bilirubin, cholesterol, alkaline phosphatase
(King and Armstrong 1934), and total and differential:
serum proteins. The colloidal-gold reaction (Maclagan
1944), the bromsulphthalein test with a 5 mg./kg. dose
and taking 5-min. and 30-min. samples (Helm and
Machella 1942), and the intravenous hippuric-acid test
(Sherlock 1946a) were also used. Routine urine examina-
tion included urobilinogen by Ehrlich’s aldehyde reagent,
and bilirubin by Hunter’s test (Pollock 1945).
Aspiration liver biopsy was performed by the method
previously described (Sherlock 1945). `
FEATURES OF THE DISORDER
- The presenting features were as follows :
No. of cases No. Gag
Fatigue gs .. 18 Fat-tolerance 6
Weight-loss .. oe. bd Relapse of hepatitis. . 8
Anorexia .. ae. a2 Palpable liver ~» 16 °
Abdominal discomfort 10 Palpable spleen = 3
Preceding Hepatitis and Relapses.—Of the 20 patients
6 had had more than one acute attack of hepatitis; 1
-_———— auala a Iiae aaa IMa aama aaa ŘŘŮĖ— o i Miamo Iacaas
* In receipt of a maintenance grant from the Medical Research .
Council, who have also defrayed the expenses of this investi-
gation.
DR. SHEILA SHERLOCK, MISS WALSHE : POST-HEPATITIS SYNDROME
[ocr.. 5, 1946
patient was said to have had six. The last acute ee
Symptoms.—The usual complaint was lack of energy
and exhaustion on minimal exertion. Inability to
regain the weight lost during the acute attack was
common. Gastro-intestinal symptoms. were prominent ;
some patients had a poor and variable appetite, with
sometimes an aversion to fatty foods. The men were very
_ faddy about their diet. Right upper abdominal discomfort,
often aggravated by exertion, was occasionally present.
Consumption of Alcohol.—Of the 20 patients 10 con-
fessed to excessive alcohol intake, 6 took moderate
amounts, and 4 were almost teetotal.
Mental State—A detailed psychiatric écamination
was not attempted. . The British patients were on the
=- whole psychologically ill-balanced. They were extremely
introspective and unduly apprehensive about their
livers. One was an Army deserter, another had. just
been invalided from the Services with ‘‘ effort syndrome.”
The Canadian group showed better understanding of their
symptoms.
was often noticed. Moreover, they were in hospital at
the end of European hostilities, when there was delay in
repatriation to Canada, and it was believed that ce men
would receive priority.
General Examination. —Despite he dapin of
weight-loss, the general development of the group was
excellent. Spider angiomata were not seen.
Hepatomegaly.—The most common positive finding
was hepatomegaly. The liver edge, smooth and rubbery.
in consistence, could be felt on inspiration 2—7 cm. below |
Tenderness
the right costal margin in the nipple line. |
was not present. Liver tenderness on fist percussion over
the right lower ribs (Barker et al.1945) was not elicited.
Splenomegaly.—In 3 patients the spleen could just be
palpated under the left costal margin.
Urine Analysis. >This was usually normal, but 5
patients showed a trace of urobilinogen in an early
morning specimen of urine. Hunter’s test for bilirubin
was consistently negative.
Biochemical Investigations.—In every patient the
serum-bilirubin, the total and differential serum proteins,
and the bromsulphthalein test were normal. The serum-
cholesterol level was high in 7 cases ; in 3 of these it was
greater than 300 mg. per 100 ml. Slight.changes among
the other estimations were a serum-phosphatase of 14
units per 100 ml. in one patient, a weakly positive colloidal-
gold reaction in two patients, and in a further two cases
the excretion of hippuric acid was at the lower limit
of normal (0:7 g. as sodium benzoate). - The biochemical
observations on the whole, therefore, gave essentially
normal results. Caravati (1944) found a low fasting
blood-sugar level and flat oral glucose-tolerance curves
in some of his patients. Glucose-tolerance tests were
performed in 5 of our subjects and gave normal results.
Hepatic Histology—There was no evidence of con-
tinuing ‘hepatitis or of cirrhosis. The lobular pattern was
not disturbed. The hepatic cells were usually normal and
contained their normal complement of glycogen. In
2 instances the glycogen was slightly deficient, and in
another there ‘was patchiness of glycogen. Iron was
absent both from the Kupffer and the hepatic cells. In`
one patient who had previously had malaria, there was
iron in both situations.. In ten sections some excess
of fat was seen in the liver-cells. It usually took the
form of scattered fine droplets evenly distributed through
the lobules. In another case the fat was peripheral.
Slight fatty change was the only abnormality encountered
with any frequency. The Kupffer cells were normal.
In 3 patients, all within three months of the initial attack
of hepatitis, excess of fibrous tissue was seen in the portal
tracts. The picture here resembled residual portal
scarring following hepatitis (Dible et al. 1943).
All, however, had been warded together,
and a similarity in the wording of their case-histories.
—
THE LANCET]
DR. SHEILA SHERLOCK, MISS WALSHE : ‘ POST-HEPATITIS SYNDROME
ILLUSTRATIVE CASE-RECORDS
Case 1.—A British officer, aged 31, was fit until October,
1943, when .he had infective hepatitis in Libya. He was
jaundiced three months and lost two stone in weight. He
was invalided home in April, 1944. Since the hepatitis he
had had persistent right upper abdominal discomfort, made
worse by exercise. Fatty foods caused nausea and flatulence.
Appetite was variable. There was exhaustion on walking only
half a mile, and some dyspneea on exertion. In October, 1944,
he was again slightly jaundiced and in bed a week. He was
a moderate drinker of alcohol.
` On examination (March 10, 1945) he was a tall well-developed
man, not jaundiced. The smooth rounded liver edge could
be palpated 6 cm. below the right costal margin. Tender-
ness was not present. The spleen was not felt. Urine
analysis was normal. The biochemical investigations were
normal. Aspiration liver-biopsy sections showed normal
liver histology (fig. 1).
This patient was extremely introspective and worried about
his health. He had had advice from many doctors, both
Army and private, before the present investigation. Even
when he was ‘told that his liver was normal the symptoms
persisted.
CasE 2.—A Canadian Nn.0.0., aged 31, had had infective
hepatitis at 16 years of age, when he was jaundiced a month.
In September, 1944, in Italy, while having arsenotherapy
for syphilis, he again became jaundiced for three weeks. The
symptoms were those of acute hepatitis.
Since then he had complained of lack of energy and
dyspnea on exertion. The appetite was poor and there was
much heartburn and gastric flatulence. During the jaundice
the patient lost a stone in weight ; this had not been regained.
In May, 1945, there was a further attack of hepatitis ; jaundice
lasted about a week. The symptoms persisted. Cholecysto-
grams were normal. Patient drank a lot of beer, usually
six pints a night, with extra beer and spirits at the week-
end; this had continued to the date of this investigation
(July, 1945).
On examination he looked well. He was s not underweight.
The liver was palpable 4 cm. below the right costal margin.
The spleen was not felt. Urine analysis was normal. The
only abnormal biochemical finding was a serum-cholesterol
level of 309 mg./100 ml.
Aspiration liver-biopsy sections showed a slight excess
of fat within the hepatic cells at the periphery of the lobules ;
the portal tracts contained a little excess fibrous tissue and
showed some round-celled infiltration (fig. 2).
The repeated attacks of jaundice had made both the
- patient and his medical advisers suspect permanent liver
damage. When the present investigation showed this not
to be the case he was much relieved and became symptom-
free. i
DISCUSSION
In the group studied there is no causal relationship
between the slight biochemical and the hepatic histo-
logical changes and the symptoms. Similar findings have
been observed in patients now symptom-free but within
AA Y at y
SEERE ERE 3; wiy
4
he Pie ds rig oR oe ee
ie. “y A , M d ad ~ pi 7 E
b; * - y % $ eae hg : 2
z š a ee: i
Sin
ne
RL EN a
etter ” z in i
S TEPER ce áA
Ae S game * sI Ng r ;
Wet t at Eee Ge
a: 7-29 + Rake
™ a om of)
Hse al TA
E ES AR
we we = S A raa
Ae we =; 8 owe a 4 T
Fig. 2—To left of the rine 2 Sorel tract shows increased fibrous
tissue and is infiltrated with mononuclear cells ; at the periphery
of the lobule the hepatic cells show slight fatty change. Case 2.
Best’s carmine stain. ( x 120.)
mon in normal subjects.
[ocr. 5, 1946 483
Page
>N i SM i
tr.
Uhtas
OLUA
Fig. |Normal kaaien structure. Caii l. Best’s carmine stain. ( x 120.)
six months of clinical recovery from acute hepatitis.
In 10 of 15 such subjects the liver was still palpable.
Hepatic sections usually showed portal-tract scars, and
in 7 excess fat was present in the liver-cells. A raised
serum-cholesterol level is also sometimes found during
recovery from hepatitis (Sherlock 1946b). Benjamin and
Hoyt (1945) believe that the symptoms may have a
psychotic basis; the psychoneurotic patterns observed
in our patients were very similar to those recorded by
these authors. Acute hepatitis is nearly always an
unpleasant experience. It usually lasts a minimum of
3-4 weeks. Convalescence is slow. If the illness relapses,
as it did in many of this group, fear may arise of further
attacks and of permanent liver damage. This is accentu-
ated if a number of men are warded together and
repeatedly examined with a view to determining liver
size. The condition has not been seen in civilian patients. |
It is commoner in those serving overseas. Some men feel
the disease may provide an opportunity for repatriation.
In the type of person affected the condition is some-
what analogous to “ effort syndrome,” with symptoms
focused on the liver and gastro-intestinal tract rather
than the heart.
The hepatomegaly may in some instances be related
to the histological picture of fatty change and residual
portal-tract scarring. A more likely cause is the down-
ward displacement of a normal-sized liver by the dia-
phragm. Some patients, with practice, become very
efficient at ‘‘ pushing down the liver.” On inspiration
the lower liver edge has been observed to move down
6 cm. in one of these patients; an impalpable liver is
thus easily felt. Similar considerations apply to the
spleen. Moreover, a palpable liver, usually but not
constantly due to downward displacement, is not uncom-
On ten occasions such a liver
has been subjected to aspiration biopsy with entirely
normal results. .
The importance of the syndrome:is in its distinction
from the serious organic sequelæ known rarely to occur
after hepatitis (Krarup and Roholm 1941, Dible et al.
1943, Rennie 1945). We have studied 6 patients in whom
cirrhosis could be related to a preceding acute hepatitis :
1 showed hepatomegaly, splenomegaly, and abnormal
results for all the biochemical methods used; 2 were
symptom-free and presented only hepatomegaly ; the
remaining 3 had clinical features and biochemical findings
identical with the series now reported. Clinical and
laboratory findings cannot constantly distinguish organic
from possibly psychogenic sequele; but a definite
conclusion can usually be reached after study of aspiration
liver-biopsy sections. The importance of this method is
emphasised. All the patients volunteered for this
procedure and usually derived great benefit from the
reassurance possible when results were known.
484. THE LANCET]
| k
MR. PATEY, PROFESSOR SCARFF: POSTANAL PILONIDAL SINUS:
[oor. 5, 1946
NLR D a AA gt ger SS
This sequel of hepatitis may be prevented if:patients
with the same condition are not herded together. Patients
apparently recovering normally should not be examined
too often. The condition is unlikely to occur with any
frequency in civilians. Treatment consists in reassurance
after the fullest possible investigation.
SUMMARY
In 20 patients fatigue and gastro-intestinal rain iors
arose, usually with hepatomegaly, after acute hepatitis.
Serum-bilirubin, phosphatase, and differential protein
estimations, the colloidal-gold reaction, the intravenous
hippuric-acid test, and the bromsulphthalein test showed
no abnormalities. There was an occasional rise in serum-
cholesterol level. |
Hepatic sections obtained by aspiration biopsy were
usually normal. In some sections slight fatty change in
the liver-cells and occasional scarring in the portal tracts
could be seen. |
No difference was found between these results and those
obtained in subjects who had recovered from acute
hepatitis and were now symptom-free.
The possible peyonegeuse basis of the symptoms is
discussed.
The palpable liver seems due to downward displace-
ment of the liver edge rather than to enlargement. _
The value of aspiration liver biopsy in the diagnosis
of this syndrome from post-hepatitis cirrhosis is
emphasised.
We are indebted to Major- Géaseal A. G. Biggam, and
Lieut.-Colonels W. R. M. Drew and W. H. Hargreaves, of the
R.A.M.C., and Brigadier Palmer and Major B. N. Fahni, of the
R. C.AM.C., for many of the cases studied; to Mr. E. V.
Willmott for the photomicrographs ; and to Mr. D. Bull for the
histological preparations.
REFERENCES
Barker, M, T. , Capps, R. B., Allen, F. W. (1945) J. Amer. med. Ass.
Benjamin, J. E., Hoyt, R C. (1945) Ibid, p. 319.
Caravati, C. M. (1944) Sth. med. A A lavam, 37,
Dible, a H., McMichael, J., Sherlock, S.P. V. (1 ois Lanak ii, 402.
Helm, J. D., Machella, T : On ae "Amer. J. digest. Dis. 9, 141.
King, E. J. ., Armstrong, ree R. (1934) Canad. med. Ass. J. 31, 376
arup, N. B., Roholm, K. (1941) Nord. Med. (Hospitaistid.)
10, 1991.
Maclagan, N. F. (1944) Brit. J. exp. ‘Path, 25, 15.
Pollock, at Pio (1945) Lancet, ii, 626.
Rennie, J. B. (1945) Amer. J. med. Sci. 210, 18.
Sherlock, S. (1945) ancet, ii, S91;
— (194 6a) Ibid, i 9.
— (1946b) in the press.,
PATHOLOGY OF POSTANAL PILONIDAL
SINUS
ITS BEARING ON TREATMENT
Davin H. PATEY R. W. SCARFF
M.S. Lond., F.R.C.S..- M.B. Lond.
SURGEON, THE MIDDLESEX
HOSPITAL, LONDON
PROFESSOR OF MORBID ANATOMY
AND HISTOLOGY IN THE
| UNIVERSITY OF LONDON
From the Wards and the Bland-Sutton Institute of Patholog Y»
The Middlesex Hospital, London |
PILONIDAL sinus, or postanal dermoid, is found chiefly
in young adults, especially in the Services, where
unhygienic conditions may be important contributory
factors (Davies and Starr 1945).
The length of treatment often necessary for cure
becomes a special worry when there is a shortage of man-
power, and in many papers, particularly in America, |
the most striking note is dissatisfaction with the uncertain
results of treatment (British Medical Journal 1944,
Peterson and Ames 1944, Sher 1944, Kooistra 1942).
Theis and Rusher (1944) even advise against operation
` for pilonidal sinus on Service personnel wherever possible.
Dissatisfaction with the position is also reflected in
the variety of surgical procedures advocated—e.c.,
the different methods of demonstrating the tracks and
excising them when demonstrated, leaving the wounds
open to granulate and epithelise secondarily (Goodsall
and Miles 1900, Gabriel 1945); the different methods
of primary suture; and various forms of flap closure,
such as the Estlander rotation flap (Davies and Starr
1945). Shute et al. (1943); review some of the technical
methods used.
The R E results of treatment have: however,
led to no real questioning of the correctness of the
standard view of the etiology—i.e., that pilonidal sinus
is primarily a developmental condition on which infection
has become superimposed. But there has been some
speculation about the origin and nature.of the develop-
mental abnormality (Peterson and Ames 1944). It is
usually regarded as a sequestration dermoid ; hence its
alternative name of infected postanal dermoid. This
view implies that surgical excision of the congenital
track should lead to cure ; but often this does not happen.
We have therefore reconsidered the developmental theory
and sought some other explanation. |
THE DEVELOPMENTAL THEORY
The main evidence for the developmental theory is
(1) that the postanal site is a recognised site for develop-
mental abnormalities, and (2) that in a fair proportion
of cases a dermoid origin is suggested by the presence of
epithelial lining, -hairs, hair follicles, and sebaceous
glands.
(1) Postanal Site-—Raven (1935) collected from the
pathological museums of London 16 sacrococcygeal
cysts and tumours, which most pathologists would
consider to be developmental in origin, though they might
disagree about the exact derivation. But there is a
world of difference between this undoubted develop-
mental condition and a typical pilonidal sinus.’ The
former is situated between the rectum and coccyx,
is often first noted in early life, and is rarely the site of
secondary infection; whereas the pilonidal sinus is a
subcutaneous lesion of the intergluteal cleft, first appears
in young adult life, and almost invariably ad as
an infected lesion.
Out of 23 cases at the Middlesex Hospital only 2 were of
undoubted developmental origin: one in a woman, aged 45,
was a typical dermoid cyst extending high up between the
rectum and sacrum, lined with skin, hairs, hair follicles, `
and sebaceous glands, and full of inspissated sebaceous.
material; the other in a woman, aged 24, was a multilocular
- cyst in the same position, which had been known to have been
present since birth and contained, among other tissues, skin
with accessory skin structures and cysts lined with columnar
epithelium.
Another reason against assessing too highly the argu-
ment that the postanal region is a recognised site for
developmental abnormalities is thatan uninfected
sequestration dermoid in the situation of pilonidal sinus is
practically never encountered ; whereas, if it were the
invariable precursor of an infected phase represented by
pilonidal sinus, it should be more common. A post-
anal dimple is common, but an infective lesion may be
directly superimposed on this without the necessity of
postulating an intermediate sequestration dermoid.
(2) Histology.—The histological appearances of
pilonidal sinus have been fully studied and reported.
What is usually regarded as the typical picture is a
track whose superficial part is lined with squamous
epithelium, sometimes dilated to form a small cyst, and
whose deeper part is lined with granulation tissue only.
The usual explanation is that the deeper part of the track
has lost its original epithelium as a result of the infection
(Kooistra 1942); an alternative explanation is that
it is a secondary purely infective track developing from
the original developmental track. Sometimes no
epithelium is found, the track being lined with granula-
tion tissue only, the assumption on the developmental
theory being that the epithelium in this case has been
completely destroyed. Of the remaining 21 cases of the
THE LANCET]
. Middlesex Hospital series, in 8 only was an epithelial
lining demonstrated on routine microscopical section ;
in the remaining 13 the track was lined with granulation
tissue only. .
Hairs are more often demonstrated, sometimes macro-
scopically but more often microscopically. Kooistra
{1942) found hairs in just over half of his 89 cases, and in
our series of 21 we found hairs in 10.
The exact incidence of hair follicles is more difficult to
determine, as it is sometimes difficult to decide whether
an odd structure surrounded by granulation tissue
represents a degenerated follicle or not; but the fre-
quency is certainly much less than that of hairs.
Kooistra (1942) found them in only 9% of his cases.
In our series, counting as positive every case in which
there was the suspicion of a degenerated follicle, we found
. follicles in 6 out of the 21 cases. In several of these the
suspicious follicle was solitary.
Sebaceous glands are much less common. We found
none. Kooistra gives an illustration of one example.
The question for decision is whether the presence of
the epithelium and structures derived from epithelium
in certain cases is conclusive proof of a developmental
origin, or whether there is any alternative explanation
of their presence. |
Sebaceous glands deep in the track are almost conclusive
evidence of a sequestration dermoid. But, as we have
already stated, this finding is extremely rare and was not
present in our series. Sebaceous glands near the opening
of the track on the skin might be derived from the surface
skin or a postanal dimple.
_ An epithelial lining is not conclusive evidence of a
developmental origin. A downgrowth of epithelium
along a track lined with granulation tissue to form a
deeper epithelial-lined cyst is a well-recognised patho-
logical process and is one of the standard theories invoked
to explain, for example, cholesteatoma of the middle
ear, and dental cyst. There is also the possibility of the
epithelium being implanted by puncture—i.e., implanta-
tion dermoid. | l
Hairs in the track are not necessarily derived from the
lining ; they might be surface hairs which have penetrated
deeply either primarily or secondarily into an already
established infective sinus.
Definite hair follicles in any number are strong evidence
for a sequestration dermoid, but an occasional hair
follicle might be implanted (Muir 1941).
Therefore it is only in a very small proportion of cases
of pilonidal sinus that evidence from the presence of
epithelium or structures derived from epithelium is
conclusive or even very strong evidence of a develop-
mental origin; in most cases there are other possible
explanations. In other words, though the evidence for
the occasional origin of pilonidal sinus in a sequestration
dermoid cannot be denied, in most cases there is no
incontrovertible evidence of such origin.
’ RECURRENCES
‘The developmental theory assumes that, if there is
a recurrence, the original track has not been excised
completely. But there is a growing feeling that many
recurrences cannot be explained on this basis. Barnett
(1944) attributes many recurrences to the situation of the
lesion in the intergluteal fold, where debris of clothing,
lint, hair, and epithelial scales tends to accumulate.
Other surgeons attribute recurrence to failure to control
infection or to obliterate dead spaces. Davies and
Starr (1945) comment on the frequency with which the
local application of acridine compounds to the wound
after the primary operation leads to recurrence.
But the histology of the excised recurrent sinus does
not differ from that of primary pilonidal sinus. Kooistra
(1942) found hairs in the tracks in 9 out of 12 recurrent
cases. In one case we excised, apparently completely,
MR. PATEY, PROFESSOR SCARFF: “POSTANAL PILONIDAL SINUS
foct. 5, 1946 485
a primary track which histologically proved to be lined
with granulation tissue, with remains of dead hairs in the
walls. A recurrent sinus, longer than the primary,
developed and was excised. This too was lined with
granulation tissue, with dead hairs along the whole
length. We were prepared to admit the possibility that
in spite of appearances we had left behind a small portion
of the primary track. We found it almost impossible to
believe that we had left behind, in the same position as
the primary track, another even longer track. In another
case section of the excised primary track showed a lining
of granulation tissue containing hairs ; and section of an
excised secondary track developing some years later
showed an epithelium-lined track containing hairs. It
is difficult to avoid the conclusion that some recurrences
at any rate are due to some other factor or factors than
the leaving behind of a portion of the primary track
at operation. And, if these factors can lead to the
development of a recurrent track histologically identical
with the primary track, may they not also have been the
cause of the primary track ?
OTHER POSSIBLE CAUSAL FACTORS
In searching for other possible causal factors, a con-
venient point to start from is the most characteristic
twofold feature of pilonidal sinus—the presence of
infection and hairs. Either the infection is primary
and the hairs are secondary, or the hairs may be the
primary cause of the infection.
Primary Infection—A primary infective origin is
supported by the increased incidence in the Services.
The intergluteal fold is a region in which infective debris
tends to accumulate, and possibly the special incidence
in young adults is related to changes in the sweat and
sebaceous secretions at this age. The final factor of
infection might be gross trauma, such as a fall (Goodsall
and Miles 1900), but is more probably the minor trauma
of the rubbing together of the buttocks during exercise.
An infective sinus once established, hairs and epithelial
debris - uld tend to enter from the depths of the inter-
gluteal fold. This would also explain recurrences.
Hairs.—That hairs might be the direct cause does not
seem to have been seriously considered. The condition
has been noted particularly in hairy people (Gabriel
1945, Barnett 1944), and we have noted it in some people
who were more hairy than normal. But this is not
necessarily so and in any case is difficult to prove.
Kooistra (1942), who accepts the developmental theory,
mentions that Warren (1854) had suggested hairs, inverted
on themselves in the follicle, as the cause. But, looking
up the reference, we did not confirm this but found instead
the statement : ‘ It would seem probable that originally
the hair was contained in a cyst.”
The fact that epilation doses of X rays (Smith 1937,
Turell 1940, Sher 1944) may be of value both pre-
operatively and in the treatment of recurrence is strong
evidence for the causal rôle of hair in the recurrent sinus.
And hair might also play a causal réle in the production
of the primary sinus by puncturing the skin and either
introducing infection alone or carrying in a small piece
of surface skin, thus causing an implantation dermoid.
Hairs as a cause of pilonidal sinus cannot therefore be
dismissed. :
SIMILAR LESION IN A BARBER’S HAND
We have recently seen a pilonidal sinus in a barber’s
hand. |
A barber, aged 31, came to hospital with a discharging
sinus on the dorsum of the interdigital cleft between the ring
and little fingers of the right hand. He attributed it to a
hair penetrating the skin at this point while he was cutting a
customer’s hair. He pulled it out, but a discharging sinus
developed and persisted, and at his work other hairs tended
to enter the sinus. i
On examination a small nodule the size of a pea could be
felt just behind the orifice of the sinus, and a probe could
t
486 THE LANCET]
wee ee ee
DR. PAULLEY, DR. AITKEN: NICOTINAMIDE METHOCHLORIDE ESTIMATIONS
[ocr. 5, 1946
be passed into this nodule from the orifice of the sinus. The
sinus and nodule were excised and the skin sutured. The
wound healed uneventfully.
The histological picture was exactly like that of a post-
anal pilonidal sinus. The sinus led into a cavity lined with
squamous epithelium and containing a hair follicle, and
the deeper part was a track lined with granulation tissue and
containing hair and debris in its walls.
' The history of this case and the difficulty of any
developmental explanation in this situation are strong
evidence that this case is an example of pilonidal sinus
due to the puncture of the skin by a hair.
Our patient said that a friend of his, also a barber,
had a similar condition, which arose in the same way.
So we sought for further examples. Assistants in two well-
known London hairdressing firms said that it was not at
all uncommon for minor infective lesions to be produced
owing to puncture of the skin during haircutting,
particularly i in the hands. Usually they cleared without
serious trouble after the removal of the hair. Occasionally,
however, a more chronic lesion resulted, and we were
told of one such case in which a legal action followed ;
but we could not trace the legal records. From our
inquiries it is obvious that among barbers hair is well
recognised as a traumatic and infective agent.
CONCLUSIONS
Pathology.—Critical analysis of the developmental
theory of pilonidal sinus leads to the conclusion that
though a small proportion of cases arise in a previously
existing postanal dermoid, in the great majority of cases
there is no definite evidence of such origin. Moreover,
many of the features of recurrence are difficult to fit in
with the developmental theory. Alternative possibilities
are that pilonidal sinus is primarily an infective lesion,
with secondary entrance of hair and debris, or the result
of penetration of the skin by a hair, which may also
introduce both infection and epithelium. We suggest
that these alternative possibilities are more in accord
with the facts.
Treatment.—If the developmental theory of pijonidal
sinus is relegated to a subordinate place, the rational
treatment of the condition demands corresponding
adjustment. No Jonger need such emphasis be laid on
the extent of the primary excision, which on the develop-
mental theory led in many cases to a probably unnecessary
removal of tissue, with consequent prejudice to the
subsequent healing. Though measures short of surgical
excision of the track may be successful in cases in which
the lining is merely granulation tissue, excision will
probably continue to be the standard treatment, because
it is impossible to tell clinically whether an epithelial
track is present or not and to remove the hairs which are
acting as foreign bodies. The main emphasis in treat-
ment becomes transferred to securing healing of a chronic
infective condition at the bottom of afold. If the causal
rôle of hairs, both in the primary lesion and in recurrences,
is as important as we believe, a preoperative epilation
dose of X rays becomes an essential part of treatment.
The results of Smith (1937), Turell (1940), and Sher (1944)
offer practical encouragement to this point of view.
SUMMARY
The increased interest in pilonidal-sinus as the result
of the war has emphasised the dissatisfaction of surgeons
with the uncertainties of its treatment, which has been
reflected in a wide variety of surgical procedures.
We have therefore submitted the accepted develop-
mental theory of pilonidal sinus to critical analysis.
As a result, we conclude that, though a small proportion
of cases are developmental in origin, the great majority
may be. acquired infective lesions, hair playing an
important rôle in the production both of the primary
lesion and of recurrences.
A similar lesion in a barber’s hand is described. © .
The emphasis in treatment should be shifted from
attempting a wider eradication by excision to the manage-
ment of a chronic infective lesion in a fold.
. A- preoperative epilation dose of x rays to the- area
should be a routine. ,
REFERENCES
Barnett, L. A. (1944) Amer: J. Surg. 64, 338.
British Medical Cee (1944) Any Questions 7 i, 708.
Davies, L. S., Starr, K. W. (1945) Surg. Gynec. Obstet. 81, 309.
Gabriel, W. B. (1 945) The Principles and Practice of Rectal Surgery,
London.
H., » Miles, W. E. (1900) Diseases of the Anus and
Goodsall, D.
Rectum, Lon
Kooistra, H. P. (1942) Amer. J. Surg. 55, 3.
Muir, R. (1941) tig a oa OET: London, p 285.
te R 944) Amer. J. Surg. 65, 384. .
. C. jun., Smith, T. E.,
Ann. Ruro 118, 706.
Smith, R. M. (1937 y Ame J. Roentgenol. 38, 308.
Theis, F. V., “Rusher, M. W. (1944) Surg. Gynec. Obstet. 79, 482.
Turell, ae (1940) Surgery. 8, 469.
Warren, J . M. (1854) Amer. I: med. Sci. 28, 113.
= ` NICOTINAMIDE METHOCHLORIDE
ESTIMATIONS IN SPRUE AND AMGBIASIS
J. W. PAULLEY G. J. AITKEN ©
M.D. Lond., M.R.C.P. B.Sc., M.B. Glasg., F.R.F.P.S.
LATE WING-COMMANDER LATE SQUADRON-LEADER —
R.A.F.V.B. R.A.F.V.R.
THE published results of nicotinamide methochloride
estimations in pellagra (Ellinger et al. 1945) seemed
to us to justify a similar investigation in active and
convalescent cases of sprue, and offered a means of.
assay of a vitamin-B factor related to sprue. -
We intended to include in the investigation amebiasis,
bacillary dysentery, and the chronic non-specific diar-
rhæas to try to determine the effects, if any, of intestinal
infection on nicotinamide excretion ; but unfortunately
we could not collect any cases of bacillary dysentery or
of chronic non-specific diarrhea.
Methods.—We used the method of Coulson et al.
(1944) and Ellinger et al. (1945). For three days 24-hour
urines were collected with the patients on ordinary
hospital diet. For the next five days the same procedure
was continued except that the patients were given 100 mg.
of nicotinamide at the beginning of each 24-hour period.
Each test therefore lasted eight days. To 2 controls,
2 cases of sprue, 6 of convalescent sprue, and 4 of amosbiasis
the nicotinamide was given parenterally. To the
remainder—7 controls, 4 cases of convalescent sprue, and —
3 of amebiasis—the vitamin was administered by
Q
(Sa)
CONTROLS
N
oO
AMCEBIASIS
NICOTINAMIDE METHOCHLORIDE OUTPUT (mg.)
0 t 2 3 4 5 6 7 8
DAY OF TEST
Fig. I—Average output of nicotinamide methochloride in sprue
amæœæbiasis, and controls.
THE LANCET] DR. PAULLEY, DR. AITKEN :
mouth. All cases of florid sprue (2) and amebiasis (2)
with looseness of the bowels received the nicotinamide
parenterally to exclude the possibility of poor gut
absorption.
Briefly, the method of determining the amount of
nicotinamide methochloride in the urine (Coulson et al.
1944, Ellinger et al. 1945) is as follows :
Nicotinamide methochloride is separated from urine by
adsorption on ‘ Decalso,’ from which, after washing with
distilled water, it is eluted by potassium-chloride solution,
then rendered alkaline, and extracted with iso-butyl alcohol.
The fluorescent derivatives thus produced are compared by
visual fluorimetry with standards similarly treated.
Resulis.—The results in controls, sprue, and amebiasis,
given in the accompanying figures (1—4), may ‘be briefly
summarised as follows :
(1) The controls produced figures of the same order as
those of Ellinger et al. (1945).
(2) There was a subnormal excretion, resting and
after test dosing, in patients convalescent from sprue
who’ had had no symptoms for three months or more and
had had nicotinic acid, ‘ Vegmite,’ and liver treatment
in: India. Figures of excretion in this group were
slightly higher than those of Ellinger et al. (1945) for
pellagra. `
(3) The excretion in two cases of florid sprue
investigated did not differ from that in the patients
convalescent from sprue.
25
N
o.
NICOTINAMIDE METHOCHLORIDE
OUTPUT (mg)
a.
§
2
4 5
DAY OF TEST
Fig. 2—Scatter diagram of nicotinamide mischoctrorids output and
saturation tests in sprue.
E 4) Whether nicotinamide was uive orally or parenter-
ally to patients convalescent from sprue and to controls,
the level of excretion was similar. This indicated that
poor intestinal absorption of the vitamin was not a
factor in’ cases without intestinal “ hurry.”
(5) Patients with amebiasis, either with active disease
or cyst passers, showed less excretion than the controls,
and a slightly higher excretion than the sprue cases.
Only two of these cases had diarrhea, and both received
their nicotinamide parenterally. :
Oomments.—The subnormal excretion in patients
convalescent from sprue, who had no symptoms and had
had their fill of nicotinic acid during treatment, was
surprising. Not less surprising was a similar deficient
excretion in cases of amebiasis, mostly inactive from
the point of view of intestinal *‘ hurry.”
It is impossible to draw any conclusions from these
few results, and a larger series is required to confirm them.
If, however, deficient nicotinamide-methochloride excre-
tion in these cases can be shown to be due to subnormal
intestinal biosynthesis and not to other factors (Perlzweig
et al. 1943, Ellinger and Coulson 1944), our observations
may be significant. We suggest tentatively that, behind
this deficient nicotinamide-methochloride excretion in:
sprue and ameebiasis there may lie deficiencies of other
NICOTINAMIDE METHOOHLORIDE ESTIMATIONS
NICOTINAMIDE METHOCHLORIDE OUTPUT (mg.)
i
focr. 5, 1946 487
oO Gl. D
© on o
N
n
©
NICOTINAMIDE METHOCHLORIDE OUTPUT (mg.)
l N
on ©
Y?
e
2
3 4 5 6 7 8
DAY OF TEST
Fig. 3—Scatter diagram of nicotinamide methochloride output ‘and
saturation tests in am obiasis.
members of the vitamin-B complex, known or unknown,
whose relation to sprue may be of direct, importance.
- We have been obliged to leave this investigation in
an incomplete state, and neither of us is likely for some
time to be in a position to continue it. We feel, therefore,
that these rather unexpected results should be recorded in
the hope that they may be confirmed or otherwise, and
possibly be of use to others continuing research in this field.
We agree with Leishman (1945) that the success of.
further research into this subject will depend on
coordinated endeavour, an adequacy of clinical material,
and laboratory facilities capable of coping with com-
plicated and tedious analyses and assays.
We should like to thank Squadron-Leaders A. F. N. Neven,
K. N. Lloyd, and J. D. Whiteside for sending us suitable cases,
and Roche Products Limited for supplies of nicotinamide.
REFERENCES
, Ellinger, P., Holden, M. (1944) Biochem. J. 38, 150.
Coulson, R
Hardwick, S. n aang Lancet, ii, 197.
EUinger, P., Benach R.,
— Coulson, R. na (1944) Biochem. J. 3
D. (1945) Lancet, ii, Sia
Ronen, F. (1943) J. biol.
Leishman, A. W.
Perlzweig, W. A., Bernheim, M. L. C.,
Chem, 150, 401.
40 —
On
on
oN
Oo
E
uo
o ff 2 3 4 5 6 7 8
7 DAY OF TEST i
Fig. 4—Scatter diagram of nicotinamide methochloride output and
saturation tests in controls: .
\ {
488 THE LANCET] DR. IGLESIAS, PROFESSOFÈ:LIPSCHUTZ : STEROID HORMONES AND FIBROMATOSIS oor. 5, 1946:
EE E
RELATIONS OF STEROID HORMONES 5 AND
ANHYDRO-HYDROXY-PROGESTERONE TO
FIBROMATOSIS
RIGOBERTO IGLESIAS, M.D.
ALEXANDER LIPSCHUTZ, M.D.
DIRECTOR OF THE DEPARTMENT OF EXPERIMENTAL MEDIOINE,
NATIONAL HEALTH SERVICE, SANTIAGO DE CHILE;
PROFESSOR IN THE UNIVERSITY OF CHILE
- UTERINE and other abdominal fibroids induced by
estrogens in the guineapig (Iglesias 1938, Lipschutz
and Iglesias 1938, Lipschutz and Vargas 1939, Lipschutz
et al. 1940) can be prevented by different steroids
absorbed simultaneously with the ostrogen (Lipschutz
et al. 1939, Lipschutz and Vargas, 1941a and b, Lipschutz
et al. 1941, Lipschutz and Zañartu 1942, Iglesias et al.
1944), and fibroids already induced regress when an
antifibromatogenic steroid is given (Lipschutz and
Maas 1944, Lipschutz and Schwarz 1944). `
A systematic search for antifibromatogenic steroids
_ has shown that all the steroids capable of preventing
cestrogen-induced fibroids—progesterone, desoxycorticos- |
terone, dehydrocorticosterone, testosterone, and dihydro-
testosterone—were 3-keto-steroids (Lipschutz 1944).
Of these progesterone was the most active. Five other
3-keto-steroids were not antifibromatogenic. in the
quantities used : pregnanedione, allopregnanedione, A1®-
dehydroprogesterone (Lipschutz et al. 1944), androstane-
dione, and cholestenone (Iglesias and Lipschutz 1944).
On the other. hand, no steroid with a hydroxyl group in
position 3 was antifibromatogenic : androsterone, A5-
_ androstenediol, androstanediol (Iglesias unpublished),
A5-acetoxypregnenolone (Lipschutz et al. 1943), A5-
pregnenolone- 3-acetate. (Iglesias and Lipschutz, unpub-
lished).
Our work on the antifibromatogenic activity of different
steroids in relation to their chemical. structure is of
interest with reference also to the hormone treatment
of other tumours, including cancer. Steroids have been
shown .to prevent many forms of cestrogen-induced
atypical growth : the hyperplasia of the prostatic stroma
and the metaplasia of the utriculus in macacus (Zucker-
man 1936, Zuckerman and Parkes 1936, de Jongh et al.
1938), and the fibromyo- epithelioma of the prostatic
region in the guineapig (Lipschutz et al. 1945). But
Steroids are active also against different spontaneous
tumours in laboratory animals : v the mammary adeno-
carcinoma of the mouse (Lacassagne 1937, Lacassagne
and’ Raynaud 1939, Nathanson and Andervont 1939,
Jones 1941, Loeser 1941, Heiman 1944, 1945), the
mammary adenofibroma of the rat (Heiman 1943), a
transplantable thoracic tumour in the mouse (Heilman.
and Kendall 1944), the leukemia of the mouse (Murphy
1944, Gardner et al. 1944). .
' Steroids have been applied also in human pathology.
Though success seems to be inconstant with testosterone
treatment of mammary carcinoma, there may be some-
times good results (Fels 1944). Œstrogens also have been
applied in similar cases (Lancet 1944). Fundamental
progress has been achieved in the hormone treatment of
prostatic cancer thanks to the work of Huggins (1943) ;
see also Dodds (1944).
Hormones have been used also for the treatment of
uterine fibroids in women (Loeser 1938, and many others).
. The work of Greenblatt (1943, 1944) with subcutaneously
implanted testosterone-propionate pellets deserves special
mention. Favourable results have been obtained also by:
workers associated with this department, (Vargas et al.
1945). Objections can be made against the use of testos-
terone because of its virilising action (Hamblen 1942),
though this is only transitory (Palmer and De Ronde
1943), and because. of its being active only on injection
_ the injected progesterone.
or on subcutaneous implantation of tablets and not
when given by mouth: :
PROGESTERONE AN D ANHYDRO -HYDROXY -PROGESTERONE
. Progesterone has in the guineapig a stronger anti-
fibromatogenic action than. has testosterone. (Lipschutz
1942a and 1942b, 1944): But, like testosterone, proges-
terone is considerably less active when given by mouth
than on injection ; ' the progestational activity of proges-
terone given by mouth is, according to Miescher and
Gasche (1943), only 1/160th of the activity of injected
progesterone. Though, as shown by our previous work,
progestational activity is not an. absolute criterion of
antifibromatogenic activity, the fact remains that
progesterone which exerts the strongest progestational
action also exerts the most antifibromatogenic one.
For the above-mentioned reasons an experimental
study of the antifibromatogenic action of anhydro-
hydroxy-progesterone (A.H.P.), or ethinyl-testosterone,
has been undertaken in this laboratory. This synthetic
compound is due to Ruzicka et al. (1938) and to German
workers. Its biological properties have beer studied by
different authorities and have been described in T
exhaustive study by Emmens and Parkes (1939).
androgenic activity of injected A.H.P. (in - po EE Í
glycol) was in the capon comb-growth test, according, to
Emmens and Parkes, only about 1/600th of the activity
of injected testosterone, whereas the progestational
activity of A.H.P. was in the rabbit test 1/10th of that of
According to Miescher and
Gasche (1943) A.H.P.. (in sesame oil) has 1/5th of the-
activity of progesterone. But A.H.P. is equally active
by mouth and by injection in producing aia
proliferation.
PREVENTION OF CESTROGEN-INDUCED UTERINE AND
ABDOMINAL FIBROIDS IN THE GUINEAPIG BY ANHYDRO-
HYDROXY-PROGESTERONE
“Small tablets of «-cestradiol were implanted sub- |
- cutaneously into forty-five castrated female guineapigs ;
1-8 tablets of A.H.P. 5 mm. in diameter were also
implanted, to obtain absorption of variable quantities
of A.H.P. The quantity of «-cestradiol and of A.H.P.
absorbed was calculated from the loss of weight of the
dried tablet divided by the number of days. , This gives
only an. approximate figure, as absorption per day
diminishes with time (Folley 1943, Shimkin et al. 1944,
Bishop and Folley 1944), and. substances from outside
the tablet are entering into it (Folley 1942, 1943).
Absorption per day was about 0-4 ug. per sq. mm. of the '
tablet ; this is about: fifteen times less than with pro-
gesterone. . Necropsies were done three months after
TABLE |—ANTIFIBROMATOGENIC ACTION OF ANHYDRO- ©
HYDROXY- PROGESTERONE (A. H.P.) IN GUINEAPIGS -
| Animale! Regional
Antifibro- yor
i =) a teste: matogenic a No. | reach- | marks | F.T.E.
B per day | Steroid | pre. | of iol we 2 ana 3 | range
(ug) ar a cunits)*| animals oe E (units)
~I | 16-57 0 57 | 23 12 | 1-9 | 1-10
A.H.P pes
ua | 24-55 | 14-25 7-1 Q. 5 26 | 1-11
ub | 14-64 | 382-85 5:3 . 9 5 2-0 | 2-8
Wie | 21-84 | 100-191 | 25 | 23 | 3 0-5 | 0-6-7
ud | 55-95 | 210-347 21) 6. o | 03 |1-4
. Progest. h ot aie F ar
III 21-63 | 13-24 | 14- 14 |. 0 j. a (| 1-2-5
l R ` Progest. = progesterone.
bd Fibroids ‘of four regions (uterine-subserous and parametric ; |
the mesosalpinx ; of the mesentery and the abdominal vate
of the spleen) are classified separately and marked 0 5-1-2-3,
~ according to size. The fibrous tumoral effect ee ‘is the
sum of the regional marks. ne toh eel
+ The average of the a-cestradiol group I.
t See Lipschutz and Maas (1944).
THE LANCET] DR. IGLESIAS, PROFESSOR LIPSCHUTZ:
implantation of the tablets. The fibromatogenic effect
was classified according to the rules already published
(see especially Lipschutz and Maas 1944). The results
were compared with those obtained in twenty-three
animals with «-cstradiol alone and with fourteen
animals into which tablets of «-cestradiol and of proges-
terone were implanted simultaneously (group 1 in table IL
of Lipschutz et al. 1944).
Table 1 (see also figure) shows that a quantity of
A.H.P. (groups IIa and ub) up to four times greater than
the antifibromatogenic threshold of progesterone (group mi)
could not prevent cestrogen-induced fibroids. With
32-85 ug. the fibrous tumoral effect (F.T.E.) and the
coefficient indicating a strong fibrous reaction (penulti-
mate column) were as pronounced as in the absence of
A.H.P. (group 1). In both groups la and ub no less than
50% of the animals reached the average F.T.F. of the
a-cestradiol group—i.e., there was no preventive action.
Things changed considerably with quantities of
100-200 ug. of A.H.P. a day (group lic). Though there
were still three out of twenty-three animals which
reached the average of the a-cestradiol group, the dimini-
-shed fibrous reaction—F.T.E.=—2-5 instead of 5-3—
indicates clearly that a.H.P. is antifibromatogenic. With
100-200 ug. of A.H.P. a day, or with about 5-10 times
the antifibromatogenic threshold of progesterone, the
TABLE HI—EFFECT OF A.H.P. ON UTERINE FIBROIDS IN
GUINEAPIGS
No. of No. of
Average | Average {Range of
Group No. of mea weet ag fibrous | weight | weight
a uterine uterine uterine {of uterusjof uterus
bleeding | fibroids |Teaction®| (g.) (&-)
I 23 : 5 18 1°25 4-9 2°-7-12°0
A.H.P.
ia 0 3 0°50 4:2 2:2= 7-0
ede) 9 0 3 0°23 4-0 2-5- 6-7
lic 23 0 3 0°15 4-0 2-2-10-0
rid 6 0 0 0 3-0 2-0— 57
Progest.
uI 14 0 0°1 3:0 1-7- 51
Sum of the uterine marks of the whole group divided by number
of animals in the group.
‘“ transitional zone ” (Lipschutz et al. 1944) is surpassed
—i.e., the antifibromatogenic action is fully evident.
A further degree of preventive antifibromatogenic~™
action was attained in group ud with quantities of a.H.P.
10-15 times the progesterone threshold (table 1).
These experiments show that 4.H.P. shares with pro-
gesterone the power of preventing cstrogen-induced
abdominal fibroids.
of A.H.P. is less than it should be if there were full con-
comitance between progestational and antifibromato-
genic action. With 130-240 ug. of A.H.P. a day—i.e.,
with ten times the antifibromatogenic threshold of
progesterone—there were fibroids in many of the animals.
The anfifibromatogenic action of A.H.P. was even less
than with testosterone (Lipschutz 1944) and especially less
than would have been expected because of the side-chain
of two carbons at C,, (Lipschutz 1944).
There is still another feature of antifibromatogenic
action which deserves special mention: the preventive
antifibromatogenic action refers in the first place to the
subserous uterine fibroids and to the parametric ones.
In groups Ira and 11b (table 11), in which the quantities
of a.H.P. were still insufficient to inhibit the abdominal
fibrous reaction, there was already a very pronounced
diminution of subserous uterine fibroids. In groups
uc and 1d uterine fibroids were absent or almost absent.
The frequency of animals with a-uterine fibrous reaction
STEROID HORMONES AND FIBROMATOSIS
But the antifibromatogenic activity .
foct. 5, 1946 489
N
O >=>
: FIBROUS TUMORAL EFFECT
-N WA TAHA @O O
0] 40 80 120 160 200 240 280 320 360
ANHYDRO- HYDROXY - PROGESTERONE #9. PER DAY
Fibreus tumoral effect induced by a-œstradiol in 45 castrated female
guineapigs. Various quantities of A.H.P. a day were absorbed
_ Simultaneously. stor izanen) lines indicate averages of groups lla,
lib, lic, and lid of table
was with 100-191 ug. of A.H.P. a day scarcely more pro-
nounced than in group 11 with small quantities of
progesterone. Table 11 gives a comprehensive picture
of the remarkable fact that the preventive action is
preferably and primarily against the uterine tumours
and only secondarily against the abdominal fibroids in
general. This statement is of special interest so far as
practical application of our results is concerned.
The differential behaviour of uterine and extra-uterine
fibroids has been found with all antifibromatogenic steroids
used in our work; it can be simply explained by the higher
fibromatogenic threshold for uterine fibroids compared with
that for extra-uterine ones. In these quantitative circum-
stances uterine fibroids certainly must be the first to be
prevented. In experiments with the progesterone treatment
of previously induced fibroids the differential regression of
uterine and extra-uterine fibroids was indeed less pronounced
(Lipschutz and Maas 1944).
OTHER ANTI-EESTROGENIC ACTIONS OF ANHYDRO-HYDROXY-
PROGESTERONE
The antifibromatogenic action coincides with other
anti-cestrogenic ones. The last two columns of table 11
show that the increase of uterine weight due to the
cestrogen is in group lid partly counteracted by A.H.P.
The thickening of the myometrium was less. Though
polypous growth was still present it was much less than
with cestradiol alone. It was the same with reference to
the vascularisation of the submucosa. Consequently
there was no cestrogen-induced uterine bleeding when
A.H.P. was absorbed simultaneously. As shown in
table 11, 5 out of 23 animals with cestradiol alone bled
from the uterus ; there should have been uterine bleeding
in about 10 out of 45 animals in group 1. But bleeding
was absent even in those experiments where A.H.P. was
absorbed in quantities which were smaller than those
necessary to prevent abdominal fibroids.
There was no masculinising action on the clitoris,
which in the guineapig is very sensitive to androgens
(Lipschutz 1919, 1924, Ruz 1939). The masculinising
action was absent even in group 11d with 210-347 ug.
of A.H.P. a day, whereas with similar quantities of testos-
terone propionate the transformation of the clitoris
into a hypospadic penis-like organ begins to be seen in
4—7: days (Ruz 1939). With A.H.P. nothing similar
happened even in so long a period as three months.
Our results corroborate fully the statement of Emmens
and Parkes (1939) about the very small ERRE RIK
potency of A.H.P.
PROSPECTS OF CLINICAL TRIALS WITH ANHYDRO-
HYDROXY-PROGESTERONE
Clinical trials with A.Ħ.P. in cases of uterine fibroids
can be recommended on the basis of our experiments.
490 THE LANCET]
The facts that a.H.P., unlike progesterone, is active by
mouth and that there is not the slightest danger of
virilisation as with testosterone give greater hopes for
the successful treatment of fibroids with 4.H.P. than with |
the two natural steroids mentioned. It is true that
findings concerning the action of steroids in laboratory
animals cannot be directly applied to women. According
to some authorities cestrogens may play a part in the
genesis of uterine fibroids in women (Hamblen 1945).
But, on the other hand, we must emphasise that -up till
now we have been unable to induce fibroids with wstro-
gens in the new-world monkey (Iglesias and Lipschutz
1946), even when these animals were kept for almost
three years in the same experimental fibromatogenic
conditions under which fibroids were induced in guinea-
pigs in three. months.
Since androgens have been revealed to be so active
against uterine bleeding and against fibroids, one may
tentatively suggest combining in clinical trials maximal
quantities of A.H.P. by mouth with the injection of small
quantities of testosterone propionate or with the sub-
cutaneous implantation of tablets sufficiently small to
_allow for an absorption of only non-virilising quantities
of the androgen..
SUMMARY
The antifibromatogenic action of steroids and their
antitumoral action in general is discussed. — -
Anhydro-hydroxy-progesterone (A.H.P.), a synthetic
steroid active by mouth, was tested for its power to
prevent ceatrogen-induced fibroids in the guineapig.
- A:H.P., whose progestational activity is about a tenth
of that of progesterone, has been shown to be -also
‘antifibromatogenic. But the quantities of a:H.P. necessary
to prevent abdominal fibroids are about fifteen times
‘greater than the antifibromatogenic dose of progesterone,
‘though the antifibromatogenic effect is evident with
injected 3—6 times weekly.
smaller quantities of a.H.P.
Uterine fibroids are more readily prevented than other
abdominal fibroids.
(Estrogen-induced uterine bleeding was counteracted
with quantities of A.H.P. much smaller than those neces-
sary for obtaining an antifibromatogenic effect.
The prospects of clinical trials with A.H. P. are discussed.
ADDENDUM _
On the strength of our laboratory results with different
steroids and especially with progesterone in the treat-
ment of experimental fibroids, A. L. Goodman (J. clin.
Endocrin. 1946, 6, 402) has tried the therapeutic
possibilities of progesterone against uterine fibromyoma
in women. In seven cases 10 mg. of progesterone was
A decrease in the size of the
tumour or of the uterus is reported in all cases; the
decrease is notable as early as 1-3 weeks after beginning
the treatment. In less than 2 months the decrease was
MR. BAILEY, MR, HARRENS: CORRECTION OF VALGUS FOOT STRAIN
[ocT. 5; 1946
REMEDIAL CORRECTION OF VALGUS FOOT.
“STRAIN BY FOOT PRONATION EXERCISE |
/ E. T. Bamey | B. S. HARRENS
M.B. Lond., F.R.C.S. SENIOR PHYSICAL TRAINING
SURGEON, FRACTURE “A” — INSTRUCTOR
DEPARTMENT we
NORTHERN HOSPITAL, WIN CHMORE HILL
Tue normal foot has been aptly compared to a tripod
balanced evenly beneath the leg, with the os calcis in
line with the astragalus and tibia. The maintenance of
this balance depends on the ability of the foot to bring
the head of the first metatarsal to the ground by adequate
foot pronation. Should this pronation be deficient, the
first metatarsal can only be brought down by a tilting
of the whole foot outwards at the subastragaloid joint.
This at once produces the characteristic appearance of
“flat-foot,” with valgus deviation of the foot as a whole
and of the os calcis in particular. In such a position of
imbalance it is not surprising that symptoms of foot
and leg strain appear with rapid fatigue of muscles
working at a mechanical disadvantage.
~
to 1/,-*/, of the original size. In one case the tumour mass —
“ appeared to be completely gone.”
This investigation has been aided by grants from the Jane `
Coffin. Childs Memorial Fund for Medical Research, the
Rockefeller Foundation, and the Ella Sachs Plotz Foundation
for the Advancement of Scientific Investigation. Acknowledg-
ment is made by A. Lipschutz for the Charles L. Mayer
Award, 1944, of The National Science Fund of the National
Academy of Sciences of the U.S. Our thanks are due to
Dr. E. Oppenheimer, of Ciba Pharmaceutical Products, Sum-
mit N.J., for a generous gift of steroids.
$
REFERENCES
Bishop, P. M. F., Folley, S. J. (1944) Lancet, i, Ti
de Jongh, S. E., Kok, D. J., van der Woerd, . A. (1938) Arch.
aa. Pharmac odyn yn. 58, 310
Dodds, E.C. (1011) vitamina and Hormones, New at vol. 11, p. 353.
Emmens, ©. W., ett S. (1939) J. Endocrinol. 2.
Fels, E. ayaa) ibid, 4 :
eer J. (1942) Nature, Lond. 150, 403, 735.
943) Ibid, 1
Gardner, W. U. Db Doun T. F., Williams, W. L. (1944) Cancer
€93. b °
Continued at foot of next column
Restoration of normal foot balance with adequate. foot
‘pronation should therefore be the aim of treatment ;
and, though corrective osteotomy of the first metatarsal
‘may be necessary in certain cases of congenital abnor-
mality, it was felt by us that remedial treatment speci-
fically directed to foot pronation could bring about the ©
desired result. With this object in view, one of us (B. S. H.)
has designed the foot corrector apparatus illustrated which
ensures maintenance of the ‘correct position of the os
calcis during pronation exercises in a manner which is
not possible with orthodox routine foot exercises.
The apparatus (fig. 1) consists of a T-shaped wooden
a c ee
References continued
Greenblatt, R. B. (1943) J. Amer. med. Ass. 121, 17.
1944) Office Endocrinology, Springfield, chap. 9,
Hamblen, rie C. (1942) J. clin. Endocrin. 2, 575.
(1945) pondoorinotogy ar cg Springfield, p. 529.
Heilman, F. R., Kendall, E pe) Endocrmol Oo’, 34, 416.
Heiman, J. (l 943) Cancer Res
(194 5} Ibid, 4
, oy A
. (1938) Tesis, Universidad de Chile (Public. Med. news
(unpublished).
Tipechtur A: (1944) Proc. Soe. exp. Biol., N.Y. 55, 41.
i Pale negra ).
gas) aca Res. 4, 510.
Jones, E. E. a9 a Ibid,
—_—
Iglesias, R
no.
—_—_ =
ynau , 586.
Lancet (1 ASET ,
Lipschutz, A. G91 9) Die Pubertatsdriise und ihre Wirkungen,
“ 1 1924) The Internal Secretions of the Sex Ta Cambridge.
(1942b) J. Amer. . Ass. 120, 171.
1942b) Cold Spr. Harb, pump. quant. Biol. 10; 79.
(1944) Nature, Lond. , 260.
Bruzzone, S., Faaalia’ F. (1943) Proc. Soc. exp. Biol. 5 N. Y.
54, 3 303
— (1944) Cancer Res. 4, 179.
Iglesias, oaan C.R. Soc. Biol. Paris, 129, 519.
45, 788. jun. (1940) Proc. Soc. exp. Biol.,
Maas, M. (1944) Cancer Res. 4,
Murillo, Re Vargas, L. jun. (1389) Lancet, ii, 420.
Schwarz, J. (1944) Cancer Res. 4, 24.
if jun. (1939) Lancet, +4, 1313.
oa
N.Y.
“| 11 se
68.
C. (194 1) Proc. Soc. exp. Biol. è N. Y. » 271.
anine, D., Schwarz, J., Bruzzone, S., Acuña, L., Serea s.
(1945) Cancer Res. 5,5
wee tare . (1942) Endocrinology, 31, 192.
peasy
|
ear Ae (1938) Le Tanca, i, 373.
Micscher, x, Gasshe, P 1943) ately physiol. Acta, 1, 287.
Murphy, J. B. (1944) Cancer mea T
chai ate I. T, Andervont, H. B . (1939) Proc. Soc. exp. Biol. N. Y.
Palmer, H. D., De Ronde, M. (1943) J. clin. Endocrin
Ruz, O, (1939) Tesis Universidad de Chile, (Public Med. tes no? 3),
Ruzicka, L., ann, K., Meldahl, F. (1938) Helv. chim. Acta,
Shimkin, M. B., E E E.. Wyman, R., Norton, S. G. (1944)
En docrinology, 3 283.
Vargas, L., OON i „Ossandon, her (1945) Rev. méd. Chile, 73, 443.
Zuckerman, S. 1939) Lancet, ii, 1259.
Parkes, A. S. (1936) ibid, i, 242.
‘6 PRLLAGRAGENIC ” ACTIVITY OF INDOLE-3-ACETIC ACID IN THE RAT
[ocr. 5, 1946 491
foot-piece with the stem
in the form of a roller
(a) mounted upon a
wooden base (b), from
the sides of which arise
two vertical adjustable
metal rods (c). <A top
cross-bar unites the rods,
each of which carries
two sliding padded inetal
plates (d) for application
to the heel and leg. Fig. 2
shows a patient seated
with the leg vertical and
resting on the T-piece.
Four padded plates are in
position, one on each side
of the heel, one on the
inner aspect of. the leg,
and one on the outer side
of the thigh immediately
above ‘the knee.
gis ment can take place now
a ae l ai l , only in the forefoot, which
is actively pronated by
the patient until the head
of the first metatarsal can
be brought down over the
roller to touch the wooden
base, as shown in fig. 3, which illustrates the degree of
pronation present in ‘the normal foot.
The use of two plates is not essential to maintain the
position. of the os calcis, which can in most cases be
effectively controlled by a single plate on the outer side
of the heel, provided the leg plate is applied well. down
the innes side of the leg about 2-4 in. above the
ankle.
Fig. l—The Harrens foot corrector :
(a) T-piece with roller ; (b) wooden
- base ; (c) vertical rods ; (d) metal
plates. . l
The {apparatus has now been in constant use for
eighteen months and has been found capable of correcting
pronation deficiency of up to 30° in about three weeks.
The pronation exercise is combined with other recognised
foot exercises and physiotherapy, and is supplemented
in most instances by wedging of the inner side of the heels
of the boots or shoes.
Fig. 3—Foot pronated.
“Fig. 2—Plates holding foot and
leg in correct position, outer
border of foot resting on .
roller.
the outer border of thefoot
Move-
9, Woolley D. W.
The types of case for which the foot corrector has
proved of value are: (1) simple valgus strains and early
flat-foot in children and adults; (2) foot re-education
after immobilisation in plaster; and (3) fractured os
calcis.
Pronation deficiency following immobilisation in
plaster can be minimised by taking care to avoid inversion
of the foot and to see that the foot is pronated in the
plaster as much as is practicable. The os calcis group of
cases have proved more satisfactory than was expected
and have in most cases been prevented from developing
the all too common painful strain below the external
malleolus.
We are indebted to the London County Council for the
illustrations and for the supply of the foot corrector, which
has been manufactured for us by Messrs. Masters & Sons,
240, New Kent Road, London, S.E.1, from whom it is
obtainable.
Preliminary Communication
‘“ PELLAGRAGENIC ” ACTIVITY OF INDOLE-
3-ACETIC ACID IN THE RAT
Krehl and co-workers! have shown that rats fed on
a low-protein, low-tryptophane diet, containing 40%
of maize, stop growing. Normal growth was restored by
the addition of nicotinic acid or tryptophane to this diet.
Woolley ? found that 3-acetyl-pyridine produced in
mice and rats a depression of growth which could be
counteracted by either nicotinic acid or tryptophane.
In search for a similar antivitamin in maize he has
recently obtained. a potent extract which was
“ pellagragenic’’? to mice in amounts of 1 mg. per
100 g. of diet. |
We have been investigating the reasons why maize
produces such a deficiency in rats, having particular
regard to possible defects in the metabolism of trypto-
phane. Now, maize is known to be a rich source of indole- ©
3-acetic acid (heteroauxin). Yellow maize meal contains,
according to Haagen-Smit et al.,3 20 mg. per kg., or,
according to Berger and Avery,* 100. mg. of indole-3-
acetic acid per kg .; it is present largely in the form’
of a precursor which can be converted into indole-3-
acetic acid by mild alkaline or enzymic digestion. For
a diet containing 40% of maize meal the above figures
correspond with 0-8 mg. and 4:0 mg. of indole-3- acetic
acid per 100 g. of diet respectively.
In our experiments young rats of 60 g. weight all
gained weight steadily on a purified diet containing
10-5% casein as the sole source of protein, and administra-
tion of nicotinic acid or tryptophane did not increase the
growth-rate significantly. However, of 32 rats fed on a
similar. diet supplemented with 1-5 mg. of indole-3-acetic
acid per 100 g. of diet, 19 rats showed a severe depression
of growth. Of these 19 rats, 9 were dosed either with
1 mg. of nicotinic acid or with 20 mg. of tryptophane
per day : this treatment in all cases effected a cure,
while the remaining 10 rats which were left undosed
as controls did not recover (see table).
The effect of indole-3-acetic acid was similar to that
produced by the addition of whole maize meal (40%)
to the diet. Of 33 rats fed on the maize-meal diet, 29 |
showed a severe depression of growth which could
always be cured either by nicotinic acid or tryptophane.
On a high-protein diet (20% casein) neither maize
meal nor indole-3-acetic acid was effective in stopping
growth.
1. Krehl, W. A., Sarma, P.
S., Teply, L. J., Elvehjem, C. A,
J. Nutrit. 1946, 31, 85; Krohl, W. A. Teply, J L.J., Elvehjem,
a A. Science, 1945, 101, 283 ; Kre A., Teply, L. J.,
Elvehjem, C A. Ibid, p. PAE
J. biol. Chem. 1945, "157, 455; 1946, 162,179;
1946, 163, ote:
3. Heo Gait A J., Leech, W. D., Bergren, W. R.
Botany, 1942, 29, 500.
Ibid, 1944, 31, 199.
Sarma, P. S.,
Amer, J.
4. Berger, J., Avery, 'G. S. jun.
492 THE LANCET]
EFFECTS OF TREATMENT * |
Average
| Average- Hi ;
weekly l i weekly
No.'of gain in te dai gain in
Diet t weight Treatment weight
rats | before after
; treatment l | treatment
= TEE (8) | | 8)
4. 15 : aein E —
4. — ou eae 18
. 10-5% casein k - preventive
1 4o o × Tryptophane, 15.
preventive
10 5 — —
10:5% casein + ki 3 Nicotinic acid, 11 |
indole-3-acetic _ curative i '
acid 2 -0 Tryptophane, 19
curative
22 4 — —
7% casein + 4 2 | Nicotinic acid, 25
40 % maize curative
| 3 2 Tryptophane, |- 13
curative
* Basal diet: 3% cotton-seed oil, 5% salt mixture, 0:15 % cystine,
casein as shown above, and sucrose ad 100. In diets containing
yellow maize meal, the oil, salts, and cystine content were
reduced by 40%. The protein content of all the diets was
about 10:°5%. Vitamin supplements as described by Black
et al., omitting nicotinic acid.
_ Further experiments are in progress to determine
whether the ‘ pellagragenic’”’ effect of maize can be
attributed entirely to its high ‘‘ auxin ’’ content, relative
to its low tryptophane and nicotinic-acid content.
E. KODICEK ;
Ph.D. Camb., M.D. Prague.
K. J. CARPENTER :
B.A. Camb.
LESLIE J. HARRIS | a
Sc.D. Camb., D.Sc. Manc., F.R.I.C.
Dunn Nutritional Laboratory, University of
Cambridge and Medical Research Couycil.
Reviews of Books
Actions of Radiations on Living Cells 4
D. E. LEA, M.A., PH.D., Prophit student of the Royal
College of Surgeons, formerly fellow of Trinity College,
Cambridge. London: Cambridge University Press.
Pp. 402. 2le. |
THE greater part of this good book is occupied by an
account of the effects of radiations (mostly X and
gamma) on viruses and on the genes and chromosomes
of higher cells; this happens to be the field where Dr.
Lea’s own experimental and theoretical work has taken
him and for which he is widely known. Exactly how
cellular death is brought about by X and gamma rays
is not yet known, but he discusses the question in detail,
especially the so-called target theory, defined as follows :
“ When the biological effect observed is due to the
production of ionization in some particular molecules, as
in the induction of gene mutations, or is due to the passage
of an ionizing particle through some particular structure,
as in the induction of chromosome breakage, it is possible
to calculate the size of the molecule or structure involved
from a knowledge of the proportion of the organisms
irradiated which are affected by a given dose or radiation.
It is further possible to predict the variation of ionic
efficiency of different radiations in producing effects of this
sort. The interpretation of biological effects of. radiation
along these lines has become known as the target theory.”
. It is perhaps not unfair to say of this theory that while
it does help towards explaining the way in which differing
ionic efficiencies are linked with different radiations, it
leaves many phenomena quite unexplained.
Many readers will welcome the full account of genetic
effects and the chromosome structural changes set up by
radiation. ‘There is much discussion at present among
radiologists as to whether the mutations set up in
drosophila have any practical bearing on man. Is
there any considerable chance that radiologists in the
course of their work (which, however carefully carried out,
does involve some degree of exposure) suffer mutational
changes ? . Unfortunately nearly all of the mutations
5. Black, S., Overman, R. S., Elvehjem, C. A., Link, K. P. J. biol.
Chem. 1942, 145, 137.
REVIEWS OF BOOKS |
[ocr. 5, 1946
seen in drosophila appear to be regressive. With
radiation work extending on all sides it is inevitable
that this subject will be widely discussed in all its bearings.
Cosmic radiation, it seems, is insufficient in intensity to
account for the spontaneous mutations known to occur
without apparent cause; we must look elsewhere.
‘Throughout the book the outlook is quantitative. It
will appeal to a growing body of people who see radiation
not only as benign but sometimes as deadly. Though
Dr. Lea does not mention it, his text makes it clear that
protective methods will have to be elaborated to cope
with the growing use of this agent.
L’anémie infectieuse — .
G. HEMMELER, privat-dozent, University of Lausanne.
Basle: Schwabe. Pp. 76. Sw. fr. 5.
THIS monograph is an attempt to amplify the scanty
sections in most textbooks on the subject of ansemia in
infectious disease. Details are given of anzmia occurring
in typhoid fever, bacterial endocarditis, rheumatoid
arthritis, and other conditions. Complete records are
given of 25 selected patients; besides full blood-counts,
sternal marrow punctures were carried out, the reticulo-
/
cyte changes followed, and estimations made of the serum
iron. Dr. Hemmeler notes that the severity of the
anæmia is directly proportional to the severity of the
fever, the acceleration of the blood-sedimentation rate,
and the leucocytosis. The anæmia is normochromic
and reticulocytes are low. The bone-marrow is less
cellular than normal and the erythroblasts are mainly
basophilic, few oxyphilic. The serum iron is normal or
low. When the infection dies down there is a spontaneous
remission of the anæmia, independent of treatment,
accompanied by a small reticulocytosis and increased
cellularity of the bone-marrow with accelerated erythro-
blast maturation. Dr. Hemmeler thinks that the ansemia
arises from the failure of a depressed erythropoietic
marrow to make up the loss of red cells due to the
increased rate of hemolysis that accompanies fevers. He
finds no evidence that it is due to iron deficiency, and
attributes it to toxic depression of erythropoiesis. He
makes the useful point that iron and liver are useless
for treating these patients; blood-transfusion should be
undertaken whenever the hæmoglobin falls below 60 %.
A good deal of valuable information is presented in this
pamphlet; but, as in other Swiss writings at present,
there is little evidence of contact with Anglo-American
literature since 1939, and no reference to the work on the
disturbance of hæmoglobin formation in infectious diseases.
The Outlook of Science
Modern Materialism. (2rid ed.) R. L. WORRALL, M.B.
Sydney. London: Staples Press. Pp.191. 12s. 6d.
THOUGH useful, this book is not in the front rank with
Maudsley’s Organic to Human and Bosanquet’s Meditatio
Medici (neither of which appears in the bibliography
appended to this work). The author’s vision is fairly
clear, but he wears glasses which are misty in spots.
As a champion of dialectic materialism he looks forward
to a time when, under a world government based on
genuine democracy (undefined), science will satisfy the
essential wants of all; and having demolished Bishop
Berkeley, Bertrand Russell, Sir Oliver Lodge, Eddington,
J. S. Haldane, Sir James Jeans, Lancelot Hogben, and
A. N. Whitehead, he takes his stand on Lenin,
Engels, and Freud. Besides science, he discusses philo-
sophy, religion, and art. Religion, he says, is founded on
idealism, the opposite of materialism ; therefore religion
is an illusion. Religion is a social product and “ exists
today because of its value to the ruling classes of capitalist
society. . . . Science and art can be considered together,
in being fertile forms of human culture. Religion, how-
ever, an inevitable phase of early culture, has become
sterile, and is now equally inevitably a reactionary force
inimical to the welfare of society.” He advocates a
“ revolutionary transformation ° of society (and points
to the U.S.S.R.), without which the successful future
of science is impossible. The preserit subservience of
science to politics is illustrated, he believes, by the atom
bomb. Few will want to follow him all the way but he
has his stimulating moments.
Messrs. H. K. Lewis, Gower Street, London, W.C.1, are
the English agents for the Year Book of Neurology,
Psychiatry and Endocrinology which was reviewed in
our issue of Sept. 21. : l
Marx, `
THE LANCET]
THE LANCET
LONDON : SATURDAY, OCT. 5, 1946
- Over to the Lords
_ TAKEN by and large, Mr. BEvAN’s handling of the
National Health Service Bill in the House of Commons
was masterly, and many of those who a few months |
ago were strongly antagonistic now understand the
strength of the Government case. There are grounds
therefore for his hope that, though the armies are
still arrayed on the battlefield, they are becoming
increasingly listless; and the president of one of the
Royal Colleges did well last week to direct attention
to the peace conferences which must soon follow.
Nevertheless a further chance remains for amending
the text of the Bill, during the debate which opens
in the House of Lords next Tuesday, and it would be
a pity if this discussion were to be a mere formality.
Much in the scheme remains highly debatable, and
the Government should welcome any attempt to make
a good Bill better—to correct weaknesses that might
eventually prove its undoing. Uneasiness over several
of its provisions is still felt by those most anxious for
its success.
Despite all the Minister’s explanations, we are still
uncertain whether the degree of autonomy granted to
hospital management committees is going to be suffi-
cient, in the long run, to induce able men and women
to serve them devotedly. The misgivings felt on this
score were cogently set out in our columns a few weeks
ago } by a correspondent who rightly pointed out that
on the management committee “ more than on any
other body or person—the Minister included—will
depend whether a hospital functions in an efficient
and humane manner.” Decentralisation of powers,
as Mr. BEVAN recognises, is the main safeguard against
a uniformly second-rate service, and he has accepted
the plea made in our first comment on the Bill?
that hospital management committees should at least
have their own pocket-money and be able to accept
gifts. He has in fact promised that the regulations
will ensure that adequate powers are delegated by the
regional boards to the committees. But.if that is his
intention, is it necessary that the Bill should specifi-
cally lay down that the regional boards shall be the
bodies to appoint officers, to maintain premises, and
“ to acquire on behalf of the Minister and to maintain
equipment, furniture and other movable property
required for the purposes of any such hospital” ?
Are the boards really going to appoint subordinate
personnel, to paint the building, and to mend broken
tables and chairs ? In general Mr. BEVAN has sought
to leave himself and his successors a free hand, so that
where experience reveals a mistake it will be possible
to modify the Bill by regulation, without new
legislation. Can he be sure that the statutory
assignment of these powers to regional boards—which,
especially if there are only 16-20 large regions,’
are capable of becoming pieces of bureaucratic
machinery ‘—will not need modification? Some
aÁ
l. Lancet, July 20, p. 103.
2. Ibid, 1946, i, 421,
3. Times, July 12, p. 5.
4. Lancet, July 27, a 137.
OVER TO THE LORDS
- plexity of the undertaking.
focr. 5, 1946 493 ©
hold that in practice it will seriously limit the devo-
lution of responsibility which all desire. If the policy
is to delegate to local management committees ©
whatever powers may be found necessary for their
functional health, would it not be wise at this stage to
omit these particularising subsections? To some
extent the scheme is admittedly experimental, and it
might be best to say quite simply that the regional
boards and the hospital management committees |
shall exercise such powers as are respectively delegated
to them by the Minister. Though nebulous, this
would at any rate not be misleading.
Another possible source of future trouble is the wide
power of direction given to the Minister in connexion
with hospital and specialist services. As we have
already remarked,® this power is not restricted to the
administrative as distinct from the professional sphere.
When Mr. Bevan was challenged on the point in the
standing committee he gave an assurance that he
would not be so foolish as to meddle in professional
matters; and this assurance, since repeated,
undoubtedly represents his attitude correctly. Yet
the profession, with its experience of directions of a
semitechnical character that have issued from the
Emergency Medical Service, cannot be so easily satis-
fied. There will be—there ought to be—medical
officers in the Ministry of Health anxious to secure
widespread adoption of modern techniques. Will
their ideas emanate from. Whitehall with all the
authority of directions made in the name of the
Minister, binding even on the regional boards? That
is the question, and Mr. BEvan did not really answer
it. We hope therefore it is not too late to incorporate
in the Bill a formula making it clear how far the
Minister’s power of direction legitimately extends.
This should not be beyond the wit of legal draftsmen,
for the distinction between administrative and
professional matters is neither new nor hopelessly
subtle ; it is commonly respected in the hospital world
today. The fact surely is that the simple wording of
the Bill as it stands is too simple to meet the com-
For simplicity’s sake
the distinction “between the adininistrative and
professional responsibility in respect of the hospital
and specialist ¿services has been allowed to slip
into the background. It would be a pity indeed
if it were to become blurred, for the ultimate
consequences could be disastrous to professional
freedom.
A related question, calling for legal debate, is
whether ptactitioners whose conduct the Minister
finds harmful to the National Health Service should
have a right to appeal from his decision to a court of
law. The procedure as now laid down is that any
complaint is made to the local executive council and
is examined in the first place by a purely medical
body, the council’s medical subcommittee. A decision
on the complaint is then reached by the council, half of
whose members are doctors, dentists, and pharmacists. —
If the defendant practitioner is dissatisfied with the
council’s verdict he can appeal to a tribunal of three
persons, of whom the chairman is appointed by the
Lord Chancellor. If again unsuccessful he can
appeal to the Minister himself, who is the person
finally responsible for the well-being of the service.
But only if one of these authorities appears to have
5. Ibid, 1946, 1, 783.
o3
494 THE LANCET]
exceeded its legal powers, or to have acted improperly,
can he seek help from an outside court. Provided the
morale of the profession and the service is high,
these arrangements should work well in practice ; and
Mr. Bevan has substance for his contention that the
High Court is not the right kind of body to say whether
a doctor has been reasonably efficient. Nevertheless
under the new régime expulsion from the public service
will be an extremely serious penalty, and it seems
contrary to the principles of justice that sentence
should be passed by the Minister who may be indirectly
responsible for the accusation. It was to overcome
this objection, of course, that the tribunal was inserted
between the local executive council and the Minister ;
but two of the three members of this tribunal are to
be chosen by the Minister himself. The arrangements
are in fact of the “ quasi-judicial ” nature which Sir
HENRY SLESSER ê and other eminent lawyers view
with alarm, and there is far more in question than
administrative convenience.
` All these are matters that the Lords are well fitted
to elucidate. It is their function to take a long view,
and we trust that discussion will not be frozen by too
ready acquiescence, on either side of the House, in
the Bill as it stands.
`
Perforated Peptic Ulcer.
“ Tus is one of the most serious and overwhelming
catastrophes that can befall a human being. Unless
surgical measures are adopted early, the disease hastens
to a fatal ending in almost every instance.” In the
decades since MOYNIHAN spoke these words, early
operation for the perforated peptic ulcer has seemed to
be as right and natural as the surgeon’s gloves. So it
comes as a shock to find HERMON TAYLOR, in the -
article we published last week, declaring that conserva-
tism has a place—he would even give it pride of place—
in the treatment of perforation. He puts forward a
convincing series of 28 cases treated by conservative
methods with 4 deaths; 3 from conditions unrelated
to the treatment, and only 1 in which, as he admits,
operation might have made a difference. TAYLOR has
turned away from immediate laparotomy, first, because
he often found at operation that the perforation was
already partially sealed and nature was clearly capable
of completing the process. The peritoneal cavity,
it appeared, could cope with a considerable quantity of
infective fluid, provided that continued gross flooding
from the perforation site was controlled by aspirating
the stomach. Secondly, he had found that the
mortality with operation was high, largely because
of chest complications. Thirdly, many of these
patients, because of bronchitis, severe hypertension,
or myocardial failure, came in the “poor risk”
class, where even a minor surgical poco was
hazardous.
These results must be studied in conjunction with
_ those .of operation. TAYLOR’s cases were mostly early
perforations, the delay before admission to hospital
exceeding six hoursin only 3—a fact that speaks well for
the diagnostic alertness of the general practitioners in
the district. Is operation really hazardous in such
early cases? GILMOUR and SarnT? record 51 cases
operated on within twelve hours of perforation with
6. Times, August 9, p. 5.
1. Gilmour, J., Saint, J. A. Brit. J. Surg. 1932, 20, 78.
PERFORATED PEPTIC ULCER
focr. 5, 1946
l death ; SourHam 2 34 cases of duodenal perforation
operated on within twenty-four hours with no deaths ;
Maincot® gives the mortality as 26%. - Unfor.
tunately it is the practice to group together all
_ perforations, and the overall mortality figures for
surgical treatment thus seem high.. Even so,
Houston,‘ in a recent analysis, gives the Newcastle |
figures for 1943 as 184 cases with 8- ‘2° mortality ; for ,
1944 as 190 cases with a 6-3% mortality. Surgery
has not a great deal to be ashamed of. with such
, figures.
These comparisons in no way detract from the
value of the information to be drawn from TAyLor’s
experience. It emphasises the need for emptying the
stomach as soon as possible after the perforation has
been diagnosed; the small Ryle tube is not enough,
and it is a useful tip to give an amethocaine lozenge to
facilitate the passage of a large tube. Morphine should
be given as soon as possible and the patient “ made
comfortable.” TAYLOR neither advocates nor con-
demns the Fowler position, and one may asgume
that the half-sitting position is the most comfortable
one ; itis noteworthy that none of his cases developed
a subphrenic abscess. His results have shown that
where the diagnosis is in doubt, or where the patient’s
poor general condition or the lack of a surgeon prohibits
operation, we have a method of treating the early case
with a reasonable chance of success. TAYLOR agrees
that when there has been a recent large meal with
a likelihood of extensive spilling into the peritoneal
. cavity, and when the patient comes `“ too late,”
surgery is indicated. It must not be forgotten that the
perforation is usually an emergency, coming under the
care of the house-surgeon or R.S.0., whereas conserva-
tive treatment obviously requires an experienced
clinical eye; it might therefore be hazardous to
advocate this treatment as the routine, even for the
early case. Most surgeons, too, will find operation less
nerve-racking than a policy of wait and see. One
surgeon with a considerable experience of conservative
treatment has remarked: “I agree conservative
treatment works, but I have given it up. I have had
too much anxiety with the early convalescence of
these cases.” The conservative method suggests
itself as particularly suitable for the aged. TANNER,’
in a series of 16 perforations in people over sixty, had
10 deaths after operation—apparently a formidable
mortality. Of 8 cases operated on under twelve
hours, however, 6 made a complete recovery, and the
2 deaths were due to bronchopneumonia and cerebral
thrombosis; in TANNER’s view failure to send the
patient to the surgeon early was mainly respon-
sible for the high mortality, and in TAYLOR’s
6 cases in men over sixty the only death was in
a patient who had perforated twenty-four hours
before admission.
The operation for perforation is usually simplicity
itself. A midline incision seems to be most popular,
though a right rectus muscle incision is used by some
surgeons because there is an 8 to 1 chance of the
perforation being duodenal. In view of the chest
complications which commonly follow the perforated
ulcer, and the difficulty of attaining adequate relaxa-
tion of the abdominal wall, various methods of
. Southain, A. H. Brit. med. J. 1922, i, 556.
. Maingot, R. H. Abdominal Operations, London, 1940.
- Houston, W. Brit. med. J. 1946, ii, 221.
. Tanner, N. C. Ibid, 1943, i, 563.
Maun
THE LANCET]
——.
anesthesia have been tried. HAmILToN BAILEY ê
advocates a local anesthetic plus ‘ Pentothal sodium,’
and his advice is followed by many resident surgical
officers ; this method has the advantage that a long
anesthesia is not maintained for what js really a short
operation. Recently curare has proved useful in these
cases. As Mprpriss and ETHERIDGE’ remark, the
incidence of chest complications is largely determined
by the state of the peritoneal cavity after operation.
We know that the peritoneal cavity is usually sterile
for about twelve hours after a perforation. The time
of the previous meal, the presence of chunks of food,
beer, and particularly the barium of an opaque meal
all these are factors influencing the prognosis which
must be carefully weighed before deciding against
operative treatment. Not enough has yet been heard
of the use of penicillin in peritonitis to enable its value
to be judged. If we are inclined to give credit to the
sulphonamides for the very satisfactory Newcastle
figures we must not forget that GILMOUR and SAINt’s
series was published in the days before sulphonamide
therapy. TayYLor’s patients had neither sulphon-
amides nor penicillin. We know that the streptococcus
is the usual infecting organism, and penicillin systemi-
cally administered does penetrate into the peritoneal
cavity. This is a large cavity, so large doses of
penicillin may be required. CRTLE 8 has recently
pointed out that in generalised peritonitis of appen-
dicular origin, where there is a mixed infection,
extremely large doses of penicillin are necessary ;
he has advocated 100,000 units every two hours for
four to six days. Generalised peritonitis following
perforation is an almost certainly fata] complication,
and there is need for more work on this subject.
TAYLOR has pointed to one way of preventing this
disaster—turn the tap off, put the stomach-tube
down, and give the peritoneum a reasonable chance
of exercising its natural function of limiting
infection.
Pilonidal Sinus
Durme the war pilonidal sinus proved, for so small
and undignified a lesion, a remarkable waster of
man-power. Thus, according to HoLMan,! it cost
the United States Navy 359,209 *‘ sick days ” in the
two years 1942 and 1943. A peripatetic corr espondent
recalls that so striking was the tendency for riding in
hard-seated vehicles to exacerbate the pilonidal sinus
that it came to be familiarly called the ‘ jeep
disease.” At first sight the treatment. of a small
discharging sinus or an apparent boil posterior to
the anus seems a simple problem; but it is one
which, from delayed healing or recurrence, has baffled
the ingenuity of many surgeons. /
The pilonidal sinus, or postanal dermoid, has
hitherto been accepted as an infected embryological
remnant. Two main theories of origin have been held
—one that the sinus arises from imperfect separation
of the hind end of the neural tube from the ectoderm,
and the other that it is a sequestration dermoid
formed during fusion of the ectoderm growing in
towards the midline. There is proof that both these
mechanisms do sometimes give rise to dermoids in
this region, but Mr. Patty and Professor SCARFF, else-
a So a cei a a a
6. Bailey, H. E menoncy Surgery, Bristol, 1943.
7. Mimpriss, T. W., Etheridge, F. G. Bril. med. J. 1944, ii, 466.
8. Crile, Q. Surg. Gynec. Obstet. 1946, 83, 150.
1. Holman pi Surg. Gynec. Obstet. 1946, 83, 94,
PILONIDAL BINUS
[oor. 5, 1946 495
where in this issue, challenge the view that all, or
even most, pilonidal sinuses are of embryological origin.
They have been struck by the number of excised
specimens in which no epithelial lining can be
detected, and by the rarity of sebaceous glands and
even of hair follicles. They have found little difference
in thè histology of a primary and a recurrent sinus,
and they think that most examples are acquired
infective lesions, probably originating from puncture
of the skin by a hair. This belief was strengthened —
by their encountering a pilonidal sinus in the hand
of a barber and finding that puncture of the skin
by hairs is by no means an uncommon cause of
minor sepsis of the hand in barbers. The idea of a
hair causing a puncture wound must be novel to
many, but it seems to offer a reasonable explanation
of pilonidal sinuses. Any puncture in an area so
heavily infected, so humid, and so constantly subjected
to friction and movement as the natal cleft, would
tend not to heal.
Conflicting theories of ætiology seldom have an
immediate practical impact on patients. What is
distressing about pilonidal sinus is the extreme
divergence of views on the best method of treat-
ment, because it indicates that no method is really
satisfactory. Every kind of operation has been tried,
from mere evacuation of pus to wide ablation of the
sinus and its surroundings. Most surgeons excise
en bloc and suture the resulting wound, but some
excise and leave healing to occur by granulation
—a process tedious to both patient and doctor.
Even among those who excise and suture, there is
no unanimity on technique, as we may see from
two recent papers from America, both reporting
series of at least 100 cases. Larsen? believes in
wide excision of skin, no undercutting of skin edges, —
and approximation of fat and skin only, with as many
layers of cotton sutures as can conveniently be
inserted. LARKIN,’ on the other hand, advises sparing
excision of the skin and wide undermining of the
flaps, and he approximates the wound edges with a
single layer of wire sutures which pierce "skin, fat,
and sacrococcygeal fascia. LARKIN secures hæmo-
stasis by catgut ligatures, LARSEN uscs cotton, while
Horman stops bleeding by pressure, because he
holds that the small tags of dead tissue caused by
clamping and tying vessels are prejudicial to healing.
It seems as if results must depend, as in so many
surgical procedures, on the man rather than the
method. One can however state in general terms
the present trends in the treatment of pilonidal
sinus. First, radical operation should be deferred
if the sinus is in a state of acute inflammation.
When the latter has subsided the whole sinus must
be excised so that the body starts its healing processes
with an aseptic wound ; and to achieve this it is not
necessary’ to sacrifice much skin. The wound edges
should usually be sutured, because healing by granu-
lation takes a long time and often leaves a scar
whose skin is ill adapted to sustain the chafe and
pressure inherent in its position. Every effort must
be made to prevent secondary infection: hemostasis
should be carefully secured with as few and as fine
ligatures as possible, the dead space must be oblit-
erated (for which purpose each surgeon must select
Ann, Surg, 1946, 123, 1090.
Surg. Gynec, Obstet. 1946, 82, pee
2. Larsen, B. B.
3. Larkin, L. C.
496 THE LANCET]
PALPABLE PEDAL PULSATIONS
[oor. 5, 19460
for himself from a bewildering number of suture
and dressing techniques the method he thinks will
best avoid “tenting ”’ of the skin), and the surface
of the wound must be kept dry. Though penicillin
can usefully be employed, local implantation of the
sulphonamides, particularly the less soluble ones like
sulphathiazole, is liable to increase exudation and
thus do more harm than good. Finally, Parry and
ScaRFF, following the implications of their hypo-
, thesis, suggest that preoperative epilation of the area
by X rays is likely to prove an essential part of the
treatment.
Annotations
`. WORLD MEDICAL ASSOCIATION
Ir the World Medical Association, whose formation’
in London last week is reported elsewhere in this issue,
is to fulfil the aims that are set before it, it will need
world support. Its first purpose must therefore be to
attract into full membership those countries which were
not represented at the meeting or which, like the United
States of America, were represented only by observers.
Its second purpose may well be to become a live body,
sharing actively in world health organisation.
week the sentiment seemed to be against the associa-
tion’s concerning itself with scientific medicine, because,
according to one delegate, each country has its own
academies competent for this work. On the other hand,
the resolution setting out the association’s functions
allowed for the exchange of information between the
different countries. It might be best if this clause
were liberally interpreted; for, as we have lately
suggested (Sept. 7, p. 352), the complexity of modern
medicine calls for the closest technical understanding
between all countries. The association, if it shouldered
the task of promoting the exchange of scientific informa-
tion, and particularly information on research, might
benefit not only world medicine but the professions in
the constituent countries.
CARDIOVASCULAR CHANGES IN AN/EMIA
DESPITE the fundamental relation of anæmia to
the cardiovascular system, published work has been
mainly concerned with particular aspects of the question,
or with rare or severe disorders. In 1939 Ellis and
Faulkner ! reviewed the effects of anæmia on the hearts
of 47 patients, but these were of all ages, and, as the
investigators themselves pointed out, degenerative
cardiovascular changes in the elderly undoubtedly
vitiated the results. In this country Alastair Hunter ?
has now made a similar study of 34 patients, excluding
all those in whom factors other than anæmia were
likely to influence the cardiovascular findings.
Dyspneea, palpitation, and cardiac pain were noted
in that order of frequency, all three symptoms being
related to exercise and relieved by rest. Dyspnea
was never orthopneic or paroxysmal. Anginal pain
occurred in 8 patients, but only 2 had radiation to the
arm or back, while 4 others had tightness of the chest.
Hunter is sure that anzemia alone can cause cardiac pain,
and he suggests that “in any woman under forty,
without hypertension, and complaining of cardiac pain,
the cause may be an unrecognised anæmia.” Hyper-
tensives were excluded; the average initial blood-
pressure was 135 mm. Hg systolic, and 70 mm. Hg
diastolic. Treatment was followed by a rise in both the
systolic and, more especially, the diastolic pressures ;
in 3 patients the rise was considerable, amounting in
2 ultimately to hypertension. In 8 patients a third
New Engl. J. Med. 1939, 220, 943.
1. Ellis, L. B., Faulkner, J. M.
Quart. J. Med. 1946, 15, 107.
2. Hunter, A.
Last-
héart sound, classified as abnormal under Evans’s recent —
scheme,® was heard. Systolic murmurs were -present
in 30 of the 34 patients; 9 had apical murmurs only,
20 had pulmonary, or pulmonary and aortic, and 1
had a pulmonary only. Of these, 2 had additional
murmurs, early diastolic and presystolic respectively,
which disappeared with treatment. Only 4 had no
murmurs. No correlation could be demonstrated between
murmurs and cardiac enlargement. Murmurs, although
disappearing after treatment, did not do so with anything
like the rapidity of the enlargement. Heart-size, which
was assesséd radiologically, was definitely increased in
12, and equivocally so in 6; size regressed with treat-
ment in 11, improvement being maximal in the early
weeks. There was no direct relation between enlarge-
ment and the severity of the anemia, although the
duration of the latter seemed a possible factor. Of 25
patients who had an electrocardiogram, 5 showed
minor changes, 2 of these being gross ; 2 of the 5 reverted
to normal after treatment. i
These are interesting findings, for the signs and
symptoms described here have often in the past led to
an erroneous diagnosis of heart-failure. The dyspnea,
palpitation, edema, cardiac pain, and murmurs may
all result directly from different qualitative changes
in the blood. Cardiac enlargement, Hunter considers,
is caused by a dynamic disorder of the circulation,
although, with excessive physical demands or pre-
existing cryptic cardiac disease, true failure may super-
vene. Sharpey-Schafer * has suggested that in severe
chronic an#mia the raised venous pressure, which is
a traditional sign of failure, may in reality represent
the final phase in an undefined process of circulatory
adjustment, directed towards maintaining the high
cardiac output necessary for the adequate functioning
‘of the defective blood. Hunter concludes that “‘ enlarge-
ment of the heart in anzemia, accompanied as it sometimes
is by a raised venous pressure, addition of the third
heart sound, and inversion of the T-wave in the right
pectoral electrocardiogram, is an expression of right
heart preponderance which may progress to frank heart-
failure with hepatic engorgement and cedema.’’ Here is
a fascinating field for investigation. The cause of the
raised venous pressure requires elucidation, and the
accurate methods of assessing venous pressure and cardiac
output by cardiac catheterisation, which led to Sharpey-
Schafer’s observations, are likely to be used sooner
or later in the investigation of uncomplicated anæmias
in younger patients.
PALPABLE PEDAL PULSATIONS
THE study of the normal, which has been rapidly
advanced by the mass medical examinations of the late
war, has provided useful data that will be of value in
the early recognition of disease. The latest addition to
our knowledge is the\finding that of 1014 healthy
American soldiers, whose average age was 20 years and
of whom over 90% were under 22, there were over 13%
in whom the pulsation of ‘the dorsalis pedis or posterior
tibial artery was impalpable.! The dorsalis pedis pulsation
was absent on the right in 11-4% and on the left in 13-6%.
The posterior tibial pulsation was absent on the right in
2-9% and on the left in 2.7%. In only 5 men was pulsa-
ee absent in both arteries on the same side, but in
7-5% the dorsalis pedis pulsation was absent in both feet,
while in 1-7% the posterior tibial pulsation was absent
in both feet.
A curious incidental observation was that the posterior
tibial pulsation was more commonly absent in the Negro,
while the dorsalis pedis pulsation was more often absent
in the white soldier. It was confirmed that when pulsa-
3. Dyane, wW. Brit. Heart J. 1943, 5, 205.
4. Sharpey- Schafer, E. P. Clin. Sci. 1944, 5, 125.
1. Silverman, J. J. Amer. Heart J. 1946, 32, 82,
THE LANCET]
tion was absent in one artery, the other artery in the
same foot had an enhanced pulsation. This observa-
_tion was first recorded in 1898, by Erb?; but pulsation
was absent in only 3 of his 381 patients. Morrison 3
found that 19% of the 1000 people he investigated had
absent pulsations ; but most of his subjects were women,
and there was a wide variation of ages. If 13 of every
1000 healthy young men have impalpable dorsalis pedis
or posterior tibial pulsations, there is clearly need for
caution in drawing conclusions from the absence of such
pulsations in patients with suspected peripheral vascular
disease.
INTENSIVE COURSE IN PSYCHOTHERAPY
AN interesting experiment on the teaching of psycho-
therapy to general practitioners is reported by Mr.
Geddes Smith for the Commonwealth Fund.) A fort-
night’s course for 25 doctors was held at the University
of Minnesota last April in an attempt, sponsored jointly
by the university and the fund, to decide whether
doctors can “‘ be taught to practise in their own offices
the kind of medicine psychoneurotic patients need.”
The course was conducted by psychiatrists with teaching
experience, including four professors and two associate
professors of psychiatry, as well as two consulting
psychiatrists, two social workers, and an associate
professor of medicine.. A group of seven neuropsychia-
trists helped with the clinica] teaching, and the univer-
sity provided the patients. Morning lectures followed
by discussions laid the theoretical groundwork of the
kind of medical care the students were to learn; after-
noon seminars for the whole group were designed to give
instruction in method; the students undertook super-
vised clinical work, and discussed it at small section
meetings consisting of an instructor and five students ;
and films and special seminars were to be arranged as
requested. In practice, the lectures and section meetings
proved the best teaching agents, the large group seminars
being less successful. The section meetings, with their
informal give and take, allowed the students to hammer
out the significance of clinical work case by case. The
lectures covered such subjects as general orientation,
patient-physician relationship, normal personality
development, the meaning of a psychoneurosis and its
diagnosis, anxiety, general principles of psycho-
therapy, common psychopathology, combat fatigue, and
the care of veterans.
The students took the course hungrily, and “ were so
full of the subject that they spent hours at night talking
with each other and with members of the teaching staff,”
and they much preferred this to evening seminars or
films. Many of the cases seen were of long standing—
patients who had had various kinds of medical and
-surgical treatment elsewhere, and who are all too
common in the general practitioner’s surgery: “it was
an excellent sample of the persistently unwell.” The
purpose of the interview was thoroughly impressed on
_ the students, this being not so much to get the facts as
to find out the patient’s attitude to the facts and to
help him to tell his own story. They were asked to listen
to the patient, to let him know he had undivided atten-
tion, and to talk with him for an hour instead of
the customary fifteen minutes. The transference and
counter-transference were explained; students soon
grasped that a positive trahsference at the first interview
gives the patient freedom and confidence, and is a good
start for treatment. The instructor usually came in
just before the end of the hour and brought out factors
the student had missed, or made clear the significance of
what the patient had already told him. At the end
2. Erb, W. Disch. Z. Nervenheilk. 1898, 13, 1.
3. Morrison, H. New Engl. J. Med. 1933, 208, 438.
1. Psychotherapy in General ‘Medicine : Report of an Experimental
l ee eauate Course. The Commonwealth Fund. New York,
- INTENSIVE COURSE IN PSYCHOTHERAPY
[oor. 5, 1946 497 .
of the first day one student, speaking of the anorexia
of a twelve-year-old said: ‘‘ Well, then, you talk her
into eating.” The instructor answered: “ You don’t
talk her into it ; you let her talk herself out of the reasons
for not doing it.”
But in psychotherapy, while principles may be easy
to grasp, management of cases can only be learnt by
years of training and experience; in the second week
the students had to be given some understanding of the
possibilities and limitations of psychotherapy—to :be
shown, in fact, when to go forward with a case and when
to leave it alone or seek help elsewhere. Moreover, they
had to learn that they themselves were influenced by
patients in ways of which they were not fully conscious ;
and that there were many cases in which they must be
satisfied to help the patient to adjust himself to irrever-
sible handicaps, without attempting to cure him. ‘* The
patient is a person needing help; the function of the
doctor is not to play God, but to give help at any and
all points where after thoughtful study he sees the way
to do 80... .”
The result, judged by written comments, was a new
orientation of the students to their relationship with
patients. Nearly all felt that they had gained help in
their daily work. From the instructors’ point of view
it was clear that the present generation of general
practitioners are not too old to learn the psychotherapy
they have never been taught : the students at this course
were both eager and quick to learn.
THE M.D.U.
IN an annual report of pre-war dimensions the
Medical Defence Union gives an account of careful work
on behalf not only of its members but of the public. In
his presidential address at the annual meeting on Sept. 24,
Mr. St. J. D. Buxton, F.r.c.8., reminded members that a
joint codrdinating committee, made up of representatives
of the M.D.U., the London and Counties Medical Protec-
tion Society, and the Medical and Dental Defence Union
of Scotland has been set up during the year to develop
a common policy in matters of mutual interest. On the
request of the M.D.U:, the British Standards Institution
set up a committee (on which the union was represented)
to report on methods of preventing avoidable accidents
associated with the use of gaseous anesthetics. This
committee have now reported, submitting a ‘‘ Code of |
Practice ” which should in time do away with all errors”
due to wrongly coupled leads, and misidentification of
cylinders. Copies of this report will soon be available
to any member who asks for it. i
In answer to many inquiries from demobilised doctors
about reinstatement, the union point out that the Act
of 1944 provides that an employer must take a doctor
back into his pre-war post if he applies for it within four
weeks of demobilisation, and “if re-engagement is
reasonable and practicable.” This second requirement
allows of shuffling, and the deliberate evasion of respon-
sibility ; moreover, if the post was honorary or only
carried a token payment it does not come within the
scope of the Act. Some governing bodies of voluntary
hospitals have refused to reinstate returning specialists
and consultants, on the grounds that they have now
given the appointments to others. This attitude, though |
contrary to the spirit of the Act, unfortunately cannot be
attacked on legal grounds. Doctors who held posts in
municipal hospitals before the war have not encountered
the same ditliculty, partly because their appointments
were paid and partly because the Act applies to municipal
staff as a whole, as local authorities fully appreciate.
During the year the union has successfully prosecuted
some unqualified practitioners who have used the titles
of “ physician,” “ surgeon,” or “ doctor” (usually pre-
ceded by some descriptive adjective), to which they
have no claim. Members who know of unregistered
498 THE LANCET]
practitioners contravening the Act in this way are asked
to inform the union. oe |
Some of the cases dealt with during the year included
questions of fees, certification, and alleged negligence.
The report again impresses on doctors the importance
of care in the coupling of anesthetic cylinders, and the
dangers of explosions in the theatre; and on surgeons
the need for capable swab-counting, the importance of
X-ray examination of bony injuries, and the duty which
lies on them to establish the diagnosis to their own
satisfaction : it is not wise to accept a colleague’s opinion
and to operate without ~confirming his findings. One
member had found a commercial firm using a quotation
from an article of his, published in the medical press, to
support their advertisement for a certain form of electrical
treatment. Permission to use his name had not been
asked. The union protested to the advertisers who
withdrew all the remaining pamphlets containing the
advertisement and undertook to issue no more of the |
kind. Other examples of the union’s work could be given,
for the annual report makes instructive reading ; but
as Mr. Buxton pointed out, the existence of the M.D.U..,
telegraphic address ‘‘ Damocles,” should suffice to remind
us that the path of the practitioner may be far from easy.
THE MAKINGS OF A MEDICAL SCHOOL .
In the hope that his findings might guide them in
establishing a university medical school, the governors
of the University of British Columbia asked Dr. C. E.
Dolman, their professor of bacteriology and preventive
medicine, to make a survey of medical education
in Canada and the United States.!
: Professor Dolman visited the 11 medical schools of
Canada, and 22 leading medical schools in the U.S.A.,
talking with heads of departments, staff members,
students, university presidents, deans, representatives
of the Rockefeller Foundation, hospital directors,
and. any others who came his way. His list of require-
ments for a first-class medical school begins with a
stable and flourishing parent university, a large body of
good applicants from whom students can be selected,
enough money, and a picked staff, of whom the heads
of departments and some others are to be full-time.
Teaching affiliations with local hospitals, he considers,
should be made on terms satisfactory to the university ;
but there must also be a university hospital staffed
“entirely by the faculty of medicine. The school should be
placed in the campus so that the students share the life
and interests of their fellows working in other faculties ;
and the medical faculty must share its resources with
the university, offering special courses to non-medical
graduates, training students for medical ancillary ser-
vices, and being fully responsible for a well-developed
university health service.
He found, he says, plenty of evidence that a second-
class university cannot hope to have better than a
second-class medical school. Though fees for the medical
course are nearly twice as high as for other courses given
in the same university, they seldom meet more than a
third, or in some schools a sixth, of the cost, and no
university should contemplate founding this expensive
form of school unless it has proper resources. Too big
a teaching load on staff puts an end to the serious and
sustained research which must be among the first duties
of a medical school. A good staff, once appointed, must
_ have proper apparatus for research, and such equipment
quickly goes out of date: “hence no medical school
ever seems to find its budget adequate.’ In the United
‘States he found that the annual cost per student ranged
from $600 to $3893; and he had no doubt that the
student in the expensive schools got better teaching.
Tutorials and seminars are better vehicles for teaching
——
1. Report to the board of governors of the University of British
Columbia, May, 1946,
THE MAKINGS OF A MEDICAL SCHOOL -
as well as with State health departments.
-
[oor. 5, 1946
than didactic lectures, but are possible only when the
ratio of instructors to students is high; and the atmo-
sphere is more favourable to learning in a school where-
research is an honoured activity, not an intermittent
and clandestine indulgence. |
The best annual entry, Professor Dolman thinks, is
round about 50 students a year. The Goodenough report,
it will be remembered, suggested an entry of 100, which
he would consider too high on the ground that if a class
is much over 56 or 60 it has to be split into sections, and
a disproportionate number of additional teachers must
be provided. Good staff are as scarce in America as here.
He notes that in the U.S.A. at least four chairs, and
numerous assistant professorships, of anatomy are vacant,
and that good pharmacologists are even harder to find
than anatomists. Medically qualified men who go in
for full-time teaching do it at a financial sacrifice, but
even so he believes that ‘‘ without plenty of money one
cannot hope to get good men.” He is also clear that it
is not enough to appoint a single full-time man in a
clinical department and leave him dependent for help
on part-time workers and volunteers: the result of that
is to push the head*of the department into “ the rôle
of chore-boy.”’ ka
In discussing the medical curriculum, Professor Dolman
insists that preventive medicine must be better taught,
but not to the point of displacing the doctor’s traditional
concern with the care of the sick. He notes the increasing
popularity of joint conferences in which the anatomist,
bacteriologist, biochemist, and pharmacologist take
equal part with the physician and surgeon. In ‘some of
the best schools the department of psychiatry arranges
lectures, demonstrations, and seminars, on ‘normal
psychology and on the psychological bases of abnormal
behaviour, for students in their first and second years.
The various departments must be closely interrelated,
not only in the intellectual but in the physical: sense ;
it is hard to codperate fully over a gap of, say, six miles.
He believes that every link possible should be forged
between the medical school and the general practitioner,
Perhaps his
most telling observation is that ‘“ the form and fame of
a medical school is very largely determined by the
character and ability.of its first Dean.”
MEDICAL RESEARCH COUNCIL
THE Committee of Privy Council for Medical Research
have appointed Group-Captain C. A. B. Wilcock, M.P.,
Dr. C. A. Lovatt Evans, F.R.S. (professor of physiology
in the University of London), and Dr. R. A. Peters, F.R.S.
(professor of biochemistry in the University of Oxford),
to be members of the Medical Research Council.
RETIREMENT OF MR. F. W. MARTIN.
WE who produce this journal have lost a: valued
colleague by the retirement on Sept. 26 of Mr. Martin,
our head printer. He and his father, W. G. Martin,
between them held this office for 56 years, and his father’s
association with THE LANcET began over 70 years ago.
On July 4, 1893, Frederick William Martin was bound
apprentice for seven years to Thomas Henry Wakley,
F.R.c.8., and Tbomas Wakley, jun., L.R.c.P., then pro-
prietors of The Lancet, to learn ‘‘ the Art of Letter-
Press Printing, which they use”; and until 1921 he
worked at 423, Strand, where the typesetting was done
above the editorial office. When 25 years ago the print-
ing was transferred to Messrs. Hazell, Watson, and
Viney, in Long Acre, Mr. Martin joined their staff but
continued his close association with the editorial and
managerial departments of the journal. Among us he
had by far the longest experience of THE LANCET, and
he did much to preserve its standards and transmit its
tradition. The apprentice became himself a teacher
and counsellor, and remains a friend.
THE LANCET]
Special Articles
ie eee eee
CHILDREN IN DAY NURSERIES
WITH SPECIAL REFERENCE TO THE CHILD UNDER
. TWO YEARS OLD
Hiba F. MENZIES
M.D. Aberd., D.P.H.
DEPUTY MEDICAL OFFICER OF HEALTH, LEYTON
Dorina the war there was a muslroom growth of
nursery accommodation for children under five years
of age. The Ministry of Labour and National Service
pressed local authorities to establish nurseries as a means
of encouraging mothers of young children to do full-time
industrial work. Whether it was really wise to give
mothers of young children this encouragement may be
doubted (Menzies 1944).
By January, 1945, up to 1500 nurseries had been
established with a maximum of 50 children per nursery.
Since then about 200 have been closed. The latest esti-
mates of the Ministry of Labour (as quoted in the Times
of June 20, 1946) show that in the first ten months of
` peace nearly a million women left industry to return to
their homes, and the number actually engaged in civil
employment in April, 1946, was 5,420,000. The propor-
tion of women therefore whose children were in nurseries
during the war represented rather over 1% of the total
number of women in industry, and as a result of closing
200 nurseries a maximum of 10,000 women may have left
industry—again 1% of the total who ceased work.
This disposes of the argument that the establishment
of nurseries has had any appreciable effect on the labour
situation.
The statement recently made in a propaganda leaflet, .
that the ability of women to remain in or re-enter
industry ‘‘ will depend largely on the speedy setting up
of more nurseries and nursery schools,’ oversteps the
bounds of justifiable einphasis which one expects to find
in propaganda. A more reasonable argument is that
nurseries have a contribution to make towards maternal
‘and child welfare; but here again we should look at
the facts in correct perspective against the background
of general maternity and, child-welfare services. The
proportion of children under five years of age who were
in nurseries during the war was only 2-3% ; so the health
of young children in general will not so far have been
appreciably influenced by nursery. provision.
The few nurseries in existence before the war were
established for social reasons—to care for children whose
mothers had to earn their living, or for those whose
home circumstances were unsatisfactory. Curiously
enough, there does not seem to be any published record
of the progress of these children.
It is perhaps less surprising that the progress of
children in war-time nurseries has not been recorded * ;
for the establishment and supervision of nurseries fell
on depleted public-health staffs who had often Civil
Defence duties besides their usual work. It seems impor-
tant, however, that the progress of these children should
be watched carefully, particularly if in the future there
is to be any extension of nursery provision to make
things easier for the tired mother.
Most mothers probably find their young children a
trial at times, and those who have to care for one or
more young children and run a house unaided have a
tiring time; but how many of them will be prepared
to secure their own relief unless they can be assured that
their children will do equally well away from them ?
This factor operated even during the war, when there
was a good deal of propaganda to induce mothers to go
* Since this paper was written a report on the health of children in
war-time day nurseries has been published in the British
Medical Journal, August 17, p. 217.
CHILDREN IN DAY NURSERIES ©
focr. 5, 1946 499
to work. In Leyton—which was not an area with much
employment of married women before the war, and has
a good standard of maternal care—when we set up two
nurseries, for 50 children each, we had 48 withdrawals
within one week, and another 36 within four weeks of
admission. The majority who left within this time were
considered by their mothers to be “ fretting.” Have we
enough knowledge of the development of young children
to tell these mothers they were wrong ?
Since I have had an opportunity of examining the
records of those children admitted before they were two
years old who remained in the nurseries over three
months, I think it is possible that those mothers who
withdrew their children made a wise decision. _
The rapid turnover of children in the nurseries is very
striking ; and, if experience in other nurseries has been
similar, this may have been one reason which deterred
medical officers from recording the progress of children.
It also suggests that the nursery population is selected :
the children of whom we have records are those who
have stayed the course. ’ In theory one would have
expected that with certain exceptions—e.g., children
withdrawn because of the mother’s pregnancy—a child
admitted to a war-time nursery would have remained
there until he went to school. Yet in three and a half
years in Leyton 368 children (occupying 100 nursery
places) have been admitted and left, and of these only
60 (16%) have stayed until they went to school; 64
left within a week of admission, another 47 within a
month, and 222 within six months. The obvious retort
of the enthusiast will be that the fault is in the individual
nurseries, and this may be suggested when my figures
of progress of children under two years are read. But I
shall be content if the critics record their own experience
for comparison. From the remarks of the numerous
visitors (official and otherwise) whom nurseries attract,
the nurseries in Leyton seem to have been as good as
the average,-and a good deal better than many. The
last inspector we had observed that as soon as she entered
the door she could tell that the atmosphere of the nursery
was good. l
ı PROGRESS OF CHILDREN UNDER TWO YEARS OLD
Gain in weight is the most obvious tangible evidence
of progress iu the young child.
I have so far only tabulated the progress of children
who were admitted to a nursery before they reached the
GAINS IN WEIGHT
x In 3 months 3-6 months 0-12 months
Age on Well ee
admission No. of AV No. of AV
(months) ery chil- gain chil- gain
dron (Ib.) dren (1b.)
12-18 A 26 1-00 20) 1°17
B 32 1:40 24 1:34
18-24 A 15 1-49 10 1:08
B 27 0-96 20 1:38
age of two. This appears to be the most important group
to study in the first place, because these children are
‘not yet old enough to benefit from association with-
other children, and there are certain obvious risks— —
namely, fretting through separation from the mother,
and infections. |
Of those admitted under two years old 76 left within
three months, and it is therefore impossible to make any
record of them.
In children under a year old the gain in weight is
very definitely related to the month of life. The numbers
in the nurseries at this age were not large enough to
subdivide them ; but, of 32 children who were admitted
in their first year and stayed more than three months,
8 gained 0-8 oz. in weight in the first three months in
the nursery, and another 7 gained 8-16 oz. An average
`
500 THE LANCET]
gain of a child at this age, putting it at a low estimate,
is 1 lb, a month.
, The accompanying table shows the gain in weight in
the first three months, in the second three months, and
in the first twelve months of two groups in each nursery
—those admitted when they were between twelve and
eighteen months old, and those admitted when they
were between eighteen months and two years old.
Besides the average gain in weight in each group over the
period stated, I have indicated the number of children in
each group on which the gain in weight is calculated. It
is obvious that the number who remained in the nurseries
for a year or longer are a selected group, and the number
in each age-group is too small to justify any definite
conclusions. The average gain in weight of children
between one and two years old may be considered to
be 5-7 lb.; hence these gains appear to be at the lower
limit of normality.
To take the average gain conceals the progress ‘of
individual children; but, of 58 children admitted at
ages between twelve and eighteen months, 3 lost weight
in the first three months, 9 gained 0-8 oz., and a further
9 gained less than 1 Ib. Thus over a third made unsatis-
factory progress in the first three months. In the second
three months 2 children lost weight, 5 gained 0-8 oz.,
and 4 gained less than 1 lb. The total number of
children here was 44; so a quarter made unsatisfactory
progress in the second three months.
Of 42 children admitted aged between eighteen months
and two years, 7 lost weight, 3 gained 0-8 oz., and 5
gained less than 1 Ib. in their first three months in the
nursery—i.e., in a third the gain was unsatisfactory. In
the second three months out of 30 children 2 lost weight,
6 gained 0-8 oz., and 3 gained less than 1 lb.
As children in nurseries are in a favoured position |
as regards rations, compared with children whose mothers
are looking after them at home, I regard the progress of
these groups of children admitted under the age of two
years as disappointing. It is reasonable to suppose that
illnesses explained the poor gains to some extent, but
this cannot be the whole explanation, because some
children had as many as four infections and progressed
satisfactorily, whereas others had no illness and yet
did badly. Nor does it seem possible to foretell which
child will do reasonably well and which will do badly.
The fact that a child has had poor maternal care does
not necessarily lead to its doing well when admitted
to a nursery. Thus in a child aged between eighteen
months and two years, with the note “‘ care poor,
verminous, went to residential nursery,” there was a
loss of weight of 15 oz. in the first three months in the
nursery, and a gain of 15 oz. in the second three months.
In that time the only illness was German measles.
Another child, who was a removal into the district and
whose mother appeared to have a low standard of care,
gained 11 oz. in the first three months and lost 3 oz.
in the second three months, again without having any-
thing more serious than German measles. Of all our
admissions we had only 1 child with chronic malnutrition
from lack of food, and this child did well, gaining 3 1b.
12 oz. in the first three months, and 3 lb. 3 oz. in the
second three months. Children whose general nutrition
on admission was poor from no obvious cause did nothing
spectacular.
In February, 1943, a warning was issued from the
Ministry of Health to medical officers that nutrition in
nurseries, particularly of children between one and
two years of age, was in some areas less good than it
should be. This was considered disturbing in view of
the fact that nursery children got extra rations. It was
evidently assumed that this poor nutrition in nursery
children was due to some lack in nursery dietaries, for
medical officers were advised to review the dietaries of
the children, and extra iron was made available. `
CHILDREN IN DAY NURSERIES
_ for squalls.
(oor. 5, 1946 |
From the time the nurseries opened in Leyton in
August, 1942, I had gone over the menus very carefully
with the matrons. We had insisted on every child having
cod,liver oil and fruit juice daily, and I had ordered a
preparation of iron for those children who seemed to
need it. I am not therefore prepared to agree that failure
to gain weight adequately in the cases I have listed is
due to anything so simple as lack of proper food.. It “
seems more likely that it is due to emotional disturbance, |
and if this is so it is much more serious.
It is not unusual for a young child to take anything
from a week to a month to settle. This period of adjust-
ment to unknown people and surroundings may be
characterised by continuous or intermittent crying,
refusal to eat, refusal to sleep, or refusal to sit on a
chamber without screaming. It is an unhappy time for
all concerned.
Susan Isaacs (1932) mentions that’ emotional causes
may affect weight gains in young children. Freud and
Burlingham (1943), who made a detailed study of
children in residential nurseries, found that in children
from one to two years old the motor control was better in
nurseries than in homes where freedom to move was
restricted, but that the nursery child “ is at a disadvan-
tage wherever the emotional tie to the mother or to the
family is the mainspring of development. Comparisons
between children under these contrasting conditions
serve to show that certain achievements such as speech
and habit training are closely related to the child’s
emotions, even though this may not be apparent at
first glance.”
It is recognised now that too early and too strict
habit-training in babies may lead to a relapse later on.
Bowley (1942) says that bowel control should not be
expected before the age of twenty-one months, and bladder
control before that of twenty-four months. In our child-
welfare clinics we advise the mothers on these lines and
warn them of the dangers of overinsistence on cleanliness,
but in nurseries it is inevitable that strenuous attempts
at habit training should be made with the under-twos.
“ Potting time ” is recognised in the nurseries as a time
The dangers of gastro-enteritis in young,
children have been brought back to us in recent years
with the rise in the death-rate from gastro-enteritis in
children under two years old, and this more obvious
risk is bound to determine procedure in nurseries.
The social development of the child is tied up with
his emotional development. So if this failure to gain
weight adequately is evidence of an emotional hold up,
the effect may be far-reaching.
INFECTIONS
At one nursery 54 children out of a total of 72 (admitted
under the age of two years) who remained longer than
three months in the nursery developed one or more
infections. At the second nursery the proportion was
35 out of 60. The commonest infections were of
the catarrhal type—measles, whooping-cough, German
measles, bronchitis, and pneumonia, but scarlet fever,
mumps, dysentery, jaundice, and chickenpox all occurred.
Some children had as many as four infections, and of
60 children (including the admissions under the age of
twelve months) who remained twelve months or more in
the nurseries, only 7 escaped infection. I counted acute
bronchitis only if it led to several weeks’ absence from
the nursery.
A preliminary study of infections in war-time day
nurseries was made in Oxford from the Institute of
Social Medicine (Allen-Williams 1945), and from the
records analysed it appeared that children attending
day nurseries were more liable to contract infections
than were children living at home, and the infections
occurred at an earlier age in the day-nursery population.
The investigator discussed the likelihood of the infection-
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INTERNATIONAL MEDICAL CONFERENCE IN LONDON
focr. 5, 1946 501
rates being underestimated in both sets of records, and
assumed that the nursery records would be more complete
as the children were under daily skilled supervision.
That might be a safe assumption so far as the Oxford
records were concerned, but anyone who remembers
the conditions in London war-time nurseries will agree
that the matrons there had every excuse for not recording
on the children’s cards all their absences through illness.
There was usually a shortage of staff, and, particularly
from June, 1944, the children were in and out of air-
raid shelters all day long. Careful recording was the last
ne one could expect. ‘under such conditions.
EXPRESSIONS OF OPINION
Kershaw (1946) criticised tle Oxford survey as being
at the same time too scientific and not scientific enough,
and in his criticism he betrayed a bias in favour of
nursery provision, but he did not provide any facts to
back his opinions. In his own words “ We have tended
to rely too much on general impressions often coloured
by preconceived ideas.”
_ Other expressions of opinion have been made recently.
“ The scope of the evidence is admittedly limited, but
so far as it goes it does not indicate a beneficial effect of
nursery life for the younger children—rather the reverse.
There was a general increase of respiratory infection, to a
significant extent in some instances, but no constant or
significant improvement in physical development as indicated
by weight or the doctor’s impression of general physique ”’
(Medical Women’s Federation 1946, in a report based on the
records of 4587 children in 22 local-government areas).
“ The advantages of a dav nursery or nursery school are
much greater (than a home help) for the child. A child needs
training and discipline from the very beginning of its life,
and this training can only be suitably given when there are
facilities for mixing with other children. . . . The children are
taught regular habits, are given well-balanced meals adequate
in quantity and quality, and have proper periods of rest and
sleep as well as of activity ’’ (Paul 1946).
“ The danger of infection was there but was just a thing to
be overcome. Good nutrition was one safeguard. The social
benefit of mixing of children was great and he doubted if
the family was always the best place for their bringing up’
(Roberts 1946).
‘ Day and residential nurseries have contributed a good
deal, to the improved knowledge and actual nutritional
standard of children” (Nutrition and Child Welfare 1946).
I shall look forward to reading the investigations which
would justify such opinions. I am not in a position to
make any such definite statement, but as the result of
studying the progress of children under two years old,
admitted over a period of three and a half years to two
war-time day nurseries in London, have come to certain
conclusions.
CONCLUSIONS
Of children under two years old a substantial proportion
do not make satisfactory progress on admission to a
day nursery, as judged by their weight gains in three-
monthly periods. This is in spite of the fact that over
the period under review children in nurseries had avail-
able what amounted to almost double rations compared
with children whose mothers cared for them at home,
and that a very careful attempt was made to satisfy
the dietary requirements of young children in the
nurseries I have been supervising.
It is recognised by psychologists that emotional dis-
turbance interferės with weight gains in young children ;
and,-as it is obvious from “their behaviour that these
children do suffer an emotional upset on admission to a
nursery, this may explain their failure to gain weight
adequately. It is not necessarily possible to tell from
their subsequent behaviour whether they are making
satisfactory gains in weight.
Most of the children admitted under two years old
who stayed in the nurseries developed one or more infec-
tions sooner or later. The extent of the infection-rate is
less obvious owing to the practice of accepting on the
register about 20% more children than there are places
available in the nursery, but a recent epidemic of measles
in one nursery reduced the attendance to 14.
In considering what proportion of children in these
ages do or do not make satisfactory progress, and do or
do not develop infections, account must be taken of
the number who leave either because their mothers
consider they are fretting or because they contracted
an infection from the nursery. There is a tendency to
forget about them. The mother does not attend mass
meetings to describe the effect of the nursery on her
child. She simply removes the child.
We require guidance from those best qualified to
judge what is the earliest age at which a normal child
may be removed from his mother, home, and familiar
surroundings, and for how many hours a day, without
the likelihood of experiencing emotional upset. As a
corollary to this, at what age does the young child: begin
to benefit from mixing with other children ?
- The opinions expressed here are personal and are not
intended to represent those of the borough of Leyton.
REFERENCES
Allen-Williams, G. M. (1945) Lancet, ii, 825.
Bowley, A. H. (1942) The Natural "Development of the Child,
Edinburgh.
Freud, As, Burlingham, D. (1943) Infants without Families, New
Yor
Isaacs, S. 'a 932) The Nursery ToN London.
Kershaw, J. D. (1946) Lancet, i, 107. i
Medical Women’s Federation 1346) Brit. med. J. ii, 220.
Menzies, H. (1944) Occup. Psychol. 18, 76.
Nutrition and Child Welfare (1 216) a 19.
Paul, H. oy 6) J.R. sanit. Inst. 4
Roberts, L . (1946) cited by Sted. oon 75, 250.
INTERNATIONAL MEDICAL CONFERENCE
IN LONDON
A CONFERENCE at which 21 European countries and
10 countries outside Europe were represented was held
at the British Medical Association House in London on
Sept. 25-27. The meeting was under the joint auspices
of the Association Professionelle Internationale des
Médecins and the British Medical Association, whose
president, Sir Hugh Lett, was in the chair. Most of the
national medical associations were represented by two
delegates, and some of them by observers also; the
American Medical Association was represented only by
observers. Delegates from both the Palestine Arab
and the Palestine Jewish Medical Associations were _
present. | :
Sir Huecu Lerr, in welcoming the delegates, mentioned
the interest of the B.M.A. in international coöperation,
as testified by its recent allocation of money for sending
medical lecturers to the Continent, and also by the
forthcoming establishment of an abstracting service to
cover all medical literature.
OBJECTS AND FUNCTIONS
- On the motion of Dr. ALFRED Cox (B.M.A.), seconded
by Dr. P. Moran (Irish Free State Medical Union), and
supported by. the Polish, Spanish, and Swedish delegates,
it was unanimously agreed that an international organisa-
tion of medical associations should be set up.. A long
discussion on the objects of such a body centred largely
on whether these should be limited to matters of medical
practice and social medicine or extended to scientific
coöperation. _ The Polish delegates wanted scientific
medicine included, but this was resisted by the French,
Belgian, Greek, and Dutch delegates, who pointed out
that every country had its academies, and that the
immediate need was for an organisation to defend the
rights of the ordinary practitioner, especially in view
of legislation passed or pending in many countries.
Dr. T. C. RoutLey (Canada) suggested that the new
O2 THE LANCET]
body might serve as the medical counterpart to the
World Health’ Organisation recently established in
New York. Without the help of the medical profession
in the different countries, he said, the W.H.O. would be
like an electric grid without power ; no national govern-
ments could do anything with this new instrument unless
the: doctors in every country made it alive. What he
desired was a world medical organisation to signify the
unity of the world’s doctors, knowing no geographical
boundaries and concerned only to help mankind to attain
the highest possible level of health.
A whole morning was:spent in considering various
formulas to express the objects of the world association.
Ultimately the following was agreed to :
“ To promote closer ties among the national medical
organisations and among the doctors of the world by
personal contact and all other means available in order
. to assist all peoples of the world to attain the highest possible
level of health ; to study the professional problems which
confront the profession ; to organise an exchange of
information on matters of interest to the profession; and
to establish relations with, and to present the views of the
medical profession to, the World Health Organisation and
the United N ations Educational, Scientific, and Cultural
Organisation.”
The last phiase:¥ was arrived at after the rejection of
a number of alternatives. Dr. P. CIBRIE (France) declared
that in his. country there was some suspicion of the
W.H.O. and of Unesco. Should these bodies assume
bureaucratic functions, any agreement to codperate
with them would prove embarrassing. Dr. F. DECOURT,
secretary of the A.P.I.M.; spoke to the same effect.
One of the reasons for the establishment of a world
medical organisation, he said, was to defend medical
practitioners’ liberty, now menaced in several countries ;
to proclaim in advance that they were prepared to
codperate with these new official organisations would be
unwise.
Dr. G. B. CHISHOLM, as an observer representing the
World Health Organisation, said that under the W.H.0O.’s
constitution there would be no interference with the
practice of medicine in any country. He quite understood
the concern at possible regimentation óf the profession ;
the interim commission “which was now engaged in
framing the constitution of the organisation was well
aware of that concern. There would be no attempt to
control the practice of medicine. On the contrary, the
new organisation desired the advice of bodies which
could speak for the medical profession ; and it was
ready to do all it could towards a a the health of
the people. T
` NAME AND CONSTITUTION
Saa delegates wished the name of the old body,
the A.P.I.M., to be retained, but an amendment to this
effect was defeated by 22 votes to 14. The suggestion
that the name should he “ World Federation of Medical
Associations ” was opposed by some countries, owing to
the implications of the word ‘‘ federation.” Ultimately,
on the proposal of Dr. I. C. MICHAELSON (Palestine
Jewish Medical Association), seconded by Dr. J. A.
PRIDHAM (B.M.A.), the title “ World Medical Associa-
tion ’’ was agreed to. |
It was also agreed that the. ‘members of the World
Medical Association should be national medical associa-:
tions. It was pointed out that in some countries ‘more
than one medical body could claim that role. Dr. CIBRIE,
who said that in France there was only one representative
body, the Confédération des Syndicats Médicaux Frangais,
suggested that the criterion for admission might be that
the membership must include half or more of the country’s
practising doctors.
It was agreed that the medical aoon represented
by: delegates or observers at the conference should be
eligible for membership, together with any other national
INTERNATIONAL MBDICAL CONFERENCE IN LONDON
- (ocr. 5, 1946
or territorial medical association which was’ repre-
sentative of the medical Brorossion ‘in its country or
territory.
` The subscription was fixed at half the rate for the
A.P.I.M., the reduction being made im view of the
straitened circumstances of several countries. Accord:
ingly, the subscription will be 10 Swiss centimes” per
member of each national group, up to a total of 20,000
members ; and 5 centimes per member above the first
10,000, with a maximum of 1500 Swiss francs. ”
. It was also agreed, subject to consideration by the
provisional committee: which was to be set up, that each
member-association should have two seats on the govern-
ing body or conference, and that voting should be by
countries. This implies one country one vote,: with
exceptions, such as Palestine, where there are two
medical associations representing different races. :
A claim was made on behalf of the British Medical
Students Association, which was represented by obser-
vers, that the medical faculty group ef the International
Union of Students should be admitted a member. This
was opposed by the French and Belgian delegates, but
the conference agreed to recommend to the committee
that the two representatives should be admitted, but
without voting power. |
COMMITTEE AND SECRETARIAT
- It was agreed to set up a provisional committee of
nine, and to entrust to it the task of putting into French
and English—the two official languages of the new body
—a draft constitution and bylaws embodying the
recommendations made by the conference. This will be
submitted to the next conference, the first meeting of
the World Medical Association, which, it was recom-
mended, should be held i in nas on a date to be decided
by the committee.
The following were elected, by ballot, members of the
committee :
Dr. F. Decourt (France), Dr. P. Glorieux | (Belgium), Dr.
Dag Knutson (Sweden), Dr. O. Leuch {Switzerland), Dr. J. A.
Pridham (Great Britain), Dr. T. C. Routley (Canada), Prof.
I. Shawki Bey (Egypt), Dr. L. Tornel (Spain), and Dr. A.
Zahor (Czechoslovakia).
It was further agreed that thers should be a dual
secretariat, one secretary to be in London and the other
in Paris. Dr. Charles Hill (secretary of the B.M.A.) and
Dr. Cibrie were appointed to act, in these capacities until
the next conference.
Regarding the future programme, Dr. MICHAELSON
suggested that ,the committee should obtain infor-
mation as to the number of refugee doctors who are still
not absorbed, and determine a general absorption rate
sufficient to give employment to all refugees. The
new association might act as a clearing- house for the
resettlement of refugee doctors.
| At the close of the conference, Sir Hucu Leon E
to a vote of thanks, said that it had been a great privilege
to preside. If only international coöperation could be
secured between the medical men of different: countries
á big step would have been taken towards permanent
peace. He wished to acknowledge the public spirit
shown- by Dr. Decourt and others in sustaining the old
A.P.I.M. through difficult years and consenting to tho
new organisation taking the place of the old.
7 GOVERNMENT LUNCHEON
The delegates and observers were entertained - by the
Government to luncheon at the Dorchester Hotel,
Mr. Aneurin Bevan, the Minister of Health, presiding.
Mr. BEVAN expressed his appreciation of the initiative
and imagination of the British Medical Association in
summoning the conference. “There is no more important
contribution that citizens can make towards universal
appeasement than to meet each other as fellow craftsmen
THE LANCET]
and as members of the same profession.” When politi-
cians got together, friction of various kinds was likely
to arise, but doctors in their assemblies “* are not primarily
concerned about who is going to do a thing, but that the
thing is going to be done.” It did not matter to the
doctor whether the patient were black or white, brown
or yellow, Communist or Fascist. “‘ There is in medicine
& catholic interest and dedication to the welfare of-
mankind, a concern for the individual, quite indepen-
dently of his social group, his inheritance, origin, or
destination. It is therefore of supreme importance that
the organisation which has been born today should
have a successful inauguration and be continually
sustained by the enthusiasm of its founders and those
who come after them.” Dr. J. A. PRipHam and Dr. P.
GLORIEUX replied. :
The council of the British Medical Association also
gave a dinner at which the presidents of the three Royal
Colleges were present. On the last afternoon of their
stay the delegates, at the invitation of Sir Alfred Webb-
Johnson, paid a visit to Middlesex Hospital.
ROYAL COLLEGE OF OBSTETRICIANS AND
| GYNCOLOGISTS
MR. BEVAN’S LETTER ON MATERNITY SERVICES
AT a dinner held in London on Sept. 27 Lord WooLTON,
proposing The College, spoke of the distinction between
being governed by public opinion—by the trust we have
in one another—and being governed by edict and legis-
lation. However high its own standards, the Government
had perhaps something to learn in this connexion from
the Royal Colleges, whose lack of specific powers made
them the more powerful. As a friend of Blair-Bell,
founder of the college—‘‘a great dynamic force con-
stantly searching out new things ’—Lord Woolton was
glad to see that the dream had come true.
Recalling how, many years ago, he and his wife started —
one of the first maternity clinics, and the first antenatal
clinic, in the North of England, Lord Woolton said that
when he became Minister of Food he regarded it as an
opportunity to do something to raise the standard of
maternal and infant life, and in this he had been fortunate
in having the help of Lord Horder and Sir Jack
Drummond. By directing cod-liver oil, orange juice,
and other supplements to pregnant and nursing mothers
s I think we did something.” No Minister could go
ahead of the general sense of the public without being
called an idealist, but as soon as he declared his policy
of putting children first, Lord Woolton had ceased to
get abusive letters about rationing: ‘‘ the public thought
I was right.” There could be no wiser expenditure of
public money than on preserving child life.
Mr. EARDLEY HOLLAND, responding as president, said
that the college had grown rapidly in its 17 years and was
hoping soon to receive a royal charter. Two-fifths of its
existence had been in the difficult years of war, in which
its members, unlike physicians and surgeons, had usually
had to turn to different tasks. But the membership,
which before the war was 580, was now 775. No less than
a quarter of the fellows and a third of the members lived
and worked in the Dominions, and the college was very
proud of its Dominion fellows, many of whose depart-
ments were second to none in this country, and wanted
them to have more part in its work. ‘ It was to hold an
examination in Australia next year, and Sir William
Fletcher Shaw, his predecessor as president, was even
now on his way to Australia to make arrangements.
Being still young, the college had still to work its way to
_fame by the quality of its work, and among the many
subjects being discussed by its committees were popula-
tion problems, human fertility, analgesia in childbirth,
neonatal mortality, maternity hospitals, and the social
and economic aspects of the maternity service. ` For the
Royal Commission on Population it had undertaken a
questionary of considerable difficulty, and in 1944 it had
issued a memorandum on a National Maternity Service
which already seemed to have influenced the planning
of a service and the Government’s Bull. si
Pd
ROYAL COLLEGE OF OBSTETRICIANS AND GYN ZECOLOGISTS
foot. 5, 1946 503
During the last few years, Mr. Holland continued,
there had been a great change of outlook onYobstetric
practice. The ‘‘ new obstetrics ’’ must be practised on
a broad national basis and was concerned with the social
and economic factors. Obstetrics had, moreover, become
a form of “ precision practice ’’’ very different from the
old. With blood-grouping, tests for rhesus factor, and
radiological examination becoming matters of routine,
and with new techniques against infection and shock,
obstetrics had been completely transformed in the last
ten years. As the techniques became more precise the
standards of accomplishment must be raised among all
who did midwifery—whether midwives, general practi-
tioners, or specialists. This year the council had decided
to double the period of training required of candidates
for membership. While the college believed that the
general practitioner should play a most important part
in the maternity service, it maintained that only practi-
tioners with postgraduate training or special experience
should be considered capable of going to the aid of th
midwife in difficulties. . l
The National Health Service Bill would become law
in a very short time, after which “ we shall have to get
round a sort of peace conference table, but with more
hope in our hearts than in Paris.” In April, 1948, he
felt sure, ‘‘ we shall, like loyal citizens, carry out the will
of the people and do our best to make the finest maternity
service in the world.” In time it should be possible to
secure throughout the country an even distribution of
those techniques now waiting to be used. The college’s
memorandum had laid emphasis on codrdination between
the various bodies which under the Bill would be
responsible for the maternity service. The Minister had
said that perfect codrdination could be assured by
administrative action, and in answer to a request for
fuller information had sent him a letter which said :
We have always envisaged that in staffing their antenatal
' clinics local authorities must enlist the coöperation of the
regional board, and that this will be done by appointing
one of the hospital obstetricians as officer in charge of each
of the local antenatal clinics. This would enable the
obstetrician to determine whether the mother will ultimately
require admission to hospital (and to take the necessary
steps accordingly) or whether she can be left to the care of
the midwife, with the facilities of the hospital or the services
of an obstetrician or experienced general practitioner
always available in the background. This arrangement
would ensure also that the social services of the local
authority in the shape of the health visitors would be at the
disposal of the obstetrician in the clinic, and similar service
will of course be at his disposal by arrangement with the
local authority in the hospital. But above all we must
. remember that the general practitioner is one of the chief
coérdinators of the service. He is the manager who
produces for the benefit of his patient all the facilities |
which the National Health Service can offer. He will have
contacts with all the working parties of the machine—the
hospital, the clinic, the health centre, and the services of
the local authority—and will personally know the men and
women who staff them. | :
We have still a good deal to do in planning out the
precise details of the organisation, but these are the main
lines along which it will be developed. j
Royal colleges, said the president in conclusion, set
the standards of specialist practice and therefore of all
practice. ‘‘ The college spirit in medicine is precious, is
unique, and is peculiarly British, and its flame must never
die down’’; but the colleges must continue to make
progress : their power and prestige now depended not on
privileges but on cultural and even spiritual qualities.
‘‘ Many of us believe that instead of working in complete
isolation, like independent sovereign States, the colleges
will come to work more and more closely together,” and
it was essential that they should achieve unity and
harmony. It was essential too—though the day might be
far distant—that they should come together geographic-
ally. His own college would in any case soon be forced to
move house because in more ways than one it had grown
out of the premises given it by its founder.
Mr. A. A. GEMMELL proposed The Guests, whom he
included in the definition of the college as “ a fraternity
with a common purpose.’ Among those he mentioned was
504 THE LANCET] | .
Mr. Victor Bonney, admitted to the fellowship earlier
in the day. Without going so far as to apply the parable
of the-lost sheep, Mr. Gemmell admitted that ‘‘ there
is more joy in our ranks because he has joined us than
there would be over any other man, ’
Sir Hues Lert, president’ of the British Medical
Association, in reply, said that today no-one would be
bold enough to put the question ‘is your.college really
necessary ?’’ Before the college was founded the situa-
tion of ‘surgery, medicine, and obstetrics recalled the
old-fashioned bicycle in which there were two big wheels
and a little one which ran behind without anybody
‘noticing. In the last few years obstetrics'and gynecology
had advanced so rapidly that it was essential to have a
body like the college not only to lead developments: but
to speak with authority. Medicine was not only a great
profession ; it was the ideal profession: no other calling
offered such opportunities for development and pursuit
of the finest ideals. The ideals often met with disappoint-
ment in practice, but it had been well said that the joy
of an ideallies in its pursuit.
After touching on the risk of dividing medicine into
specialties, which might lead the doctor to overlook the
-whole of the patient, Sir Hugh spoke of the danger that
people in certain departments of medicine should regard
themselves as the profession. It was of the greatest
‘importance at this time that the profession should feel
itself united and express its voice in such a way as to
impress those in authority. Unity must be secured
: between the colleges themselves and between the colleges
and other professional organisations. The work of the
-colleges was a special academic work, for which they
were particularly fitted, but other things could be done
only by such a body as the British Medical: Association.
One could not always be sure that the “will of the
people ” would bring about the good. of the’ patient.
Medicine should speak with one voice on what it believed
to be in the best interests of the people as well as of the
profession.
g SCOTLAND |
(FROM OUR OWN CORRESPONDENT)
‘THe University of Edinburgh is planning a con-
siderable extension of its premises. For many years
now the accommodation in the university buildings has
been wholly inadequate, and in the period after the war
of 1914-18 new departments were built on the south
side of the city some distance away from the old univer-
sity buildings and from the medical school. As a result
the university was scattered rather widely over the city
with a consequent loss of corporate sense and much
inconvenience to all concerned. The present plan has
been prepared for the university by Dr. Holden in con-
sultation with Sir Patrick Abercrombie and Mr. Plum-
stead, the town planning officer for Edinburgh. Principal
Sir John Fraser publicly described the plans some weeks
ago and emphasised the urgency of beginning to put
them into effect. The Edinburgh town council has now
expressed its general approval, at least in principle, of
the first stage of the development, and Sir John Falconer,
the lord provost, has given the scheme for the formation
of a university precinct his blessing. —
It is intended that almost the whole area between the
present old university buildings in the South Bridge at
one end, and George Square and the Meadows at the
other, should become a university area without inter-
fering with the principal traffic routes which pass through
this part of the city. The plan foresees the construction
of teaching buildings on all sides of George Square with
university hostel accommodation in Buccleuch Place and
its neighbourhood. It is intended to develop the medical
school by extending its buildings from the present New
Quadrangle in Teviot Place backwards to include the
north side of George Square. This will mean a great
increase in accommodation for the various departments
of the medical school. It is understood that the new
building programme will not involve the abandonment
of the buildings at West Mains Road, which are mainly
occupied by departments of the faculty of science, but
the arts and other faculties still accommodated in the
old university buildings in South Bridge have been in a
hopelessly cramped situation, and: the provision of addi-
tional and better ‘premises for these faculties is an
urgent matter.
PUBLIC HEALTH
tional.
[ocr. 5, 1946
Public Health ©
Prospects in Industrial Medicine -
A CONFERENCE held at Leeds last summer ! reviewed
the difficulty of giving medical care to people working
in small factories—some 53% of the whole industrial
population. Accidents and disease are commoner in
these small factories, as Dr. C. G. Kirkland pointed out.
He suggested that a mobile corps might be formed for
factories, to take the doctor to the job. Dr. J. Vaughan
Jones thought the care of people in these smaller factories
could not be left to voluntary effort. In one or two
places—at Bedford, and at Cray in Essex—small firms
have grouped themselves together to provide medical
care for workers, but such schemes he believes are not
likely to become widespread: the interests of small
firms are too diverse. He upheld the view of the Leeds
joint. council ‘that industrial medicine should be a
statutory service, regionally planned. The statutory
principle was supported by nearly all the speakers.
Many doctors felt that because they were paid by the
firm they were at a disadvantage with workers, who
suspected them of being “ gaffer’s ” men, more interested
in production than in the health of the producers.
- Discussing the organisation of a statutory service,
Dr. G. F. Keatinge said it would not do to put the
responsibility of medical supervision on the existing
examining surgeons, because they can only give a limited
amount of time to the work; besides, their approach is
personal instead -of being environmental and- -occupa-
He thought that a corps of specialists - in
industrial medicine should be formed, to be called
occupational health officers.. They would be the next
link in the chain after the school medical officer, super-
vising conditions for. the%worker from his entry to
industry to the end of his working life.
Many speakers noted that while. the industrial medical
officer can recommend alterations in working conditions,
he has at present no authority to demand them. As a
State servant he would be able to:insist that workshops
were maintained at the statutory level; though, as. we
N. J. Cochran remarked, this might limit him, too :
intelligent doctor employed by the firm could ica
improvements beyond the statutory level. >:
It was generally agreed that industrial health research
falls short in scope, speed, and operation.
The General Register Office
The branches of the office which were evacuated to
Blackpool at the beginning of the war have now returned
to Somerset House, London. The Registrar-General and
a small staff remained at Somerset House throughout
the war, but the general work of the office has been
carried out at Blackpool. The records of births, deaths,
and marriages were arranged and indexed there and
then sent to Somerset House to be kept in the vaults.
The whole of the office is now housed in London, except a
part of the statistical branch and the whole of the Central
National Registration Office which remain at Southport.
Infectious Disease in England and Wales
WEEK ENDED SEPT. 21 . |
Notifications.—Smallpox, 0; scarlet fever, 853;
whooping-cough, 1610; diphtheria, 240; paratyphoid,
17; typhoid, 13; measles (excluding rubella), 1208 ;
pneumonia (primary or influenzal), 312 ; cerebrospinal
fever, 36; poliomyelitis, 28 ; polio-encephalitis, 3;
encephalitis lethargica, 1 ; dysentery, 66 ; puerperal
pyrexia, 106; ophthalmia neonatorum, 69. No case of
cholera, plague, or typhus was notified during the week.
Deaths.—In 126 oe towns there were no deaths
from ara fever, 1 (1) from an enteric fever, 1 (0) from
measles, 6 (0) from whooping-cough, 3 (2) from diph-
theria, 38 (3) from diarrhoea and enteritis under two
years, and 5 (1) from influenza. The figures in paren-
theses are those for London itself.
The number of stillbirths notified during the week was
266 (corresponding to a rate of 30 per thousand, total
births), including 41 in London.
1. Industrial Medicine. Report of Conference held in Leeds on
June 20, 1946, by the Leeds Joint Council] on Industrial Medicine
the Burton-on-Trent Advisory Council on Industrial Medicine,
and the Derby. Advisory Council on Industrial Health.
a LANCET] - ä
In England Now
A Running Commentary by Peripatetic Correspondents
THE ‘‘ squatters ’’ have only recently burst on aston-
ished newspaper readers. But the game is not new,
as several hospitals can testify. One hospital urgently
needed a large house and actively tried to obtain it. But
the process of purchase and derequisitioning takes an
amazingly long time and the house stood: empty for
months. So the homeless understandably assumed that
since the war-time residents had long since gone, no-one
was coming in; so in they went. How to get them out
is another matter, but if the ‘‘ usual channels” in
Whitehall had not been so long, twisting, and clogged
the trouble would never have arisen. p
Another hospital, warned of its friend’s dilemma
and “being itself endowed with the experience of many
centuries, bought a house, and, since on the day it was
derequisitioned the keys were not forthcoming, it applied
padlocks to the outside of all the doors just to make sure.
Thereafter it could set applications for licences in motion
in a fairly secure frame of mind, and in the hope that its
bombed-out nurses might some day find a resting place.
But alas, that was too easy. The applications having
gone the rounds for some two months and no answer
having arrived, the premises had to remain unoccupied,
and a new requisition order was issued by a different
authority. And so the battle for derequisitioning started
all over: again. Meanwhile the nurses are thinking of
doing a bit of squatting on their own account.
* + *
It was balm to me, as one of that ignorant class who
learn most of their nutritional theory and practice from
the daily press, to read in my evening paper the suave
statement that ‘‘ the reduction in the extraction-rate,
nevertheless,. will mean that bread will have a greater
nutritional value, as the 5, per cent. reduction is equiva-
lent to that amount less bran going into the bread.”
And, having read it, I was immediately in an awful state
of mental conflict. Did not this contradict the assur-
ances, so smoothly proffered, that previous increases
were all for the good of our health and ‘ nutrition ” ?
Had I not read not so long ago an opinion of one of the
Highest, that the (then) darker loaf was to contain more
and more of five specified things and of a sixth class
‘* some of them possibly not yet discovered ” ?
Well, I took the trouble to look it up, and I had read
it all. I now suspect that these dizzy changes in our
extraction-rate are but one voice in an elaborate counter-
point, grandly interpreted by the Public Relations Officer
virtuoso on an instrument composed of ‘“ our medical
and scientific advisers.” I was pained to find how often
I had meekly made a virtue of a necessity, gobbled up
temporary surpluses, and skated round less temporary
shortages. Of course I do not know whether the state-
ment which set me inquiring was, or was not, part af
an Official hand-out. Perhaps it came from the Oppo-
sition. I hope it did; otherwise I could only say to
the official spokesmen ‘‘ Bah! Eat your words—they’re
so nutritious.” ý n k
This complex modern life has given rise to an ever-
increasing number of occupational diseases, and the
participants in such a characteristically civilised activity
as a world war have added their quota of martyrs to the
inventive genius of mankind. For example, that vehicle
of death, the jeep, has so often traumatised the posteriors
of its hardy occupants and caused inflammation to arise in
previously unsuspected pilonidal sinuses that the American
Army Medical Corps has dubbed this complaint jeep disease:
But places and circumstances as well as machines have
their own particular hazards. I well remember a winter
spent in a much-bombed Italian market town, where
there was, for some reason, a great dearth of manhole
covers.; This, combined with the black-out and a
certain partiality for indulgence in the local “ vino ”
on the part of our troops, made me familiar with a
syndrome characteristic of the place. The essential
features were a laceration of one supra-orbital region,
occurring late at night in a somewhat alcoholic member
of the Armed Forces. There was sometimes a con-
comitant abrasion of the shin, but this was usually trivial.
Cases of this syndrome were seen at the rate of one a
night on an average, and I was more annoyed than
`
IN ENGLAND NOW
' danger.
oor. 5, 1946 505
surprised when I was summoned from bed one winter
night to yet another case. He appeared quite typical
at first, except that the degree of alcoholisation was
rather more profound than usual, and some difficulty
was experienced in getting him to the theatre under his
own steam. I was in the middle of my surgical pro-
cedure, conducted under local anzsthesia, when the
patient announced with a great wail of distress that he
had gone blind. I was taken aback by this and cursed
myself for allowing my somnolence to make me omit
even a cursory examination of the central nervous
system ; there had recently been a few cases of blindness
among American troops in the neighbourhood who had
drunk wine fortified by the natives of the place with
methyl alcohol. Telling the patient not to worry I
hastily completed my operation and proceeded to a more
detailed examination. On inspection of the eyes it
appeared to my relief that the cause of his ocular symp-
toms had been merely an alcoholic inability to open the
eyes voluntarily. ‘‘ Thank God, doctor,’ said the
patient, with a cry of relief at his deliverance, ‘‘ I can
see quite all right now. You know, doctor,” he added,
“ you're the most beautiful sight I’ve seen for ages.”
Even my wife hardly ever says that to me. But then
she hardly ever touches alcohol.
* * La
In medieval times the view that disease in general,
and plague and pestilence in particular, was a punish-
ment for sin, was deep-rooted in the minds of men;
and the gradual elimination of this vigorous super-
stition has been achieved slowly with the advance of
medical knowledge and better understanding of the nature
of disease. Through the accidental circumstances of their
usual method of transmission, the venereal diseases,
and these alone, still incur the judgment and condemna-
tion of the stern moralist. Perhaps it is to the religious
convictions of our forefathers, therefore, that part of the
abnormal response to fear of these conditions must be |
attributed. The effects are variable and depend largely
on mental balance and stability, but the apparently
normal are not without their idiosyncrasies. _
In better times, at this season of the year, it has been
customary for our clinic to be invaded by workmen
who render us acutely uncomfortable for a time, but
leave us neat and shining with a coat of glossy paint.
Sometimes they have expressed fears of contagion,
but the rough and ready reassurance of our permanent
staff has sufficed to calm these fears. This year we had
to be content with a washdown of the walls and dis-
temper on the ceilings. This year, too, the consternation
of the workmen was exceptionally violent, and our
technique of reassurance, spiced with ripe comment,
failed to satisfy. The workmen were off their food, and
the foreman’s wife sternly forbade him the solace of the
connubial bed until the danger was past. It was a bitter
pill to us that we could not reassure them, and that
our own year-long heroic defiance of the danger went for
naught. Yet it had its advantages. It is long since
men were seen to work so hard. The spirit and devotion
of Dunkirk and D-day were born again, and wonders
were wrought with almost incredible rapidity. It is
hard to believe that sympathy with the foreman’s
predicament was the compelling factor, and the result `
must be attributed to a desire to restrict the period of
We are prepared, at a fee of course, to give
advice to working parties on the proper application
of the spirocheetal spur and the gonococcal goad.
i * æ *
How quickly does fame depart! A recent examina-
tion of candidates for a postgraduate diploma in child
health produced the favourite chronic arthritis child
who is always a good topic for cross-examination—of the |
candidate. The usual gambit led up to the name of-
Still. The usual question as to who Still was produced
the unexpected answer that he was an American. Lend-
lease is all very well but this is going too far. It conjured
up visions of George Frederic having an academic dis-
cussion with Andrew (somewhere in the shades) on the
use of chiropraxis in the treatment of chronic arthritis
in childhood. However, medical history is not a com-
pulsory subject, so this candidate fared better than the
one who remarked ‘“‘ If the w.R. excludes G.C., it’s O.K.”
—surely the maximum of error combined with the
maximum of irritation.
506 THE LANCET]
Letters to the Editor
MILITARY SERVICE FOR MEDICAL STUDENTS
Str,—Your leader of Sept. 21 discusses alternative
ways in which medical students may meet their obligation
of military service. As you point out, the more useful
and more convenient—namely, to serve after qualifying
—will be impracticable for the next two years or so.
May I then suggest another possibility which I believe
would meet the present situation as well as future
requirements ?
Why not split up the whole term of military service for
medical students into two independent periods? The
prospective doctor could serve the first half of his term
conveniently between school and university, thereby
filling at least part of the interval that will elapse before
he finds his place at a medical school. During this time
he would have a general ordinary military training with
the rank and file, though of course not a complete
technical training in any of the specialised weapons and
highly mechanised military craft which he does not
require. Later, after qualification, he would complete
his term of military service as a Junior Service medical
officer.
many before, and with appropriate
the first world war.
Such a system would not only provide all the advan-
tages and opportunities of the second alternative outlined
in your leader but would also have some additional
effects beneficial both to the doctor and to the fighting
men under his care. (1) The medical student need not
sacrifice too much of his precious time to purely military
training but still has all the benefit a healthy young
man can derive from military life. (2) During his short-
ened military training he acquires an intimate first-hand
knowledge of the sort of job the soldier (or sailor or air-
man) has got to do. (3) If, as he should, he serves with
the rank and file instead of with a selected group he gets
to know something of the mentality of the ordinary man.
This will stand him in good stead in civilian as well as
military practice. (4) Last, but not least, he sees some
of the methods and tricks used by comrades to evade duty.
This knowledge will help him considerably as a doctor
in assessing his patients’ complaints.
Wolsingham, Co. Durham. E. G. W. HOFFSTAEDT.
A SYNDROME SIMULATING ACUTE ABDOMINAL
DISEASE "
Sır, —The letters following our paper of August 24
have suggested two possible explanations of the group
of cases that we described—infective hepatitis and
Bornholm disease. |
Dr. Oram suggests that subicteric forms of infective
hepatitis could have caused the syndrome. We agree
that acute abdominal symptoms, rarely simulating sur-
gical emergencies, may usher in the early stages. But at
the time our wards contained many cases of obvious
infective hepatitis, not one of which showed the syn-
drome described. It. seems unlikely that subicteric
cases would show more severe symptoms.
The question of Bornholm disease requires more
careful consideration, and we admit that it might well
have been included in the differential diagnosis. Neither
of us has had experience of this disorder, which from the
multiplicity of the symptoms described would appear to
include a variety of pathological conditions. We are
grateful to Dr. Evans for drawing our attention to Dr.
Scadding’s excellent article,’ but our cases differ con-
siderably from his, the symptoms being mostly abdo-
minal while his were mainly thoracic. Pleural rub was
absent in all our patients. We rejected an epidemic
origin of our cases (perhaps wrongly) because they were
modifications during,
unrelated, and because no minor varieties of the same.
syndrome were seen on the medical side of the hospital,
as might have been expected in an epidemic. We are
aware that a small percentage of cases’ of Bornholm
disease may simulate abdominal emergencies, but nearly
100% of our cases presented with acute abdominal
symptoms. The hypothesis that abortive staphylococcal
1. Scadding, J. G. Lancet, 1946, i, 763.
S
P ;
TUBERCULOUS ENDOMETRITIS AND STERIIJTY
This scheme proved its merits in Imperial Ger- `
a
j [ocT. 5, 1946
retroperitoneal infection could be the cause of the
syndrome was suggested to us because one of our cases
developed a perinephric abscess. Dr. Evans objects to
this hypothesis and says that one of his cases had a
tuberculous apical abscess ‘‘ but this does not make the
rest tubereular.”’
abscess because it was possibly a significant lesion. It
was capable of providing an explanation which we put
forward quite humbly. At least it may stimulate
inquiry, and should it be correct it will have rescued a
series of cases from the dumping ground of varied’ con-
ditions called Bornholm disease. ‘Incidentally we
wonder if Dr. Evans has noticed a letter from Dr. Cayley ?
on ‘‘The apparently acute abdomen in pulmonary
tuberculosis.” pone a
4 B. W. GOLDSTONE,
Reading. H. S. LE MARQUAND.
ae
MYTH AND MUMPSIMUS
Str,—I -regret that Dr. Forbes in his mention of
lumber that should be thrown on the rubbish-heap, did
not include our antiquated Imperial system of weights
and measures. I can recall the expectation fifty years
ago that in the next British Pharmacopeia the metric
system would be in sole use. What is the explanation
of the retention of the older system? Isit a wise caution,
or is it just pure thrawnness ? It is not a mere question
of nomenclature. A scientific system like the metric
would tend to create a scientific outlook in its users.
Knock, Belfast. R. M. FRASER.
TUBERCULOUS ENDOMETRITIS AND STERILITY
Sm,—Your annotation of Sept. 7 says:
(1)“ The association between sterility and tuberculous
endometritis has been recognised only in the. last - few
years. .. .” , l
(2) “ His (Halbrecht’s] conclusion that occult, subclinical
tuberculous endometritis is one of the cardinal causes of
sterility in general and of tubal occlusion in particular may
have come as something of a shock to English workers. .. .”’
(3) “ It will be interesting to see whether, with furthe
experience, similar reports appear in this country.” 7
These statements require correction, not only in the
interests of scientific accuracy but also because of the
implication that the knowledge, to say nothing of original
research, was new to ‘‘ English workers.” Only a few
of the main facts can be dealt with here, but we should
like to present a more accurate picture of-the present-day
knowledge of the relationship between tuberculous endo-
metritis and sterility. A detailed account is, in fact, at
present in the press, forming a portion of a paper being read
by one of us (Sharman) at the Congress of the South
African Medical Association this month. <A study is
made of 94 cases of tuberculous endometritis in a con-
sécutive series of 1712 cases of primary sterility (5-5 %)
—this is the largest series ever recorded..
In 1943 one of us (Sutherland !), in a paper on Unsus-
pected Tuberculosis of the Endometrium, discussed at
length the clinical aspects and pathology of the con-
dition: the literature was fully reviewed. It was
pointed out that the high incidence of sterility in endo-
metrial tuberculosis was striking and that this causal
factor had been stressed by Steinsick (1922), Daniel
(1925), Halban and Seitz (1926),4 and Vogt (1928).§
The incidence was given as 7-2% in 212 patients (Stein-
sick), 7:0% in 71 patients (Schockaert and Ferin*), and
5:1% in 390 patients (Sharman). No relevant reference
was found prior to 1922, not even in the excellent and
exhaustive monograph by Norris in 1921.7 In 1943
one of us (Sharman ë) reported to the Royal Society of
. Cayley, F. E. de W. Brit. med. J. Sept. 14, p. 403.
- Sutherland, A. M. J. Obstet. Gynec. 1943, 50, 161. x
. Steinsick. Diss. Tübingen, 1922, quoted by Vogt (ref. 5).
. Daniel, C. Gynec. et Obstet. 1925, 11, 161.
J., Seitz., L. Biologie und Pathologie des Weibes,
1926, vol. v, p. 367. i
Vogt, E. Z. Tuberk. 1928, 51, 114.
Schockaert, J. A., Ferin, J. Bull. Soc. roy. belge Gynéc. Obstet,
1939, 15, 407.
. Nery “an Ms Gynecological and Obstetrical Tuberculosis, New
York, 1921. . i TA
- Sharman, A. Proc. R. Soc. Med. 1943, 37, 67 ; J. Obstet. Gynac.
1944, 51, 85.
O N An eUe tY
lae)
fo
eam
7
Š
t
However, we stressed the perinephric ’
THE LANCET]
Medicine a series of 840 cases of primary sterility, of
which 42 (5%) showed endometrial tuberculosis. i
One of us (Sutherland!) has pointed out that it is
fairly easy to understand why this high incidence of
endometrial tuberculosis in cases of sterility has not
been more generally recognised. bad
(a) Routine histological examination of the endometrium
was often omitted in the past, but in recent years has been
carried out more generally in order to obtain evidence of
ovulation.
(6) The isolated and infrequent lesions of one type of endo-
metrial tuberculosis are easily overlooked as they are small
and scanty. With increasing experience one’s visual acuity
for the lesions is correspondingly increased, but in many
cases they are found only after diligent search. .
(c) Even when the lesions are seen, their tuberculous nature
is often not obvious to the observer with an inadequate
background of general pathology. ,
(d) It is possible that the increasing incidence of tuber-
culosis in general may also apply to tuberculosis of the
endometrium.
The prognosis in the subclinical type is good from the
point of view of the patient’s general health: systemic
extension is uncommon. But the fertility prognosis is
well-nigh hopeless, not one of our 64 cases, followed up
for more than a year, having become pregnant. This is
not entirely due to tubal occlusion caused by tubal
tuberculosis, since, although every case of endometrial
infection has an associated tubal one, complete occlusion
has been found only in 62% of cases of endometrial
tuberculosis. l
A large amount of work'on this interesting subject
may be synopsised as follows: (1) careful study of
endometrium in cases of primary sterility will show
unsuspected endometrial tuberculosis in a minimum of
5:5% of cases; and (2) tubal occlusion, in the absence
of palpable adnexal swellings, is due to tubal tuberculosis
in a large proportion of cases. , :
Royal Samaritan Hospital ` ALBERT SHARMAN.
for Women, Glasgow. ARTHUR M. SUTHERLAND.
NEW WORDS ABOUT OLD AGE
Sir,—Dr. Vertue is perfectly. correct when he states
that there is no word geria in Greek. But there is a word
geras, the common word for old age, the stem being
ger(a), the root being g(e)r, from which comes also
graus, an old woman. The -ia-in the middle of the word
belongs, of course, to the second part of it, not to ger—
as indeed Dr. Vertue recognises in forming “ gerontia-
trics.” Why the newly named science should be exclu-
sively applied to men is not clear; after all, old women
preponderate. Geron never means “an old person,”
always “old man,’ “ elder,” ‘‘ senator’’; so it would
be as logical to use graus for the word and talk of
‘* griatrics.”’
neatness, “ geriatrics ° is preferable; it is justified by
derivation, and is indeed the only word properly to :be
applied (the sole alternative being the harsh *‘ geroia-
trics ’’). Son
Edinburgh.
PENICILLIN IN WOUND EXUDATES
Sir,—The results of the brilliant piece of research by
Lady Florey and her colleagues (Sept. 21, p. 405) will
no doubt stimulate other workers to produce the ideal
medium for prolonged local, application to wounds.
That this has exercised the minds of military surgeons
for some time can be gleaned by the perusal of the
' GORDON IRVINE.
21 Army Group publication, Penicillin Therapy and.
Control. One extract on pp. 114-115 reads: _.
.** Deep Wounds with or without bone involvement.—Plugs
should not be used, as during a battle when hurried evacua-
tions occur the plug may not be removed for several days. *
Then granulations grow into the meshes and removal is difficult, ,
and this is still more likely to happen in open fractures if the
jagged bone ends become entangled. It is suggested plugs of
penicillin wax might be used by those: who feel they are
indicated, These would cancel themselves out in transit and,
supply: a prolonged local application of penicillin.” a
A ‘BLA. SURGEON. `
NEW WORDS ABOUT OLD AGE
However, for the sake of euphony and
[ocT. 5, 1946 507
ARSENICAL CHICKENPOX
Sır, —I can add another case to. those described by
Dr. Parkes Weber (Sept. 14) in which a patient who
suffered from herpes zoster while having arsenical treat-
ment apparently infected a child with varicella. |
In 1932 a patient in hospital suffering from tabes
dorsalis had two or three injections of neoarsphenamine
and then developed herpes zoster of the ophthalmic
division of the right trigeminal nerve. About a fortnight
later another patient in the same ward. developed a
zoster eruption involving two or three dorsal segments,
and a boy, aged ten years, developed a mild attack of
chickenpox. The boy, who had an internal hydro-.
cephalus, died a few days later, and at necropsy was
_found to have a congenital septum of the aqueduct of
. Sylvius.
It may be contended that the arsenical treat-
ment and the attack of herpes zoster in the first patient
were not related, but it is by the accumulation of such
happenings that it may be possible to establish a more
precise relationship between arsenical treatment, herpes
zoster, and varicella. fe
‘Harrogate. |
T. G. REAH.
DESOXYCORTONE AND ARTHRITIS
Sir,—Dr. Harrison has drawn my attention to Dr.
Jennings’s letter in your issue of Sept. 7. Despite Dr.
Harrison’s generous acknowledgment of my help
(August 10, p. 215), my advice before the publication of
his paper of June 1 (p. 815) was limited to explaining how
to apply the chi-squared test to the facts as presented
in table 1 of that article. The figures given in that table
do not alone provide sufficient evidence to establish the
hypothesis that adrenalectomy and_ thyroidectomy
increase the rat’s prospects of developing arthritis. I
advised Dr. Harrison in this sense in September, 1945.
Dr. Harrison next consulted me in August, 1946. He
sought advice in replying to Dr. Jennings’s letter in
the Lancet of July 20, in which Dr. Jennings suggested
that there were fallacies in the statistical technique
which Dr. Harrison had applied to the facts as presented
in his table I. With my help, Dr. Harrison replied to
these suggestions in his letter of August 10.
Dr. Jennings’s remarks of Sept. 7 are therefore inappro-
priate. In this case, the “ expert behind the scenes ”
neither “ bullied ’’ nor ‘‘ threatened with specialised
profundities,” but gave advice on the interpretation of
the facts as given in table I. He did not “ really collab-
orate ”?” because he was not invited to do so: he first
heard of Dr. Harrison’s paper in the Lancet after it had
been published.
Dr. Jennings may argue that Dr. Harrison should
have asked a statistical expert to go through both his
paper and that of Professor Selye line by line with him,
before he appeared in print: but he surely would not
wish the expert to ‘‘ bully ” Dr. Harrison into doing this.
I agree with Dr. Jennings that scientists would profit
by asking fuller collaboration from statistical experts in
the experimental as well as the statistical aspects of
their work. Such collaboration is being developed at
Oxford, and the understanding, now gradually growing,
between scientists and statisticians will no doubt be
advanced by Dr. Jennings’s Pickwickian and (if I may
return his compliment) Jabberwockian correspondence. —
- Dr. Jennings asserts that Dr. Harrison was claiming
“ statistical proof of his rightness.” Actually, Dr.
Harrison merely claimed that the facts as stated in his
table 1 were not sufficient in themselves to establish
Selye’s hypothesis: he did not claim that they proved
Selye’s hypothesis wrong.. Dr. Jennings points out that
Professor Selye quoted evidence additional to that given
in table I, and that, when this evidence is taken into
account as well, he can disprove Dr. Harrison’s hypothesis
and establish that of Professor Selye. In particular, Dr.
Jennings refers to information about rats which died
during the experiment. This may be a point of substance,
but as Dr. Jennings has not provided the details of his
statistical proof it is not possible to pass judgment on
its validity. : |
In a controversy of this kind, the statistician’s aim
should be to’ assist in a correct interpretation of the
evidence. If Dr. Jennings and Dr. Harrison would
produce a precise formulation of the evidence, stating
in particular ‘which of the dead rats had developed
+
508 THE LANCET]
arthritis, and if Dr. Jennings then set out his proof from
that evidence that Dr. Harrison’s hypothesis about rats
was wrong and Professor Selye’s hypothesis was correct,
then the statistical experts should be able to pass
impartial judgment supporting (or discrediting) his proof.
I heartily endorse Dr. Jennings’s plea that medicine
should keep in touch with statistics and vice versa :
although since the statistician should also cover biology,
astronomy, agriculture, psychology, economics, and the
other social sciences, he must confine himself to their
statistical aspects. i | |
- Institute of Statistics,
University of Oxford.
TUBERCULOUS ABSCESS FOLLOWING
INTRAMUSCULAR PENICILLIN |
Srr,—In their article of Sept. 14 (p. 379) Mr. Ebrill
and Dr. Elek say they were unable to find the: source
of the infection, though it was probably exogenous.
In most penicillin drip set-ups there is a weak point that
I have often tried to get rectified, but I have always
D. G. CHAMPERNOWNE.
-met with the objection that the drip will’ stop flowing if
my advice is followed. The weak point is the air-
intake, which should be guarded with a cotton-wool
filter to exclude organisms ; without the filter a pint of
solution is gradually replaced by a pint of bacteria-laden
air from the ward. I do not suggest that a filter was
omitted on this occasion; what often happens is that
someone removes the cotton-wool from the filter for
‘* practical”? reasons. . : | ;
Tubercle bacilli are not uncommon in the dust of hos-
pital wards. It is not surprising that.abscesses form
at the site of injection; the surprising thing—a testi-
monial to the vis medicatrix naturee—is that there are
so few of them. =
Epping, Essex. FRANK MARSH.
DEATH AFTER CURARE
. SIR, —In your annotation of Sept. 21 you report that
the pathologist considered that the death of a patient
after an operation was due to toxemia and had been
accelerated by respiratory failure due to curare. The
effect of curare wears off rapidly and I do not believe
that it causes respiratory depression 43 minutes after
administration. The patient was 70 years of age and
the anzesthetic used was ‘ Pentothal.’ It is my experi-
ence that a high proportion of elderly patients tolerate
intravenous barbiturates extremely badly and that
delayed recovery after intravenous anesthesia is common
among patients of any age. I know of two elderly men
who never recovered consciousness after being given this
anesthetic for the performance of emergency supra-
pubic cystotomy. We have all seen the young healthy
adult who took a very long time to wake up. |
Pentothal is a drug which should be used with the
greatest caution, and it is unfortunate that so many
practitioners have been encouraged to administer an
intravenous anesthetic when some inhalation technique
could be used. In this country we are too ready to
publish our successes and too reluctant to report our
fatalities. If one. studies the American journals one
ean obtain a more accurate appreciation of the dangers
of ‘‘ modern anzsthesia,’’ which I do not find to be as
safe or satisfactory as. ether. As Flagg rightly says,
“Far too many anesthetists have tried too often to
avoid the use of ether anzsthesia, and the skill with
which it might be used is not so much in evidence today
If our medical students and newly
as it might be.”
qualified practitioners were taught to understand the
value and wide range of usefulness of ether we should
read of far fewer deaths under anesthesia being inquired
into by the coroners’ courts.
All that is modern and new is not progressive, and we
might well ponder on the fact that when ether and
chloroform were used almost exclusively in England the
number of deaths associated with ansesthesia reported to
the coroner in one year was 347, whereas in 1941 it
was 835. This in spite of the fact that far greater
surgical risks were accepted in those days, and that
restorative measures were not very satisfactory. We
also no longer see the neglected abdominal emergency,
once a common cause of operating-room deaths. E
DEATH AFTER CURARE
- substance.
‘(in the press).
-
[oor. 5, 1946
. I cannot help feeling that in the case you mention the
cause of death was the pentothal rather than the curare.
Curare may be a highly dangerous drug—we do not yet
know—but do not let us blame it for the offences of
another drug. TE E
New Barnet, Herts. _ JOHN: ELAM.
Sm,—Your annotation of Sept. 21 on the death of a
patient following an operation during which curare had.
been administered was marred for me by the fact that it
did not contain the information, which cannot be too
widely spread, that in physostigmine (eserine) or ‘ Pros-
tigmin’ we have an antidote for curare. ‘Coramine’
or '‘ Veritol’ are of no value for counteracting this
No anesthetist should administer curare
unless he has readily available an injection of' eserine
(1 mg.) or prostigmin (2:5 mg.). ee ee
— : Jas. D. P. GRAHAM.
Dept. of Materia Medica, Glasgow University. ’
AM@BOMA AND CARCINOMA
‘Sir,—Mr. M. J. Smyth’s article of Sept. 14 is of
particular value in drawing attention to a subject which
is not familiar to those who have been denied.the oppor-
tunities of tropical practice. From time to time examples
of amceboma of the rectum will occur in this country,
and only careful differential diagnosis will prevent
surgical disasters. l
Amæœboma of the rectum is one of the rarer forms of
intestinal amoebiasis, and even in tropical countries no
one surgeon is likely to see many examples. It may
present as an ulcer or as a papilliferous overgrowth,
and in either form may appear indistinguishable from
carcinoma. The diagnosis, however, will rarely present
much difficulty to those who follow Mr. Smyth’s advice
—that any tumour of the colon or rectum discovered
in a patient who has served in the East should be regarded
as amoeboma rather than carcinoma until . thorough
pathological examination has proved otherwise. This
should apply to all patients who have at any time been
exposed to amoebic dysentery, whether they give a history
of dysentery or not, and even if they have been discharged
as cured of this disease, so noted for its tendency to
relapse. l
Repeated examination of the stools and of scrapings
from the surface of an amceboma may fail to disclose
the Entameba histolytica. On the other hand, as Mr.
Smyth reminds us, the presence of the E. histolytica
does not exclude carcinoma. Fortunately in emetine
we have: a valuable aid to diagnosis. Whether
E. histolytica has been found or not, before resorting to
operation a course of this drug should be given, its effect
being checked by repeated sigmoidoscopy. As a general
rule the amceboma very rapidly responds, but only
a complete resolution can be accepted as proof that the
lesion is amoebic. If this is not obtained biopsy must
be done. as tee
During four years’ military service in endemic areas,
I saw six examples of amceboma of the rectum which
simulated carcinoma. Five of these resolved completely
on medical treatment alone. The sixth patient was
admitted as an advanced case of carcinoma of the
rectum, and the clinical condition was consistent with
this diagnosis. When repeated examination of the stools
‘and of the discharge from the surface of the tumour
proved negative, colostomy was proposed ; but a procto-
scopic examination made on the operation table produced
a specimen containing many typical EF. histolytica and
operation was therefore postponed. Emetine was given
but the patient died within a few days. Post-mortem
examination revealed how’ futile a colostomy would
have proved, for the whole length of the colon was
involved in a diffuse amoebic ulceration. These cases are
reported in Surgery, Gynecology and Obstetrics (1945,
81, 387) and the Liverpool Medico-chirurgical Journal
It would be unfortunate if Mr. Smyth’s statement
“I have no doubt that in amceboma of the rectum
colostomy is helpful rather than otherwise” were to
encourage the frequent performance of this operation.
Whereas in the vast majority of cases of rectal amceboma
medical measures result in a rapid and complete dis-.
appearance of the lesion, colostomy exposes the patient
A
THE LANCET]
` OBITUARY
focr. 5, 1946 509
to the risk of spreading amecebic infection of the wound
and to serious hepatic complications. In rectal ameebiasis
infection of the cecum and proximal colon must be
assumed even in the absence of clinical signs, and
intestinal obstruction of a type which requires a colos-
tomy so urgently that emetine cannot first be given a
trial must be very uncommon. Colostomy may of course
be needed in the rare event of failure to respond to
amecebicides, or when dealing with complications such as
intractable fistula.
Liverpool.
SIGN OF SUBMERGED GOITRE
; Smr,—There is a useful sign given by a submerged or
intrathoracic goitre which I have employed and taught
for many years. It consists in getting the patient to
elevate both arms until they touch the sides of the head ;
after a moment or so, congestion of the face, some
cyanosis, and lastly distress become apparent—presum-
ably from narrowing of the thoracic inlet and obstruction
of the venous return. I have not seen it in superior
mediastinal block.
‘Doubtless the sign has been described before and even
bears a name, but I am unaware of it.
Liverpool. H. S. PEMBERTON.
HOSPITAL PHOTOGRAPHIC DEPARTMENT
Smr,—To your issue of August 31 Dr. Hansell and
Dr. Stanford contribute most interesting articles on
‘medical photography. Both see the necessity of adequate
apparatus and premises, but their ideas on personnel
(especially Dr. Stanford’s) seem extremely wasteful.
Why should a request for a photograph be so vague as
-to need a qualified medical man to interpret it ? Surely
those who request are the ones to be taught to know
what they want and to appreciate its uses.
How often are photographs praised merely for their
detail without regard to whether they show off the
condition; or requests made at absurdly short notice
for theatre work, showing only too clearly the general
ignorance of the hospital of how to get the best out of
its photographic department.
The time has come when medical photography should
be a subject in our medical schools, clinical photography
being on an equality with radiology. Then we will not
need to waste doctors by putting them in photographic
departments as elaborate buffers to the ignorance of
their brothers on the staff. A photographer with really
wide experience is essential, and once he or she has a
certain amount of medical knowledge, the doctor who
has “joined his hobby to his profession’’ becomes an
extravagant and unwanted figurchead.
No photographer, if he is wisely chosen, needs a nurse’s
training to treat his patients with kindness and con-
sideration. SYLVIA TREADGOLD
Photographer-in-charge.
Photographic Dept., Guy’s Hospital, London, S.E.1.
CHRISTIAN SCIENCE
Sır, —The Chadwick lecture published in your issue
of Sept. 21 (p. 427) contains a reference to Christian
Science which I should like to correct.
Christian Scientists do not regard disease or other ills
as merely imaginary. Christian Science teaches that
sickness and disease, and other ills, are phases of the
belief in an existence apart from God. It further teaches
that these evils can be overcome, not by ignoring them,
but by cofrecting them intelligently by means of a right
understanding of God and man and their relationship
to one another.
This question is fully developed in the Christian
Science textbook, Science and Health with Key to the
Scriptures, by Mary Baker Eddy, the Discoverer and
Founder of Christian Science, and on p. 460 the attitude
of Christian Science to “ the ills of the flesh ” is briefly
stated as follows: ‘‘ Sickness is neither imaginary nor
unfeal,—that is, to the frightened, false sense of the
patient. Sickness is more than fancy ; it is solid convic-
tion. It is therefore to be dealt with through right
apprehension of the truth of being.”
; CoLIn R. EDDISON.
PHLILr HAWE.
Christian Science Committee on Publication, i
Donington House, Norfolk Street, London, W.C.2.
Obituary
THOMAS WATTS EDEN
M.D. EDIN., F.R.C.P., F.R.C.O.G.
Dr. Watts Eden, who died at Torbay on Sept. 22,
was consulting obstetric physician to Charing Cross
Hospital, and consulting surgeon to Queen Charlotte’s
Hospital and the Chelsea Hospital for Women. A former
editor of the Journal of Obstetrics and Gynecology of the
British Empire, he continued his association with the
journal as chairman of the editorial committee and the
board of directors.
Born in 1863, the son of Alfred Thomas Eden, of
Evesham, he was educated privately and at the Uni-
versity of Edinburgh, where he graduated M.B. in 1888.
Of his student days Sir Ewen Maclean writes: ‘I first
met Watts Eden in connexion with the Drummond
movement, which was inspired by the simple religious
addresses given by Prof. Henry
Drummond to his students in
Glasgow. In this as in many
other directions when effective
speaking was required Eden’s
superb diction and delivery
were in great demand. Though
he was a year in front of me in
the Edinburgh curriculum we
contrived to room together,
and I could not but envy
as well as admire the apparent
ease with which he assimilated
notes and relevant parts of
textbooks, gained medals
galore, graduated with first-
class honours, and was awarded
the much -coveted Ettles A
scholarship. But despite bis en
brilliant achievements and [Press Portrait Bureau
ability there was no aloofness
about him, and in Edinburgh as later in London he made
many warm friends.”’
After postgraduate years spent in Berlin, Leipzig, and
Birmingham, Watts Eden came to London and joined the
staff of the Chelsea Women’s Hospital, where his colleagues
included Fairbairn, Comyns Berkeley, and Victor Bonney.
“ I became acquainted with him,” writes Mr. Bonney,
“in 1898 when I went to Chelsea Hospital for Women
as resident surgical officer. He had been attached to
that institution, in a minor capacity, for a short time
before the debacle which led to its reorganisation in 1894,
and when the new staff was formed he was appointed
assistant physician, a title subsequently changed to
surgeon. He had already made a name for himself by
a paper on the structure of the placenta which attracted
much attention, and I remember him as a sparely made
young man, somewhat sallow of complexion, with a
kindly smile and a deliberate, though incisive, manner of
speech. |
“ He formed one of that small band of surgeons, now
alas all departed but one, who, by their devoted and
earnest work, raised the reputation of the hospital from
the zero to which it had fallen to the highest level of
professional estimation, and with them he played a
great part in putting abdominopelvic surgery on a sure
foundation. A
“ His own reputation steadily grew. He became a
member of the staff of Queen Charlotte’s Hospital, and
by the time that I went there as a resident officer he and
William Gow stood head and shoulders above the rest of
their colleagues.”
In 1898 he was appointed to the staff of Charing Cross
Hospital, where his gifts of clear thinking, writing, and
expression quickly won him recognition as a great teacher.
To this period belong his manuals of midwifery and
obstetrics which have run into many editions, and later
in collaboration with Dr. Lockyer he published Gyna-
cology for Students and Practitioners. Outside his own
hospital he found time to examine for the universities
of Oxford, Cambridge, Edinburgh, and Leeds, to serve
on the council of the Royal College of Physicians of
London, and to sit on the governing body of the British
Postgraduate Medical School. During the first world
war he held the rank of major in the R.A.M.C., and our
510
portrait shows him at this period. In 1930 he was
elected president of the Royal Society of Medicine and
his American colleagues made him an honorary member
of the American Gynecological Society. He inter-
preted the responsibilities of his specialty widely, and
in his Lloyd Roberts lecture at St. Mary’s Hospital,
Manchester, in 1925, and in an address to the Oxford
Medical Society in 1931, he put the case for the unborn
THE LANCET]
child, urging his colleagues to beware of regarding the
infant as the by-product of the confinement. 7
A member ofthe joint council of midwifery appointed
by the National Birthday Trust, he was chairman of the
committee which in 1935 presented a scheme for an
organised national midwifery service designed to raise
the status of the midwife, and even after his retirement
he continued to take an active interest in the Midwives
Guild of St. Breca. ‘‘ It was my good fortune,” writes
Dr. Cuthbert Lockyer, ‘‘ to be Dr. Eden’s junior colleague
at Charing Cross for many years, and during that time
I learned to esteem and respect him. : Although never
robust, his industry was remarkable and even in retire-
ment at Thurlestone he gave unselfishly of his strength
in the promotion of the welfare of the Royal College
of Obstetricians and Gynecologists, of which he had been
an active and influential founder. With his many
interests he would spend whole weeks in London attending
as many as 15-20 committee meetings before returning
spent to his country home. Our coöperation in clinical
work was uniformly harmonious, our collaboration in
writing was a labour of love, and our friendship has been
up to the last close and intimate.”
In Mr. Bonney’s words, ‘‘ A long life filled with honour-
able work has come to an end, and viewing it as a whole
certain great qualities of the man stand out clearly:
a steady level-headedness, a wide humanity, an unassail-
able integrity, and a great dignity. These are the things
which, beyond all else, procured him the respect and
affection of those who worked with him, and the
specialty, which he made it his life’s work to serve, grieves
at his passing, for he kept its flag flying very high.”
In 1900 Dr. Eden married Miss May Bain, of Cocker-
mouth, who survives him. 7 ;
FRANK McCALLUM
_M.B. MELB., D.P.H., D.T.M. & H.
THE death is announced of Dr. Frank McCallum,
who just over a year ago was appointed director-general
of health for the Commonwealth of Australia. Son of the
late Rev. Alexander McCallum, D.D., of Melbourne, he
was educated at Wesley College and Melbourne Uni-
versity. At the outbreak of war in 1914 he joined the
A.A.M.C. at once, only interrupting his service to graduate
M.B. in 1917. After holding a house-appointment at
Cardiff Royal Infirmary, he returned to Australia in
1920 to take his D.P.H. at Melbourne and to join the
-Commonwealth quarantine service. During 1922 and
1928, with a Rockefeller travelling fellowship, he visited
the United States and returned to this country to take
his D.T.M. & H. In 1927 he was appointed director of the
division of epidemiology of the Commonwealth depart-
ment of health, and two years later became chief medical
officer at Australia House in London. During this
period he represented Australia on the permanent
committee of the Office International d’Hygiéne publique.
In 1934 he became chief quarantine officer of the North
Eastern division and in the same year senior medical
officer of the administrative staff at the health depart-
ment at Canberra. Dr. McCallum was 56 years of age.
N. M. G. writes: ‘‘ McCallum was: chiefly known in
this country for his interest in international health
work. While chief medical officer in London from
1929 to 1934, and afterwards, he often represented
Australia at international public-health meetings and
I well remember how greatly the tedium of a return
from Paris to London was relieved by his quiet and
likeable companionship. His little book—now scarce—
on International Hygiene, published in 1935 by the
department of health of the Commonwealth and based
on lectures he gave at Melbourne University, was acknow-
ledged to be the most useful publication in that field.
His friends in this country will deplore his untimely
death so soon after he had taken over the leading
public-health post of his country.”
NOTES AND NEWS
\
[oct. 5, -1946
Notes and News-
TRAFFIC IN NARCOTIC DRUGS
TEE secretariat of the League of Nations at Geneva has
lately issued a summary of the annual reports for 1941 from
the countries party to the several opium and narcotic drugs
conventions (1912-36), with apology for unavoidable delay.
The s surveys the position of the narcotic drugs
traffic in the 67 contracting countries. China was said to be
complacent at the completion of the “‘ six-year suppression
plan,” and opium-smoking by overseas Chinese was to be
taken in hand, while illicit cultivation and trade in many
provinces in Japanese occupation was deplored. In the
United Kingdom addiction to narcotic drugs, chiefly morphine,
was reported to be decreasing. The number of addicts in
1941 was 503 (252 men and 251 women) of whom: 89 were
doctors. In India opium was being illicitly imported from
border countries and Afghanistan, and illicitly exported
to Burma and Ceylon from Bengal. In Canada there was still
some addiction to codeine, and hypodermic injection of
smoking opium was being practised by occidentals and
orientals on the Pacific coast—addicts have been known
to resort to the ointment of galls and opium to obtain its
morphine content. -In Egypt the Central Narcotics Bureau
reported the continued smuggling of hashish and opium
through Syria and Palestine, while the southern’ Sudan
was growing illicit hashish and sending it north on river
steamers.. Z | |
As regards “‘ raw opium ” the area under poppy cultivation
in India in 1941 was 1950 hectares, the whole of the produce
being sold to the government opium factory at Ghazipur ;
the consumption of ‘ excise opium ” for ‘‘ medical, quasi-
medical, and non-medical purposes ”’ in 1941 was 136,822 kg.
Five firms are licensed in the United Kingdom to manufacture
narcotic drugs, and a like number in the United: States.
From Colombia comes an urgent appeal, supported by the
Apostolic Nuncio, for ‘‘ reducing the cultivation of the coca
plant to the level of world medical requirements” since
its habitual abuse is said to cause widespread ravages by
tuberculosis. l
FOOD BULLETINS
King Edward’s Hospital Fund for London circulates
bulletins periodically to hospitals in which tested recipes are
given to a wider public, current food problems are discussed,
‘and inquiries to do with food or catering are answered. The
first bulletin, which appeared in May, contained notes on
dried milk, and recipes for puddings without fat. The August
bulletin discussed allowances for expectant and nursing
mothers, and gave some recipes for breakfast dishes. A third
bulletin, nearly ready, will deal with the feeding of children.
The fund’s address is 10, Old Jewry, E.C.2. |
MIDWIVES’ PROGRESS
RETURNS made to the Central Midwives Board! by local
supervising authorities show that the number of midwives who
notified their intention to practise during 1945 was 16,680—
some 300 more than in 1944. Of this number only 3 had been
in practice before 1902, when the Midwives Act was passed,
and only 109%% had been enrolled before 1920. Some 7800
midwives have been trained and enrolled under the most
recent rules of the Central Midwives Board, which. have
operated since May, 1939. More than half of these women
were practising in 1945, and 90° of these were State-registered
nurses. Probably about 62°, of practising midwives are in
the peak period of their working lives—between the ages of
27 and 47. es ee
A great many women who do not intend to practise as
midwives take the board’s examinations. There are 72,248
names on the register, and of some 14,000 midwives enrolled in
the six years 1936-41, only 24°, notified their intention to
practise in 1945. This custom of training an excess of mid-
wives is not wholly extravagant, for the experience is doubtless
useful to nurses who take up public-health work; indeed,
employing authorities are apt to look for this qualification.
But it has the effect of reducing the numbers of cases available
for medical students, and it does not offer the prospective
public-health nurse a course ideally suited to her needs. It
would be useful to consider whether a more appropriate
certificate course might not be offered to nurses who do not
12 Report on the work of the Centra] Midwives Board for the year
ended March 31, 1946.
THE. LANCET]
NOTES AND NEWS
focr. 5, 1946 511
intend to practise as midwives, with less emphasis on delivery
and more on the care of infants after the first month. The
board, with the approval of the Ministry of Health, have
amended their rules to enable sick children’s nurses to be
admitted to a shortened period of training, not described in
the report; and such a course might serve the purpose of
other nurses who do not intend to practise midwifery.
In view of the present shortage of practising midwives the
board have decided that the time has not yet come to restore
the rules, suspended in 1939, requiring midwives to attend
post-certificate refresher courses; but they welcome the
voluntary schemes for providing such courses which many
local authorities are supporting.
ASPHYXIA AND ANOXIA
WEITING in Science (1946, 104, 112), Prof. E. J. Van Liere
protests against the misuse of the terms asphyxia and anoxia.
He contends that during anoxia there is a diminished supply
of oxygen to the tissues, but there is no accumulation of CO,
in the alveolar air, or presumably in the tissues, because the
associated hyperpnæœa washes the CO, out of the lungs. In
asphyxia, on the other hand, diminished oxygenation of the
tissues is accompanied by an increase of CO, tension in the
blood and tissues. He quotes Yandell Henderson’s criticism
that the term asphyxiated is well established but there is no
equivalent term for a condition of anoxia: ‘‘ Then let us
create one,” savs Van Liere: “the equivalent would be
‘ anoxiated ’.”” This term would certainly describe accurately
the state of a man who has ascended to such a height that the
oxygen tension is too low to sustain life.
VITAL STATISTICS FOR JUNE QUARTER
THE Registrar-General’s return for the June quarter
(H.M. Stationery Office, 6d.) confirms that the birth-rate
was 19-2 per 1000 total population, the highest rate recorded
in any quarter since June, 1925. The total number of births
was 203,797 and the proportion of boys to girls 1069 to 1000.
Births exceeded deaths by 89,727, compared with an excess
of 64,252 for June quarter, 1945. Infant mortality, pro-
visionally corrected, was 41 per 1000 related live births—
9 per 1000 below the average of the previous ten June quarters.
The number of illegitimate births was 14,789, this being
2625 fewer than in June last year. Deaths numbered 114,070,
representing a death-rate of 10-7 per 1000 compared with
10-4 for June quarter, 1945, and an average of 11-6 for the
previous five June quarters. Marriages totalled 100,814,
an increase of 6620 over the average for the June quarters
1941-45.
ART EXHIBITION FOR THE HOSPITALS
King Edward’s Hospital Fund for London has organised
& loan exhibition of pictures from the collection of Sir Harold
Wernher, xK.c.v.o., at the Wildenstein Gallery, New Bond
Street, W.1l. The exhibition was opened by the Duchess
of Kent on Oct. 2, and will remain open until Nov. 9. The
charge for admission is 2s. 6d., and all proceeds will be given
to King Edward’s Fund. |
University of Sheffield l
At recent exarninations the following were successful :
M.D.—H. B. Stoner.
Final M.B., Ch.B. eramination,—Michael Redfern (with first-class
honours); Derrick Dexter (with second-class honours).
Postgraduate Course at Leeds
A two-weeks’ general refresher course for class 2 demobilised
medical officers and insurance practitioners is to be held by the
University of Leeds, commencing on Monday, Nov. 25.
Inquiries should be directed to the Senior Administrative
Officer, School of Medicine, Leeds, 2.
Royal College of Physicians of London
Dr. D. Evan Bedford will deliver the Bradshaw lecture at
the college, Pall Mall East, S.W.1, on Thursday, Nov. 7, at
5 p.m. He will speak on Hypertensive Heart Disease.
Society of Medical Officers of Health
Sir Allen Daley, medical officer of health and school medical
officer, London County Council, will be installed as president
of this society for the session 1946-47, and will give his presi-
dential address at a meeting to be held at Tavistock House,
Tavistock Square, London, W.C.1, at 5.30 p.m. on Thursday,
Oct. 17. .
British Institute of Philosophy ,
A course of five lectures on Contemporary World Outlooks
will be delivered at 5.15 P.M. on Fridays from Oct. 11 to
Nov. 8, at University Hall, 14, Gordon Square, W.C.1. `
Central Council for Health Education
The council has lately formed a field work committee,
and a materials committee. The chairmen are Dr. A. B.
Williamson, M.o.H. for Portsmouth, and Dr. H. Maurice
Williams, M.o.H. for Southampton.
Medical Photographic Exhibition
An informal display of medical photographic apparatus
and records is to be held in the department of medical photo-
graphy, Westminster Hospital School of Medicine, from
Oct. 8 to 11, between the hours of 10 a.m. and 4 P.M. |
West London Medico-Chirurgical Society
A dinner will be held on Friday, Oct. 18, at 7 P.M., at the
South Kensington Hotel, 41, Queen’s Gate Terrace, S.W.7.
Dr. G. S. Hovenden will deliver the presidential address on
Fifty Years of General Practice.
Medical Defence Union |
At the annual meeting held in London on Sept. 24, Mr. St. J.
Buxton was elected president, Dr. Henry Robinson treasurer,
and Dr. G. Roche Lynch chairman of the council committee.
Dr. Janet Aitken, Mr. Buxton, and Dr. Peter Macdonald
were re-elected members of council. The union now has more
than 30,000 members, all of whom are registered medical
practitioners. The annual report is reviewed on another page.
Local Responsibility for Hospitals
In an address at the annual meeting of the Nelson Hospital,
reported in the Times of Sept. 28, Sir Alfred Webb-Johnson,
P.R.C.S., suggested that in the National Health Service the
freedom given to the teaching hospitals should be extended
not only to the hospital management committees but also
to individual hospitals. Local interest and support would
thus be retained, and opportunities for donors, and for funds
such as King Edward’s Hospital Fund and the Nuffield Trust,
would be greatly extended. He hoped that Parliament would
allow the largest measure of local responsibility for the
planning and conduct of hospitals.
British Orthopedic Association
The association’s annual meeting is to be held in London on
Friday and Saturday, Oct. 18 and 19; the meeting will be held .
on the first day at the Royal Society of Medicine, 1, Wimpole
Street, W.1, and on the second day at St. Thomas’s Hospital,
S.E.1. The programme on Oct. 18 begins at 9.30 a.M. with
a discussion on Fractures of the Os Calcis, to be opened by
Mr. N. W. Roberts and Mr. W. Gissane ; this will be followed
by Mr. George Perkins’s presidential address on Rest versus
Activity in the Treatment of a Fracture, and by short papers.
There will be a dinner at Grosvenor House Hotel, Park Lane,
W.1, at 7 p.m. The annual general meeting will take place
at 9.30 A.M. on Oct. 19, and will be followed by a demonstra-
tion of cases. l
Centenary in Anesthesia ° oo » oh
The section of anesthetics of the Royal Society of Medicine
is to celebrate next month the centenary of the first public
administration of an anesthetic. A reception by Sir Gordon
Gordon-Taylor, the society’s immediate past-president, will
be held on Friday, Nov. 1, at 7.30 p.m. This will be followed
by a buffet supper, after which Dr. E. S. Rowbotham, presi-
dent of the section, will speak on A Hundred Years of
Anesthesia. |
The Association of Anasthetists of Great Britain and
Ireland is marking the centenary of the first administration
of ether in Great Britain with events on Oct. 30 and 31 and
Dec. 21. At 8.30 P.M. on Wednesday, Oct. 30, the Princess
Royal will unveil at the Royal College of Surgeons a plaque
commemorating four pioneers in anesthesia; the ceremony
will be followed by a reception. On the morning of Thursday,
Oct. 31, there will be operating sessions at various London
hospitals; the annual general meeting will be held at the
Royal College of Surgeons at 2 P.M., and at 7 p.m. there will
be a dinner in the Great Hall of Lincoln’s Inn. An exhibition
of anesthetic apparatus will be open at the Royal College
of Surgeons from Oct. 29 to Nov. 1. On Saturday, Dec. 21,
there will be a dinner-dance at the Dorchester Hotel.
512
Heberden Society
. The annual general meeting of this society is to be held on
Oct. 25 and 26, at 11, Chandos Street, London, W.1. At
4.45.P.M. on Friday, the 25th, there will be a discussion on
Future Trends of Research in Rheumatoid Arthritis, when
Dr. G. M. Findlay will speak on Arthritis in Rats and Mice
due to Pleuropneumonia-like Organisms, and Dr. D. H.
Collins on Erysipelothrix Polyarthritis of Swine. The annual
dinner will take place at 7.45 p.m., in the Euston Hotel. On
THE LANCET]
_ Saturday, the 26th, at 11 a.m., Prof. J. A. Höjer, chief medical
` officer of the Royal Swedish ministry of health, will read a
paper on the Organisation and Work of a Rheumatic Service
in Sweden. Further particulars may be had from the general
secretary, Miss Bereton, 91, Priory Road, West Hampstead,
N.W.6.
Louis Gross Lecture
Dr. Roy R. Grinker, director of the Institute for Psycho-
somatic and Psychiatric Research and Training of the Michael
Reese Hospital, Chicago, will deliver the ninth Louis Gross
lecture at the Jewish General Hospital, Montreal, on Wednes-
day, Oct. 23, at 8.30 p.m. He will speak on Psychiatric
Objectives of our Time.
Return to Practice
The Central Medical War Committee announces that
the following have resumed civilian practice :
Mr. D. J. MaoRag, F.R.C.S., M.R.C.0.G., 10, Harley Street,
London, W.1.
Dr. R. J. Twort, 11, Park Terrace, Nottingham (Tel. 66486).
WEAPON AGAINst MipcEs.—In reply to our peripatetic
correspondent of Sept. 21, who wondered whether D.M.P.
has yet got through to the civilian, Dr. A. R. Neligan writes
that it has, in the form of ‘Mylol’ (Boots), and is proving.
invaluable against this autumn’s clouds of midges.
Messrs. Allen &. Hanbury inform us that they now have
limited stocks of ‘ Rutin °’ available: The use of this drug in
the treatment of increased capillary fragility was discussed in
our columns on July 6, p. 16.
Births, Marriages, and Deaths
BIRTHS
BoRLAND.—On Sept. 23, ant Sunbury-on-Thames, the wife of Dr.
' A. K. Borland—a so
‘CATHIE.—On Sept. 24, at “Guildford, the wife of Dr. I. A. B. Cathie
—a daughter.
Cross.—On Sept. 21, in London, the wife of Dr. W. George Cross,
of Elstree—a gon.
FLOWERDEW.—On Sept. 26, the wife of Dr. F. Digby Mackworth
Flowerdew—a son. —
GowaR.—On Sept. 24, in London, the wife of Mr. F. Sambrook
Gowar, F.R.C.S. —a daughte
Hrnps.—On Sept. 27, in London: the wife of Dr. S. W. Hinds—
@ son.
JAMISON.—On Sept. 23, in London, the wife of Dr. Howard M.
Jamison—a daughter.
KimnG.—On Sept. 20, at Clifton, Bristol, the wife of Dr. Charles A.
King—a son.
LEIGH.—On Sept. 26, in London, the wife of Dr. A. D. Leigh—a son.
MacKENZIE.—On Sept. 21, in Edinburgh, the wife of Mr. Ian
MacKenzie, F.R.C.8S.E.—a daughter.
OxLEY.—On Sept. 25, in London, the wife of Lieut. -Colonel W.
Malcolm Oxley, R. 'A.M.0.—a son.
SARSON.—On Sept. 24, at Kettering, the wife of Flight-Lieutenant
J. M. G. Sarson, M.B.—a daughter.
Srmons.—On Sept. 20, at Southborough, the wife of Dr. H. McN.
Symons—a son
THORNTON.—On Sept. 21, at Stratford, the wife of Dr. Kenneth
Thornton—a son.
MARRIAGES
GORDON—PEEL.—On Sept. 25, at Guildford, Frederick William
Gordon, M.D., to Muriel Peel.
HuNT—CLAPHAM.—On Sept. 10, at Henfield, Geoffrey Notley Hunt,
M.R.C.8., to Deborah K. R. Clapham.
SLOPER—CHAPPEL. —On Sept. 21, at Bedford, John Chaplin Sloper,
M.R.C.P., to Irene Mary Susan Chappel, M.B.
DEATHS
ADAM.—On August 8, William Caldow Adam, L.R.C.P.E.,
Officer R.A.F.V.R., aged 26.
` BaSKETT.—On_ Sept. 25, Bertram George Mortimer Baskett,
M.B. Oxfd, of London, S.E.26, aged 84.
JENKINS.—On Sept. 25, at Almondsbury, Glos., Robert Donaldson
Jenkins, M.B. Brist., surgeon-commander R.N.V.R.
MAcLEOD.—On Sept. 21, ” Neil Macleod, M.D. Edin., of Horsforth and
Leeds, aged 52.
MoorRE.—In September, presumed lost when sailing, Joseph
Hodgson Moore, M.B. Lond., of Swinton, Manchester, aged 44.
epee rs Sept. 26, at Norw ich, Cecil Jeffery Muriel, M.R.C.8.,
age
PHELPS.—On Sept. 29, at Great Malvern, John Henry Dixon Phelps,
M.B. Oxfd, aged 74.
UTTING.—On "Sept. 22, in Surrey, Ercenwin Anstey Utting, late
assistant medical officer of health, St. Pancras,
flying-
BIRTHS, MARRIAGES, AND DEATHS—MEDICAL DIARY—APPOINTMENTS
. HOLDEN, ©. E., M.R.C.S.
foc. 5, 1946
Medical Diary
OCT. 6 To 12
Sunday, 6th
INTERNATIONAL SOCIETY OF MEDICAL HYDROLOGY
9.30 A.M. (Buxton.) Dr. Victor Ott: Present Swiss Cont of
Rheumatism and Physical Medicine.
10.15 4.M. Dr. Abraham Cohen: Use of Physostigmine in
Rheumatoid Arthritis.
11.15 a.m. Dr. Loring T. ‘Swaim : American Concepts on Arthritis
Monday, 7th
ROYAL COLLEGE OF SURGEONS, Lincoln’s Inn Fields, W.C.2
3.45 P.M. Dr. K. J. Franklin : Fostal Circulation and Cardio-
vascular System.
5 P.M. Prof. J. Z. Young :
Tuesday, 8th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Dr. K. J. Franklin: (1) Deglutition in Man and Other
Animals ; and (2) Pulmonary Mechanisms for Dealing with
Inhaled and Insufflated Dusts.
5 P.M. Prof. W. R. Spurrell: Control of Secretion of Saliva, Gastric
Juice, and Pancreatic Juice.
ROYAL SOCIETY OF MEDICINE, 1, Wimpole Street, W.1
5.30 P.M. Hazperimental Medicine and Therapeutics. Prof. H. P.
‘Himsworth: Protein Metabolism in Relation to Disease.
(Presidential address.)
Aubrey Lewis:
Nerve Injury and N erve Regeneration.
5.30 P.M. Psychiatry. Prof.
Psychiatrists. (Presidential address.)
CHELSEA CLINICAL SOCIETY
6.30 P.M. (South Kensington Hotel.) Dinner Meeting. Dr.
Ronald Jarman: Modern Anesthesia.
LONDON SCHOOL OF DERMATOLOGY, 5, Lisle Street, W.C.2
5 P.M. Dr. A. C. Roxburgh : Cutaneous Syphilis.
‘CHADWICK PUBLIC LECTURES
2.30 P.M. (26, Portland Place, W.1.) Sir Arthur MacNalty :
Sir Thomas More as Public Health Reformer.
Wednesday, 9th
ROYAL COTLECE OF SURGEONS
3.45 P.M. Dr. K. J. Franklin: (1) Eustachian Valve, Tuberculum
Intervenosum, and Superior Caval Blood Flow; and
.(2) Vascular Short-circuiting within the Kidney.
6P.M. Dr. C. J. C. Britton : Blood Grouping.
ROYAL SOCIETY OF MEDICINE
4.30 P.M. Physical Medicine. Dr. F. S. Cooksey: Planning and
Organisation of Physical Medicine Departments. (Presi-
dential address.)
NATIONAL HOSPITAL, Queen Square, W.C.1
4 P.M. Dr. Ludo van Bogaert ARINO)
of the Globus Pallidus.
UNIVERSITY OF GLASGOW
8 P.M. (Department of Ophthalmology). -Dr. Michaelson : Prop-
tosis and Exophthalmos.
Thursday, 10th
Education of
paperecetye Atrophies
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. A. J. E. Cave: Thoracic Operculum.
5 P.M. Dr.C. J. C. Britton: Blood Grouping.
ROYAL SOCIETY OF MEDICINE
5 P.M. (Cpe eney:} Mr. A. H. Levy: Æsthetics of Vision.
( idential address.) Mr. John Foster: Ophthalmic
Four in France and Switzerland.. Cases will be shown at
e P.M.
LONDON SCHOOL OF DERMATOLOGY i
5 P.M. Dr. H. MacCormac: Industrial Dermatitis.
Friday, 11th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Prof. G. R. de Beer: Segmentation of the Vortebrate
Head. -
5 P.M. Dr. Bernard Johnson : General Anæsthetics.
ROYAL SOCIETY OF MEDICINE
5 P.M. Clinical. Cases will be shown at 4 P.M.
ROYAL MEDICAL SOCIETY, 7, Melbourne Place, Edinburgh
8 P.M. Sir Henry Wade: Life of an Edinburgh Medical Student
300 Years Ago. (Inaugural address.)
Appointments
Bates, J. L., M.B. Lond., M.R.C.P., D.C.H. :
Kent County Hospital,
Bowes, R. K., M.S. Lond., F.R.C.@.
Hospital, London.
CLAY, JOHN, jun., M.B. Durh. :
ertford.
GILLIES, HUNTER, M.D. Glasg., D.P.M.
tendent, Crichton a Dumfries.
examining factory surgeon, Surbiton,
temp. asst. physician,
: obstetric physician, St. Thomas’s
examining factory surgeon, Baldock,
deputy medical superin-
urrey.
O’DONNELL, J. H., M.B. Leeds, D.L.O., F.R.C.S, :
. dept., Leicester Royal Infirmary.
PERKINS, GEORGE, M.C., M.CH. Oxfd, F.R.C.S.
. Thomas’s Hospital, London.
SWANN, W. G., M.D. Belf., D.P.H., D.OBST.R.O.0.G. ! * deputy medica]
superintendent officer of health and deputy .port M.o., Belfast.
St. George’s Hospital, London : l
CHARLES, A. H., M.B. Camb., F.R.C.S., M.R.C.0.G.; asst. obstetric
and gynæcological surgeon.
CRAWFORD, THEODORE. M.D. Glasg., F.R.F.P.8.: director of
pathological services.
DOGGART, J. H., M.D. Camb., F.R.C.S. ; ophthalmic surgeon.
MALLINSON, Sir PAUL, B.M. Oxfd, M.R.C.P. : e psychiatrist.
MARNHAM, "RALPH, M. CHIR. Camb., F.R C.S. ; surgeon i/c procto-
logical dept. :
psychiatrist to children’s
MILLER, EMANUEL, M.R.C.P., D.P.M. :
director of physiotherapy dept.
dept.
SHIELDs, D. C., B.M. Oxfd:
YOUNG, ROBERT, B. CHIR. Camb., F.R.C.S.: asst. orthopedic
surgeon.
asst. surgeon,
: orthopedic surgeon,
* THE LANCET]
SYMPATHETIC CONTROL OF BLOOD-
VESSELS OF HUMAN SKELETAL MUSCLE*
HENRY BARCROFT O. G. EDHOLM
M.D. Camb. M.B., B.Sc. Lond.
PROFESSOR OF PHYSIOLOGY, PROFESSOR OF PHYSIOLOGY, .
QUEEN’S UNIVERSITY OF ROYAL VETERINARY COLLEGE,
BELFAST LONDON
Vasoconstrictor Tone
THE question whether or not the sympathetic nervous
system supplies the blood-vessels in muscle and maintains
vasoconstrictor tone during muscular inactivity is of
fundamental importance in peripheral vascular disease.
Animal investigations on the whole seem to point in that
direction. Sympathetic nerve-endings have been identi-
fied histologically in the walls of blood-vessels in cat
muscle (Hinsey 1928). Increase in blood-flow through
muscle in the dog and cat has been observed after section
of the sympathetic nerve-supply (Anrep et al. 1934,
Baetjer 1930). Nevertheless general opinion, as shown
by reviews by Abramson (1944), White and Smithwick
(1941), and Wilkins (1942), is against the presence of
sympathetic tone in the vessels in human muscle. Recent
work in Belfast, however, has convinced us that such tone
exists, and we submit here a summary of the evidence
in favour of our view.
METHODS
The blood-vessels investigated were those in the
muscles of the forearm. Details of the plethysmographic
technique have already been published (Barcroft et al.
1943). We wish to emphasise here only the following
points :
(1) It is important to maintain the temperature of the
forearm as near as possible to its normal physiological
level. Lack of this precaution is one of the reasons why
the presence of tone in the blood-vessels in human muscle
has not been noted by previous observers. During the
experiments the limb is kept in a constant-temperature
water-bath. Most workers use a water temperature
near skin temperature. Grant (1938) used 30° C, most
others 32° C. We have measured the temperature and
blood-flow in normally clad forearms and find they are
maintained at their normal levels when the limb is
immersed in water at 34° C (Barcroft and Edholm
1946). Lower water temperatures depress muscle
temperature and blood-flow. For example, at 30° C
the rate of flow is only about a third of the normal.
(2) We have confirmed Grant and Pearson’s (1938)
dictum that blood-flow as measured with the forearm
plethysmograph is mainly muscle blood-flow. The table
shows the approximate distribution of the blood-flow
to the different tissues of the forearm in the clothed
EXPERIMENTAL
The proof of the existence of sympathetic tone in the
blood-vessels in muscle is summarised below from the
paper by Barcroft et al. (1943). Fig. 1 (a) shows that
the blood-flow in the right forearm is about equal to that
in the left. Fig. 1 (b) shows that the blood-flow in the left
forearm is greatly increased by blocking the median,
radial, and ulnar nerves just above the elbow, a technique
developed by Dr. W. M. Bonnar.
ing possible explanations for this vasodilatation :
(1) Release of the sympathetic tone in the vessels of the
forearm skin,
(2) Diminution in the resistance opposed to the blood-stream
owing to paralysis of tonic contraction of the skeletal
muscles,
(3) Release of sympathetic tone in the blood-vessels in the
muscles,
* Based on Arris and Gale lectures delivered at the Royal College of
Surgeons of England by Professor Barcroft on Dec. 19 and
by Professor Edholm on Dec. 20, 1945.
6424
ORIGINAL ARTICLES
There are the follow- -
Gilding (1932) reviews the published work showing that
the sympathetic fibres to skin travel with the cutaneous
nerves, whereas those to muscle accompany the motor
nerves. The first explanation can therefore be discarded,
since the forearm skin is supplied by the antebrachial
cutaneous nerves, which are not blocked. The second
suggestion can be discarded, because paralysis of the
muscles by nerve-block in sympathectomised subjects
does not increase forearm blood-flow. Therefore the
last suggestion must be correct. The increased blood-
flow in the blocked forearm must be due to release of
sympathetic tone in the blood-vessels of the muscles.
This experiment has been done more than 25 times with
consistent results. In the average forearm, blood-flow
on the blocked side is about doubled. This means
that the muscle blood-flow is increased about 2!/, times.
If the vasomotor centre were to release the vasoconstrictor
tone throughout the skeletal muscles of the body, the
blood-flow throughout the muscles would increase by
more than a litre a minute.
Some experiments were done under even more strictly
controlled conditions. Fig. 2 shows a forearm with
adrenaline introduced into the skin by electrophoresis
to arrest the cutaneous circulation. By this technique
the skin becomes blanched, with occasional small cyanotic
patches. The penetration of the adrenaline into the
deeper layers was shown by goose-flesh and by paralysis
of the sweat-glands. In such forearms the blood-flow -
was slightly reduced because of the decrease in the
amount of blood flowing through the skin, Even so, as-
fig. 1 (c) shows, deep nerve-block increased the blood-
flow far above that on the normal side. Obviously the
hyperemia could not have been in the blanched skin
and must have been in the underlying muscle. The bone
could be safely left out of consideration since its blood-
flow is negligible compared with that of muscle (Edholm
et al. 1945).
Woollard and Phillips (1932), Friedlander et al. (1938), .
and Grant and Holling (1938) blocked the sympathetic
PARTITION OF BLOOD-FLOW THROUGH VARIOUS TISSUES OF
FOREARM
— Muscle | Skin | Bone pon ee
Blood-flow c.cm. per 100 c.cm. ——————
of forearm per minute et
flow=3:1c.cm.) .. 2:1 0'8 0:2
Tissue c.cm. per as c.cm. id
arm .. 64°0 8:6 14:0 13-4
Blood-flow c.cm. per 100 ¢.cm.
of tissue per minute Bs 3°25 9-7 1:0 0°5
fibres to muscle and noted that temperature in or over the
muscle did not rise. Since blocking the cutaneous nerve-
supply to the fingers often causes a very large rise in
finger skin temperature, these workers considered that
the sympathetic vasomotor tone in muscle must be
negligible. However, muscle is less vascular than finger- |
tip skin; so release of tone would cause far less increase
in blood-flow per unit volume of tissue. Moreover in
exposed forearms the muscle would be cooling, and
release of tone would merely delay the rate of cooling.
Further, if the limb had been exposed for some time
before the block, muscle blood-flow would be subnormal,
and the effect of the block would be reduced. Inferences
concerning muscle blood-flow made on the basis of tem-
perature measurements cannot be so reliable as direct
plethysmographic determinations.
Warren et al. (1942) measured the forearm blood-
flow with the plethysmograph and found that it was
increased after paravertebral block. Their suggestion
that the increase was entirely in the skin is not borne
out by the deep nerve-block and. adrenaline electro-
phoresis experiments described above.
P
514 THE LANCET] PROFESSORS BARCROFT AND EDHOLM: CONTROL OF BLOOD-VESSELS IN MUSOLE ([ooT. 12, 1946
¥
BLOOD-FLOW IN FOREARM
(ccm. per min. per 100 ccm.)
N o
0 10 20 30 40 0 10 20 o 10 20
(a) MINUTES (b) (e)
Fig. |—-Blood-flow in forearms: (a) right and left arms normal, showing
flow equal in both arms; (b) deep nerve-block of left radial, median,
and ulnar nerves (right arm intact); (c) same nerves blocked and
cutaneous circulation abolished by adrenaline electrophoresis In ieft
arm (right arm intact), The numerals in parentheses denote the
number of experiments from which the averages were obtained on
which the curves are based.
To sum up, there is good evidence that the release of
sympathetic tone in the blood-vessels in muscle would
more than double the rate of blood-flow.
PHYSIOLOGICAL RELEASE OF VASOCONSTRICTOR TONE IN
MUSCLE VESSELS BY BODY HEATING
Grant and Holling (1938) found that the blood-flow
to the forearm could be increased by heating the legs,
but that this required very considerable heat, and the
rate of increase varied. They considered that the increase
in blood-flow was due to cutaneous vasodilatation.
Wilkins and Eichna (1941) also obtained an increased
blood-flow in the forearms on body heating, and suggested
that some of the increased flow was due to vasodilatation
in muscle vessels. We have now carried out this pro-
cedure on a large number of subjects with the forearm
in water at 34° C, and usually found a considerable
increase in the forearm blood-flow when the legs were
heated. The effect is absent in sympathectomised
subjects. We have also used the skin-blanching tech-
nique to analyse the effect, and have shown that the
dilatation definitely takes place in the muscle blood-
vessels. Fig. 3 shows dilatation in the blanched forearm
following immersion of the feet in hot water. Since the
increases in forearm blood-flow after deep nerve-block
and after feet heating were similar, we concluded that
the hypersemia in the forearm was mainly due to release
of vasoconstrictor tone in the blood-vessels of resting
muscle.
COMMENT
Grant and Pearson (1938) and Wilkins and Eichna
(1941) have shown, and we have confirmed, that fore-
arm blood-flow is practically normal some weeks after
sympathectomy. The tone of the blood-vessels in
muscle which is released after operation gradually returns.
Hence, on theoretical grounds, it does not necessarily
follow that sympathectomy could achieve any permanent
improvement in peripheral vascular conditions such as
intermittent claudication. ;
Vasodilator Tone
It is now proposed to present some evidence concerning
the presence of vasodilator fibres in the blood-vessels of
human skeletal muscles.
Vasodilator fibres have been demonstrated by Bülbring
and Burn (1937) in muscle vessels in certain animals,
notably the hare. Grant and Pearson (1938) and
Holling (1939) have shown that adrenaline in small
quantities produces vasodilatation in human skeletal
muscles. We have confirmed this (Allen et al. 1946)
but have found that the dilatation is only fleeting, and,
with continued infusion of adrenaline, dilatation is
followed by constriction. Nevertheless the fact that a
sympathomimetic substance can produce a vasodilatation
suggests that adrenergic vasodilator nerves exist.
Grant and Holling (1938) have also presented evidence
of vasodilators in cutaneous blood-vessels,' but their
conclusions have been criticised by Warren et al. (1942).
The first experiments we carried out—namely, com-
parison of the effects of nerve-block and of heating the
legs on forearm blood-flow—were inconclusive. As
described above, these two procedures produced nearly
. similar effects ; so it was considered that the increase in
blood-flow produced by leg heating was due to release of
vasoconstrictor tone alone, not to any active vaso-
dilatation mediated by vasodilator nerves.
More convincing evidence was obtained unexpectedly
during an investigation of the effects of hemorrhage on
the peripheral circulation in man, to determine the extent
and degree of peripheral vasoconstriction after vene-
section. In one of the earliest experiments the subject
fainted, and, to our great surprise, the forearm blood-
flow very much increased during the faint, in spite of the
sudden drop in blood-pressure. This unexpected finding
made us change the original scheme, and instead an
investigation of fainting was initiated (Barcroft et al.
1944, Barcroft and Edholm 1945). It was in the course
of this work that evidence was obtained of the existence
of vasodilator nerves to muscle blood-vessels.
The large number of blood-donors submitting to vene-
gection has provided opportunities for skilled observa-
tion of fainting ; so the literature on the subject is now
considerable. The incidence of fainting in blood-donors
varies, but with a venesection of some 400 c.cm. the
average fainting-rate is about 5% (Poles and Boycott
1942, Brown and McCormack 1942). The incidence is
affected by fatigue, hunger, and thirst. Posture is
important ; fainting can and does take place with the
subject prone, but is much more easily provoked in the
sitting or upright position. Room temperature is also
a factor. In the Middle East, with a temperature of
100° F or more, the incidence of fainting in blood-donors
might be as high as 20% (Buttle 1945). Emotional
factors certainly play a part. It has been a common
experience in blood-donor centres to observe epidemic
fainting when many donors are together in view of each .
It has also
other ; one donor faints, others follow suit.
Fig. 2—Forearm, after introduction of adrenaline by electrophoresis into
the skin to arrest the cutaneous circulation, showing blanching and
occasional small cyanotic patches.
been observed that those subjects who faint as a result
of a small venesection often give a history of previous
fainting. So it has been considered that fainting is
an abnormal reaction implying an unstable vasomotor
system. Nevertheless it is generally agreed that it is
extremely difficult to predict who will faint as a result
of a given hemorrhage ; there is no test which will reveal
the potential fainter. However, Wallace and Sharpey-
Schafer (1941) have shown that the incidence of fainting
increases steadily with increase in the volume of blood
withdrawn. i
Hæmorrhage is not the only stimulus which wil
provoke fainting ; emotional shocks, such as the sight of
blood, hypodermic or intravenous injection, the upright
posture, and anoxia, can all be effective. It is a subject
which merits investigation.
Lewis (1932), in a classical paper on the subject,
emphasised the salient features of a faint: sudden drop
in blood-pressure, slowing of the heart, pallor, sweating,
THE LANCET]
commonly nausea, and often loss of consciousness.
He showed that the cardiac slowing was not an essential
feature of the circulatory collapse, since atropine admini-
stered during the faint accelerated the heart without
hastening recovery. Lewis epitomised his work by
describing fainting as the vasovagal syndrome, meaning
that there were two components of the faint, the vagal
effects of cardiac slowing, nausea, &c., and a vascular
effect. More recently, Barcroft et al. (1944) confirmed that
fainting was not a cardiac event. They measured cardiac
output with the cardiac catheter and showed that there
was no fall in cardiac output during fainting. Fainting
is not a cardiac
T 8 lg syncope; it re-
3 Y IN presents a peri-
<Q 6 . is pheral failure—
es SKIN X : .
BLANCHED i 1.€., the fall in
& 34 . F blood-pressure is
2s due to peripheral
wS2 vasodilatation.
S R In our investi-
N Š o 10 20 30 40 s0 60 $ehon we ve
Ql MINUTES hemorrhage’ to
Fig. 3—Effect of leg heating on forearm blood-
flow after abolition of cutaneous circulation.
Curve based on average of 5 experiments.
We wished to
have a high inci-
dence of faints
so, as Wallace and Sharpey-Schafer (1941) had shown
that the greater the volume of bleeding the higher the
incidence of faints, we used large venesections. This
was done by combining a venesection from the arm
with a simulated venesection by inflating pressure cuffs
on the thighs to diastolic pressure. Ebert and Stead
(1940) have shown that such a procedure dams back up
to 700 c.cm. of blood in the lower limbs. It is not unduly
uncomfortable, and by releasing the pressure on the
thighs the trapped blood is rapidly returned to the general
circulation. The average volume of the venesection
from the arm was about 500 c.cm., and this, together
with pressure on the thighs, produced a faint in nearly
every subject. Since our subjects were young healthy
adults, this showed that fainting was not an abnormal
reaction but one which could be produced by a suitable
stimulus in all persons, though the strength of the
required stimulus varied from subject to subject. The
forearm blood-flow was recorded and the original finding
confirmed ; the forearm blood-flow increased in every
case during the faint.
The next step was to investigate the mechanism of this
vasodilatation : was it nervous or humoral? There is
evidence that adrenaline secretion is increased during
hemorrhage, and adrenaline has been shown to produce
a considerable vasodilatation in the forearm. So there
seemed to be a distinct possibility that adrenaline secre-
tion was responsible for this dilatation. To test this
hypothesis, fainting was induced in sympathectomised
subjects. These patients were rigorously tested to
establish that the sympathectomy was still complete.
Resting forearm blood-flow was within normal limits,
as in all cases the sympathectomy had been performed
some time previously. (Grant and others have shown that
the forearm blood-flow is only temporarily increased after
sympathectomy, the vessels soon recovering their tone.)
In these subjects forearm blood-flow did not increase
during fainting; on the contrary, the blood-flow
diminished as the blood-pressure fell, and recovered
when the pressure rose again. This finding provided
definite evidence that the dilatation in normal subjects
was not due to the secretion of adrenaline or any other
humoral agent, for such effects would still have been
present after sympathectomy. On the other hand, since
the dilatation was abolished when the vasomotor nerves
were absent, it was evident that the dilatation was
mediated by the vasomotor nerves.
produce fainting. ©
PROFESSORS BARCROFT AND EDHOLM: CONTROL OF BLOOD-VESSELS IN MUSCLE [oct. 12, 1946 515
The next problem was to establish the site of the
vasodilatation. A striking feature of the vasovagal ©
syndrome is the intense pallor of the skin, and it seemed
very unlikely that the considerable increase in blood-
flow could be taking place in the skin vessels. This was
investigated by comparing the blood-flow in the hand
and forearm. The hand consists largely of skin and
bone with only 15% muscle. If the vasovagal dilatation
takes place in muscle vessels only, the rate of flow
through the hand should diminish during fainting.
And that was what we found. Weiss et al. (1937) have
previously shown. that, during the circulatory collapse
induced by amy] nitrite, a collapse which closely resembles
the vasovagal reaction, the blood-flow through the hand
is unrecordable. However, Rushmer (1944) reported
that, in the collapse induced by needling the brachial’
artery, plethysmograph records of the finger-tip indicated
a vasodilatation. Nevertheless in the hand as a whole
there is no doubt that the blood-flow decreases during
fainting. So it was concluded that, during fainting
induced by hemorrhage, there was a sudden vaso-
dilatation in muscle blood-vessels due to nervous
impulses.
This conclusion led to the next question: was the
dilatation solely due to the removal of vasoconstrictor
tone, or did active vasodilatation occur? Experiments
were carried out in subjects in whom a nerve-block was
performed in one arm. This procedure, as described
above, removes vasoconstrictor tone and therefore
increases the rate of forearm blood-flow. When fainting
was induced in these subjects, the blood-flow decreased
as the blood-pressure fell, behaving similarly to the
sympathectomised forearm. But in these subjects the
level of blood-flow during the faint was much less than
that in the normal arm during the faint. Considering
the conditions in the two arms, one with the nerve-block
and the other intact, in the first vasoconstrictor tone
had already been removed by the nerve-block. If the
vasodilatation during the faint was solely due to the
removal of vasoconstrictor tone, then the conditions in
the two arms during the faint should be the same: in
the one arm vasoconstrictor tone removed by nerve-
block before the faint, in the other removed by fainting.
But the flow in the normal arm at this stage was much
greater than in the blocked arm ; so this increase could
not be solely due to the removal of vasoconstrictor tone,
otherwise the level of blood-flow during the faint should
be the same in the two arms. During fainting, in
brief, there is an increase in forearm blood-flow greater
than can be explained solely by the removal of vaso-
constrictor tone. It has been shown that no humoral |
agent is involved and that the skin vessels play no part.
The only reasonable conclusion is that part at any rate
of this vasodilatation is mediated by vasodilator nerves. |
Summary
The technique of demonstrating sympathetic vaso-
constrictor tone in blood-vessels in human skeletal
muscles is described.
Blood-flow in muscles is more than doubled by the
release of sympathetic tone.
Heating the body relaxes the vasoconstrictor tone in
blood-vessels supplying muscles.
Vasoconstrictor tone gradually returns to the blood-
vessels of sympathectomised subjects. 3
Vasodilatation takes place in the muscles of the
forearm after fainting, except in sympathectomised
subjects. ‘Therefore this vasodilatation is due to nervous
control.
It is shown that vasodilatation in the forearm muscles
is not due merely to removal of vasoconstrictor tone
but that it is, at any rate in part, mediated by vaso-
dilator nerves.
References at foot of next page
516
THE LANCET] DR. MILLIGAN :. PSYCHONBUROSES TREATED WITH ELECTRICAL CONVUISIONS
[ocr. 12, 1946
PSYCHONEUROSES
TREATED WITH ELECTRICAL CONVULSIONS
THE INTENSIVE METHOD
W. LIDDELL MILLIGAN
M.D., B.Sc. Glasg.
DEPUTY PHYSIOIAN-SUPERINTENDENT, ST. JAMES HOSPITAL,
PORTSMOUTH
THOUGH there has been some agreement concerning
the benefit obtained from electro-convulsive therapy in
certain psychoses, recent publications show divergent
Opinions about its use in the psychoneuroses. Those
who believe in its efficacy have so far produced little
evidence in support of their statements. Good (1940),
Cheney et al. (1941), Zeifert (1941), Furst and Stouffer
(1941), Low et al. (1938), and Shapiro and Freeman
(1939) report good results in small series of cases, and
Feldman et al. (1945) have reported a considerable
improvement in 2 cases of acute hysteria. Kerman
(1945) mentions only 1 case of psychoneurosis out of
300 various psychotic patients treated by this method,
and this patient was only partially improved. Pacella
and Barrera (1943) report rather poor results, Smith
et al. (1943) state that it is of doubtful value, and Walshe
(1945) goes so far as to.say that convulsion therapy has
no place in the treatment of the psychoneuroses.
This report deals with 100 psychoneurotic patients —
treated in St. James Hospital, Portsmouth, during the
past five years. The intensive method described was
originated by Dr. Thomas Beaton, physician-superinten -
dent of this. hospital.
METHOD
The apparatus used is a special model manufactured
by the Solus Electrical Co. Ltd. All unnecessary recording
instruments—e.g., for determination of head resistance—
have been eliminated. The maximum voltage is 200,
and the time mechanism is calibrated in tenths of a
second, increasing by 1/, sec. intervals to a maximum of
1 sec. It has been found, in treating many patients,
that a high voltage can be used with certain advantages
and. no untoward results. The average dose used has
been 180 volts at 0-4 sec. This produces a convulsion
in nearly every case and has the further advantage that
it eliminates the usual preceding cry. This is very helpful
PROFESSORS BARCROFT AND EDHOLM : REFERENCES
Abramson, D. I. (1944) Vascular Responses in the Extremities of
Man in Health and Disease, Chicago.
Allien, W.: J., T OCEN H., Edholm, o. G. (1946) J. Physiol.
haroa, O. G.
olm, O. G. (1945) Ibid, 104, 161.
(1946) Ibid, 104, 366.
McMichael, J., Sharpey-Schafer, E. P.
Brown, H., he ormak, P. (1942) Brit. med. J. i,
Bülbring , Burn, J. H E a Physiol. 88, 341.
Buttle, le G. Te H. (1945) persona communication.
Ebert, R. V., Stead, E. A. jun. (1940) J. clin. Invest. 19, 561.
Edholm, O. G., Howarth, S., McMichael, J. (1945) ig Sci. 4, 103.
Friedlander, M., Silbert, ’s., ’ Bierman, W., Laskey, N. (1938) Proce.
Soc. e . Biol., N.Y. 38, 150.
Gilding, H. P. (1932) J. Èhysiol, 74, 34.
Grant, R. T. (1938) ‘Clin. Sci. 3, 157.
. (1938) Tora, p. 273.
Effron, A. S. (1943)
(1944) Lancet,
—— Holling, H è
— Pearson, k B S. (1938) Ibid, p. 119.
Hinsey, J. C. (1 928) J. comp. Neurol. 47, 23.
Pune H. E. (1939) Clin. Sci. 4, 103.
Lewis, T. (1932) Brit. J. i, 873.
Poles, p a Boycott. M . (1942) Lancet, ii, 531
Pemon n F. (1944) Amer. “i Ph hysiol. 141, kog, `
Wallace, Sharpey- Schafer, P. (1941) Lancet, ii, 3
Warren 3. YW Stead, E. A. Tua, (1942)
Walter, C. aN ARERO, J.,
J. clin. Invest. 21,
Weiss, S., Wilkins, R. W., yaen E W. (1937) Ibid, 16, 73.
. (1941) The Autonomic Nervous
Ha
White, J.C. Smithwick, R.
ilkins,, R. W. (1942) Advances in Internal Medicine, vol. 1, New
System, “New York.
Yor
eet) Bull. Johns Hopk. Hosp. 68, 425.
— Bichon, I A W.
Woollard, H. » Phillips, R. (1932) J. Anat., Lond. 67, 18.
when many patients are being treated in a ward with
only movable screens between the beds. No restraint is
used, and the only precaution taken, apart from the
usual gauze gag, is the use of a dorsal pillow to keep the
patient in a position of slight opisthotonos.
The machine, which has a silently acting switch, is
- moved slowly down the ward on a trolley, and the
ward sister manipulates the electrodes while the doctor
operates the apparatus. The electrodes are mounted
on a flexible metal band of horseshoe shape similar to
that used in headphones. This is held momentarily in
position on the patient’s forehead by means of insulated
handles on the outer side of the electrodes.. By this
method it is possible to treat 20 patients in eight minutes.
We have recently introduced a wireless-set to provide
light music during treatment. This is perhaps a minor
point, but it helps patients awaiting treatment to pass
the time and prevents apprehension while the patient
in the next bed is receiving treatment. It also ensures
that patients regaining consciousness return to a more
cheerful environment.
The number and spacing of treatments vary from
case to case. Cook (1944), in a review of convulsion
therapy, quotes the average as three a week, and
Stockings (1944) refers to the frequency used in some of
his own cases—one a day—as drastic. We have employed
an intensive method in many cases, particularly in those
of long standing. This sometimes involves as many as
four treatments a day, the dosage being modified as the
patient responds to treatment. The confusion, amnesia,
and complete disorientation produced by such treatment
call for very careful nursing. In some cases it is necessary
to reduce the patient to the infantile level, in which he
is completely helpless and doubly incontinent.
The course of treatment is then adjusted so that the
patient is allowed gradually to emerge from the con-
fusional state. During this time simple psychotherapy,
in the form of explanation and reassurance, is given, and
the helpful attitude of the nurses is of the greatest impor-
tance. Occupational therapy is used as an adjuvant, and
the patient is encouraged to take part in social activities.
We are fortunate in that this hospital is situated in the city
itself, so that, by a system of gradually extending parole,
the patient can slowly resume a normal form of life.
After discharge from hospital the patient usually
returns to work immediately and reports at the out-
patient department for several months, if necessary.
All cases in this series have been followed for a period
ranging from eight months to five years..
THEORY OF ACTION
The most satisfactory explanation of the action of
electro-convulsion therapy so far advanced is quoted by
Brain and Strauss (1945). This postulates the presence
of faulty electrical patterns in the brain which are altered
by the treatment, the resulting amnesia allowing time
for the brain to become accustomed to simplified patterns.
If this is so, it is a definite indication for the use of the
intensive method, which appears to obliterate entirely
the faulty patterns, and thus allows the patient to be
rehabilitated along correct lines. |
RESULTS
The criteria used in assessing the condition of patients
on discharge were as follows: `
Patients noted as “recovered” were discharged
symptom-free and apparently quite stable; no patient
discharged in this category has relapsed.
All patients noted as “ relieved ” were much improved,
and most of them were symptom-free, but they were
placed in this category if there was any doubt about
their stability. Only 6 of the 46 patients in this category
have shown any signs of relapse, and 3 of these had
received insufficient treatment, having left hospital before
the course was completed.
THE LANCET]
DR. MILLIGAN: PSYCHONEUROSES TREATED WITH ELECTRICAL CONVULSIONS [ocrT. 12,1946 517
The 2 women noted'as “ not improved ” responded
to treatment at the outset but left hospital before the
course was completed. The male patient included in
this category was approaching senility and was precluded
from receiving intensive treatment because of his
physical condition.
The numbers discharged in these categories are as
follows :
MALE FEMALE
Recovered rae eeu par 220° .ogatine 27
Relieved es ae pe EO Gaius 26
- Not improved .. xi zis Li netek 2
Thus 51% were classified as ‘“‘recovered,” 46% as
“ relieved,” and 3% as ‘‘ not improved.”
The differential classification is as follows :
MALE FEMALE
Re- Re- |Notim-| Re- Re- {Not im-
covered| lieved | proved | covered! lieved | proved
Anxiety states ..
Hysteria ..'
Obsessiona] states
Mixed states
_ È ILLUSTRATIVE CASE-RECORDS |
CasE 1.—A male married chartered accountant, aged 36,
was admitted on April 30, 1945, with four months’ history
of inability to work owing to a “constant series of figures
passing through my mind.” He also complained of a severe `
pain in the throat, preventing him from swallowing properly,
and he expressed the fixed idea that this was due to cancer.
Mental State——An immature type of man, rather childish
in manner, very hvpochondriacal, anxious, worried, and very
apprehensive. He could not speak without first striking his
left thigh.
Family History.—Father, aged 56, had died of cancer of
the stomach. Mother had died of cerebral hemorrhage six
months ago. She was said to have been a domineering type
of woman, on whom the patient had been very dependent,
even after his marriage. Her sudden death seems to have
been the precipitating factor in the patient’sillness. Nosiblings.
Personal History.—Patient had not had any serious illness.
He was said to have worried over details. His school career
had been brilliant, and he now held a very responsible position.
Diagnosis.—Obsessive-compulsive neurosis.
Treatment.—April 30, 1945: 3 convulsions induced at
10 a.m., 11 A.M., and 3 P.M.
May l: 2 convulsions induced at 10 a.m. and 4 P.M.;
patient was confused and rather restless, but made no
complaints about his throat, and spoke naturally and without
his thigh-striking ritual. May 2: 2 convulsions induced at
10 a.m. and 3 P.M. May 3: a convulsion induced at 10 A.M. ;
patient was confused, amnesic, and completely disoriented.
May 5: a convulsion induced at 10 a.m. May 10: he was
no longer confused, but there was complete amnesia for events
which happened during the week before admission. May 12:
@ convulsion induced at 10 a.m. May 30: he was well and
Aie E tise. except for a patchy amnesia, which was slowly
clearing.
June 8: improvement had been maintained ; patient was
discharged “f recovered.”
July 12: reported in outpatient department (oP); he had
remained well and now had a full recollection of events
leading up to his admission; he said that he still had slight
difficulty in remembering the names of acquaintances,
Sept. 4: reported in op; he had remained very well and
said that he had now no memory difficulties.
Dec. 6: reported in op; he was completely symptom-free
and had no complaints whatsoever.
April 2, 1946: contacted by telephone, he said he had
remained perfectly well,
CasE 2.—A male married draughtsman, aged 41, was
admitted on March 29, 1945, with fifteen years’ history of
recurrent attacks of vomiting.
' Personal History—He was said to have been liable to
worry unnecessarily since childhood.- The attacks of vomiting
had been becoming progressively worse; and whereas they
had formerly lasted only a few days, with remissions of several
months, the present attack had lasted three months, even a
glass of water causing him to. vomit. In the past ten years
he had attended sixteen different doctors, had been admitted
to general hospitals four times, for periods varying from two
to five months, and in one of these hospitals a laparotomy
had been performed. No organic lesion had been found at
any time during his illness.
Family History.—Mother, aged 64, said to be nervous and
unstable. Father, aged 61, fit and well. Siblings, eight brothers
and two sisters, all said to be nervous. |
Mental State —Very hypochondriacal, anxious, worried, and
easily upset by trifling incidents, manifesting this by acute
attacks of anxiety. He realised that these acute attacks were
responsible for his gastric upset. l
Diagnosis —Chronic anxiety state. .
Treatment. —March 30, 1945: 3 convulsions induced at
10 a.M., 12 noon, and 2 P.M. At 4 P.M. patient was only slightly
confused. March 3l: 4 convulsions induced at 10 A.M.,
12 noon, 2 P.M., and 4 P.M.; at 6 P.M. patient was confused,
amnesic, and disoriented in time. l
April 1: 3 convulsions induced at 10 A.M., 2 P.M., and
5 P.M.; patient. was now very confused and completely dis-
orionted, tended to be restless, and required careful super-
vision. ‘April 2: a convulsion indueed at 10 a.m. April 6:
a convulsion induced at 10 a.M.; patient was now only
slightly confused, was bright and cheerful, had nọ complaints,
and enjoyed full hospital diet.. April 8 and 10: a convulsion
induced at 10 A.M. each day, . April 16: he was now bright
and cheerful, coöperative, and symptom-free; he said he
-= enjoyed his food for the first time in fourteen years and could
eat anything; his interests were varied, and he was doing
some fairly heavy manual Jabour in the villa garden. April 26 :
he remained. well and, though he was occasionally upset, the
resulting anxiety reaction was much less severe than formerly.
April 28 and 30: a convulsion indyced at 10 a.m. each day.
May 17: he remained well and symptom-free, May 20:
discharged ‘‘ recovered.” y |
` June 21: attended op; had remained well, had started
work, and reported no difficulties.
Sept. 6: attended oP; was very ‘well and said he could
eat anything and had gained 2 st. in weight during the past
three months.
Dec. 20: attended or ;. he had remained well.
Feb. 21, 1946: attended op; he said he felt elec fit
and had no complaints; he had gained self-confidence and
was apparently stable.
April 11: reported at op; had remained perfectly well.
CasE 3.—An unemployed single man, aged 51, was admitted
on Sept. 1, 1945, with twenty years’ history of epigastric pain
and ten years’. history of inability to swallow solids.
Personal History.—No illness or accident until the age of
22, when he was badly wounded while serving in an infantry
regiment during the war 1914-18. He had been in hospital
eighteen months and had subsequently had many operations
for the removal of shrapnel. He had been employed as a
stage hand from 1921-to 1926, but since then had done no -7
work, lived on his disability pension, and had been a chronic `
invalid. He had been admitted to five general ‘hospitals for
investigation, and laparotomy had been performed twice. °
No organic lesion had ever been found. For the past ten -
years he had been existing on a diet composed solely of three
pints of milk a day, with an occasional raw egg.
Family History.—Parents had died of natural causes, and
little information was available about them. He had one
brother and four sisters alive and well. These relations lived
in widely separated parts of the country and had on many
occasions received telegrams summoning them to patient’s
bedside. On each occasion the message has been dictated
by patient, who said he was dying.
Mental State.—Egocentric, petulant, E plausible, and
delighted in giving a long circumstantial account of his
illness, going into unnecessary details. He showed no trace
of depression, though he complained bitterly of his treatment
in other hospitals and said that no doctor had ever properly
understood his case.
Diagnosis.— Hysteria.
Treatment.—Sept. 2, 1945: 3 NA maata at 10 A.M.,
12 noon, and 4 P.m. Sept. 3: 2 convulsions induced at 10 a.m.
and 2 P.M. Sept. 4: 2 convulsions induced abt 12 noon and
3 P.M.; he was very confused, completely disoriented, and
restless, and his habits had become faulty. Sept. 5, 6, and 8:
@ convulsion induced at 10 a.m. each day. Sept. 10: he was
less confused but tended to be very elated. Sept. 12: a
518 THE LANCET] DR. MILLIGAN:
convulsion induced at 10 a.m. Sept. 16: he was bright,
cheerful, and contented, and had no complaints.
Oct. 3: he was quite settled, worked well in the villa garden,
and had, for the past fortnight, enjoyed full hospital diet ;
he ate his. food with great relish ; there was no trace of either
confusion or amnesia.
Oct. 9: he was discharged “‘ rovera Oct. 23 : reported
in OP; he had remained well and had no complaints.
Nov. 20: reported in or; he had remained well and was
apparently stable. .
March 28, 1946: reported in oP; he had remained very
well and said he could eat anything and hoped to find employ-
ment in the near future.
CasE 4.—A married male bus conductor, aged 48, was
admitted on Nov. 2, 1945, with three years’ history of severe
pain in the back, preventing work.
Personal History. —Had been healthy and had a good work -
record until 1941, when he had received severe burns of the
lower limbs in a motor accident. He had spent nine months
in a general hospital and been unable to resume employment
until November, 1942-
Three years ago, while employed as a bus conductor, he had
accidentally fallen down the stairs of his omnibus. He had
complained of pain in the back, but had been able to continue
work. He had consulted his doctor, who had treated him for
a month; but, as the pain had still persisted, he had been
referred to the op of a general hospital. There it had been
thought that he had a tuberculous lesion of the spine, and he
had spent the next two months in a sanatorium, He had
then been referred to an orthopædic surgeon, who had recom-
mended massage and radiant heat, as no bony injury had been
found on radiography. As there had been apparently no
alteration in either the nature or the severity of the pain, he
had been fitted with a plaster-of-paris spinal jacket.
months later he had been admitted to an E.M.S. hospital, where
for three months he had been investigated and treated. He
had again been fitted with a spinal jacket and discharged from
hospital.
For three years he had been receiving £3 a week compensa-
tion.
Family History—He was one of a family of fourteen. One
brother had died of pulmonary tuberculosis.
Mental State. —Though he said he was very worried and
depressed because of his inability to work, there was no trace
of this at the interview, when he was quite cheerful. He
walked in a most peculiar manner, with the aid of two walking-
sticks. He gave a reasonable account of himself and said he
was most anxious to resume his employment.
Diagnosis.— Hysteria.
Treatment —N ov. 3, 1945 : 4 convulsions induced at 10 a.m.,
12 noon, 4 P.m., and 6 p.m. Nov. 4: 3 convulsions induced
at 10 A.M., 2 P.M., and 4 P.M.; patient was very confused,
constantly asked “why he was in hospital, and said there
was nothing wrong with him. He walked in a fairly natural
manner. Nov. 5 and 6: a convulsion induced at 10 a.m. each
day. Nov. 8: he was much less confused, but did not remember
why he was admitted. Nov. 9, 12, and 14:. a convulsion
induced at 10 a.m. each day. Nov. 15: he was now rather
elated, but had no complaints and was walking normally.
Dec. 20: He remained very well and was much more
settled ; he now fully appreciated the reason for his admission.
Dec. 25: he was bright, cheerful, and symptom-free, and was
assisting the gardener; he had been demonstrating his
p hysical capabilities to his fellow-patients by man-handling a
eavy garden roller single-handed.
Jan. 2, 1946 : discharged “‘ recovered.”
Feb. 14: reported in oP ; he had remained well and had
resumed work.
April 9: reported in op; he said he felt very well, was
completely symptom-free, and was finding no difficulties in
connexion with his employment.
Case 5,.—A married housewife (ex-school teacher), aged
43, was admitted on Jan. 16, 1944, with fifteen years’ history
of a constant feeling of faintness ; ; inability to walk more
_ than a few steps without collapsing ; inability to write or
knit, owing to weakness of hands; and inability to sleep.
Personal History.—She had been fairly well until the birth
of her son, fifteen years ago. Since then she had adopted the
rôle of a permanent invalid, had been very jealous and pos-
sessive, and constantly demanded the complete attention of
her husband and son. She said she had no friends.
Family History.—Mother had died of cancer at 65. She was
said to have been a dominating type of woman, who never
PSYCHONEUROSES TREATED WITH ELECTRICAL CONVULSIONS
Two |
[ocr. 12, 1946
allowed the patient to do anything for herself. Father had
‘died of cancer at 62. No siblings.
Mental State-——She was very miserable, self-pitying, and
petulant, and could talk of nothing but her various symptoms.
She constantly demanded attention and, if this was not
forthcoming immediately, wept copiously and called out for
her husband and “‘ baby.” Her conversation was carried on
in an exhausted whisper, but she could raise her voice
considerably when she wanted anything.
Diagnosis.—Hysteria. l
Treatment.—Jan. 17, 1944: 2 convulsions induced at
10 A.M. and 12 noon. Jan. 18: 2 convulsions induced at 12
noon and 4 P.M. Jan. 19: 2 convulsions induced at 10 a.m.
and 3 P.M.; she was still miserable and emotional but was
sleeping well without sedatives. Jan. 20: 2 convulsions
induced at 10 a.m. and 4 P.m.; she was becoming more
confused but was now very hostile. Jan. 21: 2 convulsions
induced at 10 a.m. and 12 noon; she was very confused,
disoriented, and very restless, Jan. 22 and 23: a convulsion
induced at 10 a.m. each day. Jan. 27: a convulsion induced
at 10 a.m.; she was now bright and cheerful and had no
complaints, though she was still confused.
Feb. 2 and 6: a convulsion induced at 10 a.m. earch day.
Feb. 15: she was very much improved, bright, cheerful, and
coéperative, attended the occupational therapy department
daily, and mixed well with other patients; she now said
her husband had always spoiled her, and that it would “ do
her good ” to have another child.
March 23 : improvement maintained ; she wag cheerful and
energetic; she attended all functions and was especially keen to
be present at the dances. March 30: discharged ‘‘ recovered.”
April 18: reported in oP ; she had remained well and was
doing all her own housework for the first time in seventeen
years.
June 7, 1945: reported in op ; she had remained very well,
and her husband said she was a “ changed woman,’
March 22, 1946: social worker visited patient in her home
and reported that she was perfectly well; bright and sociable,
and had made many friends in the neighbourhood.
Case 6.—A single female cashier, aged 25, was admitted on
Jan. 3, 1945, with two years’ history of breathlessness, palpi-
tation of heart, frontal headache, and a constant feeling of
tension.
Personal History.—She had been perfectly fit until three
years ago, when she had had an attack of rheumatic fever.
She had been told that her heart might be affected, and since
then she had been very easily upset. .
Family History.—Mother had died of cancer at 53. Father,
aged 63, had “‘ heart trouble.” She had two brothers. A
sister had died of “heart trouble.”
Mental State —She was very anxious, worried, apprehensive,
dissatisfied with life, and very hypochondriacal. Her father
had remarried two years ago, and she expressed great resent-
ment at this, becoming rather excited and emotional when
discussing it. She was very miserable and said she did not like
being an invalid.
Diagnosis.— Anxiety state.
Treatment,— Jan. 24, 1945: she had been treated on general
lines ; but, though slightly brighter, she was still very unstable
and complained of her cardiac condition. There was no
physical lesion to explain her breathlessness and tachycardia,
which were undoubtedly anxiety manifestations.
Feb. 3: 2 convulsions induced at 10 a.m. and 5 p.m. Feb. 4
and 5: 2 convulsions induced at 10 a.m. and 2 P.M. each
day. Feb. 6-10: a convulsion induced at 10 a.m. each day.
Feb. 14: a convulsion induced at 10 a.m.; she was confused
and rather restless, but was now elated and made no com-
plaints. Feb. 16: a convulsion induced at 10 a.m. Feb. 28 :
she was still slightly confused and amnesic but more settled
and was sleeping well.
March 10: she was bright, cheerful, codperative, and
symptom-free, attended the occupational therapy department
daily, enjoyed walking, and took part in all social] activities.
March 28: discharged “‘ recovered.”
April 19: reported in op; she had remained wel] and
was anxious to start work.
July 5: reported in op ; she said she was very well and had
been working as a cashier for the past two months and had no
difficulty in carrying out her duties.
Nov. 22: visited by social worker, who said that she had
remained well and could take part in all normal social activities.
March 21, 1946: reported in op; she had remained very
well.
THE LANCET]
Case 7 is included to illustrate the necessity of giving
a thorough course of treatment to every patient. In this
case treatment was suspended owing to an unfortunate
accident, and the patient left hospital against advice.
She remained well for three months but subsequently
relapsed. She was recently readmitted and is now
receiving a complete course of treatment.
CASE 7.—A single woman, aged 52, of no occupation,
was admitted on Oct. 7, 1945, with two years’ history of
overwhelming fear that she would do some “‘ terrible thing ”
if she did not wear a particular pair of gloves.
Personal History.—She had always been very healthy and
had led an active life in the country. About two years ago
she had had an inconclusive love affair (her only one), and
this had left her with a strong feeling of guilt. Since then
there had been a gradual development of obsessional ideas
and ritual, which now dominated her completely.
Family History—Father, a country gentleman of high
intellectual attainments, had died of cerebral haemorrhage
10 years ago. Mother an overanxious type, on whom the
patient depended completely and who treated the patient
as a child. Mother and daughter had been living alone for
the past three years and were inseparable. No siblings.
Mental State-—She was very restless, apprehensive in the
extreme, and agitated, and continually ‘asked that her hands
should be tied together in case she should harm anyone. She
said she was terrified Jest she should be left alone for even
a minute.
Diagnosis.—Obsessional state.
Treatment.—Oct. 7, 1945: 3 convulsions induced at 11 A.M.,
12 noon, and 5 P.M. Oct. 8: 2 convulsions induced at 10 a.m.
and 4 P.M.; patient was very restless and confused, and
constantly asked where she was. Oct.9: patient accidentally
fell out of bed and sustained an injury to the left side of the
face; radiography revealed no bony injury; but, as she
complained of severe pain on opening the mouth, electrical
treatment was suspended for the time being. Oct. 12: she
was still slightly confused but bright and cheerful, having
forgotten her obsessional ideas.
Nov. 7: she remained fairly well and said she remembered
her previous obsessions but now laughed at them ; she refused
to remain in hospital for further treatment as she was worried
about her mother. Nov. 12: discharged at her own request,
contrary to medical advice, ‘‘ relieved’; she was cheerful,
had no complaints, and no memory difficulties, and was
relatively stable, but it is unlikely that she will remain so
in view of the curtailed course of treatment.
Feb. 6, 1946 : patient telephoned to report that she remained
well.
March 2: patient telephoned to report that she had been
very worried about her mother’s health during the past
fortnight; she had lost a good deal of sleep and was again
afraid that she might injure someone. March 10: readmitted
to hospital; her mental condition was similar to that on her
first admission.
DISCUSSION
These results seem to indicate that electro-convulsive
therapy, particularly the intensive method, is of the
greatest value in the treatment of selected cases of
psychoneuroses. Though this is a physical method of
treatment, it is of the utmost importance to adopt
sound psychological principles in the rehabilitation
and remoulding of the patient’s personality during the
recovery period. Mere obliteration of psychologically
unacceptable patterns of thought and conduct is not
sufficient, and the resynthesis of the personality requires
much care and judgment.
In the present series the main factor militating against
successful treatment has been an inherent constitutional
defect, which may range from slight immaturity to
definite high-grade mental deficiency. As might be
expected, approaching senility is another factor of
unfavourable prognostic import.
The anxiety states, on the whole, respond well,
especially those of long duration. Cases of conversion
hysteria do very well and, more important still, do not
tend to relapse, if thorough treatment has been carried
out. Striking results are obtained in obsessional states,
which do not respond to other methods of treatment,
DR. MILLIGAN : PSYCHONEUROSES TREATED WITH ELECTRICAL CONVULSIONS [oct. 12, 1946 519
except prefrontal leucotomy. It is admitted that, except
in four cases, the follow-up has not been long enough
to permit of dogmatic statements regarding the benefits
of electro-convulsive therapy over the latter procedure,
but the advantages are, nevertheless, apparent. There
is practically no danger attached to the use of electro-
convulsive therapy, and in our opinion no patient should
be subjected to prefrontal leucotomy before a complete
intensive course of electrically induced convulsions has
failed to produce the desired effect.
In the light of experience it has been the custom of
this hospital, during the past year, to use electro-con-
vulsive therapy on inpatients only. It was found that
_ outpatients returning to their home environment after
each treatment did not respond satisfactorily. In using
the intensive method it is essential to have the patient
in hospital, and in view of the gross confusion, restless-
ness, and, especially in hysterics, the occasional outbursts
of impulsive behaviour, this treatment should only be
carried out in a mental hospital, where there are adequate
facilities for dealing with disordered behaviour. The
mental hospital has the added advantage that it usually
possesses extensive grounds, and this is of great impor-
tance to the convalescent patient.
The use of electro-convulsive therapy greatly shortens
the duration of psychoneurotic illness; and, especially
in chronic cases, it seems to be of much more value to
admit the patient to hospital for a month or six weeks
rather than to compel attendance at an outpatient
department for many months or even years. Many
psychoneurotics are notoriously lacking in patience
with regard to their treatment and become very bored
with hospital life. The use of electro-convulsive therapy
prevents this completely and tides the patient over the
initial period of readjustment to hospital routine. It is
just this adaptation that the psychoneurotic often finds
impossible because of his general maladjustment to
environment. It is not, however, suggested that this
treatment should be used merely as a short cut—on the
contrary, great care should be exercised in the selection
of cases. In this hospital only a relatively small propor-
tion of psychoneurotics have been treated by this
method. In most of these cases the symptoms were of
long duration and the more recent cases had proved
resistant to psychotherapeutic measures.
None of these cases has exhibited the prolonged
memory defects noted by Brody (1944), and in this
connexion it seems that his statement about the contra-
indications to the use of this form of therapy is, to say
the least, dogmatic. This series included several school
teachers, a chartered accountant, the department
manager of a large business, a bus conductor, and a
cashier. It would have been grossly unfair to debar these
patients from treatment on the grounds of occupation
alone. A patient (not included in this series), who was
treated by . intensive electro-convulsive therapy, is
employed in a Government department as a linguist and
reports that she has no memory difficulties but continues
to express herself freely in five languages.
SUMMARY
The results of electro-convulsive therapy in 100 cases
of psychoneuroses are summarised.
An intensive method was used in many cases, up to
four convulsions being induced daily. This procedure is
especially suitable for chronic cases.
All cases responded well, but the most striking results
were noted in those of long duration.
Electro-convulsive therapy should not be used indis-
criminately ; the greatest care should be taken in
selecting cases.
The course of treatment for each patient should be
based on the. original clinical findings and modifed
according to the response produced.
520 THE LANCET]
I wish to thank Dr. Thomas Beaton, physician-superinten-
dent of this hospital, for helpful criticism and for permission
to use the case. material: and Dr. Elizabeth Barker, senior
assistant physician of the hospital, for help in connexion with
the female case-records.
REFERENCES
Brain, W. R., Strauss, E. B. (1945) Recent Advances in Neurology
and 1 Neuropsychiatry, Dondon, - 125.
Brody, M. (1944) J. ment. Sci. 90, 777.
Cheney, CG. O., Hamilton, D. M., Heaver, W. L. ATARE Neurol.
Psychiat. 46, 935.
Cook, L. (1944) J. ment. Sci. 90, 435.
Feldman, F., Susselman, S., Lipetz, B., Barrera, S. E. (1945) J. nerv.
peni Dis 102, 498.
Furst, W Stouffer, T ee Arch. Neurol. ‘Psychiat. 46, 743.
Good, R. (1940) J. ment. Sci. 86; 491.
Kerman, I 945) J nerv. ment. Dis. 102, 233.
Low, A » Sonenthal, I. R.,
man, f Whitcomb, F. C. (1938) Arch. Neurol. aire 9, 717.
Pacella, B. L., Barrera, S. E. (1943) Amer. J. Psychiat. 9 a Si.
Shapiro, H. D., Freeman, W. (1939) Med. Ann. Dist. Columbia,
Smith’, a 28 Hastings, D. W., Hughes, J. (1943) Amer. J. Psychtat.
Stockings, G (1944) J. ment. Sci. 90, 551.
baer F. M. R. (1945) Diseases of the N eryous System, Edinburgh,
. 341.
Zeitort, M. (1941) Psychiat. Quart. 15, 172.
EFFECT OF TEMPERATURE ON
SEDIMENTATION-RATE
K. B. ROGERS
M. B. Lond.
LATELY PATHOLOGIST, SHOTLEY BRIDGE EMERGENCY
HOSPITAL, CO. DURHAM
Tue effect of temperature on the erythrocyte-sedimenta-
tion rate has been noted by workers using all the different
techniques that are known. ‘Westergren (1921) suggested
a correction for it, especially if cases were to be followed
up, but he stated that the difference ‘in temperature in
the average laboratory was not great. Nichols (1942)
states that any technique is valueless if the results are not
comparable on repetition, and he notes thé importance
of a constant temperature if the results are to be repro-
ducible. It was through trying to obtain reproducible
results that the following work was performed; there
is a regional chest centre based on this hospital, and some
cases have to be tested many times.: -
The standard E.M.S. issue is the Westergren ADATOT:
With the stand supplied, if one of the six tubes was fixed
vertically with its lower end ‘in the centre of the rubber
pad at the base, it was found that, if the other five tubes
were also to be vertical, their lower ends were scattered
round the periphery of their respective pads, and none
of them would occupy the same relative position ; this
ANALYSIS OF 736 CASBS USED IN TESTING SEDIMENTATION-
RATE
Che at : No. of Medical No.o _ Surgical No.of
investigation cases} ' wards ‘}easesf wards cases
Carcinoma of . Psycho- Carcinomata 23
cesophagus neurosis —
, ee) ee a. % Osteomyelitis 7
Carcinoma 27.0. Peptic. f
of bronchus | ulceration Postoperative | 21
sepsis
Mediastinal 7 Diarrhea .
, Hodgkin’s
disease. Infective
i af ee aS hepatitis
Cardiovascular | 12
lesions , Malaria
Lung abscess 17 Urinary —
infections
Empyema | 50 aa i
- ; - Blood .
Bronchiectasis | 55 _ diseases
Rheumatism
- Bronchitis’: | 72 :
' and chorea.
Pulmonary | 142
tuberculosis Arthritis and
spondylitis
Pick’s diseasé td
Total .. 51
' DR. ROGERS: EFFECT OF TEMPERATURE ON SEDIMENTATION-RATE
Blaurock, M. F., Kaplan, M., Sher-
foct. 12, 1946
Wasted a great deal ~
of time when the
tubes were set up.
Also, it became
obvious that the
Westergren tech-
nique would not 20
allow for the
changes in corpuscu-
lar volume, such as
resulted if a patient
had had much
blood-loss or a
transfusion before 0 20 30 40
operation. Fall in Perkins stand (mm. per hr.)
A change was
therefore made to
the Wintrobe tech-
nique, using the Perkins stand and the correction graph
of Hynes and Whitby (1938). The results were still not
reproducible, and the variant factor was temperature.
The laboratory is a single-storied building placed on an
exposed hillside, and the temperature could vary 7° C
in a day, and more than 15° C between winter and
summer. Mere statement that the test was performed
in a certain season gives no indication of the average
temperature: four
inches of snow ap- 2
peared in a recent
May.
Fall in hanging tubes (mm. per hr.)
Fig. l—Comparison of readings at 20° C
n the Perkins stand and in hanging
tubes, showing very little difference.
Gs
oO
TECHNIQUE
To perform the
following experi-
ments an apparatus
had to be devised
that would allow
the sedimentation
tubes to be kept
at controlled tem-
peratures. A holder i0 20 300
was designed to slip Fall in narrow tubes (mm. per hr.)
over the top of the Fig. 2—Ccomparison of readings at 20° Cin
tube and allow it tubes 3:5 mm. in diameter (Rourke and
: Ernstene 1930) and in tubes 2:5~2:8 mm.
to hang as its own in diameter (Wintrobe), showing very
plumb-line (Rogers
little difference.
1946). The tubes
were suspended in water contained in a glass 7-lb. sweet-
jar by passing them through a perforated cardboard
lid; one set of tubes was kept at a standard tempera-
ture of 20° C and the other at the test temperature. (A
tube stops swinging within a few seconds waen suspended
in water.)
The temperature was maintained to within 1°C; thus,
if there was to be a mean temperature of 10° C, the water
was placed at 9-5° C; when it was warmed to 10-5° C,
the lid was lifted off the jar, and the tubes were trans-
ferred to another sweet-jar with water at 9-5° C. This
would necessitate about two changes of water when there
was 10° C difference between the external room and the
test temperature.
The material used consisted of blood from routine
examinations, mostly from chest cases. The bloods were all
drawn by me, using no. 20 hypodermic needles, oil-sterilised
syringes, and no tourniquet ; 2 c.cm. of blood was placed
in a tube containing the correct amount of Heller and
Paul’s mixture or heparin. Up to six different bloods
were put up for the test, 1/,—2 hours after collection ;
the bloods were thoroughly mixed, and a set of tubes was
filled at 1/,-min. intervals and placed at 20° C; the same
bloods were remixed and then placed into duplicate
tubes at the test temperature.
There was, therefore, in each point plotteä a strict
comparison between the same blood, in the same anti-
Fall in wide tubes (mm. per hr.)
o
|
LANCET]
40
w
oa
30
20 20
Falilat 10° C (mm. per hr.)
Fall at 15° C (mm. per hr.)
Fall at 20° C (mm. per hr.)
Fig. }—Comparison of readings at
-~ 20°C and 10° C.
coagulant put up in a similar tube but at a-different
temperature. The fall was recorded an hour after each
blood was put up; comparisons were made between the
corrected rates, after the bloods had been centrifuged
and corrected by Hyne and Whitby’s graph.
Weingarten (1945), using Westergren’s technique, has
shown that the accelerating effect of high temperature is
not constant ; that, when ‘liver damage is well marked,
a sedimentation-
rate test per-
formed at 3-5° C
will give a higher
reading than
will a duplicate
test at 38° C.
An analysis of
the cases used
in this investi-
gation is given
in the accom-
panying. table.
None of the
cases would be
likely to fit into
Weingarten’s
group Im; they
would all seem
to be in his
group I, which
is probably the same for most cases in.any English
hospital.
Fall at 25° C (mm. per hr.)
10
20
Fall at 20° C (mm. per hr.)
Fig. 5—Comparison of readings at
20° C and 25° C.
30 40
RESULTS
Figs. 1-7 show the patterns obtained ; they record
the results of just over 100 experiments at each tempera-
ture. No graphs have been drawn, as |
it is not desirable that corrections
should be attempted ; but it would
be more useful if a standard tem-
perature was always used. Figs. 3-7
show the effect of varying the tem-
peratures at which the tests are done.
The differences are most marked in
the middle range; for example, a
“ sight’ could become a ‘* moder-
ate ” increase in rate, if the tempera-
ture were 5° C higher (20°-25° ©).
The 10° C chart shows that this
temperature provides results that are
too scattered, at all increases in rate,
to be trustworthy. :
TIME TAKEN FOR BLOOD TO REACH TEM-
PERATURE OF SURROUNDING WATER
A micro-ammeter was connected
to a thermocouple kept in an ice-
water mixture at 0° C; another
$0
30
20
Fall at 30° C (mm. per hr.)
10
Fall at 20° C (mm. per hr.)
DR. ROGERS: EFFECT OF TEMPERATURE ON SEDIMENTATION-RATE
Fall at 20° C (mm. per hr.)
Fig. 4—Comparison of readings_at
20° C and 15° C.
20
Fig. 6—Comparison of readings at
20° C and 30° C,
loct. 12, 1946 521
thermocouple, in series, was first placed
in water at 22° C, then at 32° C, and
readings were taken on the ammeter
for the purpose of calibration. A Win-
trobe tube, with a thermocouple placed
down the centre, was filled with blood
and suspended in water at 32° C; it
. was then transferred to water at 22° C,
and the time that the ammeter took to
equilibrate to the 22° C reading was
noted. The experiment was repeated
with the tube transferred back to the
water at 32° C. The thin type (Baird
and Tatlock) Wintrobe tube took an
average of 52'/, sec. and the thicker
(Hawksley) glass Wintrobe tube took
67!/, sec.. to attain an equilibrium. (It
was realised that the type of curve was
really asymptotic, but the results are sufficiently accurate
for this type of work.) Each result is the average of four
experiments.
CONCLUSION
It seems that the experiment of Wintrobe and Lands-
berg (1935), from which they concluded that there was
no significant effect of temperature betwen 22° C and
27° C, gave a wrong impression, and that a rise from
22° C to 27° C has very appreciable effects. In their
paper giving a correction graph for varying corpuscular
volumes Hynes and Whitby (1938) do not mention
the temperature, but Whitby and Britton tell me that
this work was carried out in winter, without temperature
being recorded or controlled. From the above results
it appears that their average temperature was probably
about 18° C ; this is at variance with Whitby and Britton
(1944) who suggest performing the tests at temperatures
between 22° C and 27°C; this range is both too high
and too wide.
The ranges of temperature experienced in this labora-
tory are probably very similar to those in sanatoria, and
it is desirable that the temperature at which the tests are
carried out may be controlled in the future. Often a
test is set up in the ward, which is well ventilated ; hence
in winter the temperature will be very near 10° C, a
temperature at which results are untrustworthy. This
will explain the results quoted by Edwards. and Cuttrill
(1942) who urge the use of a standard temperature.
SUMMARY |
A method has been devised of keeping sedimentation
tubes at a controlled temperature by suspending them
in a container of water. The use of only one constant
temperature is desirable. ue
Fall at 35° C (mm. per hr.)
30 40
20
Fall at 20° C (mm. per hr.)
Fig. 7—Comparison of readings at
20° C and 35° C. -
10 30 40
522 THE LANCET]
DR. HILL AND OTHERS: TREATMENT OF YAWS WITH PENICILLIN
[oor. 12, 1946
In the cases investigated (in England) variation in
temperature affected the sedimentation-rate, increased
rates being recorded with rises in temperature. Tem-
peratures below 15° C should never be used.
I wish to thank Mr. E. W. Switzer, of Shotley Bridge, who
produced the original holders; Messrs. Willen Bros. Ltd.,
for making the holders; Sir Lionel Whitby and Dr. C. J. C.
Britton for help and advice; my colleagues in this hospital
for their coöperation ; and Mr. L. B. Holt, who supplied the
apparatus and advised in the experiments using the micro-
ammeter.
REFERENCES
Edwards, P. W., Cuttrill, L. J. (1942) Brit. med. J. ii, 379.
Hynes, M., Whitby, L. E. H. (1938) Lancet, ii, 249.
- Nichols, R. E. (1942) J. Lab. clin. Med. 27, 1317, 1410, 1569 ; 28, 75.
Rogers, K. B. (1946) Lancet, i, 502.
Rourke, M. D., Ernstene, A. C. (1930) J. clin. Invest. 8, 545.
Weingarten, R. J. (1945)
Westergren, A. (1921) Brit. J. Tuberc. 14, 94. ž
Whitby, L. E. H., Britton, C. J. C. (1944) Disorders of the Blood,
. ondon.
ea M., Landsberg, J. W. (1935) Amer. J. med. Sci.
> e
Ld kd J
TREATMENT OF YAWS WITH PENICILLIN
K. R. HEL G. M. FINDLAY
M.B. Lond. C.B.E., M.D., D.Sc. Edin.
LATE O.C. MEDICAL RESEARCH LATE CONSULTING PHYSICIAN 9
UNIT, WEST AFRICAN WEST AFRICAN COMMAND
COMMAND
A. MACPHERSON
M.B. Edin.
MEDICAL OFFICER, WEST AFRICAN MEDICAL STAFF
THE original observations of Mahoney et al. (1943)
on the curative action of penicillin in syphilis have
now received ample confirmation. Comparatively few
investigations, however, have been made on the action
of penicillin in yaws.
In a preliminary communication from West Africa,
Findlay et al. (1944) recorded results obtained with
penicillin in 24 cases of primary and secondary yaws.
‘Whitehill and Austrian (1944) reported the successful
treatment of 17 cases in Fiji, da Cunha et al. (1944a.and b)
12 cases in Brazil, and Logfren (1944) 1 case in a Euro-
pean. These observations showed that Spirocheta
pertenue is highly susceptible to penicillin ; the period of
observation, however, was in all cases short.
In the present communication, in addition to the 24
cases originally described (Findlay et al. 1944), of which
20 were followed for considerable periods, 104 further
cases are discussed. The patients were all African
children or mothers belonging to various tribes.
TECHNIQUE OF ADMINISTRATION
Both sodium and calcium salts were used intra-
muscularly. With 20,000 units dissolved in saline and
injected every three hours for twelve to twenty-four
hours, the primary and secondary lesions rapidly dis-
appeared, Continued observation showed, however,
that after two to three months some cases relapsed, as
had been noted in syphilitics by Mahoney et al. (1944).
A total dosage of 1,000,000-1,500,000 units thus seemed
indicated, but a course of three-hourly injections for
six or seven days was impossible with African children.
On the appearance of the paper by Romansky and
Rittman (1944), suggesting the suspension of penicillin
in ground-nut (pea-nut) oil with beeswax, this technique
was adopted : 5c.cm. of sterilised 2% beeswax in ground-
nut oil is added to the solid penicillin in the phial, and the
mixture is shaken with glass beads for an hour. Despite
great care the resulting suspension, at any rate in the
tropics, was lumpy. It had to be injected through a
wide-bore needle, and the injection caused extreme pain.
A second method was therefore tried. The dried peni-
cillin was first dissolved in 1 c.cm. of sterile physiological
saline; then 4 c.cm. of sterile beeswax in ground-nut
oil was added. On shaking immediately before admini-
stration a fine emulsion was produced. One daily injec-
tion of 100,000 units was given intramuscularly. This
was well tolerated and caused little pain.
CONCENTRATION OF PENICILLIN IN BLOOD AND URINE
Tests on the concentration of penicillin in blood and
urine, when penicillin was given by the above two
methods, were made both by the slide-cell technique
and by the capillary-tube method described by Fleming
(1944). j l
The administration of 100,000 units every twelve hours
in beeswax and oil suspension gave a persistent blood
concentration of 0-1-0-15 unit, and urine concentrations
of 60 units per c.cm. throughout the twenty-four hours.
When the same dose was given in an emulsion of saline
with oil and beeswax, the blood and urine concentra-
tions were of the same order and only more sustained by
two or three hours than those obtained when penicillin
was given in saline alone (cf. Fleming et al. 1944).
TIME OF DISAPPEARANCE OF SPIROCHETES
In 6 cases of secondary yaws in children, serum from
lesions was examined for spirochetes by dark-field
illumination. Results are shown in table1. Spirochætes
were no longer visible in the lesions nine to twenty-
four hours after the start of treatment. Logfren
(1944), in his case of yaws in an adult European, found
that the spirochztes had disappeared eighteen hours
after treatment; Whitehill and Austrian (1944) found
them absent after sixteen hours in 16 cases, and forty
hours in 1 case. ` f
RESULTS OF TREATMENT |
There appeared to be little difference between the
clinical results obtained with sodium penicillin and with |
calcium penicillin ; nor, despite the low blood and urine
concentrations obtained with the saline and ground-
nut oil ‘suspension, did the results appear inferior to
those obtained with penicillin in saline alone or in
oil suspensions.
The only serious reaction was an abscess in the buttock
of one small boy; the pus contained penicillin but
TABLE I—-DISAPPEARANCE OF SPIROCHZTES .
Time of dis- Dose of penicillin* | Total penicillin®
Case | appearance after | (units) up to time | (units) used to com-
treatment (hr.) of disappearance plete treatment
18 9 75,000 100,000
19 9 50,000 50,000
21 9 75,000 120,000
58 24 200,000 1,200,000
75 9 100,000 1,300,000
110 24 200,000 1,200,000
* In saline
yielded a pure growth of Ps. pyocyanea. No Herxheimer
reactions were observed, though in syphilitics treated
with penicillin Mahoney et al. (1944) and Moore et al.
(1944) encountered them in 86% and 59% respectively.
It must be remembered, however, that African children
so constantly have attacks of malaria that they make
little of a temperature which would at once send a
European to bed. |
Primary Cases.——We treated 15 cases of primary
yaws; dosage varied from 100,000 to 1,500,000 units.
There were 2 failures, though 1 of these cases showed
slight improvement in four months. The average time
for a clinical cure—that is, the disappearance of the
mother yaw—was nine days. Within twenty-four hours
there was drying up of the yaw and flattening of the
verrucous base, or, in cases where a scab had already
formed, pronounced desiccation; within forty-eight
hours commencing epithelisation was apparent or
desquamation of the scab; in three to six days healing
i
THE LANCET]
of the lesion was well advanced; by about the ninth
day the site of the lesion was denoted by a grey-brown
or pink scar, or, in the case of a thick keratinised surface
like the sole of the foot, by complete restitution of
normal tissue.
Of these 15 cases, 6 were followed up: 4 showed
sustained cures, 1 at four months, 1 at five months, and
2 at seven months; 1 case had relapsed at three months
but again responded to further treatment and had no
relapse five months later ; and 1 case, which had appeared
to be an immediate clinical failure, was found to be
cured when seen eight months later.
In 5 cases the Kahn reaction was reversed ; in 2 after
one or two weeks, in 1 within four months, and in 2
within seven months of treatment. The first 2 cases had
only two or three weeks’ history of yaws; the dosage of
penicillin was 100,000 units. The other 3 cases were of
six weeks’ to three months’ standing; and, though the
Kahn reaction was not reversed three months after
treatment, it later became reversed. In 1 case, which
had four days’ history of yaws and a negative Kahn,
there was an immediate clinical cure, which was sustained
TABLE II —FOLLOW-UP RESULTS IN SECONDARY YAWS
Period of No. of relapses
observation No. surveyed | Pe aA during this
e 3 63 | 61 2
4 — 6 45 44 1
7 -12 : 21 | 21
after a month’s follow-up, the Kahn reaction being still
negative.
A typical primary case treated with penicillin was as
follows.
CasE 1.—A girl, aged 2 years, had two weeks’ history of
a large primary yaw on the left heel, consisting of an ulcer
1 cm. in diameter, with a fungoid granulomatous base. Kahn
and Ide tests both negative. Penicillin sodium, 100,000 units,
in beeswax and oil, injected into buttock.
Within twenty-four hours there was drying up of the ulcer
and flattening of the verrucous base; at forty-eight hours
epithelisation was apparent ; and at seventy-two hours healing —
At. six days the lesion was
A month later cure was
Kahn and Ide both
of the ulcer was well in progress.
healed, leaving pink scar tissue.
found to be sustained. No relapse.
negative. No further follow-up.
Secondary Cases.—We treated 96 secondary cases ;
81 completed the course, and 78 of these showed imme-
diate clinical cure. The result in 15 cases was uncertain,
because immediately after the course of treatment the
patients ceased to attend and left the district.
The average time for clinical cure was eight and a
half days. The papules desquamated, and the typical
yaw scabs dried up and lost their yellow colour within
twenty-four hours. Between two and ten days the
scabs underwent further desiccation and flaked off,
leaving white, pink, or greyish-brown scar tissue at the
site of the original lesion.
Table 1 gives the results of a clinical follow-up over a
period up to a year of cases which were originally
“ immediate clinical cures” : 63 cases were followed
up to three months, 45 up to six months, and 21 up to
twelve months.
On relapse, yaws lesions in new situations were
commonly encountered, but also there was often a
breaking down at an old site to form a shallow ulcer,
which sometimes had a very mixed flora, including
on occasions spirochetes and fusiform bacilli; such
lesions may therefore have been ordinary tropical ulcers.
Table mı gives the results of a serological follow-up over
a period up to one year. This survey shows 7 cases
with reversal of Kahn out of 40 cases examined, up to a
year from the date of treatment.
DR. HILL AND OTHERS: TREATMENT OF YAWS WITH PENICILLIN
[ocT. 12, 1946 523
TABLE III—SEROLOGICAL FOLLOW-UP RESULTS IN
SECONDARY YAWS
Period of No. of cases No. of cases No. of cases
observation ‘amined with reversal | with positive
(months) a aca of Kahn Kahn
1*/-- 3 1 39 ,
4 -6 4 27
7 -9 23 ` 17
10 -12 i 8
è Includes one case that had a reversed Kahn reaction at 4 months
but a serological relapse at 5 months, though Still main-
taining clinical cure.
A typical secondary case was as follows.
CasE 2.—A boy, aged 2'/, years, had eight months’ history
‘of a primary lesion on the inner border of the right thigh
and six months’ history of multiple secondary lesions. The
main sites were chin and neck, abdomen, pubis, perineum,
and occiput. Nasal discharge and seborrhoea present. Ide
test positive. Spirochztes demonstrated in the yaws in large
numbers. Sodium penicillin 100,000 units was given over
twelve hours intramuscularly.
Spirochetes disappeared from the yaws within nine hours.
Within twenty-four hours the primary lesions had dried up
and presented a pink glazed appearance; snuffles ceased.
Within forty-eight hours all yaws showed thinning and shrink-
ing of their crusts, and darkening and complete disappearance
of the typical yellow colour, the whole giving an appearance
of desiccation. Some lesions had already shown separation
at the periphery. By six days all yaws had disappeared,
leaving either a pale fairly sound skin at the site of the lesion
or a grey-brown leathery surface. By ten days there was no
evidence of active yaws, and the only stigmata left were the
areas of scarring denoting the site of the original lesions.
Ide test positive after twenty-one days. Eleven months
after the start of treatment the cure had been sustained
and there had been no relapse, the Ide test still being positive.
Tertiary Cases.—We treated 17 cases with bone lesions
due to yaws: 11 gave immediate clinical remission
of symptoms, and almost complete disappearance of
osseous signs within sixteen and a half days; 4 showed
improvement ; and 2 did not respond to treatment at all.
We followed up 6 cases: 2 patients observed at four
months, 1 at eight and a half months, and 2 at ten months ~
were in good health. In 1 case there were clinical relapses
at six weeks, and at four, seven, and eleven months, but
nevertheless the Kahn reaction was negative at the last
date.
There were also 2 cases of goundou, which is commonly
regarded as a tertiary manifestation of yaws. Neither
TABLE IV-—RESULTS OF TREATMENT WITH ARSENICALS ALONE
OR PRECEDED BY ONE INJECTION OF PENICILLIN
Acetylarsol | Penicillin and | Neoarsphena- Penicillin and
alone acetylarsol mine alone — neoarsphenamine
ro © uo] K a © cy} ©
blacan Elak ef 2 | ab|)e2| 8 | ables
mele) MRSS mR AS | 3
Secondary
aj.js[siia]f. [sts fa] ee]. |
Tertiary
Si Salen A fae ee ee ae ae
of them was cured, but I had relief from pain and
considerable decrease of swelling.
Of 2 cases of foot yaws treated, 1 was clinically cured,
and 1 showed considerable improvement immediately
after treatment, and on examination seven months later
was completely healed without any further treatment.
A typical tertiary case was as follows.
CasE 3.—A boy, aged 10 years, had had primary yaws
two and a half years ago, and had a week’s history of pain and
524 THE LANCET]
swelling above the left wrist. Kahn and Ide tests positive.
He had had tropical ulcers for many years.
April 14, 1945: radiography showed a yaws periostitis
at lower end of right radius, with slight medullary rarefaction.
Sodium penicillin in beeswax and oil in daily dosage of
100,000 units was given intramuscularly for fifteen days.
The arm was splinted. Within two days the pain subsided.
April 24: clinically much improved, with very little swell-
ing ; radiographic appearances showed no extension of lesion,
and an area of increased translucency, with cortical erosion
and periostitis, in the shaft of the radius 1 in. above the
epiphyseal line.
May 5: pain and swelling had disappeared ; clinical cure ;
radiography showed some regeneration of cancellous bone,
and less translucency.
June 12: radiography showed a slightly decalcified oval
area about 1 in. long in the lower radial shaft, with an
associated thin layer of smoothly ossifying periostitis.
August 1: cure clinically sustained; Kahn and Ide tests,
both positive; radiography showed slight sclerosis and
restoration of normal structure in the formerly translucent
areas, and periosteum ossified and almost united to cortex.
Thus there was clinical cure after about a week, but
radiologically the lesion progressed at one to two weeks,
and then steadily retrogressed until, three and a half
months afterwards, there was little evidence of former
disease.
COMPARISON OF PENICILLIN AND ARSENICALS
To compare penicillin and arsenicals in the treatment of
yaws, each of the following treatments was given in a few
cases: (1) acetylarsol 1-25 g. daily for fourteen days ;
(2) one injection ‘of penicillin 100,000 units in oil followed
by acetylarsol 1-25 g. daily for fourteen days; (3) three
weekly injections of neoarsphenamine 0-6 g.; (4) one
injection of penicillin 100,000 units in oil followed by
three weekly injections of neoarsphenamine 0°6 g. The
results are given in table Iv.
The period of observation has been a month; no
reversal of Kahn has taken place. Though the series
is obviously too small to allow any definite conclusion,
a single injection of penicillin followed by acetylarsol
seems to be preferable to acetylarsol alone, but with
neoarsphenamine the synergic action of penicillin is
not in evidence. Of the 62 tertiary cases treated, 11 had
yaws ulcers. The result of treatment of the cases with
ulcers was as follows :
Im- No
Treatment Cured proved change
Acetylarsol .. i PM eg sak * 2 I
Penicillin and acetylarsol eit I i
Neoarsphenamine .. sä ca) oD sr ;
Penicillin and neoarsphenamine 1 ‘
DISCUSSION
: In most cases the penicillin dosage consisted of 100,000
units in oil injected intramuscularly once or twice daily,
the object being to obtain a continued low concentration
of penicillin in the blood, as distinct from the initial
peak followed by rapid elimination of penicillin, which is
produced by an intramuscular injection of the drug
dissolved in saline (Fleming et al. 1944).
McDermott et al. (1945) suggest that, in the treatment
of syphilis by repeated doses of penicillin, a minimal
effective level need not be maintained absolutely con-
tinuously. Intermittent treatment, aimed at obtaining
a minimal effective concentration in the blood at intervals
corresponding to the growth phases of the spirochete,
would be as efficient. This may well apply to yaws. |
Disappearance of the organisms from the yaws lesion
does not appear to be influenced by the amount, above a
minimal concentration, of the single or the total dosage
of penicillin, a fact also noted in syphilis by Moore et al.
1944).
ou results showed that in 12 of 14 cases with primary
lesions, and in 78 of 81 cases with secondary lesions,
healing took place in an average period of nine and eight
-and a half days respectively. Out of 17 cases with
DR. HILL AND OTHERS: TREATMENT OF YAWS WITH PENICILLIN
'
[ocr. 12, 1946.
bony lesions (tertiary), 11 showed complete disappearance
of signs and symptoms, and 4 were improved at an early
date. Of 2 cases of goundou, 1 showed a slight response
and 1 no response at all. The results with penicillin com-
pare favourably with those of other forms of treatment,
an important feature being the absence of toxic reactions.
In both syphilis and yaws it is well recognised that,
though it is possible to clear up the lesions of the primary
and secondary stages with comparative ease, protracted
observation is essential if the final results of treatment
are to be evaluated. This applies as much, if not more,
to yaws. Many African soldiers, for instance, are seen
with active tertiary yaws of recent onset who say that
years ago they had a series of injections of a yellow fluid
into the vein of the arm. It is therefore fully realised
that the period of observation ôf our own cases—and this
applies also to all other investigations so far reported on
penicillin in yaws—is far too short to allow of final
judgment being passed.
In the present series, out of 5 primary cases originally
cured and observed during a period of four to seven —
months, 1 relapsed ; out of 45 secondary cases originally
cured 3 relapsed during a period of one to twelve months ;
and during a similar period 1 tertiary case relapsed out of ¢.
In yaws there appears to be considerable uncertainty
as to how far serological reactions are a significant
guide to ultimate cure. In the present series treated with
penicillin, the following results were obtained in sustained
cures of primary, secondary, and tertiary yaws : |
Period of No. of Kahn . Kahn
observation cases positive negative
(months)
11/2 3 a 43 aN 42 E 1
4 '-—- 6 ta 38 z4 33 gs 5
T -9 a 38 ae 25 ats 13
10 -12 a 12 bsg 11 e 1
The number of serological reversals was thus small, and
it seems that a serologically positive reaction does not
necessarily mean lack of therapeutic response. If this
is so, serological controls should at the most act as a guide
to treatment rather than as a test of permanent cure.
During a short period of observation Whitehill and
Austrian (1944) were unable to determine any effect of
penicillin treatment on the serum Kahn reaction in
yaws, even though the dosage they used was about
1,000,000 units. On the other hand, da Cunha et al.
(1944a and b), though they used only 9600—54,000 units,
claim to have obtained complete reversal of the Wasser-
mann reaction in 8 out of 11 cases, and in a further
case the Wassermann reaction was negative at the
beginning of treatment and remained negative. No
explanation is forthcoming for the different results
in the serological reactions obtained in West Africa
and Fiji on the one hand, and in Brazil on the other.
A striking result of penicillin treatment has been
the change in the granulomatous bone lesions of tertiary
yaws. According to Goldmann and Smith (1943), without
treatment the osseous lesions of yaws invariably become
worse, either with thinning of the cortex and subsequent
deformity, or with bone thickening, so that the medulla
is encroached on and the line of demarcation between
medulla and cortex is lost. This picture may remain
unchanged for years or may slowly progress to give the
appearance of ‘‘ marble bone.”
As shown radiologically, there is after treatment a
very rapid rarefaction of bone, a process which suggests
a deterioration, were it not that the clinical signs indicate
improvement. This initial rarefaction, which is similar
to that observed in penicillin-treated cases of coccal
infection of bone, is followed by a rapid formation of
normal new bone. Stokes et al. (1944) found that
bony lesions in syphilis treated with penicillin healed in
from one to six and a half weeks, but they make no
mention of radiological control of the healing process.
Helfet (1944), in yaws treated with either neoarsphena-
THE LANCET]
mine or bismuth and ‘ Sulphostab,’ found relief from
pain in the bones in one or two weeks, with some early
healing of the osseous lesions in six weeks. Our experi-
ence of the osseous lesions of tertiary yaws treated with
‘Sobita’ or with neoarsphenamine indicates a much
slower period of healing than with penicillin.
At this stage it would be foolish to compare the per-
manent results of penicillin treatment of yaws with those
obtained with such drugs as neoarsphenamine, acetyl-
arsol, and sobita, ‘but penicillin clearly has some advan-
tages over bismuth and the arsenicals. The rapidity with
which the lesions begin to heal is remarkable and has
an excellent psychological effect on African patients.
The single daily intramuscular injection allows the
therapeutic course to be completed in a much shorter
time than with either sobita or the arsenicals, an advan-
‘tage both to those who are giving numerous injections
and to the patients, whose attendance is more likely to be
regular. Penicillin is far less liable to: cause toxic
reactions than either arsenical or bismuth preparations.
As mentioned previously, Findlay et al. (1944) in one
instance found that the lesions of both yaws and of
bismuth stomatitis, associated with spirochetes and
fusiform bacilli, were rapidly removed by penicillin.
Preliminary observations suggest that acetylarsol and
penicillin in combination may act synergically on the
spirochetes of yaws, and that penicillin for the acute
stage, followed by protracted arsenical therapy, is possibly
the ideal treatment if complete and lasting cure is to be
attained. Whether, in an area where the possibility
of reinfection is by no means remote, it is desirable to
effect a radical cure is a problem which requires much
fuller investigation.
In the two small villages from which the bulk of our
patients were derived there has not appeared any case
of primary or secondary yaws in the last five months,
suggesting that, if all early cases could be promptly
treated and rendered non-infectious, the incidence of
yaws in particular areas might be greatly reduced.
SUMMARY
In 128 cases of yaws (15 primary, 96 secondary, and
17 tertiary) treated with penicillin the method of choice
‘was a daily injection of 100,000 Oxford units in ground-
nut oil and beeswax, up to a total dosage of at least
1,000,000 units.
Spirochzetes disappeared from the lesions in 9-24 hours
after doses of 50,000—-200,000 units.
There was remarkably rapid healing of the acute
lesion in primary and secondary yaws, the average times
being 9 and 81/, days respectively.
With bony lesions of tertiary yaws considerable success
was achieved both clinically and radiologically in a few
weeks.
No correspondence could be found in the follow-up
investigations between sustained clinical cure and
reversal of Kahn reaction.
In 20 cases penicillin was given with either acetylarsol
or neoarsphenamine. The results suggest that penicillin
in the acute stage, followed by a more prolonged arsenical
treatment, is the ideal therapy for ultimate and permanent
cure, but further controlled observations are required.
Our thanks are due to Brigadier H. B. F. Dixon, D.D.M.S.,
West Africa Command, and the Director of Medical Services
(Colonial Medical Service), Gold Coast, for permission to
publish these observations ; and to Dr. O. Ampofo and Mr. A.
Kpeglo. Private Amoah, wW.A.A.M.C., gave us much assistance.
REFERENCES
da Conia . M., Aréa Leão, A. E., Néry Suen: F.,
T. (94a) Mem. inst. Oswaldo Cruz, 40, 195.
(1944b) Ibid, 41, 247.
Findlay, G. “M. “Hill, K. R. a Macpherson, A. (1944) Nature, Lond.
Fleming, A. (1944) Lancet, ii,
Young, M. Y., Suchet, Ti a bite. Kk. J. E. (1944) Ibid, p. 621.
Continued at foot of next column
Cardoso,
MAJOR BLAINE: THE USES OF PLASTICS IN SURGERY
its way to the surface (Blaine 1945b).
[oor. 12, 1946 525
THE USES OF PLASTICS IN SURGERY
GEORGE BLAINE
M.D. Berlin, L.R.C.P.E.
MAJOR R.A.M.C.; LATE OF THE DIRECTORATE OF BIOLOGICAL
RESEARCH, WAR OFFICE
In the last few years plastic chemistry has developed
a number of new materials and has shown that many
biochemical substances possess plastic properties which
can usefully be applied in surgery. Most of the funda-
mental and pioneering applied work has been done
in Great Britain and in North America.
Since instruction in plastics is not included in
the medical curriculum, a summary of their salient
characteristics is a necessary preliminary to a survey
of their place in surgical practice.
Plastics are chemical substances of high molecular
weight. They are deformable (mouldable) under suitable
conditions and retain their acquired shape thereafter
in a normal environment. They are versatile in that the
end-product of the plastic process can be given different -
physical properties. For instance, some plastic might
be made into a moulded ivory-hard object, a flexible .
rubbery mass, a thin adhesive film, a yarn that might
be woven into fabric, or a highly porous spongy or foam-
like structure. Provided they fulfil the requisite criteria
of surgery they can be used in place of existing materials,
and in some cases they make new surgical procedures
possible.
Plastics can be grouped according to their physical
and chemical behaviour and divided into absorbable and
non-absorbable materials according to their interaction
with living tissue (Blaine 1945a). The accompanying
table gives the facts of interest to the surgeon.
SPECIAL APPLICATIONS
In bone surgery plastic materials have been used for
filling gaps in the cranial vault and facial bones. Acrylics.
have been found most useful for this. After animal
experiments had proved the harmlessness of polymethyl
methacrylate in trephine holes of the cranium of the
cat (Blaine 1946a) and rabbit (Beck et al. 1945), Small
and Graham (1945) reported 30 cases in which acrylic
obturators had been used in filling cranial defects. Shelden
et al. (1944) used entire acrylic “ cranial vaults ’”’ in
investigations on shock in monkeys. A good description
of the current *‘ dental”? technique of use of acrylics
is found in both these papers.
Attention has to be drawn to the late behaviour of
acrylic plates in bone gaps. Sometimes the plate, quiescent
for six months or more, has become loose and worked
This was more
likely to happen where transplanted skin was used to
provide skin cover ; experimentally it happened regularly
where the bulk of the implant caused tension in sur-
rounding tissue and possibly interfered with vascularisa-
tion. I have seen two cases where acrylic plates were
used in covering defects after operations on the frontal
sinus ;` in one case the plate was firm for three years
before it became loose; it could be moved about under
References continued
Goldmann, C. H., Smith, S. J. CD Brit, J. Radiol. 16, 234.
Helfet, A. J. (1944) J. Bone Jt Surg. 72
Logfren, R. C. (1944) Nav. med. Bull., Wash, 43, 1025.
see t, W., Benoit, M., DuBois, R . (19:45) Amer. J. Syph.
345.
Mahoney, J ae , Arnold, R. C., Harris, A. (1943) Amer. J. publ. Hith,
Sterner, B. L., Harris, A., Zwally, M. R. (1944) J. Amer.
med. Ass. 126, os
Moore, J. E., Mahon J. F. ar e Ww. H., Sternberg, T. H.,
Wood, W. B. Ni. Yapi) Ibid, p.
Homandk y, N J » Rittman, ADA Bull. U.S. Army med. Dent.
Stokes. "J. rp: Sternberg, T. H., Schwartz, W. H., Mahoney, J. F.,
Moore, J. E., Wood, W. B. jun. (1944) J, dmer. med. Ass.
126, 73.
Whitehill, R., Austrian, R. (1944) Bull. Johns Hopk. Hosp. 15, 232.
526 THE LANOET]
MAJOR BLAINE: THE USES OF PLASTICS IN SURGERY
(ocr. 12, 1946
the skin but it caused otherwise no discomfort. There was
no tendency in this case for the plate to “‘ work itself out.”
Acrylics are currently used with the ‘“ dental
impression ” technique. Many excellent descriptions,
with as many individual modifications, are available,
and two have been referred to above. The use of this
method demands the assistance of trained dental
mechanics and necessitates a two-stage operation: in
the first stage the impression of the gap contour is taken ;
in the second the finished prosthesis is fitted. The use of
this technique is an obvious drawback and provides,
in comparison with tantalum, the advantages of radio-
lucency and cheapness only; many brain surgeons
consider it more complicated than the fashioning of a
bone graft to the gap. : `
Two methods have been described and demonstrated
(Blaine 1945a) which permit the use of acrylics in one
stage. The one makes use of ultraviolet-ray acceleration
of polymerisation (setting) of “‘activated” acrylic
dough, formed in situ; the other method makes use of
the ‘‘ thermoplastic ” properties of preformed unplasti-
cised methyl methacrylate sheet. This sheet when
heated to 130°C becomes readily mouldable and soft
to handle. Pressed to a model it takes the exact shape
of the ‘‘ master” and retains this acquired shape on
rapid cooling. Either of these methods enables methyl
methacrylate to be used in a short time, say 15-20 min.
A detailed description of the methods is' given elsewhere
(Blaine 1946a). Another simplified in-situ process has
since been developed and will be described shortly.
Harmon (1943) described the use of acrylic “ joint-
caps ’’ in the operative treatment of arthritis. of the hip
and in the reconstruction of the small joints of the hand and
foot. Very little has been heard of this application since
the first paper on the subject, and it is therefore difficult
to evaluate its usefulness in comparison with the metals.
It may be remarked that indifferent and frankly
bad results following the use of acrylics in these and
other fields might well be due to the purely practical
exploitation of acrylics, inevitable in war-time, without
due attention to fundamental physiological research ;
it must be realised that reaction to acrylics varies with
the amounts and nature of plasticisers and other added
substances which are found in most commercial prepara-
tions. Cutler (1946) expressed himself particularly
forcibly.on this subject, drawing attention to the ‘‘ mere
trickle ” of really scientific dental contributions in this
specialised subject, as against the spate of technical
articles and notes.
In dental and faciomazillary work acrylics are now well
established. Many appliances formerly made of precious
metal are now made of these plastics, as a routine.
Clarkson et al. (1946) summarise the work of the facio-
maxillary units in the Central Mediterranean Force;
about 90 acrylic Gunning splints were fixed in 45 cases
of fracture of the edentulous jaw. |
Acrylic splints are enthusiastically recommended
(McGowan 1945, Scales and Herschell 1945, Cholmeley
1945) for splinting forearms and wrists, and at the National
Orthopedic Hospital at Stanmore a method has been
devised for adapting acrylic sheet for use as a spinal jacket.
At present acrylic splints hardly fulfil all the criteria
one ought to apply to new materials replacing old and
trusted ones (see Blaine 1945b). However attractive
and elegant a plastic splint or appliance looks, its direct
moulding to the human frame requires greater heat than
the operator’s hands and the patient’s skin will tolerate ;
its ‘‘ indirect ” application by the dental method is too
complicated ; the fact that it does not absorb moisture
is hardly as advantageous as has been claimed (McGowan
1945). The plastic splint allows sweat to accumulate ;
pruritus develops, and the odour of the skin fully counter-
acts the elegant appearance, lightness, radiolucency, and
“ washable ”?” nature of the splint. However, in cases
where the splint can be removed daily—e.g., in radial-
nerve palsy—acrylic splints are useful. | .
I have used acrylic dough (of the commercial type)
for splinting a forearm in a patient who volunteered for
this treatment. The method consisted of the application
of the “‘ kneaded ” and “‘ flat-rolled ” dough to the limb ;
the dough could be cut with a pair of scissors. The
splinted limb was exposed to the rays of the tropical sun
to accelerate the setting of the plastic. Though the result
was mechanically excellent, the dough caused acute
dermatitis and had to be removed on the second day.
Whether specially treated dough would be more satis-
factory remains to beseen. Excess monomer was probably
responsible for the dermatitis. a
Before any plastic is recommended to replace plaster-
of-paris in orthopædic splinting, it is well to bear in mind
that it would have to possess the following properties :
cheapness; foolproof handling: quick setting without
complicated machinery ; and porosity. Were these added
to the existing properties of plastics—radiolucency,
lightness, elegance, and the fact that they allow the patient
to wash and bathe—the plastic splint or spinal appliance
would come to stay.
OPHTHALMOLOGICAL USES
Contact lenses and artificial eyes made from acrylic
plastics do not break easily, but they ace easily scratched,
and their cost is relatively high (Stewart 1946).
Flexible rubber-like plastics of the polyvinyl group
are increasingly used as drainage-tubes (Mann 1945)
and take the place of rubber on many an anesthetic
airway (Thornton 1944). The tolerance of tissues to
polyvinyls varies, however, and it must be remembered
that this material is always plasticised and that countless
varieties exist. Before these materials are recommended
for use, the tolerance of tissues to the different makes wil]
have to be established. Š
Polyvinyls are also used as soft-tissue prostheses
(masks) in plastic surgery. Reports from the U.S.A.
(Lougee 1943) and from Australia (Woerner et al.
1945) are encouraging. The polyvinyls are, however,
photosensitive and cannot therefore be worn indefinitely
(Offce of Scientific Research and Development 1943).
In suture materials plastic chemistry produced ‘ Nylon,
the popularity of which makes further comment unneces-
sary. The reaction of the tissues to it is excellent (Aries
1941) ; its only drawback is that the material slips, and
knots have to be double and tied with great care.
ABSORPTION
The finding that certain plastics were absorbable was
perhaps the most important step in the development
of plastics for surgical uses. Research was long directed
towards the development of absorbable materials for
surgery. Used as thin homogeneous films such materials
are required to “ isolate ” healing tissues, thus preventing
the formation of adhesions. Amnioplastin, used for some
time, was found unsatisfactory ‘by Rogers (1943). Used
as carriers of biochemical hemostatics, such as thrombin,
they must facilitate control of capillary oozing. Woven
into gauze-like fabric they can control hemorrhages
otherwise difficult to deal with. They can possibly also
be used as vehicles for penicillin and thus ensure a more
prolonged action. Painted or sprayed over surface wounds
and burns they can combine the advantages of the
open and closed methods of treatment. The ideal absorb--
able material must naturally be sterilisable by heat
and compatible with added substances, and its handling
must be simple.
The first practical development was made with oxidised
cellulose (Frantz 1943, Frantz and Lattes 1945, Frantz
et al. 1946). Suitably treated cellulose (oxycellulose)
was woven into gauze and made into film and foam;
it was found that it could carry thrombin. Experiments
have shown that. it was readily absorbable with a
THE LANCET]
MAJOR BLAINE: THE USES OF PLASTICS IN SURGERY
ocr. 12, 1946. 527
CHARACTERISTICS AND SURGICAL USES OF PLASTICS
Physical form in
hich used
Material vee Tissue reaction Sterllisability {| =. Uses
Aen (pol ly- Processed and moulded | Mild fibrous reaction to all | By heat and pressure; | Cranial] and faciomaxillary
‘meth HR n - plates, dough, and ultra- physical forms; no giant S lasticised materi obturators, plates; exter-
acryla violet-sensitised dough celis ; some solventse—e.g., undergoes some de- nal prostheses
acetone—irritant formation — :
Cellulose acetate | Flexible films Massive fibrous tissue formed | By heat and pressure Experimentally ‘for pro-
around implant (Graef and i ducing ‘‘ armour plating ”
Page 1940) round kidney aad blood-
l À vessels
Methyl cellulose Solution i Not tested By heat and pressure
Polyamide
(‘ Nylon ’)
Filament yarns, solid plates
giant cells
Resin, for coating and miia:
ing cloth
Flexible sheets, tubes, blocks
Urea and phe-
nolic resins
Polyvinyl
chi
oride on added materials
Polyvin y 1 | Solution Not tested
alcohol
Casein .. Solid rods, blocks, film-
forming emulsions
ae aa aa E A
Mild fibrous reaction; no
The resins are highly irritant
Variable reaction depending
Transient aseptic inflamma-
tion during absorption
Experimentally as - plasma
substitute
‘Suture matrial aspari
mental bone plates and
screws
Experimentally as splints |
By heat and pressure.
Sterile
B Drainage - PEN
By heat and pressure
facial prostheses.
airways, l
Experimentally as plasma
substitute
Experimental bone. ‘plates
and ‘screws; films
By heat and pressure
Deforms on _ heat-treat-
ment unless specially
= l packed ‘treatment of burns
Fibrin and | Solid blocks, foam, film ; with ditto By formalin treatment | Tissue-isolating films, ‘cover
fibrinogen thrombin “insitu’ formed only; not sterilisable of dural defects, 'hæmo- s
5 i clots by beat ©- (v; Stasis
Gelatin .. Porous elastic “ sponge ” ditto By heat and pressure ditto
Oxycellulose Woven fabric as gauze, ditto By formalin ‘treatment | 77. © ditto
i ae cotton-wool; solution (less highly oxidised material only (also experimental plasma
get ot l creates fibrous reaction) - i By Be Re eubetituse):
Alginates. Woven fabric as gauze, | Mild aseptic inflammation | By heat and pressure ` C. o ditto ``
A cotton-wool, film, foam | in course of absorption l : ee SRA
sponge; solution of sodium ;
salt with CaCl, for ‘‘in
situ’’ clotting and plasma |
clotting -- |
T
comparatively minimal tissue-reaction. Clinical use was
made of it in neurosurgery ; it was satisfactory as a
thrombin carrier and controlled capillary hemorrhage
in brain surgery. In general surgery it was used to
control hemorrhage from highly vascular organs. Draw-
backs of this material are that it cannot be sterilised
by heat and is incompatible with penicillin, reducing the
pen at of the drug. It destroys penicillin la
PROTEIN PLASTICS
About the same time when the uses of oxycellulose
were published it was found, almost simultaneously in
the U.S.A. (Ingraham and Bailey 1944, Bailey and
Ingraham 1944) and in Britain (Blaine 1945a), that
proteins possessed suitable plastic properties.
_Fibrin—In course of plasma-protein fractionation
experiments at Harvard Medical School and elsewhere
fibrin was particularly experimented with in this con-
nexion. Fibrin was made into film and foam and into a
sprayable solution. Used in covering dural defects
the film was found highly satisfactory (Ingraham and
Bailey 1944, Bailey and Ingraham 1944).
in combination with thrombin it proved of great help
in arresting capillary hemorrhage.. Sprayed on burns
and clotted with thrombin it was also useful.
Drawbacks to the ubiquitous use of fibrin (or fibrinogen)
plastics are their non-sterilisability by heat and the
relatively’ complicated and expensive method of their
production. Used’ experimentally in the treatment of
scleral wounds (Blaine et al. 1944) it was found too
quickly absorbable, though it fulfilled the other criteria
admirably. Workers in the U.S.A. réported persistence
of fibrin film for. about 80 days over the dura (Ingraham
and Bailey 1944).
Casein.—In Britain the. protein-plastic experiments
were mainly directed towards the development of solid
plastic appliances as plates and screws for the internal
fixation of fractures (Blaine 1945a, 1946a). Though the
' it a very promising foam in hemostasis. .
As a foam >
initial physical properties of casein plastic—the protein
predominantly used—were promising, such . pragtig
softened in tissue too early to be of use.
Casein plastic films formed in situ were used by Curtis
and Brewer (1944) for burns. Their results speak well of
this method. ,
Gelatin.—Light and Prentice (1945) described the use ‘of
gelatin plastic sponge, ‘ Gelfoam,’ as. a thrombin carrier.
The easy handling and availability of the material makes :
Alginates.—The latest development: in absorbable
plastics to be used as a tissue isolator, absorbable gauze,
cotton-wool, and a “‘ carrier’ of added substances in the
form of a foam, film, or gel is the adaptation of alginate
products to surgery (Blaine 1946b). These are a derivative
of seaweed ; though not generally known and developed
as a plastic, certain of its salts possess plastic properties.
Evidence has been presented that. certain alginate
products are absorbable in tissue; sterilisable by heat, and
compatible with penicillin (Blaine et al. 1944, Blaine
1946b). Used (also in’ combination with plasma as an
alginate-plasma film) as “ puncture patches ’’ over scleral
defects, alginate film was found satisfactory both experi-
mentally and clinically (Blaine 1946b). There is, however,
no further report of its use in this connexion in this
country. Alginate films clotted in situ with calcium
chloride (the quick clotting of the sodium alginate
solution under the action of calcium chloride is Parti-
cularly noteworthy) were used by me in the treatment of
wounds and burns in troopship hospitals in the Far East.
| Results were very encouraging, but lack of facilities and
“ exigencies of the Service ” made it unpractical to
follow up the cases methodically. The same holds good
for penicillin “ carriage ” experiments.
Gough (1945), in the National School of Medicine -in
Wales, reported the usefulness of alginate gels in: the
sealing of bronchi i in the surgical creation o! p ETORTEN
tuberculosis.
P2
528° THE ‘LANCET]
_ TUBERCULOSIS ASSOCIATION
_foor. 12, 1946
PLASTIC SOLUTIONS © ` `
Experimental use of plastic solutions was made in
the search for plasma substitutes in blood-transfusion.
Sodium alginate (Solandt 1941), methyl cellulose, and `-
polyvinyl alcohol (Roome et al. 1944) were reported
on in this field of research. Polyvinyl alcohol alone
showed sufficient promise. Roome et al. (1944) in Canada
une that it was well tolerated by patients.
CONCLUSION
It will be seen that a considerable amount of work
was carried out, mostly under the stimulus of war-time
needs of surgery, in this newest field of experimental
surgery. Further research might produce many a
useful innovation. One factor must be borne in mind.
‘The plastic industry is not ancillary (like the pharma-
ceutical industry) to the medical profession. Stimulus
for further work in these fields must therefore come from
the surgeon. —
REFERENCES
Aries, L. J. (1941) Surgery 3,
Bailey, O. T., Ingraham B.dan J clin. Invest. 23
Beck, D. J. K., Russell, 5: S, S ., Graham, Mw P (1945)
Brit. J. Surg. 33, 83.
Blaine (Blum), .G ay 45a) Proc. R. Soc. Med. 38, 169.
945b) ics, 31.
ae A TR Brit. J. Surg. 33, "24 ae
— (1946b) Ann. Surg. Se ptembe
— aa onar J. M., Sorby A. (1944) Trans. ophthal. Soe. U.E.
doado, J. a (1945) Brit, med. J. ii, 5
Marinon; P., Wilson, T. H., Lawrie, R. 685 "(1946) Ann. Surg. 123,
1
- Curtis, R. M., Brewer, J. H. (1944) Arch. Surg., Chicago, 48, 130.
Cutler, R. 1946) Proc. R. Soc. Med. 39, 103.
Frantz, V
mT. La tes,
f,
a Plastics
Ingraham, F Motley. O° Ti (1944) J. Neiroiii. 1, 23.
Ligii, R. Ues D M ‘ (1945) Arch. Surg. sj Chicago, 51,
Lougee, E. F. (1943) Modern Plastics, 21, 80, oe oe
McGowan, A , (1945) Brit. Plastics, 17, 30. j
Mann, S. (1945) Brit. med. J. i, 84.
Office of Scientific Hescerch and Develymene Washington (1943)
Monthly Ropotan 13.
Rogers, L. (1943 Brit. med, J. i, 423.
Roome, N. W., illiams, L., Smith, W. asa Sinad
Scales ,J.T esaki, W. (1945) Brit. med. J. ii, 423.
See a H., Pudenz, R. H., Restarski, J. S., Craig, W. M. (1944)
J. Neurosurg. 1, 67.
Graham, M. P. (1945) Brit. J. Surg. 33, 106.
M. (1941) Quart. J. exp. Physiol. 31, 25.
Stewart, F.J - (1946) Proc. R: S067 Med. 39, 251.
Thornton, H . L. (1944) Brit. med. J. ii, 14.
Woerner, H. K., et al. (1945) Aust. dent. J. 1, 28.
Small, J. u
Solandt, O
Medical Societies
TUBERCULOSIS ASSOCIATION
AT a meeting in London on Sept. 20, with Dr. NoRMAN
TATTERSALL, the president,'in the chair, a paper on
Tuberculosis of the Nervous System
was read by Dr. HQnor SmirH. She said that while
there are powerful new weapons against purulent
meningitis, the tuberculous form is still as great a thera-
peutic problem as when Whytt first. described it in 1768,
though hopes are now raised by streptomycin.
Apart from Pott’s disease, there were two types of
infection—meningitis and the much rarer large tuber-
culoma. The latter presented as an expanding lesion,
with raised intracranial pressure and localising signs ;
the diagnosis was from tumour or abscess, and though
tuberculosis elsewhere was a pointer, biopsy was some-
times necessary for diagnosis. Radiological evidence
of calcification was not pathognomonic; it was, for
example, seen with gliomata. Removal of a tuberculoma
did not necessarily result in tuberculous meningitis ;
of 6 cases operated on at the Nuffield Department of
Surgery, Oxford, 4 had recovered completely. A simple
decompression might suffice, especially with cerebellar
tuberculomata.
Tuberculous meningitis was said by Rich and
McCordock to result from rupture of a tuberculous focus
into the ventricles or subarachnoid space. Dr. Smith
said she had found small tuberculomata with meningitis,
but their piecemeal removal did not inevitably result in
meningitis. Of 25 cases of tuberculous meningitis, rather
more than half were over ten years of age. The insidious
prodromal phase might be due to concomitant miliary
tuberculosis rather than to meningeal involvement.
The stages of nervous involvement were as follows :
1. Meningeal Irritation.—This might be absent or hard to
detect in infants. There was evidence (O’Connell) that it was
due to irritation of the posterior nerve-roots. The site of the
exudate might substantially influence the effect of chemo-
therapeusis.
2. Signs of Raised Intracranial Pressure——Headache was
closely paralleled by vomiting. The further increase in
pressure at a later stage was usually due to obstructive
hydrocephalus.
3. Mental Changes.—There might be a change of tem-
' perament, succeeded later by delirium, and finally stupor
or coma.
4. Hpilepsy.— When this ocon it was usually at the
end of the prodromal phase and was focal or jacksonian.
5. Focal Signs.—These might include ophthalmoplegia,
extensor plantar responses (often unilateral), and hemiplegia
or. paraplegia. They might be caused by tuberculomata, or
by vascular occlusion and infarcts. Chemotherapeusis, to be
effective, must act before these vascular changes developed.
The average chloride content of thè cerebrospinal fluid
(c.S.F.) was 650 mg. per 100 c.cm., as compared with
663 mg. in a series of pneumococcal meningitis; but
in half the tuberculous patients the content was less
than 600 mg. The chloride level might be depleted by
persistent vomiting (as also in pyogenic meningitis) or
it might be raised owing to uræmia. The content was
usually less than normal, but there was no diagnostic
level. Differentiation from pyogenic meningitis might
be aided by the discovery of tuberculosis elsewhere in
the body and by a positive family history ; and a history
of a pyogenic focus might cause contusion. Unfortunately,
tubercle bacilli could seldom be found in the C.s.F.
Ventriculography might show a moderate symmetrical
hydrocephalus, which was diagnostic. When the diagnosis
was in doubt the condition might justifiably be treated
as a pyogenic infection.
Dr. P. DANIELS remarked that the capacity of patients
with severe pyogenic meningitis for almost complete
` recovery after suitable treatment encouraged hope for the
successful. treatment of tuberculosis of the central
nervous system. If an effective drug were found it must
be applied early; with complete blockage. of c.s.F.
circulation the condition became almost hopeless, and
the changes with infarction were irreversible, though
there might be some improvement with resolution of
surrounding cedema.
Treatment of Lupus Vul garis
Dr. G. B. DOWLING said that lupus, though uncommon,
was extremely chronic; there was thus always a pool
of affected patients, who constituted a serious social
problem. In this country the larger general hospitals
bore the brunt of treatment. In Denmark the Finsen
Institute treated all cases, numbering, in the ten years
between 1914 and 1923, 975, of which 735 were cured,
chiefly by local Finsen therapy, carbon-arc baths,
heliotherapy, and nutritional remedies; other methods,
such as diathermy and cautery, pyrogallol and other
caustics, and surgical excision, had. also been used. He
thought that treatment would be materially helped by
intensive vitamin-D therapy, but that there was still
need for skilful local treatment.
The first patient treated intensively with vitamin D
had had local treatment for five years; he was ordered
150,000 I.u. daily without much confidence in success.
The condition was almost cured after 21/, months.
There were, however, two relapses, the first within a few
weeks with congestion and swelling of the area.; more-
over, two small lupus nodules embedded in scar tissue
were untouched. Between 1943 and 1945 Dr. Dowling
THE LANCET]
REVIEWS OF BOOKS
ee 12, 1946 529
and Dr. Prosser Thomas had treated 32 cases: 18 had
been cured and 9 much improved. These patients had
received very little local therapy, in contrast to similar
groups treated by Charpy from 1941 onwards. With
toxic symptoms—nausea, malaise, and sometimes vomit-
ing—the usual dose of 3 high-potency ‘ Ostelin ’ tablets
daily might have to be reduced. Hypercalcemia occurred
‘erratically and was not necessarily associated with toxic
symptoms or improvement of the condition.
Calciferol in Tuberculous Conditions
Dr. D. E. MacrRA®& described a trial of calciferol in 20
long-standing cases of lupus vulgaris, in which the
average duration of the disease exceeded nineteen years.
Of.these, 14 had so far been discharged as clear of disease.
Results could be summarised as follows: (1) profuse
soft granulations, easily removed by scraping, required
additional local. treatment; (2) raised firm plaques
responded well; (3) more deep-seated lesions, level with
the skin, responded well; (4) isolated nodules responded
on the whole badly; (5) with lesions inside the mouth,
nose, and the results were mixed; and (6) with
multiple areas of affection, the larger the areas the slower
the response. During the first 2-3 weeks there was a
reaction ; patches became angrier and isolated nodules
more scarlet, and spontaneous ulcers might develop.
Calciferol, he suggested, acted by promoting reaction in
the lupus tissue ; this resulted in some general toxemia,
as shown by a stronger tuberculin reaction and increased
blood-sedimentation rate; and it was succeeded by
fibrosis which “literally squeezes the lupus to death.”
The effect did not seem to be influenced by either the
method of administration or by altered calcium metabolism.
The addition of local therapy hastened improvement. |
He had also observed improvement with calciferol in
2 cases of adenitis, though in these again there was an
initial reaction, with softening and pus-formation ; and
in 1 case of advanced wrist tuberculosis, 1 case of
multiple dactylitis, and 1 case of tuberculous cystitis ;
though these had shown unexpectedly rapid improve-
ment, no precise claims could yet be advanced for
calciferol in these conditions.
He had twice seen calciferol treatment complicated
by abdominal discomfort and constipation proceeding
eventually to coma, peripheral neuritis, and optic atrophy ;
both patients had ultimately recovered. There had been
no evidence of treatment causing renal damage;. but
calciferol should probably not be given to completely
recumbent patients; and the possibility of the initial
reaction causing a flare- -up necessitated caution where
there was active lung disease.
Dr. Emrys JONES, of Cardiff, said that lupus, usually of
long standing, had "cleared with calciferol in 16 out of
18 patients. Adenitis also had been cured with this
treatment; the periadenitis seemed to clear up first,
so that the glands became more discrete.
Dr. M. C. WILKINSON referred to the effect on resistance
of increase in the body sterols, and quoted a case of lupus
which had cleared up when the patient became pregnant.
So far he had not been impressed with the effect of
calciferol on tuberculosis of bones and joints.
PRODUCTION OF STREPTOMyYCIN.—At a recent press con-
ference held at the London headquarters of Messrs. Boots,
‘Sir Jack Drummond, F.R.S., described the process employed
in the manufacture of streptomycin. In the surface-
culture method spores of the Actinomyces griseus are sprayed
-on the surface of a medium containing sugar and meat extract
or corn steep Jiquor filled into milk bottles from a conveyor
belt (some 250,000 milk bottles are in use). Streptomycin is
excreted in measurable quantities after the 7th day, and
after 14 days the mould is discarded and the liquor made
‘acid and pumped through charcoal filters which absorb the
impurities. After further purification and freeze-drying a
white powder emerges which is packed into sterile ampoules.
The cost of producing sufficient streptomycin for the three-
months course of treatment at present considered necessary
for a case of tuberculosis works out, on the basis of American
costs, at about £3000, employing the surface-culture process.
Messrs. Boots are planning to replace. surface culture in
bottles by deep. culture in. huge tanks, nnd by this process the
cost may be reduced to a quarter of the present figure.
the Royal Navy 1943.
Reviews of Books
Abnormal Behaviour |
. R. Q. GORDON, M.D., D.SC., F.R.C .P., late inedia director,
Child Guidance Council. ‘London “Medical Publications.
Pp. 75. 5s. >-
Dr. Gordon writes with the elna aid charm of an
acknowledged master, but he spends too many of his
75 pages on going over old ground; consequently,
when he comes to the problems of capital and corporal
punishment he disposes of them with ‘it is impossible
to go into all the arguments which might be advanced
in this complicated problem.” This is just the sort of
topic, however, about which readers would be glad to
see the arguments set out with Dr. Gordon’s objectivity. -
‘Dealing with the question of punishment, Dr. Gordon
sticks to the familiar three purposes—retribution,
deterrence, reform—and does not attempt to break new
ground. When he comes to the practical issues he
writes with good sense and wisdom and makes a con-
vincing case for the psychological attitude. His tolerance,
his kindliness, and his obvious soundness must help to win
understanding and sympathy for the mentally abnormal.
The Ship Captain’s Medical Guide
(18th ed.) Ministry of War Transport, London. H.M.
Stationery Office. Pp. 225. 3s. 6d.
NEARLY twenty years have elapsed since the last
edition of this venerable publication, and pending a
complete revision the compilers have made a determined
effort to bring it up to date by rewriting 11 of the 24
chapters and introducing material from First Aid in
The ingenious Neil Robertson —
stretcher is described in detail, with a series of good
photographs to demonstrate its use. The diagrams
throughout the book are useful.
Much ‘of the elegant 18th-century English of the
original composition, and some of the remedies current
at the time, have been retained. The burning of feathers
under the nose of the fainting patient is highly com-
mended, and the amount of castor oil and Epsom salts
consumed by the patients should keep the ship’s lavatory
accommodation fully occupied. Any suggestion of heart
weakness may be countered by the exhibition of brandy,
whisky, or gin at two-hourly intervals, and in the case
of the apparently drowned 4 tablespoonfuls are advised
as an enema, a pleasure which we must regretfully
deny our patients ashore. The style throughout is
dogmatic and obviously intended to inspire confidence
in the master and his patient.. In the background one
can almost hear the clanking of irons for any who raise
their voices in dissent. We quote one paragraph without
comment :
‘*PLEURISY.... If the patient is robust a tablespoonful
of Epsom Salts in just sufficient water to dissolve it should
be given every morning. This produces copious liquid
_ discharges and helps to get rid of the. accumulation of fluid
in the chest by draining it through the bowel.”
There is a fine nautical description of appendicitis,
commencing with a sudden pain in the south-west
corner of the abdomen; but as suspected appendicitis
is the biggest bogy facing. the unqualified ship’s doctor
it would be better to rewrite this chapter and say that
most cases start with central pain, backing later to
south-west, localising, and with the onset of peritonitis
veering south and east. McBurney’s point is incorrectly |
described ; few surgeons would agree. with 4 oz. of milk
or liquid ' nourishment being given every two hours;
and the instruction to give a dose of castor oil as soon
as the pain and tenderness disappear (when the appendix
bursts, for instance) is dangerous. —
: Since much of the book is concerned with good hygiene,
it is odd to find modern fungicides and D:D.T. com-
pletely omitted. Penicillin is not even mentioned, though
most American ships carry a supply with a purser
instructed in its use. All senior officers in our Merchant
Navy are required to pass a course in first aid, and ‘it
would require little more instruction to enable them to
clear up their cases of gonorrhoea with 200,000 units of `
penicillin or to use the same technique as a life-saver
for cases of pneumonia or appendicitis in mid-Atlantic.
Where common sense obtains the text is magnificent.
ences might be better chosen :
THE LANCET]
530
NEW INVENTIONS
[oor 1 12, 1946
`
Among the usual- anti-shock treatment we find the
following splendid advice: > .
“CHEER HIM UP. , Remember that a casualty is
wondering what has happened, whether he is ‘going to live
or die and whether, if he lives, he is.going to be scarred or
mutilated for life. His thoughts are turning in a lonely little
personal world of fear, no matter how brave a man he may
be. : All this mental worry serves to increase his shock and
it can be lessened very much by a sympathetic shipmate.
’ Talk to him, be natural . . . and while vane. near Papua
men, never whisper. AOR
We wish all the book was as good as this.
. Forensic Medicine
(4th ed.) Doveras Kerr, ; M.D., F.R.O.P.E., D.P.H., lecturer
‘in forensic’ medicine, School of Medicine, Royal Colleges
of Edinburgh. London :
enjoy the affection and regard of both the. student
and his teacher,
reliable, and so free from the recondite that ruins many
standard textbooks as they achieve success. This fourth
_ edition. in some ten years has been augmented with
benefit, and new illustrations have been added. Refer-
in toxicology, especially,
there is much useful new reading on industrial aspects.
' The new material—on blood and head injuries in parti-
cular—is as clear as the rest. How eminently reasonable
it all is, and what sound witnesses we should. all be if
we digested its principles. The time has come, however,
to reduce the references to the pharmacy laws to essentials,
and to cut down the sections on artificial respiration.
and. Binet-Simon tests, and the . verbatim judgments
such as that on Rex v..Savage. And the examiner would
have an easier time if the “Schedule to an Order in
Council dated April 13th 1937 (s.R..& o. 1937...No. 327) ”’
(sic) were stated, and if no doubts were. roused. on the
gestation at which the law.recognises viability. But
how little there is in this good book with which to
differ. Kerr remains a shining example of clear eee
for the student, readable to a degree, A
Food and Nutrition ag
' The Physiological Bases of Human Nutrition. E. W. H.
_ CRUICKSHANK, M.D. ‘Aberd., v.30. Lond., PH.D. Camb.,
. ‘M.B.C.P.,-regius professor of physiology in ‘the Univer-
~ sity ‘of: ' Aberdeen. Edinburgh: „E. & S. eens
Pp.-326. ‘163. `
_ Tae author of this addition tò the numerous textbooks
on nutrition has in mind medical practitioners, medical
students, candidates for the diploma in public health,
and sociologically minded laymen. But it is a book with
a difference : though the basic science is all there—and
well set out—there is much emphasis upon the sociological
implications and applications of the science of nutrition.
In fact the author introduces the subject with no less
than four interesting and valuable chapters on the
evolution of human dietaries, the problem of world
, malnutrition, and the problem of nutrition in Great
Britain in 1939-45 and in the coming years. And then,
having polished off the science of the subject in six chapters,
with three more on foods, he reverts to dietary planning,
the appraisal of the nutritional state of individuals
and communities, and the Food and Agriculture Organisa-
tion. There are numerous digressions into the histories
of foods and the science of nutrition for which ne auveer
. will be both thanked and criticised.
Sciatiques et lombalgies _ |
“ par hernie postérieure des disques, intervertébrauz. D,
Perrrr-DvuraILus, professeur de pathologie chirurgicale,
Paris; S. DE Size. Paris: Masson.. Pp. 178, Fr. 235.
Tas book is a full and straightforward account
of the anatomy,. pathology, clinical features, and treat-
ment of prolapse of the intervertebral disk, and most of
what the authors have to say will. meet with general
agreement in this country. They emphasise the fre-
quency with which sciatica may be complicated by
paralysis -below the -knee; and they use intrathecal
iodised oil as a routine in diagnosis, where we have learnt
- to do without it. Their operative approach is a full lamin-
ectomy done under local anesthesia, and the extradural
removal of the prolapse is supplemented by division of
the sensory root on both sides at the level of the lesion.
A. & C. Black. Pp. 359. 188.
Douglas Kerr’s well-known textbook continues to
It is so readable, so. reasonable, so-
Pathology of the Central Nervous System I
(2nd ed.) Cyr B. COURVILLE, M.D., apa of nervous
diseases, College of Medical Evangelist, Los Angeles.
: London :. H. K. Lewis. Pp. 450. 36s. .-
THE second edition of this book has been: somewhat
expanded to include recent work on problems of the
circulation, infection, and some neoplastic and degenera-
tive diseases. Special attention is paid to the effects of
trauma and bony diseases of the cranium and’ spine.
Rather more space might have been given to the impor- -
tant subject of the virus infections, and more might with
advantage have been said about the postexanthematous
demyelinating diseases and their relationship to dissemi-
nated sclerosis. The presentation is clear and the micro-
and macro-photographs and diagrams. are well. chosen
and reproduced. The book is comprehensive and well
written, and. lays a sound foundation in. neuropathology
for the ‘student of neurology or general mediane, vs
New Inventions.
NEEDLE AND CANNULA FOR CHEST
: i ' EXPLORATION | a,
ONE of the dangers associated with the dpto of
the pleural space is spontaneous pneumothorax. It is
not perhaps & very common one, but experience on a
thoracic surgical unit, where aspiration is an evéryday
occurrence and forms a major part of treatment, shows
that it is sufficiently common, in spite of the most careful
technique, to justify efforts to reduce its incidence to a
minimum.
‘The danger lies in the penetration of the lung with the
large aspirating needle used, but this alone ‘need not
necessarily give rise to spontaneous ' pneumothorax.
The latter is far more likely to develop as the result of
unnecessary manipulations of the needle when the pleural
space has been entered, and it should be the main rule
in chest exploration to avoid these manipulations.
The special needle (incorporating ` a two-way attach-
ment) described below and in the accompanying ig
was devised with a view to minimising this danger, and
has been used extensively in the thoracie surgical unit _
at Harefield with good results.
Essentially, the instrument consists of a cannula into
which a large-bore needle is fitted closely enough to avoid
leakage of air and yet allowing the needle to slide freely
within the cannula. A guiding pin, firmly attached to
the shaft of the needle, fits into a slot at the base of the
cannula. The slot is arranged in’ the following: way :
1. When the cannula is pushed right home, preparatory to
-~ aspiration, the needle point protrudes from its distal end.
2. When the pleural space has been entered, the needle point
may be withdrawn into the cannula, and a small side
extension of the slot allows the needle to become locked
.in this position.
3. If necessary—e.g., for cleaning—the needle can be removed
from the cannula. ar 5 esate 3
The advantages of this needle are’ as follows: `
l.. Once it is in the pleural space, the needle point can be-
withdrawn into the cannula, thus considerably reducing
the likelihood of trauma to the lung. |
2. The cannula protects the point of the. needle when: not in
use, particularly when it is being boiled.
/
3. The incorporation of the two-way tap - reduces the —
_ possibility. of an air leak at the junction.
' The only disadvantage appears to be the size of the
needle, which is necessarily large, though not unduly so.
I wish to thank Mr. E. Blackburn, of Chas. F. Thackray
Ltd., for his assistance and advice on the manufacture of
the instrument.
E. V. ‘Mapm, M.R.O.8.
Harefield County Hospital, Middlesex.
~
THE LANCET]
NUREMBERG— TWENTY YEARS OF TYPHUS RESEARCH
[ocr. 12, 1946 531
THE LANCET
~ LONDON : SATURDAY, OCT. 12, 1946
Nuremberg
HisToRyY,. contemporary or otherwise, may be
conceived as a series of dramatic and important
happenings, such as wars, separated by intervening
periods which are undramatic and unimportant.
This way of looking at human affairs is taught in
schools because it is easy, and encouraged by news-
papers because it is exciting ; but it leads to bewilder-
ment when the course of events does not take so
simple a form. A different view of history, though it
involves the acceptance of some painful ideas, will
lead to less bewilderment. On this alternative view
the movement of individuals and of groups, even
nations, is determined not by their intrinsic character
but by the field of forces of which they are a part ;
their individual volition, if it exists at all, is less
significant, in the shaping of their destinies, than
the total of forces which moves them. The Aristotelian
notion that a stone falls because it is in its nature
to go towards the earth gave place to GALILEO’s
and NEwrTon’s idea that the stone falls because
it is influenced by the forces in the field: and in
the same way, in human affairs, we must look to the
total pattern before we can understand the movement
of a part. On this basis one may look on wars and the
intervening periods of peace as phases of human
adjustment, both having ultimately the same purpose.
“This purpose is to achieve a situation of looser tension
—to redistribute the forces of constructiveness and
destructiveness so that eventually a condition of less
‘danger to valued objects may be established. For
the preservation of loved persons and loved ideals
is central to any rational consideration of human
affairs. `
The Nuremberg trial of a score of ageing malefactors
and the impeachment of a few disgraceful political
organisations can be looked at from two quite different
angles. `The opinion which has been generally
expressed is that it represents a stage in the gradual
_ extension of the range of law ; it is a demonstration
that, even though the resentment of having been
dragged into war is still strong, the principles of fair
play are dominant in the victors; and even if it sets
higher international standards. than the victors
always themselves observe it is at least a statement
of the moral principles to which they aspire—a
statement which may be justified by their future
behaviour. True though all this may be, however,
it is certainly not the whole truth. Perbaps. more
fundamentally, the Nuremberg trial may also be
regarded as a theatre of operations where the victors
came together and worked through their states of
tension and mistrust. It too is part of the technique
of post-war adjustment, and for this reason no less
than the other has potential value. Nobody can
now assess this value, though it is easy to suffer
illusions about it. On the one hand it is reassuring
that the governments can treat abominations in
international affairs as they treat crimes in their
domestic affairs; on the other hand, law-courts
however fair, and sentences however just, do more to
assuage the ruffed feelings of the community than to
remove the cause of crime.
The victorious nations were a team forced together
by a common external danger; they were far from
being united, and it would be a foolish act of mis-
belief to imagine that they were. Profoundly con-
flicting views as to the way social life should be lived
are held by the parties to the peacemaking ; there is
mutual suspicion, mistrust, and hostility—all the
more disquieting when the nations are so explosively
armed and when the techniques for reducing tension
otherwise than by arms are so poorly integrated into
the structure of international life. Nevertheless these
techniques exist: there are today many theatres
of adjustment where stresses of conflict can be worked
out, and the various conferences of foreign ministers,
Uno, UNEsco, and others serve as outlets of aggres-
sion and means of acquiring experience of distrusted
people. A conference that ends in discord may
seem a disaster but may rather be a valuable
cathartic; whereas a trial which ends in unanimity
may be a soporific. We cannot judge: indeed most
of us can now do nothing except observe the course
of events. But. we shall do more for the cause of
constructiveness and cohesion if we try to keep in
mind the whole agony of the world than if we
dream, or even hope overmuch, that the condemning
of conspicuous criminals is a measure of the world’s
unity.
: Our unity as allied nations was greatest when the
common foe was pressing hardest. What common
enemy threatens us now ? None perhaps is greater
than despair over the settling of our own internal -
difficulties, and the weakness of our methods of
dealing with tensions within our groups and with
our individual disquiet.
Twenty Years of Typhus eek:
THOSE who were young a quarter of a century ago
are apt to compare the present age unfavourably
with the years which succeeded World War 1. What-
ever enchantments distance may lend to the political
scene there is no doubt that medically we are now
far better equipped with knowledge of how to deal
with menaces to life and health than we were in
the early twenties. This was clearly brought out
by Prof. HerMANN: MoosER? in his address to the
British-Swiss Medical Conference on progress in
typhus research.
Twenty years ago almost all that was aden
of the rickettsial infections was that typhus was
transmitted by lice, a fact discovered by NICOLLE,
COMTE, and CONSEL? in 1914, and that Rocky
Mountain spotted fever and tsutsugamushi disease
were distinct specific infections with their own
epidemiological peculiarities. Names like tick typhus,
Sad Paulo typhus, summer typhus, pseudotyphus
of Delhi, tropical typhus, scrub typhus, shop typhus,
Manchurian typhus, and mild endemic typhus were
indiscriminately applied to febrile diseases for which
no specific classification was available. The first step
in resolving this confusion was the differentiation
of flea-borne or murine typhus from the epidemic
r Mooser, H. Schweiz. med. Wschr. 1946, 76, 877.
a a ee » Comte, C., Conseil, E. C.R. Acad. Sci., Paris, 1914,
532
or louse-borne variety. MoosEr’s account of how this
‘was accomplished differs somewhat from that usually
accepted. Doubts as to the louse being the sole
insect vector of typhus were’ first raised in 1923 by ©
Jost Trrrts* in Mexico, where the disease had
‘been endemic and occasionally epidemic from shortly
after the Spanish conquest. Since the local population
was heavily infested with lice it was icult to
disprove the louse transmission theory in México.
A series of mild cases, however, was recorded by
SINCLAIR and Maxcy,* from the American side of
the Rio Grande valley, where the rarity of Pediculus
humanus var. corporis made it unlikely that that
insect could act as an effective vector. Previously
Hone ë in Australia had observed cases of typhus
_ in Adelaide in 1922 and 1923 among persons handling
wheat and other foodstuffs, while WHEATLAND,®
another Australian, connected his cases of mild
typhus with a migration of mice; associated with an
epizootic. WHEATLAND went so far as to give the
name “mouse fever” to the disease from which his
patients suffered, though they all had positive Weil-
Felix reactions. In 1924 FLETCHER and LESSLAR ”
had observed in the Federated Malay States cases of
what they called tropical typhus -where there was
no evidence of man-to-man transmission but the
possibility of. contamination from rats was high.
In 1925 Mooser ® obtained a strain of typhus in
guineapigs inoculated with the blood of a patient
from Mexico City; this and subsequent strains
produced a scrotal reaction in male guineapigs
similar to that observed by NEIL ® in 1917 in guinea-
pigs injected with the blood. of typhus patients in
Texas. In smears from the hemorrhagic tunica
vaginalis stained by Giemsa’s method, MoosER 1°
for the first time saw cells with the cytoplasm heavily
loaded with rickettsia, cells which since 1933 have
been known as “ Mooser cells.” Later, in 1928,
Maxcy! isolated strains from the south-eastern
United States which also produced Mooser cells in
the tunica vaginalis of male guineapigs. Shortly
afterwards DYER and his colleagues 1?
forward conclusive evidence that the rat flea was a
carrier of what is now known as murine typhus,
a disease endemic not only in America but in Europe,
Asia, and Africa. Investigations on louse-borne
epidemic strains soon showed that some of these also
produced scrotal reactions in guineapigs, though the
lesions were not so frequent or so advanced as with
murine strains. Moosrer}* was therefore led to
regard the differences between murine and louse-
borne typhus as quantitative rather than qualitative,
and to suggest that the classical strain results from
the adaptation of the murine strain to the louse-
man-louse cycle of transmission. No conclusive
evidence, however, has yet been advanced for the
soundness of this hypothesis. We are still uncertain
how typhus manages to persist for years in a popula-
: Terres, J. Mem. Segundo Cong. nacional d. Tabardillo, Mexico,
1
Sinclair C. C., Maxcy, K.F. Publ. Hlth Rep., Wash. 1925, 40,241.
Hone, F. S. Med. J. Aust. 1922, i, 1.
` Wheatland, F. T. ibid, 1926, i, 26.
: Fletcher, W., Lesslar, . E. Bull. Inst. med. Res. F.M.S.,
Kuala Lumpur, 1925, 2
r. med. * Ass. 1928, 91
. Mooser, H. J. Ame
.. Was a $3,1 1105.
11. meae K.F. Publ. h Rep., Wash. 89.
12. . B., Ranih, A., Badger, L. Fr "Ibid, 1931, 46, , 334,
st tty 2415, 2481.
13. Mooser, H. Arch. Inst. Past. Tunis, 1932, 21,17.
ped `
CLUES TO THE ANTI-ANÆMIC LIVER PRINCIPLE
brought |
[oor. 12, 1946
tion where no known cases exist. There are three
possibilities : (1) the rat and the rat flea may maintain
the infection which: periodically becomes converted
into the louse-borne form when a patient with murine
typhus also harbours lice; (2) the faces of lice
deposited on clothes and furs may retain their activity
for many months, a view specially favoured by
Polish, and German workers ; or (3) persons who have
had typhus may carry the rickettsiæ in the. bone-
marrow and may relapse after months or years.
ZINSSER,14 working on Brill’s disease in Boston,
convinced himself that all cases of that. disease were
late relapses of a typhus infection acquired -many
years previously in Eastern Europe, and MoosEr!
has recently observed a case of classical louse-borne
typhus in Zurich in a man who had suffered . from
typhus in Russia in 1918.
The other typhus-like fevers have now been
classified. In the Mediterranean area fiévre bouton-
neuse has been shown to be related to Rocky Mountain
spotted fever, as is the South African tick-borne
fever and incidentally that discovered during the war
in West Africa. Sad Paulo typhus i is now known to be
identical with Rocky Mountain spotted fever. The
scrub typhus of India, Malaya, and Java is identical ©
with tsutsugamushi, while the so-called Manchurian
typhus turns out to be of the murine type. Recent
studies on the tick-borne typhus of North Queensland
suggest that it may be related antigenically to the
South African form. Great progress has also been
made in the production of vaccines, which, if not
entirely protective, are sufficient to lessen the severity
of the infection. In p-aminobenzoic acid a chemo-
therapeutic remedy of considerable value has been.
discovered. Finally, there have been developed
insecticides, such as D.D.T., whose lethal- action
on lice was demonstrated by MoosER?® as early as
September, 1942. The researches of the last twenty
years have thus clearly pointed the way to the control
and eventual elimination of the rickettsial infections.
Clues to the Anti-anemic Liver Principle
Ir is twenty years since MınorT and MURPHY intro-
duced the liver treatment of pernicious anemia; and
for twenty years biochemists have been striving to
find out just what it is in liver that has this anti-
anæmic effect. The clinical worker who follows their
work! will find himself in a world of filtrates, :precipi-.
tates, extracts, eluates, and dialysates, and may well
ask if such a protracted effort in which, from the lack
of a satisfactory animal test, every step had to be
checked on human beings has been worth while.
The answer is that this research has brought pro-
gressively more effective materials for the treatment
of pernicious and allied anæmias, and has taught us
a great deal about the composition of anti-anzmic
factors. It has reduced the amount of solid material
needed to bring about remission in a patient with
pernicious anzmia from several kilogrammes to ‘about
20 mg., and for maintenance in normal health from
400 g. a day to less than 1 mg., and it has replaced
the daily “ sandwiches ” of almost raw liver by an
14. Zinsser, H. Amer. J. Hyg. 1934, 20, 513.
15. Mooser, H. Schweiz. med. Wschr. 1944, 74, 947.
1. see. the review by SubbaRow, Y., Hastings, À.. , Elkin, M., in
tamins and Hormones. Edite 6) Ae oie à K. V.
Taming New York, 1945, ah ge D. Ros 37.
wits,
THE LANCET]
intramuscular injection of l c.cm. once a week or even
once a mònth.
In 1927 Coun and his co-workers started by
preparing a liver extract free from known vitamins ;
they eventually obtained a material containing 10:8%
nitrogen which they thought was a nitrogenous base,
but its low nitrogen content excluded purine or
pyrimidine bases. West showed that phosphorus-
free fractions were active, and obtained a material
thought to be a peptide or diketo-piperazine, and on
hydrolysis -was able to identify §-hydroxy-glutamic
acid among others. In 1935 Dakin and West
adopted a different technique for fractionating COHN’s
parenteral liver product, using Reinecke acid, and
they obtained a material of which ‘ Anahzemin’ is a
type. Hydrolysis of this product yielded arginine,
lysine, leucine, a trace of histidine, hydroxyproline,
aspartic and glutamic acids, glycine, and 15% of
aminohexose ; pyrimidine and purine bases were
absent. Later they obtained active preparations free
from aminohexose, and finally concluded that the
hzemopoietic substance in liver was, or was associated
with, a peptide “ possessing many, but by no means
all, of the properties of an albumose.” In 1942
WEsT and Moore, by electrophoretic methods, split
up their most active fraction still further into an
active “ slow component ”’ and a practically inactive
‘* fast component.” A group of Scandinavian workers
tackled the problem by utilising adsorption on char-
coal and elution with phenol, and two of them, LaLanp
and KLEM, eventually prepared active fractions
0:2-03 mg. of which corresponded to 100 g. of liver ;
but the technique seemed to spread the anti-anzmic
principle among different fractions, rather than effect
a separation. Ten years ago, in Manchester, WILKIN-
SON purified still further the Reinecke acid precipitates
and obtained a material of which 18-36 mg. would
produce a complete remission of pernicious anemia—
the greatest concentration of active material so far
obtained. In Switzerland, KARRER and his associates,
using an initial acetone extraction, and adsorption on
charcoal with phenol elution, prepared materials of
similar activity to WILKINSON’ s. This material was
. free from flavine, pterine, and reducing carbohydrates ;
it contained a small amount of sulphur, and yielded
amino-acids, including arginine and tyrosine, on
hydrolysis. In 1937 SussaRow and his colleagues
postulated that the active principle comprised more
than one factor; they described a primary hæmo-
poietic factor and three accessory factors—l-tyrosine,
a complex purine, and a peptide. The accessory
factors were inactive by themselves but when com-
bined with the primary factor they gave rise to a
much better response than did the primary factor
alone. The complex purine was later found to be an
impure mixture containing mainly xanthine, but also
a strongly fluorescent xanthopterin. Attempts to
determine the nature of the primary factor failed,
but its properties suggested a pyridine derivative.
Many other attempts to identify the liver principle
have been made without, on the whole, adding any-
thing significant to our knowledge. There is general
agreement that it is some form of amino-acid: com-
bination resembling a peptide. Organic chemistry
does not take us further than this point. It is the
stage at which the analysis of the pituitary hormones
and insulin have remained for so long.: The appear-
THREE IN ONE?
focr. 12, 1946 533
ance, during this period of deadlock, of folic acid, a
synthetic hzemopoietic substance with the same anti-
anemic effect as liver principle, is a surprise ; for folic
acid is a pteridyl glutamic acid, and pterines—which
are complex pyrimidines—have repeatedly been
excluded from the analyses of the liver principle.
The manner of folic acid’s action has yet to be worked
out, but it is likely that it acts, like heemopoietin, as an
enzyme catalysing the reaction by which liver principle
is produced in vivo ; for it is this enzyme, rather than
the liver principle itself, that’ is deficient in human
pernicious anemia. The action of folic acid was
demonstrated in the course of researches into the
activity as growth factors of the vitamin-B complex
in bacterial metabolism ; and its discovery once again
illustrates the occasional startling advances gained by
indirect approach when the direct method is gravelled.
Annotations
THREE IN ONE?
IN announcing the establishment of a new Ministry of
Defence ! the Government say that the possible advan- —
tages of combining the medical (and certain other)
services of the Navy, Army, and Air Force—perhaps
under the direct administration of the Defence Minister—
are now being studied. This is welcome news, for, as
we lately indicated,? amalgamation would reduce the
number of doctors needed by the Forces both in peace
and in war. Examples of redundancy in the triple system
both here and overseas are fresh in the minds of those
who served in the late war; and the wastage impressed
even more forcibly the hard-worked civilian doctor.
The medical service must be (1) reasonably economical
in money and men, (2) efficient and readily available to
all, (3) flexible enough to fit in with administrative and
_ operational needs, and (4) capable of rapid expansion
in war. The efficiency of a unified service would, as
now, depend chiefly on the men operating it, but also
on the administration and leadership. Plainly, the
enlistment of able men is of the first importance. One
consideration that has often deterred keen young doctors
from finding a career in the Forces has been the compara-
tive dearth of clinical experience—a disadvantage
which, in a unified service, might be partly offset by the
chance of working, in turn, with each of the three Fighting
Forces, in which everyday medical practice differs, even |
in peace-time. No doubt, too, men could be attracted
by a further increase in the establishment of senior
clinicians ; a perennial grouse against all three Services |
has been the scarcity of senior clinical appointments ; and
many have rejected a Service career knowing that when
they reach a certain rank they will go no further unless
they abandon clinical medicine for an administrative
post. Nevertheless the importance of administration
should not be decried—especially in a single medical
organisation where precise inter-Service codrdination
would be a first essential. In war, not only must the
medical service be rapidly expanded but in all probability
it must also be temporarily broken up into constituent
parts, some of which will come under the operational
control of field commanders. These parts must be |
swiftly and smoothly formed, and, once separated, must
be wel] administered ; and this calls for the training and
maintenance of a corps of administrators out of all
proportion to peace-time needs. One of the difficulties
that may be set against a single service is the restriction
it would impose on the training of this reserve
of administrators. Lay administrative officers were
1. Central Organisation for Defence. Cmd. 6923. H.M. Stationery
Ce. ° 1 e e
2. Lancet, Sept. 21, p. 421.
534 THE LANCET]
THE HOSPITAL OF THE FUTURE
{oor. 12, 1946
employed to some extent in the late war; the Army,
for example, appointed non-medical stretcher-bearer
officers, company officers, registrars, and deputy. assistant
directors of medical services who acquitted themselves
with distinction. No doubt the still wider use of laymen
will be. considered when the reserve of administrators is
in the making. : |
A unified service can be evolved and operated only
by the closest understanding between representatives
of the clinicians, the. medical administrators, and the
combatant arms of the Fighting Services; and the
_ Ministry of Defence might well decide to set up a per-
manent council of this constitution. The difficulties
should not be under-emphasised ; but given good will in
planning, and efficiency in execution, the scheme could
benefit all three Services and enhance Britain’s already
notable reputation in Service medicine.
=. NICOTINIC ACID IN HYPOMENORRHEA
_EXPERIMENTAL results from Australia suggest that
nicotinic acid may be usefully employed in amenorrhea,
hypomenorrhea, and dysmenorrhosa. Hawker! found
that the ovaries of guineapigs which had been given
nicotinic acid in their feeds weighed 44:5 mg. on the
average, whereas the average weight in the untreated
- animals was 36-5 mg. The application of nicotinic acid
to functional disorders of menstruation first suggested
itself when a patient who was under treatment with
nicotinic acid for a, chronic inflammatory lesion at the
corners of her mouth started to menstruate, although
she had never done so before; in addition, she lost
18 lb. in weight in four months, having previously been
inclined to obesity. She was given 75 mg. of nicotinic
acid a day for seven months and has menstruated regu-
larly ever since. For the treatment of hypomenorrhea
Hawker suggests the coincident use of. stilbcstrol
1 mg. three times a day for fourteen days from the
commencement of the period and nicotinic acid 50 mg.
three times a day throughout the whole cycle. His —
nine cases of hypomenorrhea so treated all showed an
increase in the duration and quantity of the flow. The
material on which this paper is based is scanty, but it
would be foolish to belittle any therapy which may
help in these intractable conditions. Further experi-
ments will be needed to discover the exact effect, if any,
of nicotinic acid on the ovary ; meanwhile, this relatively
benign treatment is worth a trial in selected cases.
THE HOSPITAL OF THE FUTURE
'EvEN the most modern hospitals nowadays become
outdated in the course of twenty or thirty years. The
moral seems to be that permanent buildings are not for
hospitals: let them rather be transitory, functional,
easily assembled, and quickly demolished. That is
part of the solution to our present difficulties recom-
mended by Prof. Harry Platt, whose address ? last year
to the Ulster Medical Society has now been reprinted.
A rigid pattern of hospital, he holds, tends to determine
_ function, which is fundamentally wrong. Rebuilding
every thirty years is out of the question, and remodelling
within the shell is a makeshift, not always economical.
- The type of hospital in which function is best served,
Professor Platt considers, is that in which a number of
separate blocks or units, with self-contained ancillary
services, each houses one of the major branches of medi-
cine or surgery. These should be placed on an island
site with a green belt encircling them, and with space
for expansion. Such a multiple-block hospital need
not be unsightly : he recalls a fine example of harmonious
layout in the University Hospital at Lund, in Sweden,
where the separate clinics are Georgian in style, though
1. Hawker, R. W. Med. J. Aust. 1946, i, 872. `
2. Ulster Medical Journal, May, 1946. n
-** shack period.”
widely differing in age. In Manchester, his own
university, the Royal Infirmary, built on the pavilion
plan in 1908 is. already becoming out of date in every
way as a university teaching hospital, and the adjacent
Eye Hospital, and St. Mary’s. Hospital for Women and
Children are both structurally obsolete. There is,
however, a large potential island site of some 100 acres,
visible from the air, which is to be zoned, cleared of some
dingy property, and dedicated to’the purposes of a new
hospital centre. | an a e N
In Manchester the separate institutes are to melude
university preclinical departments of anatomy,- physio-
logy, and pharmacology ; separate units of medicine,
surgery, obstetrics, child health, orthopaedics, neurology,
ophthalmology, otolaryngology, radiology, dermatology,
an institute for the chronic sick, and a health centre;
a group of administrative, educational, and residential
blocks—including the administrative headquarters. of
the hospital centre, the preliminary training school for
nurses, students’ hostels, residential flats for the staff,
and a medical institute and library: Professor Platt
even foreshadows a shopping centre. But the first
stage will be what the university architect calls the
The first new block contemplated is
a neurological institute of 120 beds with both public and
private wards and its own outpatient clinic; it will
also have its own X-ray department and pathological
laboratories, in both of which research will be under-
taken. The director, and probably his assistant, will.
have consulting-rooms in the institute. The principle
of the multi-institute hospital could probably be applied;
Professor Platt thinks, on a miniature scale in smaller
cities. | 2 l
Building itself is in a state of rapid change at present,
and he suggests that it would be profitable to choose
and subsidise a hospital architect, and give him'five years
to study and travel. Meanwhile hospitals could be making
use of the shack period to concentrate on personnel:
THE BUSY NERVOUS SYSTEM
_ Ir may be possible to predict what will happen when
a known electrical force is released into a known circuit ;
but when conditions within the circuit are constantly
varying, what then? Prof. J. Z. Young, in his inaugural
lecture at University College, London, last February
(now published 1), described the ceaseless change which
is the normal state of the nervous system, and attacked
firmly the custom of representing it as a mere telegraph
system along which messages are transmitted: `
We now think of nerve-cells as elongated bags of fluid
in which compounds are constantly being built up and
broken down. And, thanks to studies on the giant
nerve-fibres of the squid, we know that the fluid runs
the length of the fibres, which therefore have the pro-
perties of cylinders of liquid. They are conductors, but
not passive conductors like electric wires; for a nerve-
fibre is made ready to conduct by “‘ the production of a
state of tension usually referred to as a charge across its
membrane.” The nerve-cell works hard to: maintain
the fibre in the right condition to: respond to such
a charge. The various sensory nerve-endings are
similarly triggered, but not all in the ‘same way—one
will respond to touch, another to temperature, another
to light, and each must be maintained in the right state
to do its selective work.
The mechanistic theories on which most of us were
brought up paid much attention to reflex action, leaving
us with a picture of a conducting system which responded
in a given way to a given stimulus, but which, in the
absence of such stimuli, returned to a state of rest- or
inactivity. This picture, it seems, has had a wide
influence on our attitudes and behaviour, not only in
1. Patterns of Substance and Activity in the ‘Nérvous System.
London: H. K. Lewis. 1946, Pp.19. 1s. 6d.
THE LANCET]
- medicine and science but in life generally, for it implies
determinism. For Professor Young, ‘‘ this view of the
. organism as a marionette dancing under the pull of its
sensory impulses is wrong. There are abundant quite
simple facts which show clearly that the brain is not by
any means a passive thing, receiving all its orders from
outside. Its actions cannot all be adequately described
as reflex, as reflections of outside influence.”
Physiologists in general, he considers, have not yet
responded fully to the facts revealed -by the electro-
encephalograph—that there are continuous rhythmical
changes of potential betwéen neighbouring parts of the
brain. These are independent of external stimuli:
rhythmical activity of the kind continues in the fore-
brain of the frog even in a piece of brain removed from
the body. When an image falls on the retina a pattern
of nerve impulses is sent to the cortex of the occipital
lobe; but the cells there are already active, ‘‘ exciting
each other or changing their thresholds in manners as
yet unknown.” This activity must certainly affect the
reaction of the brain to the impulses reaching it. In this,
he feels, we may begin to study the problems of recogni-
tion of form and the p process of learning. “‘ Remembering ”
may consist in “ the maintenance of a particular pattern
or mode of activity.”
In this conception of the brain as a continually active
agent he sees the opportunity for a much more fruitful
collaboration between anatomy, physiology, neurology,
and psychology than was possible on the basis of the
reflex concept. To those who think of anatomy as a
cut-and-dried subject, which early reached the end of
its gge of discovery, it will be revealing to learn that
‘whatever part of the body you study you soon find that
very little is known about it, at least from current points
of view.” Professor Young wishes to see more than
collaboration between anatomists and physiologists :
he would have a fusion in which those expert in special
techniques work side by side, remembering that they
are dealing with ‘‘ an organised substance in a state of
organised and directed activity.”
. HEPARIN IN INFECTIVE ENDOCARDITIS
THE possibilities of heparin in the treatment of infective
endocarditis have been overshadowed by recent spec-
tacular successes with penicillin. Although final evalua-
tion is not yet possible, it now seems certain that heparin,
if used at all, will be used rarely in this disease. It was
first employed in the treatment of endocarditis in 1939,
and it was soon found that its problematical advantages
are usually outweighed by its proved dangers. When
heparin was given in conjunction with sulphonamides,
the recovery-rate—6-5%—was an improvement of only
2. 5% over results with chemotherapy alone. When it
is given with penicillin, hemorrhagic complications are
more common than with penicillin alone, although the
recovery-rate (55%) remains high ; no direct synergism
between heparin and penicillin can be demonstrated.?
Dawson and Hunter * have summarised current opinion
in concluding that heparin is not essential to the treat-
ment of infective endocarditis. They find only two
indications for its use: to prevent retrograde intra-
vascular clotting where a large embolus lodges in a vessel ;
and to inhibit thrombosis when penicillin is given intra-
venously. The latter indication is now rarely encountered
since the intravenous route has been virtually abandoned
in favour of intramuscular injection, which gives equally
good results ; moreover, the increased purity of present-
day penicillin has undoubtedly lessened the risk of
intravenous clotting. Other workers 4 advise resort to
. Friedman, M., Hamburger, W. W., Katz, L. N. J. Amer. med. Ass.
ere 113, » 402. Kelson, S. R., White, P.D. Ann. intern. Med.
9
2. Mokotoff, R., Brams, W., Katz, L., Howell, K. M. Amer. J.
i med. Sct. 1
1946, 211, 395.
3. Dawson. Me H., H . H. Ann, intern. Med. 1946, 24, 170.
unter,
. McKrill, N. Ah intern. Med. 1946, 77, 367.
; HEPARIN IN INFECTIVE ENDOCARDITIS
[ocT, 12, 1946 535
heparin only when the disease has not responded to one
course of penicillin, and add: ‘in such a case we would
hope that heparin might cause disintegration of the
vegetations and pray that the fragments will not enter
the cerebral vessels.” |
The value of penicillin in infective endocarditis has
now been firmly established in this country.5 The
principal points which suggest that the drug is likely to
fail are congestive failure, particularly when the aortic
valve is infected ; embolic incidents ; and a long history.
Where the condition has existed for more than a few
months there is increased resistance to the penetration
of penicillin according to the size of the vegetations and
the fibrin and platelet barrier with which they are
covered. Necropsies have not provided histological proof
that anticoagulants influence the course of the disease
under such circumstances*; nevertheless, the bad
prognosis in these resistant cases may still tempt physi-
cians to give heparin a further trial on the score that
nothing can be lost by heroic measures. .
SUPPLIES OF ARTIFICIAL | RADIOACTIVE
SUBSTANCES |
TuE Government is to establish a national centre for
the processing and distribution of radium, radon, and
artificial radioactive substances for scientific, medical,
and industrial purposes. The centre will be operated
by Thorium Ltd., acting as agents for the Ministry of
Supply, and as a first step the Ministry will purchase its
buildings and plant at Amersham, Bucks. The extraction
of radon, which during the war was carried on at Barton-
in-the-Clay under the auspices of the Medical Research
Council, will be transferred to the new centre, and
Johnson Matthey & Co., Ltd., are voluntarily handing
over to it their business of filling radium into containers.
The Amersham site will not be large enough to accom-
modate the centre permanently, so it will be removed
to new premises when the shortage of building labour
has eased and the volume and scale of its work can be
assessed more clearly. The centre will be controlled by
a council, which will include representatives of the
Ministry of Supply, the managing agents, and users of
its products.
In the United States the distribution of radioisotopes
prepared at the Clinton Laboratories, Oak. Ridge,
Tennessee, began in August, the first recipient being the.
Barnard Free Skin and Cancer Hospital of St. Louis,
which received a so-called unit of carbon 14 (C14) weigh-
ing about one ten-thousandth of an ounce. The unit has
a radioactivity equal to that of 1 millicurie, and, since
future investigators with radioisotopes will often refer
to the actual emission of the substances they are using,
it may be recalled that 1 millicurie emits 37 million
alpha particles per second. It is understood that activities
will be referred to in terms of the curie or millicurie
rather than to radium; the C!4 unit cost the hospital
about $400, which can be reckoned a permanent invest-
ment, seeing that the half-life of C4 is estimated to be
between 10,000 and 25,000 years. It is to be used for
studying the processes by ‘which cancer is produced.
The investigations planned! will tackle such diverse
medical problems as the mechanism of cancer production,
the utilisation of sugar in diabetes, the dysfunction of the
thyroid gland, the growth and composition of tooth
and bone, and the role of iron in anemia. Outside the
fields of medicine the various new isotopes will be applied
to problems in agriculture and industry ; the outstanding
agricultural problem to be studied is the mechanism by
which plants utilise the energy of sunlight. Most of the
subjects for study are not essentially new, but the method
5. Ch Christie, R. AA Lancet, 1946, i, 369.
Prios t W. 8. , Hildebrand, E, Proce. Inst. Med., Chicago, 1946,
1. See News Notes (Washington), August August 15, 1946.
536 THE LANCET]
of approach may be said to be so, for the investigators
aim at following processes step by step, any faltering
being signalled to the observer by the Geiger counters
in circuit.
ANTICOAGULANTS IN CORONARY THROMBOSIS
EMBOLI and thromboses in various parts of the arterial
system are recognised complications of coronary throm-
bosis, occurring in 14% of Blumer’s 1000 cases, and in
18 of the 100 cases reported by Nay and Barnes.?' These
complications have usually been attributed to narrowing
of the arterial lumen and stasis in the blood-flow, but
Peters and colleagues * have noted that in three-quarters
of their patients with coronary thrombosis there was
an increased prothrombin activity. This observation is
in agreement with de Takats’s $ observation that patients
with coronary thrombosis show an increased resistance
to heparin.
In view -of. Solandt and Best's evidence: 5 that myo-
cardial infarction -and thrombus formation in the
coronary tree can be prevented by the administration of
heparin, it was only natural that physicians should
consider its clinical application. There are difficulties
and even dangers in this use of heparin; but the intro-
duction of dicoumarol by Link and his colleagues ê
gave fresh impetus to the study, and several reports
have recently appeared in American journals.‘ Peters
and his associates have used dicoumarol in a series of
50 patients with coronary thrombosis, among whom the
incidence of clinical embolism was 2%, as against 16%
in a control group. The mortality-rate in the dicoumarol
group was 4%, compared with 20% in the untreated
group. Although dicoumarol was given for at least six
weeks and sometimes much longer, no serious toxic
effects and no frank hemorrhages were noted; but in
three patients microscopic hematuria was found. It
is emphasised that this treatment should be given only
when there is a laboratory for the estimation of the
prothrombin clotting-time.
are hepatic disease and any blood dyscrasia. Special
care must be exercised in the presence of hypertension,
and the dicoumarol-like action of salicylates* and
quinine ® must be borne in mind. Dosage was determined
entirely by the prothrombin clotting-time of diluted
plasma (12-5%), for which the normal is 85-100 seconds.
The usual dose is 300 mg., which can be repeated daily
unless the prothrombin clotting-time of 12-5% plasma
reaches 400 seconds, which is the upper limit of safety.
Hemorrhage, should it occur, can be controlled by the
intravenous administration of menadione bisulphite
37-5 mg. The scheme is very similar to that of Wright,’
who uses the prothrombin time of undiluted plasma as
his guide: the normal figure here is 13-17 seconds, and
dicoumarol was discontinued if the time exceeded 30
seconds. Wright’s report is only a preliminary one ;
but, considering that most of bis patients were selected
for treatment because of repeated episodes of multiple
thrombi or repeated embolic phenomena elsewhere in
the arterial tree, his results are certainly encouraging.
Of 43 patients selected because of complications known
to be associated with a very high mortality-rate, only
11 (25%) died, compared with an anticipated risk of
60-70% ; while of 33 patients having their first or second
uncomplicated attack of coronary thrombosis, 4 (12°)
died, compared with an anticipated mortality of 20-30%.
Two further aspects are worth considering. It has
been confirmed by Peters and his co-workers that one
- Blumer, G, Ann. intern. med. 1937, 11, 499.
. Nay, R. M., Barnes, A. R. Amer. Heart J. 1945, 30, 65.
Peters, H. R., Guyther, J. R., Brambel, C. EB. J.A Amer. med. Ass.
1946, 130, 398.
. de Takats, G. Surg. Gynec. Obstet. 1943, 77, 31.
Solandt, D. U., Best, C. H. Lancet, 1938, ii, 130.
. Campbell, H. A., Smith, W. K., Roberts, W.
J. biol. Chem. 1941, 138, 1.
. Wright, I. S. Amer. Heart J. 1946, 32, 20.
> Shapiro, S. J. Amer. med. Ass 1944, 125, 546.
miak: A., Engelberg, R. Ibid, 1945, 128, 1093.
L., Link, K. P.
ae Co Ou im toe
ANTICOAGULANTS IN CORONARY THROMBOSIS
Definite contra-indications |
(ocr. 12, 1946
risk in using digitalis for the heart-failure of coronary
thrombosis is its tendency to increase the clotting-time
of the blood.1® Does dicoumarol neutralise this danger ?
Scherf and Schlachman 1! found that the prothrombin
time and the plasma coagulation time are shortened
after the intravenous administration of theophylline
with ethylenediamine, and also of theophylline sodium
acetate. A similar effect was obtained by ‘the oral
administration of the methylxanthines (theophylline
with ethylene diamine, theobromine, and theobromine
sodium acetate). This is nat a new observation (some
of the earlier German workers actually recommended
theophylline with ethylenediamine as a coagulant, and
‘Wright gave it as part of his “ conventional treatment ”
to patients receiving dicoumarol); but it suggests that
a careful review of our treatment of coronary thrombosis
is called for. Until much fuller data are obtained
dicoumarol should clearly be used only in “selected
cases treated in hospitals.
SIXTH AND LAST
THE final issue of the sixth volume of the ‘Bulletin of
War Medicine contains'two epilogues which mark the
end of this publication. The first, by Sir Edward
Mellanby, F.R.S., secretary of the Medical Research
Council, recounts briefly the history of its inception ; the
second, by Dr. Charles Wilcocks, director of the Bureau
of Hygiene and Tropical Diseases, acknowledges the
services of all those whose work contributed to the value
of the Bulletin. Together, these epilogues reflect a fruitful
collaboration between the Medical Research Council and
its publications officer, the bureau, and the large number
of abstracters who devoted part of their meagre leisure
to the task of providing medical information for those
who otherwise might have missed it. Though the
immediate purpose of the Bulletin has now been served,
the medical historians of the war will find in it much
of the material they may need for describing the develop-
ments of that period of—in some directions—phenomenal
progress. The rapid growth of knowledge in relation to
transfusion, penicillin, D.D.T., and mepacrine, for instance,
is reflected in these abstracts.
The enormous importance of diseases (especially
tropical diseases) in military campaigns has been
reaffirmed during the war, when the success of operations
turned on the maintenance of forces healthy enough to
undertake them. That many of the problems involved
were quickly solved was largely due to the stimulus
given to research by the urgency of the situation. But
the same or similar problems persist among the indigenous
inhabitants of these tropical countries, and we must
hope that research will be pursued as vigorously for
peace as for war. There is still, therefore, the same need
for information on tropical diseases and on public-health
measures, and this will continue to be supplied by the
bureau in its two publications, the Tropical Diseases
Bulletin and the Bulletin of Hygiene, which were in
existence long before the war, and which were the models
on which the Bulletin of War Medicine was based.
A MEETING has been arranged at the London School of
Hygiene, Keppel Street, London, W.C.1, for Thursday,
Oct. 17, at 3.30 P.M., with the object “of inaugurating a
council for the care of spastic children. The chair will be
taken by Mr. G. R. Girdlestone, F.R.c.S. The acting
secretary is Mr. H. P. Weston, c/o Council for the Care of
Cripples, 34, Eccleston Square, S.W.1.
WE regret to record that Lieut. -Colonel R. J. C.
THOMPSON, who retired from the secretaryship of
St. Thomas’s Hospital medical school last month, died on
Oct. 2. He was 66 years of age.
10. Ce D., Trump, R. A., Gilbert, N. C. Ibid, 1944, 125,
11. Scherf, D., Schlachman, M. Amer. J. med. Sci. 1946, 213,
THE LANCET]
TUBERCULOSIS IN POLAND
focr. 12, 1946 537
Special Articles
TUBERCULOSIS IN POLAND .
Marc DANIELS
M.D. Paris, L.R.C.P.E., D.P.H.
MEDICAL OFFICER, HEALTH DIVISION, UNRRA -
` Tms report is based on information collected during
six weeks’ tour of the Polish tuberculosis services,
covering the areas of eleven of the sixteen regional
authorities, and including personal visits to twenty-
three sanatoria and numerous hospitals and dispensaries,
and discussions with doctors in these places, in provincial
health offices, and at the ministry of health. :
The situation, a tragic one, must be set against the
background of war-time and post-war Poland. The
six years’ occupation of Poland was so grim that the
people must be considered primarily as survivors of
the occupation. Almost every Pole has lost relations
or a home, has starved, or has lived in unimaginable
conditions. Very many can roll up a sleeve and show
concentration-camp numbers tattooed on their arm.
The Germans set about systematic extermination of
intellectuals and professional people, with the object of
reducing Poles to the level of slaves. Leading medical
specialists were taken from the wards and shot in their
offices or against a street wall. Their equipment and
apparatus for research was stolen or deliberately
destroyed, as were their documents representing many
years of valuable work. Of the 12,900 doctors in 1939
only 6000 are left. In a rural area we gave a lift to a
country doctor; he is sole doctor for an area with
14,000 people and has no car. Nurses also are very
scarce ; half of them were killed during the war.
The devastation of Warsaw, Poznan, and Wroclaw
is indescribable. Warsaw was destroyed systematically,
house by house, street by street. In the shambles
that remain live half a million people. Among this
population living in dark cellars and one-room flats
which by a miracle retain four walls and a ceiling there
are several thousand cases of tuberculosis.. Overcrowding
and shortage of food provide all the tubercle bacillus
requires in order to flourish. In.devastated rural areas
families are living in dugouts and mud huts. Millions of
acres are still lying fallow for lack of seed, equipment,
or labour. Some areas have yet to be cleared of mines ;
peasants impatient to plough their land are sometimes
blown to pieces.
To the rural areas are returning peasants and children
of peasants who were taken off for slave labour in
Germany. Many contracted tuberculosis there and,
returning home, are spreading infection. Millions of the
people are, or have recently been, on the move. They
return from camps for displaced persons in Germany,
from the armies, from Russia. Large communities
are being transferred from the old eastern provinces to
the newly acquired western provinces. People who
sought refuge in the country during the war are trying
to return to the city, even to Warsaw. `
- Against this background of devastation and potential
chaos reconstruction is going on. Some of the work
is described in this report. In assessing the services and
work done to date, the background must not be forgotten.
The work of public- health officers with no records, of
professors of medicine with no clinics, of scientists with
no laboratory or equipment in Poland needs to be seen
to be believed.
MORTALITY
There has been an alarming increase of tuberculosis
in Poland during the war years, and the disease is now
widespread. Destruction of all pre-war records by the
Germans renders detailed comparisons impossible. During
the war only such services were allowed to function as
would protect the Germans from danger of infection,
and public-health services worked on a very reduced
scale. Towards the end of the war, during the retreat,
there was wilful destruction of public buildings and
records. At present the services are being restored, but
records are still very limited and fragmentary, since
new workers are being trained to replace the many
thousands killed and executed, and many new workers
are still inexperienced and overworked. In view of these
limitations, statistical information has been considered
carefully, and only that considered valid after personal
discussion with the health authorities is given here.
The only figures of value come from large towns. Death
certificates outside towns may be given by non-medical
persons and are for statistical purposes valueless.
Warsaw.—The number of deaths from tuberculosis
per 100,000, already high before the war, rose 200% in
the war years, from 155 to 452 in 1941 and 500 in 1944,
Before the war the rate was four times as high as in
U.S.A. (white population) ; in 1944 it was fifteen times
as high. The tuberculosis mortality in Warsaw and
Lodz, compared with that in U.S.A., Copenhagen, and
Stockholm, was as follows :
1938 «1941 1944
Warsaw ; a 155 .. 452 500
Lodz : All persons .. 176 316 371
; Germans 3 139 155
Poles es 378 461 —
_ U.S.A. (whites) 39 35 34
-© New York (all persons) | ss 46 48
_ Copenhagen .. \ 51 44 40
Stockholm .. 92 75 70
In 1945 the registered tuberculosis deaths in Warsaw
totalled 1189, which figure for a population of 400,000
gives a death-rate of 297. It must. be remembered,
however, that in that year, after the destruction of the
city, the population numbered only.a few thousands in
January, and former inhabitants returned during and
after liberation, to reach a total of nearly half a. million
only at the end of the year. If a mid-year population
figure were available, the rate on this basis would be much
higher than 297.
The recent census has bowi that the proportion of
young adults in Warsaw has fallen to an. abnormally
low level, owing to killing and deportation of all active
members of the community; the population age-
distribution curve shows a well-marked dip between the.
ages of 15 and 30. An adjustment of the death-rate
to take into account the absence of this most susceptible
age-group would have the effect of raising the rate
considerably. -
In Jews the death-rate before the war was relatively |
low, about 80. In 1941 it had risen to 440.
Lodz.—Here the mortality rose from 176 before the
war to 401 in 1943, dropping later to 371 in 1944 and
288 in 1945. The war-time rates relate to the combined
German and Polish population. For the Poles alone,
the figure was 488 in 1943 and 461 in 1944, while in
Germans the death-rate was only a third of that in the
Poles (see fig. 1).
Poznan. — Mortality rose from 198 before the war
to 360 at the end of the war.
Krakow.—In 1945 there were 615 deaths from tuber-
culosis in a of 221,260, a death-rate of 278.
INCIDENCE
Mass Rädiographi Surveys.—This is the most valuable
method of determining incidence of pulmonary tuber-
culosis in large communities.. Several such surveys have
been made in Poland since the end of the war. There
are no similar results covering the pre-war period, but
these recent figures are very striking.
$
1
538 THE LANCET]
'(1) At Krakow University 9387 students: have
been examined by mass radiography in ‘1945-46,
with the result that 392 (42%) are’ found to have
tuberculous: lesions: considered active, and - 623
(66%) tuberculous lesions | requiring observation,
making a total of 10:8% who require ‘treatment or
~ observation. |
(2) In the Poznan surveys of 1945-46 7% of 4000
university students, 6-5% of 201 high-school students,
7-1% of 463 school-children, and 13-5% of 1361 factory
employees have been found to have tuberculous lesions
requiring treatment or observation.
(3) A Swedish Relief Service team is examining
students in Warsaw. Provisional results, for 2000 students,
indicate that over 15% have pulmonary tuberculosis
requiring treatment or observation.
(4) During the occupation 1941-44, of 180,000 rail-
way employees examined by the social-insurance
organisation 7% were found to have pulmonary
tuberculosis requiring treatment and. 5% required
observation. |
Mass Radioscopy Surveys.—Of 4220 Lodz high-school
and university students examined 5:8% have tuberculous
lesions requiring treatment or observation; and of
1500 Lublin university students examined 2:1% have
tuberculous lesions requiring treatment and 9-7%
have tuberculous lesions requiring observation. These
figures of the results of mass X-ray examinations are
approximately ten times as high as corresponding
_ figures in England (fig. 2) or the U.S.A. They confirm
the impression given by the very high mortality i in large
towns of Poland.
Known Clinical Cases. _‘The “figures given ‘above
indicate the prevalence of undiagnosed tuberculosis in
` the general population. They do not include the known
cases, diagnosed by ordinary clinical methods. Tuber-
culgsis is not notifiable in Poland ; but some information
is provided by the numbers of patients attending tuber-
culosis dispensaries. In Upper Silesia, in a population of
1,600,000, there are over 16,000 cases (1%) known to
the tuberculosis clinics. In Poznan, a city of 283,000
inhabitants, there are 3293 (1-2%) cases known to the
city dispensary. In the town of Zgierz 1-7% of the
population are known to be tuberculous and requiring
treatment. These figures are high compared with
similar figures in U.S.A. and Great Britain. More-
over it must be emphasised that not all cases are reported
to the tuberculosis clinics; the figure, therefore, falls
far short of the total of diagnosed cases. `
. WARSAW
1930-44
DEATHS PER 100,000-
Fig. |—Tuberculosis mortality in Warsaw and Lodz.
TUBERCULOSIS: IN POLAND
~ schemes.
_ specialised personnel.
[ocr. 12, 1946
TUBERCULOSIS SERVICES
After 1918, legislation placed the onus for establishing
and maintaming dispensaries, tuberculosis: wards, and
sanatoria on the smaller local authorities—districts or
communes—empowering them to unite to form joint
The province (vaivodeship) was to have
an overall responsibility of directing the small local
authority regarding when and where such services should
be established. General control was exercised by the
ia of health of the ae of lsbour and
LESIONS REQUIRING TREATMENT E
LESION RESVEING OBSERVATION EJ
ENGLISH FACTORY HB
WORKERS
| KRAKOW STUDENTS valentines BRE
POLISH RAILWAY
WORKERS _
LODZ STUDENTS
LUBLIN STUDENTS RA:
6
INCIDENCE |
. Fig. 2—-Incidence of tuberculosis found by mass. X-ray surveys.
social welfare. adcadonal and propaganda” wotlk
was conducted largely by the National Anti-Tuberculosis
Association.
The main work of the services was conducted from
tuberculosis dispensaries, which numbered 532 in 1937.
Of these, 436 were in health centres administered mainly
by the local authority and providing diagnostic and
treatment facilities for venereal diseases, trachoma,
tuberculosis, and incorporating also maternity and
child-welfare services. They were staffed by doctors
who usually also carried on private practice and worked
for social-insurance and other organisations. The social-
insurance body also conducted a few tuberculosis
dispensaries independently.
In 1938 there were 2680 beds for tuberculosis in —
general hospitals and 5638 in 45 sanatoria. Only 7
of the sanatoria belonged to local authorities ; the rest
were owned by the social-insurance organisation, private
bodies, Polish Red Cross, and professional and occupa-
tional associations. There was no central. or regional
control or planning of the institutions.
Payment for hospital and sanatorium treatment was
the responsibility of district local authorities in all cases
not covered by such organisations as social insurance.
Local-authority funds being very limited, this meant in
practice that institutional treatment could be provided
to only a very small proportion of those unprotected by
insurance or private income.
At the present time general control is exercised by the
tuberculosis control section of the newly created ministry
of health; the section is directed by Dr. Telatycki.
Regional health control is exercised through the health |
departments of the fourteen provinces and of the cities
of Warsaw and Lodz. The tuberculosis subcommittee
of the National Health Council acts as an advisory body.
The Anti-Tuberculosis Association is being reconstituted.
Dispensary Service.—The services, which suffered severe
losses during the war, are being reorganised with more or
less the same general structure, and the same unequal
division of financial responsibilities. Dispensaries, many |
of which ceased to function during the war, and which
in any case were allowed to serve only as diagnostic |
centres without being able to provide or arrange for treat-
ment, are now being rapidly restored; 440 are operating
at present, nearly all within health centres. : There is a
serious lack of equipment, X-ray units especially, and
a great shortage of doctors and nurses, particularly of
-The doctors at these centres,
THE LANCET] |
TUBERCULOSIS.IN POLAND
[ocr. 12, 1946 539
nearly all of them doing this service in addition to busy
private practice, are doing a heavy job of work. Rela-
tively few of them have any particular training in tuber-
culosis. In the province of Kielce, for instance, for
forty-five dispensaries there are forty-five doctors,
only four of whom have special qualifications. The
dispensary service, main prop of the tuberculosis organi-
sation, is for the most part staffed by unspecialised per-
- sonnel provided with a hare minimum of equipment, and
struggling with an ever-increasing tide of tuberculous
patients. The.chief tuberculosis officer (also part-time)
in the provincial health department has very little
authority either over the dispensary service or over the
sanatoria.
Case-finding Surveys. — Several case-finding schemes
are under way; the results of some of these have
been given. There are seven photofluorographic units,
located as follows :
1 in Warsaw, in op., 70 mm., Swedish Relief Service.
1 in Krakow 35 mm.
: N Belongs to social-
1 in Poznan, ,, 35 mm. } l on
1 in Poznan, not in op., lens missing ) ‘*Urance organisation.
2 in Bydgoszcz, ,,
1 in Katowice, _,,
The main universities have an excellent diagnostic
service for their students resumed on the same basis
as before the war. There is also a very fine students’
sanatorium, probably the first to have been founded in
Europe (inaugurated in 1907).
Hospital and Sanatorium Services.—A complete picture
of these services cannot be given at present, as the
situation changes from day to day; only information
collected quite recently is presented. .
In general hospitals, out of a total of 86,000 beds,
4000 are set aside for the treatment of tuberculosis.
During the six years of war all the sanatoria except
one were occupied by the Germans. Towards the end
of the war, as the Germans retreated, they destroyed,
looted, and burnt many of the buildings, stripping them
of all equipment. This was the situation the Poles faced
a year ago: a country which had been without sanatorium
facilities for its tuberculosis population for six years,
sanatoria destroyed, sanatoria with no beds, no equip-
ment, and no staff. During the past year people have
been occupied with the enormous task of restoring these
sanatoria within the Polish tuberculosis services. Almost
the whole time, for instance, of the director of the
students’ sanatorium in Zakopane is taken up by problems
of rebuilding and by search for equipment, instruments,
and drugs. This search, in a country plundered
systematically during the war, is no easy task. Principal
items lacking are thoracoscopes, replacement bulbs for
thoracoscopes, surgical sets for thoracoplasty, X-ray
film, developer, and fixer, X-ray tubes, needles, plaster,
laboratory reagents, and narcotics.
In spite of lack of material the sanatoria are being
restored very rapidly. Much equipment has been
received from Unrra. There is now more sanatorium
accommodation than before the war, thanks to the
acquisition of previously German institutions in Lower
Silesia. There are 11,580 “‘ potential ’’ sanatorium beds.
A description of the situation in Southern Poland, where
most of the best sanatoria stand, will help to explain
what this “ potential ” figure means at present.
In Lower.and Upper Silesia and in Zakopane there are
sixteen sanatoria with a possible total of 6078 beds:
1301 are not yet ready (equipment lacking, premises not
completed); 1840 are still requisitioned by armed
forces ; and 2937 are available for tuberculous patients.
Of the 2937 available beds 1905 are occupied by patients
(of whom 237 are German) and 1032 are empty. =
The 2937 beds are in excellent sanatoria, equipped for
active treatment of tuberculosis and staffed by competent
doctors. Yet 1032 stand empty. The main reason for
this lies in the financial difficulties of the health authorities
Belongs to dispensary
awaiting film service.
responsible. For some patients cost of hospital treatment
may be covered by an insurance organisation, the
Polish Red Cross, or the ministry of health, which
_ assumes responsibility for treatment of repatriates.
A few persons may bear the cost privately. But the
majority have no protection of any kind, and for them
the small local authorities are theoretically responsible
for provision of treatment for tuberculosis. In fact,
with the present high cost of maintenance in institutions,
100-200 zlotys a day, and with few local taxes collectable,
most authorities can only afford to maintain very few
patients in hospital or sanatoria. Most of their patients,
when they do go, are sent only for a short time. From
Lublin city dispensary for instance, where 1211 new
cases were diagnosed in 1945, only 99 patients were sent
to hospital (for an average interval of three weeks)
and 9 to sanatoria. This dispensary has a waiting-list
of 646 persons. Bydgoszcz provincial authority has a
good sanatorium at Smukala, with 124 beds, yet of the
360 new tuberculous patients diagnosed in the first three
months of this year none could be sent to sanatoria.
The ministry of health is able to pay for only 1000
patients for the whole country, and these include repat-
riates. For patients unprotected by insurance, private
income, or otherwise, there is little hope of any treatment
other than two weeks in the local hospital for induction
of pneumothorax when this is thought advisable; they
are then sent home again. These patients are the ones
in the worst economic condition ; it is not difficult to
imagine the prognosis for such patients, and the risks —
for their families. Even for insured patients, the limit
of stay in sanatoria is usually three months.
On the basis of an overall tuberculosis death-rate of —
300 per 100,000, and setting the minimal standard of
100 beds against every 100 deaths, there should be at
least 66,000 beds. There are only 11,580; and, though
half of these are not ready or are still "requisitioned,
there are still many beds standing empty because no
one can bear the cost.
The main cost is food. Sanatoria are obliged to buy
most of their food in the open market. The cost of food
varies from one province to another. In one, 100 zl.
may cover a relatively adequate diet of about 3000
calories (with too high a proportion of carbohydrate) ;
in Lower Silesia 150 zl. may provide only a diet well
below the minimal requirements for a healthy person.
For example, in Zeylandowo, patients receive a small .
portion of meat or fish twice a week, no cheese, and no
butter. For three months they had no milk except. in
soup, now they have 0-25 litre a day. Nurses are con-
stantly leaving because of the bad diet, since they have
the same as patients but minus the milk. In one sana-
torium, arriving at 1 P.M., we partook of the main meal ;
it consisted of a thin vegetable soup and a plate of rice. .
In several institutions the diet is not more than 2000
calories. From Kamieniegura sanatorium we brought
away a complete list of all foods consumed during March
by the 400 persons in the sanatorium. An analysis on
the basis of figures given by the M.R.C. Memorandum
(no. 14, 1945) on “ Nutritive value of war-time foods”
shows that the average daily diet per person in this
sanatorium amounted to 1995 calories, with 348 g. of
carbohydrate, 37 g. of fat, and 67 g. of protein (of
which 23 g. was animal protein).
Thus the problem of food not only affects the condi-
tion of patients in sanatoria but also is indirectly
responsible for many beds standing empty. UNRRA
is committed to a programme of provision of food to the
. whole Polish people through the central government
and cannot undertake specific allocation and distribution ;
but any assistance that could be given in provision of
food to the sanatoria would go a long way to the solution
of their problems.
Staffing of Services.—Reference has already been made
to the severe shortage of doctors and nurses. There is
keep any record of patients.
- defective.
540 THE LANCET]
TOWN MEETS COUNTRY |
oe 12, 1946
an average of one doctor for 3600 people, and one nurse |
We met a woman doctor running a,
health centre who works there all day, has no nurse to
for 7000 people.
help her; and is so overworked that she has no time to
In her district previously
there were 72 doctors ; now there are only 10. In the
sanatoria there are for 100 patients usually 4 qualified
nurses, this number including both day and night
nurses. In one sanatorium for 275 patients. there are
5 nurses. Many dispensary nurses have no time, to: do
any health visiting. .
The lack of specialised personnel is particularly great,
as a relatively high proportion of these were killed. The
chief thoracic surgeon for Warsaw was shot by the
Germans. There aré now in Poland only two surgeons
specialising in chest surgery.
Courses are- being arranged for doclor: $ “they are
planned as intensive courses lasting two or three months
and will be given in the principal university centres.
Grave difficulties are arising in this connexion. Owing
partly to economic difficulties of doctors, and partly to
the fact that a country doctor can find no locum to
replace him even for a few weeks, there are very few
. candidates, though the ministry is offering maintenance
ane 8000 zl. a month to those attending the course.
_ In Poland, as throughout the rest of liberated Europe,
a constant cry is the need for medical literature covering
the war period. In addition, Poland suffered complete
and: wanton - destruction of many medical libraries,
public and private, so that she has lost also much valance
medical nioravure from hefore 1939.
INTERNATIONAL | SOCIETY OF. MEDICAL |
HYDROLOGY
F “Tae first post-war annual meeting of the sadoty
was held at Buxton from Oct. 4. to 6
‘The principal
representatives from abroad were: “Belgians Dr. J.
Michez (Brussels); Czechoslovakia, Prof. :F. Lenoch
(Prague) ; ; _ France, Dr. P. Petit (Royat) ;. Holland,
Dr, J. van Breemen ; Switzerland, Dr. V. Ott (Zurich) ;
U.S.A., Dr. Loring Swaim. The following officers were
elected for 1946-47: president, Lord, Horder : F chairman
of council, Dr. J. B. Burt; vice-chairman, Dr. G. D.
Kersley ; hon. treasurer, Dr. Frank Clayton; hon.
secretaries, Prof. František Lenoch: and: Dr. Donald
Wilson; 39 new members and 5 associate ‘members
were elected. Arrangements for renewing the publica-
tion of the society’s journal were discussed. `
In his presidential address, Lord Horder, one of the
two surviving founder members of the society, empha-
sised the great part which would be played in the
restoration of international relations by free associations
of medical men of different countries for discussion of
common problems. |
Dr. J. van Breemen discussed the four causal factors
in rheumatic disease—focal. or other infection; con-
stitutional anomalies; abnormalities of. the peripheral
circulation and in the defence jmechanism of the skin ;
and social and environmental influences—in relation to
medical hydrology. ~°
Dr. V. Ott described research work done i in ‘Switzerland
in testing the effects of thermal treatment: on ‘the auto-
nomic nervous system.
Dr. Abraham Cohen, . of the Philadelphia. General
Hospital, gave an. „account of the use made in his hospital
_. of physostigmine ‘in’ the relaxation of muscle spasm.
- CONCLUSIONS -
The incidence of tuberculosis in Poland is now lace
ingly high. Involving usually chronic disease over many
years, and affecting mainly adolescents and young adults,
it causes an immense wastage of human life. Of the toll
on health taken by the war and the German occupation,
it is by far the most serious disease, and will continue to
= be so for many years to come.
The fact that it is not
an acute epidemic disease renders less apparent the need
for an intensive campaign ; the need, however, is urgent.
_ Great progress has been made in re-establishment and —
-re-equipment of the services.
But these services started
almost from zero after liberation a year ago ; equipment
is still in very short supply, and organisation is still
The situation is such that it must be regarded
as nothing less than a national emergency. Recom-
mendations have been made for an emergency supply
programme and for urgent reorganisation along lines
practicable under present conditions.
- The task that lies before the ministry’ ‘of health is no
mean one; it is that’ of. planning tuberculosis control
- in a country which has been systematically devastated,
which has a very high incidence of tuberculosis, which
lacks equipment, doctors, nurses, and trained admini-
strators, and which must concentrate its economy mainly
on reconstruction. In a five-year programme far more
equipment will be required, particularly for the establish-
ment of tuberculosis hospitals to raise the total to
30,000 beds. ` Radical reorganisation will be necessary
if the service is to be well staffed and to come within
a single national plan of attack on tuberculosis. A
much greater proportion of the national budget will
have to be devoted to the anti-tuberculosis campaign
(before the war the proportion was exceptionally low).
Only after the initiation of such a programme, and
after a raising of the living standard, which will of
necessity be slow, can any. important and continuous
decline in this disease be expected in Poland. Further,
though much will depend on the Polish people themselves,
war-time devastation has been such that assistance
from without will be needed for a long unis and on a
generous scale. D a
. according to whether side-effects on `
He referred to the experience of other workers’ with
‘Prostigmin ’ but maintained that- physostigmine sali-
cylate was ‘equally efficacious, less ‘expensive, and less
toxic. The method adopted in the arthritis (inpatient)
ward was to give all patients injections. of isotonic
saline daily for a week. .If these and complete rest
produced. no improvement, hypodermic. injections. of
atropine (0-06 mg.) were given daily for. the next week.
If again there was no improvement, -he gave physostig-
mine and atropine mixed in the same syringe, beginning
with 0-06 mg. of each. The atiti, E ‘adjusted —
he autonomic
nervous system were produced. by vither ‘of the two
drugs.: If the physostigmine/atropine balance -was
ean the treatment could be administered indefinitely,
but the usual period. was six weeks. The best results
were obtained in rheumatoid arthritis when the spasm
- was very severe. The treatment was not to be regarded
in any way as a cure but as an auxiliary method which
might produce considerable amelioration of symptoms,
particularly relief of :pain. Among other conditions
in which good results had been’ obtained ‘were spasm
due to war wounds and other traumata, Velty’s syn-
drome, and paralysis resulting from nerve injuries.
Dr. Loring Swaim discussed American concepts of the
treatment of chronic rheumatic. diseases, stressing the
importance of individual reactions to personal and social
environment, and the responsibility of the. physician
to reorientate the patient.
“Mr. R. B. Whittington: (Manchester) discussed the
correlation between the plasma viscosity of the blood
and the erythrocyte-sedimentation rate; he produced
evidence of the greater reliability of "the former in
nObeC une the progress of various diseases. cs -
“TOWN MEETS COUNTRY i
“ ONLY when the soil of a ‘country is in good heart
and fruitful can the rest of that country’s system -be
in good heart also.” In this belief the founders of a new
Association of Agriculture seek to engage the interest of
the British public in a prosperous countryside,. which
they regard as necessary ‘“ economically, nutritionally,
and socially.” They hope to achieve.this object parti
by the education of the young, but partly also through
the coöperation of medical authorities who can emphasise
the need for a national food ‘policy that will enable
British Beneulbure, to ‘make its full contribution. “OA
PERSEE ea ae
THE LANCET}
MEDICINE AND THE LAW
[oor. 12, 1946 54]
healthy farming industry is everybody’s affair, and every-
body should realise it.”’ |
The new association was launched last Monday night
at a Mansion House dinner with the Lord Mayor of
London in the chair. Mr. Tom WILLIAMS, Minister for
Agriculture, said that only 7% of the population of this
country now work directly on the land, and the man
living in the heart of urban Britain naturally has more
regard for the habits of the people among whom he was
brought up than for the environment of his great-
- grandfather. Agriculture was now fully recognised as a
national asset, but ‘‘ town and country must eventually
learn to understand each other’s problems.”
Lord DE LA WARR, president of the association, said
that in the past the towns had demanded a rising
standard of life at the expense of food-producers both:
at home and abroad. That scheme of things had broken
down between the wars because of the glut which pre-
vented food-producers from buying the products of the
town, and it had now broken down again for precisely
the opposite reason. He based the claims of British
agriculture not so much on good will or gratitude for
war services as on the continuing need for food-produc-
tion at home: why should precious money be sent
abroad to pay for food that can be grown in this country?
“ Periods of plenty exploited by the consumer, and
periods of shortage exploited by the producer, are not
going to lead us anywhere,” said Lord De La Warr.
It was the task of the new association to show that,
wherever temporary advantage may lie, in the long
run the interests of town and country are the same.
It was not concerned with policy but with education,
- seeking to create the mental background against which
policy may be considered. This country should face the
future not as two nations but as one, with equality of
rights and responsibilities.
Colonel WALTER ELLIOT, F.R.C.P., said that as a former
Minister of Agriculture he shared the uneasiness of the
countryside ; and when Minister of Health he had been
responsible for inviting over a million women and
children into the country—thereby introducing the
word “ evacuee.” He asked the City to consider the
great and steady markets that can be built out of “ the
processing of mud ’’—a raw material of which, in this
country, there is unlikely to be any shortage.
Mr. ANTHONY DE ROTHSCHILD spoke of the need for
a balanced economy, and Mr. CHARLES DUKES, president
of the Trades Union Congress, said that the Government
must ensure that goods produced under sweated condi--
tions shall not unfairly compete with the products of
labour on our own soil. Mr. J. TURNER, president of the
National Farmers’ Union, thanked the medical profession
for showing that agriculture should produce what is
needed by the people rather than what it would like to
produce. Agriculture, he said, was now straining at the
leash to produce what the country really needs.
The address of the Association of Agriculture, which
hopes to receive the widest possible support, is 32, Bedford
Square, London, W.C.1.
INFECTIOUS DISEASE IN ENGLAND AND WALES
f WEEK ENDED SEPT. 28
Notifications.—Smallpox, 0; scarlet fever, 1001;
whooping-cough, 1451; diphtheria, 285; paratyphoid,
19; typhoid, 12; measles (excluding rubella), 1461 ;
pneumonia (primary or influenzal), 373; cerebrospinal
fever, 32; poliomyelitis, 30; polio-encephalitis, 0;
encephalitis lethargica, 2; dysentery, 66; puerperal
pyrexia, 164; ophthalmia neonatorum, 67. No case of
cholera, plague, or typhus was notified during the week.
Deaths.—In 126 great towns there were 2 (0) deaths
from enteric fevers, 1 (0) from measles, 1 (0) from scarlet
fever, 8 (1) from whooping-cough, 7 (0) from diph-
theria, 47 (3) from diarrhcea and enteritis under two
vears, and 5 (2) from influenza. The figures in paren-
theses are those for London itself.
3 Willesden and Swansea each reported 1 death from an enteric
ever.
The number of stillbirths notified during the week was
275 (corresponding to a rate of 28 per thousand total
births), inchiding 29 in London. |
Medicine and the Law
Insanity Moral or Legal
SINCE the Court of Criminal Appeal was created, an
appeal thereto in all cases of conviction of murder has
been almost automatic. The judges of that court indeed
have sometimes found themselves saying that there
is no explanation of a particular appeal except the
fact that it is a case of murder. Neville Heath, sentenced
to death at the Central Criminal Court on Sept. 26,
has furnished an exception to the usual practice. He
made no appeal to the Court of Criminal Appeal, but
left his case to the medical board which the Home
Secretary consults when the defence is insanity. Thus
his fate will depend not on the narrow definition of
insanity enshrined in the rules in McNaghten’s case as
long ago as 1843, but upon up-to-date medical opinion
informed by all relevant evidence, whether or no the
evidence was given at the trial.
Heath was convicted of the murder of Mrs. Margery
Gardner at a London hotel on June 21. British justice
requires that an accused person be tried for one offence
only at one time, lest a jury be tempted to believe that,
because he has been guilty of one crime, he is therefore
probably guilty of another. Heath, as his counsel
conceded, had also murdered Doreen Marshall at Bourne-
mouth on July 4. The worse his conduct, the more
material for a plea of insanity. For the defence Mr. J. D.
Casswell, K.C., asked the jury to say that Heath was
“as mad as a hatter, absolutely insane, a maniac.”
The conduct of the accused, who suffocated one of his
victims, lashed her, and tied her up so that she was
helpless, did not (urged counsel) show the premeditation
of a sane person ; no man in his senses could possibly
have done what this man did ; it was a case of sudden
but latent insanity.
The expert testimony at the trial showed the usual
conflict. Called by the defence, Dr. W. H. D. Hubert,
psychotherapist at Wormwood Scrubs Prison before
the late war, said that the injuries inflicted on the two
women were extremely savage, the actions of a sadist.
Heath, when visited in prison, appeared to show no
remorse or appreciation of what other people would
think of his behaviour ; after committing these crimes,
he behaved in quite a casual manner, considering his
intelligence. In the witness’s opinion, Heath was not an
ordinary sexual pervert, but he suffered from ‘ moral
insanity °” and at times was quite unaware that what
he was doing was wrong; he was certifiable as morally
insane. Under cross-examination Dr. Hubert described
Heath as a moral defective in law, but, when referred to
the statutory definition in the Mental Deficiency Act of
1927, he could point to no evidence of arrested or incom-
plete development of mind before the age of 18 years.
In answer to the Judge, Dr. Hubert said Heath was
suffering from a disease of the mind, a general
abnormality ; he suffered from a defect of reason
inasmuch as he was unaware of other people’s attitude
towards these offences. Prosecuting counsel called Dr.
Hugh Grierson and Dr. Hubert Young, senior medical
officers at Brixton and Wormwood Scrubs prisons
respectively. Neither considered Heath insane ; he' was
a sadist, but sadism is an abnormal exaggeration of
a normal instinct of the human race. Neither was pre-
pared to agree that Heath did not know that what
he was doing was wrong and punishable by law. For
the defence it was suggested that these two witnesses
were not consultants, had not practised in mental
hospitals, and had experience only as prison doctors ;
they had found Heath repressed, uncommunicative, and
uncodperative because he knew that they were prospective
witnesses for the Crown. -
Mr. Justice Morris, in summing up to the jury, used
the usual judicial definition of insanity. Everyone was
R42 THE LANCET]
presumed to be sane and responsible for his actions until
the contrary was proved. Insanity was not established
merely by outrageous and unexpected behaviour. This
had been described as an instance of ‘ partial” or
“ moral” insanity or as mental defectiveness. These
were not the real issues. The judge emphasised that
the jury must consider whether they thought that
Heath did or did not know that he was doing what was
wrong. It seems to have been upon this issue that he
was convicted. The prosecution suggested that in his
conversation with Miss Symonds about the crime, in his
letter to Superintendent Barratt as to the identity of
the criminal, in his' change of name (to ‘‘ Group-Captain
Rupert Brooke ”) when he went to Bournemouth, and
in his attempts to conceal the body of Miss Marshall,
Heath had been trying to cover his tracks. These
matters were among those mentioned by the judge as
possibly material to the issue which they were trying.
After a retirement of an hour they brought in a verdict
of guilty. Heath, when called upon, made no statement
and indeed showed indifference and unconcern.
. . The lay. public was probably less interested in the
issue of criminal responsibility than in the details of the
crime. Heath’s past career was narrated by a police
witness in answer to questions by Mr. Casswell.
Born in 1917, he had served. in the Territorial Army in
1934, and in 1936 had joined the Royal Air Force. He
was dismissed. by court-martial sentence next year,
after trial for absence without leave, for escaping while
under arrest, and for unauthorised taking of a motor-
. car. A month later he was placed on probation for .
frauds at an hotel and for attempting to obtain a car
by false pretences, eight other cases of fraud being taken
into consideration. In July, 1938, he was sent to
Borstal on charges of stéaling jewellery and cheque
frauds, ten other cases being taken into consideration.
He was released at the outbreak of war, enlisted in the
R.A.8S.C., and went to the Middle East in 1940 with
a commission. In 1941 he was court-martialled and
-cashiered for frauds as to pay ; there were other charges.
Sent back to England, he landed improperly at Durban
and found his way to Johannesburg where he posed as
Captain Selway, M.C., of the Argyll and Sutherland
Highlanders. Changing his name to Armstrong, he
joined the South African Air Force as a pupil pilot,
reached the rank of captain, and in 1944 was seconded
to the R.A.F. and took part in operational flying. He
had been married in South Africa in 1942; his wife
obtained a divorce nine months later but with no
suggestion of cruelty or sadism. In December, 1945, he
was convicted by general court-martial in South Africa
on various charges, including three for wearing decora-
tions without authority. He was then sentenced for the
third time to dismissal from the R.A.F. Returning to
London last February, he was fined in April at Wimble-
don for unlawfully wearing uniform and decorations to
which he was not entitled.
How the recital of this record may have affected a jury
it is difficult to say. There was little in it to suggest .
disease of the mind, and there was nothing in the case to
suggest delusion. . -
In his recently published recollections Mr. Justice
Travers Humphreys seems to deprecate taking away the
decision in respect of a death sentence from the judges and
giving it to the Home Secretary. Be that as it may, there,
will be considerable relief in many minds that Heath’s
strange case has forthwith been made the subject of a
medical inquiry instead of merely leading to the repetition
of the McNaghten rules in the Court of Crimina] Appeal.
A aRrour of patients with disseminated sclerosis have
initiated in New York the Association for Advancement of
Research.on Multiple Sclerosis, of which the chairman is
Dr. Tracy Jackson Putnam, New York. The aims are to
coérdinate research, gather statistics, act as a clearing-house
for information, educate the public on the problem of the
disease, and collect funds for research. A large medical
advisory board has been appointed.
IN ENGLAND NOW
e
[ocT. 12, 1946
In England Now
A Running Commentary by Peripatetic Correspondents
THE latest experiments with yellow maize meal
(Lancet, Oct. 5, p. 491) are a reminder that this coming
winter marks the centenary of perhaps the largest
experiment ever made with maize in human dietary.
In 1846 the potato crop, the staple food of the Irish
poor, completely failed, and both the Government and
charitable organisations supplied vast quantities of
‘‘ Indian corn’’ or maize for cooking at home and set
up thousands of ‘‘ kitchens,” where the meal was cooked
before distribution at a nominal price, both to avoid the
stigma of charity and to maintain the morale of the men,
who were put to all sorts of road-making and hill-shifting
to earn money to buy the maize. For several years
afterwards hundreds of derelict wheelharrows lay about
the roads and fields. Anthony Trollope, who has ‘‘ come
back ” so remarkably in the past few years, was then a
post-office surveyor, his job taking him over a large
part of the Irish countryside. He has left vivid descrip-
tions of the ravages caused, especially among young
children, in his novel Castle Richmond. One wretched
woman is made to say: ‘‘ Is it the mail? An’ shure an’ .
haven’t I had it the last month past? ‘Nothin’ else.
Not a taste of a praty or a dhrop of milk for nigh a month.
And now look at. the childher. . . . They are dying by
the roadside.” And she shows a child, aged nearly two
years, whose little legs seem to have withered away ;
its cheeks wan, yellow, and sunken; its head, back,
and legs covered with sores. ‘‘ Look at that,” the mother
says, almost with scorn, ‘‘ that’s what the mail has done
—my black curses be upon it, and the day that it first
came nigh the counthry.”’ .
x * +%
The Royal Life Saving Society’s handbook ! makes
it all look so easy. Even the drowned man in bathing-
drawers wears a calm smile as the rescuer, sometimes
disquietingly called the operator, pushes him in the face,
shoves a knee in his chest, tows him ashore, leans on his
ribs, rubs his arms, rolls him over, and generally does
him good. The rules for saving life were not always so
cut and dried; the drowned man is probably smiling
at the thought of what he escaped by being born well
after the society got down to its enlightened work. Dr.
Rowland Jackson, who published in 1746 A Physical
Dissertation on Drowning (Price One Shilling), had no
such mine of information to draw on, and though on
his very first page he exclaims against ‘ that ignoble
and unmanly: Turn of Mind, commonly known by the
Name of Credulity,’? he seems to have been led into
accepting some pretty tall stories. There was the
“ Gardner of Froningholm,’’ for example, who fell
through the ice and ‘‘ went perpendicularly to the
Bottom, in which his feet stuck for sixteen Hours before
he was found.” This sturdy fellow (for he survived)
said afterwards that he ‘‘ perceived a Kind of Bladder
before his Mouth which hindered the Ingress of the
Water by that Passage, tho’ it enter’d freely into his
Ears, and produc’d a Dulness of Hearing for Some
Time after.” Then there was the woman who had the
misfortune to be thrice drowned. The first time she was
three whole days under water, ‘“ but the two other Times
had more Speedy Relief afforded her.” She died at 75.
And so on, from the Painter of Falung, who was eight
days in the water and had a good deal to say about it,
to Laurence Jones, who continued seven weeks under
water—though about him even Dr. Jackson seems to
have felt a few qualms in his organ of faith.
From drowned men he passes to the drowned Polish
swallows, who, on the word of Fortunus Licetus, towards
the end of September ‘ plunge themselves into Ditches
and Rivers, where they remain conceal’d till about the
Middle of May ”’?; and clusters of these swallows taken
out from below the ice only needed warming to come to
life again. Moreover, if released ‘‘ they forthwith fly
back to the Water and plunge themselves into it.”
But Dr. Jackson’s readiness to believe all he heard
sprang from a human and practical desire to see the
1. Illustrated Handbook of Instruction (21st ed.). ai bon Life
Be ng Pocet 14, Devonshire Street, Portland Place, London,
e s P S.
4
THE LANCET]
drowned resuscitated, and though nearly as credulous
about remedies as he is about recoveries, yet he gives
first place to sensible measures. His opening directions
are to the patient into a house and warm him
gradually before a gentle fire, wrapping him in warm
cloths and rubbing him until circulation is restored. He
does not believe in rolling patients on barrels because
one of his authorities had known it to cause sudden
death. He shares contemporary opinion on the value
of bleeding but advises the utmost caution in the use
of cordials in the early stages. If other measures prove
ineffectual he advises tracheotomy, and neatly describes
the method. If no tracheotomy tube is at hand the
shank of a common pipe—presumably a churchwarden—
is to be slipped into the tracheotomy opening, and the
operator (as the R.L.S.S. handbook .would call him)
“ blows into the Bole.” He recommends another and
much more extraordinary use for the common pipe,
this time loaded and burning. The small end is to be
introduced into the anus, the bowl covered with a piece
of perforated paper, and the operator is then to blow
tobacco smoke into the intestines as strongly as he
possibly can. On one occasion, when this remedy was
put to trial at the instigation of a soldier, “ at the fifth
Blast, a considerable rumbling in the Woman’s Abdomen
was heard, upon which she discharg’d some Water from
her Mouth and in a Moment after return’d to Life.”
Dr. Jackson was so much impressed with reports of this
method that he invented an instrument, illustrated in
his frontispiece, ‘‘ contriv’d on purpose for impelling
the Smoke of Tobacco into the Intestines.” It enables
the blower to operate from a distance of some
feet, but has no advantage for the patient unless,
like the users of cigarette-holders, he prefers his smoke
cool. One look at it is enough to prove that we
should all be very grateful to the Royal Life Saving
Society. |
PARLIAMENT
[ocr. 12, 1946 543
When my fellow peripatetic of Sept. 21 spoke of-
“ swanning ”’ he stirred up many memories of days in
the Western Desert with the 8th Army, including one
which throws light on the origin of the term. In the
second desert campaign of November, 1941, a variety
of codes were used for R.T. communication by the different
branches of the Service. One of these, known as the
“ Bird ” code, and originating, I believe, with the then
D.D.M.S., 30 Corps, for use by medical units taking part
in the campaign, referred to motor ambulances as
“ swans.” One of the commoner sights in that campaign
being ambulances crossing and recrossing the desert,
‘*swanning’’ came to be applied to their activities.
The term persisted, eventually becoming common
8th Army slang for any apparently aimless wanderings.
From the 8th Army it diffused outwards to the rest
of the Army, carried no doubt by old members of the 8th.
How tantalising it is to travel in the train past fields
full of mushrooms, knowing that all we shall get this
season is a quarter of a pound of tasteless cultivated
things costing several shillings. We are still very
conservative in this country about eating fungi other
than the common mushroom, mainly because of the
fear of poisonous toadstools, though Mr. Ramsbottom
says in the Times that the toadstool is becoming more
fashionable. His excellent King Penguin book on
poisonous fungi shows how uncommon dangerous forms
are, for he has to fill up his slim volume with kinds
which are liable to give slight indigestion. Personally
I don’t think that we miss a great deal by our con-
servatism. To my palate few compare in flavour with a
freshly gathered field mushroom, and in England it is
an awful job to pick enough of other sorts to produce a
decent portion. Even in France I have been faced with
a repellant dish resembling tenderised ‘Sorbo’ rubber in
the guise of a great delicacy.
Parliament
THE BILL IN THE LORDS
ACCOMMODATION in the smaller but by no means
cramped quarters now used by the House of Lords—
whose proper benches are still occupied by the Commons
—was taxed to capacity when last Tuesday afternoon
the LORD CHANCELLOR rose from the Woolsack to
open for the Government the Lords’ debate on the
second reading of the National Health Bill. There was
nothing in Lord Jowitt’s speech to suggest that during
the parliamentary recess the Government has con-
sidered any revision of the Bill. Most of his survey and
his arguments followed the now familiar lines of minis-
terial speeches in the lower House. The one new fact
he disclosed was that the Government (adopting a sugges-
tion of which Lord Moran had given notice) propose to
set up a ‘‘Spens Committee ”?” to consider and report
upon the proper remuneration of consultants. He
defended at length and with conviction the powers
given to the Minister under the Bill—powers without
` which, he said, it would be impossible for the Minister,
as commander-in-chief of the health forces, to provide
the service the country has been promised.
It was to these same powers, vested in one individual,
that the Earl of MUNSTER, opening for the Opposition,
took strong exception. He welcomed the conception
of a National Health Service but was very sure that a
better and more democratic service could have been
framed if greater use had been made of local authorities. `
He hinted that his party would be putting down amend-
ments in the committee stage designed to liberalise the
administration and preserve the autonomy of the
voluntary hospitals.
The Marquess of READING saw in the Bill the logical
= development of the social services inaugurated by the
Asquith ‘‘ Government of all the Talents,” but feared
the possibility of over-centralisation of administration
in a Ministry of Health already overburdened with
housing responsibilities. He believed that, with adequate
devolution of power and function to the regional boards
and to the executive councils, a service may be built
not unsatisfactory to the doctors. He suggested that
when the time comes it may be only the very few—and
they the very elderly—wbho will prefer to “reign in Hell
rather than serve with Bevan.”
The Archbishop of YORK saw in the Bill a great
opportunity for ensuring that preventable illness does
not go unprevented. He was followed by the first of
the medical speakers, Lord MORAN, who dealt with the
need for establishing conditions of practice, in all branches
of the profession, that will ensure the continued recruit-
ment of the right men and women in numbers sufficient
to provide a complete and balanced service. At present
(but this may be partly due to demobilisation) the
would-be entrants to the medical schools are more than
the schools can absorb. If medicine is to remain attrac-
tive, conscious effort is needed to make all branches of
medical work satisfying. In particular, the provision
of an extended consultant service should not be allowed
to exclude the general practitioner from his proper access ©
to, and share in, the work of the hospitals. Lord Moran
referred to the present difficulty in which the Minister
finds himself in his negotiation with the Insurance Acts
Committee. He felt this was largely a procedural diffi-
culty which with good will could still be overcome.
He appealed to the Minister to try again to come to some
agreement with the profession before prejudice over this
present trouble mars the reception of the final scheme.
Lord TEVIOT, speaking from knowledge gained from
his long chairmanship of the Teviot Committee, stressed
the even greater need for attracting urgently and by
all possible means many more students to dentistry.
The country, he said, could well afford to have each year
three times the number who now qualify.
Lord INMAN saw in the new service not the death
of the voluntary hospitals but enlarged opportunity
free from all-pervading worries about finance. Lord
HORDER regretted the lack of real consultation with the
medical profession in the preparation of the Bill, and was
glad that the Minister at last realised that there can be
no new service without the willing codperation of the
men and women who have to work it. |
The first day’s debate ended with a plea from Lord
AMULREE for a better, a more scientific, and a more
humane treatment of the problem of the chronic sick.
The debate continued on Wednesday, when Lord
LISTOWEL replied for the Government to the first day’s
critics.
544 THE LANCET]
CHILDREN IN DAY NURSERIES
[oor. 12, 1946
Letters to the Editor
PERFORATED PEPTIC ULCER TREATED
WITHOUT OPERATION 2
Sm,—Some twelve months ago I had the opportunity
of visiting Professor Winkelbaum’s clinic in Graz. In his
wards I noticed several patients With what he called
perforated duodenal ulcer. They had not been operated
upon. ‘‘ Why ? ” I asked. The professor was obviously
a little taken aback by so naive a question. The substance
of his reply was that if the cases were brought into hospital
early for treatment the ulcer sealed itself off. It was
necessary to operate only on cases, usually late, in which
there was evidence of a lot of fluid in the peritoneal
cavity ; and these were usually gastric, not duodenal
ulcers. The routine was to await recovery from perfora-
tion, and in 3—4 weeks perform a partial gastrectomy.
Whether the latter action is commendable is a subject
for debate. But the efficacy of the conservative treatment
of perforation in these. cases left no room for doubt, and
made me realise that there was a great need for revision
of the usual and long-established teaching of immediate
operation for all cases of perforation ; for the mortality
of such a procedure is considerable, and the postoperative
morbidity great.
Mr. Hermon Taylor’s article of Sept. 28 is both timely
and encouraging. The results—admittedly this is a small
. geries—compare favourably with any that could have
been obtained by routine laparotomy. It will be noted
that nearly all the ulcers in Mr. Taylor’s series were
duodenal. Conditions for spontaneous sealing of a
perforated duodenal ulcer are more favourable than those
for sealing of a perforation on the anterior wall of the
: stomach ; and I feel that if one is to adopt conservative
treatment it may be wise to restrict it to duodenal
ulcers, if differential diagnosis permits the distinction
to be made.
London, W.1. HAROLD C. EDWARDS. ’
Sir,—Although I have never had the courage to treat
. without operation cases of frank perforation of a peptic
ulcer as practised by Mr. Hermon Taylor, I have fre-
quently treated by generally conservative means those
cases in which the diagnosis appeared somewhat indefinite
and which appeared clinically to be cases of what
we might call a local peritonitis in relation to an ulcer—
such cases as are often referred to as ‘‘ leaking ulcers.”
And in such cases the symptoms have subsided, though
there has been noted from time to time a gas shadow
under the diaphragm a few days later when a barium
meal was about to be contemplated. This has led me to
the conclusion that in many so-called perforated ulcers
there has been a gas leak only, which can settle down
with restriction of fluids by mouth for 24 hours and a dose
of morphine without actually going to the trouble of
gastric aspiration in this less severe type of case.
One other point I should like to mention, though
it is not exactly relevant: it has been my experience
that operation on late cases of perforation (i.e., those
over 24 hours old) is almost inevitably fatal, but that
a number of these cases may be saved by intravenous
fluids coupled with a small suprapubic drain inserted
under local anesthesia. This form of drainage is recom-
mended because I have always felt that a quantity of
fluid plus gas inside the ccelom has kept the viscera of
the upper abdomen apart and so prevented the falling
together of those tissues, the apposition which might
result in the perforation becoming sealed off.
Selly Oak Hospital, Birmingham. JAMES GORE.
Smr,—I read Mr. Taylor’s paper with great interest.
Thirty years ago I reported a case in which perforation
of an ulcer of the lesser curvature was cured by non-
operative treatment.1 The ulcer, having perforated
between the layers of the lesser omentum, was observed
by radiography ; the perforation disappeared, and later
the ulcer greatly diminished after routine dietetic treat-
ment. So far as I am aware this was the first case
in which gastric perforation was deliberately treated
medically without operation, as noted previously by me.?
Berl. klin. Wschr. 1916, no. 34.
1. Rosenthal, E.
Lancet, 1936, i, 1263
2, Rosenthal, E.
The X-ray pictures of the ulcer before, during, and
after the perforation have been published in my text-
book. Many years later Prof. M. Roch,‘ of Geneva,
reported a case of ‘‘spontaneously healed gastric
perforation.”
- Conservative treatment should be restricted to those
perforations which are sealed off. Therefore the question
arises of how these cases are to be recognised. The
partial or total absence of muscular rigidity cannot
be regarded as pathognomonic of a sealed perforation,
since rupture of an ulcer sited on the posterior wall
of the duodenum or of the stomach induces primarily
rigidity in the musculature of the posterior abdominal
wall. Only later, mostly after 2 or 3 days, with the
appearance of meteorism, and intestinal obstruction, is
it possible to make a certain diagnosis of diffuse peri-
tonitis, indicating that the perforation was not sealed off.
An operation at that stage, however, carries a great risk.
Hitherto it has not been known, or even supposed,
that in most cases the perforation was sealed off. The
value of Mr. Taylor’s treatment will be enhanced if some
early and reliable sign differentiating between open
and sealed perforations can be found.
Letchworth. EUGENE ,ROSEN THAL.
CHILDREN IN DAY NURSERIES
Sır, —-Dr. Menzies, in her paper of Oct. 5, quotes me
as having described the Oxford survey of the incidence
of infections in day nurseries as being ‘‘ at the same
time too scientific and not scientific enough.” This
suggests a serious misunderstanding of my comments
which were, actually, that the Oxford survey was too
much of an academic exercise and was based on data
whose scientific validity was open to serious doubt.
I use the term ‘‘ academic exercise” to describe a
type of investigation which draws inferences from
observed facts but does not concern itself with the
practical importance or application of those inferences,
and it is with regret that I notice that other investigations
into the welfare of nursery children seem to share this
character.
The recent paper on the incidence of infections of the
respiratory tract, published by a group of members of
the Medical Women’s Federation, though unimpeachable
so far as data and analysis were concerned, is a case in
point. Its findings were, in brief, that a child who leaves
home to enter a nursery runs thereby a serious risk of
catching colds or bronchitis. But it has been a matter
of common knowledge for years that the child’s first
departure from the restricted circle of the home to enter
a mixed group is likely to be followed by a series of colds
and coughs. The two pertinent questions, ‘‘ What is the
long-term effect on the child’s health of these colds? ”’
and, ‘‘How much harm is done by shifting this phase
of infection from the normal school ‘entrance age of
4-5 years to the earlier age of 11/,-2 years,” remain
unanswered.
Dr. Menzies is concerned because in her nurseries
the gain in weight of the entrants is ‘‘ unsatisfactory.’’
Her anxiety would be pardonable if the children were
being fattened for the pot, but it is rash to suggest that
at this particular stage in a young child’s life it is possible
to lay down arbitrary standards of satisfactory gain on
purely physiological grounds. It is quite true that loss
of weight may arise from emotional disturbance. It
may also arise from a change of diet, from a change from
a bad diet to a good one, or from the fact that the child,
for the first time taking adequate exercise and discovering
the open air, is merely getting rid of his ‘‘ puppy fat.”
It is difficult, if not impossible, to assess whether either
the emotional disturbance or the failure to gain weight
is, in any given child, likely to cause long-term harm,
and Dr. Menzies is not to be blamed for not having
attempted it. Yet without such an assessment her
investigation is barren. |
Can we be realistic about this nursery business? A
majority—often a large majority—of nursery children
are the children of mothers who are compelled to work
either by poverty or by the needs of industrial recon-
struction. It is fallacious to compare nursery children
3. Rosenthal, E. Diseases of the Digestive System, London, 1940,
: p. 72.
4. Roch, M. Schweiz. med. Wschr. 1942, 72, 1307.
ile eal gs a a eee SS
ey a Ore et
THB LANCET]
ARSENICAL CHICKENPOX
[ocr. 12, 1946 545
with children from normal homes; the true comparison
is with children from necessitous homes and children
who are cared for by ‘‘ daily minders.’’ I should be
happy to see a state of things in which no woman with
a child under the age of two years was compelled by
social or economic circumstances to go out to work,
and if Dr. Menzies finds me ‘“‘ biased in favour of nursery
provision ” it is a bias in favour of the nursery as against
unsatisfactory alternatives. I plead guilty, also, to a
bias against unpractical ‘‘ research ’’’ and would suggest
some questions with which future ambitious researchers
might profitably occupy themselves.
1. What is the relationship of infection in nursery days to
illness or physical defect in later childhood ?
2. Does the school record of ex-nurserv children suggest
that their * social training ” in the nursery has helped them
toward social adjustment ?
3. Does the comparison of irfection-rates in different
nurseries, and possibly in different towns, suggest that certain
remediable factors are associated with high infection-rates ?
But there is, as yet, no totalitarian suggestion that all
children, from rich families and poor, shall be com-
pulsorily drafted into nurseries at the age of six months,
and therefore no need to discuss whether nurseries are
or are not an evil in themselves. In point of fact, nurseries
are our present therapy for an admitted social evil, and
our concern should be to investigate their work con-
structively with the intention of improving them.
Accrington. JOHN D. KERSHAW.
ARSENICAL CHICKENPOX
Sm,—Dr. Parkes Weber (Sept. 14) may be interested
in an account of arsenical polyneuritis in a family,
one of whom developed both local (segmental) and
generalised zoster 12 and 19 days respectively after
ingestion of arsenic (London Hosp. Gaz. July, 1946,
p. ey and Clinical Supplement, September, 1946,
p. xiv).
This case supports the theory of activation by arsenic
of a latent virus infection, since the zoster rash appeared
12 days after a single dose of arsenic. This is the usual
incubation period of the naturally occurring disease,
so that if the cause were exogenous exposure must have
taken place at the same time as the poisoning—which
is improbable. The postulated selective action of arsenic
on the pyruvate enzyme system of cells, interfering
with their normal oxidation, may possibly explain
the assumption of activity of a cell parasite such as a
virus.
Loughton, Essex. A. L. CRADDOCK.
WOMEN IN MEDICINE
Srr,—In reply to Dr. Usborne’s letter of Sept. 28,
it should be stated that, apart from direction of the
recently qualified, it was not found necessary to direct
medical women, except perhaps in a few isolated cases,
since those available by age for direction were either
already employed or were not liable. It would seem,
therefore, that those medical women who resumed work
after definite intervals of retirement did so in spontaneous
response to the urgency of the times and the increased
opportunities for work, especially in part-time posts
suitable for those with family ties.
ANNIS GILLIE
Hon. Secretary, Medical Women’s Federation.
USE OF REASSURANCE
Sir,—For some time I have been experimenting with
a method of explanation and reassurance designed for
long-standing and severe psychoneurosis.
It consists in a short elementary and ad-hoc quasi-
correspondence course on the effect of emotion on bodily
and mental functioning. On each visit the patient is
given a lesson stencilled on a sheet of paper with a large
blank space. He takes this home, studies it, and writes
on the blank space examples, illustrating the point of
the lesson from his own experience and what he knows
is the common experience of others. On his next visit
these examples are discussed and he is given the next
sheet, which is dealt with in the same manner, and so on
to the end of the course.
Bromley, Kent.
Thus the patient teaches himself, with only the
minimum of guidance, to understand his illness, or
rather, to arrange, in relation to his own symptoms,
knowledge which he and everybody possesses about the
effects and manifestations of emotion. The reassurance
that the patient feels is all the stronger because the
explanation has been arrived at by himself:
I hope to publish a full account of this method in the
near future.
Graylingwell Hospital, Chichester. M. B. Bropy.
ROYAL MEDICAL BENEVOLENT FUND
S1r,—Christmas once again draws near and it is time
to ask the hospitality of your columns to launch our
annual Christmas appeal on behalf of the poor bene-
ficiaries of this Fund.
The reasons for this appeal are now well known to all
your readers and there is no reason to stress them again.
I would rather emphasise the point that they are as
cogent as ever. It is true that the old-age pension which
is now in force, whilst making the financial position of
old people more bearable—whereas previously it was
quite intolerable—still means that the actual increase
in annual income is only £41 12s., which, bearing in mind
the tremendous increase in the cost of living, still makes
the position of the poor housewife very difficult indeed.
Further, very many of our beneficiaries are under 70 years
of age and so not able to draw this pension. Lastly,
there is that very real sense of being ‘‘ not forgotten ”’
at the festive time of Christmas, and the knowledge that
our Christmas gift will ensure the purchase of a few
extra luxuries which just make all the difference.
I recall that my appeal last year for £2000 to enable
the Fund to give £4 to every beneficiary—a record sum
for which I scarcely dared to hope—actually reached the
grand total of £2127, and I know every generous donor
will feel amply repaid by. the gratitude and pleasure
these gifts have evoked. May I venture to plead for a
similar sum this year ? I feel sure that, although I well
recognise that times are very difficult for everybody
just now, the still greater difficulties and anxieties of our
very poor brethren will not pass unheeded.
Please forward contributions marked ‘‘ Christmas
Gifts ” to the secretary, Royal Medical Benevolent Fund,
1, Balliol House, Manor Fields, Putney, London, S.W.15,
who will gratefully acknowledge. ARNOLD LAWSON
London. President, R.M.B.F.
MEGALOBLASTIC ANEMIA IN CHILDREN
Sir,—In your annotation of Sept. 28 you say that
“ ordinary crude [liver] extracts should be used and not
the purified extracts specially designed for the treatment
of pernicious anzemia, like ‘ Anahzmin.’ ”’ If it is implied
that crude liver extracts administered parenterally
provide a reliable method of treatment in cases of
megaloblastic anemia in children, I wish to dissociate
myself from this view. From my own experience, and
from my reading of the literature, it seems that oral
liver therapy is by far the most effective and certain
therapeutic measure hitherto available, not only in
megaloblastic anzemia of childhood but in other types of
megaloblastic anæmia proving refractory to refined
parenteral liver extracts—with the possible exception of
tropical nutritional anæmia, in which autolysed yeast
may be preferred on the score of cheapness.
Your annotation quotes the case of a boy of 14 years,
previously reported by me, in which ‘a purified liver
extract was ineffective, but proteolysed liver by mouth
and a crude liver extract parenterally produced a remis-
sion... .’? In my original report, however, it was pointed
out that the crude parenteral extract ‘ Plexan’ was
ineffective, the condition relapsing with this treatment
but responding when it was replaced by proteolysed
liver given by mouth.
I am aware that claims have been made, from time to
time, for the superiority of ‘Campolon’ to more refined
parenteral liver extracts in the treatment of certain types
of megaloblastic anemia. Opinion on this question,
however, is by no means unanimous. Nevertheless,
if it be accepted that genuine crude liver extracts pre-
pared by the Gansslen or some similar process may in
certain cases be more effective than purified extracts,
I feel that your advocacy of ‘‘ ordinary crude extracts ”
pa
546 THE LANCET]
OBITUARY
focr. 12, 1946
may be dangerous and misleading,- since the various
preparations on the market vary considerably in their
constitution and mode of preparation. Some of them
appear to differ from refined extracts mainly by their
greater content of water.
Regarding the type of oral liver therapy effective in
megaloblastic anzmias, including those of childhood,
refractory to injections of refined extracts, my own
experience has demonstrated the efficacy of proteolysed
liver (‘ Hepamino’) in daily doses of 1'/, oz., but a few
- recent trials suggest that oral liquid liver extract, now
generally available once more,
efficacious.
Muirhead Department of Medicine,
University of Glasgow.
EXTRANEOUS CAUSES OF UTERINE BLEEDING
"Str,— Nobody will quarrel with your advice to the
gynecologist, confronted with a case of menorrhagia, to
bear in mind the various systemic conditions which may
cause this symptom (Sept. 28, p. 460). But if you include
idiopathic hypochromic anemia among the extraneous
causes of uterine bleeding, are you not putting the cart
before the horse ?
Bethnal Green Hospital, London, E.2. HERBERT LEVY.
THE NATIONAL LOAF
Sm,—The fact that an attempt has been made to keep
secret the instruction to force us to swallow extra doses
of calcium, as revealed by Sir Ernest Graham-Little’s
letter of August 17, is in keeping with other strange
methods employed in this business.
Originally the scheme applied to white bread, which
does not contain phytic acid, and not to brown; the
idea underlying the proposal was to prevent osteoporosis
among the adult population. The authority concerned
was challenged to produce a dozen cases of calcium
deficiency in adults (Lancet, 1941, ii, 25) but did not do so.
The proposal to adulterate white bread had to be dropped.
But evidently the authority in question felt that its
amour-propre had suffered by the failure of the Food
Minister to act on its suggestion. In such circumstances
the phytic acid bogy was resurrected, and now it was
maintained that only brown bread needed fortifying
and not white. But the American ‘‘ Council on Foods ”’
in 1937 came to the conclusion that ‘‘ there is no good
evidence for the existence of a decalcifying factor in
may prove equally
L. J. Davis.
cereals’? (quotation from J. Physiol. 1942, 101, 304). —
Long after the recommendation to add calcium was
made it was sought to justify this recommendation.
The first paper by McCance and co-worker was received
by the Journal of Physiology in October, 1941.(J. Physiol.
1942, 101, 44). But in a paper received in April, 1942,
by that journal these workers had to admit that their
first paper was inconclusive, because ‘‘ brown bread
had a laxative action,” and the negative calcium balance
therefore might have been due to this factor. Still no
justification! A new investigation therefore became
necessary. No-one would hang a dog on the type of
evidence offered in the second paper. Thus it was
virtually admitted that at the time the recommendation
was made to add calcium to bread there was no valid
reason for the proposal. Otherwise there would not have
been a call for the two papers. It should be borne in
mind that the recommendation was made years before
the appearance of these two papers. A more damning
admission it is difficult to imagine. Years after the
recommendation, and after an investigation, the workers
had to admit that the evidence to justify the proposal
was inconclusive.
to consume extra doses of so potent a substance as calcium
without valid reason is surely an amazing procedure !
Furthermore, Mellanby himself admitted that much of
the phytic acid is destroyed in the process of baking
(Nature, Lond. 1944, 154, 394); and people usually eat
baked bread.
Again, when bread became whiter the Minister of
Food stated in Parliament, in reply to a question by
Sir Ernest Graham-Little: ‘‘ The addition of calcium to
the loaf was retained when the extraction-rate was
reduced to 80% in order to ensure good intakes of
calcium as a beneficial nutritional measure ’’ (House of
Commons, Feb. 20, 1946). When the bread was dark it
was phytic acid that required calcium ; when it became
To force forty million human beings °
whiter it was calcium deficiency in dietary which needed
calcium ; and now it is again phytic acid. ;
If the authority who recommended the adulteration of
our bread has a good case, why this twisting and ‘turning
and concealing ? The subject is of grave importance,
and, in the interest of public health, an independent open
inquiry into the whole matter -by a competent body is
long overdue.
I. HARRIS.
Liverpool.
CHILDREN WHO SPEND TOO LONG IN BED
Srr,—The view that some children who are on the go
all day need longer sleep is, I think, a relic of the days
before metabolism became an accurate science. If it is
true, why is it that as the child gets older and his calorie
expenditure goes up he needs less and less sleep? The
view may arise from the confusion of length of sleep
with intensity or depth of sleep and with ability to fall
asleep easily. Activity certainly leads to easy sleeping.
During the examination of parents I find repeatedly
that these three factors are tied up in confusion. Far
from meaning the same thing, length and intensity of
sleep are vaguely in inverse proportion to one another.
Whatever may be practicable in the home, it is much
more satisfactory to arrange the children’s hours in bed
according to age-weight grouping than according to
“ activity.” Mothers require guidance in this matter
. particularly during the first three years of a child’s life,
for it is then that the effects of the long transition
period from animal polyphasic sleep to human mono-
phasic sleep are most intense and most badly handled.
Westcliff-on-Sea. JOHN A. McCLUSEIE.
Obituary
WALTER LANGDON-BROWN
KT., M.D. CAMB., SC.D., LL.D., F.R.C.P.
Ir is perhaps as a teacher in the profession that
Sir Walter Langdon-Brown will be best remembered.
When he died on Oct. 3 he was 76 years of age but
was still capable of influencing and inspiring younger
men, because maturity never impaired the enterprise
of his mind. Holding high professional positions as
physician at St. Bartholomew’s and regius professor at
Cambridge, he could yet be intellectually unconventional,
and he showed courage as well as skill in advocating
unfamiliar ideas.
His father was the Rev. John Brown, Congregational
minister at Bedford, who wrote what has become the
standard life of John Bunyan. Born at Bedford on
August 13, 1870, he was
named after his mother’s uncle,
J. Langdon Down, physician
to the London Hospital. Thus
heredity contrived to blend
in him those diverse qualities
that make for distinction in
medicine and literary accom-
plishment. On leaving Bedford
School he was too young to
go to Cambridge, where he
had won a scholarship at
St. John’s College, and he
spent a useful year at Owens
College, Manchester, working
at biology under Milnes
Marshall. At Cambridge he
took a first in both parts of
the natural sciences tripos and
won a Hutchinson research
scholarship at his own college.
The thorough training in
physiological principles and thought which he thus
gained was the background of his medical career, and
enabled him to consider his clinical problems with a
scientific approach and to teach with an exceptional
clarity. l
Entering Bart’s with the senior science scholarship
in 1895, he qualified in 1897, and in the same year became
house-physician to Samuel Gee, one of the best clinical
teachers of his time. In 1899 his bent towards physiology
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led him to become junior demonstrator in physiology,
and in two years he was senior demonstrator. At the same
time he continued his clinical work and teaching in the
posts of casualty physician and demonstrator of practical
medicine. In 1906 he relinquished his appointment in
the physiological department to become medical registrar
and demonstratqy of morbid anatomy ; but it was not until
1913, at the age of 43, that he was elected to the senior
staff as assistant physician. He became a full physician
in 1924, and retired from Bart’s in 1930, but continued
for some time to work at the Metropolitan Hospital to
which he had been appointed at the beginning of the
century.
Langdon-Brown was widely read on many subjects,
and his ward rounds were enlivened and illustrated
by references to English literature. From early in his
career he was especially interested in endocrinology and
showed his originality of thought,-and he was one of
the first to draw attention to the similarity of the
features produced by lesions of the anterior pituitary
and of the adrenal cortex, some years before Cushing
described the syndrome associated with pituitary
basophili The importance which he placed on a
knowledge of physiology in the practice of inedicine is
reflected in his Croonian lecture, delivered at the Royal
College of Physicians in 1918, on the Rôle of the
Sympathetic Nervous System in Disease, and in his
best-known book, Physiological Principles in Treatment,
first published in 1908, and now in its eighth edition.
To him, more than to any other man in recent years,
belongs the credit for teaching medicine as applied
physiology, and he introduced successive generations of
medica] students and doctors to the new facts and ideas
of which physiology was so prolific between the two
wars. If he sometimes, perhaps, over-simplified the
physiology, this was the result of those qualities which
made him such an excellent expositor. His attention
to things of the mind led him naturally to consider
the minds of his patients, and the close linkage between
the endocrine glands, the autonomic nervous system, and
the emotional hfe brought him face to face with this
aspect of the body-mind relationship. He was thus
a pioneer of what is now called psychosomatic medicine,
though he was not much interested in the more recondite
schools of medical psychology and preferred the simpler
approach of Adler.
From the first Langdon-Brown showed himself a fertile
writer with an unusual range. He was joint editor of
The Practitioners Encyclopedia of Medical Treatment,
published in 1915; and his own works included The
Sympathetic Nervous System in Disease (1920), and The
Endocrines in General Medicine (1927). All these had a
practical application to the art of clinical medicine, of
which he was a master. His wide learning, his breadth
of vision, and his erudite style are seen at their best in
Thus we are Men (1938), which examines human nature,
and in Some Chapters in Cambridge Medical History, a
small gem at which he laboured with increasing difficulty
during the last year of his life. He had a sense of history
which constantly illuminated the present with the past.
Some of his lectures and occasional writings, such as
The Pursuit of Shadows, deserve to survive as models
of their kind, for he brought wit and elegance as well
as culture to the discussion of clinical problems.
At Cambridge, because of age-limit rules, he occupied
the regius chair for only three short years, from 1932
to 1935, but he faithfully maintained its great traditions.
He loved Cambridge, with which he was intimately
associated by many ties of relationship. ‘‘ In his own
profession,” writes L. W., ‘‘ there can have been no
man better known or better loved by young and old
alike. It was revealing to be his co-examiner and to note
how many candidates he would put at their ease at the
beginning of a viva by inquiring whether they were
the sons of his medical or lay friends. Ilis wisdom, his
experience, and his counsel were always available to the
undergraduate, the newly qualified, or the embryo
professor, and many sought his advice, always kindly
and patiently given however trivial the problem.”
‘* All Bart’s men,” A. W. S. writes, ‘‘ will call to mind
L.-B.’s arrival in the square for his ward round at ten
minutes to two, with cigar, not yet fully smoked, that
had to be discarded. On his rounds the opinion and
OBITUARY
foor. 12, 1946 547
argument of anyone, howeverlowly, were always carefully
considered, and his kindly manner endeared him to his
housemen and students. He would never hesitate to seek
the opinion of a junior on a matter about which there
was some doubt: humility is one of the marks of a great
man, and this L.-B. had. Of him can be said what Sir
Norman Moore has said of his old chief, Samuel Gee,
‘ He was a constant friend and a pleasant companion, a
learned physician, and a most excellent teacher ’.”’
At the Metropolitan Hospital, as well as Bart’s, he
was a tower of strength. A colleague there, P. H., speaks
of ‘‘ his constant endeavour to relate clinical observation
to physiological knowledge and to bridge the gap between
the laboratory and the ward,” and recalls that he was
one of the first in this country to apply the work of
Pavlov on gastric secretion and the teachings of Lenharz
to the treatment of patients suffering from gastric and
duodenal ulcer. ‘‘ He inspired his house-physicians with
a scientific attitude while at the same time taking a
broad view of the problems of the individual patient.”’
The same theme isagain repeated by anotherand younger
associate, R.G. “ Langdon-Brown,”’ he says, ‘‘ was one
of the first, perhaps the first, of modern physicians to
attempt to apply to clinical medicine the teachings of
modern physiology—the physiology, that is, of the
present day rather than of his student days. He acted
as a catalyst between the laboratory and the ward, and
this line of thought inevitably led him to endocrinology
as a major interest, endocrinology not as a specialty (for
his was, too Hippocratic a view for the admission of a
specialty) but as a tool to the better understanding of
medicine as an indivisible whole. For this reason he gave
his support to the formation of a section of endocrinology’
of the Royal Society of Medicine, and, knowing his end
was near, was happy to see it in being in time to become
its first president. He was too ill to read his inaugural
lecture, but not too ill to write it. His mind was unclouded
to the end and only a few days before his death he was,
able to remember full details of a case not seen for |
years.” In this last presidential address he described
the development of endocrinology, adding ‘‘ I ventured
to call the pituitary gland ‘the leader of the endo-
crine orchestra,’ though it later transpired that the
hypothalamus holds the still more important rank of
conductor.” This now celebrated simile is an indication
-of his aptitude for exposition.
His wisdom was broadly based in experience. As a
young man he served in the South African War as senior
physician at the Imperial Yeomanry Hospital at Pretoria,
contributing later to the book on Imperial Yeomanry
Hospitals in South Africa, and he kept up his military
associations .as a Territorial. As a young man, too,
he lectured to working men’s institutes on biology
and physiology. Afterwards an: examiner in many
universities, he went to Egypt in 1936 on behalf of the
General Medical Council to report on teaching and
examinations as there conducted, and he presided over
the Committee on Postgraduate Training in Psychological
Medicine which reported in 1943. Through his multi-
farious activities he came to know an immense number
of people, and he was a charming host with a great
knowledge of good food and good wine, a vast fund of
anecdote, and a gift for stimulating conversation. ‘‘ One
remembers him sitting in his combined consulting-room
and study in Cavendish Square, surrounded by cats, or
standing like a rock in a seethe of more mobile persons
at some medical meeting. He said many good things,
which he enjoyed as much as his hearers. He was a
humanist in every sense of the word: ‘in mind, as in
body, he was totus, teres, alque rotundus’.”’ |
Langdon-Brown’s distinction and industry brought him
many honours. Elected a fellow of the Royal College of
Physicians in 1908, he became senior censor and delivered
the Harveian oration of the college in 1936. He wasa
fellow of Corpus Christi College, Cambridge, and received
honorary doctorates in science from Oxford, and in law
from the National University of Ireland, and from
Dalhousie University, Canada. The Royal College of
Physicians of Ireland elected him an honorary fellow in
1940, and he was also an honorary fellow of the Royal
Society of Medicine, the Faculty of Radiologists, the
Hunterian Society, and the Harveian Society, and
548 THE LANOET}
honorary freeman of the Society of Apothecaries of
London. He served on the council of the Pharmaceutical
Society, and was president of the Medical Society of
Individual Psychology. The variety of his interests
was evident in his presidency at various times of no
less than four sections of the Royal Society of Medicine—
urology, therapeutics, the history of medicine, and
endocrinology—and he also presided over the section
' of medicine of the British Medical Association. He
gave the Horsley lecture at University College Hospital
in 1935, and the Linacre lecture at Cambridge in 1941.
In 1935 he was knighted.
Sir Walter’s first wife died in 1931. Lady Langdon-
Brown, who survives him, is the daughter of Mr. H. B.
Hurry. He had no children.
MEMORIAL TRIBUTE
A memorial service was held last Tuesday in the church
of St. Bartholomew-the-Less. In the course of his
address Mr. Geoffrey Keynes said: ‘‘ Langdon-Brown
was a big man both mentally and physically, handsome
in face and stature, and endowed with an intellect which
was robust rather than brilliant. He was the ideal
teacher in a school such as this, where tradition combines
so happily with progress, for his historical sense, his
profound knowledge of medicine, and his breadth of
grasp, were united with a forward-looking sense of what
was most important to patient and to student. Thus
he kept always abreast of contemporary knowledge
while furnishing his mind with a treasure-house of
experience from which’ he could draw with effective
ease. ... It is true to say that Langdon-Brown was the
wise architect with the materials that came to hand
rather than the experimenter and innovator. But that
was the source of his strength as physician and teacher—
his mind was always balanced between the learning of
the past and the illumination of the present, without
omitting an inquiring glance to the future. ©
¢ ‘In spite of his great qualities, success came to him
but slowly, and he was sometimes a little impatient at
the fate that seemed to hold him down. But his zest
in life, in everything that belonged to cultivation of the
mind, and in clinical medicine never flagged. Wherever
he worked he was a great humanising influence, and he
always gave to the utmost, whether to his Hospital or
his University.”’
HASSAN SUHRAWARDY
KT., D.SC., M.D. CALCUTTA, F.R.C.S., D.P.H.
Sir Hassan Suhrawardy died in Calcutta on Sept. 18,
at the age of 62. A great champion of the Moslems in
India, he did much to raise the standard of education
among them, and thereby had a considerable influence
on medical education throughout the country.
He was born in Dacca, a great Moslem stronghold and
centre of the jute-growing industry in Bengal. He
received his early education there, but later went to
Calcutta and took his basic medical course at the Bengal
Medical College, obtaining his M.B. and afterwards
achieving that rather rare distinction—certainly for a
Mohammedan—the Calcutta m.p. He made several
visits to Europe to complete his medical education, and
attended further courses in this country and in Ireland.
His outlook was liberal, for he took both the F.R.c.s. and
the D.P.H., the latter at Edinburgh. Nor were his
scholarly interests limited to medicine, for he studied
the history and culture of his faith and made many
pilgrimages to the holy places of Islam. A
His first important appointment was as health officer
to the East India Railway, and eventually he became
head of the medical service of that railway. In 1931 he
was appointed to the chair of public health at Calcutta,
and in the following year he became vice-chancellor of
the university and dean of the medical faculty. He was
appointed adviser of the Secretary of State for India in
1939, in succession to Sir Abdul Qadir, and in this capacity
spent five war years in England. On his retirement in
1944 he returned to Calcutta and was appointed professor
of Islamic history and culture in the university.
“ I remember very clearly,” writes L. E. N., “when I
first met Hassan Suhrawardy, his expression of concern
about the relatively poor position of Mohammedans in `
the medical institutions of Bengal. A senior medical
APPOINTMENTS— BIRTHS, MARRIAGES, AND DEATHS
[ocr. -12, 1946
officer to whom he complained pointed out that this was
largely due to the very poor primary. education that
Mohammedans received _in the province. Hassan
Subrawardy said, ‘‘ That is what I am complaining about,’
to which the reply was, ‘‘ Well, why don’t you do something
about it?’ And he did. This conversation took place
25 years ago, and during the rest of his life he spent a great
part of his diverse energies in helping to raise the level
of the standard of primary, college, and medical education
of the Moslems in Bengal nearer that of the Hindus.”
He received a knighthood in 1932, an honour which
would undoubtedly have come his way very shortly, but
which was precipitated by his saving the life of Sir
Stanley Jackson, at that time governor of Bengal, when
a girl student attempted to shoot him at a university
ceremony. He relinquished his knighthood a few weeks
ago when the Moslem League called upon its members to
give up their British decorations. He had been appointed
honorary surgeon to the Viceroy, an exceptional honour
for a non-Service Indian, and he was the first
Mohammedan vice-chancellor of Calcutta University. He
had a full and valuable life, and his wide experience
would have been a great help to his countrymen in
holding up medical organisation in India under their
new-found national independence.
Appointments
BULL, J. W. D., M.B. Camb., M.R.C.P., D.M.R.: asst. radiologist,
National Hospital, Queen Square, London,
MCARDLE, M. J., M.B. Lond., M.R.c.P.: asst. physician, National
Hospital, Queen Square, London.
London County Council:
FELDMAN, WILLIAM, M.D. Lond., M.R.C.P.: medical. superin-
tendent (group 1), St. Giles Hospital. oo ae
LEEBODY, J. G., M.B. Edin., F.R.C.S.E.: medical superintendent
(group 111), Fulham Hospital.
Y, J. MON., M.B. Glasg., F.R.C.8.: Medical superintendent
(group III), St. Mary Abbots Hospital.
WATKIN, J. H., M.D. Lond., D.P.M.: medical superintendent,
Leavesden Hospital.
Hospital for Sick Children, Great Ormond Street, London :
NORMAN, A. P., M.B. Camb.: resident medical registrar.
SHEEHAN, JOAN M., M.R.C.S.: asst. resident M.O. at Tadworth
ourt.
SLOWE, J. J., M.R.C.S.: resident ansesthetic registrar.
Births, Marriages, and Deaths
BIRTHS
BrNsOoN.—On Sept. 29, in Bath, the wife of Dr. G. E. M. Benson
—a son.
Bo.ttron.—On Oct. 4, in Belfast, the wife of Dr. Sloan Bolton
—a son.
BRAMWELL.—On Oct. 2, in London, the wife of Dr. Byrom Bramwell
—a daughter.
CUMMING.—On Oct. 1, in London, the wife of Dr. Alister Cumming
—a son. ~
DaLy.—On Oct. 2, in London, the wife of Dr. Anthony Daly
—a daughter.
Dawson.—On Sept. 20, the wife of Dr. R. L. G. Dawson—e son.
GORDON.—On Oct. 1, at Walton-on-Thames, the wife of Surgeon
Lieut.-Commander K. G. O. Gordon, R.N.—a daughter.
Hinps.—On Sept. 27, in'London, the wife of Dr. Stuart Hinds
Hosss.—On Oct. 4, at East Molesey, the wife of Mr. Henry Hobbs,
F.R.C.8.—a daughter..
KELLY.—On Sept. 30, in London, the wife of Mr. P. M. Kelly,
F.R.C.S.—a son. :
Kxemp.—On Oct. 2, in London, the wife of Dr. J. W. L. Kemp
—a daughter.
KIPLinc.—On Oct. 4, in Liverpool, the wife of Dr. Miles Kipling
—a daughter.
Morr.—On Sept. 26, in Oxford, the wife of Prof. J. Chassar Moir,
F.R.C.0.G.—& son.
PENNYBACKER.—On Sept. 29, in Oxford, the wife of Mr. Joe
Pennybacker, F.R.C.8.—® son.
PLAYFAIR.—On Oct. 3, at Whitby, the wife of Dr. A. S. Playfair
—a son.
PRIEST.—On Oct. 3, in London, the wife of Dr. W. M. Priest—a son.
l MARRIAGES
CRAWSHAW—GOODDEN.—On Sept. 28, at North Cheriton, Everard
ey Aitken Crawshaw, major R.A.M.C., to Susan Woulfe
oodden.
POWELL—-MULLER-ROWLAND.—On Sept. 28, at Woking, Richard
Pearce Powell, L.D.S., to Joan Veronica Muller-Rowland, M.B.
WAGNER—WILSON.—On Sept. 30, in Bristol, Michael S. Wagner,
M.B.E., to Elizabeth Nan Russell Wilson, M.B.
DEATHS
ELLIOTT.—On Oct. 2, at Tunbridge Wells, Andrew Royston Elifott,
M.D. Lond., of Crowborough, aged 55. ea
LANGDON-BrRown.—On Oct. 3, at Cambridge, Sir Walter Langdon-
Brown, M.D. Camb., F.R.C.P., aged 76.
THOMPSON.—On Oct. 2, in London, Richard James Campbell
Thompson, C.M.G., “D.S.0., M.D. Durh., M.R.C.P., lieut.-colonel
R.A.M.C. retd.
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Notes and News
ON THE RECORD
Last March Westminster Hospital broke new ground by
establishing a department of medical photography under the
full-time charge of a doctor. This week the department has
held an exhibition. Part of its work is to help in clinical
investigation -by enabling the staff to keep permanent visual
records and to compare serial studies. But it also caters
largely for the student; already one film (on inflammation)
has made, and others are planned. For tutorials,
photographic displays—on gout, for example—are arranged ;
and considerable use is made of filmstrip, which is shown,
among other purposes, as replacing the familiar lantern-slide.
With a projector that can be fitted easily into a suitcase,.
pictures are reproduced on a screen up to any magnification
that the light will allow. A lecturer can carry 300 pictures
in 30 ft. of 35 mm. film, weighing no more than an ounce; and
for those that choose to vary the order of their showing, the
strip can be divided and the pieces mounted as for a lantern-
slide, but without the lantern-slide’s cost, weight, and fragility.
The exhibition shows clearly enough that photography has
much to offer both student and doctor; it may, perhaps,
prompt others to follow the Westminster Hospital’s lead.
A NEW JOURNAL OF ANSTHESIA
THE Association of Anesthetists is launching a new quarterly
journal, Anesthesia, of which the first number has appeared
this month. Edited by Dr. C. Langton Hewer, assisted by
Dr. R. Blair Gould, the journal will be primarily scientific,
but it will also publish official news of the association. “It
has become obvious,” writes the editor, “that the rapid
advance in all types of aniesthetic and analgesic technique
requires fuller and quicker expression than can be provided
in the overloaded columns of the general medical press.”
Sir Alfred Webb-Johnson, P.R.C.S., in a foreword, remarks
on the fitness of this, the centenary of the first operation under
general anæsthesia in this country, as the year for initiating
the venture. Among other papers are an account of the
association since its inception, by Dr. H. W. Featherstone,
its first president, and a sketch of anesthetic practice a
hundred years ago by Dr. A. D. Marston, who is now president.
NARCOTICS CONTROL
Tue Drug Supervisory Body and the Permanent Central
Opium Board, which were established under the auspices of
the League of Nations for the international control of narcotics,
are meeting in London this week and next. The Economic
and Social Council of the United Nations has lately agreed that
the present members of these two bodies should be invited to
continue for the time being in office.
Drug Supervisory Body.
University of London
Mr. Frank Dickens, v.sc., F.R.S., has been appointed to the
Philip Hill chair of experimental biochemistry tenable at the
Middlesex Hospital medical school.
In 1923 Dr. Dickens was appointed first assistant in the Courtauld
Institute of Biochemistry at the school.
he worked at the Cancer Research Laboratory at the Royal Victoria
Infirmary, Newcastle-on-Tyne, and he was research director for the
North of England council of the British Empire Cancer Campaign.
In March of this yeav he returned to the Courtauld Institute of
Biochemistry.
Dr. Clifford Wilson has been appointed to the university
chair of medicine tenable at the London Hospital medical
college, as from Oct. 1.
Dr. Wilson, who is 40 years of age, qualified from the London
Hospital in 1931 and took his p.m. Oxfd five years later. After
demonstrating in physiology at the London he went with a Rocke-
feller research fellowship to work at Harvard medical school and
Boston City Hospital under Dr. George Minot. He returned to this
rea 3 1935 and was appointed assistant director of the medical
t the London Hospital in 1938. From 1939 to 1942 he was
E.M.S. physician in the London Hospital sector, and from 1942 to
1946 he was on military service, attached to no. 2 Medical Research
Section, G.H.Q., Home Forces. Last year he became acting director
of the medical unit. London Hospital. Dr. Wilson is the author of
papers on renal lesions in hypertension, and was associated with
Prof. Arthur Ellis in work on Bright's disease on which Professor
Ellis’s Croonian lectures were based.
Dr. J. L. D’Silva has been appointed, as from Oct. 1, to
the university readership in physiology tenable at St.
Bartholomew’s Hospital medical college, where he has been
lecturer in physiology since 1944.
Mr. J. F. Danielli, D.sc., has been appointed to the university
readership in cell physiology tenable at the Royal Cancer
Hospital, as from Oct. 1. g
NOTES AND NEWS
The British repre- ,
, sentative is Sir Malcolm Delevingne, who is chairman of the
From 1933 until this year .
focr. 12, 1946 549
Royal College of Physicians
The Charles West lecture will be delivered on Tuesday,
Nov. 19, at 5P.m., by Prof. J. C. Spence, whose subject will
be the Care of Children in Hospital. l
Royal College of Surgeons of England
Three lectures are to be delivered at the college, Lincoln’s
Inn Fields, London, W.C.2, by Prof. Alexander Lipschutz
(Chile), who will speak on the Tumorigenic Action of Steroids
and its Implication for the Problem of Cancer (Oct. 28);
the Antitumorigenic Action of Steroids (Oct. 29); and
the Steroid Balance and the Antitumoral Autodefence (Nov. 1).
The lectures, which will be given at 3.30 P.M. on each day,
are open to medical practitioners and advanced students.
Royal College of Obstetricians and Gynzcologists
At a meeting of the council, held on Sept. 28, the following
were admitted to the membership :
H. R. Arthur, S. J. Barr, B. E. Blair, Catherine I. Blyth, Joyce
Burt, Harold Burton, G. B. W. Fisher (in absentia), R. L. Hartley,
Derek Jefferiss, Iola L. T. Jones, L. W. Lauste, Margaret Orford,
H.C. Perry, D. L. Poddar, Esther M. Pollock, J. E. Scott-Carmichael,
E. W. L. Thompson, T. G. E. White.
At the end of the meeting Mr. William Gilliatt assumed
the office of president, Sir William Fletcher Shaw and Mr.
James Wyatt of vice-presidents, and Mr. A. A. Gemmell of
treasurer.
Faculty of Radiologists
The following are the officers of the faculty for the present
session : president, Dr. C. G. Teall (Birmingham); vice-
presidents (radiodiagnosis), Dr. Peter Kerley (London),
(radiotherapy), Dr. Robert McWhirter (Edinburgh) ; immediate
past president, Dr. Ralston Paterson (Manchester) ; warden of
the fellowship, Dr. S. Cochrane Shanks (London); treasurer,
Mr. G. F. Stebbing (London) ; secretary, Dr. J. F. Bromley
(Birmingham).
Research Defence Society
The annual general meeting will be held at 26, Portland
Place, London, W.1, on Wednesday, Oct. 23, at 3.15 p.m. The
Stephen Paget memorial lecture will be given by Prof.
N. Hamilton Fairley, F.R.s., who will speak on War-time
Research in Malaria and Other Tropical Diseases of Military
Significance.
| Tuberculosis Course at Newcastle
The Tuberculosis Educational Institute announces a
refresher course, for medical practitioners and tuberculosis
officers, at the Literary and Philosophical Library, Westgate
Road, Newcastle-upon-Tyne, from Nov. 4 to 9. Programmes
may be obtained from Dr. Harley Williams, Tavistock House
North, Tavistock Square, London, W.C.1. i
College of Pharmaceutical Society
Opening the college’s 105th session in London on Oct. 2,
Sir Percival Hartley, F.R.S., director of biological standards
at the National Institute of Medical Resgarch, recalled the
valuable work undertaken by the health organisation of the
League of Nations. The organisation had advanced the
prospects of an international pharmacopeia—a project
which had been under discussion for over half a century—
and this year had published a report which could fairly be
regarded as the nucleus of such a pharmacopeia. ‘“‘ My
experience,” he concluded, “ has convinced me that inter-
national coöperation among men of science is not only easily
secured but is a kind of natural impulse.”
Hunterian Society
A dinner meeting will be held at Pimm’s (3, Poultry, E.C.2)
on Oct. 14, when Dr. J. B. Cook will deliver a presidential
address on the Evolution of Municipal Medicine. On Nov. 18,
at the Apothecaries’ Hall, a discussion on the advertisement
of proprietary medicines will be opened by Mr. Hugh Lin-
stead, M.P. On Dec. 16, at a further dinner meeting, Dr.
Geoffrey Evans will open a discussion on flatulence. The
Hunterian lecture will be delivered at the Mansion House on
Jan. 20, 1947, by Professor Debaiseux (Louvain), whose
subject will be Hypotension in Intracranial Injuries. The
annual dinner will be held at Grosvenor House on Feb. 13.
On Feb. 24 Mr. Zachary Cope will deliver the Hunterian
oration on Literature and Doctors, and on March 17 there
will be a dinner meeting at which a discussion on Sprains
and Strains is to be opened by Sir Reginald Watson-Jones.
550 THE LANCET]
MEDICAL DIARY
[ocr. 12, 1946
Society of Apothecaries of London |
Gillson Scholarship in Pathology.—This scholarship of £105
a year is open to candidates under 35 who are licentiates or
freemen of the society or become so within 6 months. The
regulations may be had from = registrar, Black Friars
Lane, E.C.4.
Society for the Study of Addiction
On Tuesday, Oct. 15, at 4 P.M., at 11, Chandos Street,
London, W.1, Dr. W. R. Bett will give an address entitled
Poppies, Dawamesk, and the Green Goddess:
Study of Literary Genius.
Medical Society for the Study of Venereal Diseases
A general meeting will be held at 11, Chandos Street,
London, W.1, at 2.30 P.M. on Saturday, Oct. 26, when Dr.
F. R. Curtis will speak on Venereal Disease in Occupied
Germany.
Food and Agriculture: Organisation
_ Mr. 8. M. Bruce, F.R.S., has been appointed chairman of the
preparatory commission appointed at the F.A.O. conference
in Copenhagen to examine methods for setting up a world
food board (see Lancet, Sept. 28, p. 463). The first meeting
‘of the commission will be held in Washington on Oct. 28.
Mr. Bruce, who was prime minister of Australia from 1922 to
1929 and represented Australia in London from 1932 to 1946,
took a leading part in the social and economic work of the
League of Nations.
Centenary of Anesthesia
Two further celebrations of the Eny of anæsthesia
are announced to be held'on Oct. 16, the anniversary of
Morton’s first operation at the Massachusetts General Hos-
pital. At 2.30 p.m. there will be a special meeting of the
history of medicine section of the Royal Society. of Medicine
at 1, Wimpole Street, London, W.1, when papers on the
development of anæsthesia will be read by Prof. Charles
Singer, Mrs. Barbara Duncum, Dr. Joseph Blomfield, and
Dr. E. Ashworth Underwood.
After this meeting, at 4.45 P.M., Lord Moran will open an
exhibition of anesthetic apparatus and literature at the
Wellcome, Historical Medical Museum, 183, Euston Road,
N.W.1. The exhibition will remain open until Dec. BL
Middlesex Hospital Dinner
Presiding over the annual dinner held in London on. Oct. 4,
Dr. G. E. Beaumont spoke of losses from the honorary staff
by retirement (Lakin, MacCormac, Cockayne, Gordon-Taylor,
Webb-Johnson, Hastings, Greeves, Bankart) and by death
(Voelcker, Berkeley, Bennett). He welcomed the appointment
of F. Ray Bettley as dermatologist, O. P. Dinnick as anæs-
thetist, A. J. B. Goldsmith as assistant ophthalmic surgeon,
R. S. Handley and C. J. B. Murray as assistant surgeons,
P. H. Newman as assistant orthopædic surgeon, and Arthur
Willcox as assistant physician. Mr. Plimsoll had been suc-
ceeded as secretary by Brig. Harvey Roberts. Meanwhile pro-
fessors seemed to be sprouting on every bush, perhaps because
of the wet summer; and the wisdom of the young suggested
that original sin been replaced by original knowledge.
Dr. H. E. A. Boldero, as dean, spoke of changes in the medical
school, including the retirement of Prof. S. Russ, the promotion
of Dr. R. W. Scarff to be professor, and the return of Prof.
F. Dickens, F.R.s., to the Courtauld Institute. By a happy
innovation, Colonel: J. J. Astor, succeeding Mr. Samuel
Courtauld as chairman of the school board, would unite that
post with chairmanship of the hospital. Dr. Boldero regretted
the circumstances which obliged some of the young men who
were to have entered the school this autumn to enter the
Forces instead, and he hoped for a change of policy by which
military service, if required, would follow completion of the
medical course. During the war the school had admitted
80 students a year, and he hoped the number would rise
to 100 as recommended by the Goodenough Committee ;
but this would be impossible until more preclinical accommoda-
tion was provided by rebuilding, and until the number of
teaching beds could be increased. The board had bought
a sizable piece of adjoining land which offered, said Dr.
Boldero, ‘“‘ a very real additional opportunity for extension
of clinical facilities under our own control.” Dr. J. Marks,
Broderip scholar, averred that the students had no complaints
this year, and their athletic record was very satisfactory.
Replying to his health, eloquently proposed by Sir Gordon
Gordon-Taylor, the chairman said that his mention of the
rowing club’s difficulties had caused Sir Alfred Webb-Johnson
to promise it a boat of its own.
an Exotic-
Medical Diary
oct. 13 TO 19
Monday, 14th
ROYAL COLLEGE OF SURGEONS, Lincoln’s Inn Fields, W.C.2
3.45 P.M. Prof. A. J. E. Cave: Anatomy of the Larynx.
5 P.M. Dr. F. W.. Roberts : Local Anesthetics.
MEDICAL SOCIETY OF LONDON, 11, Chandos Street, W.1 -. -
8 P.M. Sir Philip Manson-Bahr : Biological Basis of Tropical
Medicine. (Presidential address. )
Tuesday, 15th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Dr. E. L. Patterson: Bicsa-eappiy of the Brain.
5 P.M. Prof, R. J. S. McDowall: Blood-pressure.
LONDON SCHOOL OF DERMATOLOGY, 5, Lisle Street, W.C.2
5 P.M. Dr. I. Muende: 8 Infections of ea Skin.
EDINBURGH POSTGRADUATE nee FOR MEDICIN
5 P.M. o Eoyal Infirmary.) Prof. F. A. E. Crew, F.R. 8.: Place
Genetics in Clinical Medicine.
Wednesday, 16th
ROYAL COLLEGE OF SURGEONS
3.45 P.M. Dr. E. L. Patterson: Cerebral Ventricular System.
5 P.M. Prof. W. D. Newcomb: General Pathology of Bone.
ROYAL SOCIETY OF MEDIOINE
2.30 P.M. History of Medicine. Prof. Charles Singer : Ansesthesia
in the Pre-anssthetic Period (before 1846). Dr. Barbara
Duncum: Development of Inhalation Ansesthesia in the
Second Half of the 19th Century. Dr. Joseph Blomfield :
Modern Development of Aneesthesia (1900-35). Dr. E.
Ashworth Underwood: Contribution to the Early History
of Ansesthesia in this Country.
Comparative Medicine. Prof. G. R. Cameron: Shift of
Body Fluids.
Unrversiry OF GLASGO
(Department ‘of. Ophthalmology.) Professor Loewenstein: :
` Phakomatoses. _
Thursday, 17th
ROYAL COLLEGE OF SURGEONS 1.
3.45 P.M. Dr. wE L. Patterson : Cerebellum.
5.P.M. Prof. W. D. Newcomb: General Pathology of Bone.
ROYAL SOCIETY OF MEDICINE
5P.M. Dermatology. Cases will be shown at 4 P,M. `
Rora Ou OF TROPICAL MEDICINE AND HYGIENE, 26, Portland
ace,
8 P.M. Dr. C. J. Hackett: Clinical Course of Yaws in Uganda.
Friday, 18th
ROYAL COLLEGE OF PHYSIOIANS, Pall Mall East
3 P.M. Sir Maurice Cassidy: Coronary Disease.
oration.)
ROYAL COLLEGE OF SURGEONS
5 P.M. Prof. R. J. S. McDowall: Shock.
ROYAL SOCIETY OF MEDICINE
5.30 P.M. Radiology. Dr. Whately Davidson: Basis for Staffing
a Radiological Department. (Presidential address.)
8 P.M. E epy and Gynecology. Mr. James Wyatt: Future
eaching of the Undergraduate. (Presidential address. )
BRITISH e ASSOCIATION =
9.30 a.M. (1, Wimpole Street, W.1.) Annual Meeting. Mr. N. W.
Roberts, Mr. W. Gissane : Fractures of the Os Geleit.
11.30 A.M. Mr. George Perkins: Rest versus Activity in the
Treatment of a Fracture. (Presidential address.)
2 P.M. Short papers.
FACULTY OF RADIOLOGISTS
2.30 P.M. (Royal College of Surgeons.) Dr. Solve wen (Stock-
holm), Dr. H. Graham Hodgson: X-ray Diagnosis of
Cholesteatoma in the Temporal Bone.
WEST LONDON MEDICO-CHIRURGIOCAL SOCIE
7 P.M. (South Kensington Hotel.) Dr. G. S. Hovenden : Fifty
Years of General Practice. (Presidential address, )
Saturday, 19th
BRITISH ORTHOPEDIC ASSOCIATION
9.30 A.M. (St. Thomas’s Hospital, S.E.1.)
continued.
10 a.M. Demonstration of cases.
ASSOCIATION OF INDUSTRIAL MEDICAL OFFICERS
10.30 a.m. (London School of Beene Keppel Street, W.C.1.)
Dr. Donald Hunter, DE: R. S. F. Schilling : Industrial
Medicine in the U.S.A
. 5 P.M.
(Harveian
Annual meeting,
Sir Lionel Whitby and Mr. A. E. Porritt have accepted the
invitation of Harvard University to occupy the chairs of
medicine and surgery there for a short period. Sir Lionel
Whitby leaves for the United States next week.
In future the new quarterly, the Journal of the History of
Medicine and Allied Sciences, will be issued in this country
and the British Empire by William Heinemann Ltd., London.
The subscription in Britain is 50s. per annum or 12s. 6d.
per single copy.
A warning against the uncontrolled use of a new drug,
‘Triodione,’ for the treatment of epilepsy, has been issued
by the American Medical Association, which states that two
deaths have been zeporten in patients who were treating
themselves.
l
i
THE LANCET]
CARCINOMA OF PROSTATE TREATED
WITH G@STROGENS *
J. D. FERGUSSON
M.D. Camb., F.R.C:S.
SURGEON, CENTRAL MIDDLESEX COUNTY HOSPITAL
THE treatment of carcinoma of the prostate by castra-
tion or by the feminising influence of oestrogens has been
introduced comparatively recently but already seems
capable, in many instances, of giving greater relief than
other methods.
In 1935 an investigation into the origin of enzymes
found in urine led to the discovery that the normal human
prostate is a prolific source of an acid phosphatase.
Further observations by Gutman and Gutman (1938)
showed that this enzyme is only elaborated in appreciable
quantity by the mature gland. This significant finding
was later confirmed by Gomori (1941), who demonstrated
the phosphatase in adult prostatic epithelium by a special
staining method. Subsequent research on pathological
material has established that a high percentage of
carcinomatous prostates also produces large amounts of
the enzyme.
Huggins et al. (1941) considered that these findings
meant that the majority of carcinomatous prostates con-
tain epithelial cells of a highly differentiated type, capable
_ of elaborating acid phosphatase. Acting on this assump-
tion, and with the knowledge that normal adult prostatic
epithelium could be made to atrophy by removing the
male genital glands, Huggins advocated castration in
the treatment of prostatic carcinoma. The synthesis of
cestrogenic substances by Dodds (1938) afforded an
alternative and perhaps more humane method of treat-
ment; for, by their antagonistic action to androgen, these
substances appear to induce a response similar to that
obtained by castration.
_ ZETIOLOGY OF PROSTATIC CARCINOMA
Little is known about etiological factors in prostatic
carcinoma, but, so far as I can ascertain, it has never
been noted in a eunuch. The prophylactic implications
TABLE I— REPEATED BIOPSIES IN PROSTATIC CANCER
' DURING TREATMENT WITH CSTROGENS
Case No. of Intervals between Total dosage of
biopsies biopsies estrogens
) 4 5 months, 16 months, 6130 mg. S
| 1 year
2 | 2 30 months 3548 mg. S
3 ! - 3 10 days, 17 months 4380 mg. S
4 2 10 months 1792 mg. S`
5 | 2 6 months 500 mg. D
6 2 1 year 1560 mg. D
7 | ae 33 39 days, 10 nonths 1150 mg. D
8 ! 2 | 9 months 960 mg. D
-9 | 2 16 days 200 mg. D
10 | 2 23 months 4641 me. 8
11 | 2° 10 months 2326 mg. S
* Biopsy supplemented by necropsy. S, stilbæstrol; D, diencstrol.
are hardly likely to meet with universal approval, but it is
of interest to compare this observation with the effect of
castration on the established disease. Unfortunately the
rarity of prostatic cancer in animals has so far prevented
any confirmatory investigations.
VARIATIONS IN PROSTATIC CARCINOMA
The pathology, symptoms, -and clinical course of
carcinoma of the prostate vary widely. Differences in
+ Abridged from a Hunterian rae oe hh at the Royal College of
Surgeons of England, June 13, 1946
6425
ORIGINAL . ARTICLES
| Biopsi
CCAP a OSPSSSSSS SFO
e pote d
Ca Do a ae aDDP ay
L Dat Dra Y
se a SUT
4K m
[ocr. 19, 1946
the cellular arrangements of the tumour are common,
all gradations being met with, from anaplastic forms
through glandular to scirrhous types. Even in the same
prostate the histological appearance is seldom uniform,
though this may be due in part to anatomical factors.
. I am prepared to believe that most growths originate in
that portion of the gland lying below and behind the
verumontanum; but, from a dissection of many adult
prostates, I am now inclined to think that there is no
well-demarcated posterior lobe. No part of the prostate
need ultimately remain exempt, and in a high proportion
of cases the growth is already widespread when detected.
Very occasionally the reverse obtains, and a small
area of unsuspected malignant tissue may be found in
TABLE II—ACID PHOSPHATASE IN PROSTATIC TISSUE
Acid phosphatase (King-Armstrong
units per 100 g. of moist tissue)
Source
Lateral lobe | Posterior part
Necropsy :
Benign ‘glands (6 cases)... 1410 484
960 14,500
8420 10,900
1900 10,340
2190 11,670
11, "500
Average 7300; highest 15,600; less
. than 1000 in 4 cases
Average 11,784; highest 28,200 :
less than 1000 in 1 case
Benion glands "(20 cases)
Carcinomatous glands
(14 cases)
what was considered clinically to be an ‘‘ adenomatous ”
prostate. _ |
Differences in the dissemination of metastases are
common and explain much of the disparity between
general and urological symptoms. In this connexion I
- would emphasise the frequency of superficial lymphatic
metastasis—a point liable to be overlooked.
Variations in the clinical course are determined largely
by the metastases, and the disease may sometimes
pursue a relatively asymptomatic course for years, only
being detected at necropsy. . |
It is important to appreciate fully such variations
before assessing the merit of any treatment. -
TREATMENT OF PROSTATIC CARCINOMA
In a review of 1000 cases of -prostatic carcinoma,
Bumpus (1926) showed that two-thirds of the patients,
if untreated, died within a year of coming under observa-
tion. If metastases were detected when first seen, this
period was reduced to nine months.
With improved methods of treatment the average
survival period became somewhat longer, but few pro-
cedures gave any constant relief. In some instances
the complications of therapy proved a greater affliction
than the disease. Many of the methods, however, remain
of value, and, with the addition of castration and oestrogen
therapy, now constitute the basis of treatment of pros-
tatic cancer. Omitting radical prostatectomy as applic-
able in only a small proportion of cases, treatment in the
remainder falls into three categories :
(1) Palliation of symptoms by medical means.—This is
entirely non-specific and has no direct application to the
growth.
(2) The surgical relief of urinary obstruction by urethral
dilatation, cystotomy drainage, or perurethral resection.
With cestrogen treatment, the indications for cystotomy
drainage are becoming less frequent. It remains of value in
patients almost moribund from uremia, and in cases where
involvement of the external urinary sphincter leads to
incontinence.
(3) The suppression of neoplastic activity by radiotherapy,
cestrogen treatment, castration, or irradiation of the testes.
It has been the experience of many observers that the
addition of castration or cstrogen therapy is often
Q
552 THE LANCET]
MR. FERGUSSON: CARCINOMA OF PROSTATE TREATED WITH C&STROGENS
"oor. 19, 1946
followed by a degree of relief not achieved by other
methods. This evidence, though significant in its
volume, is necessarily based largely on the subjective
statements of patients. i
levelled against the uncorroborated clinical findings of
the surgeon, particularly those relating to repeated
rectal examinations during treatment.
though in many cases the giving of estrogens is
apparently accompanied by a satisfactory response,
such an opinion is often open to the objection of the wish
‘being father to the thought.
METHOD OF INVESTIGATION OF RESULTS .
OF ŒSTROGEN TREATMENT
Hoping to overcome such criticism, I decided in 1942 to
carry out repeated biopsies of the carcinomatous prostate,
and of any accessible metastases in suitable cases during -
continued cestrogen therapy. This method of investiga-
tion appeared of additional value in affording a positive
control by means of which primary errors in the diagnosis
of prostatic carcinoma could be definitely excluded—
a risk which might otherwise lead to false claims for
cestrogen therapy (Fergusson and Pagek 1945).
My preference for conducting this survey with cestro-
gens, instead of following the results of castration, was
based on a hope that I might also discover the optimum
dosage. Further, if such treatment proved ineffective,
it would still be possible to resort to operation.
Opinion seems to vary geographically as to the value
of retaining the male genital glands, and in many reports
from transatlantic clinics a preference is expressed for
bilateral orchidectomy. Such treatment is often mitiga-
ted and even embellished by the substitution of a plastic
Fig. \—Serial biopsy specimens of prostatic carcinoma during cestrogen
treatment, showing regression of tumour and replacement fibrosis :
(a) initial ; (b) after 5 months ; (c) 16 months later ; (d) a year later.
A similar criticism may be
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Fig. 2—Serial biopsy specimens of prostatic carcinoma during œstro
treatment, showing regression of tumour: (a) initial; (b) after
10 days ; (c) 17 months later
prosthesis, but the psychological effect is liable to be
disturbing. On the other hand, with prolonged
administration of oestrogens the testicular atrophy and
loss of desire are more gradual and are accepted with an
equanimity seldom evinced after castration.
When I started my survey during cestrogen treatment
I was unaware of a parallel investigation by Schenken
et al. (1942) conducted for two months in the United
States, but my longer-term results agree closely with
theirs. I have since been able to corroborate the
histological findings by ‘simultaneous estimations of the
acid-phosphatase content of the affected tissues.
It was clear from the outset, in view of the known
variations in the histology of the growth, that such a
comparison of serial biopsy material might be unreliable.
Therefore the following conditions had to be satisfied :
(1) All the patients should have a proved prostatic cancer.
In 23 cases treated with oestrogens since 1942 the diagnosis was
confirmed by biopsy in 21, the remaining 2 having indisputable
clinical, radiographic, and serological evidence.
(2) The patients should preferably show a good clinical
response to cestrogens since, if they did not, no well-defined
histological changes could be anticipated. The ideal case
would thus be one showing relief from pain, increase in weight,
and general well-being, but in which a degree of urinary
` obstruction persisted requiring surgical relief. -
(3) Any tissue for comparison should be removed from the
same site as far as possible on each occasion, and care taken
to avoid at the first biopsy undue trauma which might affect
the later histological appearances. To satisfy this condition
I carried out every biopsy with the Gershom Thompson “ cold
punch” resectoscope, removing tissue from behind the
posterior quadrant of the urethra above the verumontanum.
I do not believe that there is any great risk of stimulating
metastatic spread by this technique. Diathermy hemostasis
is reduced to a minimum to avoid subsequent necrosis, and
bleeding is preferably controlled with a Foley’s bag catheter.
A control series of repeated resections of “ adenomatous ”
prostates made in a similar manner showed negligible
traumatic reactions. i
(4) Enough tissue should be removed on each occasion
to minimise any error due to vagaries of anatomical structure
and distribution of the growth. . |
T
THE LANCET]
MR. FERGUSSON: CARCINOMA OF PROSTATE TREATED WITH ŒSTROGENS
[ocT. 19, 1946 553
RESULTS OF REPEATED BIOPSIES
On these lines I carried out repeated prostatic biopsies
on nine of the eases receiving œstrogens (table 1). The
intervals between these biopsies varied from 10 days to
23 months, and in a few instances additional biopsies
were undertaken over periods extending up to 3 years.
A minimum of 1-5-2-0 g. of tissue was removed on each
occasion for examination. In a further two cases, where
after preliminary biopsy and initial response to treat-
ment tħe patient later deteriorated, valuable serial
material was obtained at necropsy.
Every patient received continuous œstrogen treatment,
and any adjuvant therapy was on uniform lines. @Œstro-
gen was administered as stilbcestrol or diencestrol in
doses of 2-15 mg. a day. As each successive biopsy
was performed, serial sections were made and stained
simultaneously for accurate comparison.
The preliminary visual impression on examining the
sections suggested that in nearly all cases the neoplasm
was regressing considerably during treatment. The
collections . of cells forming the tumour units were
decreasing not only in size but also in number. The
general trend appeared to be away from a glandular
adenocarcinomatous to a less cellular scirrhous form.
This is well exemplified in fig. 1, which shows the histo-
logical appearance on four occasions extending over
nearly 3 years. The photomicrographs are entirely
representative of many serial sections. Fig. 2 shows a
similar picture of three biopsies extending over 17 months.
In the remaining seven cases similar findings were
obtained.
A more detailed histological examination was under-
taken in several instances, involving a computation of
the tumour units in microscopic fields of standard. size,
and a measurement of the nuclear diameters of the
tumour cells, which in the later specimens appeared to
be smaller. These examinations were conducted by
skilled laboratory technicians for whose impartiality and
ability I have the highest respect ; and the results obtained
fully confirmed the original visual impressions. The
reduction in average size of the nuclei is shown in fig. 3, .
where in three cases the nuclear diameters are plotted
against the number of nuclei.
During the last 18 months it has been possible to
substantiate these findings by examining half the fresh
t
ie
p
r
r A
{
2
` Fig. arvore sections i adult benign prostates, at level ‘ory veru-
montanum, stained to show acid phosphatase. Notice increased
amount of enzyme in posterior part of gland.
biopsy material for tissue acid phosphatase. There are
two ways of detecting it—biochemical estimation of the
enzyme, and demonstration by the lead-nitrate and
ammonium-sulphide staining method used by Gomori
(1941). The methods seem to give comparable results in
that a positive staining reaction visible to the naked eye
appears to
develop
with reason-
able uni-
formity
when the
concentra-
tion of the
enzyme ex-
ceeds 1000
King - Arm-
strong units
per 100 g.
of tissue.
When I
first - tried
the staining
method I
had two 20
objects in 10
view. Be-
- NW DAD
O O Oo:
PERCENTAGE OF NUCLEI
O oO
W
O
sides hoping 2 4 6 8&8 0 2 n
DIAMETERS OF NUCLEI (2)
Fig. 3—Decrease in nuclear diameters of tumour
cells of prostatic carcinoma during cestrogen
treatment: solid lines, diameters at Initial biopsy ;
broken fines, diameters at subsequent biopsies.
A shift from right to laft denotes reduction in
diameters,
to find a
demon-
strable
reduction in
the amount
of enzyme
in carcinomatous prostates as treatment progressed, I
was anxious to discover whether the amount was
greater in the posterior portion of the normal gland, a
point which might possibly have a bearing on the
frequency of malignant change in this situation. After
a considerable number of normal adult prostates had
been stained, my findings agreed with Gomori’s (1941)
view that the quantity and the distribution of the enzyme ©
vary widely throughout the gland.
A few physiological adult prostates do not stain
sufficiently to be visible with the naked eye, but in most,
despite irregular distribution, there is evidence that a
greater concentration of enzyme is common in the :
posterior part of the gland. This finding may, however,
be influenced by potential ‘‘ adenomatous ” changes in
the lateral lobes. Fig. 4 shows sections from two benign
prostates differing in the distribution of the black-
staining phosphatase, but in each case showing a quantity
of enzyme in the posterior part behind the. verumon-
tanum. (Incidentally, staining of the complete female
urethra to detect acid phosphatase has so far given
no indication of a prostatic homologue.)
Carcinomatous prostates, on the other hand, generally
show a consistently large amount of enzyme throughout
their extent.
made on benign and malignant glands, and table 11
shows that whenever the whole benign gland was avail-
able a greater amount of enzyme was found in the
posterior part. In the biopsy material, figures for
carcinomatous tissue are slightly above the average for
benign glands. =
In four of the cases of prostatic carcinoma in which
repeated prostatic biopsy was done the histological findings
were supplemented by tissue acid-phosphatase estima-
tion. In each case the concentration of the enzyme
diminished during treatment, as illustrated in figs. 5 and 6.
At the same time quantitative estimations showed
decreases in units per 100 g. of tissue as follows: 8000
fell to 200, 3000 to 600, 8000 to 100, and 28,000 to
`
A few quantitative estimations have been _
ka
554 THE LANCET] MR. FERGUSSON: CARCINOMA OF PROSTATE TREATED WITH GSTROGENS [ocr. 19, 1946
i abe
‘og st BT Re we
' Ser Ea eee eee ’ e
UE gil eee T E a TA
(a) i (b) (a) | (b) ’
_ Pig. 5—~Serial biopsy specimens of prostatic carcinoma during cestrogen Fig. 6—Serial biopsy specimens of prostatic carcinoma during cestrogen
treatment, stained to show decrease in amount of acid phosphatase : treatment, stained to show decrease in amount of acid phosphatase :
(a) initial ; (b) after 8 months. (a) initial ; ~(b) after a year. aa
\
These investigations indicate that, in some cases of So far as clinical evidence is allowable, one of my cases
prostatic carcinoma showing a good clinical response to. did comply with this condition. The patient. had two
estrogens, there is a well-defined improvement in the affected glands in the right axilla, similar in size‘ and
condition of the primary growth, as shown by the histo- donsistence, and showing equal clinical evidence of
logical changes and corresponding reduction of tissue’ carcinomatous involvement. One gland was removed
acid phosphatase. This accords with the clinical finding at the start of estrogen treatment, and the other, which
that the prostate appears, on rectal examination, to lose became noticeably smaller and softer, 24 days later.
some of its malignant characteristics. . I hasten to add The microscopical findings are depicted in figs. 7 and 8,
that some cases of prostatic carcinoma do not seem to which show that the second gland exhibits less malig-
respond to cestrogens, and that, apart from anaplastic, nancy and contains a much smaller concentration of
forms as noted by Sullivan et al. (1942), I have been acid phosphatase. Normal lymph-glands show no acid-
unable to correlate this failure with any particular phosphatase staining reaction. This comparison is-
histological picture. . undoubtedly open to criticism, but, taken in conjunction
Another point of importance is that there is no intimate with clinical evidence in other cases, gives reason for
connexion between the concentration of acid phosphatase the belief that œstrogens may produce, a beneficial, if
in the affected. prostate and the amount in. the blood- temporary, effect on metastases.
serum. The serum value undoubtedly derives from the No further opportunity for comparison has yet arisen,
quantity elaborated by metastases as well as by the but in several other cases I have carried out phosphatase
primary growth. Out of 50 cases of prostatic carcinoma staining on solitary lymph-glands affected with prostatic.
treated since 1940, the serum value exceeded 3 units cancer. In every case where the primary growth showed
per c.cm. in 90% of 39 patients with radiological a positive staining reaction the gland did likewise.
metastases. I then tried to discover whether secondary involve-
BEN AVIOUR OF METASTASES ment from other types of primary growth was accom-
Though most metastases from prostatic carcinoma panied by acid-phosphatase production, and to decide
are not readily accessible for histobiochemical investiga- whether glandular biopsy with phosphatase assay would
tion, superficial lymph-nodes are -not uncommonly be of any value in diagnosis. Many lymph-glands
involved. The opportunity, however, seldom presents affected by various pathological processes, including
for comparative study of these affected tissues, since malignant disease, were examined, but acid phosphatase
this would presuppose identical malignant involvement was rare except in secondary prostatic carcinoma. It
of at least two glands at the outset. was noteworthy that several tuberculous glands gave a
>
De E 4
PTET TE A
Deg Pl ee
we
at
m ow hh
4
oo
. 4%
ae
a
nee 4
xs
a ree
i AT
a
ee ee rd
= p
2
$ oe
rus
(a) (b)
ring cestrogen treatment. Fig. 8=—Same sections as in fig. 7, stained to ow acid phosphatase
Gland (b) was removed 24 days after gland (a) and appears less malignant. Gland (b) has less enzyme than gland (a).
Fig. 7—Sections’ rom two similar axillary lymphegiands, affected by
metastases from prostatic carcinoma, du
eee OD Å
THE LANCET]
moderate staining reaction, and I suspect this may be
connected with subsequent calcification (fig. 9). Of
the malignant glands examined, only two, apart from
those affected by prostatic carcinoma, gave a positive
reaction. These were glands secondarily affected by
carcinoma originating in the stomach in one case, and in
the penis in the other.
-~ It seems therefore that the presence of much acid
phosphatase in a secondarily affected gland strongly
suggests a primary growth in the prostate, but does not
prove it.
SIDE-EFFECTS OF @STROGEN THERAPY
Most of the side-effects of cestrogens, particularly in
large doses and over long periods, are relatively harmless,
and in several instances I have used diencstrol 40-50 mg.
daily without adverse results other than occasional
vomiting.
Changes in the male breast appear in about two-thirds
of the cases. There may be tenderness of the nipple
area, diffuse mammary swelling, and pigmentation.
Pigmentation is usually confined to the areola but may
. rarely involve the surrounding skin (fig. 10). The breast
changes do not seem to bear any constant relation to the
prostatic response.
Shrinkage of the testes and diminution of sexual feeling
have taken place in about a quarter of my patients but
have been accepted with equanimity. Microscopy of
such testes shows no special changes beyond those
associated with senile atrophy. (I have incidentally
p
f
! M
|
:
f
(a) (b)
Fig. 9—Sections of (a) tuberculous lymph-gland and (b) phani
affected by metastasis from prostatic carcinoma, both stained to show
acid phosphatase. Note amount of enzyme in (a).
found -œstrogen therapy of considerable value in cases
of benign so-called prostatism associated with sexual
aberrations.)
Change in Complexion. —Though I have been unable
to detect any conspicuous loss of hair in my patients, it —
has been pointed out to me that many who have received
prolonged treatment develop a choir-boy countenance.
Vertigo.—Apart from these minor side-effects and
sporadic mild skin rashes and cedema, the only thera-
peutic complication which I thoroughly respect is vertigo.
Several cases have been recorded in which patients died
of a cerebral castastrophe, and I have had one such case.
“It is difficult to ascribe such an event to the giving of
cestrogens, particularly in elderly patients, but I have the
impression that vertigo may be the precursor of this
disaster. How far it is vascular in origin, and thus
possibly akin to the spasmodic vascular affections of
females, is a matter for speculation.
On the whole it may be said that, compared with many
other methods of treatment for prostatic cancer, ostro-.
geu therapy seldom has disturbing sequele.
RESULTS OF TREATMENT
Of. 50 cases of prostatic cancer which I have treated
during the last six years, 27 were treated on standard
MR. FERGUSSON: CARCINOMA OF PROSTATE TREATED WITH GSTROGENS
[ocr. 19, 1946 555
lines without cestrogen, and the remaining 23 received,
in addition, continuous cestrogen therapy. I have .
excluded any cases of more recent date than December,
1945. From this small series, observed over a relatively
‘short period, no conclusions are justifiable in- respect of
curé, but the survival-periods are interesting (fig. 11).
Many of the surviving patients are in good health and
appear likely to remain so for some time to come.
Fig. i0..Circumareolar pigmentation of male breast in patient Deceiving
castrogen treatment.
DISCUSSION
Roughly speaking, patients dying during cestrogen
treatment can be divided into three classes :
(1) Patients who are moribund or in an advanced stage of
renal failure when treatment is begun. |
(2) Those who, though otherwise apparently eligible, show
no reaction to cestrogens, and in whom the natural course
of the disease proceeds unchecked. Probably many such
patients have anaplastic tumours, possibly of a type that
does not produce acid phosphatase.
(3) Patients who show a satisfactory initial response, as
judged clinically, biochemically, and histologically, in whom
a delayed and often sudden relapse takes place, as if all
‘ sensitivity to cestrogen was abruptly lost.
About half the deaths in the group receiving wstrogens
fall into this last category of delayed reactivation of the
growth. At necropsy in three of such cases almost
complete regression of the primary prostatic growth was
found, despite the coexistence elsewhere of widespread
metastases, many of which, from clinica] evidence, were .
of recent origin. In all these cases prostatic biopsy at
the start of treatment had shown a highly active primary
growth. A similar finding after castration has been
reported in the United States by Huggins (1942) and by
Gilbert and Margolis (1943). One is reminded forcibly
of the observations of Prym (1925) on the spontaneous
inactivation of primary chorionepithelioma of the testis
in conjunction with spreading metastases, and of the
sporadic success of odphorectomy performed for
mammary cancer.
Two questions arise :
(1) Is this peculiar behaviour limited to neoplasms of the
sexual apparatus ? If so, may it not be possible that the
action of oestrogen is physiological, primarily affecting the
organ in which the growth arises ?
1942-46 (23 cases)
CESTROGENS GIVEN
1940-43 (27 cases)
NO CESTROGENS
f DIED
mi SURVIVING
MONTHS
Fig. |i—Survival periods of patients with carcinoma of prostate, with
and without aetrogen treatment,
556 THE LANCET]
MR. ALVES, DR. BLAIR: DIAGNOSIS OF SCHISTOSOMIASIS .
[oor. 19, 1946
(2) If this is not so, may it not still be possible that the
action of organic chemotherapy is pre-eminently directed
against the primary growth, and that metastases by virtue
of their ectopic position sometimes acquire a degree of
immunity. I know of no instance where, from the clinical aspect,
metastases have undergone regression without corresponding
changes in the primary tumour.
In view of this apparently delayed veaotivation in
several cases, one may ask whether specific treatment
should not be reserved for the terminal stages of the
disease. With an irrevocable form of treatment like
castration this may be advantageous, but with œstrogen
therapy it seems very doubtful. Besides the difficulty
of determining the onset of the final decline before
starting treatment, it seems to me that any prospect of
cure, however remote, is thereby abandoned. In the
present state of knowledge therefore it appears that
estrogen treatment, if it is to be adopted, should be used
early and continuously, and the underlying pathology
should be confirmed as far as practicable by biopsy.
In pursuing such a course it is possible that accumulating
information may lead to the advancement of organic
chemotherapy in other spheres of malignant disease.
SUMMARY
The pathology, symptoms, and clinical cause of pros-
tatic carcinoma vary widely, and this must be borne in
mind in estimating the value of any form of treatment. .
A method of investigating the results of cestrogen
therapy of prostatic carcinoma by repeated biopsies is
described.
The results obtained by this method in 9 cases are given.
In nearly all of them the neoplasm regressed during
treatment, as judged both by ordinary microscopy and,
in 4 of the cases, by tissue acid-phosphatase estimation. .
But some cases of prostatic carcinoma do not appear to
respond to cestrogens.
Some evidence is produced that Ceerogous may exert
a beneficial effect on metastases. _
In an attempt to discover whether the presence of
acid phosphatase in metastases in lymph-glands was
. pathognomonic of prostatic carcinoma it was found that
acid phosphatase was rarely present in other conditions ;
but it was found in one lymph-gland secondarily affected
by carcinoma of the stomach, in another by carcinoma of
the penis, and in some tuberculous lymph-glands. The
presence of much acid phosphatase in a lymph-gland
therefore strongly suggests, but is not proof of, a primary
growth in the prostate.
The side-effects of ostrogen therapy include changes
in the male breast, shrinkage of testes and diminution
of sexual feeling, change of complexion, and vertigo.
Vertigo may possibly be the precursor of a cerebral
catastrophe.
The average survival periods of 23 patients treated with
cestrogens were longer than those of 27 patients not 80
treated.
About half the deaths of patients receiving costrogens
were due to delayed, and often sudden, reactivation of
the neoplasm.
With great pleasure I acknowledge my indebtedness to
Dr. W. Pagel and his assistants in the pathological laboratory
at the Central Middlesex County Hospital, without whose
willing coöperation these investigations could hardly have
succeeded.
REFERENCES
Bumpus, H. C. jun. (1026) Surg. Gynec. Obstet. 43, 150
Doan: a í Gy Solberg, L. +» Lawson, W., Robinson, R. (1938) Nature,
07
Fergusson, J. D., Pagel, W , (1945) Brit. J. Sure. 33, 122.
Gilbert, G., Margolis, G » 82.
; . (1943) J. Urol.
Gomori, G. (1941) Arch. Path, 32, 189.
Gutman, A. B., Gutman, E. B. (1938) Proc. Soc. exp. Biol., N.Y.
9,5
Huggins, C. ` (1942) Ann. Surg. 115, 1192.
tt, W. W., Hodges, C. V. fiiy J. Urol. 46, 997.
Prym P. S 25) Diech. med. Wschr.
Schenken, J. R., Burns, E. L., Kahle, P - (1942) J. Urol. 48, 99.
Sullivan, T. J., Gutman, E. B., Cutan A . (1942) Ibid, p. 43 6.
_9 eggs were found on six days.
DIAGNOSIS OF SCHISTOSOMIASIS
‘'INTRADERMAL TEST USING A CERCARIAL
| ANTIGEN |
Wi1am ALVES Dyson M. BLAR
B.A. South Africa O.B.E., M.B. Edin., D.P.H.
From the Schistosomiasis Research Laboratory, Salisbury, -
Southern Rhodesia
THE diagnosis of schistosomiasis by the present methods
of microscopical examination of excreta for the eggs of
the schistosome worms is costly of staff, time, and
equipment, and is ill-suited to a country with a small
and scattered population. Unless the disease is so wide-
spread that it can be assumed that all the inhabitants
are infected, as in some parts of Egypt, no campaign of
large-scale treatment should be undertaken unless the
infestation can be diagnosed in each person.
In Southern Rhodesia schistosomiasis is found prac-
tically everywhere, but previous surveys have shown
that the intensity of infestation varies greatly from place
to place. There may be very few cases at higher altitudes
on the central plateau. Any campaign of mass-treat-
ment must therefore be preceded by diagnosis. .
DIFFICULTIES IN DIAGNOSIS
Diagnosis by the examination of samples of excreta
for the eggs of the parasite is made difficult by biological
and technical factors. Biological factors which may affect
the production of eggs and their evacuation in stool or
urine are (1) an infection with worms of one sex, or a
great disproportion between the sexes; (2) a natural
rhythm in the production of eggs; (3) misdirection of
eggs, owing to an unusual position of. the female worm
at the time of laying; and (4) inability of the eggs to
penetrate the wall of bladder or bowel because of
fibrosis resulting from previous damage. |
The technical factors affect chiefly the alivenosin of
S. mansoni infestations, though they may operate to
some extent in urinary infestations. These factors
include (5) the collection of specimens in the wrong way
by the patients; and (6) the examination of too few
slide preparations of the centrifugalised deposit,
(1) Infection with Worms of One Sex, or a Great Dispropor-
tion between the Sexes.—Mayer and Pifano (1942), in experi-
ments on mice infected with S. mansoni, have shown that
eggs are produced in the fæces only in those cases where the
proportion of male and female worms is about equal. Necropsy
of mice which were not passing eggs in the feces showed a
preponderance of one sex—e.g., one mouse had 22 male
-worms and only 1 female ; another had 20 male and 1 female,
and in both instances a few eggs were found in the liver.
In their opinion the most important cause of. absence of
eggs in the fæces is infestation by worms of a single sex. This
type of infestation, they consider, may occur by chance if
the person is infected by a single exposure.
Girges (1934) amassed a large body of evidence favouring
his thesis that Egyptian splenomegaly is due in almost all
cases to infestation with male worms. He distinguishes two
types of S. mansoni infestation: the hepatic, and the intes-
tinal. In 40% of his hepatic cases no eggs were ever found in
the dejecta while in the remainder very few eggs could be
seen; this, he says, is associated with a disproportionate
number of male worms.
(2) Natural Rhythm i in Production of Eggs. —Orpen (1916)
investigated the egg output in a case of S. haematobium
infestation. Three drops from the deposit of 2:5 c.cm. of
residual urine was examined daily for over two months in
the rainy season. No eggs were found on fifteen days; 1-3
eggs were found on thirty-four days; 4-6 eggs were found
on eleven days; 7-9 eggs were found on six days; and over
The record output was 31
eggs on one day. If egg output follows this pattern, it is
obvious that there are many occasions on which schisto-
somiasis would not be diagnosed by microscopical methods.
Mayer and Pifano (1942) state that in their experience egg
production is greatest when the worm has just reached
maturity. If this conclusion is correct, it seems logical to
THE LANCET] z
assume that with increasing age a stage will be reached when
the worm no longer produces eggs, although all the toxic
signs and symptoms due to its presence will still be manifest.
(3) Musdirectton of Eggs owing to Unusual Position of
Female Worm.—There have been many published examples
of the discovery of worms and eggs in unorthodox places. In
Southern Rhodesia, for instance, schistosomal appendicitis
is relatively common, and the eggs found have invariably
been those of S. haematobium. In very few of these cases is it
possible to demonstrate the eggs in either stool or urine.
(4) Inability of Eggs to Penetrate Wall of Bladder or Bowel.—
In many cases in Rhodesia intensive efforts to establish a
diagnosis of schistosomiasis by the demonstration of eggs has
failed although when such cases come to necropsy eggs can
be found in the bladder and bowel wall. Tissue reaction by
the formation of “ tubercles,” in which the eggs are effectively
sealed off, is also a common finding.
Begg (1944) has advocated cystoscopy in every suspected
case of schistosomiasis. He claims that in a very high propor-
tion of his positive cystoscopy cases no eggs can be found in
the urine. Ottolina and Atencio (1943) are even less satisfied
with microscopical examination of stools. They advocated
biopsy of the liver, but gave up this drastic procedure in
favour of biopsy of the rectum. They found 11 cases of
S. mansoni infestation by this means in 100 patients whose
stools were negative.
(5) Collection of Specimens by Patient in Wrong Way.—It
is accepted that a positive diagnosis is most often obtained by
examining the last portion of the early morning urine voided
after straining. With stools, when the whole specimen cannot
be collected, the surface of the stool, particularly any portion
containing blood or mucus, should be scraped off. It is
difficult. enough to persuade educated Europeans to adhere
to instructions for the collection of excreta, but vastly more
. 80 when a primitive African population is to be examined.
(6) Examination of Too Few Slide Preparations of Centri-
fugalised Deposit.—In our experience, when light infestations
are common, it is possible to examine several slide prepara-
_ tions from the one centrifugalised deposit of urine before an
egg is seen, although there may be large numbers of red blood
cells present, and a single examination would obviously miss
this type of case.
Heavy infestations with S. mansoni in cases giving a
history of dysentery are not often seen in Southern
Rhodesia. Light infestations with S. mansoni in dysen-
tery patients present an even greater problem than do
light infestations of the urine. The handling to which
the stool specimen must be subjected before it can be
examined microscopically may lead to the loss of some
of the few eggs present, and it is also more difficult to
recognise eggs in a stool slide preparation. To overcome
these difficulties Senra (1942) discusses the methods of
Fulleborn and Hoffman by which the whole stool is
broken up first in warm saline and then diluted with
distilled water. If eggs are present, the miracidia hatch
and can be seen in the supernatant fluid with the aid
of a hand lens. Scott (1942) uses a combination of
dilution count and sedimentation methods on a 6-g.
sample of feces and claims 93% accuracy. Neither of
these methods is practicable in this country owing to
lack of skilled staff and the need for examining both
urine and stool, a problem which does not face workers
in South America,
TESTS WITH ANTIGENS
Attempts to overcome these inherent difficulties in
diagnosis have included the use of skin-tests and com-
plement-fixation tests with antigens derived from various
helminth products. This is a logical development and
seems to be the only one likely to confirm a diagnosis in
situations such as have been discussed above.
Fairley was apparently the first worker to attempt
diagnosis by a skin-test (Fairley and Williams 1927).
He used livers from snails infected with S. spindale as
his antigen. Other workers have since tried to devise
antigens from whole worms, using either one of the
schistosomes or worms of a related species. Kan (1936)
used adult S. japonica reared experimentally in animals,
and Culbertson and Rose (1942) used the lung fluke of
MR. ALVES, DR. BLAIR: DIAGNOSIS OF SCHISTOSOMIASIS
focr. 19, 1946 557
frogs, Pnewmoneces medioplexrus. There are various
unsatisfactory features of the use of snail liver as an
antigen. Taliaferro and Taliaferro (1931), for instance,
found that 16% of 120 persons, some of whom were not
infected, reacted to normal snail-liver extracts. °
Adult schistosomes grown to full maturity are difficult
to obtain. For this reason, working with W. R. Blackie
in 1938, we attempted to nse miracidia of S. hematobium
obtained by scraping the wall of urinary bladders
removed at necropsy. This antigen gave satisfactory
results in a few cases, but obviously an antigenic sub-
stance obtained from such a source is not ideal. Work
was stopped by the war and was not resumed until 1942,
when Alves began to experiment with the use of cercarix
as antigen. Risquez and Boza (1941) used cercariw of
S. mansoni obtained from ‘‘ washed ” P. guadaloupensis.
They do not describe the method of preparation of the
antigen nor do they advance any claims for this method
as a diagnostic procedure,
PREPARATION OF ANTIGEN i
Wild physopsis snails are collected and brought to
the laboratory in Ball jars holding several hundred
snails. These snails are taken from two habitate ; and,
although several thousand have been obtained there, it
is always possible to find four or five hundred snails
in the same place a few weeks later. The proportion of
infected snails remains remarkably constant at about
10%. The habitats are, in the Rhodesian winter, very
slowly moving streams with much vegetation.
Tubes 3 in. x 1 in., filled with clean pond-water, are
used for the study of the snails, two of which are placed
in each tube. The tubes are placed in the morning sun,
and about 10% of the snails can be seen to be shedding
human-type cercariæ within forty-eight hours of collec-
tion. With this high infection-rate we have found it
unnecessary to keep the snails under observation for .
more than a few days, when the uninfected ones are
discarded. The infected snails are put into individual
tubes and kept there until many cercarie are seen. ‘It
is not unusual, in: our experience, to get 3000-4000
cercariæ from one snail in forty-eight hours,
When enough cercaris have been produced, the snail
is transferred to another tube ; and the water, containing
cercaris, snail fæces, and any detritus, is filtered through
a very fine muslin bag. The cercaris pass through this ~
filter, but the undesirable matter is held up. The filtrates
thus obtained are pooled and passed through filter paper
' which traps the cercarizs but lets through bacteria and
other microscopic matter. We have aimed at a concen-
tration of about 10,000 cercaris per circle of 15 cm.
diameter of filter paper, but this is probably not of great-
importance. It is undesirable to prepare much liquid
antigen at a time, unless it can be used quickly, so the
papers are allowed to dry and are stored, without any
special precautions, until required.
For the preparation of the liquid antigen the dry
filter papers are cut up into pieces about 1 cm. square
and placed in a flask with sufficient 1% carbol saline to
give about 2000 cercariw per c.cm. The flask is agitated
from time to time and is left at room temperature for
twenty-four hours. The surplus fluid, of which there is
usually very little, is decanted and saved, and the mass
of wet filter paper is then squeczed until as much fluid
as possible is expressed. To prepare large quantities
of antigen it would probably be advisable to devise
some type of small metal wringer. S
This fluid has never contained any pathogenic organ-
isms and is in fact often sterile, but we have made a
practice of filtering it through a Seitz filter. The filtrate
is then dilated with an equal quantity of sterile normal
saline, so that the final product contains 0-5% phenol
and the extract of about 1000 cercaris per c.cm. It is
stored at refrigerator temperature in rubber-capped
558 THE LANCET]
vaccine bottles. So far no loss of potency has been
demonstrable, even in antigen kept at room temperature
for six months. Before general use each batch of antigen
is tested on a known positive subject and a known
negative subject.
Since human-type cercaris from physopsis have. been
used exclusively, it is probable that the antigen is com-
posed largely of S. hamatobiwm products ; but we feel,
on epidemiological grounds, that these snails must be
acting as intermediate hosts of S. mansoni, and we intend
to investigate this question later. For the purposes of
the skin-test the question is of academic interest only,
since all workers agree that there is a common antigenic
factor in the schistosomes.
PERFORMANCE OF TEST
We use the ordinary intradermal technique, with a
tuberculin-type syringe and a fine-bore short bevelled
needle. Influenced by Coca (1931), we inject as little of
the antigen as possible, the aim being to use a dose of
0-01 c.cm., which usually raises a weal 3-5 mm. in
diameter. The injection is made into the skin of the
flexor surface of the forearm, choosing if possible an
uninjured hair-free area. The importance of securing
a true intradermal injection cannot be over-emphasised.
If a small intradermal bleb is not obvious when the
needle is withdrawn, the injection should be repeated
at once in another place.
In view of suggestions that phenol per se may produce
non-specific positive reactions in intradermal tests for
trichiniasis (Spaeth 1942), we made control injections
of carbol-saline in 200 of our cases. They included both
positive and negative reactors to the antigen, but no
positive reactions to the carbol-saline injection were
seen.
We have been careful not to use ice-cold antigen —
direct from the refrigerator, since it is believed that
false positives due to cold allergy may be encountered.
READING OF TEST
The reaction of the skin to the intradermal injection
of the antigen is observed at 10, 15, and 20 min. In
the negative reactors the original weal may disappear so
completely that only the injection prick enables the site
_ to be located.
not entirely disappeared at the end of this period but
is certainly no larger than the original weal, Erythema
is of no significance and 18 often seen in young children
and women.
The commonest type of positive reaction is the formation.
of a disk-like button-weal which appears to be raised
above the level of the normal skin. The elevation of
this weal is often more apparent to touch than to sight.
The increase in size of the weal varies enormously, and
‘a weal 25 mm. across has been observed. In many
positive reactors a ninefold increase in weal area is
seen. Another. type of weal commonly seen is charac-
terised by an irregular outline and the pushing out of
‘‘ pseudopodia ” into the surrounding skin. In white-
skinned positive reactors erythema round the weal can
also be seen. In the flat type of weal it is often necessary
to grasp the dorsum of the forearm and stretch the skin
of the flexor aspect to blanch the erythema which may
mask the outline of the weal.
LATE REACTIONS
We have no first-hand information about late reactions
as described by Risquez and Boza (1941)—in fact, we
have not had described to us any reaction at the site
of injection. One patient described a transient œdema
of the fingers of the arm into which the injection was
made ; he was a negative reactor, and the alleged cedema
occurred six hours after the test. Another patient, a
boy who was a positive reactor and in whom eggs of
S. hematobium were subsequently found in the urine,
MR. ALVES, DR. BLAIR: DIAGNOSIS OF SCHISTOSOMIASIS
total of 592 subjects.
- obtained from each subject at the time of testing, printed |
instructions. having been issued on the best methods of
In other negative reactors the weal has-
[ocr. 19, 1946
developed, mainly on the trunk, ten days after the
injection, a scarlatiniform rash sufficiently severe to
cause his parents to call their doctor.
in twenty-four hours.
MATERIAL AND RESULTS
We performed skin-tests on three population groups—
European schoolboys aged 12-17 years, Eurafrican
schoolboys aged 7-17 years, and African young adult
males enlisted in the S. Rhodesian native regiment; a
Urine and stool specimens were
collection. Further stool and urine specimens were
examined from all skin-test positive cases until four
sets of specimens had been obtained, or until eggs were
demonstrated. Some of the subjects. defaulted-in the
submission of specimens, The results are summarised in
tables 1 and II.
It is difficult to obtain reliable histories of previous
treatment from Africans and the: Eurafrican children.
These children particularly were so unreliable that no .
attempt has been made to classify treated and untreated.
The African treated group, however, had all received
treatment in the Army in 1943-45. The treated group
of European boys had been treated by private practi-
tioners in 1940-45. All the -cases shown as positive
were passing at least a proportion of viable eggs..
There appears to be a significantly higher percentage
of active infections in the treated, than in the untreated
European schoolboys. Whether this is due to insufficient
TABLE I— COMPARISON OF RESULTS OF SKIN-TESTS AND OF
EXAMINATIONS OF SPECIMENS, AND ANALYSIS OF INFECTIONS
197 Eur-} 150 Eur-
opean
school- |; school-
boys boys
Specimens =v) 93 | 87
euT o| o
int epsciaen 406" 3 23 41
Skin vest +ve \ . 4 3
nd specimen +ve i
a | Æ 5
specimen +ve i
Skin-test kvo o}. ` a i
pecimen +ve
Skin-test infection-rate % .. i 52-5 | 62-0
Infection- rate % of egg ee found
on a single specimen 11:7 — 27:3
Infection-rate %.of egg passers found
on examination of 4 specimens .. | 18-7 33-3
S. hienitobiunmi. = Dero . 28 26 37 (a) 103
S. mansoni ss sae ais a 12 _ 19 | 29
Double infections—urine and stool .. 1 7 5
S. mansoni in urine .. “4 | si 1 | a
S. hematobium in stool ies ix ine 1 (b) 3
Hookworm i 3 i 6 20
Strongyloides stercoralis s 1 l 4
Trichiuris trichiura 1 8 a
Tecnia spp. T sii 1
Ascaris lumbricoides 3 2
Enterobius vermicularis l 4 2 so
Hymenolepis nana a 1
a aee e e a e a a
(a) includes two infections with eggs passed of S. bovis (S. matthet)
ype.
(b) An infection with eggs passed of S. bovis (S. matthet) type.
The rash. faded |
THE LANCET]
treatment or to liability to reinfection on returning to
their usual environment, we do not know. One boy,
aged 16 years, gave a history of no fewer than seven
courses of antimony in the past eight years, and is still
passing viable eggs of S. mansoni.
DISCUSSION
Value of Negative Result of Test.—The tables show that
we have not encountered a negative skin reaction in a
patient who passes schistosome eggs. It must be admitted
that many of the negative skin reactors have only been
examined once, and by our own showing single exami-
nations of excreta for eggs are unsatisfactory. Never-
theless we feel that in the many hundreds of controlled
examinations we would have at some time encountered
such a phenomenon if the test were not sufficiently
sensitive. We therefore think it justifiable to assume
freedom from infection in patients who have no skin
reaction. In a country where schistosomiasis must be
considered in all obscure and indefinite illnesses such an
exclusion test as this will be of great value to clinicians
and laboratory workers alike. In mass-treatment
campaigns it can reliably be used to weed out the non-
infected. We have already discussed the varying district
incidence of schistosomiasis in Southern Rhodesia, and
such a rapid “‘ screening ” will be of the utmost impor-
_ tance in saving drugs, material, staff, and time.
Value of Positive Result of Test.—In the earlier work
carried out by one of us, the antigen could be used only
on a small scale, and it was decided to attempt to assess
the antigen by skin-testing hospital patients passing
eggs. These patients, 90 in all, had positive skin reactions.
Table r shows that we have not succeeded in com-
pletely correlating positive skin-tests with the passage
of eggs in the excreta. Nevertheless, the follow-up data
indicate that the gap lessens as the number of repeat
_examinations is increased. We have not been able to
do as many repeat examinations as are desirable ;
patients are lost sight of or may become reinfected. In
any case we believe that there must always remain a
hard core of infected persons whose infections will
never be diagnosed by microscopical methods and in
whom proof will be forthcoming only at operation or
necropsy.
We would, however, cite our experience in examining
a group of 50 children as opposed to adults. These
children were Eurafricans in an orphanage. Of the 50
children examined, 25 were skin-test positive, and on
the first examination of their excreta 16 infections were
diagnosed. On the first re-examination of the remaining
9, 2 more infections were discovered; on the second
re-examination-of the remaining 7, 2 more were found ;
and on the third re-examination of the remaining 5, I
more infection was diagnosed. A fourth re-examination
did not reveal any further infections, but blood-counts
revealed eosinophilia in all of the 4 remaining cases.
In our opinion the patient who presents a suggestive
history and has a positive skin reaction, and in many
cases an eosinophilia, should be given specific treatment.
Positive reactors seen in mass investigations should also
receive treatment. Some of these patients may not be
infectious in that they are not passing eggs, but the
debilitating and damaging effect of this disease would
justify their treatment on public-health and economic
grounds,
Value of Skin-test in Treated Oases.—Treated cases
may be placed in one of several categories :
(1) Patients who can be shown to be passing viable
eggs soon after a course of treatment, when sufficient
time for reinfection has not elapsed. We have seen
_ geveral such cases ; they are all skin-test positive.
(2) Patients who cease to pass viable eggs but whose
clinical condition shows only a transient improvement.
This failure to maintain improvement may be due to
MR. ALVES, DR. BLAIR: DIAGNOSIS OF SCHISTOSOMIASIS
— . European
schoolboys
| Tr | Untr
No. in group S | 35 | 162
Skin-test —ve
Specimen aie oe oi 3 | 85
.Skin-test +ve .. .. | 26 | 77
: ; ; + 8 15
Ist examination { ae 18 62
+ 3 1
2nd examination, ad 15 60
|
Spar +} 2 4
3rd examination, os 12 52
4th examination { + | i je
Skin-test infection-rate % | 743| 47-5
Infection-rate % of egg | |
passers found on exami- ' l
nation of four sets eal
40-0 | 14:2
two factors:
joci 19, 1946 559
TABLE II —ANALYSIS OF RESULTS OF SKIN-TESTS
197
specimens oe - |
tissue damage may have been so extensive
that it cannot be ameliorated by drug therapy alone ;
or all the worms in the body have not been killed.
Fairley et al. (1930) present evidence that, in experimental
infections, male worms are more resistant than females to
treatment with tartar emetic. Fairley (1924) records positive
complement-fixation tests in patients who have been treated
with tartar emetic and are passing no eggs, and he later
(1926) postulated the survival.of the more resistant male
worms.
Many of our patients who have esveiged by ordinary
standards an adequate course of treatment fall into the
second group ; their skin-tests are positive. On the other
hand, patients are met whose skin-tests are negative but
whose clinical condition remains unsatisfactory. .
- (3) Patients who cease to pass eggs and whose clinical ~_
improvement is maintained and whose skin reaction
becomes negative. In our series of 100 cases treated
with intensive antimony (Alves and Blair 1946) many
such cures were obtained. It was possible to demonstrate
in some of these a negative skin reaction two months
after the cessation of treatment, whereas others showed.
negative reactions after. three months. This reversion
to negative after two months probably represents too
rigorous a standard for clinical application, but we
have no reason to believe that in a cured case the skin
reaction will remain positive after a period much in
excess of this. |
We therefore suggest that further treatment is needed
in cases showing positive skin reactions six months after
treatment. We have been much impressed with the
apparent failure of the ordinary course of antimony
and sodium tartrate to cure even those subjects who
codperate completely in ne to the prescribed
= routine,
The several groups of treated: cases may therefore
be summarised as follows: ©
(1) Complete Fatlures.—Passage of viable eggs, no improve-
ment in clinical condition, positive skin- test. Further treat-
ment indicated.
2. “ Public-health”” Cures.—No eggs passed, possible
clinical improvement, positive skin-test. In mass campaigns
no further treatment.
3. Partial Failures.—(a) No eggs passed, possible clinical
improvement, positive skin-test ; further treatment indicated
for the individual patient. (b) No eggs passed, little or no
clinical improvement, negative skin-test; further drug
treatment useless,
4. Perfect Cure.—(a) No eggs passed, clinical improvement
manifest, negative skin-test. (b) Passage of dead eggs,
_ for patients over the age of 2 years.
560 THE een
DR. JEAN BUCHANAN: PENICILLIN IN INFANCY AND CHILDHOOD
[ocr. 19, 1946
possibly for considerable periods after cessation of treatment ;
clinical improvement and negative skin-test.
| _" SUMMARY |
Routine microscopy in the diagnosis of schistosomiasis
is inaccurate and expensive.
The preparation and use of a cercarial antigen for
intradermal testing is described.
A higher proportion of cases of schistosomiasis is
revealed by this antigen than can be detected even n by
repeated microscopical examinations,
The efficiency of treatment of this disease can be
measured more accurately with the skin-test.
Since no negative skin reactors have been found to be
passing eggs, the test can be used as a rapid and accurate
“screen ° in mass-treatment campaigns.
Its use in indicating the need for further treatment is
also outlined.
Our thanks are due to Dr. A. P. Martin, 0.B.E., medical
director, Southern Rhodesia, for permission to make this
communication.
| REFERENCES
Alves, a o Ps D . M. (1946) Lanca, i, 9.
ese, R . C. (1944) S. Afr. med. J. 18 > 239.
Coca, m SE 931) Aerumi and Hay Fever, Baltimore, p. 316.
Culbertson, ., Rose, H. M. (1942) Ama J. Hyg. 36, 311.
Fairley, N i 924) Indian . Gaz. 377.
— (oie). Trans. R. Soe. trop. Med. ae 20, 236.
— Macki o, F. P. , Jasudasan, F. (1930) Indian J. med. Res. memoir
_20. 17, eS 67.
WwW. , F. E. (1927) Med. J. Aust. ii, 811.
Girges, R. 1934) Schistosomiasis, London, p. 313.
Kan, H. C. (1936) ee med. J. suppl. p. 387.
: F. (1942) Rev. P Sania. Asist. social, 7, 397. -
Orpen, L. KOOY Rep. publ. Hlth S. Rhodesia.
t S Rev. policlin. Caracas, 12, 348.
Risquez, J. R., Boza, A vV. (19 41) Gac. med. Caracas, 48, 289.
Senra, J. de M. (1942) Brasil-med. 56, | T
Spaeth, H. (1 942) Disch. med. V schr.
PENICILLIN IN INFANCY AND.
CHILDHOOD *
JEAN L. BUCHANAN
M.B. Glasg.
` From the Royal Hospital for Sick Children, Glasgow
PENICILLIN can be given to infants and young children
(1) by continuous intramedullary, intramuscular, or
intravenous drip; (2) by intermittent intramuscular
injection ; or (3) by mouth.
Injection into the bone-marrow near the lesion has been
successfully used in acute osteomyelitis (Aird 1945).
Alternatively, the sternal marrow may be used. But
intramedullary injection or infusion carries a risk of
infecting the marrow with penicillin-insensitive organisms
and ought not to be undertaken without skilled super-
vision.
Intravenous injection presents: special difficulties in
young patients because their veins are small and readily
thrombosed ; and since the veins may later be required
for blood-transfusion it is inadvisable to cut down on-
more than one. Also children need frequent nursing
attention which tends to eee the needles, with .
added risk of infection.
Despite nursing difficulties, don tinuous intramuscular
injection by drip is the method preferred in the surgical
wards of the Royal Hospital for Sick Children, Glasgow,
Since children’s
small muscles have a limited power of absorption and
_ Jess resistance to infection than adult tissues, particular
care must be taken not to distend them and to avoid
infection at the site of the needle-punctures. -
' The standard dose for the intramuscular drip in this
. hospital is 100,000 units per 24 hours, and the apparatus
used is the ‘ Eudrip’ no. 3 (McAdam et al. 1944). With
this dose the blood-penicillin level is usually adequate,
* Work done during the tenure of a MeCunn scholarship.
but occasionally, when the infecting organism is relatively
penicillin-resistant, dosage is doubled, and in exceptional
cases it may even be increased to 500,000 units per 24
hours. Table 1 shows the maximum dilutions of serum
producing complete inhibition in eleven cases selected
from various age-groups and receiving penicillin 100,000
TABLE I—-MAXIMAL DILUTIONS OF SERUM PRODUCING ‘COMPLETE
INHIBITION IN CASES RECEIVING PENICILLIN, 100,000 UNITS
PER 24 HR. BY CONTINUOUS INTRAMUSCULAR DRIP ,
` Case Age (yr.) Dilution of serum*
1 or’ Undiluted . .
2 3 | lin 4
3 5s in
4 6 Undiluted
5 7 1 in 16
6 TIJe 1 in 32
7 8 : lin 4
8 8 1 in 16 |
9 9 ' Lin 4
10 9/9 l Undiluted `
11 10 lin 2 .
* Serum diluted with broth.
units per 24 hours by continuous inoramuaeulag drip.
The slide-cell method of estimating the level of serum
inhibition was used (Bigger et al. 1944), and the test
organism was the Oxford staphylococcus. Complete
inhibition in a serum dilution of 1 in 32 was accepted
as equivalent to 1 unit of ponei per o. cm. of the
patient’s serum.
In the medical wards of this hospital intermittent
intramuscular injection and oral administration are
employed for infants and young children. Bodian (1945)
advocated injection into muscle of 1000 units per lb. of
expected body-weight per 24 hours in divided doses at
3-hourly or 4-hourly intervals, and obtained complete
bacteriostasis in undiluted serum up to 4 hours after
injection in only 60% of children. It is generally accepted
that the basic principle of penicillin therapy is to maintain
a minimum therapeutic level constantly in the blood,
and Garrod (1944) and Kolmer (1945) consider inhibition |
in undiluted serum adequate. Our experience showed
that penicillin 1000 units per Ib. of body -weight per 24
hours was often insufficient to attain this, even in young
infants in whom, presumably owing to inefficient.
excretion by kidneys not yet fully functioning, the blood-
penicillin level tends to be higher than in other age-
groups. Accordingly the dose was doubled, and further
blood tests-were performed. Fig. 1 shows that 2000 units
per lb. per 24 hours maintains inhibition in undiluted
serum. Since, however, occasions might arise where
higher levels would be desirable—e.g., in infections with
less sensitive organisms—experiments were, undertaken
with 4000 units per lb. of expected body-weight per
TABLE .II—BLOOD-PENICILLIN LEVELS WITH INTRAMUSCULAR
PENICILLIN 5000 UNITS .(APPROX.) PER LB. OF EXPECTED
BODY-WEIGHT PER 24 HR. (6-HOURLY INJECTIONS OF 25,000
UNITS FOR CHILDREN UNDER 2 YEARS OF AGE, AND OF 50,000
UNITS FOR THOSE AGED 2-5 YEARS),
Blood-penicillin level
Case i
1/3 hr. after injection 57/3 hr. after injection |
1 Inhibition— Inhibition—
complete atlin 64 complete in undiluted serum
partial at 1 in 128 i .
2 complete at 1 in 64 partial in undiluted serum
. partial ati in 128 l
3 complete at 1 in 128 artia] in undiluted serum
partial at 1 in 256 .
4 complete at 1 in 32 complete in undiluted serum
5 cd 99 lin 64 ” si. 7 . »
6 » »lin 64 » atrm? `
THE LANCET]
DR. JEAN BUCHANAN: PENICILLIN IN INFANCY AND CHILDHOOD
[ocr. 19, 1946 561
24 hours. Fig. 2 shows results resembling those in fig. 1,
but with the blood-penicillin level better maintained.
Accordingly, we regard 4000 units per lb. of expected
body-weight per 24 hours given intramuscularly at
3-hourly intervals as the optimum dose. This view
conforms to the latest recommendation on adult dogage
(Hudson et al. 1946, Agerholm and Trueta 1946) and
_ supersedes the 1000 units per lb. originally suggested
as the standard adult dose by Florey (1944).
Since penicillin is relatively non-toxic, the optimum
dose may be exceeded for ease in dispensing. For
example, in this hospital the practice ig to maintain in
the ward refrigerators solutions of penicillin in strengths
of 5000, 10,000, and 15,000 units per c.cm., and of 25,000
and 50,000 per 2 c.cm., prepared in phials or ampoules
in the laboratories with pyrogen-free sterile saline. For
children under the age of 3 months 5000 units is given
eight times a day by injection or by mouth, and for
children aged 3-6 months 10,000 units eight times a day
by injection. These doses correspond approximately to
x 1/32 1-00
0-50
>
Q
DILUTION OF SERUM INHIBITING GROWT)
<
PN
PENICILLIN (UNITS per ccm.)
HOURS AFTER INJECTION
Fig. |~—Blood-penicillin levels of children having 2000 units per Ib.
. @f expected body-weight per 24 hours by intramuscular Injection at
s-hourly intervals.
4000 units per lb. of normal body-weight per 24 hours.
Though an adequate serum-penicillin level can be
reached by 3-hourly intramuscular injections, the
repeated punctures, with msk of infection, are a dis-
advantage, especially in infants and young children, and
it seemed advisable to reduce the frequency of injection
if this could be done without therapeutic loss. Accord-
ingly 6-hourly injections of 25,000 units were given to
children under the age of 2 years, and 50,000 units-to
those aged 2-5 years.. This dosage approximates to 5000
units per lb. of expected body-weight per 24 hours and
maintains a constant therapeutic blood-penicillin level.
Turner (1944) also found 6-hourly injections satisfactory
in infants and children, and Fleming et al. (1944) recom-
mend 6-hourly injections of large doses. Table 11 shows
the Picod-pomeraa levels obtained by this method.
ORAL PENICILLIN
Administration by mouth, if proved as effective as
intramuscular injection, would make penicillin therapy
simpler for the doctor and the nurse and less trying for
the patient. In adults it has been demonstrated that
oral administration is practicable, at least in infections
with the most sensitive organisms, but only by expendi-
ture of four or five times the amount of penicillin needed
systemically.
Since Rammelkamp and Helm (1943) have noted that
saliva, succus entericus, and bile do not exert a destructive
effect, the main inactivating factor is the acid of the
stomach (Abraham et al. 1941, Rammelkamp and Keefer
. gastric juice.
1/32 = 1-00
seal
=
O
0-50
1/8 40-25
1/4 0-125
1/2 0:06
PENICILLIN (UNITS per c.cm.)
1/1 0:03
DILUTION OF SERUM INHIBITING GROWTH
| 2 3
HOURS AFTER INJECTION
Fig. 2—Blood-penicillin levels of children having 4000 units per ib.
of expected body-weight per 24 hours by intramuscular injection at
3-hourly intervals.
1943). Levinson and MacFate (1937) and Miller (1941, 1942)
investigated the gastric juice in infancy and found low
acidity, both total and free, except in the first few days
after birth. Acidity, which then approximated to the >
adult level, did not again reach that level until the age
of 3 years. The degree of free acidity appears to be
correlated with the birth-weight, and a large proportion
of the premature infants investigated had achlorhydria.
-It has been found in this hospital (F. M. Earle, pereonal /
communication) that, as a general rule, infections materi-
ally reduce the amount of free hydrochloric acid in the
In view of these facts, it was considered
feasible to explore the possibilities of oral administration
to babies under the age of 6 months—the age-group in
which a method other than intramuscular injection is
most desirable.
A series of 25 babies was investigated, some in the sick
nursery of the Royal Maternity Hospital, and others in
TABLE III—LEVELS OF SERUM INHIBITION AFTER ORAL
PENICILLIN
(a) 1/2 hr. eg penicillin ; (b) 2!/ hr. after penicillin ;
) 3°/e-4 hr. after penicillin
Case Serum ee Case Serum inhibition
1. (a) Partial at 1 in 2; com- | 13. (i) (a) Complete at 1 in 4
plete in undiluted b) Complete at 1 in 2
seruin
(b) Complete in undiluted a (2) “serum ; ‘partial at 1
serum l n 2
(c) Partial in undiluted
SCR (b) Complete in undiluted
2. (a) Partial at 1 in 16;] 44,
complete at 1 in 8
(b) (c) Complete at 1 in 2
3. (a) Complete at 1 in 16
(b) Complete at 1 in 2
(a) Suan at 1 in 16
(b) Complete at 1 in 8
15. (a) Complete at 1 in 16
(b) Complete at 1 in 8
(c) Complete in undiluted | 16. (a) compere at 1 in 2 and
serum a
(b) Complete at 1 in 2
nhib A
” Biss so dilute ds oe = an 17. (a) (6) Complete at 1 in 4
(e) Goniplete at 1 in 2 serum; . partial at
5. (a) (0) Complete at 1 in 4
6. (a) (b) Complete at 1 in 4 19.
7. (a) (b) Complete at 1 in 8 (b) Complete in undiluted
serum
8. (a2)Complete at 1 in 2; | 20. (a) Complete at 1 in 4
partial at 1 in 4 o Complete at 1 in 2
(b) Complete at 1 in 4 21 ) Complete at 1 in 8
9. (a2) Complete at 1 in 4;| 22+ (0) (c)Comple =
partial atlin 8 | 22. (a) Complete in undiluted
(b) Complete at 1 in 8 serum ; partial at
10. (a) (b) Complete at 1 in 8
11. (a) Complete in undiluted |.
Serum ; partial at 23
1 in 2
(b) Complete at 1 in 2
(a) Complete at 1 in 2
1 in 2
(c) Complete in undilutdé
serum
. (a) Complete at 1 in 8
1 in
(b) Complete at 1 in 2 24. (a) (c) Complete at 1 in 8
12. (a) Complete at 1 in 2 25. (a) Complete at 1 in 2
(b) Complete in undiluted (c) Complete in undiluted
serum serum
562 THE LANCET].
the Royal Hospital for Sick Children, most of the infants
being in the first month of life.. The penicillin was given
in the first 1/, oz. of the 3-hourly or 4-hourly feed, in the
dosage of 4000 units per lb. of expected body-weight
per 24 hours. The first 4 babies were healthy, and the
‘penicillin by mouth was experimental. In the other 21
babies penicillin was given therapeutically for various
neonatal infections. The immediate clinical results of
oral‘administration were on the whole striking, though
there were a few relapses, which responded to prolonged
treatment. Two cases of-clinical jaundice with liver
enlargement did not respond to oral penicillin but
improved on changing to parenteral penicillin. The:
_blood-penicillin levels after oral administration in this
group of infants are recorded in table m1.
These results show serum-penicillin levels at least as
good as those obtained by intramuscular injection—in
fact in many cases inhibition is maintained longer. This,
as has been mentioned, is due mainly to the fact that
the kidney of the very young infant, especially the
premature infant, is relatively inefficient (McCance and
Young 1941). Probably the adult type of function is
not acquired until the end of the first year of life.
It may therefore be said that administration of
penicillin in feeds ‘to infants, especially to premature
babies, gave results both clinically and serologically
comparable with those following intramuscular adminis-
tration. .
_ The number of babies and premature infants is too small
to warrant detailed analysis, but there is no doubt of
the striking clinical improvement in the children to
' whom penicillin was given by mouth.
infections were respiratory and, though the causal
organisms, owing to the diffculty of obtaining material,
were not identified, the exhibition of penicillin was |
followed immediately by a fall in temperature, an
increase in weight, and improvement in general nutrition.
Ross Couper (1945) has already published equally favour-
able clinical findings.
Oral administration to older children, in whom free
hydrochloric acid is present in the gastric contents, is
a problem similar to that of its administration to adults.
Many vehicles have been used for this purpose (Lancet
1945). Experience in this hospital has been limited to
penicillin-in-egg mixture (Little and Lumb 1945) and
to penicillin combined with aluminium hydroxide
(Welch et al. 1945). The former proved nauseating ;
and, though it was possible to achieve adequate serum-
penicillin levels with repeated loading doses of the
aluminium-hydroxide mixture, the results on the whole
were inconsistent.
SUMMARY
Using intramuscular injections of penicillin, 2000 units
per lb. of expected body-weight per 24 hours is required
` to maintain constant bacteriostasis, with the standard
Oxford staphylococcus as the test organism.
It is recommended, however, since infecting organisms
vary in their penicillin sensitivity, and to leave a margin
of safety, that for general therapy this dose should be
doubled.
In infants under 6 months, owing to the low hydro-
chloric acid content of the gastric juice, penicillin can
be administered satisfactorily by mouth in feeds.
Penicillin 4000 units per lb. of expected body-weight
per 24 hours given orally to infants has yielded results
clinically and serologically comparable to those obtained
by injection and should be the method of choice.
I wish to thank Dr. G. L. Montgomery and Dr. K. J.
Guthrie for their help both in the work involved and in the
preparation of this paper ; Dr. Stanley Graham for his valued
advice and criticism; and Dr. F. M. Earle for permission to
quote some results of her work.
References at foot of next column
DR. MACFARLANE, MR. PILLING: OBSERVATIONS ON FIBRINOLYSIS
peptone shock. Later (1921,-
Most of the.
Levinson, S. As,
[ocr. 19, 1946 _—
OBSERVATIONS ON FIBRINOLYSIS |
PLASMINOGEN, PLASMIN, AND ANTIPLASMIN |
CONTENT OF HUMAN BLOOD `~
' R. G. MACFARLANE
~ M.D. Lond.
RADCLIFFE LECTURER IN HÆMATOLOGY, OXFORD UNIVERSITY
CLINICAL PATHOLOGIST, RADCLIFFE INFIRMARY .
| J. Prune
B.Sc. Manc.
RESEARCH ASSISTANT, DEPARTMENT OF PATHOLOGY, o
RADCLIFFE INFIRMARY
THE clots formed by normal whole blood, or by
recalcified citrated or oxalated plasma, will remain
intact in their own serum for days, or even weeks, if
bacterial growth is prevented. -In certain circumstances,
however, this stability is lost, so that soon after coagula-
tion they break up and disappear. This phenomenon,
called by Dastre (1893) “ fibrinolysis,” was until recently
mainly of academic interest ; now there are indications
that it may prove to be a manifestation of a fundamental
physiological process.
Nolf (1905, 1908), one of the principal workers on this
subject, produced fibrinolysis experimentally in dogs.
by complex procedures involving hepatectomy and
1922) he studied the
fibrinolytic activity that can be produced in plasma. by
treatment with chloroform ‘in vitro.” He concluded
that the fibrin was digested by the proteolytic action
of thrombin, an agent considered by him to consist of
two factors (‘‘thrombozyme and thrombogen ”’) whose
proportions determined proteolysis. Part of. this con-
clusion is supported by the work of Tagnon et al. (1942),
who confirmed.the early observation of Delezene and
Pozerski (1903) that chloroform-treated plasma becomes
capable of digesting casein and gelatin, and related this
proteolytic activity to the destruction of fibrin and
fibrinogen by such plasma. They considered that an
enzyme resembling ‘trypsin is liberated in some way by
chloroform, but that it is not thrombin.
Recently a new aspect of the process has been revealed
by Kaplan (1944), Christensen (1944, 1945), and
Christensen and Macleod (1945). They have sbown
that the familiar fibrinolytic power ascribed to culture-
filtrates of certain strains of ®-hemolytic streptococci
is actually due, not to direct action of the filtrate on the
fibrin, but to its activation of an enzyme precursor
present in normal plasma and likely to contaminate the
usual preparations of fibrin. Christensen and MacLeod
(1945) have found that the enzyme so activated, though
proteolytic, is not trypsin. It is associated with the
DR. JEAN BUCHANAN: REFERENCES
Abraham, E. P., Florey, H. W., Chain, E., irere r, C. M., Gardner,
A. D., Heatley, N. Se Jennings, M. À. (19 41) Lancet, ii, 177.
Agerholm, M., Trueta, J. (1946) Ioa i, 877.
Aird, I. (1945) Proc. R. Soc. Med. 38,
Bigger. J J. BE A ana G. E., Caldwell, W. G. D. (1944) J. Path.
act.
Bodian, bis) Proc. R. Sac. Med. 38, 572
Fleming, A., Young, M. Y., Suchet, J., Rowe, A. J. E. (1944) Lancet,
ii, 621.
Florey. M: E, (1944) Brit. med, Bull. 2, 9.
Garrod, P. (1944) Brit. med. J. i, 528.
Hudson, R. vM Meanock, R. I., McIntosh, J., Selbie, .F. R. (1946)
anie 5 i
` Kolmer (I 545) Penicillin Therapy, New York and London.
Lancet Nilay ii, 746.
MacFate, R..P. (1937) Clinical Laboratory
Diagnosis, Philadelphia, p D. 616. l
Little, C. J.H H., Lumb, G. (1043) Parca: i, 203.
McAdam, I. W.J., Duguid, J hallinor, S. N. (1944) Ibid, ti, 336.
McCance, R. A., Young, W. E (ugg) J. P diii 99, 265.
auner h. A. (1941) Arch. Dis. C
— (1942) Ibid, 17, 198.
Ramnoka nip, C. H., "Helm, J. D. jun. (1943) Proc. Soc. exp. Biol.,
_ N.Y. 54, 324.
— Keefer, C. ra TIAE clin, Invest. 22, 425, Wen iu
Ross Couper, E. C. (1945) Arch. Dis. Childh. 20, 117. EAR
Turner, E. K. (19 44) M . J. Aust. ii, 205. :
Wo Hi T Hoa; » Cc. W., Chandler, V. L. (1945) J. “Amer. med. ASS.
THE LANCET]
DR. MACFARLANE, MR. PILLING: OBSERVATIONS ON FIBRINOLYSIS
focr. 19, 1946 563
globulin of the plasma, and is apparently identical with
the enzyme activated by chloroform. They suggest
the name “‘ plasmin ”’ for the enzyme, “‘ plasminogen ”’
for its inactive precursor, and ‘“‘ streptokinase ’’ for the
bacterial activator. A fourth component must be added
to these. It has long been recognised that normal
plasma or serum contains an antiproteolytic factor
(Delezene and Pozerski 1903) associated with the albumin
. fraction (Opie and Barker 1907). This factor is probably
concerned with the absence of fibrinolysis in normal
blood, and may be called, for convenience, ‘ anti-
plasmin.”
The recognition of these components of a proteolytic
“system existing in normal blood greatly facilitates an
approach to the problem of spontaneous fibrinolysis in
man. It is most probable that the disappearance of
fibrin in blood taken after sudden death (Yudin 1936),
trauma (Macfarlane 1937), or burns and hemorrhage
(Tagnon et al. 1946) is due to the activation of this
system. The possible significance of such a process
becomes the more apparent when it is realised that the
plasminogen of normal blood is of a potential activity
sufficient to destroy the total fibrinogen of the body in a
few minutes, and the more interesting since it is
apparently associated with the problematical condition
of “shock.”
might be divided into studies of three aspects of the
‘problem—first, the interaction of the plasma factors
culminating in fibrinolysis ; secondly, the nature of the
physiological process that activates the proteolytic
system-; and thirdly, the effect on the living subject
of the proteolytic enzyme when present in the blood-
stream. The present paper describes some observations
on the first of these. Later publications will De concerned
with the other aspects.
EXPERIMENTAL TECHNIQUE
A first necessity in the study of the inter-relations of
plasminogen, antiplasmin, and plasmin is a method for
the quantitative assay of plasmin. Since this is a
proteolytic enzyme, it would have been desirable to
measure its activity by determining the rate of digestion
of a pure substrate such as gelatin or casein. Fibrino-
lysis, indicated by the disappearance of a fine clot formed
by the action of thrombin on dilute fibrinogen, has
proved, however, to be a far more sensitive index of
plasmin activity than protein degradation. In human
material], activity, though present, may be so low that
fibrinolysis is the only demonstrable effect, and in
consequence it has been adopted as the indicator in these
experiments. It has the disadvantage that only the
presence or absence of the clot can be determined ; the
extent of partial lysis cannot easily be measured with any
reliability. Plasmin activity could therefore be assessed
either in terms of the time required for the lysis of a
certain amount of fibrin, which is inconvenient, or by
determining the greatest dilution of the sample that will
lyse an amount of fibrin in a given time. The latter
has been adopted here, though it was realised that other
reactants besides plasmin would be involved in the
- dilution, which might lead to complications. As will
be seen, complications did arise but were themselves
of interest.
The basic technique was as follows. Blood obtained by
venepuncture was mixed with 1/9th of its volume of
3-8% sodium citrate solution and spun in the centrifuge
at 2500 r.p.m. for 10 minutes; the plasma was then
separated. The plasma was diluted with twice its
volume of buffer-merthiolate-saline* containing any
agent -required. After any other necessary treatment
9 serial twofold dilutions of the mixture were made
s ane. buffer is made as follows: 1-72 g. glyoxaline and 90 c.cm.
N/10 HCl are made up to 100 c.cm. with water; 5 c.cm. of
fete is added to 245 c.cm. of 0:9% saline containing 0:001%
merthiolate. l
a
Further investigation is desirable, and
using a 0-1% solution of fibrinogen prepared by the
method of Milstone (1941) in the buffer mixture. Three
volumes of each dilution were placed in a Wassermann
tube and one volume of thrombin solution | added to
each tube of the series. Clotting took place in about
30 seconds, and was firm enough to allow the tubes to
be inverted without spilling. The final dilutions of the
plasma were 1 in 4, 1 in 8, 1 in 16, and &o on, to 1 in 2048 ’
in the 10th tube of the series. Assuming that the
fibrinogen content of the original plasma was about
. 300 mg. per 100 c.cm., the fibrinogen concentration in
each tube was approximately constant at a mg. per
100 c.cm.
After 24 hours’ incubation at 37° C, the pntant of the
tubes were examined for lysis of the fibrin. The end-
point was usually sharp, one tube containing an intact
clot, the next in the series nothing but clear fluid and a
slight amorphous precipitate.
‘“ Chloroform plasma ”° was prepared by the method of
Tagnon et al. (1942) and then treated as described.
“ Active plasma ’’—that is, plasma showing spontaneous
fibrinolytic activity—was obtained from suitable sub-
jects.ł The “globulin ” fraction was separated by
dialysing plasma against moving distilled water in the
cold for 24 hours, bringing its pH to 5-5 (estimated by the
glass electrode) with N/10 acetic acid, and separating
the precipitate. The precipitate was then washed with
distilled water saturated with CO,, and finally dissolved.
in a volume of buffer mixture equal to the original
volume of plasma. The “ albumin ” fraction remained
in the supernatant fluid after separation of the globulin
precipitate at pH 5-5. The last traces of the latter were-
removed by spinning at 4000 r.p.m. for 15 minutes, and
the pH was then brought to 7:2 with N/10 caustic soda.
These fractions were treated in the way described for
plasma, except that fibrinogen was added to the albumin |
solution to a final concentration of 300 mg. per 100 c.cm.
The globulin contained the fibrinogen of ‘the original
plasma.
Dry streptokinase was prepared by the method. of
Christensen (1945) by Dr. E. S. Duthie and used in a
final concentration of 0-1%. It had no action alone on
-the fibrin prepared in these experiments, but, as a
precaution, after 30 minutes’ incubation with the plasma
or plasma fraction to be studied, it was inactivated by
the addition of a predetermined amount of antiserum
also prepared by Dr. Duthie.
EXPERIMENTAL RESULTS
The results of the experiments (A—F) are shown in the
table, each horizontal row indicating the presence (+)
or absence (0) .of fibrinolysis at a particular dilution.
They are representative of a number of repetitions.
A—Dilutions of normal plasma show no lysis in 24 hours.
B—Incubation of normal plasma with streptokinase before
dilution results in lysis in tubes 4 to 9, this last dilution
(1 in 1024) representing the titre of the activated plasmin.
The surprising absence of lysis in the first three tubes is
important. It is probably due to the presence of an inhibitor
which loses its effect on dilution.
C-—‘‘ Chloroform plasma ” destroys fibrin to a diction of
1 in 256 (tube 7), but without any initial inhibition.
D—Streptokinase added to chloroform plasma increases
the plasmin titre to 1 in 2048 (tube 10), suggesting that
chloroform alone does not activate all the enzyme precursor.
_ 4—Spontaneously active plasma lyses fibrin to ‘tube 6,
with inhibition in the first tube.
F—Streptokinase added to “ active plasma ” extends lysis
to tube 8, without inhibition, » suggesting that there is a
t A 1/250 dilution in buffer mixture of ‘clotting globulin ’’
prepared by Lederle Laboratories Inc., New York. This
thrombin preparation has no fibrinolytic activity. Prepara-
tions of human thrombin have becn used- but are Rometimes
spontaneously fibrinolytic. |
tł The methods by which spontaneous fibrinolytic activity can be
produced human subjects will be described in a later
publication.
564 THE LANCET] |
DR. MACFARLANE, MR. PILLING: OBSERVATIONS ON FIBRINOLYSIS.
[ocr. oe 1946
reduction of inhibitor but incomplete activation of the
enzyme precursor in “ active plasma.”
G—Normal globulin is spontaneously active to tube 5,
without inhibition in the first tubes. .
H—The activity of normal globulin is increased to tube 8
by streptokinase. It contains, therefore, both active enzyme
and its precursor.
~ I and J—Albumin has no activity, even whai treated with
streptokinase.
K—The spontaneous activity of globulin is lost when it is
re-combined with albumin in the normal proportions.
L—The albumin from chloroform plasma has no inhibitory
power on normal globulin.
M and N—The globulin fraction from chloroform plasma is
more active than normal globulin, but is completely inhibited
by normal albumin.
O—The albumin fraction from plasma treated with strepto-
kinase inhibits normal globulin in the first three tubes, but
there is lysis in tubes 4 and 5. This may suggest that there
is some reduction of the potency of the inhibitor after treat-
ment with streptokinase, but it is possible that some of the
kinase was carried over with the albumin fraction to activate
the globulin.
P and Q—The globulin fraction of spontaneously active
plasma is more lytic than normal globulin, but, in this experi-
ment, is completely inhibited by normal albumin. In other
experiments, however, with more active globulin, normal
albumin may not completely inhibit lysis.
R—The albumin from “ active plasma ” does not completely
inhibit normal globulin.
DISCUSSION AND CONCLUSIONS
From these experiments it appears that normal plasma
contains at least three factors concerned in fibrinolysis.
In the “ globulin fraction ” is a certain amount of active
plasmin, and a further quantity of its precursor, plasmino-
gen. It might be argued that the activity observed in
this fraction was induced hy the technique of separation,
but, since it is lost on re-combination with albumin; it
is reasonable to suppose that this proportion of plasmin
exists in normal blood in combination with the anti-
plasmin of the albumin fraction. If this is so, the
combination is a loose one, being broken by fractiona-
tion. Moreover, if the plasmin content of plasma is
: PLASMA
: ALBUMIN GLOBULIN
| PLASMINOGEN
ACTIVATED BY-
STREPTOKINASE,
* SHOCK” —
PLASMIN
FIBRINOLYSIS ,
PROTEOLYSIS
FRACTIONATION,
DILUTION
ANTIPLASMIN
DESTROYED
BY CHLOROFORM
DISSOCIATED BY }
-. m anaoa gp:|o m a m a m m m ho & ow aM eh
for any reason inċreased, fibrinolytic activity first
becomes apparent in the higher dilutions of the plasma,
suggesting that dilution favours dissociation of the
plasmin- antiplasmin complex, though in normal plasma
there is a sufficient excess of inhibitor to prevent activa-
tion. This dissociation explains the results of Macfarlane
(1937), who found diluted plasma a more sensitive index
of fibrinolysis than whole blood. A similar effect of
dilution has been observed on trypsin-antitrypsin
mixtures (Hussey and Northrop 1923) and on toxin-
antitoxin mixtures (Glenny and Barr 1932).
_ It is alteration of the plasmin-antiplasmin balance,
therefore, that determines the presence or absence of
fibrinolytic activity in blood. Alterations resulting in an
increased activity have been observed as follows :
(1) Streptokinase increases the plasmin content of the
plasma by activating available plasminogen, but does not
appear greatly to affect the antiplasmin, a conclusion in
conformity with that derived by Christensen and MacLeod
(1945) by other methods.
(2) Chloroform destroys antiplasmin, thus releasing the
plasmin normally in combination with it. It has been
previously observed that the antiproteolytic action of
‘serum is destroyed by chloroform (Jobling and Peter-
son 1914, Dale and Walpole 1916, Teale and Bach 1919).
PRESENCE OR ABSENCE OF FIBRINOLYSIS IN DILUTIONS OF PLASMA OR PLASMA FRACTIONS WITH VARIOUS .
REAGENTS, AND CONSTANT FIBRINOGEN
Exp Reagents | a? 1 9
Pee | eee
a een, e
Norma! plasma
Normal plasma +streptokinase -
“ Chloroform plasma’’
l
“Chloroform plasma” + streptokinase |
“ Active plasma ”’
‘** Active plasma ’’ + streptokinase
_ Normal globulin
Normal globulin + streptokinase
Normal albumin
Normal albumin + norma] globulin
“ Chloroform ” albumin +normal globulin
** Chloroform ” globulin |
Normal albumin +“ chloroform ”? globulin
“ Kinase ” albumin +normal globulin
“ Active ” globulin
Normal albumin +“ active ” globulin
SEO Se E SS E E E E E SS
Povo ARPMrAH KEM Oewv aw bP
SCOP SooSoH PSC SCOR, HE HE OH HOO
Normal albumin + streptokinase
|
‘
“ Active ”?” albumin + normal globulin
Tube number and dilution of plasma or plasma fraction
3 | 4 5 6 7 8 | 9
1/16 | 1/32 1/64 | 1/128 | 1/256 | 1/512 | 1/1024 1/2048
rene | eee eee | ete | ee |S | (NN | SN
o | œ 0 0 0 0 0 0
o + + + + + + oo
+ + + + | + o | o 0
+ + + + + + | + +
+ + + + 0 0 o | o
+ + + + + + | 0 0
+ + + 0 0 0 0 0
+ pl Ve +-| + | + | 0 0
0 0 0 o | o o | o | o
0 0 0 0 o | 0 0 0
0 0 0 0 0 0 0 0
+ + | + + 0 0 0 oO
+. + | + + + + | o 0
0 0 0 0 0 0 o | 0
0 + + 0 0 o | 0 0
+ + + | + + + 0 0
0 0 | 0 0 0 0 0 - 0
+ | + 0 0 0 o | o
THE LANCET]
SIR ADOLPHE ABRAHAMS: EXERCISE AND CARDIAC HYPERTROPHY
[oor. 19, 1946 565
Such an action was considered but rejected by Christensen
and MacLeod (1945), who did not suppose that plasmin
was normally present in the blood.
(3) The spontaneous fibrinolytic activity observed
in our subjects is due to an increase in plasmin, and also,
apparently, to a decrease in antiplasmin, an observation
that requires further confirmation and investigation.
The mechanism by which plasminogen is activated in
these subjects is at present unknown.
The foregoing conclusions can be illustrated dia-
grammatically (see figure). Such a scheme, it is realised,
is hypothetical, and further work may require funda-
mental alterations.
Our thanks are due to Dr. E. S. Duthie, of the Lister Institute,
Elstree, for much advice and practical help, and to Dr. A. H.T.
Robb-Smith for his encouragement and criticism. The
general investigation of fibrinolysis is financed by the Medical
Research Council.
REFERENCES
Christensen, L. R. (1944) J. Bact. 47, 65.
— (1945) J. gen. Physiol. 28, 383.
— MacLeod, C. M. nat) Ibid, 55
9.
Dale, H. H. Walpole, G . (1916) Brocher: J.
10, 331.
Dastre, A. (1893) Arch. Physiol. 5, 661.
eat Pozerski, E . (1903) C.lt. Soc. Biol. Paris, 55, 327,
90
Glenny, ee T., Barr, M. (1932) J. Path. Bact. 35, 91.
Hussey, R. G., Northrop, J. H. (1923) J. gen. Physiol. 5, 335.
Jobling, J. W., Peterson, W. (1914) J. erp. Med. 19, 459, 481.
Kaplan, M. H. (1914) Proc. Soc. erp. Biol., N.Y. 57, 40.
Macfarlane, R. G. (1937) Laneel, i, 10.
Milstone, H. (1941) J. Immunol. 42, 109.
Nolf, P. (19035 ATEN: int. Physiol. 3, 1.
— (1968) Ibid, 6, 306.
— (1921) Ibid. 16, 374; 18, 549.
ieee) Ibid, 19, 227.
Opie, Barker, B . I. (1907) J. exp. Med. 9, 207.
Tagnon, H. J., Davidson, C. S., Taylor, F. H. L. (1942) J. clin.
invest. 21, 525, 533.
— Levenson, N. M., Davidson, ©. S., Taylor, F. H. L. (1946)
Amer. J. med. Sci. 211, 88
Teale, F. Ro Bach, E. (1919) F Proe. R. Soc. Mead. 13 (path.), 4, 43.
Yudin, S. S. (1936) Pr. méd. 44, 68.
EXERCISE AND CARDIAC HYPERTROPHY *
Sir ADOLPHE ABRAHAMS
O.B.E., M.D. Camb., F.R.C.P.
PHYSICIAN TO WESTMINSTER HOSPITAL AND TO THE INTER-
NATIONAL ATHLETIC BOARD ; HONORARY MEDICAL OFFICER
TO THE BRITISH OLYMPIC ATHLETIC TEAM
PHYSICIANS and physiologists differ in opinion on the
subject of cardiac hypertrophy iu response to exertion.
On the one hand, there is the 4 priori expectation, the
analogy of the musculature of the blacksmith’s arm.
On the other hand, there is the pronouncement of cardio-
logists that, provided the cardiac muscle is healthy and
there is no valvular disease, hypertrophy does not develop
even after the most severe physical exertion of which a
human being is capable, whether that exertion be
a repetition “of occasions of supreme intensity or a
long-continued submaximal effort: hypertrophy is
regarded as evidence or proof of some pathological
condition in the cardiovascular systom or in some
other system with cardiovascwar repercussions. Though
the present communication is intended as a criticism
which may be at variance with previous experi-
ence and admit some vacillation in the retention of a
long-established opinion, I have on clinical and radio-
graphica] grounds never found occasion to doubt that the
healthy heart never hypertrophies, and this belief is
founded on very considerable experience of athletes of
every variety: of oarsmen; of runners at all distances,
from sprinters to Marathon performers; of cyclists
engaged in such feats as twenty-four hours’ continuous
pedalling; and of Channel swimmers.
- Analogy with the blacksmith’s arm may well be fal-
lacious.; cardiac muscle is not the same thing as voluntary
skeletal muscle. Moreover, I have always felt that
undue emphasis is laid on the fonction of the heart in
* A communication to the Association of Physicians, April, 1946.
considering the capacity for athletic distinction and
regarding it as the limiting factor for endurance.
Admittedly the work done by the heart in extreme
exertion is of a very high order: each ventricle at maxi-
mal pressure delivers thirty-four litres of blood a minute.
But, though the argument is specious, it seems to me a
gratuitous assumption that, granted a peculiarly super-
lative circulation ensuring an unlimited provision of
blood, a corresponding delay or avoidance of fatigue
would result. The capacity for phvsical effort depends
on various circumstances. It may well be that the super-
athlete owes his capability to the quality of his blood; to
its viscosity, perhaps, or even to some subtle biocbemical
factor. It may be that his muscles have exceptional
endowments for oxygen utilisation, for tolerance for lactic
acid, or for the development of antibodies to ensure its
neutralisation. Above all there is the nervous element,
not only as a coordinating agent for the most perfect
harmonisation of all the factors concerned but also from
the psychological aspect.
Comparison with the lower animals is unconvincing.
We may measure such details as stroke volume, circula-
tion-rate, vital capacity, and oxygen debt. What are
immeasurable and imponderable are such qualities as
determination, stoicism, the ability to withstand dis-
comfort and fatigue, or to endure the miseries of heat,
cold, hunger, and thirst, and most of all in respect to long-
continued exertion, monotony and boredom. The limiting
factors of endurance are by no means restricted to the
circulation. -
AN ILLUSTRATIVE CASE
A man, aged 78, consulted Mr. G. T. Mullally for a swelling
of the neck of three months’ duration. His previous health,
had been consistently excellent; his activity until the last
few weeks of his life had remained unimpaired. A tumour
(probably malignant) of the thyroid gland compressing the
esophagus and invading the right external jugular vein was
diagnosed, and deep X-ray therapy was undertaken. Sudden
death took place shortly after the start of treatment.
As a necropsy was permitted, I requested particular atten-
tion to the heart and blood-vessels. I had not known the
deceased in life, but his reputation as an athlete in his youth
was of an almost legendary order. In the opinion of
authorities he was the greatest long-distance cyclist of any
generation. At the ago of 18 he broke records for the bicycle
and tricycle rides from Land's End to John o'Groats. During
eloven years of incessant cycling he created nineteen
national records. He had a partiality for the Land’s End
to John o’Groats achievement, and contemporary members
of our profession warned him that every such performance
reduced his life expectation by ten years. This effort he
accomplished on twenty-four occasions.
After torminating his career as a long-distance cyclist he
continued as an outstanding performer at cricket, hockey,
swimming, and lawn tennis for the remainder of his life. As
a professional soldier he took part in the 1914-18 war (lieut.—
colonel and D.s.o.) and in the 1939-45 war with full duties
in the Home Guard. I regret that no clinical details—e.g.,
cardiac rate and blood-pressure—are forthcoming. His
height was 5 ft. 11 in., and his weight, which remained sub-.
stantially unaltered throughout adult life, was just under I 1 st.
He was a non-smoker and almost a total abstainer from alcohol.
At the necropsy an emLolus—the cause of death—-was found
in the left pulmonary artery.
The lungs were healthy and free from emphysema; there
was adherence of the left pleura, with a calcified nodule at
the left base. The heart was large, weighing 18 oz., but was
“ remarkably healthy for a man of his age.” The muscle was
firm and without fatty changes or infarctions. The coronary
vessels were entirely free of atheroma. The aorta was in a
remarkable state of health. The valves were normal; the
aortic valves appeared larger than normal, measuring
4 cm.X 2 cm.
“The kidneys were quite normal, weight rt. 6 oz.,
Liver, spleen (woight 4 oz.),
normal.”
lt. 8 oz.
and other viscera were quite
DISCUSSION
Here is an example of a man who indulged in the
most severe form of violent exercise in his youth
566 THE LANCET]
for eleven years and in moderately strenuous exertion
for the rest of his life ; who survived with perfect health
to the age of 78 to succumb to malignant growth of the
thyroid and a fortuitous pulmonary embolus; at whose
death a considerably hypertrophied heart was discovered,
with complete absence of any disease in the cardio-
vascular system and a condition of exceptional healthiness
of all viscera for a man of his age.
It is generally accepted that species or even breeds of
animals distinguished for muscular power have unusually
. heart weight x 100
large hearts. The ratio dy weight
greater than 0-6 in those capable of severe continued
exercise. The qualification continued must be stipulated,
' since animals with very small hearts are capable of
extreme exertion for a short time if no considerable
oxygen debt is incurred.
is always
But this is not to presume that hypertrophy of the —
heart can be induced by severe exercise, and clinical
and radiological investigations applied to athletes who
indulge in long-distance events have provided little
evidence of such effect. Admittedly, these investiga-
tions, however skilfully performed, are not conclusive.
The only proof is that afforded by necropsy, and appro-
priate opportunities’ are exceptionally rare. Necropsies
REVIEWS OF BOOKS
`
ie 19, 1946 `
of subjects aged 78 are only too likely to reveal EEN
tive changes which are the usual consequence of age.
The factors of inactivity, gluttony, and intemperance
all have a bearing ; hence the responsibility of physical
exertion in earlier life can rarely þe incriminated. as an
isolated factor.
I venture to advance two provocative alternatives
as a lesson from this example.. Either cardiac hyper-
trophy, analogous to muscular hypertrophy generally,
does develop in response to violent exercise; or some
human beings naturally possess exceptionally large hearts .
and are constitutionally fitted for protracted exertion.
SUMMARY
An example is presented of a phenomenal athlete,
who died at the age of 78, in whom at necropsy con-
siderable hypertrophy of the heart was revealed, but
whose cardiovascular system was in an extremely healthy
state.
The relationship of cardiac hypertrophy to physical
exertion is discussed.
I am greatly indebted to Mr. G. T. Mullally for permission
to record this note, and to Prof. R. J. V. Pulvertaft for
his generous coöperation in respect to. the necropsy and
information relating to the crucial details.
Reviews of Books
Atlas of Surgical Approaches to Bones and Joints
TourIıcK NICOLA, M.D., F.A.C.S., professor of orthopedics,
New York Polyclinic. London: Macmillan. Pp. 218.
25s.
By over 200 diagrams and black-and-white drawings,
Professor Nicola cleverly and clearly represents the
methods of approach to all bones and joints. The chief
features are the large scale of the illustrations—almost
life size—and the bold delineation of the structures.
Here are no detailed anatomical drawings in the da Vinci
style, nor loose impressionist effects, but bold, semi-
diagrammatic drawings which certainly get their message
across. The approaches are those that Nicola has found
of value, and as such should be good enough for most
of us. The majority are familiar, but some—such as the
deltoid-displacing methods for the shoulder-joint—
should be used more often. There are definite advantages
in exposing the lumbar spinal cord with the patient in
the lateral position, as he describes. For the young,
this is a simple textbook of the essentials of orthopedic
anatomy, for the old a quick reference work for use
before a less familiar operation on bone or joint.
Carbohydrate Metabolism
SAMUEL SosKIN, director of the research institute,
Michael Reese Hospital, Chicago; and RACHMIEL LEVINE,
director of metabolic and endocrine research at the
hospital. London: Cambridge University Press. Pp. 315.
33s.
; Claude Bernard’s genius is emphasised in this book.
The authors return again and again to the views of the
great pioneer, upon whose work so much of our know-
ledge of carbohydrate metabolism is based. And in this
the authors show their own greatness, for they set
out to provide a book'to be used for teaching, bringing
the subject matter up to date, and presenting it suitably
for the scientifically minded ‘physician. Well designed
and critically and sympathetically written, the book
could only have been put together by men who had
themselves thought and worked for many years at the
subject. The diagrams and structural formule are
helpful, and the summary, in the biochemical section,
of the enzymatic processes involved in carbohydrate
oxidation is very clear. The section criticising the
classical criteria of diabetes is interesting, the authors
piling up the evidence against the non-utilisation theory
in an instructive manner. The rôle of the endocrine
glands in carbohydrate metabolism is fully discussed,
and with surprising simplicity. Some of the final chapters
will appeal most to clinicians. Some aspects of carbo-
hydrate metabolism which have been almost neglected
might with advantage have been included. The references
to, and' accounts of, the pentose sugars for instance
are incomplete enough to be misleading, and there is
little description of our growing knowledge of the sugars
concerned in nucleic acid metabolism; but perhaps
these subjects hardly came within Rea terms of
reference.
Symptomatic Diagnosis and Treatment of Gyneco-
logical Disorders l
(2nd ed.) MARGARET MOORE Wans: M.D., F.B.C.S.,
M.R.C.0.G., surgical specialist, Three Counties Emer-
gency Hospital. London: H. K. Lewis. Pp. 246.
16s. l
THIs small book, published in the ‘‘ General Prac-
titioner ’’ series, covers a wide territory and covers it
well. The subject matter is up to date; the diagnosis
and treatment are sound, and the illustrations graphic.
Miss Moore White counsels expectant treatment in
intratubal pregnancy with death of the foetus, and in
abortion of a separated tubal pregnancy. This may be
safe for a surgeon of her diagnostic acumen and wide
experience, but in writing for general practitioners such
advice seems dangerous, since the extra-uterine pregnancy
which is likely to bleed and the one which is not may
easily be confused, with disastrous results for the patient.
The chapter on sterility i is among the best in any textbook
of gynecology, and a useful chapter on contraception
has been contributed by Dr. Mary Redding. Irradiation
therapy is discussed by Mr. I. G. Williams, who APANA TENY
covers the needs of general practice.
A Textbook of Surgery
(4th ed.) Editor: FREDERICK CHRISTOPHER, M.D., F.A.C.S.,
associate professor of surgery, Northwestern ' Univer.
sity, Chicago. London: W. B. Saunders. Pp. 1548.
50s.
THIS new edition has been revised and reset, and two
new sections have been added on chemotherapy and
military surgery. New readers may or may not dislike
the double-column page; and there is some inevitable
unevenness associated with the multiplicity of authors,
so that the sections on the operative treatment of
trigeminal neuralgia or spina bifida are as long as the
whole section on tuberculosis of jomts. But these are
minor criticisms. The illustrations are everywhere
good, particularly those of operative procedures, and
the style is generally lucid and fluent. This book has
always been among the transatlantic productions which
British undergraduates could read with profitand pleasure,
and they will find it a useful adjunct fo our own mandaia
works.
.
-THE LANCET]
THE LANCET
LONDON: SATURDAY, OCT. 19, 1946
Sats g The Curtain
It is a great misfortune that so many doctors should
be dissociated from the Government’s effort to create
a comprehensive medical service. Now that many of
the desires and aspirations of the profession stand a
chance of fulfilment, a substantial proportion of its
members seem to he chiefly concerned with the incon-
veniences and risks that are inseparable from any
major change. These inconveniences and risks are
very far from negligible, but they should not obscure
the larger. view presented once again in the Lords’
= debate last week. In that debate one of our spokesmen
had to admit that in approaching the Bill “ too many
of the doctors have merely expressed their fears and
prejudices ”’ and “it has been left to: the Minister to
generate the momentum that overcomes obstacles and
to enlist the strenuous support of ardent minds.”
The House of Lords at least showed itself aware of the
significance of the project now being undertaken :
“I am quite convinced,” said the Archbishop of
York, “ that the National] Insurance Act . . . and this
Bill .° . will prove by far the greatest social reforms
which have ever been passed by Parliament.” Its
evolutionary, rather than revolutionary, character
was emphasised by Lord ListowEL: there has been,
“he pointed out, a deplorable hiatus between the
progress of medicine and its social application, and
“as a citizen of a country which still cares about
social justice and the intangibles that really matter ”
he welcomed a measure which “ by its inclusiveness,
by its more even distribution of the nation’s medical
resources, and most of all by breaking the cash nexus
between medicine and the individual, will remove the
gravest of the present obstacles to one of the most:
important forms of equality’ of opportunity.” Lord
BEVERIDGE approved of.the Bill as giving effect to the
vital principle that bread and ‘health for everybody
should come before cake and circuses for some. It
sets up for the first time, he said, a true Ministry of
Health (“ a national authority with the duty and with
the power of attacking disease as a national enemy ’’)
and it means that the medical profession will now be
a service rather than in any way a business. _
So much for intentions. But, as Lord ADDINGTON
remarked, under the new régime “ the love, care, and
consideration which are so essential to healing cannot
` be exercised if there is friction between the doctors
and the Government or between the doctors and the
patients ” ; and the LORD CHANCELLOR agreed that it
would be very foolish to construct the scheme on the
basis of a disgruntled and dissatisfied profession.
Unhappily that is just what a great many doctors are
today—distinctly disgruntled. And perhaps the main
reason for their state of mind is that they suppose that
the Minister of Health, receiving plenary powers from
a political majority, is not paying, and need never
pay, any attention at all to the views of their repre-
_ sentatives. People who have closely followed the
development of the plan for a comprehensive medical
service know that, as Lord Listowg. argued, it is the
outcome of a concerted effort, over a long period of
THE CURTAIN
—_
[ocr. 19, 1946 567
years, in which every view of any importance has been
given a fair hearing and prolonged and serious con-
sideration. Nevertheless Mr. BEVAN’s treatment of the -
Negotiating Committee has made it just possible for
opponents to assert that the scheme in its final form
was thrust on the profession “ without consultation.”
Though he listened repeatedly to the committee’s
views, expressed both collectively and individually,
he believed, rightly or wrongly, that the shaping of
the main policy was a matter for himself and Parlia-
ment, not to be prejudiced by bargaining in advance.
Thus, though there were consultations, it is true that
there were, strictly speaking, no negotiations.
Mr. Bevan evidently looks forward to detailed
discussions later; which indeed will be essential.
Meanwhile, however, the failure to achieve more
genuine codperation—a failure for which both parties
bear some responsibility—has proved singularly unfor-
tunate. Its most conspicuous result at the moment is
the trouble over the National Health Insurance
capitation fee.. The Minister, while recognising that
in the light of the Spens report the remuneration of
panel practitioners must be increased, was naturally
unwilling to discuss this subject except in its relation
to remuneration in the National Health Service which
will supersede National Health Insurance in eighteen _
months’ time. The Insurance Acts Committee, on the
other hand, demanding immediate action on the Spens
Committee’s findings, declined to discuss remuneration
in some hypothetical service which may or may not
materialise in 1948. On their refusal, the Minister
increased the capitation fee by 2s. as a token payment
without prejudice—an action which has apparently
led countless practitioners to think that such matters
will never be decided on their merits, and that, even in
a National Health Service, the Ministry will never
change its spots. We are thankful to hear of the
Minister’s new approach ; for though both sides have
a good case, there is really less need of good cases
than of good will.
But mere appeasement between two separate
parties—the Ministry and the profession—is not of
course enough: we have to construct an organisation
whose different parts work harmoniously to a common
end. This has to be done, moreover, without dictator-
ship. Much of the anxiety of the profession arises, as
Lord HogpeEr said, from the centralisation of power in
one man, who was compared by several speakers to
the commander-in-chief of an army. Lord LIstOWEL
gave an assurance that the Minister’s duty will be to
exercise direction rather than control ; and Mr. BEVAN
has recognised that every professional member of the
new servicé must remain responsible for his own work.
The Archbishop of York did well, however, to point
out that the staff of the commander-in-chief “ will
consist largely of those who live and work in Whitehall,
and probably the majority of them will be people who
have never practised within this profession and fail to
understand its spirit.” Though the scheme provides
mechanisms through which the profession at all
stages can profoundly influence the development and
administration of the service, “‘ the Minister ’’—which
usually means “the Ministry ’—could no doubt by
bureaucratic action do much to defeat the object of
those who have designed these mechanisms. Against
this the best safeguard is that the Minister’s staff
should include many men who are for part of their
568 THE LANCET] _
CIRCULATORY EFFECTS OF OSTHITIS DEFORMANS
_foor. 19, 1946
time actually engaged in the practice of medicine.
‘ Tt is only in this way,” said Lord Moran, “ that you
. can lift the curtain which in recent years has fallen
between the Ministry and the profession, leaving SO
much want of sympathy and understanding.” And
-in this he was endorsing the far-seeing policy by which
Sir WILSON JAMESON has been widening the medical
staff of the Ministry and intends to widen it further.!
The new service will succeed if those who hold’
office in it, whether medical or lay, prove themselves
colleagues and are trusted accordingly. The immediate
necessity, however, is effective consultation over the
framing of the regulations which will bring the service
to life. In these consultations our representatives
can certainly wield -their proper influence, and they
can also prove their readiness for real coöperation.
The Government, as Lord ADDINGTON said, has yet
to win the confidence of the medical profession and
the public; but the profession might itself do more
to gain the confidence of its associates in a great, and |
now inevitable, undertaking.
Circulatory Effects of Osteitis E
WHEN Sir James Pacer 1 described the generalised
.disease of bone now known by his name he recognised
-that the bones were hyperæmic, and this led him to
think of an inflammatory cause and hence to use the.
term “osteitis.” Orthopsedic and cranial surgeons
are familiar with the highly vascular state of the
affected bones at operation, and Consx,? in his
studies of the bone pathology, emphasised the impor-
tance of this feature. KLIPPEL and Wer? in 1908
observed that the temperature of the skin over an
affected bone was higher than normal. For a ‘long
time cardiovascular complications of the generalised
form of Paget’s disease have been recognised. Kay
and others 4 were struck by the frequency of high
pulse-pressures in a series which they studied. Out
of 33 cases, 14 had pulse-pressures over 60 mm. Hg.
Cardiac enlargement was often noted, as were systolic
‘ murmurs over the precordium. Even in cases in whom
the Korotkoff sounds could be heard right down to
zero pressure, there was no satisfactory evidence of
aortic valvular disease. Kay and his colleagues and also
SNAPPER 5 ascribed these findings to arteriosclerosis.
Further light has now been thrown on these
phenomena by a detailed study ê of a case in the
British ‘Postgraduate Medical School. A patient with
generalised Paget’s disease had venous congestion
and oedema. Cardiac catheterisation showed that his
cardiac output was 13-3 litres per minute, or nearly
three times the normal average. This is a state of
affairs somewhat similar to that found in arteriovenous
aneurysms, and in fact closing the circulation through
the legs of this patient produced effects on the general
circulation similar to those seen when an arteriovenous
aneurysm is partially shut off, including slowing of
the pulse and a slight rise in diastolic arterial pressure.
This led the investigators to believe that’ the circu-
latory phenomena might be explained by a great
1. See Lancet, 1945, fi, 569.
1. Paget, J. Med. -chir. Trans. 1876-71, 60, 37.
2. Cone, S. M. J. Bone Jt Surg. 1922, 4, 751.
3. Klippel, M., Weil, M. P. Rev. al "1908, 16,1228
+. Kay, H. D., Simpson, S. L., Riddoch, G., Vilvandré, G. E.
Ai intern, Med. 1934, 53, 208.
5. Snapper, I. Medical Clinics on Bonc Dinen es New York, 1943.
6. Sa: O. G., Clin. Sci. 1945,
Howarth, S., MeMichael,
‘have opened again.
increase in blood-flow through the affected bones. -
Direct study of the bone blood-flow was then under-
taken.
affected by Paget’s disease ‘the flow. through that leg
may be five to seven times as high.as that in the
normal leg.
Grant-Lewis plethysmograph the actual bone’ blood-
flow was estimated in the humerus of a normal person
and the patient with Paget’s disease. It was found
that the normal flow was probably about 1 c.om. per 100
c.cm. of bone per minute, while that through Paget’s
bones was about 20 c.cm. Applying these figures to
the whole skeleton, the total skeletal blood-flow is
normally about 75 c.cm. per minute, while the enlarged
skeleton of the case of generalised Paget’s disease
received a blood-flow of about 3-3 litres per minute.
This work is an important contribution to the living
pathology of Paget’s disease, but it is also the first
time that bone blood-fiow has been measured in man,
It adds another thought-provoking instance to the
group of conditions in which “ cardiac failure ” is
associated with high output, of which severe anæmia
constitutes a well-established example.” Compre-
hension of the nature and sequence of events in these
cases of apparent heart-failure would shed much
light on other ordinary forms of heart-failure, and we
may look forward to further results of such research -
in the next few years. ce at . e
The Convalescent Home |
“ LET not thy left hand know what. thy right
hand doeth,” however apt as advice on personal -
almsgiving, is hardly a suitable maxim for charitable
institutions. . Yet convalescent homes in England
have grown up on this isolationist plan, each pursuing
~ a course of its own, knowing nothing of its neighbour
in the next street. No complete list of convalescent
homes. has ever been compiled; even the Public
Health Act of 1936 did not call for a complete survey ;
and hospital almoners; local health - officers, and
practitioners must make their own lists of openings
available for their patients recovering from illness.
Many homes were closed during the war and not all
Moreover, there is no clear
definition of the term “ convalescent home.” Some
offer treatment, others none; some wil] not take
patients for more than a month, others will not take
them for less ; some insist that patients must be able
to look after themselves, others will take the bed-
ridden; some of the children’s homes are special
schools approved by the Ministry of Education,
others are not.
certain criteria—they must be of a given sex or
age-group, or must belong to a‘given religious sect,
fraternity, friendly society, or social class, or must work
at or be retired from a given occupation, including
the Services, or must, live in a given district.
The variety of our convalescent homes is an advan-
tage, for the restrictions on the type of patient are
designed to make those who are accepted feel more
at home, the first essential for pleasant convalescence.
A merchant seaman, a distressed gentlewoman, and
a resident of West Ham, placed in one home, might
be poor company for each other, but they will be at |
ease among those who share their tastes, whether in
ee ee
7. Sharpey- Schafer, E. P. Lancet, 1945, ii, 296.
It was shown that when one tibia. only is _
By an ingenious adaptation of the
At many, patients must conform to '
\
THE LANCET]
navigation, needlework, or darts. The chief feature
that the homes have in common is that patients go
there after an illness expecting to get better without
further active treatment. Almshouses may therefore
be excluded from the definition—whatever that is
finally decided to be—and classed among provisions
for the old; for no-one expects to get better of-old
age. And so may the active reablement centres
which have developed in the last few years, for in
these the patients are as much under treatment as
they were in hospital, though at a later stage of
recovery.
English convalescent homes range in size from those
taking more than 200 to those taking less than 20
people; and though those who are planning our
National Health Service are said to prefer large units
there is little doubt that patients prefer small homes
of 10 to 20 beds, especially when these are run with
@ friendly personal touch. The existing homes vary
in this, of course, as in everything else: in one home
the children make a friendly rush at the chairman the
moment he appears, and the matron speaks of the
patients by name ; in another the efficient filing system
is the keynote of the institution, and the patients are
called cases. There is the story of the old lady in a
large, clean, airy, perfectly run home in Prague who
said with a sigh, “ There’s nothing left but tidiness.”
The English may respect institutions but are peculiarly
ill-fitted for living in them. The main argument in
favour of large hospitals—that only they can afford
the special equipment and personnel required for
: modern diagnosis and treatment—does not apply
to the general run of homes for convalescents, who
need neither apparatus nor highly skilled care. It
does, however, apply to the reablement centres which
aim, by active and often complex and expensive
methods, to get working men and women back to
their jobs. In the no-treatment home large size is a
handicap, for it necessitates a medical and nursing
staff, whereas the small home can rely on local
practitioners to attend to minor ailments and keep
an eye open for unexpected complications. The small
home where the matron and committee know the
patients personally, and where freedom is respected,
cups of tea can be had without formality, and no-one is
sent packing because he drinks a glass of beer in the
‘local inn, is clearly the iene kind for English
convalescents.
Variety and small size, then, are qualities in conva-
lescent homes which we should strive to keep. Their
weakness lies in their having no connecting Jink, no
central body to which inquiries can be addressed by
almoners and others trying to place a patient, or to
which the homes themselves can look for advice or
help in moments of difficulty. Some degree of central
supervision would clearly improve the service that
_ the homes can offer: and most homes would welcome
it as relieving them of the responsibility inherent in
isolation. A central organisation would simplify the
task of almoners: for though there is probably a
suitable type of home for anyone who needs it, there
` is not always a bed waiting for a particular patient
at a particular moment; or, if there is, the almoner
has no means of knowing it. The central organisa-
tion could set up a simple form of admission bureau,
on the lines of the bed service run by the King’s Fund
in London for emergency admissions to hospitals. Asa
_ WINTER IN EUROPE
[oor. 19, 1948 569
“first step the King’s Fund and the Institute of Almoners
are preparing a detailed list of homes, based on.
personal inspection. This will meet a real need, and |
will also show which groups of people are poorly
served by the homes already existing, and possibly
which have more opportunities for convalescence than
they require.
Annotations -
ee es
WINTER IN EUROPE
In Europe this winter, and particularly i in the eeciaied
zones, hardship is likely to be extreme. The Control
Commission recently announced that during the last
week of July, in the British zone of Germany, 12 people
died of hunger, while 1189 cases of famine œdema
were reported in Hamburg alone. During six months
the new-case rate of tuberculosis, it was stated, rose
by a third. In a pamphlet lately issued,' Viennese rations
for a day during the past summer are described by
Mr. G. E. R. Gedye.2 They were two rounds of bread
(under 9 oz.), a teaspoonful of sugar, a tablespoonful of
coffee and coffee substitute, halfia square inch of sausage
and an equal amount of tinned ham, a tablespoonful
each of maize flour, dried peas, oatmeal, and lard, a
seventh share in a shell egg, a pinch of egg powder,
half a soup cube, a dessertspoonful of salt, and two |
tablespoonfuls: of meat-and-vegetable ration (three-
quarters -vegetable): the total calorie value being
estimated at 1181—about half the figure (2200) regarded
as adequate for a non-worker. These embittering priva-
tions can only be ended by good harvests and political
decisions; but in the meantime there is room and to
spare for voluntary. effort.
Since 1945 British voluntary societies have been doing
welfare work in the British zone of Germany.’ They are
grouped in teams of 12 and represent the British Red
Cross and Order of St. John, the Friends Relief Service
and Friends Ambulance Unit, the Salvation Army, the
Girl Guides, the Save the Children Fund, the Catholic
Committee for Relief Abroad, and the International
Voluntary Service for Peace. Many of these bodies,
of course, are sending help to other distressed countries
—to France, Poland, Austria, Italy, Yugoslavia, and
Greece., The relief workers in Germany receive their
rations, petrol, and other stores through the Army, and
use Army vehicles ; but they are not paid or regulated
by the Army and many of them receive no pay at all.
They began by caring for refugees and victims of
epidemics and starvation in Normandy, Belgiun,
Holland, and Rhineland, while the fighting was still
going on; later they helped to repatriate displaced
persons of Allied nationality in Germany. Later still |
some of them became free to give help to the German
population, and additional teams arrived from England
to supplement them. Supplies of course are limited, and
are used primarily for children, sick people, and the
aged. Wherever possible German organisations which
understand local needs are asked to help with distribution.
In towns with a population over 5000 the education
branch of Control Commission has arranged for school-
children to receive a coupon-free midday meal; and
supplementary feeding schemes for children under school
age have been arranged by the relief teams. The Swedish
Red Cross and the Swiss relief organisation known as
Don Suisse are helping with this work. Swedish teams
in the Ruhr have provided a daily hot meal for
120,000 children in the past six months, and Don Suisse
1. Have You Thought What Winter will be Like in Europe this
Year? Issued by Save Europe Now, 14, Henrietta Street,
London, W.C.2.
. Reprinted from the Tribune of August 2.
. Council of British Societies for Relief Abroad.
ber, 1946, 75, Victoria Street, London, S.W.,
oo Se ptem-
’
.. voluntary societies,
570
THE LANCET]
AN AMERICAN VIEW OF RHEUMATISM
[ocr. 19,1946
are feeding 30,000 children daily in eight towns of
North Rhine and Westphalia. Holiday camps have been
established for children and young people, and many
thousands had. a week in the open country or by the sea
this summer.
Refugees streaming through the British zone from the
east are adding to the heavy burden on the local admini-
stration of towns and villages. British and German
working side by side, help with
billeting arrangements and personal difficulties, and
arrange social and occupational activities for the young
people.
Only about 500 British voluntary workers ; are engaged
in these many tasks, a tiny force considering the enormous
population needing help. The Council of British Societies
for Relief Abroad. (COBSRA), however, believe that
though they can bring little physical help to those in
distress their presence is a token of good will and‘ an `
example of persoņal service: which will help to restore
morale. Tbe Cossra relief fund has raised £100,000 ;
but the Friends Relief Service, operating not only in
Germany but in France, Greece, Poland, and Austria,
could use more than that in buying food, medical
supplies, clothing, and blankets, over and above the
£125,000 required for its. regular work in the coming
year. The Aid to Austria Appeal Committee needs
£20,000 for food, and the Œcumenical Commission for
Refugees, under the World Council of Churches, needs
£10,000 for the purchase of drugs and medical supplies
for Austria and Germany. The Save Europe Now Fund
pays! Deanna by the Bishop of Chichester, Mr. Victor
ancz (whose pamphlets have done much to make
ae misery in Europe generally known), Lord Lindsay
of Birker, Prof. Gilbert Murray, and the Rev. Henry
Carter—is appealing for £150,000 on behalf of these three
bodies. The sponsors point out that supplies can be
bought immediately, day by day as the money becomes
available, so they appeal not only for maximum contri-
butions but.for a quick response: a little extra haste in
responding may save lives which will otherwise be
lost. Cheques should be made out to “ Save Europe
Now (European Relief Fund) ” and sent to 14, Henrietta
Street, Covent Garden, London, W.C.2.
FETAL RESPIRATION
WHETHER amniotic fluid is inhaled by the footus in
utero is a controversial question which has been discussed
at some length by Windle,’ who investigated it experi-
mentally in guineapigs. There are two main points at
issue—whether the foetus makes any spontaneous
respiratory movements at all, and, if it does, whether
_ these cause the entry of amniotic fluid into the lungs.
From general inquiries into fetal movements there seems
no doubt that respiratory movements do oceur from
time to time in utero, but probably not continuously
unless there is some special stimulus. The obvious
stimulus is anoxemia from embarrassment of the
placental circulation, and when this is experimentally
.induced—as by constricting the umbilical cord—most
mammalian footuses above a certain age respond by
respiratory efforts. In investigating the onset and
progress of organised movement in the sheep fœtus,
Barcroft ? employed tactile stimuli, the maternal uterus
having been opened in a warm bath. The muscular
response of the fotus became more and more brisk
and generalised between the 35th and the 50th days of
pregnancy, but during the next 10 days inhibition from
the higher centres appeared to gain ascendancy, the
response becoming less general and the foetus quiescent.
In the phase of rising excitability, the response was more
sustained and was rhythmic, being dominated apparently
by the respiratory centre. The capacity for respiratory
1. Windle, W. F. The Physiology o the Fætus, London, 1940,
2. Barcroft, J. Lancet, 1942, ii, 117
movements, harelore, develops early, but the response
to asphyxia does not appear until inhibitory control of
the musculature has set in.; by this time the likelihood
of spontaneous respiratory movements has greatly
diminished. Owing to the difficulties of observing the
fœtus, demonstrations of the inhalation of -amniotic
fluid have hitherto not been convincing.
Lately Davis and Potter ? have introduced thorotrast
into the amniotic cavity of human subjects. In twelve
therapeutic abortions in which thorotrast was injected
17—48 hours before operation they found that the medium
was invariably present in the lungs, while in four where
it was administered only 1/,-1 hour before operation it
was absent. The X-ray findings were. confirmed histo- -
logically. The significance of this experiment is increased
by the observation that thorotrast failed, or almost
failed, to penetrate the alimentary tract of the four
control foetuses, but penetrated that of all the others.
In ten babies delivered by cesarean section, thorotrast
placed in the amniotic fluid 16-48 hours previously
was definitely present in the lungs of half, and doubtfully
present in the remainder. Although the control experi-
ments included the three smallest foetuses of the series,
the results certainly suggest that aspiration of amniotic
fluid. may normally take place; but the extent and
frequency are uncertain, and its ee aaa ie games
remains doubtful.
' AN AMERICAN VIEW OF RHEUMATISM,
ADDRESSING the Empire Rheumatism Council in
London on Oct. 11, Dr. Loring T. Swaim (Boston), former
president of the American Rheumatism Association, said -
that extensive surveys in the United States had shown
that more than 1 in 6 of the population had some chronic
disease. The commonest disorders were rheumatism, heart .
disease, arteriosclerosis and high blood-pressure, and
asthma; and the most potent. causes of disability,
reckoned by lost work-days, were nervous and mental
disorders, rheumatism, and heart disease.
Much has been done to improve the treatment of
rheumatism by better teaching and by the activities
of the American Rheumatism Association. In 1942 this
association, in conjunction with the American Medical
Association, produced a primer in, which the rheumatic
disorders were classified as (1) the frankly infectious,
(2) the probably infectious (such as rheumatic fever and
Still’s disease), (3) degenerative joint disease (osteo-
arthritis), (4) arthritis due to physical trauma, and
(5) disorders associated with disturbed metabolism
(gout).. The first aim, in Dr. Swaim’s opinion, must he
to improve general health. The patient: should have at
least six weeks’ complete rest, if possible in hospital,
where he is removed from the environment in which
he has become ill and can be rested in splints under the
care of physician and orthopedist. It is important that
the general nutrition should be maintained, with special
regard to vitamin deficiency. Small repeated transfusions
may help the debilitated, and benefit may be derived
from heat and sunlight, and the conservative removal
of infective foci. The prevention of deformities is of
paramount importance; the deformities of rheumatoid
arthritis can, he held, mostly be prevented. Gold therapy,
to which the American approach has hitherto been
cautious, is now being more widely tried, but not in
doses exceeding 50 mg. For Marie- Strimpell disease
irradiation and the control of deformities has proved.
the most reliable treatment.
Dr. Swaim emphasised the importance of psychic
factors, and particularly unsettled circumstances at home
or at work. In his experience 70% of the onsets and
exacerbations of rheumatoid arthritis are traceable to
emotional disturbance, of which bad home relations
are the commonest cause. Doctors must, he suggested,
3. Davis, M. E., Potter, E. L. J. Amer. med. Ass. 1946; 131, 1194.
ieee —
e e
THE LANCET]
abandon their preoccupation with the treatment of
disease, fascinating as this may be, and, to prevent
chronic disease, take a closer interest in the way people
live.
. CONTROL OF ICE-CREAM |
Most ice-cream manufacturers, and certainly those in
a big way of business, are eager to satisfy the public- -
health authorities ; and the neglect by others to ensure
reasonable purity may often be due to ignorance of
elementary hygiene -rather than to carelessness of the
consumer’s fate. Be that as it may, much of the ice-
cream sold today is potentially dangerous to the consumer,
who is protected by no general sanctions empowering
authorities to inspect ingredients and to supervise manu-
facture, packing, and storage.
Last week the Ministry of Health published new draft
regulations for the heat treatment of ice-cream, which
go some way towards filling this: deficiency. Where a
** complete cold-mix powder ” is used, with which only
water and colouring or flavouring agents have to be added,
the powder is taken to be sterile from the heating it
‘received in manufacture, and no further sterilisation is
required, but the powder must be converted into ice-
cream within an hour of reconstitution. Other mixtures
must be heated to 150° F for 30 minutes, or 160° F for
10 minutes ; within 1!/, hours the temperature must be
reduced below 45° F, and it must be kept so until frozen.
If, after freezing, the temperature of any mixture should
rise above 28° F it must be submitted or resubmitted to
heat treatment.
This announcement drew a brisk rejoinder from the
Ice Cream Alliance, which, according to. the News
Chronicle,s objects that, owing to the difficulty of
obtaining suitable machinery, the regulations cannot be
met by next May, when they are to come into operation.
At a meeting of the Royal Sanitary Institute the view
was ‘that the regulations in themselves are admirable,
and will eliminate the maker whose factory is the back
bedroom and whose showroom is the street. But they
do not go far enough. Plant for heat treatment should
_ be fitted with an automatic recording thermometer,
which alone can tell the visiting sanitary inspector
whether the regulations are being followed. Jt should,
moreover, not be too much to ask that all ice-cream be
sold in closed cartons or wrappers. The regulations do
nothing to dispose of the carrier, who may infect a
mixture made from sterile powder which, under the
. regulations, is not resterilised. Tragedies such as that
at Aberystwyth this summer will recur until there is
some control of the personnel engaged in the handling
of ice-cream. This can be attained only by rousing the
social conscience with or without the support of the law.
ANTI-MIDGE CAMPAIGN
Last year a subcommittee of eminent entomologists,
under the chairmanship of Prof. F. A. E. Crew, F.R.S., set
out to find the best way of using dimethyl phthalate
(D.M.P.) to ward off the attacks of Scottish midges
which were causing serious irritation among tourists
and even the Scottish people themselves. An interim
report? has now been published. Various ointments
containing water were discarded as unsuitable owing
to a tendency for the D.M.P. or the water, or both, to
creep out. A good paste, however, was made (D.M.P.
15 g., kaolin 10 g., zine oxide 1 g., soft paraffin 5 g.)
which could be put up in collapsible tubes and carried
in thé pocket. But the most suitable preparation proved
to be an emulsion (D.M.P. 100 c.cm., water 100 c.cm.,
‘Lanette wax’ 5 g., triethanolamine 9 c.cm., oleic acid
27 c.cm.), which remained reasonably stable for several
months. . Preparations based on these formule have been
1. 1. ‘Oct. 11, 1946.
. Department of Health for Scotland. Control of Midges. An
Interim E POR of a Subcommittee of the Scientific Advisory
Committee. Edinburgh : H. M. Stationery Oflice. 1946.
Pp. 11. 2d.
CÆSAREAN SECTION
[oor. 19, 1946 571
on sale during the midge season just ended (July-
September). Patch tests were performed, mainly on
women forestry workers, and in most cases the application
of D.M.P. to the skin caused only a slight tingling or
burning for a minute or so, which passed off but returned,
perhaps a couple of hours later, on washing the face.
During washing, care must be taken that no D.M.P.
gets into the eyes, and D.M.P. should not be applied to
sunburns or soon after shaving; otherwise no adverse
effects on the skin were observed. Field tests were made,
with controls who did not use the repellent, and were
eminently successful with the paste and emulsion
already described, one application to. exposed parts
warding off attack for at least two hours. Preparations |
with only 35-40% of D.M.P. were not really effective,
hecause the midges were not repelled but merely paralysed
after landing and caused annoyance by crawling about
on the skin. Experiments also proved that veils impreg-
nated with D.M.P. were completely successful, whereas
unimpregnated veils gave no protection.
The opportunity .was taken of making a survey of
Scottish midges, about which very little has been known
hitherto. Fifteen species of -culicoides were collected,
of which three had not previously been recorded. in
Scotland. C. impunctatus constituted 76% of the midge
population of the west of Scotland and was there respon-
sible for 90% of over 800 bites. In nearly all the collec-
tions of C. impunctatus and of C. obsoletus the sex ratio °
was ‘‘ very abnormal.” For instance, Glasgow records
gave only 4% males, and Dundee only 1%. But in a few
collections of C. impunctatus the sexes were about
equal in numbers. The significance of this fact is said to
be obscure. In view of the probability that ‘‘ the female
of the species is more deadly than the male,” in that
she alone bites, the discrepancy may arise from the
different methods of collectors, some collecting only
from their attackers, others sweeping with nets the
natural habitats of the midges.
CASAREAN SECTION
IF there is one operation for which by now the indica-
tions should be clear and the technique standardised,
it must surely be cxsarean section. Yet anyone who
cares to compare the figures in different maternity-
hospital reports will find that this happy state has not
been reached. Czesarean section can be regarded in two
lights according to temperament. The Tory performs
the operation only when the indications are so clear as
to leave him little choice. The Radical does the bulk of
his obstetrical practice by the abdominal route ; to him
a caesarean section is the master key to any obstetrical
problem, real or imagined.
From the experience of three firms of surgeons over
14 years Waters! has tried to assess the indications for
the operation. In 75,238 deliveries, -cæsarean section
was performed 2039 times. Waters objects to the term
“ elective cesarean section,” and asks who elects and
on what foundation. There is, of. course, no dispute
about the need for the operation in the presence of
obvious fcetal-pelvic disproportion, but only a small
minority of cases of so-called disproportion fall into this
class. Waters frankly admits that in borderline cases
he cannot assess the potential capacity for moulding of
the foetal head, the extent of relaxation of the pelvic
joints, and the power and efficiency of the uterine
contractions. These are imponderables about which
no clinician, however experienced, can prognosticate ;
and patients in the borderline group should be given a
short test of labour, when it will be found that very few
need a section. Waters finds that of the last 223 cardiac
patients only 4:4% were submitted to section; the
decision to operate was determined, even with decompen-
sation, solely hy strictly coincidental obstetric indications.
Among the group loosely classified as antepartum
1. Waters, E. G. New Engl. J. Med. 1946, 234, 849..
572 THE LANOET]
hemorrhage not due to placenta previa, Waters main-
tains that caesarean section has little place in mild cases
but is important in the severe cases; by severe cases
he implies extensive hemorrhage with an undilated
cervix and disruption of the myometrium by interstitial
-bleeding—so-called Couvelaire’s uterus. His maternal
mortality in 88 severe cases was 4% after cesarean
section and 5% from vaginal delivery. For pre-eclamptic
and eclamptic toxzmias he never performs section until
the eclampsia is controlled. Among 879 cases of mild
pre-eclampsia section was done in 61; and among 117
cases of severe pre-eclampsia section was done in 26—
_ a high proportion, but 11 had antepartum hemorrhage,
4 had disproportion, and 11 had other complications as
coincident indications for operation. There were 341
,cases of placenta praevia, and section was performed in
104 with no maternal death ; of the 237 patients delivered
‘by the vaginal route, 2 died.
‘These indications largely coincide with those accepted
in Britain. Some British obstetricians are more conserva-
tive and some more radical, but we are tending to become
‘more conservative with the toxzmias and a little more
radical with placenta previa. In this country we do
- either a classical or a lower- segment operation. Of the
2039 sections in Waters’s clinic, 121 were classical, with
a mortality of 6-6%; 28 were cesarean hysterectomy,
_ with a mortality of 10-7% ; and 1 was a vaginal hysterec-
~. tomy. The remainder were some type of lower-segment
operation ; 1406 were transperitoneal, with a mortality
of 0-92%, and 483 extraperitoneal, with a mortality of
1:038%. .For these 483 a supravesical operation was
employed in 290 and a Latzko operation in 193; mor-
tality from the former was 0-6% and from the latter
1:-5%. These are excellent figures, especially for the
extraperitoneal methods, which have perhaps not been
given a fair trial by British obstetricians. Patients dying
after caesarean section usually die from peritonitis.
Waters’s contention is that if the peritoneal cavity can
be completely avoided these women are being delivered
in the safest possible manner, and his figures bear out
his contention. The extraperitoneal operation i is anatomi-
cally fairly difficult but is nevertheless within the powers
of any man competent to open the abdomen.
MEDICAL PRACTICE IN NEW ZEALAND
A YEAR or two ago Mr. Douglas Robb, writing as
a New Zealand surgeon, suggested! that the peculiar
scope and discipline of general practice ought to be
recognised as a specialty, and receive like rewards
and status with other specialties. But he also: felt
that economic considerations should be secondary: we
should be seeking first the bene esse of the different
branches of medicine. Thinking along the same lines,
he has now written on the place of the hospital in medical
affairs.2 The emphasis on organic illness, he says, has
attracted much of the total energy of the profession,
most of which is released in hospitals ; and the hospital
is the only professional corporate effort to which a doctor
or nurse can belong :
‘‘A hospital post thus means much more than its face
value, It represents social and professional prestige, and
constitutes one of the vested interests, struggled for by
those who have it not, and clung to by those who have... k
Students grow up with the belief that tbe hospital
teaching staff are the only men worth emulating; and,
with notable exceptions, think of general practice either
as a necessary evil or merely as a short cut by which they
can earn enough to do something more agreeable.
' In New Zealand social security legislation has
obscured these trends: the large sums to be earned in
general practice and midwifery have led to the neglect
of specialist practice and salaried posts. But the results,
Mr. Robb considers, are not good, in terms of the quality
1. N.Z. med, J. 1944, 43, 248 ; see Lancet, 1945, i, 633.
2. N.Z. med. J. 1946, 45, 183. acs
MEDICAL PRAOTICE IN NEW ZEALAND
` does them they are wofth 7s. 6d. each.” |
[oor. 19, 1946
of the service given. The fact that payment is made on
the number of acts done has led doctors to do personally
“ many trivial things which ought to be done by. a nurse
or a secretary, but are not so done because if the doctor
and high taxation tempt doctors to refuse night calls ;
. and the genuine medical emergency is often ill served.
Nor is there evidence, he thinks, that the high rewards
have ;encouraged doctors to combine for the benefit of
the patient, or even to relieve each other; or that the
preventive approach to medicine has been favoured.
Relative and absolute neglect of the specialist and the
salaried: officer have brought a retrograde tendency
towards the combination of specialism with general
practice, to the detriment of both branches. Established
specialists can of course earn a good. living in private
. work, but the young specialist is ‘‘haunted by the
fleshpots of general practice °; and salaried officers are
so poorly paid that it is becoming hard to fill their ranks.
Yet “ any effort to raise the financial status of, say, an
M.O.H. disturbs a swarm of other public officials.” Again,
there are too few men to fill the higher teaching posts,
and the better rewards of private practice draw many
of the abler men away ; though, as Mr. Robb says, the
professor should be the best man of all. -
To restore the balance in the various . branches of
medicine, and to transfer the emphasis from cure to
prevention, he would like to see a unifying plan, managed
in each area or region by one authority, the health board,
which would control the money available for health
services, assign their proper dutics to hospitals and
health centres, see that they were properly equipped,
and ensure that they did their work efficiently. Repre-
sentatives of technical personnel on the board would
be elected by their groups—doctors, nurses, and. tech-
nicians ; i
seven out of thirteen, should be given to representatives
of the public. Such an arrangement, he thinks, would
be better than a lay board with professional advisory
committees, because it would put a direct responsibility
on the profession to see that the public are well served.
A believer in group practice, he would like to see general
practitioners working in health centres under good —
conditions, with time for leisure and study, and oppor-
tunities to take a higher degree in, their subject.
Specialist practice, on the other hand, would be.largely
confined to the hospitals, where it can be peppertes by
adequate services and equipment.
SALUTE FROM THE BOWLER
Lieut.-General Sir Alexander Hood, director-general
of the Army Medical Services, was last Monday presented
by war-time Army consultants, now demobilised, with
an album containing the consultants’ photographs and —
records, and a sum of money which is to be used for a
prize. Sir Heneage Ogilvie, who as a major-general was
consulting surgeon to the Army in Africa, said that the
presentation was intended as a reminder of a happy
association. The British soldier had received better
‘medical attention from the service directed by General
Hood than had any other fighting man in history. Sir
Alexander, in expressing his thanks, emphasised the .
value of the consultants’ work, mentioning in particular
their help with the Army M edical Depariment Bulletin,
the useful meetings between them and consultants of the
Allied Armies and representatives of the Emergency
Medical Service, the Medica] Research Council, and other .
bodies, and their influence in Tanne the standard of
medical practice overseas.
Dr. C. S. MYERS, F.R.S., died at his Somerset home on
Oct. 12, at the age of 73. The first president of the
British Psychological Society, he was until his retirement
director of pee psychological laboratory at Oambridge
University, done of the National Institute of
Industri Psycho
Easy money —
and a majority of five seats out of nine, or `
THE TEE
Parliament
THE BILL IN THE LORDS
= Lord Jowitt, the Lord Chancellor, in moving the
- second reading of the National Health Service Bill on
Oct. 8, said he was no iconoclast, but he did not doubt
that our existing institutions must be modified and
expanded to fit the new ideal of an integrated medical
service. This was not a Bill to preserve ancient
monuments.
Summarising the provisions of the Bill, he admitted
that part v, dealing with the mental-health services, was
obscure. But it was a temporary job and the Govern-
ment hoped when time permits to review the legislation
dealing with mental health. The language of the first
clause, simple and curt as the Commandments, defined
the greatest task ever placed upon the shoulders of any
one man. If these duties were to be placed upon the
Minister of Health he could not be denied the wide powers
- necessary to carry them out. According to the Bill the
Minister would exercise these powers through regulations
subject to the approval of Parliament, a method which
would allow the administration to profit by experience.
THE MACHINERY
Our hospital system, he suggested, failed because it
was not a system at all, and modern developments in
medicine and surgery demanded more specialised
organisations. Admission to a hospital was not enough ;
the patient must be admitted to the right hospital.
Often where the need was greatest the resources were the
least, and at present it was nobody’s duty to see that
hospital services were fairly distributed among the people.
Whether we liked it or not, we could no longer run these
services on the principle of “ drop a shilling into my little
tambourine.” The proposals in the Bill for hospital
administration, Lord Jowitt claimed, would provide
an integrated system. The hospital management
committees would act on behalf of the regional hospital
boards, he hoped without undue interference from the
boards, and, he was quite certain, without undue inter-
ference from the Minister. For services provided by local
health authorities under the Bill reliance was placed,
rightly he thought, on the larger units of local govern-
ment. But the exact division of functions between the
hospital side and the local-authority side obviously gave
room for argument.
clinics had been placed on the hospital side of the line,
though no doubt the hospital boards would make use of
the health centres by agreement with the local health
authority. The Bill expressly provided that the local
- authority need not themselves provide all these services.
For home nursing or health visiting they could rely on
existing voluntary organisations, such as the District
Nursing Association. |
For the general medical services new machinery had
been set up to meet the doctors’ unwillingness to be
` placed under the local authorities. No doctor would be
compelled to enter the national scheme, but if he entered
the scheme there must be two methods of control—the
sale of practices was prohibited, and new entrants could
not go to areas already fully covered and neglect areas
which were not covered. A tribunal was also to be set up
to investigate serious allegations against doctors. This
machinery, the Government believed, would give full
freedom, scope, and opportunity for the exercise of
professional skill free from political factors or lay
direction.
In paying the doctors the Government did not wish
to rely solely on capitation fees; but while they wanted
some element of salary they did not think that that should
be the sole, or indeed the main, element.
would be foolish if they tried to construct this national
PARLIAMENT
For instance, tuberculosis and V.D..
The Government .
foct. 19, 1946 573
health scheme on the basis of a disgruntled and dissatisfied
profession, and for that reason they appointed the Spens
Committee. They must try to arrange with the members
of the profession themselves not only the range but also
the method of remuneration, and the Minister, Lord
Jowitt announced, was anxious to appoint a similar
committee to deal with specialists’ remuneration.
At every step the organisations in the scheme were
interlocked, and its success would depend on the day-to-
day coöperation of all the people working under it. He
did not doubt that after this Bill had been threshed out
all sections and classes of the community would sink their
differences and press forward a great ideal for the better-
ment of the health of the people.
Party Criticisms
The Earl of MUNSTER asked whether it was merely for
political and doctrinaire reasons that the whole of the
medical profession were to be saddled with a system which
they disliked, that institutions which the British people
had so generously supported for centuries were to be
removed from their control, and that fields in which local
authorities had made much progress were to be taken
over by the State. He did not believe that a single
Government department could run a highly qualified and
skilled service such as hospitals. Local administration
might well require reform, but to transfer the whole
hospital service to a single centre was to ensure that
“ wisdom at one entrance is quite shut out.” For the
Lord Chancellor to support such a proposal, he continued,
as the confiscation of endowments for specific purposes
must be unique in the history of trusteeship. Nothing
could give less encouragement to the public to subscribe
in future to any charitable enterprise. He did not believe
that the Government could have done more to undermine
the confidence of the medical practitioners, because the
proposals for the general medical services offered no
freedom of choice or movement, and little freedom of judg-
ment, and pointed directly to the scheme becoming before
long a full-time salaried service.
The Marquess of READING, speaking for the Liberal
peers, supported the Bill in general terms, for, he pointed
out, they had before them only the scenario of the ulti-
mate Bill which would not have grown into its full
splendour of technicolor for exhibition to adult and
other audiences till 1948. The gaps would be filled by
multitudinous regulations which would demand the
closest scrutiny of both Houses. Of 74 clauses,
26 prescribed a regulation. He feared that before 1948
dawned not only the printing presses of the Stationery
Office but the permanent officials of the Ministry of
Health would be chronically overheated. Yet upon the
good sense, good English, and foresight of these regula-
tions the efficiency of the scheme would ultimately
depend. He agreed that it was an anachronism that the
health of the nation should: continue to be left in the
hands of voluntary organisations dependent upon
charity. But he confessed that he found this rapacious
engulfing of all the funds of the voluntary hospitals
a considerable mouthful to swallow. Professional men
were on the whole conservative—he did not mean
politically Conservative, indeed from reading the papers
lately he doubted whether anyone was politically Con-
servative any more—and some doctors were no doubt
opposed to the scheme; but he hoped that discussions with
the Minister would allay the fears raised by incautious
utterances of some members of the Socialist party, and
that the profession would lend itself with a good grace
in the difficult circumstances at the outset to working the
scheme, once satisfied that it was in the interests of the
nation as a whole. He had a feeling that those who
elected to reign in Hell rather than serve with Bevan
would be few in number, secure in practice, and advanced
in years.
574 THE LANCET)
The Archbishop of YorK, though impressed with the
need for a national health service, feared that the Bill in
its present form might undermine the independence of
the medical profession. In these days when the State
must own, control, and plan where once it only acted
in a negative capacity, he attached great. importance
to preserving in the nation associations which had
independence of their own. No doubt the Government’s
scheme made for efficiency, but sometimes efficiency
could be bought at too great a price when it meant the
loss of freedom. Ma
Professional Criticisms
Lord MORAN, P.R.C.P., said that the surveys of the
hospital service carried out during the war showed that
drastic and expensive reorganisation was necessary. It
was agreed that the money could only come from public
funde, and that such expenditure must entail some
measure of public control which could only be exercised
by the Minister or the local authorities. The medical
profession was in no doubt that it preferred the control
of the Minister, and it was the removal of the dread
that the hospitals might come under the control of the
local authorities which had reconciled so many doctors
to prefer the hospital provisions of the present Minister
of Health to those of his predecessor. But there agree-
ment ended. Many of his colleagues could not agree
with the transfer of ownership of hospitals. They argued
that the Minister should give the regional boards a
block grant for distribution to the hospitals of the
region, to be withheld from any hospital which did not
put its house in order. But Lord Moran did not believe
that any board, particularly one recently created, could
thus apply sanctions to-a powerful local authority, or
that sanctions would be enough to bring about the drastic
reorganisation which was essential. If, however, the
medical profession felt that these hospital provisions
were inevitable it did not mean that they were agreed
that the particular provisions in this Bill would necessarily
work. |
The importance of the hospital service being a uni-
versity service had, Lord Moran thought, received too
little notice. Yet that was the original conception
underlying the establishment of the regions. During
the war specialists of every kind were sent by the teaching
hospitals into the important hospitals in the region.
They raised these hospitals almost to university standard.
When they were called back at the end of the war he
thonght that doctors would agree that there was a sharp
fall in the efficiency of hospitals at the periphery. In
the past specialists had tended to congregate in the great
centres. By a university service there could be a redistri-
bution of specialists without duress, because men would
willingly be seconded, feeling they were part of one great
service. a,
If there was going to be this essential measure of
centralisation in a scientific service, it was perhaps a
paradox that there must also be:a degree of decentralisa-
tion. The powers. of the regional boards were but
vagnely defined in the Bill. Suppose there was a com-
plaint about dieting or nursing in a hospital, if the
Ministry sent its own inspectors to investigate the
complaint the board would lose authority. The Earl
of Donoughmore had raised the point last April when
nursing officers had been appointed who were to be the
nursing authority in those regions. These officers would
have the power to appoint and dismiss nurses. Were
these officers going to exercise their powers through the
regional boards, or independently of them? There was
no guarantee that the Minister of Health would not
interfere in clinical matters. That was not a fictitious
vague. fantasy; it had actually happened under the
Emergency Medical Service during the war. The
Minister must trust the regional boards, the hospitals,
and the doctors to get on with their job.
a
f
‘4
/
f
/
PARLIAMENT
profession had hardly been mentioned.
[ocr. 19, 1946
THE DOCTOR’S LOT
Speaking of the doctors’ fear that they would lose their
independence, Lord Moran agreed that if that happened
the profession would indeed have received a mortal blow.
However effective the reformation of the health services,
it would be of no avail if the conditions under which
doctors worked did not bring contentment and happiness
to them. Looking at this Bill, were these conditions such
that the good type of man who had come into medicine
in the past would continue to enter it? In the innumer-
able discussions on the Bill its effect on. entry into the
It was because
the Minister treated the teaching hospitals so sympa-
thetically, and refused to blunt the growing edge of
medicine, that in the first instance many doctors examined
the provisions of the Bill with sympathy. Those who
worked in the academic world in medicine were perturbed
at present about the powers and composition of the boards
that would govern the teaching hospitals. Medicine
in the past had been able to attract exceptiorial men.
Would it continue to do so? How were these gifted few
to be protected, and what did they want ? First the Bill
must be scanned to see that there was nothing in it
which encroached upon the leisure which the man had
given in the past to research. Leisure was going out
of the learned professions, to their detriment. Nowadays
the spare time of a specialist was taken up by attendance
on committees, which were the drowsy syrup of the
democratic State. Many men with the greatest minds
were indifferent to material rewards, hut it would be
folly to handicap medicine in its competition with other
professions by a false parsimony. He had given notice
to the Lord Chancellor that he would ask the Govern-
ment to appoint a committee on the lines of the Spens
Committee to inquire into the remuneration of consultants,
and he was glad to hear that the Government had agreed
to that proposal. : |
At present the number of people seeking to enter
medicine had leapt up, and though this was partly due to
the effects of demobilisation Lord Moran thought it
would continue, because in the past the entrants had
come from only a narrow section of the community,
many people being unable to afford the cost of training.
lf the new entrants into medicine were to be subsidised
by the State there must be new machinery for selection.
Turning to the work of the general practitioner, Lord
Moran pointed out that the , present-day tendency
of patients who were gravely ill to seek institutional
treatment meant that the general practitioner, saw a case
whisked out of his hands just when it became pro-
fessionally interesting. The consultative service under
this Bill would accentuate the difference between the
general practitioner and the consultant. There was
only one remedy. The general practitioner must. be
brought into the work of the hospital. Lord Moran
confessed that he was less happy about the general-
practitioner service planned in the Bill than about the
hospital service, and that he was gravely disturbed by
the fears of the general practitioners as to the future.
They said they were against the abolition of the sale of
practices, a measure of direction, and the basic salary.
But all these came down to one fear—that there would
be a whole-time medical service which would interfere
with their liberty: He was certain that unless there
was an adequate incentive to keep men on their toes,
a whole-time service would be an incalculable disaster.
In the unfortunate dispute that had arisen at the eleventh
hour between the Ministry of Health and the panel
practitioners Lord Moran was convinced that the doctors’
claims were fair and just. But the dispute was not about
terms but about procedure. The Minister wished to
discuss the remuneration of panel practitioners at the.
same time as the remuneration. of men in the future
service, but the panel practitioners felt they had no
-
THE LANCET]
mandate for this. Lord Moran was sure, however, that
the Minister would meet the doctors’ claims. It would
be a disaster if the service were begun with some practi-
tioners feeling that they had had a raw deal.
In medicine, Lord Moran ended, they always made
a prognosis in a case feeling that they might be wrong.
Men who knew the facts told him that if this service
broke down it would be because there were not admini-
strators to run it. If the Bill was to work something
unusual must be done. He hoped the Minister would
put into the service a small number of experienced men,
trusted leaders of the profession, familiar with hospital .
work, who would give their whole time for about five
years, to try to make the regions work. Many doctors
working under the Ministry had not practised for 20 years.
Men actively engaged in the profession were needed to
come into. the service. Only thus could the curtain
be lifted which had fallen between the Ministry and the
profession, leaving so much want of sympathy and-
understanding. Much of the criticism which the Bill
had provoked. seemed to him to be tethered to the earth ;
it had never become airborne, and it had been totally
lacking in idealism. The politicians had made debating
points and too many of the doctors had merely expressed
their fears and prejudices. It had been left to the
Minister to generate the momentum that overcame
obstacles and to enlist the strenuous support of ardent
minds. When it became law Lord Moran believed that
despite all past differences the whole medical profession
would unite to try to make the service a success.
Lord Trviot, speaking as chairman of the inter-
departmental committee which had inquired into the
condition of the teeth of the nation, described the need
of the public for dental improvement as gigantic. - The
annual intake into the dental profession would have to
be increased from 300 to 900.
~ Lord Inman pointed out that today the voluntary
hospitals were only partially voluntary ; last year 45% of
the income of Charing Cross Hospital came from public
authorities and patients’ payments. In a modern com-
-‘munity, he believed, the heavy cost of curative and
preventive treatment, of buildings and equipment, made
financial demands which it was not within the power of
voluntary effort to satisfy. This Bill would continue and
expand the work of the hospitals, building on their
tradition and experience a firm and worthy edifice of
which this country would be proud in years to come,
PROPOSED AMENDMENTS
Lord HORDER, F.B.C.P., affirmed that the medical profes-
sion were not obstructionists. For the last 20 years they
had done their utmost to persuade the powers-that-be to
get a move on in integrating the medical services of the
country. But the doctors had hoped that it would be
through. the more natural process of evolution rather
than through the present method of revolution. The
doctors thought they could have attained more certain
benefits with less risk. They believed that they could
have rationalised the hospitals without transferrmg
their ownership to the State, covered the health of the
dependents of the workers, set up health centres without
sacrificing the doctors’ liberty, and brought together in —
a comprehensive whole the industrial medical service
and the medical services of the various Government
departments. He agreed that this Bill enhanced one
desirable thing—the availability of medicine to the
citizen. But too much might be paid for that advantage,
and it would be a loss to society if through this Bill
medicine became stereotyped.
The ideal to be aimed at in framing a national medical
service policy was not this terrific centralisation of power
in one man, but a maximum of central direction and a
minimum of central control. Closer contact with the
medical profession during the framing of the Bill would
‘PARLIAMENT
committee or house-committee.
[oor. 19, 1946 575
have safeguarded Mr. Bevan and his successors from this
danger. The Minister had spoken many times about his
“ consultation ’”? with the profession, but that had been a
euphemism for the most blatant form of ipse dizit-ism.
As soon as their Lordships had dealt with the Bill the
doctors would be asked by a plebiscite issued by the
British Medical Association if they would work the Bill.
The answer to the plebiscite might even at this late hour
be influenced by what happened during the committee
stage in their Lordships’ House, because Lord Horder
hoped that the Government would sympathetically
consider certain amendments to preserve the autonomy
of the voluntary hospital, and to safeguard the freedom
of the doctors. This Bill went far towards nationalising
medicine. Whatever natural talent a doctor had,
however ambitious he might be, he was condemned to
a dead level of mediocrity. Not only his economic
position but also his professional status and prestige
had been given a ceiling. Unlike bis fellow civil servants
of the future, he was to have no chance of promotion.
Lord Iforder saw no escape from this state of affairs -
except through the medium of a black-market in doctor-
ing, and his mind boggled at the thought of its probable
immensity.
The Minister said it was not possible to insert the terms
of remuneration in the Bill, but it should be possible to
amend an existing clause so that the method of payment
was stated, and this should be the capitation method
unless, in the opinion of the executive council in whose
area the services were rendered, a different basis was
considered necessary. The prohibition placed on the
selling of practices, the power of negative direction, and
the refusal to allow a doctor charged with some offence
under the Bill the right of appeal to the High Court,
were surely matters that required amendment. Doctors
thought that the standing advisory committees of the
Centra] Health Services Council should be appointed by >
and take their references from the council, and that they
should report through the council to the Minister. They
also considered’ that the Minister should sacrifice his
power to vary the proportion of medical and lay repre-
sentatives on the local executive councils. To retain
local interest, hospital management committees, acting
for a group of hospitals, should appoint a house-committee
in. each hospital, subject to the hospital management
committee and the regional board. It should also be
one of the functions of the hospital management com-
mittee, or of the house-committee, to set up a medical
staff committee with the right to nominate a reasonable '
number of its members to the. hospital management
On the side of medical
education, the Bill also needed amendment, for it laid
on the boards of governors of teaching hospitals no duties
to further medical education and research. It was a
glaring anomaly that gifts and legacies received by the
non-teaching hospitals between the passing of the Act
and the appointed day would go direct to the Hospitals
Endowment Fund; whereas any gifts and legacies
received after the appointed day would be retained by the
management committee. We were about to embark
on a great experiment, Lord Horder concluded, and it
was the doctor’s duty to do his utmost to make it
succeed. If he could fulfil his paramount duty to his
patients through these means he would ; if not it would
be for the patient to decide how long the sacrifice of
efficiency should continue. |
CHRONIC DISEASE
In a maiden speech Lord AMULREE, F.R.C.P., spoke of the
condition of the chronic sick today. The transfer of the
‘municipal hospitals to the central authority under the
Bill would; he thought, benefit these people enormously.
In 1944 there were about 60,000 of these patients in the
whole country, of whom at least a third were under
576 THE LANCET]
sixty-five. In some of the smaller institutions conditions
were deplorable and no attempt had been made to classify
the patients. Yet with a proper approach much could
be done for them. In one big institution of which he
knew, about 60% of the patients who came into the chronic
sick ward were discharged into their own homes or into
hostels for old people. When the Bill was passed he
hoped the chronic sick would share the same medical
staff as the acute sick. It was difficult to separate
elderly people into the healthy and the sick, for when
people grow old there was a narrow borderline between
sickness and health, and there should be a simple and
easy flow to and from hospital. Lord Amulree suggested
therefore that sick and healthy old people should all
come under the same authority.
The Second Day
The Earl of LISTOWEL opened the second day of the
' debate by replying to some of the points raised. It
was a misunderstanding, he said, to suggest that the
` Bill proposed that the Ministry of Health should run
the hospitals. The Minister must—not may it should
be noted—delegate his powers to the regional hospital
boards, and from there to hospital management com-
mittees or, in the case of teaching hospitals, to hoards
of governors. The regional boards would not interfere
in the affairs of these.committees in the daily routine
business of the hospitals. Their job was to supervise
and plan for the region as a whole. There would be
no financial leading strings, for each hospital committee
= would be free to decide how its money should be spent
within the limits of the annual budget. The investiga-
tion of complaints and the engagement or dismissal of
nursing staff would be delegated to the regions, and there
was no real danger of Whitehall interfering in the domestic
affairs of the hospitals.
The size of the regions had not yet been decided, but
each would, so far as possible, centre upon a university ; ;
and after consultation with the interested parties the
Minister would define the regions under regulations
to be submitted to Parliament: Lord Listowel cate-
gorically denied that the Government policy was to
institute a full-time salaried medical service, and he
promised that when an allocation was made from the
Hospital Endowments Fund the wishes of the donors
would not be forgotten.
The Minister was anxious to break the deadlock that
had arisen between the Ministry and the panel practi-
' tioners, and Lord Listowel announced that a meeting
between Mr. Bevan and representatives of the profession
would take place on Oct. 10. They were not dispensing, he
added, with material or moral incentives to an efficient
medical service, and there would continue to be a
graduated scale of salaries in the hospital service and
progressive remunerations for general practitioners.
By wider éducation and mass publicity campaigns
it was hoped that the rising generation would grow up
physically as well as mentally literate, and sufficiently
sensible not to regard good health as merely a state of
not being ill. The Bill was not the product of any single
party or Government. It was the outcome of concerted
effort over many years, involving doctors, laymen, and
Governments, to improve the efficiency of our. medical
services and to make them more easily accessible to the
public. A typically British scheme, it strove to incorporate
in the new structure all the serviceable elements of proved
usefulness in the old. If it moved:a bit further in the
direction of State medicine it still combined freedom,
for doctors and patients alike, with overall planning,
private with public practice, and unpaid voluntary service
with salaried contractual obligations. It was as far
from the all-embracing State system of medicine practised
in Russia as it was from the commercial medicine favoured
by the United States of America. By its inclusiveness,
PARLIAMENT
[ocr. 19, 1946
its more even ' distribution of the nation’ 8 medical
resources, and most of all by -breaking the cash nexus
between medicine and the individual, the Bil would
remove the gravest obstacle to equality of opportunity.
TO BE CONSIDERED IN COMMITTEE i z -a
_ Lord LYLE feared that even with amendments it would
be impossible to make what was fundamentally a bad
Bill into a good Bill. He regretted that a nation which
had vanquished totalitarianism should propose to enslave
its medical profession. Under the Bill the Ministry of
Health would obtain dictatorial powers affecting the
‘intimate lives and health of every. single man and woman
in the country. Lord BEVERIDGE on the other hand ~
thought it was a good, Bill well worth making better
by amendment. For the first time it set up a true
Ministry of Health with the duty and power of attacking
disease as a national enemy. Health as well as bread
for everybody, he asserted, should come before cakes and
circuses.
Lord UVEDALE, F.R.C.S., in a maiden speech suggested
thatin an efficient medical service it was essential that every
patient should be free from financial anxiety, and have
a free choice of hospital and doctor. Admitted to hospital,
he should find himself in pleasant sympathetic
surroundings and free from unnecessary and irksome
restrictions, for in sickness every man and woman was
an individualist. It was also essential that the doctor
should have independence in medical treatment, adequate
equipment, and ancillary help. Remuneration must be
sufficient to attract able men and women, and there must
be opportunities for the gifted to attain positions of
influence and distinction in the national life. Finally the
medital profession must be controlled by the medical
profession.
Lord LUKE was disturbed by the hesitancy people were
showing at present in subscribing to hospitals, and
appealed to the Minister to evolve a formula for this
interim period to prevent generous habits being broken.
Lord ADDINGTON, speaking as.a vice-president of the
_ Association of Municipal Corporations, was distressed
that the non-county boroughs should lose their maternity,
child-welfare, and other health services. He would like
provision made enabling the county councils to delegate
their public-health functions to the non-county boroughs
which had performed them efficiently. He felt that the
local health authorities should be able to nominate their
own representatives to the regional hospital boards,
hospital management committees, boards of governors
of teaching hospitals, and the central council. Lord
LLEWELLIN felt that the equalisation of the voluntary
hospital endowments was not worth while i in view of the
difficulties it would create.
Lord Jowirt, in summing up, said he would. not -go
through the detailed points, for they would be dealt
with in committee. He promised careful consideration
for their Lordships’ amendments, but pointed out that
great care had been taken in preparing the Bill and that
thé Minister had already made considerable concessions
in another place. He agreed that doctors would much
_ dislike to become salaried civil servants, and he reiterated
that the Government had no such intention. If such a
thing were done, he pointed out, it would have to be by
a regulation which must be submitted to Parliament.
In three respects the Government were accused .of
enslaving the doctors—by payment’ of part of their
remuneration as salary, by negative direction, and by
prohibition of the sale of practices. Taking a com-
parison from his own profession, Lord Jowitt asked if
our full-time salaried judges were enslaved: County-
court judges were even directed to certain regions.
Were they enslaved ?
He wished to underline everything that had been said
about decentralisation. The nursing inspectors who had
THE LANCET]
MEDICINE AND THE LAW
focr. 19, 1946 577
been appointed, for instance, were not inspectors in the
ordinary sense. Their function was to go round to the
matrons of the various hospitals to try to help them to.
get staff. Turning to hospital endowments he reminded
their Lordships that if he were accused of taking six-
pence out of the till he was putting a shilling on the
counter, for he was giving from public funds far more
than he was taking. When the Minister came to
reallocate the funds he would consider whether a particu-
lar bequest was obviously for some local purpose. | If so it
might be treated differently from a bequest which was
quite general. |
The Bill was read a second time and committed to
committee of the whole House. |
QUESTION TIME
Family Allowances
Mr. James GRIFFITHS, Minister of National Insurance, in
reply to questions, said he recognised that there had been
some disappointment among those. in receipt of payments
under one or other of the existing social services which already
include additions for children, because they have not continued
to receive those additions over and above the new family
allowances. It had, however, throughout been made clear
that so far as existing schemes of social provision for risks
arising in civil life provided specifically for children, payments
under the Family Allowances Act would be in substitution
for or would be taken into account in determining the amount
of the additions made for children under other schemes. In
the present transitional period improvements in one direction
had been made in advance of others which would substantially
benefit many of those now affected and would be brought
in later under legislation already passed or to be passed. It
was the Government’s aim to build up the various schemes of |
social provision as a coérdinated whole, and the place of family
_ allowances in them must be looked at in relation not only
to existing schemes but also to schemes still to be brought
into force. The Government are examining the whole position
from this point of view.
- In answer to a further question, Mr. T. STEELE stated that,
in accordance with the provisions of the Family Allowances
Act, family allowances of 5s..were being substituted for
children’s allowances of 38. for the second and subsequent
children of widows under the Contributory Pensions Acts in
about 35,000 cases.
Shortage of Medical Textbooks
Sir E. Granam-LitTLe asked the President of the Board
of Trade if he was aware that the shortage of medical
textbooks was a handicap to medical education; that many
of the standard books in use by medical students were unpro-
curable, and that students and practitioners ordering them
had been waiting nine months for delivery ; and if he would
take steps to remedy this position.—Sir STAFFORD CRIPPS
replied: The main factors limiting the production of medical
and other textbooks, for which there are increasing and
accumulated demands, is the shortage of labour and of paper.
The numbers employed in the printing and book-binding
trades were still well below the pre-war strength, although
the lakour force increased, in July, 1946, to 74% of its pre-war
figure. Publishers’ regular paper quotas had been sub-
stantially increased over the last 18 months—from 42'/,% to
80% of pre-war usage. In addition, it was open to any publisher
who cannot bring out an important textbook merely from lack
of paper to apply for a special allocation for that purpose.
Flour Extraction
. ` Sir E. GRAHAM-LITTLE asked the Minister of Food if he
would name the medical adviser mentioned in the secret
instruction to Controlled Millers, C.M.C. 646, dated Sept. 19,
1946, as advising the reduction of extraction in national flour
from the current 90% to 85% ; why, in the same instruction,
millers were informed that they must maintain the quota
of chalk 14 oz. to 280 lb. in view of the explanation offered
by his department that the quota had been doubled to meet
the increased extraction of 90%; and whether he would
decrease this quota of chalk pari passu with the decrease in
_the rate of extraction—Mr. JoHN STRACHEY replied: The
_ medical advisers mentioned in the instruction are the members
of the Interdepartmental Standing Committee on Medical
and Nutritional Problems. The original recommendation was
that 14 oz. of creta preparata should be added to each sack
of 280 lb. of 85% extraction flour, but in practice only 7 oz.
was added. When the extraction-rate was raised to 90% the
addition of creta preparata was raised to 14 oz. per 280 Ib.
on the grounds of the increased amount of phytic acid in the
flour. Now the extraction-rate was being lowered to 85% it was
considered inadvisable to lower the rate of addition of creta
preparata below the original recommendation as alternative
sources of calcium in the diet are short at present, but this
course was subject to any further recommendation from the
medical advisers.
_ Saving through Bread-rationing
Replying to a question, Mr. STRACHEY said that the saving
in flour achieved by bread-rationing appeared to be about
214,000 tons so far, but he hardly thought that saving would
continue at so high a rate.
Medicine and the Law
Alleged Cruelty to Cats .
Dr. E. G. T. Liddell, Waynflete: professor of physiology
at Oxford, did not succeed in his appeal against the
magistrates’ decision convicting him of causing unneces-
sary suffering to cats kept by him in the animal-house
of the university department of physiology. Quarter
sessions, however, after a patient re-hearing which
lasted nearly three days, reached findings which went
far to justify his appeal. The fine of £25, imposed on
him in the magistrates’ court, was reduced to £5. The
appeal of Mrs. Scragg, the woman who had charge
of the cats and who had been fined £5, was allowed.
The allegations of cruelty were indicated in our
account of the proceedings before the magistrates
(Lancet, July 13, p. 64). Dr. Liddell, it may be recalled,
was conducting research into the treatment of distemper
in cats by sulphamethazine. At the recent quarter
sessions the learned recorder held that Dr. Liddell
had committed an error of judgment in putting too
many cats into the enclosure while they were suffering
from distemper. Apart from this overcrowding, said the
recorder, Dr. Liddell had acted in a humane and proper
manner; he had performed no cruel experiments; his
treatment of the animals was a non-painful experiment,
designed to cure the disease; none of the allegations
against him, except the overcrowding, was proved.
The prosecution was undertaken by the Royal Society
for the Prevention of Cruelty to Animals, whose inspectors
gave evidence of what they saw when they visited
the cats’ compound. The recorder made the comment
that he thought the witnesses for the society were entirely
honest, but they were upset by the sight of this very
distressing distemper ‘‘ and failed, in. my judgment,
to distinguish between the natural symptoms of dis-
temper, which it was impossible to cure while the
ee was raging, and the further aspects of the- —
isease.”’ :
An accusation of bad faith, made against Dr. Liddell,
was satisfactorily disposed. of. The prosecuting counsel
had declared that Dr. Liddell was not conducting any
experiment upon the cats and that his claim to have
done so was an afterthought. The recorder said he
accepted the evidence of Dr. Liddell and Mrs. Scragg in
its entirety ; ‘‘ Dr. Liddell was conducting experiments
on these cats and I accept his evidence entirely on
that.” There seems indeed to have been an element
of exaggeration in the allegations. It was put in cross-
examination to one of the society’s witnesses that, out
of eleven cats which, at the hearing before the magistrates,
he had said would have to be destroyed, eight had since
recovered. Sir Howard Florey, F.R.S., called on behalf
of Dr. Liddell, observed at one point of his evidence that
a lot of nonsense was talked by people who transferred
human feelings to cats—a remark which involved
him in an inconclusive argument with the society’s
counsel. The recorder put the matter more cautiously
when, in deciding the case, he began by stating the
opinion that charges of offences against animals often
-led to “ public emotion ” and to a certain “lack of
judgment. : , :
578 THE LANCET] .
IN ENGLAND NOW
`
{ocr. 19, 1946
In England Now
A Running Commentary by Peripatetic Correspondents
THE other week I visited a recovery home for boys
which was run, for no obvious reason, on ship’s routine.
Like all such things it was more naval than the Navy.
Lads running up to my guide and asking “ Permission
to go ashore, sir ? ’ took me back to previous years with
a jolt. But it was a form of play-acting that appealed
greatly to the boys and could be developed into a handy
way of getting them to carry out the routine laid down
for their recovery. When, however, it came to the
doctor’s pennant that was hoisted whenever a doctor
came aboard I was out of my depth, my naval duties
having always been on the dry side of high-water mark.
The final ceremony, however, designed to promote His
Majesty’s good health, was in the true naval style and
left all concerned in a happy frame of mind.
Why is it that some convalescent homes manage to
make their inmates enjoy their stay while others just
fail? At one institution, run by a religious order to
provide convalescent women with a month at the seaside,
the sister-in-charge seemed to be: responsible for the
happy atmosphere. Those who have never encountered
religious sisterhoods expect a sister to be rather a remote
other-worldly sort of being, but this one altered the
visitor’s ideas literally in the twinkling of an eye, for
she certainly had a twinkle in hers. ‘‘ You see,” she
explained, ‘‘I am lucky. This place was closed during
the war, so I could start afresh and forget tradition. I
don’t have any rules—why should I? The patients are
reasonable people who come here to rest. So I let them.
I expect them to be in time for meals and not to sit up ©
late talking—that’s only normal good manners and they
see the reason for it. Reading in bed ? Well, I know they
ought not to really, but nor ought I for that matter,
and I do so like doing it. So I can’t very well stop them.”’
For all her light-hearted air she must have had many
troubles in managing such a home in these days of
rations, controls, and shortage of domestic staff. But she
managed to look as though she hadn’t a care in the world.
Then there was that other home, spotlessly clean,
where a dozen women were taking a much-needed rest.
Two elderly ladies were taking their elevenses in a peaceful
sunny room. One of them, seeing a man being shown
round, suspected (wrongly !) that he might be a pros-
pective donor and took the opportunity to make. a little
speech, prefaced by a charming formal bob, saying how
happy she had been there. She had never been away
before and had come in some doubt and apprehension,
but she had enjoyed herself immensely and was sorry
to be going next day. ‘‘ It’s the Christian atmosphere
that counts, sir,” and with another bob sat down again.
Here there was no question of a religious order and the
atmosphere must have been the result of the unselfish
labours of a small committee of local people with their
hearts in the right place. There could be no question
of a M.B.E. arriving, let alone a title. The work was its
own reward. This must have a good deal to do with the
secret. The weight of the work rests on voluntary workers
who, I suppose, can be taken as the spiritual descendants
of the religious orders of medieval days, so that we get
back to a common ancestry for the inspiration -of both
institutions.
Since the dissolution of the monasteries such people
have always worked in small and highly individualistic
units. How will they fit into a large and tidy organisation
such as is now projected ? True, the religious orders were
once the largest administrative units in the civilised
world, but can the secret of organising such people in large
units be recaptured, or will they always have to work
on the fringe of the State’s domain ? For work they will.
a oe * xk , i
The deadly nightshade seems to be commoner than
usual this year. Tlave many cases of poisoning been seen ?
I am always surprised that people do die from eating
these berries, for they do not taste at all pleasant, and
a careful exploratory lick would reveal this without doing
much harm. Unfortunately, some children will devour
handfuls of a berry they have discovered in the hedge
regardless of how it tastes, though at home the same
children may be particularly finicky about their food.
The detective story in which the victim fell dead
after one taste of a nightshade berry put among his
fruit is as inaccurate as most accounts of sudden death
by poison. Cyanide is no doubt a pretty deadly sub-
stance, but in fact it is much slower than in fiction. In
some metabolic experiments I had to kill some frogs
instantaneously to isolate certain normal substances
from the tissues. When KCN solution was squirted into
their mouths they pulled a wry face, spat it out, hopped
off, and survived quite happily. An injection into the
peritoneum caused death in about five minutes. They
died in under a minute when it was injected intra-
venously. But it was quite different from the rich uncle
who suddenly slumps into his chair in the library, and the
detective notices ‘‘ the pungent smell of bitter almonds.”
¥ xk w
A physician to a teaching hospital has only too many
opportunities of appreciating the platitudinous observa-
tion that an old dog finds it difficult to learn new tricks.
- And, with more or less justified self-pity, I have often,
when taking stock, considered what proportion of one’s
knowledge is in fact employed in the actual practice of
one’s professional life and what proportion represents a
concession to the demands of the curriculum and _ the
various examining boards. Such a reflection supplies
an easy transition to a.comparison between ourselves
and the practitioners of our great sister profession. It
will be recalled that, after twelve years’ retirement from
his practice at the Bar to devote himself to national
service, Lord Simon returned to preside over a Court
of Appeal in his capacity of Lord Chancellor. And,
notwithstanding the interval, the great lawyer recom-
menced his legal activity in full flood. Instantaneously
the cogs meshed; the intellectual machine resumed its
work without friction. Suppose our profession to possess
the analogous office. We are reminded in Iolanthe that
the Lord Chancellor embodies the law. To suggest that
after twelve years’ retirement the Lord Physician or
Surgeon could embody medicine or surgery would be too
ridiculous for even momentary consideration. —
The law, I take it, is very nearly static. Its basic
principles remain unchanged; any alterations or accre-
tions which result from newly established precedents
are in substance comparatively trivial. The possession
of judgment; the capacity of persuasive advocacy’; the
ability to present facts and arguments with clarity and
conviction, in part natural talents, in part the result of
practice and experience, are not necessarily prejudiced
by a period of inactivity even as long as twelve years.
But the art of the doctor is one of continuous progress.
Admittedly, basic principles remain for all time, but the
acceptance of discoveries and innovations is essential in
the daily practice of any physician or surgeon. The
physician who returned to practice after twelve years’
absence would for a time be as puzzled as if he were
transported to a strange land of people speaking a foreign
tongue. He would be confronted with the names of
“ new diseases ’’ which, though they must have existed
in his day, had never been recognised. He would find
that certain conditions which he had accepted as
eetiologically obscure and incurable were being rapidl
and completely relieved and sometimes even cured.
Diabetes by insulin for example ; addisonian anemia by
liver; myasthenia gravis by ‘ Prostigmin.’ A vast
therapeutic field presents itself under chemotherapy ;
another by the introduction of sex-hormones. Vitamins,
which occupied a few lines in the textbooks of his day,
have now acquired a vast bibliography. At first he
would be more ignorant and feel more helpless than a
first-year student ; or, to resume analogy with the other
profession, a very young gentleman who has started to
eat his dinners. T
To what extent would adjustment be possible?
Would he in time become again the great man of
the day? I doubt it. For one thing, the influence of
experience would compel a timid if prudent reluctance to
accept all these panaceas, since experience recalls the
precocious confidence in the value of so many cures
which had failed in the test of time. Yes, thẹ old dog
learns new tricks with difficulty.
And so I turn with a sigh to master the principles of
D T ee 2 which I am: to lecture tomorrow.
or even though by sedulous application I may grasp
sufficieht for this temporary purpose, I am most uniikely
ever to carry its application into practice. .
THE LANCET]
Letters to the Editor
ROYAL COLLEGE OF PHYSICIANS OF LONDON
Sm,—Certain members of the college have written to
the medica] journals about the representation of members
in the counsels of the college. They must know that
the President took the initiative in calling a meeting of
members of the college in January. This was attended
by three hundred members and a committee was
appointed to go into the matter. This committee
reported to another meeting in April and their recom-
mendations were accepted practically unanimously. The
President thereupon brought the matter before the
- council of the college, who made recommendations to the
comitia which involved alterations in the by-laws of
the college, and this was put in hand at once. There
is no reason to believe that the great majority of members
are not satisfied with the procedure adopted.
A few members criticised the method of election of
fellows but did not receive substantial support.
H. E. A. BOLDERO
Royal College of Physicians,
L A Registrar.
ondon, S.W.1
CHILDREN WHO SPEND TOO LONG IN BED
SIR, —May I thank Dr. J. A. McCluskie for his most
helpful article in your issue of August 31? In my three
children, ranging in age from 6 years to 2 years, I have
noticed many improvements since I cut down their
= sleep to the times he recommended.
I do not understand the difficulties of Dr. Catherine
Storr (Sept. 7, p. 363), as the management of differing
hours of sleep is just part of the household routine which
must be followed if all the work is to be done; an
-understanding husband is of the greatest help in this
connexion.
have no help with the housework. I feel that when we
have our next baby I shall be very glad of the guidance
given by Dr. McCluskie in the difficult matter of infant
ie is small wonder that the child propped in the pram,
his toys around him, should go to sleep ; he does so from
sheer boredom. I have always left my infants (quite
happy) in the playpen to play, even when they could
only lie and kick.
It seems very surprising that a woman as busy as the
one described by Dr. Storr should find time to stay in
bed after 6 A.M. or have an afternoon rest. Perhaps
Dr. McC€luskie could give us some guidance on adult
_ sleep requirements. |
Pinner. BETTY AINSWORTH.
BOVINE PLASMA AGAIN
Sır, —There is a tendency to regard experiments done
on the production of new blood-plasma substitutes as
acts of supererogation, although it is conceded that such
substitutes may be means of avoiding hepatitis and, less
important, of relieving blood-donors of their heavy respon-
sibility. I have long felt that a more favourable attitude
is imperative, and anyone who has worked abroad among
people who have an atavistic dislike to giving blood
will agree. A. dramatic presentation of the exsanc uin-
ated air-raid casualty will produce volunteer donors,
but the equally pitiful case of a cholera patient raises
different emotions. An efficient blood-plasma substitute
which could be stored without refrigeration in out-
station dispensaries and given with the same technique
‘as a hypertonic saline would be one of the greatest
blessings science could confer on doctors called on to
deal with epidemic cholera or dysentery. The argument
applies with equal force to the treatment of surgical
and medical emergencies and the protracted treatment of
nutritional hypoprotecinzmias, biliary cirrhosis, &c.
Your annotation of Sept. 7, evoked by Dr. Massons’s
article in the same issue, gives certain criteria for assess-
fing the suitability of plasma substitutes—i.e., non-
antigenic, non-toxic, free from agglutinins (and hzmo-
lysins), and of an osmotic pressure comparable with
human plasma. To these I would add an extension of
the criterion ‘‘ non-toxic ” and one further criterion.
The new criterion (making no claim for originality)
is that the substitute is capable of being metabolised with
profit by the patient. Obviously gum acacia, cellulose
BOVINE PLASMA AGAIN
Admittedly I have no small baby, but I .
[oor. 19, 1946 579
ee CS + EE wee
derivatives, and colloidal products of polymerised
organicsubstances are excluded under this additional rule ;
- but so is gelatin, which may still act very efficiently,
in producing prolonged hemodilution, but which is not
metabolised (except perhaps when given with a mixture
of amino-acids to make up for its constitutional
deficiencies) and is in fact excreted in the urine almost
cent. per cent. within 24 hours. Dr. Massons does not
give data which would enable judgment to be passed
from this point of view on his preparation of calf plasma.
True he says. that the results in the treatment of certain
hypoproteinemic conditions were as good
human blood plasma, but American investigations have
shown that it is extremely difficult to alter the plasma-
protein concentration in such states by the administra-
tion of human plasma, so the only evidence, apart from
the diuretic effects (which could equally well be produced
by gum acacia), that true ‘“ profitable ” metabolisation
of the product occurs would be on the basis of nitrogen-
balance experiments. This is a request for information
and not carping criticism.
The extension of the criterion “‘ non-toxic,” possibly
implied though not specified in the annotation, is that
the substitute should not produce the syndrome which
follows the use of macro-molecular substances such as
gum acacia or even gelatin, which includes depression
of plasma-protein production and prothrombin, an
increase in the E.S.R., and a greater or less degree of `
blocking of the reticulo-endothelial system. Such an
effect with colloidal solutions is to be expected unless
the substance is metabolised, and each item in the
.syndrome can be of clinical importance, although these
might justifiably be ignored when the infusion is not to
be repeated, as in cases of surgical emergency. Cholera
in a patient on the verge of, or actually in, a state of
nutritional hypoproteinzemia presents such a condition
where a further depression of plasma-protein production
might just tip the scale between survival with rapid
convalescence and death or a protracted convalescence.
With salines only, such patients can die with a depressed
blood-volume (dehydration) and simultaneous tissue or
pulmonary cedema, and only human plasma or serum,
or a metabolisable protein substitute, can be useful
therapeutically. | i
Your comment. that the osmotic pressure of such a
preparation as Dr. Massons has described is probably
less than that of human plasma is almost certainly
erroneous. The denaturation increases the osmotic
tension in this preparation to the extent of about 15%
of the total osmotic tension of the original plasma, and
the increase will be almost entirely due to a rise in
the colloid osmotic tension. The probability is that the
colloid osmotic tension of the preparation is well above
that of human plasma.
determined largely by the amount of electrolytes intro-
duced with the colloid, the actual colloid osmotic tension
matters little.
Impressed by the great need for an easily available
plasma substitute I have made several series of experi-
ments under difficulties. In the first Colonel L. A. P.
Anderson, I.M.S., then director of the Pasteur Institute,
Shillong, and later director of the transfusion services,
G.H.Q., Delhi, prepared bovine serum to which had been
added 8:5% glucose and which was then spray-dried.
This product was non-antigenic and non-toxic to guinea-
pigs and could be sterilised by boiling. However, large-
scale spray-drying was then impossible.
Later, after the publication of Edwards’s article on
‘* despeciated bovine serum,” I started experimenting
again and finally. decided on egg-white as the protein
basis because the whole process could be carried out
easily and aseptically, the globulin could be precipitated
by dilution with distilled water, and the complications
of removing clot and corpuscles did not arise. This
preparation was apparently non-antigenic and non-
toxic and had quite phenomenal diuretic effects on
patients with famine cedema when given as an approxi-
mately 5% solution in normal saline 300 c.cm. The
criterion I insist on was not then applied for lack of
facilities to work out a metabolic balance ; neither was
any estimate made of the effect of despeciation on the
avidin (antibiotin complex)..: 7 P
An egg shortage and more work brought this experi-
ment to an end! Although it sounds more bizarre
as with ;
bes
In any case, within wide limits
580 THE LANCET]
even than bovine plasma, the application of denaturation
to egg-white albumin might well be worth further
PERFORATED PEPTIC ULCER TREATED WITHOUT OPERATION
study—a thing which I will.certainly do unless someone .
better qualified and with better facilities does it first.
I am extremely glad that Dr. Massons has given us
the details of his procedure and investigations into the
properties of denatured calf plasma, and I hope that he
will publish soon the metabolic studies complementary
to its use in hypoproteinzmic states.
Brixham, Devon. R. ARTHUR HUGHEs.
TUBERCULOUS GLANDS AND CALCIFEROL
Srr,—In his letter of Sept. 28 (p. 473) Dr. Wallace
writes that treatment of tuberculous glands with
calciferol seems ‘‘ helpful when sinus formation is
present ” but that it “has a clinically adverse effect
on glands which have not broken down.” He admits
that this is “ little more than an'impression.”’ I should
like to record that in three cases of tuberculous cervical
adenitis of the multiple type, without sinus formation,
quite unsuitable for treatment by radical excision,
there has been a markedly favourable response to
calciferol, resulting in a reduction in size of the masses
in the neck sufficient to excite pleased- comment from
the three patients concerned. It would be ridiculous
to draw any conclusions from this. My sole purpose
- is to register an ‘‘impression”’ quite different from that
` of Dr. Wallace.. |
Dr. Wallace is right when he advises that calciferol
“a
_ focr. 19; 1946
had, or who contract, gonorrhea ;
required hysterectomy. _
‘Within the last few months this device has achieved
an alarming popularity, for certain practitioners: claim
it to be the method of choice, even for young nulliparous
brides. Members of this committee have met with many
cases of infective lesions occurring in such patients,
which they will be happy to publish if it appears neces-
sary. It is very difficult for the average practitioner to
get guidance on such a matter, and, without it, he is
at a great disadvantage when his patients claim to have
had friends who have been highly delighted with the
method. . | i
In point of fact, no progress has recently been made in
one such patient
the essentials of the ordinary contraceptive technique: |
for security, either some type of occlusive rubber cap
must be used by the wife, in conjunction with a chemical
spermicide ; or a sheath, preferably with a spermicide,
must be used by the husband. Such methods are non-
_injurious, and offer a high degree of safety (at least
should be given with caution when pulmonary tuber- `
culosis is present, at any rate until more is known
_ about its effect on this condition. On the theory that `
the beneficial effect of calciferol on lupus might be
due to a specific effect on squamous epithelium I treated
four cases of tuberculous laryngitis accompanying
pulmonary tuberculosis by the administration of 100,000
to 150,000 units of calciferol daily. This treatment
had to be abandoned after 5 days owing to undesirable
toxic effects. | |
Though Dowling and Prosser Thomas! declare that
the effect of calciferol on mupur does not seem tọ be
related either to symptoms of toxicity or to the serum-
calcium level, this point obviously requires further
elucidation. Clinically, this might be done by treating
a series of. cases with parathyroid extract and large doses
of calcium or by -other measures designed to keep the
serum-calcium at an abnormally high level.
Best and Taylor ? point out that the overdosage effects
of parathyroid and irradiated ergosterol are similar.
Both cause the same degree of hypercalcemia, hyper-
phosphatemia, and a rise in the non-protein nitrogen
of the blood. The symptoms during life and the post-
mortem findings after poisoning with either material are
identical. ; |
A comparison of series of cases treated by the two
methods might shed important light on the mechanism
by. which calciferol produces its effect on lupus lesions.
Neath, Glamorgan. T. FRANCIS JARMAN.
CONTRACEPTION WITH THE SILVER RING
Sir,—The medical committee feels that a warning
should be given concerning the sudden revival of a method
of contraception called the silver or Grafenberg ring.
This appliance consists of a small ring, composed of
silver, platinum, or other metal, which is inserted into the
uterine cavity, where its presence, provided it is retained,
is intended to prevent the embedding of the fertilised
ovum.
The advantages of such an unexacting method are so
manifest that the device was fairly widely studied some
fifteen years ago, both here and on the Continent.
Unfortunately, the risks in its use have proved greater
than were at first anticipated. In addition to the fact
that, even in cases where the ring is retained, the failure-
rate is high (at least 5%, the ring often being born with
the baby), the incidence of pain, menorrhagia, and
metrorrhagia has been considerable, and subacute
infections and acute salpingitis have been caused in
healthy nulliparous women. Moreover, the technique
entails the utmost danger to women who have previously
1.. Lancet, 1946, i, 919.
2. Physiological Basis of Medical Practice, London, 1943, p. 1189,
98% used over ten fertile years) provided they are
competently chosen and applied. *- = `
My committee would be grateful if you would
this warning to reach fellow practitioners. a
Family Planning Association, _ M. A. PYKE
London, S.W.. . Hon. Secretary.
PERFORATED PEPTIC ULCER TREATED.
WITHOUT OPERATION
Sm,—In reading Mr. Hermon Taylor’s article of
Sept. 28 and your leader of Oct. 5 I. was amazed by the
omission of both to refer to previous American: articles
on conservative treatment. I have a reference dated
1943. A short note om the method describing a small
series was published in this country last } |
impression given is that this is a new method invented
by Hermon Taylor, which is wrong. Hedley Visick, of
York, has adopted conservative treatment for all perfora-
tions as a routine for the last two years with, I believe,
uniform success. The results of all methods acknowledge
the tremendous mortality associated with this catas-
trophe, a condition of affairs that is regarded. with
equanimity by most surgeons in that the condition is,
as you point out, usually looked upon as only worthy: of
the attention of a house-surgeon or resident surgical
officer. The normal operative mortality is 20%. .
You refer to one or two series of operative results
in early cases with a small mortality ; that this need
not be regarded as only to be achieved by a few is shown:
by my own series of 50 cases with 2 deaths in eight
years, cases not selected and including perforations up
to three days old. : My own routine is to avoid general
anzesthesia except in the young and healthy adult, and
in all other cases to use spinal or local with morphine ;
this ensures the absence of those postoperative chest
conditions which are so fatal. There is no way in which
we can be sure that the perforation is sealed off. My
last case was in a girl of 21, severely shocked and with a
rigid board-like abdomen. Operation showed a large
perforation in the anterior wall of the stomach into which
one could put the tip of a finger. In my opinion it would
have been criminal not to have operated on this girl.
Two days later she was sitting up smiling and on a
normal diet. In some cases we can assume from the
mildness of the symptoms and the relative well-being
of the patient that it is justifiable not to operate, and
following the lead of Visick I have treated 4 cases this
year conservatively without a death, each being proved
radiologically or at subsequent operation.
All surgeons should know that the use of a drainage-
tube in a perforation is dangerous as well as useless.
Subphrenic abscess and pelvic abscess occur where
tubes are used, and intestinal obstruction: frequently
follows its use in the pelvis. I have not used a drainage-
tube in a perforation for over ten years, and I have not.
‘had an intestinal obstruction and only one subphrenic
abscess. It is unnecessary to use chemotherapy. as a.
routine; as Patey recently pointed out, cases which
have been on prophylactic penicillin and/or sulpha-
thiazole will still develop chest complications, and I have.
had one postoperative death, following a gastrectomy
where a chest complication was anticipated, where.
penicillin and sulphathiazole were both used from.
allow
year. The.
THE LANCET]
SPLANCHNIC BLOCK, ELECTROLYTE BALANCE, AND UREMIA
[ocr. 19, 1946 581
before the operation and the patient died of 9 bilateral
bronchopneumonia.
After operation many cases develop pyloric obstruction,
and the surgeon must be prepared to recognise this
early and perform a further operation within a few days
when it is clear that the stomach contents will not pass
freely through a pylorus narrowed both by the original
ulcer and by the sutures used to obliterate it. No-one
who reopens an abdomen a few days after a perforation
can fail to be struck by the clean appearance of the |
abdominal contents and the absence of adhesions, or to
realise that it is unnecessary to remove the fluid present
at the time of operation and to insert a drainage-tube
with the object of letting it off. In any case a drainage-
tube does not carry out this function since it is rare
for more than a few ounces to exude from it.
My experience as R.S.0. in several hospitals taught me
that the mortality following perforations was due to
carelessness or ignorance on the part of the operator ;
the use of general anzsthesia in debilitated patients
or those with chest or heart lesions ; the failure to recog-
nise postoperative intestinal obstruction until it was
too late; the failure to appreciate that the pylorus
might be mechanically obstructed; the inability to
diagnose subphrenic abscess; and the insistence on
draining pelvic abscesses when diagnosed suprapubically
rather than through the rectum.
In a hospital where: the operative mortality is the
generally accepted one of 20%, conservative treatment
should have no greater risk and may, by the avoidance
of an- operation, have a lower one. Where, however,
the surgeon can be sure of a reasonable mortality of
under 5 % then it seems to me that conservative treatment
should not be the routine but should be used in selected
cases where the crisis of the disease is over and the
patient is already recovering.
Halifax General Hospital. H. I. DEITCH.
CHILDREN IN DAY NURSERIES
SırR,—The argument in Dr. Hilda Menzies’s paper
of Oct. 5 is that since a substantial proportion of the
children did not make satisfactory progress as judged
by weight gains in the first or second 3 months after
admission to the nurseries, and since the children had
almost double rations compared with those under
the care of their mothers, their unsatisfactory progress
was more likely to be due to emotional disturbances
"“ anything so simple as lack of proper
There is no information on fluctuations in
weight growth of preschool-children in this country,
but if the experience for preschool-children in other
countries and for older children in this’ country can
be taken as a guide, then the same sort of fluctuations
could be expected for children under their mothers’
care as were found for children after admission to the day
nurseries. :
The practical significance to“ health of short-term
fluctuations in weight growth has not so far been satis-
factorily explained. From a recent Australian study,!
no explanation could be given of them in young children
living in child centres; Bransby ? found short-term
fiuctuations in weight growth in older children with
a good health record and living in a good environment.
By all accounts the latter chidren were happy and
contented. The short-term fluctuations in weight
growth: of these two groups of children might, of course,
have been due to. emotional disturbances, but they
might well have been due to some other physiological or
environmental factor. Similarly, emotional disturbance
or some other factor may have been responsible for the
short-term fluctuations found by Dr. Menzies. Her
i ent concerning emotional disturbances would have
been strengthened had data been presented to show
1. Commonwealth of Australia Department of Health (1945):
The Lady Gowrie Child Centres. Commonwealth Government
Printer, Canberra.
2. Bransby, E. R. Med. Offr, Sept. 22, 1945.
that the children who were emotionally disturbed did,
in fact, have unsatisfactory weight gains and vice versa. |
Ministry of Health. | E. R. BRANSBY.
Sır, —I was extremely interested in the article by
Dr. Menzies. It gives confirmation to a thesis on
the dangers of separation anxiety in young children
which I, in common with other psychiatrists, have held
for some time now. My own observations were made
on hospitalised children and are embodied in a monograph
(Separation Anxiety in Young Children. Genetic Psycho-
logy. Monographs, 1943). Others have written to you
at different times, notably in connexion with the evacua-
tion of children during the war, and a letter in the -
British Medical Journal (1939, ii, 1202) from Dr.
John Bowlby, Dr. Emanuel Miller, and -Dr. D. W.
Winnicott is so apposite that I cannot forbear tô quote
at least part of it here:
“ There are dangers in the interference with the life of a
toddler which have but little counterpart in the case of older
children. . . . Apart from such a gross abnormality as chronic
delinquency, mild behaviour disorders, anxiety and a tendency
to vague physical illness can often be traced to such disturb-
ances of the little child’s environment [i.e., removal from home]
and most mothers of small children recognise this by being
unwilling to leave their little children for more than very
short periods.”
Though the findings of analytic psychiatry on -this
point have up to now been more or less disregarded,
perhaps this corroboration of their views by Dr. Menzies’s
carefully. recorded experience will call more attention
tothem. To quote again, this time from my own paper :
‘‘In these days with increasing interference of the State
in the handling of even very young children it is as well to be
aware of all the pitfalls involved. One cannot know too much
of the consequences of interference when dealing with two
such fundamental biological urges as the parental instinct
and its counterpart . . . [the need for] security and depen-
dence. ...”
Leeds. H. EDELSTON.
SIR ALMROTH WRIGHT AND ANTI-TYPHOID
INOCULATION
SIR, —I am much indebted to Dr. Leonard Colebrook
for drawing attention in your issue of Sept. 14 to an
apparent mis-statement in my History of Medicine. I
admit that, on page 348, I have unwittingly conveyed |
the impression that Sir William Leishman was the
originator of anti-typhoid inoculation ‘‘ along with
Sir Almroth Wright,” although, on a previous page (288),
I describe Sir Almroth Wright as ‘‘ the pioneer of vaccine
therapy and of anti-typhoid inoculation.”
Of course the title of ‘“ originator,” although I did not
use that word, belongs to Sir Almroth Wright, whose
outstanding achievement in the field of preventive
inoculation is certainly a landmark in the history of
medicine. Sir William Leishman, it would appear, simply
gave his powerful support to the introduction of the
method into the British Army. I need scarcely add that
the paragraph will be revised in any future edition of my
book. |
Edinburgh. = DOUGLAS GUTHRIE.
SPLANCHNIC BLOCK, ELECTROLYTE BALANCE,
AND URAMIA
Str,—Recent correspondence on uremia following
trauma or abortion has suggested that this condition can
be successfully treated by restoration of the renal circula-
tion, either by splanchnic block or by correction of the
electrolyte balance. While I do not propose to question
the correctness of both these procedures, I should like
to draw attention to their limitations.
Although successful cases of splanchnic block in the
human have been reported, Porritt et al.1 were not
impressed by its use in the casualties from B.L.A. The
reason for this failure lies in the fact that. the kidney will
withstand ischemia for only a limited period,? and,
should the renal circulation be deranged long enough to
1. Porritt, A. E., Debenham, R. K., Ross, C.O. Brit. med. J. 1945,
2. Allen, Ñ. M. J. Urol. 1943, 49, 515. Scarff, R. W., Keele,
C. A. Brit. J. exp. Path. 1943, 24, 147. van Slyke, D. D.,
Phillips, R. A., Hamilton, P. B., Archibald, R. M., D ,
ole, V. P.
Emerson, K. Trans. Ass. Amer. Phys. 1944, 58,119. Badenoch,
A. W., Darmady, E. M. (in the press). -
582 THE LANCET]
cause massive degeneration of the kidney epithelium,
death will certainly follow from accumulation of waste
products.’ —
I am hoping to show in a paper to be published shortly
that in some cases, even if electrolyte balance is estab-
lished early, death from uremia still occurs. Moreover,
that when the syndrome is fully developed there is
considerable risk in giving fluid intravenously, since not
only is the alkali reserve, sodium and chloride, difficult
to maintain but there is also danger of overloading the
circulation.
The area and extent of the renal necrosis must be the
factor which determines unassisted recovery, but if the
accumulation of waste products—in particular potassium
—can be removed until such time asthe kidney regener-
ates there is greater chance of the patient surviving.
An apparatus for such a purpose, consisting of pump
and dialysing membrane, has already been put forward
by Kolff and Berk * and recommended by Bywaters t and
Snapper.’
Simplification and modification of these methods are
now under consideration at this laboratory and show
promising results.
Pathological Dept., Salisbury
Inormary, Salisbury.
PILONIDAL SINUS
Str,—After reading the article on postanal pilonidal
sinus by Patey and Scarff in your issue of Oct. 5 I
cannot understand their readiness to relegate the develop-
mental theory to a secondary place. They state that
an uninfected sequestration dermoid—ought it not to
be dermoid fistula or cyst ?—is almost never encountered ;
but does not this depend on whether it is looked for ?
E. M. DARMADY.
I have found a few, symptomless, in patients complaining
of other conditions. It does not seem to be appreciated
by many practitioners that the congenital opening is
extremely small and sometimes multiple. I have seen
an eminent rectal surgeon demonstrate, to his own
satisfaction, that no external opening was present by.
using a probe with an end as big as a match-head.
Another case recurred after a drastic excision which
had left the sy tar opening intact. To demonstrate
this opening I find a fine straight sewing needle, used
eye end first, a ani probe.
Patey and Scarff seriously suggest that the fine hairs
found in this region are capable of penetrating the skin,
but an examination of the hairs in the sinus will show
that they are often of considerable length, and must
have grown from the wall of the sinus. Their conclusion
that the pilonidal sinus in the hand was due to puncture
by a hair seems incorrect in view of the histological
picture, which showed a hair follicle in the wall of the
sinus. The explanation of the recurrent sinus, longer
than the original, containing dead hairs may simply be
that the upper end of the sinus was not excised ; hairs
and debris from the remnant continued to collect and
formed a sinus in the dead space left by operation.
On the choice of operation your editorial puts the
position fairly. If it is undertaken in the “ cold ” stage,
with careful excision of the track and its offshoots and
care in suturing to obliterate dead spaces, there should
be no need for any of the fanciful operations devised.
Plymouth. EDRIC WILSON.
Sm,—Patey and Scarff state that this condition in
the majority of cases is not of congenital origin. They
base this dogmatic statement on the slender and incon-
clusive evidence of being unable to find an epithelial
lining in 18 out of 21 cases, and a description of an
interdigital sinus in a barber’s hand.
In 1933 (Brit. J. Surg. 1933, 21, 219) I fully described
the condition under the title of Coceygeal Sinus, and
(as I thought) conclusively proved with histological
evidence that such sinuses are congenital in origin. They
can, of course, be easily confused with other septic
conditions. A coccygeal or pilonidal sinus is a definite
clinical entity and is always characterised by one or
several minute openings situated accurately in the middle
line. It requires careful observation to detect these
3. Kolf, W. J.. Berk, H. T. J. Acta med. sran: N 121.
4. Bywaters, E. G. L. Brit. med. Bull. 1945
5. Snapper, I. J. Amer. med. Ass. 1946, 131, 738.
-~ PILONIDAL SINUS |
focr. 19, 1946
openings. | I have seen them many times i in the newborn,
the adult, and elderly, causing no symptoms whatever.
It is only when they become infected that they give rise
to trouble, with the resulting secondary sinus lined with
granulation tissue.
I venture to suggest to the authors that if they were
to restrict their observations to the true pilonidal sinus
and were to take serial microscopic sections of the
excised tissue they would in all cases find the epithelial
lining. Having operated upon a very large series of
` these cases I am confident that the theory I advanced
is the true one.
It seems a pity that a paper emanating from the
Bland-Sutton Institute of Pathology should make no
reference to Sir John Bland-Sutton, that supreme and
accurate observer, who in his classic book Tumours
Innocent and Malignant regarded these sinuses as due
to faulty coalescence of the skin. He even suggested
they were comparable to the interdigital pouch of the
sheep and stated that similar interdigital pouches occur
in connexion with webbed fingers in man.
Manchester. R. L. NEWELL.
DISTRIBUTION OF DISSEMINATED SCLEROSIS
Str,—Disseminated sclerosis is well known to be
common in some countries (e.g., Switzerland) and very
rare in others (e.g., South Africa). Its incidence varies
also in different parts of a country, for it is more common
in north than in south Switzerland. |
Investigations at present being carried out ‘indicate
that disseminated sclerosis is relatively common. in
England, and that patients suffering from the disease
number 2—4 per 10,000 population. There seem, however,
to be certain parts of the country where it is much more —
common than this, and others in which it is rarely, if
ever, seen.
Information regarding its geographical distribution is
being. collected here for research purposes, and if any
doctor can give information regarding its local incidence,
or has been impressed by its frequency or rarity in his
district, we should be grateful if he would, communicate
with us. Areas of the country where the disease does not
occur are just as important as those in which it is frequent.
W. RITCHIE RUSSELL.
Radcliffe Infirmary (Neurology), Oxford.
EARLY OVULATION
SIR, —The conclusions that Dr. Sevitt draws in his
article of Sept. 28 may be unintentionally misleading.
He says: (1) “. . . ovulation can occur on any day of
the first half of the cycle’’; (2) “... it appears therefore
that premature ovulation is not uncommon ’ and
(3) “. . . it follows that there is no safe period: in the
first half of the cycle.” ?
Of his 10 cases there is not one with a normal men-
strual history. AH except 2 are menorrhagias, which
may be due to an endocrine disturbance, as in fact he
seems to prove with the sections. The other 2 were
cases of severe leucorrhosa. One of the causes of “ func-
tional”? menorrhagia is claimed to be an excessive
development of the secretory endometrium. Dr. Sevitt
seems to. confirm this and even shows that ovulation
seems to occur early in this type of case—i.e., the luteal
phase lasts longer than the normal 14 days and -presum-
ably gives rise to an abnormally thick endometrium,
though he has no sections to confirm this. ~
‘In case 6 he found an early secretory endometrium
during the bleeding phase. I cannot see why he postu-
lates a new corpus luteum, since the same findings
can surely be expected with a persistent corpus luteum
or with an incomplete shedding of the endometrium,
imperfectly stimulated to secretion by the corpus luteum
of the previous cycle. In case 9, the only evidence he
gives for a ‘‘ very early secretory "phase ” is vacuolation
and basal nuclei with some dilated glands of the endo-
metrium. This change can be produced by a. high
cestrogen blood-level in the absence of a functioning
corpus luteum, and therefore ovulation.
I feel therefore that the conclusions I have -quoted
can stand only if the words ‘‘in some cases of menor
rhagia ” are added at the end of each.
London, N.W.6. W. P. Hrrsca.
get am ee ee eee O — aranana
t
THE LANCET]
Obituary
STANLEY WYARD
M.D. LOND., F.R.C.P.
Dr. Stanley Wyard, physician to the Cancer
Hospital and the Princess Beatrice Hospital, London,
who died on Sept 29, was a first-class physician whose
clinical acumen was founded on experience as a clinical
pathologist. The son of the late Rev. G. L. Wyard, of
Bournemouth, he was educated privately and at the
University Colleges of Cardiff and London. After
graduating M.B. Lond. in 1909 he held house-appointments
at the West London Hospital before taking up a research
assistantship in pathology at Leeds. He returned to
London to set up in consulting practice, joining the staff
of the Bolingbroke Hospital, the Belgrave Hospital, and
the Victoria Hospital, Chelsea. His earliest bent was
thus for pediatrics, but he retained his interest in
pathology, and alongside his other work he found time
to act as medical registrar at the Cancer Hospital, where
he was later appointed to the staff. Besides the well-
known Clinical Atlas of Blood Diseases, of which he was
part author, he also published in 1927 a Handbook of
Diseases of the Stomach which reflected his wise judgment
and wide experience. The first world war interrupted his
clinical work, for he served in France with the R.A.M.C.
as a pathologist. In the last war he took on additional
work as temporary consulting physician to Hounslow
Hospital and, under the 15.M.S., as physician at the South
Middlesex Hospital.
His clinical work was characterised by the great
interest he took over every aspect of each case, which
won him the confidence of patient and doctor alike.
Scrupulously upright and honest in all his dealing, as a
colleague writes, ‘‘ he had no axe to grind but just did a
good job of work.” With his command over affection
and respect he made an excellent chairman of the medical
committee at the Princess Beatrice Hospital, and until
lately he also served as chairman of the board of manage-
ment of the Victoria Hospital. Behind his quiet exterior
he had tremendous moral courage, and when many
months ago he realised that he was suffering from a
fatal illness. he told no-one inside or outside his
family but carried on as long as he could with no change
in manner or appearance. His ambition had been to
retire when he was 60—just about his age when he died—
and go to live in South Africa where he hoped to find
leisure and light for his favourite recreations—photo-
graphy and biology—and to continue his games of golf
which the war had interrupted.
ARTHUR NORMAN BOYCOTT
a M.D. LOND.
Dr. A. N. Boycott, who died on Sept. 17, was a well-
known figure in St. Albans, where he had lived since
his appointment as medical superintendent to Hill
End Mental Hospital in 1898. The third son of the
late Richard Boycott, of Rugeley, he was born in Lucknow
in 1866 and was educated at Monmouth School, where he
was a brilliant scholar and a good athlete. He qualified
at St. Thomas’s Hospital in 1888, winning the Cheselden
medal in surgery, and in 1893 took his London M.D.
After holding a house-appointment at St. Thomas’s
under Sir William MacCormac he went to Cane Hill
Hospital in 1890 as assistant inedical officer to start a
long and successful career in mental diseases. At the
age of 32 he was appointed to Hill End Hospital, where
as the first medical superintendent he was responsible
for organising and equipping the new hospital. He worked
hard to raise the standard of medical and nursing care
and to improve the welfare of his patients and his staff,
and his kindly administration earned him a lasting reputa-
tion and affection. A member for many years of the
Royal Medico-Psychological Association,: he took a
great interest in improving the training of mental nurses.
In 1925 he retired from the superintendentship of the
hospital, but he continued to work as a consultant
to the Hertfordshire county council until the early
years of the war.
Apart from his professional work Dr. Boycott had
many other activities. As secretary and later treasurer
` OBITUARY
(ocr. 19, 1946 583
of the St. Albans branch he was intimately connected
with the Red Cross in Hertfordshire, and during the
second world war he spent much time doing Red Cross
work for the relatives of prisoners-of-war. He was also
a governor of the St. Albans School and a trustee of
the Kentish Educational Foundation. His friends in
the profession and in St. Albans will miss him not
only for his work but for his kindly quiet manner and
his steadfastness. |
In 1905 he married Lota, the eldest daughter of the
late Edward Griffith. Brewer, who survives him with
their only daughter. ai
RICHARD JAMES CAMPBELL THOMPSON
C.M.G., D.S.O., M.D. DURH., M.R.C.P.
Lieut.-Colonel R. J. C. Thompson died on Oct. 2 in
St. Thomas’s Hospital, London, where he had been
secretary to the medical school for over twenty years.
Born in 1880, the son of R. P. Thompson, of Stamford,
he came to St. Thomas’s as a medical student in 1898
from Marlborough, and became a prominent member of
one of the great rugby football teams which the hospital
produced at that period. He qualified in 1904, and after
doing hospital appointments in 1905 he joined the
R.A.M.C. Five years later he was seconded to the
Egyptian Army to serve on the Sudan Sleeping Sickness
Commission where Andrew Balfour was one of his
associates. As a result of the investigations of the
commission extensive measures were introduced which
have proved successful in controlling sleeping sickness
in the southern Sudan. Returning to the R.A.M.C. in
the first world war he established a reputation as com-
manding officer of one of the best casualty-clearing
stations in France. An injury to his leg led to his being
invalided out of the Service. From 1919 to 1922, while
acting as physician and surgeon to the Royal Hospital,
Chelsea, he took the M.R.C.P. and the M.D. Durh. To this
period also belong his papers on the problems of old
age. For a short time he practised in Bordighera, but
his main lifes work began when he returned to St.
Thomas’s Hospital as secretary to the medical school.
Tommy Thompson, as he was generally called, was
aman big in physique and heart, whose charm of-
manner brought him friends wherever he moved. , He
had the power of evoking affection, and consequently
willing work from all his staff and subordinates, and he
filled his post as secretary with energy and success. The
death of his only son, whose plane failed to return from
an Atlantic patrol, was a crushing blow from which he
never entirely recovered, and after he retired a few weeks
azo on St. Thomas’s he seemed to have little zest left
or life.
HENRY BEECHER JACKSON
M.A. CAMB., M-R.C.S.
Dr. Beecher Jackson, who died in the Wilson Hospital,
Mitcham, on Oct. 8, succeeded his father as coroner
for Croydon, and together they held office for nearly
sixty years. From Epsom College he obtained an open
exhibition to Clare College, Cambridge, and on leaving
the university he was admitted to the roll of solicitors.
In 1918 he Obtained his medical qualification at
St. Bartholomew’s Hospital, after serving in the first
world war as a temporary surgeon in the Royal Navy.
In 1919 he succeeded his father in the office to which
he had an obvious vocation, and for which he had
assiduously prepared himself by constant attendance
at the London coroners’ courts. He was noted for his
attention to detail, his courtesy, and his consideration.
In 1939 he presided over the Coroners’ Society. He
leaves a widow and one daughter.
“<... Rifle bullets kill men, but atomic bombs kill cities.
Our defense is not in armaments, nor in science, nor in going
underground. Our defense is in law and order. ...I do
not believe that we can prepare for war and at the same time
prepare for a world community.. . . Science has brought forth
this danger, but the real problem is in the minds and hearts
of men. We will not change the hearts of other men by
mechanisms, but by changing our hearts and speaking bravely.”
— Prof. ALBERT EINSTEIN, New York Times Magazine.
584 THE LANCET] |
BIRTHS, MARRIAGES, AND DEATHS
foor..19, 1946
On Active Service
` AWARDS
O.B.E.
Wing-Commander C. W. COFFEY, M.R.C.S.
Wing-Commander DONALD MaGRATH, M.B. Birm.
Squadron-Leader R. A. CUMMING, M.B. Aberd..
M.B.E.
Flight- Tisutenant F. A. FORBES, M.B. Aberd.
Flight-Lieutenant Jonn LILLIE, M.B. Belf.
Flight-Lieutenant F. W. Parke, B.M. Dubl.
Flight-Lieutenant F. R. Pumps, M.B. Lond.
Flight-Lieutenant W. N. RILEY, M.R.C.S.
Flight-Lieutenant W. F. TIERNEY, M.B. N.U.I.
Flight-Lieutenant C. B. I. WILLEY, M.C., B.M. Oxfd.
The following have been mentioned in despatches:
R.A.M.O. °
Brigadiers.— J. P. MacNamara, R. R. Bomford, P. Wiles.
Colonels.—R. A. Anderson, 0.B.E., J. D. Driberg, P. J.
Stokes, A. B. Dempsey, R. R. Leaning, O.B.E.
Lieut.-Colonels.—P. H.-R. Anderson, A. J. Dalzell-Ward,
G. T. Ashley, H. L. Ellis, G. J. Evans, P. P. Fox, W. R. N.
Friel, W. G. Garrow, W. H. Graham, K. H. Harper, G. C.
Hernan, M. S. Holman, C. H. Hoskyn, 0.B.£., R. H. Isaac,
K. Kumar, D. A. Lowe, G. G. Mer, 0.B.E., R. S. Ogborn,
R. A. Philp, R. K. Pilcher, m.c., J. R. Squire, H. Stevenson,
J. C. Watts, m.c., A. L. Wilson, I. Calvert-Wilson, T. K.
Howat, H. L. Wolfe.
. Majors —A. M. Hutton, J. C. Coates, A. Colbert, J. O.
Collin, H. W. F. Croft, J. P. Donnel, H. F. Ferguson, A. Gould,
E. J. Harrison, R. G. Henderson, J. Hemphill, N. Leitch,
P. F. Maguire,.A. L. R. Mayer, A. I. McCallum, J. A. McPher-
son, R. Murray, J. O’Hara, N. C. Porter, J. A. Ritchie, W. T.
Walker, M.B.E., G. Wynne- Griffith, K. T. Grey, J. W. Miller,
W. G. Mills. -
Captains.—R. M. Allan, R. F. Antonio, G. D. G. Barnes,
R. H. Bowie, E. G. Dryburgh, R. C. Evans, J. A. S. Forman,
C. R. Forrest, P. Fuchs, J. C. Heskith, K. Heslop, L. P.
Hodgson, N. B. Jones, S. H. Madden, W. D. Mail, P. L. Masters,
S. J. T. Merryfield, C. E. S. Myers, M.B.E., B. A. Protheroe,
I. Reubin, A. C. Ritchie, P. R. Robinson, K. R. Urquhart,
J. A. K. Wallace, G. L. Whitmore, K. W. Andrews, J. W.
Hitchens, F. H. Kelland, G. W. Park, D. H. Rea, A. Smith,
R. B. C. Smith, M. W. Stock, W. T. Stone, S. D. Cuthbertson,
A. Harrop, A. T. Makin.
Lieutenants.—F. Birch, A. E. Davies, H. Harris, A. I.
Hyman, D. I. Jones, J. W. Lewis, G. F. Strickett.
R.A.F.
Squatra- Leader D. A. Duthie.
Flight-Lieutenants.—R. G. Blackledge (deceased), M. H.
Kinmonth, L. C. Liddell, J. Simpson, C. B. I. Willey, m.c.
` I.A.M.C.
Colonels.—F. R. Cawthorn, 0.B.£., B. R. Tandon, Avyak-
tanand, M.B.E., D. R. Cattanach, D. K. L. Lindsay, 0.3.8.
Lieut.-Colonels.—K. M. Unnikrishnan, G. V. Chaphekar,
M.B.E., A. N. De Monte, M.B.E., M.C., G. T. M. Hayes, J. R.
Kerr, D.s.0., W. N. Niblock, J. P. O’Riordan, G. A. Ransome,
F. W. Snedden, G. B. R. Walkey, J. L. M. Whitbread,
B. Bhattacharjya, W. F. J. M. Thom, V. R. Mirajkar.
Majors.—A. H. Vatsyayan, C. R. K. Carroll, A. L. D’Cunha,
C. A. Fegredo, F. M. F. Forrest, M. W. Grunstien, F. G.
Millar, M. G. Hyder, A. C. Molden, N. U. Khan, Pattanath
Shankaran, S. K. Sen, D. S. B. Stephens, U. P. D. Gupta,
E. Watson, J. G. Webb, G. S. Dhaliwal, K. L. Chittwal,
J. J. D. Lobo, A. S. Reilly, J. H. York. .
Captains aya K. Bose, B. S. Dhillon, B. N. Chatterjee,
B. N. Bali, Brindaban Bakhshi, C. M. Patnaik, C. K. Kurup,
C. J. David, C. L. Bahl, V. N. Datar, G. W. D’Sena, D. H.
Biswas, G. S. Godiwalla, M. R. G. Aratham, K. Govindarajulu,
H. K. Ray, H. B. Parelwali, Husain Reza, J. M. Bose,
K. V. G. Kurup, Mohindar Sinjh, Monoranjan Dutt, Mvu
Raja, C. P. Nair, M.B.E., N. M. Maitra, Nezamuddin Talukdar,
N. S. Ahluwalia, C. M. Patnaik, J. M. Pinto, P. P. Ramadivi,
R. N. Dutta, S. P. Ghose, Sarju Prasad, S. K. Mazumdar,
Swwan Sinjh, R. M. S. Terry, Thekkepat Karunakaran,
P.. S. Bhat, B. R. Chaudhuri, D. B. Patnaik, C. R. Peck,
Prem Chandra, Rangaraj, N. N. Santhanam, Shrivastava,
T. R. Sibramanian, A. K. Mitra.
Lieutenants.—I. A. Khan, J. N. Ghosh, S. J. Mascarenhas.
INFEG PIOUS DISEASE IN ENGLAND AND WALES
WEEK ENDED OCT. 5
Notifications. —Smallpox, 0;
whooping-cough, 1311 ;
20; typhoid, 11;
scarlet ‘fever, 1079 ; ;
diphtheria, 319 ; paratyphoid,
measles (excluding rubella), 1781 ;
pneumonia, (primary or influenzal), 411; cerebrospinal
fever, 32; poliomyelitis, 23; polio-encephalitis, 2;
encephalitis lethargica, 2; dysentery, 63; puerperal
pyrexia, 163 ; ophthalmia neonatorum, 80. No case of
cholera, plague, or typhus was notified during the week.
The number of service and civilian sick in the Infectious Hospitals
of the London County Council on Oct. 2 was 839. During the previous
week the following | cases were admitted: scarlet Tovor, 56; diph-
theria, 28; measles, 17; whooping-cough, 26.
Deaths.—In 126 great towns there were no deaths
from scarlet fever, 2 (0) from enteric fevers, 2 (0)
from measles, 12 (3) from whooping-cough, 5 (0) from
diphtheria, 39 (3) from diarrhoea and enteritis under
two years, and 7 (1) from influenza. The figures in
parentheses are those for London itself. `
Leeds and Oldham each reported 1 death from an satanic fever.
Liverpool had 7 fatal cases of diarrheea and enteritis.
The number of stillbirths notified during the week was
253 (corresponding to a rate of 26 per thousand total
Paes including 33 in London.
_ Births, Marriages, ane Deaths
BIRTHS
PEU rrr ee 11, the wife of Mr. A. C. Bell, F.R.C.8., F. R.C.0.G.—
a da
BURKITT. On. Oct. 7, the wife of Dr. Eric Burkitt, of Wimbledon—
a son.
DENT.—On Oct. 4, the wife of Dr. Charles Dent—a daugh
ter.
HALLPIKE.—On Oct. 6, in London, the wife of Dr. C. S8. Hallpike— é
a son
HART. —On Oct. 3, Dr. Bridget Hart ee Egan), the wife of Dr.
J. A. G. Hart, of Londonderry—a s
HaRWARD.—On Oct. 7, at Odiham, Hants, the wife of Dr. R. L.
Harward—a son.
Hick.—On vee 8, at Chippenham, the wife of Dr. A. P. Hick—a son.
LEIGH. ee ct. 5, at Romsey, the wife of Dr. R. E. Derek Leigh
a so l
MITCHELL, On Sept. 25, in London, the wife of Dr. Herbert Mitchell
—twin sons.
MOLESWORTH.—-On Oct. 7, at St. Albans, the wife of Dr. David
Molesworth—a s
Moncey: ae Oct. 6, at Southborough, the wite of Dr.C. R. Morgan
MOSEL. OD Oct. 5, at Carlisle, the wife of Dr. A. Moselhi—a
a
MoYNAGH. On Oct. 4, at Bristol, the wife of Dr. Kenneth Moynaghb
NOBLE. On Oct. 3, the wife of Dr. Andrew Nobles: Stonehaven
RENATY. —On 0 Oct. 9, in London, the wife of Dr. M. c. T. -Reily—
a da
SCADDING. —On Oct. 12, in London, the wife of Dr. J. G. Scadding
—a daughter.
SCHOFIELD.—On ‘Oct. 4, at Harpenden, the wife of Dr. Theodore
T. Schofleld—a son
SMYTH.—On Sept. 28, at Dublin, the wife of Lieut. Colonel S. Smyth,
I.M.S.—a 80N.
Wootr.—On Oct. 5, at Edinburgh, Dr. Cecil Mary Drillien, wife of
Mr. Barnet Woolf—a daughter.
MARRIAGES
CALDER—HERRIOT.—On Oct. 1, at Glasgow, Francis Robert Murray
Calder, M.B., to Janet wiliteon Herriot, M.B., captain R.A.M.C.
KonsTaAM—RITCHTE. —On Oct. 12, at Alford, Aberdeenshire,
Peter G. Konstam, F.R.C.S.E., lieutenant R.A.M.C., to ‘Sheila
T. Ritchie, M.B.
_ O’NEILL—PEARSON.—On Sept. 30, in London, Desmond Francis
O’Neill, M.c., M.B., to Ruth Mary Pearson
RocHE—HARDY. >On’ Oct. 4, in London, James Wallace Roche,
M.B., to Margaret Joan Hardy.
WALTON-—TRUMP. —On
Walton, surgeon lieut.-cominander R.N.Z.N.V.R., tO Barbara
Trump.
DEATHS
BaKER.—On Oct. 10, Arthur Ernest Baker, M.R.O.8.,.L.D.8.; of
Bromley, Kent, aged 83.
BEARD. er Oct. 12, at Epsom, Frederic Beard, M.B. Camb.,
age
Briccs.—On Oct. 7, at Wigston, Christopher Duffield Briggs, M.R.c.S.
HARDWICK SMITH. —On Oct. 6, at Wellington, New Zealand, H Henry
Hardwick Smith, F.R.C.8.
HaRVEY.—On Oct. 7 Wiloughby Henwood Harvey, M.A. Camb.,
M.D. Toronto, of Cambridge, aged 65.
J ACB TON rO Oct. 8, Henry Beecher Jackson, M.A. Camb., M.R.C. S.,
aged 67
MYERS.—On Oct. 12, Charles Samuel Myers, c. B.E., M.D., SC.D.
Camb., F.R.S., of Minehead, aged 73.
Rreron.—On Oct. 4, in London, Thomas Stanley Rippon, 0.B.F.,
M.R.C.8., late wing- commander R.A.F
RoysTon.—On Oct. 6, at Moordown, Bournemouth, Charles James
Royston, M.B. Aberd. ‚aged 46.
Sept. 21, at Salcombe Regis, Richard .
THE LANCET]
Notes and News
NURSERY WORKERS IN SCOTLAND
To ensure a sufficient supply of properly trained workers
in nurseries, nursery schools, and children’s homes, Mr. Joseph
Westwood, Secretary of State for Scotland, has decided to -
institute a new course for a nursery nurses’ certificate to be
` awarded to girls in nurseries of all types who have followed
a course of practical and theoretical training and have passed
an examination conducted by a Nursery Nurses Examination
Board which has just been set up. The course, details of which
will be announced later, will cover two years, and will include
practical work and training in nurseries or nursery schools,
and vocational study and general education. The age-limits
will be 15-25 at the start of training, and candidates will
probably be required to have completed three years in a
secondary school, and to serve for a probationary period
before being accepted. The written part of the first examina-
tion by the board—to be taken by girls already in training—
will be held on Nov. 16, and the oral and practical part on
Dec. 3, 1946.
FOR CHILDREN AT TROGEN
THE Swiss exhibition of planning and building now open
at the Royal Institute of British Architects, 66, Portland
Place, London, W.1, illustrates a pleasant contribution to
international understanding in the section of child welfare
and youth service. This is the Pestalozzi children’s hamlet
at Trogen, Appenzell, where houses have been built on a lovely
hillside to receive children of various nations. Building is
not yet completed, but in each house 16 homeless children of
both sexes, ranging in age from 3 to 15, will live with foster
parents, and some 400 children will be given something like
a normal home life for several years. Groups of houses will
be occupied by children of one nationality, speaking their
own language and keeping their national character, but each
group will take part in the central organisation—an inter-
national community of children.
The hamlet is voluntarily financed, and school-children
and students from Switzerlagj, France, Holland, and Austria
have volunteered to help in building it. The Swiss had much
experience during the war in dealing with tens of thousands
of refugee children; the hamlet is therefore being founded
under happy auspices.
MEDICAL AND DENTAL DEFENCE UNION OF
SCOTLAND
THE membership of this union has in the past year increased
by 279 to a total of 5742. The surplus on the year’s working
was £727, and the total surplus of assets over liabilities now
amounts to £35,048. The union has still further strengthened
its position notwithstanding the loss of revenue through the
waiving of subscriptions from members in the Forces, who
numbered 1883 at the beginning of the financial year. These
figures are given in the annual report, which also contains
this advice to a member threatened with a claim: (1) to
report all the facts to the secretary, and send copies of all
records of treatment ; (2) to obtain and forward any relevant
hospital, X-ray, and other reports; (3) to make no statement .
which might later be construed as an admission of liability ;
(4) to send to the secretary, without replying to them, any
letters received from patients or their agents in connexion
with the case; and (5) not to divulge that he or she is a
member of a defence union.
University of Cambridge
Titles of degrees were conferred on the following during the
months of August and September :
M.B., B.Chir.—R. S. J. Pouer, H. F. Barnes, K. A. C. Bowen,
J. E. G. Brieger, F. M. Fountain, J. F. Grant, M. C. Hare, M. Hobson,
P. A. Howard, E. G. Howe, G. M. Hunt, H. M. J. Lawn, B. M. Leach,
J. Raymond, A. M. Sibly.
University of Sheffield
Dr. R. S. Illingworth has been appointed full-time professor
in charge of the new department of child health. It is expected
that Dr. Illingworth, who is now assistant to the Nuffield
professor of child health in the University of London, will take
up his duties in the New Year.
Dr. A. R. Kelsall and Dr. J. Pemberton have been ae ca
full-time lecturers in medicine.
British Social Hygiene Council
Dr. Fred Grundy, medical officer of health for Luton, has
been appointed chairman of the executive committee in the
place of the late Dr. Otto May.
NOTES AND NEWS
[ocr. 19, 1946 585
Royal College of Surgeons of England
A quarterly meeting of the council was held on Oct. 10,
with Sir Alfred Webb-Johnson, the president, in the chair.
Mr. J. P. H. Davies, of Lewes County School, was admitted as
a Macloghlin scholar. Dr. R. J. Last and Mr. H.. F. Lunn
were appointed anatomical curators.
The council decided to hold an additional primary fellow-
ship examination in January, and an additional final fellow-
ship examination in February, 1947.
Diplomas of membership were granted to P. T. Ballantyne,
Hans Dasch, and D. A. Richards.
Diplomas were granted jointly with the Royal College of
Physicians to the following candidates :
D.T.M. & H.—C. G. Bree, D. J. Conway, Madjdeddine Mir-
Fakhrai, S. T. Nakib, C. J. A. O’Kelly, A. Me Woodruff.
D.O.M.S.—Svlomon Abel, H. Y. Bakre, P..B. Banaji, Edgar
Benjacar, W. M. de C. Boxill, Mary Campbell, Prem Chandra,
D. G. Cracknell, R. P. Crick, P. pe Day, D. W. Degazon, K. J. L.
de Silva, k. F. J. Dunlop, J J. Freeman, A. I. Friedmann,
J. G. Gillan, Irene D. R. ees Cc. D: Gun-Munro, K. J. Higham,
J. J. Kennedy, Marian Lones, Edward Lyons, R. L. McKernan,
J. M. Mallett, R. M. Mathers, R. C. E. Motfat, Louis Mushin,
J. M. G. Nixon, G. N. Pattison, A. J. G. eee K. B. Redmond,
H. N. Reed, Edward Riley, C. C. Ring, J. A. Robertson, M. J.
Roper-Halli, B. L. N. S. Sack, John Smaiipiece, Helen S. C. Smith,
A. H. Staples, R. W. Stephenson, Charles Swanston, H. J R.
Thorne, C. R. Todd, H. J. Wales, E. P. Walsh, J. J. Walsh, W. F.
Walton.
D.C.H.—Daphnue S. A. Anderson, D. C. Arnott, Katharine M. D.
Bailey, C. L. Balf, A. C. Blandy, Andrew Bogdanovitch, P. T. Bray,
Lorna M. Brierley, Marion Brown, F. R. Buckler, A. B. Buckwold,
D. J. Conway, N. J. Cook, Pamela J. Coope, Janet E. W. Copland,
P. J. N. Cox, W. H. Craike, Rosemary Davies, Walter Dickson,
J. H. Diggle, Margaret. 1). D. Dudley-Brown, Vera S. Emanuel,
G. A. Emmerson, Ethel R. Emslie, Linde B. U. owad Roth M.
Fawcett, A. A. H. Gailey, W. H. Galloway, R. E. Glennie, S. G.
Hamilton, J. D. L. Hansen, E. W. Hart, Denise O. ‘Henry, Isabella
Hood, A. M. Jelliffe, Marion E. Jepson, C. C. Joannides, A. O. John,
Cyril Josephs, Nest Kahan, Gwendoline M. E. Keevil, Elizabeth M.
Kingsley Pillers, Kathleen M. Lane, Margaret J. Lezemn, H. A.
Leggett, K. R. Llewellin, Muriel J. Lowe, Patrick Macarthur,
Alison D. McDonald, N. R. McEvoy, Mary S. McGladdery, Bessie R.
Mackenzie, Douglas McLean, Antoinette M. H. MacMahon, W. J.
Matheson, J. B. Mehta, E. W. Miles, Mary reece aoa Enid E.
Mitchell, Lucille M. Morgan, J. M. Mounsey, Agnes D. D. Murray,
P. J. O'Reilly, B. D. Patel, S. H. Patel, Jean W. Paul, J. 0. Pickup,
E. M. Poulton, P. J. Preston, Ruth Prothero, L. B. Robinson,
Sutcliffe Ruttle, Gwladys M. Sewart, Mary D. H. Sheridan,
Katherine V. Smith, Helen M. Wagstatfe, H. R. E. Wallis, L. L. R.
White, T. K. Whitmore.
D. Phys. Med.—J. H. Crosland, C. R. L. Orme, J. D. Stewart.
Scottish Universities By-election
Colonel Walter Elliot, F.R.C.P., F.R.S., will stand as Unionist
candidate in the forthcoming election caused by Sir John Orr’s
resignation. Colonel Elliot, who is a graduate of Glasgow
University, has been Minister of Agriculture (1932-36),
Secretary of State for Scotland (1936-38), and Minister of
Health (1938-40).
ed for the Relief of Widows and Orphans of Medical
en -7
At a meeting of the court of directors held on Oct. 9, with
Dr. R. A. Young, the president, in the chair, it was stated
that in the last half year £1940 had been given to widows in
relief. Membership of the society is open to any registered
medical man living within twenty miles of Charing Cross.
Full particulars may be had from the secretary, 1l, Chandos
Street, London, W.1.
Empire Rheumatism Council
Mr. Aneurin Bevan and Lord Horder will receive the
guests at the reception which is to be held at the Apothecaries’
Hall, Black Friars Lane, London, E.C.4, on Monday, Oct. 28,
at 4 P.M., to celebrate the tenth anniversary of the foundation
of the council. The guests of honour will be Mr. M. G. B.
Prytz, the Swedish minister, Prof. J. A. Höjer, chief medical |
officer of the Royal Swedish health departmont, and his
` deputy, Dr. B. Strandell, and Dr. Loring T. wa, of the
American Rheumatism Association.
Family Allowances
That family allowances are intended to assist in improving
the standard of health of the most needy section of the
community and must therefore not be reduced for any reason,
was the view expressed by the council of the Socialist Medical
Association at their recent meeting. At present those receiving
special allowances for tuberculosis, workmen’s compensa-
tion, and other contingencies are liable to-have their total
income cut by the amount of the family allowance, robbing
the latter of all the beneficial effects it was intended to have.
The association supports the strong protests being made and
asks that family allowances be given as a right and without
any reference to the total income.
586 THE LANCET]
Biochemical Society
A joint discussion on Quantitative Biochemical] Analysis by
Microbiological Response will be, held by the Biochemical
Society and the Society for General Microbiology at the
London School of Hygiene, Keppel Street, London, W.C.1,
on Saturday, Nov. 2, at 11.15 a.m.
Course on Diseases of the Chest
A course of lectures and demonstrations will be held at
the London Chest Hospital, Victoria Park, E.2, on Fridays
at 5 P.M., from November till March. Those to be given
this year are: Nov. 1, Dr. S. Roodhouse Gloyne, Industrial
Diseases of the Lung; Nov. 8, Mr. S. C. Suggit, Carcinoma of
the Larynx and Pharynx;. Nov. 15, Dr. Shirley Smith, the
Heart in Pulmonary Disease; Nov. 22, Mr. Holmes Sellors,
Surgery of the Heart; Nov. 29, Dr. J. R. B. Hern, Asthma ;
Dec. 6, Dr. Browning Alexander, Consideration of Diagnosis
and Treatment of Lung Abscess ; ‘Dec. 13, Dr. Franklin Wood,
Recent. Advances in the Radiology of Lungs.
Field Marshal Montgomery on Morale
The Lloyd Roberts lecture will be delivered at the Royal
Society of Medicine on Monday, Oct. 28, at 3 P.M., by
Field Marshal Viscount Montgomery. His ‘subject is to be
Morale, with Particular Reference to the British Soldier.
At a scientific reunion of the Société Internationale de
Chirurgie Orthopédique et de Traumatologie in Brussels on
Oct. 3 and 4, Prof. Louis Ombrédanne was re-elected president,
and Dr. Jean Delchef secretary-general; Prof. Harry Platt
and Dr. San Ricart were elected vice-presidents; and Dr.
Henry Meyerding, of the Mayo Clinic, was elected president
of the next congress, which will be held in Amsterdam in
September, 1948.
Medical Diary
ocr. 20 To 26
Monday, 21st l
ROYAL T OTEEOR OF SURGEONS OF ENGLAND, Lincoln’s Inn Fields,
5 P.M. Prof. Harry Platt: Localised Cystic Disease of Bone.
Tuesday, 22nd
ROYAL COLLEGE OF SURGEONS OF ENGLAND
5 P.M. Pee Geoffrey Keynes: Surgery of the Anterlor Medias-
inum. .
ROYAL SOCIETY OF MEDICINE, 1, Wimpole Street, W.1
5P.M. Medicine. Dr. Maurice Davidson : J udgment in Medicine.
(Presidential address.)
LONDON SCHOOL OF DERMATOLOGY, 5, Lisle Street, W.C.2
5 P.M. Dr. W. J. O'Donovan: Psychosomatic Dermatoscs.
Wednesday, 23rd
ROYAL COLLEGE OF SURGEONS OF ENGLAND
5 P.M. Mr. A. C. Palmer: Atiology, Symptoms, and Treatment
of Procidentia.
ROYAL SOCIETY OF MEDIOINE
5.30 P.M. Endocrinology. Mr. L. R. Broster, Dr. E. F. Scowen,
Dr. F. L. Warren: Over-activity of the Adrenal Cortex.
RESEARCH DEFENCE SOCIETY
3.15 P.M. (26, Portland Place, W.1.) Prof. N. Hamilton Fairley
F.R.S.: War-time Research in Malaria and other T Tropical
Diseases of Military Significance. (Stephen Paget lecture.)
Thursday, 24th
ROYAL COLLEGE OF SURGEONS OF ENGLAND
5 P.M. Mr. W. B. Gabriel: Causation and Treatment of Anal
Incontinence.
ROYAL SOCIETY OF MEDICINE
8 P.M. Urology. Mr. R. H. O. B. Robinson : Problems of oan
Lithiasis. (Presidential address.)
LONDON SCHOOL OF DERMATOLOGY
5 P.M.. Dr. G. Duckworth: Virus Diseases of the Skin.
MEDICO-LEGAL SOCIETY
8.15 P.M. (26, Portland Piace, W.1.) Mr. L. Le Marchant Minty,
PH.D.: Legal Aid to Assisted Persons.
Friday, 25th
ROYAL COLLEGE OF SURGEONS OF ENGLAND
5P.M. Mr. R.C. Brock: Surgery of Lung Abscess.
Roya. SOCIETY OF MEDICINE —
2.30 P.M. Epidemiology and State Medicine.
Kennedy, Colonel Horsburgh, Colonel H. A. Raeburn:
Health Problems in Germany.
5 P.M. Padiatrics. Professor Debono: Kala-azar in Infancy.
ROYAL MEDICAL SOCIETY, 7, Melbourne Place, Edinburgh
8 P.M. aor puptra P. H. Mitchiner : Aftermath Sot War in
Ledicine
Saturday, 26th
MEDICAL SOCIETY FOR THE STUDY OF VENEREAL Diseases, 11,
Chandos Street, W.1
2.30 P.M. Dr. F. R. Curtis:
Germany.
Brigadier Tom
Venereal Disease in Occupied
MEDICAL DIARY
- HARTLEY, J
—_—
[oce. 19, 1946
Appointments -
Govan, A. D. T., M.B. Glasg., PH.D. Birm., F.R.F.P.S: : : director of
research, Glasgow Royal Maternity and Women’s Hospital.
GRIERSON, A. M. M., M.B. Edin., D.P.H.: deputy medical officer of
health, City of Manchester.
. B., M.D. Durh., F.F.R., D.M.R.E.: radiologist (diag-
nostic department), Christie Hospital ana Holt Radium
Institute, Manchester.
LINDABL, J. W. S. H., M.cHIR. Camb., F.R.C.8. : second laryngologist,
King Edward Memorial Hospital,
MAIN, T. F., M.D. Durh., D.P.M.: medical director Caneel Hospital
for Funen onal Nervous Disorders, Stoke-on-Tren
PEROIVAL, R. C., F.R.C.8., M.R.0.0.G. : gynecological surgeon, King
George Hospital, liford.
WaRIN, J. F., M.D. Leeds, D.P.H. : | deputy medical officer of health,
City of Leeds.
Guy’s Hospital, London :
BAKER, C. G., 0.B.E., M.D. Lond., M.R.C.P. : assistant physician.
PLACE BURN, GUY, M.B.E., M.CHIR. Camb., F.R.C.8.: assistant
surgeon
Crisp, E. J., M.B. Camb. : physician in charge of odid
D department. surgical registrar.
REW, F.R.C.8. 2 ca P
Evans, P. R. C., M.D., M.80. Lond., F.R.C.P.: director of tbe
department of child health and physician to children’s
department., 5
Hus, T. H., M.B. Lond., D.M.R.E.: director of department of
surgical registrar.
diagnostic radiology.
HORTON, R. E., M.B. Lond. :
KENSHOLE, H. H., D.S.O., T. D., M.R.C.8., L.D.S. $ assistant dental
surgeon.
-KESSON, C. W., M.R.C.P. : children’ s registrar. .
F.R.C.8.: surgical registrar.
LILWALL, B. G. A.,
NICHOLAS, C. P., F. R.C.8. : surgical registrar. `
PRINGLE, K. E., L.D.8. R. 0.8. : assistant dental surgeon in child-
ren’s department.
obstetric registrar,
RIPMAN, H. A., M.B. Lond., D.R.0.0.G. :
- Royal Waterloo Hospital Tor Children and Women:
ANSON, B., M.R.C.S., D.A.: ansesthetist. .
ARMSTRONG, J. R., F.R. C.3.: orthopredic surgeon.
Baynes, T. L. S., "M.D. Lond., F.R.C.8.; gyneecological registrar.
BLACKBURN, F. H., M.B. Durh., M.R.C.8., D.A.: ansesthetist.
BLOOM, Ross, F.R.C.8&. surgical registrar.
BRADDON, I. G., M.R. C.8., D.A.: anesesthetist.
EXNER, G., L.D.S. R.C.8. dental surgeon.-
LANCKENAU, N. I., M.D. ‘Lond. : physician in charge of physical
medicine.
MYERS, G., F.R.C.S.: surgical registrar.
SPIERS, B. G., F.R. C.S., M.R.C.0.G. : gynæcological registrar.
WIGODER, L., M.B. Dubl., M.D.S., : dental surgeon,
Royal Sussex County ee
ALLEN, T. S., F.R.C.8.E. : ear, ose: and throat surgeon.
BINNING, REX, M.R.C.S. : _ anesthetist.
BOURNE, W. A., M.D. Camb., M.R.C.P.: physician.
CRAWFORD, J. H., M.R.C.S8. : anesthetist.
DOWNER. H. G. .» M.B. Melb., D.L.0.: ear, nose, and throat surgeon.
FORRESTER-W0o0D, W. R., F.R.C. 8. surgeon. -
FRASER, G. A., M.B. Edin., D.L.O. : assistant ear, nose, and throat
surgeon.
JONES, E. C., M.B. Lond., M.R.C.S.: assistant dermatologist.
McCurricgu, H. J., M.S. Lond., F.R.C.S., M.R.C.0.G, : surgeon.
MCGREGOR, H. G., M.D. Lond., M.R.c.P.: physician.
MILLINGTON, E., M.R.C.S., D.M.R.: radiotherapist, `
PRICE, R. K., M.D. Lond., M.R.C.P. : physician.
WATT, A. W., M.B. Glasg., D.P.M.: psychiatrist.
WAUCHOPE, GLADYS M. -» M.D. Lond., F.R.C.P. consulting
physician.
WILLIAMSON, J. C. F. L., F.R.c.8., M.D. Camb. : assistant surgeon.
Warwickshire Hospitals Council:
BERRILL, T. H., M.B. Brist., F.R.C.8.: visiting general surge
WATSON, A. J. M.B. Lond., F.R.C.B. : director ‘of Socldent. ‘and
fracture services.
Oldham Royal Infirmary
DAVIES, J. H. T., M.B. re :
HESsSLOP, J. F., M.B. Menc., F.R.C.S.
surgeon.
/
visiting dermatologist. E
visiting genito-urinary
JELLY, G. O., B.M. Oxfd, M.R.C.P., F.R.C.8.: visiting surgeon.
KENYON, A. L., B.SC., M.B. Mano. “» F.R.C.8.: visiting surgeon.
MURRAY, A. R., M.B. Edin., F.R.C.8. : first assistant to orthopsedio
and accident service.
NICHOLSON, W. F., M.A., M.D., M.CHIR. Camb., F.R.C.8.: Visiting
thoracic surgeon. 2
NISH, J. N., M.B. Melb., F.R.C.S. : orthopædic surgeon.
RACKER, D. C., M.B. Manc., M.R.C.0.G., F.R.C.8.E.: Visiting
gynæcologist. l
RICHARDSON, A. H., O.B.E., M.R.C.S., D.M.R.: visiting radiologist.
SMITH, V. T., M.D. Manc., F.R.F.P.8.: visiting ear, nose, and
throat surgeon.
SYKES, R., B.SC., M.D. Lond., M.R.C.P.
visiting physician.
TAYLOR, W. V., M.B. Lond., D.M.R. :
arolstant radiologist.
` Swansea General and Eye Hospital:
BowEN, J. G., M.B. Lond., F.R.C.8.: assistant surgeon.
BOLTE; i H., H.D.D. & L.D.S. Glasg., H.D.D. Edin.: surgeon
: aenvulst. :
CELLAN-JONES, C. J., M.D. Durh., F.R.C.S.E. surgeon.
DAVIES, V. J., M.D. Lond., F.R.C.3.E., E : gynæcologist.
Evans, I. Q., F.R.C.S.E. : assistant surgeon
HOWELL, H. W., M.D. Lond., M.R.C. P.: assistant physician.
JONES, D. S., L.M.S.S.A., D.A. anesthetist.
JONES, G.-W., M.K.C.S. ‘ assistant radiologist. \
JONES, W. H., M.B. Wales: anesthetist.
MACLEAN, W., M.D. Manitoba, F.R.C.S.E.: surgeon,
MORGAN, J. ©., L.D.8. R.C.S. surgeon. dentist.
. C ds
TANNER, C. H., M.B. Lond., F.R.C.S.: assistant surgeon.
J gs. Lond., F.R.C.8., 'F.R.O.8.E. ; assistant gyneæ-
G D e a = * aiaa e E
A A a n E a Re
As
THE LANCET]
ee
CORONARY DISEASE
THE HARVEIAN ORATION OF 1946*
Sir MAURICE CASSIDY
K.C.V.O., C.B., M.D. Camb., F.R.C.P.
PHYSICIAN TO H.M. THE KING ; CONSULTING PHYSICIAN
TO ST. THOMAS’S HOSPITAL, LONDON
é
HARVEY was one of the first, and perhaps the most
famous, of the experimental physiologists ; certainly he
is the most venerated. Even after the lapse of three
hundred years our admiration for his genius is mingled
-with affection engendered by the many endearing facets
-of his character. His operative technique was of necessity
-somewhat crude. For instance, in the introduction to
De Motu Cordis he refers to Galen’s experiment :
“ An artery having been exposed is opened longitudinally
. and a reed, or other pervious tube, is inserted into the vessel
through the opening, and the wound is closed.”
Harvey comments :
“ I have never performed this experiment of Galen, nor
do I think it could very well be performed in the living
body, on account of the profuse flow of blood that would
take place from the vessel which was operated on.”
In the second disquisition to Riolan, however, Harvey
-describes the performance of this operation and notes
obscure pulsation of the artery distal to the ‘* pervious
tube,” and that blood escapes in spurts from this distal
portion on section of it. But he goes on to lament that
“t the effusion of blood from the wound confuses every-
‘thing, and renders the whole experiment unsatisfactory
and nugatory.” When watching Dr. Crafoord, of
Stockholm, excise an aortic coarctation, and perform
the almost incredible feat of effecting an end-to-end
-anastomosis of the thoracic aorta above and below the
-coarctation (Crafoord and Nylin 1945), I thought how
-delighted Harvey would have been with this triumph of
modern surgery. He would also have shared with us our
admiration of the skill which enables the surgeon of
‘today to undertake the ligation of the patent ductus
arteriosus with little more trepidation than before
‘appendicectomy. He would have joined with us in
‘congratulating Blalock, who successfully anastomoses the
‘innominate or the subclavian artery with the right or
left pulmonary artery (Blalock and Taussig 1945), and thus
‘relieves some of the inconveniences of Fallot’s tetralogy.
= Harvey would surely have appreciated splanchnic
sympathetic resection as an interesting physiological
experiment, and would, like us, have been delighted to
‘hear that the extensive lumbodorsal splanchnic resection
- devised by Smithwick (1944) can rob essential hyperten-
‘sion of much of its terror, for some years at any rate.
But perhaps Harvey’s admiration would be tinged with
.a little not unnatural envy were be to witness the work of
“his successors in the field of experimental animal surgery
—the work, for instance, of Murray, Wilkinson, and
Macgregor (1938), of Toronto, who excise a portion of
the mitral valve and repair it with a strip of external
jugular vein, with complete recovery of the animal.
What would Harvey have thought of Cutler’s cardio-
‘valvulotome, or of cardiac endoscopy as practised by
Harken and Glidden (1943)? —
before long the surgical treatment of valvular stenosis in
man will become a justifiable and successful operation ?
I have to confess that I have had neither the
opportunity nor the aptitude to obey Harvey’s injunction
“* to search and study out the secrets of nature by way of
experiment,” except so far as every clinician experiments
in a desultory sort of way in respect of treatment. But
at last we physicians are beginning to recognise the value
-of controlled, as opposed to haphazard, experimental
treatment. The brilliant results of the treatment of
bacterial endocarditis with penicillin under the egis of
T ee a a ee et
s cake AAT before the Royal College of Physicians of London on
c . ry : O y S i
6426
ORIGINAL ARTICLES
Who can doubt that
f g *
af dl ty
ee ee o RY
EO cnet hig wee
S lu OLN nee Vibe r
> IGWA ` Toor. 26, 1946
Prof. R. V. Christie and his committee would not have
been achieved so quickly or so successfully on the old
haphazard lines. l ni
PREVALENCE OF CORONARY DISEASE
For many years I have been especially interested in
cardiology, and I have been impressed, like many others,
by the increasing prevalence of coronary disease. Even
during so short a period as the last twenty years this
increasing prevalence seems to be beyond question. In
the year 1926, 64,465 persons died in this country of all
forms of heart disease.. Ten years later this number was
almost doubled, 126,584 to be exact. The figures-for
coronary disease are even more startling: 1880 died
in 1926; 14,095 in 1936; and 19,496 in 1939. The
crude death-rate from all causes per 1000 persons
living fell from 22 in the decade 1851-60 to 12 in 1930,
and has subsequently remained almost stationary at
about that figure. The similar crude death-rate from
heart disease, and particularly from coronary disease,
has risen in a spectacular fashion during this period,
especially during the last twenty years. Jn the case of
coronary disease the figures increase rapidly year by year :
48 per million living in 1926; 148 in 1930 ; 473 in 1939.
Part of this rapidly increasing death-rate from coronary
disease is no doubt attributable to the increasing age of
the population. In 1900 there were 1,750,000 persons
over 65 years of age in Great Britain ; in 1937 there were
over 3,750,000 (Dudley Committee 1944). It is true that
the standardised death-rate, corrected for ageing, for
policy holders of the Metropolitan Life Insurance Com-
pany (1946), of New York, shows a 70% decline for
diseases of heart, arteries, and kidneys in 1940—45 com-
pared with 1911-15. But this astonishing decline in
mortality is for ages 1-74. When the figures for the
different age-groups are examined, it is clear that the
improved mortality affects chiefly persons up to the age
of 25, and is no doubt attributable, in part at least, to
more efficient treatment of the acute infections which are
largely responsible for cardiovascular and renal deaths
in this lower age-group. Between the ages 35 and 64 the
standardised mortality among men shows little or no
decline in the past two decades, and there is in fact an |
increased mortality now compared with the level reached
in the early nineteen-twenties. |
The crude death-rates in America, without correction |
for increasing age of population, have increased as they
bave done in this country ; thirty-five years ago cardio-
vascular diseases accounted for less than a quarter of all,
deaths. Now they account for nearly half.
Part of this mounting coronary mortality has been
ascribed by some to increasing accuracy of certification.
But I cannot believe that increasing accuracy of certi-
fication can play a very important part. The position
here is very different from that in such a disease as
bronchial carcinoma, for example, where accurate
diagnosis largely depends on refinements of investigation,
such as are afforded by bronchoscopy and radiography.
Angina pectoris is one of the easiest of all diseases to —
recognise. Its clinical features have been well known to
every doctor since Heberden recounted them before this
college in 1768. In most cases of angina pectoris
electrocardiographic and radiographic investigations are.
superfluous aids to diagnosis. — ;
Certainly the clinical recognition of coronary throm-
bosis has till recently been hidden from us. Though first
well described clinically by Herrick (1912), its diagnosis
did not become widespread in America till about 1920.
Curiously enough. it was not until 1925 that McNee
brought to the notice of physicians in this country the
clinical picture of coronary thrombosis as first described
by the American cardiologists, and the rapid increase in
the certification of deaths from coronary thrombosis
since that date must be partly attributable to this. Even
so, I have the impression that coronary thrombosis is
R
588 THE LANCET]
far more prevalent than it was. . Looking through my
notes of patients seen twenty or thirty years ago, I come
across occasional cases where I failed to recognise the
coronary thrombosis, which now, on paper, is the obvious
diagnosis. But such cases are surprisingly few. It is
interesting to read now Janies Mackenzie’s notes of
case 112, one of the 160 case-records in his book on
Angina Pectoris (1923). He describes this as ‘‘ one of the
most puzzling cases I have met.” It is now evident to
‘us that this patient had at least two attacks of coronary
infarction, the second associated with pericardial friction,
and that six months later the consequent myocardial
degeneration brought on three attacks of acute pulmonary
codema, the last fatal.
It is odd, too, that coronary thrombosis figures so seldom
in the post-mortem reports of thirty years ago, despite
the fact that the very astute morbid anatomists of those
days were fully alive to the existence of this condition.
Consider, too, the clinical experience of great physicians
of the past. Mackenzie (1923) states that “ 380 patients
consulted me for angina pectoris.” Osler (1910) says:
“ It is a disease for seniors to discuss, since juniors see
it but rarely ; indeed I had reached the Fellowship before
I saw a case in hospital or in private practice. During ten
years I did not see a case at the Montreal General Hospital,
and only one case at the University Hospital, Philadelphia... .
A consultant in active practice may see 10, 15, or more
cases in the course of a year, and this is about the figure
reached in this country by a consultant with recognised
cardiovascular leanings.” -
He goes on to say that he has now seen 268 cases,
which included 42 “of the mild neurotic or pseudo
form.” Contrast these figures with those of the modern
cardiologist, who counts his coronary patients by
thousands rather than by hundreds, and remember. that
there was but one James Mackenzie, and one William
Osler, whereas the modern cardiologist’s name is legion !
During the ten years 1898-1908 Sir Richard Douglas
Powell (1909) saw 96 cases. of angina, 26 of which he
classified as vasomotor angina. Surely Osler, Mackenzie,
and Douglas Powell were at least as competent to diagnose
angina pectoris as are physicians of this generation.
1
DIAGNOSIS
, What is the explanation of the increasing prevalence
of coronary disease? In an attempt, and I confess at
once a vain one, to find some answer to this question I
have analysed the notes of 1000 cases of coronary disease,
including both coronary occlusion and angina pectoris, seen
in consulting practice. I have notes of approximately
another 1000 cases which I have not analysed. I was
careful to include only those cases where I was reasonably
certain that coronary disease was present. And here
may I put in a plea for the abandonment of such terms as
angina minor, angina innocens, and (worst of all) pseudo-
angina? Wither the patient has angina—or he has not.
If he has, we believe that some portion of his myocardium
is ischemic, usually as a result of coronary atherosclerosis,
with or without a coronary thrombosis or a subintimal
hematoma. Syphilis is a rare cause of true anginal pain,
and embolism a rarer cause still. A severe anemia may
‘play a part, probably in association with some degree of
coronary atherosclerosis, for I have never seen a severe
angemia cause angina in a young subject, though this
happens commonly in the more elderly. Alastair Hunter
(1946), however, has described 12 cases of anemic angina,
of which 10 were in women, and 5 in persons aged 40 or
less, the youngest being 31, which certainly suggests that
anzmia alone may cause anginal pain.
Anginal pain is sometimes a symptom of rheumatic
heart disease, but I have not included such cases in my
series, because in my experience they do not conform to
the clinica] picture of the atherosclerotic type, though
we know that rheumatic infection may produce somewhat
similar coronary changes (Karsner and Bayless 1934).
~
SIR MAURICE CASSIDY: CORONARY DISEASE
[oor. 26, 1946
I have never seen a coronary occlusion complicate
theumatic heart disease, nor do I feel that anginal pain
in a young rheumatic subject has the same serious
significance as in the atherosclerotic patient.
We can conceive of the. possibility of spasm of a
healthy coronary artery producing a localised myocardial
ischemia with consequent coronary pain; but we have
no proof that this does in fact ever happen, though we may
suspect that an unstable vasomotor control may play a
part in the clinical picture of the patient, familiar to us
all, who suffers, perhaps for years, from anginal paroxysms
of great severity, provoked by trivial physical effort, and
especially by emotion. Findings on physical examination
may be surprisingly negative; and consequently these
patients are often regarded as cardiac neuropaths till
at last the diagnosis of organic coronary disease becomes
only too clear, perhaps as.a result of the sudden and
unexpected death of the patient.
Some years ago I used to diagnose ‘“‘ vasomotor angina ”
not infrequently in patients who complained of anginal
pain of typical distribution, this pain being provoked by
effort, but especially by emotion, without physical signs
of organic cardiovascular disease and with a normal
electrocardiogram. Sometimes there was evidence. of
vasomotor instability, such as easy flushing, Or. Raynaud-
like phenomena, or a history of migraine. But increasing
experience has convinced me that sooner or later these
patients present undoubted evidence of organic coronary
disease. Ifthe same amount of effort constantly provokes
substernal pain or even discomfort, however slight, and
if this discomfort disappears promptly with rest, I think
we may assume with confidence some degree-of coronary
obstruction, ‘however negative the findings may be.
As for that large heterogeneous group of so-called
false angina, we can only speculate as to the explanation
‘of their pain, feeling assured that it is not of.coronary
-origin. Many of them are suffering from a cardiac
anxiety state. There is an interesting, and sometimes a
diagnostically difficult, group of patients, usually women,
who have severe paroxysms of precordial, usually not
sternal, pain, which may radiate into the arms, back, or
jaws. These paroxysms may be provoked by emotion,
or there may be no obvious exciting cause. They come
after, rather than during, effort, and they are usually
widely spaced, with periods of robust health, without
limitation of physical effort, between them. ‘The subjects
of these attacks, though sometimes temperamental, are
often quite stable psychologically. Their symptoms are
very real and severe, and may indeed be alarming.
Possibly these paroxysms may be due to spasm of the
esophagus or of the cardiac sphincter. Radiological
confirmation of this is obviously difficult to obtain,
though I understand that William Evans has made some
interesting kymographic observations in this class of
case. Diagnosis is ‘made more difficult here by the fact
that nitroglycerin gives relief ; but perhaps it does so by
relaxing gastric or esophageal and not coronary spasm.
I submit that in the differential diagnosis between
true angina and these non-coronary pains, careful
history-taking is even more important than physical,
including instrumental, examination, and that the
characteristic and constant relationship between anginal
pain and effort is fundamental.
ETIOLOGY
Sex-incidence—Turning now to my own statistics,
out of 1000 patients, 779 were males, 221 females, giving
a female-to-male ratio of 1 to 3-5, which seems to be about
the usual ratio found in the literature, though in a
recent report from the Mayo Clinic on 3440 anginal
patients the female-to-male ratio was 1 to 4-3 (Parker et
al. 1946). This far heavier incidence of angina on males
rather than on females has never, so'far as I know,
received a satisfactory explatation. In the past no
doubt women led a more sheltered life. But certainly
THE LANCET]
today no-one would contend that men work four times
as hard: as women; in fact some might argue that the
reverse is true. I have not been able to satisfy myself
that the incidence of angina on women has increased of
recent years compared with that on males. If smoking
plays an important part in the causation of coronary
disease, which I doubt, we should certainly expect a more
equal sex-incidence during the next ten years or so.
Nor is there any satisfactory explanation of the
unquestionably heavier incidence of coronary disease on
the non-hospital as opposed to the hospital population.
Age-incidence.—My figures are much the same as
those of the Mayo Clinic : |
.. Under 30 30-40 40-50 50-60 60-70 70-80 80
Age..
Females .. 0 13% 117% 29% 39% 15% 4%
Males 02% 32% 146% 33-9% 36% 111% 1%
About 70% of all patients were aged between 50 and 70
at the onset ; 58% of women and 48% of men were over
60 at onset, which confirms tbe general impression that
coronary disease tends to become manifest at a later age
in women than in men. In 26 males the age at onset was
under 40, in 2 under 30, the youngest being 26. There
were only 3 women under 40 and none under 30.
it has become evident that coronary disease in young
subjects is not so rare as used to be thought. French and
Dock (1944) have reported 80 cases of coronary disease
in American soldiers aged 20-36 during the recent war,
and Newman (1946), in this country, 50 cases of coronary
occlusion in Service men and women, aged 25 or less.
Of Newman’s patients 22 were under 30, the youngest
aged 20. At autopsy atheromatous changes were found, in
several instances accompanied by extensive calcification.
Stolkind (1928) reported 4 personal cases of angina
in children and collected a further 25 cases from the
literature. Many of these cases were in rheumatic
children, and in some the evidence of angina was not
very convincing. :
Family history plays a notorious part in the wtiology
of cardiovascular disease, and it did so in almost exactly
half my cases. But this leaves another 50% of
patients whose coronary disease cannot be attributed
to inheritance. `
Stress.—Mental or physical stress is often thought to
be responsible for early cardiovascular death, and
coronary disease has been brought into the ever-increasing
ambit of psychosomatic disease (Halliday 1945). But
does the population really work harder or live more
strenuous lives than their grandfathers did? I some-
times doubt it. Certainly we eat and drink much less
than they did. I have looked carefully through the
histories of my patients, and in only 20% of them do
I find evidence of subjection to outstanding stresses.
Many of them in fact seem to have lived remarkably
placid and sheltered lives. Dr. Paul White, of Boston,
on a recent visit to this country told us that in the first
edition of his book Heart Disease a sentence emphasising
the relationship between angina and stress was in italics,
in the second edition in ordinary print, and in the third
deleted.
Nor am I familiar with the ‘“ coronary-disease per-
sonality,” as described at some length by Arlow (1945) :
‘‘A stubborn self-willed child who early entered into
competitive relationship with a much feared and envied
parent; the conflict is repressed and identification made
with the parent. ... He attempts to equal his superiors,
to surpass and dominate others. A masochistic trend may
be noted in the manner in which these patients neglect
themselves and make themselves martyrs to their own
ideals. ... The compulsive striving for achievement and
mastery never seems to end. Success brings no gratification
nor release from tension.”
Tobacco has long been thought to be a factor in the
causation of arterial spasm, and there seems to be
convincing experimental evidence of this. Numerous
SIR MAURICE CASSIDY °:
CORONARY DISEASE [ocr. 26, 1946 589
workers—e.g., Stewart et al. (1945), Evans and Stewart
(1943), and Roth et al. (1944)—have demonstrated that
the smoking of two cigarettes usually lowers the peri-
pheral skin temperature, diminishes the peripheral
blood-flow, and raises the systolic, and still more the
diastolic, blood-pressure. It is said that these changes
may be evident not only during the smoking of the
cigarettes but also sometimes for as long as 30 minutes
subsequently. This is depressing information to the
smoker, but he will be encouraged to hear from Goetz
(1942) that very similar results are obtained if the subject
is alarmed, or asked to do a difficult sum, or even to take
a series of deep breaths. Goetz concludes that the
driving of a car in traffic would produce more adverse
circulatory effects than the smoking of several cigarettes
in an armchair at the club.
J always advise sufferers from intermittent claudication
to stop smoking, and usually this brings no amelioration
of their symptoms. But very occasionally the results are
dramatic, and I have seen a relapse if smoking is resumed.
So far as so-called “ tobacco angina ” is concerned, I have
never encountered such a condition, and certainly I have
never seen angina cured by stopping smoking. Statis-
tically 17-6% of my coronary patients were non-smokers,
42-6% smoked moderately—i.e., not more than twenty
cigarettes a day—and 39-8% were heavy smokers. As a
control I investigated the smoking hahits of a small series
of non-cardiac cases, and found much the same figures.
PROGNOSIS |
Coronary disease persisted more than twenty years in
11 of my patients, more than thirty years in 2 of them.
The record duration was fifty-two years, in a lady who
had her first attack of angina at the age of 30; she
was leading a busy life at the age of 80, though still
liable to angina whenever she walked. She died suddenly
at the age of 82. | |
It has long been known that quite extensive coronary .
disease is compatible with an active life and need not
necessarily be associated with angina. In fact this used
to be put forward as an argument against the view that `
angina is due to coronary ischemia. Coronary occlusion
often antedates angina. It did so in 225 (22-46%) of my
cases. Yet before coronary occlusion can occur there
must almost always be coronary disease. Moreover, a
remarkably complete functional recovery is possible
after a coronary occlusion. One of my patients played
vigorous games after a coronary occlusion at the age of 39.
He had a second attack at the age of 48, and, against
advice, was playing tennis regularly two years later,
without any angina. Now at the age of 58 he is at work,
plays golf, and mows his lawn without cardiac symptoms.
It is common for coronary disease to be entirely
latent till sudden death takes place. Professor Hume,
of Newcastle, tells me that since 1911 he has performed
or attended post-mortem examinations on 160 miners who
had died suddenly and unexpectedly in the pit or in
close proximity to it. The cause of death in each instance
was coronary atheroma, and most of the men had been
working regularly, without complaint, up to the moment
of their fatal collapse. Only 40 had premonitory symp-
toms. In 1 case there was a clear history of an attack of
coronary thrombosis two years previously, after which `
the man had resumed his normal work in the mine and
continued it till his sudden death. . In about half the 160
cases there were old fibrotic scars in the heart muscle.
The explanation of coronary disease without symptoms
is presumably that a wonderfully efficient collateral
circulation may be formed if arterial obstruction ‘develops
sufficiently slowly. As Lowe and Wartman (1944) point
out:
“ Complete obstruction may, gradually produced, effect
no disturbance whatever in the blood-supply to the tissue.
On the other hand, should the parent vessel supplying the
anastomotic circulation become suddenly blocked, tho
590 THE LANCET]
area deprived of blood-supply will be much greater than that
following. blockage of a similar vessel in a normal
circulation.”
Hence, presumably, the sudden fatal attacks in Hume’s
coalminers with previously symptomless fibrotic hearts.
In this way too we find an explanation for the fact that,
on the whole, angina in those aged over 70 runs a more
benign course than it does in those aged under 50.
RELATION TO HYPERTENSION |
_ Investigating the relationship between hypertension
and coronary disease, I classified my cases .as having a
normal blood-pressure where the readings were below
160/100, moderate hypertension above these figures but
below 200/120, and gross hypertension above 200/120.
Throughout the entire series, in 44: ‘6% the pressure was
normal, in 337% moderately, and :in 21-7% grossly
increased.. Excluding those cases in which an existing
or recent coronary occlusion was thought to be responsible
_ for.a low blood-pressure, the figures were normal tension
30-6%, moderate hypertension 42:3%, gross hypertension
27:1%. So nearly 70% of my anginal patients without
coincident or recent . coronary occlusion were hyper-
tensives. These findings surprised me, for I had not
realised that the proportion of hypertensives was so high.
Fisher and Zukerman (1946) say that, in the literature,
hypertension antedating coronary occlusion has varied
between 33% and 73%. Of their own 108 cases of coro-
nary occlusion, hypertension antedated the occlusion
in 65% of the women and 39% of the men. They point
out that negroes, though more liable than whites to
hypertension, show a significantly lower incidence of
coronary -disease. Nevertheless, .. one cannot help
suspecting that there may be some etiological factor
in common between hypertension and coronary disease. -
But unhappily, in spite of all the intensive investigation
of hypertension during the last decade, fruitful though
- it has heen, we are still abysmally ignorant of its etiology
—in the words of. Harvey, ° ‘all we know is infinitely
less than all that still remains unknown.” Is it possible
that in the remarkable sex-incidence of coronary disease
we may find some clue to etiology? Can it. be that
masculinity predisposes one to coronary disease, and
that femininity . safeguards from it—that perhaps
cholesterol metabolism is vitiated by maleness ? In this
connexion it is. interesting to note that some maintain
that it is.the more masculine type of woman who is
prone to -develop coronary disease—though I confess
that Mae nase not been my experience.
ENVOL
During the past few months I have often asked myself
how Harvey would have approached the problem which
I have here so lamentably failed to solve. Certainly
not by speculations, nor by clinical impressions ; and I
very much doubt whether the statistical approach would
have made much appeal to him. He would have agreed
with Fernel that ‘‘ We cannot be said to know a thing
of which we do not know the cause ” (Sherrington 1946).
When asked why the.blood circulated, he replied that he
could not say. Harvey was interested only in proving by
experiment that it did circulate: ‘‘it is shown by the
- application of a ligature that the passage of the blood is
from the arteries into the veins ’’ (Harvey 1616). I hope
that today he would have accepted coronary arterial
disease as the cause of angina,.and I believe that he
would be one of the many workers who are endeavouring
‘“ to search and study out the secrets’ of hypertension
and of arterial disease by experiment, whether in the
laboratory or at the bedside.
In conclusion I recall the indenture of Harvey, dated
June 26, 1656, in which he conveyed to the college the
gift of his patrimonial estate of Burmarsh, in Kent. He
exhorted the fellows and members to search and study
out the secrets of nature by way of experiment; and
MAJOR HYNES AND OTHERS: SERUM-PROTEIN LEVEL OF INDIAN SOLDIERS |
Parker, R. L., CERT T J. wW
6, 541.
Stolkind, E. J. (1928) Brit. J. Child. Dis. 25,1.
(ocr. 26, 1946
also for the honour of the profession, “ to. continue in
mutual love and affection amongst themselves, without
which neither the dignity of the college can be preserved
nor yet particular men receive that benefit by their
admission into the college which else they might expect,
ever remembering that Concordia res parvæ oresount,
discordia magne dilabuntur.”
Never before was it more vital to the college, to the
profession, and to the State, that these exhortations of
Harvey ue be faithfully obeyed. .
REFERENCES .
Arlow, J. A. (1945) T uchot, Med. 7, 195.
Blalock, A., Taussig, H. B. (1045) J. Amer. med. At, 128, 189.
Crafoord, C., Nylin, G. a 945) J. thorac. Surg. 1
Dudley Committee Ministry of Health Peon 5544) Design of
Dwellings, London.
Evans, W., one communication;
Evans, W. F., Stewart, H. J. (1943) Amer. Heart J. 26, 78.
Fisher, R. E ' Zukerman, a (1948) J. Amer. med. A88 . 131, 385.
nch, A. J., Dock, W. 44) Ibid, 124, 1233.
Goetz, R. H H. (1942 ) Clin. Pre 1, 190.
Halliday, J. L. (1945) Psychosom. ate 135.
Harken, D. E., Glidden, E. M. (1943) J. ioraa. Surg. 12, 566.
(1616) Lecture notes (in polars Museum).
Harvey, W.
9, 2015,
i6
Herrick, J. B. (1912) J. Amer. med. Ass.
Hume, W. E., personal communication,
Hunter, À. (19 £6) Quart. J. Med. 15, 107.
Karsner, H. T., Bayless, F. aro ne. Heart J. 9, 557.
Lowe, T. E:, Wartman, W. B. (1944) Brit. Heart J. 6, 115..
Mackenzie, J nd 923) poema Pectoris, London.
MecNee, J. W. (1925) Quart. J. Med.
nee’ an Life Insurance Co. of New. York (1946) Stat. Bull.
3
Murray, G., Wilkinson, F. R., Macgregor, R: (1938). Canad. med.
Ass. J. 38, ae l
Newman, M. (1946) Lancet, Sept. 21, p. 409.
Osler, W. (1910) Ibid, i, 697, 839, 973.
illius, F. A., Gage, R. P. (1946) J. Amer.
med. Ass. 13
Powell, R. D. (1 90: 9 1 in Allbutt and Rolleston’s System of Medicine,
London, vol. vI, p. 171.
Roth, 2 a McDonald, Y B., Sheard, C: (1944) J. Amer. med. A833.
Sherrington, C. (1946) The Endeavour of Jean Ferne), London.
Smithwick, R. H. (1944 ae Surg. 49, Pea
Stewart, H. J., Hoskell, É » Brown, H - (1945) Amer. Hear J. 30,
SERUM-PROTEIN LEVEL OF INDIAN
SOLDIERS
MOHAMMED IĪSHAQ
L.S.M.F.
. CAPTAIN. I.A.M.O.
T. L. MORRIS |
SERGEANT R.A.M.C.
Pron the Anaemia Investigation Team, General Headquarters,
India.
It is now generally accepted that the specific gravity
of the serum, estimated by Van Slyke’s copper-sulphate
method, is a reasonably accurate measure of the serum-
protein level. We used the method as part of a nutritional
and hematological survey of Indian Army recruits
(Hynes et al. 1946), but our results were so at variance
with expectation that we could not be satisfied of their
validity without a more detailed investigation, which is
reported here. The work was done deep in the jungle
with very limited laboratory facilities, and it is a fair
criticism that it raises more problems than it solves.
If it is accepted that the sp. gr. of the serum of our
subjects bears the usual relation to the serum-protein
level, then we have shown that the recruit, fresh from a
life of extreme poverty on a grossly protein-deficient
diet, has a serum-protein level higher than that of the
trained soldier. We found also that the effect of exercise
on the sp. gr. of the serum was considerably greater
than we had anticipated from the literature, but we
present data to show that this effect can be avoided by
simple precautions.
This work was done in Harihar, Mysore State, 1700 ft.
above sea-level, during August, September, and October,
1945. The weather was cool but rather humid, with early-
morning temperatures of about 75° F, and a maximum
not exceeding 90° F. |
r MARTIN HYNES
M.D. Camb., M.R.C.P.
MAJOR R.A.M.C.
THE LANCET]
MAJOR HYNES AND OTHERS: SERUM-PROTEIN LEVEL OF INDIAN SOLDIERS [oct. 26, 1946 591
TABLE I—FREQUENCY DISTRIBUTION OF ELEVATION OF SERUM-PROTEIN LEVEL BY 15 MIN. WALKING, CALCULATED FROM SERUM
SP. GR. AT O AND 60 MIN. AFTER EXERCISE '
l Below- Above resting level Elevation
Serum-protein Total
(g./100 ml.) cases
l 0-18 0 0-18 0-36 0-54 0-72 0-90 | 1:08 1-26 Mean | S.D.
Recruits .. ae 6 12 29 31 23 6 4 — 1 112 0°33 . 0-2623
Trained soldiers .. 2 | 3 | -17 11 4 4 1 — — 42 0:30 0:2375
{ ;
The subjects belonged to a Madrasi Pioneer Battalion
and were either recruits with less than a month’s service
or trained soldiers (mostly junior N.c.o.8) with over a
year’s service. The recruits’ mean height was 63 in.,
S.D. 1-92 in., and mean weight 102 lb., s.p. 8-51 Ib.
The mean gain in weight of a recruit during six months’
training is about 10 lb. All the men were aged 18-30,
and most of them about 20.
METHOD OF INVESTIGATION
The men rose at dawn, 7 A.M., had a light breakfast
of tea and chapattis (unleavened bread) at 7.30 A.M.,
walked to the laboratory, and rested until 8.30 A.M.,
when the experiment began.
Exercise consisted of either marching or pack test. For
marching the men wore shirts, shorts, and chaplis (sandals).
They marched on flat ground at the normal army pace for
15 min. For the pack test they wore shirts, shorts, and
Army boots, and carried a third of their own weight in a
pack. They mounted a 15-in. step (both feet up) thirty times
a minute for 5 min., or for a shorter time until they were
completely exhausted. They then sat down for 4!/, min.
while the pulse-rate was counted. Few men took the full
thirty steps a minute, but even so this was a most severe
test. As each man completed his prescribed exercise he
walked a few yards into the laboratory and squatted on the
floor (sepoys are not comfortable on chairs). He remained
` in the same place until the observations were completed.
Venepuncture.—Blood was taken from an arm vein with
a syringe sterilised with hot liquid parafin. No tourniquet
was used, but if necessary the veins were made prominent
by the pressure of a hand not exceeding 10 sec. Blood
for serum (3 ml.) was allowed to clot in a sloped position ;
the serum was withdrawn and its sp. gr. determined after
4-6 hours. Blood for hæmoglobin and hematocrit deter-
minations (2-5 ml.) was mixed with Wintrobe’s dry anti-
coagulant (Whitby and Britton 1942), and the hemoglobin
pipette and hxmatocrit were immediately filled before sedi-
mentation began. i
Specific Gravity of Serum.—This was determined by Van
Slyke’s copper-sulphate method (Phillips et al. 1945). The
stock solution was made by dissolving 170 g. of CuSO,.5H,O
in 1002-4 g. of water, and the standard solutions were made
by dilution of this stock. The sp. gr. of the stock solution
and of a standard solution (usually 1028) were checked by
weighing. l
For the sake of clarity in our calculations and tables we
use the notation 1000 (not 1-0) for the sp. gr. of water. Our
standard solutions were l unit apart in this notation—e.,
1020, 1021, &c.—and we estimated the sp. gr. of the serum to
` the nearest 0-5.
We renewed a standard solution when about a fiftieth of
ita volume of serum had been added. According to Phillips
et al. (1945) the sp. gr. of the solution at this time would
be decreased by about 0:4; hence the mean sp. gr. of our solu-
tions during their life was about 0-2 below their initial value.
We have made no allowance for this rather variable error in
_ the sp. gr. figures given in this paper. :
In calculating mean serum-protein levels we have tried
to allow for the degradation of our solutions by using a
modification of van Slyke’s formula :
Serum-protein = (serum sp. gr. — 1007-2) x 0:36.
` Hæmoglobinometry.—Blood 0:02 ml. was mixed in N/10
HC1 0-4 ml., allowed to stand for 80 min., diluted to 1-59 ml.
with distilled water, and matched against the glass wedge of
the Zeiss hemometer. The standardisation of this instrument
has been described elsewhere (Hynes et al. 1945, 1946). The
standard error of a single reading is +016 g. of hæmoglobin.
” When two hæmoglobin determinations were made on the same
person, the same pipette and dilution tube were used on each
occasion, and the same worker matched the colour without
reference to the previous reading.
Packed Cell Volume.—The blood was spun for 45 min. at
3000 rev.jmin. in Wintrobe hematocrits. The same tube
was used for both determinations on each person. a
RESULTS OF EXERCISE .
Marching.—Both in recruits and in trained soldiers,
marching for 15 min. raised the mean serum-protein
level (calculated from the serum sp. gr.) about 0-3 g.
above the resting level. The course of the return to normal —
is shown in fig. 1. The recovery was 75% complete
after 15 min. rest and complete after 30 min. |
The statistical significance of these findings was
tested by analysis of the variance of.the serum sp. gr.
figures between times and between persons (Fisher 1942,
1944). From the residual mean square we calculated
the standard error of the difference between means and .
then tested the significance of these differences by the
t test. Both in recruits and in trained soldiers the mean
serum sp. gr. after 0, 15, and 30 min. rest differed very
significantly from one another (P less than 0-001), but
there was no significant change after 30 min.
There was a wide variation between individuals in
the degree of elevation of the serum-protein level after
marching (table 1). The mean elevation in recruits
was not significantly higher than in trained soldiers
(t : 0-636, P : 0-5). |
Pack Test.—We first determined the serum sp. gr.
when the men had sat down for 30 min. before the
test, and then after the test at. intervals from 5 to
95 min. This violent exertion caused an elevation of the
serum-protein level twice as great as did gentle exercise
(marching), and the return to normal took twice as
œ=-0 Pack ata | RECRUITS
©- Marching
om Pack test | TRAINED
e——e Marching j
SOLDIERS
SERUM- PROTEINS
(g. per 100 ml.)
SERUM SPECIFIC GRAVITY
o~
© 30 . 60 ~ 90
MINUTES AFTER EXERCISE
Fig. l—Return of serum-protein levei to normal on rest after exercise.
long (fig. 1). The recovery curve followed the same
pattern both in recruits and in trained soldiers—after
20 min. rest the serum-protein level had fallen half-way .
towards its resting level ; after 35 min. recovery was 85%
complete ; and the resting level was reached in an hour.
Statistical analysis showed that the mean serum
sp. gr. 5, 20, 35, and 65 min. after the exercise differed
very significantly, but there was no significant difference
. between the means after 65 and 95 min. rest, nor did
these differ significantly from the mean resting sp. gr.
before the exercise. : :
There was wide variation between individuals in th
degree of elevation of the serum-protein level by the
pack test (table m). The mean elevation was 20%
greater in trained soldiers than in recruits, and the
difference was definitely significant (t : 2-777, P : 0-01,
592 THE LANCET]
TABLE TI—FREQUENCY DISTRIBUTION OF ELEVATION OF SERUM-PROTEIN LEVEL BY VIOLENT EXERTION,
MAJOR HYNES AND OTHERS: SHRUM-PROTHIN LEVEL OF INDIAN SOLDIERS .
Maa -
[ocr. 26, 1946
CALOULATED FROM
SERUM SP. GR. AT 5 AND 65 MIN. AFTER PACK TEST
— —_—
Above resting level | Elevation `
Serum-prote No. of. l
(g. /100 ml. ‘a
0-18 0-36 0°54 0-72 0-90 1:08 1-26 1°44 1-62 1-80
Recruits... ae 2 6 12 ‘ 54
Trained soldiers ate 1 2 7 48
(In tables 1 and II, 1 sp. gr. unit is taken as equivalent to 0-36 g. of serum-protein per 100 ml.)
from the serum sp. gr. figures). It is impossible to
assess the meaning of this difference, for the trained
‘soldiers were better disciplined than the recruits and
undoubtedly worked harder at the pack test.
The change in serum sp. gr. bore no relation to the
pack-test score, which is supposed to measure physical
efficiency, but our subjects codperated in the test so
badly that we place little reliance on the scores.
Concomitant Measurements.—We measured the serum
sp. gr., hemoglobin, and packed cell volume (P.C.vV.)
immediately after exercise and 90 min. later after rest
in 67 recruits after marching and in 30 trained soldiers
after the pack test. The results are shown in table m1.
TABLE III —EFFECT OF EXERCISE ON MEAN SERUM SP. GR.,
SERUM-PROTEIN LEVEL (G./100 ML.), PACKED CELL VOLUME
_ (P.C.V.), HÆMOGLOBIN (G./100 ML.), AND MEAN CORPUS-
CULAR HAEMOGLOBIN CONCENTRATION (M.C.H.C.)
Serum
SD. gr.
1027:91
globin M.C.H.C.
33-98
F Marching 7:46 | .
67 recruits{ $e rest., |1027-12 | 7-17 | 42-74 33-78
30 trained f Pack test | 1028-87 | 7-80 | 52-52 33-28
soldiers At rest.. | 1026-57 6°97 48°55 34°15
Values obtained at 0 and 90 min. ance marching and 5 and 95 min.
; after pack test.
After marching, the hæmoglobin and P.c.v. increases
were of the same degree as the elevation of the serum-
protein level; the range of the changes is shown in
tables 1v and v. The resting mean corpuscular hemo-
globin concentration (M.C.H.C.) was slightly lower than
the working value, and the mean difference, 0-197%,
S.D. 0:6764, was significantly different from zero (t : 2-384,
- P : 0-02). The suggestion is that the red cell is a little
larger at rest than during gentle exercise, but so slight
a change might well be extraneous rather than physio-
logical.
After violent exercise the changes in hæmoglobin and
P.C.V. were much greater (tables 111, Iv, v). The average
increase in hæmoglobin was 0-9 g. (range 0-1-6 g.),
and the average P.C.V. increase was 4% (range 2-6%).
The working M.C.H.c. was considerably below the resting
value, and the mean difference, 0:873%, S.D. 0:7182,
differed very significantly from zero. The working mean
corpuscular volume must therefore have been about
2-5% above the resting volume.
If we assume that the return of the serum-protein
level to the resting level after exercise is effected solely
by the addition of protein-free fluid to the circulating
plasma, then the resting plasma volume must be:
P
p BQ00—-H) o a «ee ()
where B, H, and P are the working blood-volume,
P.C.V., and serum-protein level respectively, and P’
is the resting serum-protein level.
slight expansion of the red cells after gentle exercise
demonstrated above and assume the circulating red-cell
volume to remain unchanged at B.H, then the new
P.C.V., H’, should be given by the equation :
»_..._ 1000 BH _ 100. HP”
H’ = 3,H+P(100—H).B/P’ — 100P—H(P—P’) °° (2)
If we neglect the
Such an equation, containing three estimations subject
to experimental error, must be very inaccurate; but,
if our hypothesis is true, it should give an equal number
of positive and negative errors. We calculated the
equation for our 67 results after marching and found
that the mean difference (observed— calculated value)
was +0-124, which was less than its standard error of
+0-1259. Our results are therefore consistent with the
hypothesis that the return of the serum-protein level
after gentle exercise to the resting level is due simply
to the addition of protein-free fluid to the circulating
plasma. (It should be noted that we have not proved
this hypothesis, we have merely failed to disprove it.)
The pronounced change in mean corpuscular volume
after the pack test necessitates. a more complicated
calculation. If we assume that after the pack test no
red cells went out of circulation, then the resting blood-
volume would be given by B a where B is the working
blood-volume, and Hb, Hb’ are the working and resting
hemoglobin levels respectively. The equation (1)
derived above for the plasma volume may therefore be
equated to: 7
P be
P B(100— H) = Hb’ B(100 — H’)
or ;
100-—-H’ P’
Hb’ = ioo -H ` P Hb .. (3)
This equation contains five estimations subject to
experimental error; but again, if our hypothesis is
true, it should give an equal number of positive and
negative errors. We calculated the equation for the 30
results after the pack test and found the mean difference
(calculated— observed value) to be -+-0-393, s.p. 0:5741.
So great a difference from zero would not occur one
time in a thousand by chance (t : 3-783), so we must
conclude that our hypothesis is wrong. The discrepancy
would be explained either if the new fluid added to the
circulating plasma had a small protein content, or if
TABLE IV— FREQUENCY OF DISTRIBUTION OF ELEVATION OF
HÆMOGLOBIN LEVEL BY EXERCISE
Hæmo- Below Above resting level Elevation
lobin o Z o Noot
(g. 100 mi.) 0-5— | 0- | 0-5- 1-0- 1-5- ire Mean 8.D.
Marching.. | 17 | 25 | 20 | 5 | — | 67 | 0-36 | 0-3921
0°89 | 0°4185
Pack test.. | — | 4] 14] 8 | 4 | 30
Calcwated from the figures immediately and 90 min. after exercise.
TABLE V—- FREQUENCY OF DISTRIBUTION OF ELEVATION OF
PACKED CELL VOLUME BY EXERCISE .
Below Above resting level No. | Elevation
P.c.v. (%) ee er. i e
Å: cases .
1- |0-/1-| 2- 3—| 4- 5-| 6- M S.D.
Marching ..| 13 |26|19| 9 | — |— | —|—]| 67 10-81 | 0-9573
Pack test ..| — |—|—| 7 6| 612] 30 13-97 |1-2313
i
Calculated from the figures immediately and 90 min. after exercise:
THE LANCET] MAJOR HYNES AND OTHERS :
a substantial volume of red cells were abstracted from
the circulation during the hour after the pack test.
THE RESTING SERUM SPECIFIC GRAVITY
Table vr shows the frequency distribution of the
resting serum sp. gr. in recruits, trained soldiers, and
a few young European men who had been in the station
for at least three months. Fig. 2 shows the Indians’
distribution in terms of serum-protein. There was no
significant difference between the mean serum sp. gr. of
the Europeans and the trained Indian soldiers (t : 0-460,
P_: 0-65), but the recruits’ mean was very significantly
SERUM-PROTEIN LEVEL OF INDIAN SOLDIERS [ocT. 26, 1946 593
The raised serum-protein level is largely due to a
diminution in the plasma volume on exertion, and the
other blood constituents naturally reflect this change.
The average hæmoglobin level after walking a mile is
0-4 g. per 100 ml. (3% Haldane) above the resting level,
and differences exceeding 1 g. (7% Haldane) are often
seen. The average P.C.v. is 1% higher, and in indi-
vidual cases often 2% higher. After violent -exertion
the mean increase in the hemoglobin level is 0-9 g.
(6% Haldane), and the increase may exceed 1-5 g.
(10% Haldane). The mean rise in the P.c.v. is 4%,
and an increase of 6% is not uncommon.
TABLE VI—FREQUENCY DISTRIBUTION OF RESTING SERUM SP. GR. IN INDIAN RECRUITS AND TRAINED SOLDIERS AND IN EUROPEANS
Serum sp. gr. 1023 | 1025. 5! 1024 |1024- s 1025
emm
1025-5] 1026 | 1026-5] 1027 | 1027- J 1028 | 1028-5] 1029 | 1029- lis eee ea
14 | 29} 31 | 29 171 ce ae 81
10 | 27 | 23 | 14 1026-25
AE SS a e a
Recruits j2 eee ilı 3 |1 1-2213
Trained soldiers — — | — 1 S 0-7238
Europeans — — | — 1 1 | 5 5 3 21 1026-17 0:8416
above that of trained soldiers (t : 3-994) and significantly
above that of Europeans (t : 2-348, P : 0-02).
The mean hæmoglobin in the 171 recruits was 14-67 g.,
8.D. 1-424, range 9-17 g. ; in 90 trained soldiers 16-31 g.,
s.D. 0-9073, range 13-19 g.; and in 2) Europeans
15-85 g.,‘3.D. 0-7048, range 14-17 g. In none of these
groups was there any suggestion of a correlation between
the hemoglobin level and serum sp. gr. If blood is taken
from incompletely rested subjects, a spurious correlation
between the hemoglobin and serum-protein levels must
be created. Each hemoglobin group will contain a
proportion of men who on further rest would fall back
into lower hemoglobin and serum-protein groups. The
highest hemoglobin group is always numerically the
smallest ; _ hence it will contain a high proportion of
subjects who, if their hemoglobin, and serum-proteins
had reached the resting levels, would be in the larger
penultimate hæmoglobin group. The highest hemoglobin
group as observed will therefore have an artificially
high sernm-protein level. It is easy to see that this
will apply to all classes on the descending part of the
hemoglobin frequency distribution curve; and by the
reverse process groups on the ascending part of the curve
will be given an artificially low serum-protein level.
We have shown elsewhere (Hynes et al. 1946) that in
these recruits there was a clear correlation between mal-
nutrition, as assessed clinically, and the hæmoglobin level,
but we found no similar correlation between nutrition and
serum sp. gr. i
_ DISCUSSION
The Medical Research Council (1945) has emphasised
the importance of taking blood for serum-protein
estimations after a strictly standardised period of rest.
Our figures re-emphasise the necessity of this precaution
not only for serum-protein estimations but also for other
blood investigations. The very moderate exertion of
walking a mile raises the average serum-protein level
0-3 g. per 100 ml., and the increase is often three times
as great. When the subject sits down, the protein level
falls within 30 min. to a stable resting level; three-
quarters of this fall takes place in the first 15 min.
Very violent exertion for 5 min. raises the average
serum-protein level 0-75 g., and an increase twice as
great is not uncommon. After 20 min. rest the serum-
protein level has fallen only half-way towards its resting
level, and after 35 min. only 85%. The resting level is
reached in an hour.
Vaughan (1945) has suggested that these variations `
are greater in untrained persons. We found no difference
between recruits and trained soldiers in the elevation
of the serum-protein level after gentle exercise, and after
_violent exertion the trained men showed the greater
change. They had, however, worked harder.
It is recognised (Medical Research Council 1945)
that there is an appreciable increase in the volume '
of the red cell as the blood passes from the arterial to ©
the venous state. Our data show that a person’s activity
affects the size of his venous red cells, presumably in an
analogous fashion. We calculated that the red cell was
very slightly smaller after walking a mile than after
sitting down for 90 min.—presumably in walking an
increased venous return without an appreciable increase
in oxygen consumption increases the oxygenation of
venous blood. On the other hand, the cells of men still
in oxygen debt from violent exertion were some 2-5%
larger than in
the resting state.
We have
shown that our
data are com-
SERUM SPECIFIC GRAVITY
patible with the 60 Recruits Cy Train
hypothesis that Š Soldiers
the increase in ÑX 50
plasma volume N ag
on rest after &
gentle exerciseis Q 30
due simply to $
the addition of 20
protein-free fluid °` jg
to the circula-
ting blood. After o)
violent exertion,
however, a more
complex change
must take place;
besides an in-
crease in plasma volume and a contraction of the red
cells, either protein must pass into the circulation or red
cells must be abstracted from it.
Since hypoproteinæmia is a feature of famine starva-
tion, it has been supposed that less absolute degrees of
dietary protein deficiency will be reflected in the serum-
protein level. Verma (1946) has shown that the civilian
diet of our recruits was grossly deficient in animal
protein and low in vegetable protein, yet we found
that their serum sp. gr., and presumably serum-protein
6 8: .
SERUM-PROTEINS (g. per 100 ml.)
Fig. 2—Frequency distribution of serum-protein
level in Indian recruits and trained soldiers.
‘ level, was definitely higher than that of trained soldiers
of the same race. We could correlate anæmia, but not
the serum sp. gr., with the degree of malnutrition. It
does not necessarily follow that this was true before the
recruits left their villages. When we examined them,
they had enjoyed the Army ration (animal protein 20 g., `
vegetable protein 100 g. daily) for 1—4 weeks, and it is
possible that this unaccustomed protein richness had
raised their serum-protein from an abnormally, low
to an abnormally high level. Alternatively a change
‘ Phillips, R.
4
594 THE LANCET}
in the level of some other blood constituent—e.g., |
cholesterol—may have been responsible for the increased
serum sp. gr. On-either hypothesis, with custom would
come tolerance to protein and a fall of the serum sp. gr-
to normal.
We may conclude by re-emphasising the importance
of strictly standardised conditions in any hematological
survey. ‘The change in the plasma volume after exercise
not only depends on the amount of exercise, but also
there are wide individual variations in the response to a
given amount of exercise. A stable value is only reached
after !/,-1 hour’s rest, and it is essential that the subject |
‘should rest for this period before he is bled, and be
bled where he has rested. The variations seen after a
_ less complete period of rest may be unimportant in the
individual case, but they are large enough to introduce
serious errors into the statistical analysis of even
moderately large series.
It remains an open question whether the serum-
protein level -may be taken as an index of the protein
adequacy of the diet. Certainly we have shown that the
serum sp. gr. is above rather than below the normal level
in men who after a lifetime of protein semi-starvation
have eaten a good diet for two or three weeks. It is to be —
hoped that this problem’ will be further investigated
= with the aid of the biochemical methods which were not
at our’ leone in the jungle during this investigation.
SUMMARY
-We estimated the serum-protein level of Indian
recruits and trained soldiers by she copper- a
serum sp. gr. method.
Gentle exercise- caused average increases of o 3 g.
` per 100 ml. in the serum-protein level, 0-4 g. per 100 ml.
in the hæmoglobin level, and 1% in the packed cell
volume (P.C v.). ‘The increases were sometimes, three
times as great as this.
These blood values returned to their resting level after
30 min. rest. This change may have been due simply to
the addition of protein-free fluid to the circulating blood.
~ Violent exertion caused average increases of 0-75'g.
per 100 ml. in the serum-protein level, 0-9 g. per 100 ml.
in the hemoglobin level, and 4%. in the P.c.v. The
increases were sometimes twice as great as this.
The resting levels were again reached after an hour’s
rest. This change was largely due to an increase in the
plasma volume, but also the red cells contracted, and
either protein passed into the circulation or red cells were
abstracted from it.
Our findings re-emphasise the importano, in any
large-scale hæmatological survey, of taking blood after
an adequate and strictly standardised period of rest.
There was no difference between the resting serum
sp. gr. of trained Indian. soldiers and Europeans, but
the resting serum sp. gr. of newly joined Indian recruits
was significantly higher than that of either. Possible
explanations are briefly discussed.
Our thanks are due to the D.M.S. in India for permission
to publish this paper; Prof. E. J. King for his very helpful
advice and criticism; Mr. ©. K. Dilwali, statistical officer
(research), General . ‘Headquarters, India, for advice on
statistical methods; and Lieut.-Colonel G. M. Holland,
commanding no. 3 Training Battalion, I.P.C., and his officers
for their help and coöperation.
REFERENCES
Fisher, D ve 1912) The Design of Experiments, London.
(1944) Statistical Methods Bs Research Workers, London.
M., Morris, T. L. (1945) Indian J. med. Res.
Verma, O. P. (1946) Ibid, in the press.
Hynes, M..
33, 27
Ishaq,
Medical Research Council (1945) Spec. Rep. Ser. med. Res. Coun.,
Lond.. no. 252.
A., Van Slyke, D. D., Dole, V. P., Emerson, K.,
Hamilton, P. B., Archibald, R. M. (1915) ‘Copper Sulfate
Method for Measuring Specific Gravitics of Whole Blood and
te T New Yo
. M. of, 945) cited by Medical Reséarch Council (1945).
J. (1946) in the. pres
‘Whitby, OF, E. H., Britton, C. J. C. (1942) Disorders of the Blood,
London.
DR. MARGARET BABER, DR. STUART: LEPTOSPIROSIS CANICOLA. 7
[oor. 26, 1946
LEPTOSPIROSIS CANICOLA
A CASE TREATED WITH PENICILLIN `
M. D. BABER R. D. Stuart ~
M.D. Lond., M.R.C.P. M.D., D.Sc. Aberd., D.P.H.
PHYSICIAN, ST. HELIER HOSPITAL, CITY BACTERIOLOGIST,
CARSHALTON, SURREY GLASGOW
Leptospira canicola is morphologically and culturally
similar to Leptospira icterohæmorrhagiæ, from which it
can be distinguished by serological tests and by the
fact that it is carried and transmitted solely by dogs
(Walch-Sorgdrager and Schiiffner 1938). In the dog
L. canicola produces a variety of symptoms, from trivial
to severe, but generally referable more to kidney damage
than to liver involvement (Dhont et al. 1934). Thus
various forms of nephritis, particularly that variety
recognised clinically as Stuttgart disease, are common,
and jaundice is rare. After recovery the animal is liable
to become a carrier, though usually for a few months
only (Klarenbeek and Voet 1933). Leptospire are then
found lying in masses within the lumina of the kidney
tubules, in exactly the same situation as L. icterohemor-
rhagie are found in the rat, and are excreted similarly in
the urine, JL. canicola is highly infectious to dogs, but ©
its pathogenicity is much less than that of L. ictero-
hemorrhagie, and its invasive power in other animals,
such as guineapigs, is very much less. This may explain
why the number of human infections recorded has been
so small. -
The first instance of human disease was identified in
Holland by Dhont et al. (1934), and by 1941 Raven noted
that 22 such infections had been discovered: 12 in
Holland, 1 in Austria, 7 in Denmark, and 2 in California.
Since that time 2 cases have been claimed by Bruno
et al, (1943), and another by Tievsky and Schaefer
(1944), all in the U.S.A. The first case in Norway has
lately been recorded by Aalvik (1946). Other cases may
have been, reported in journals inaccessible during the
war, but the incidence is unlikely to be high. Tiffany
and Martorana (1942) investigated sera from 1351 persons
in New York City without finding any positive to L.
canicola. —
In Britain no disease directly ascribable to L, canicola
has so far been recorded. Stuart (1938) found low-titre
agglutinins to this organism (proved to be specific by
absorption tests) in the serum of a woman tripe-scraper,
aged 43, who gave no history of illness. The dog-trans-
mitted leptospiral disease recorded by Gardner (1943)
was ascribed by him to a serologically distinct organism,
L. icterohemorrhagie 5260,
SYMPTOMS OF LEPTOSPIROSIS CANICOLA IN MAN
Walch-Sorgdrager (1939) discussed the largest series
of human cases so far recorded, She pointed out that
clinically the disease was very variable in signs and
symptoms; jaundice, however, was rare, and mortality
nil. The typical syndrome produced by L. canicola in
the dog—the serious kidney disorder leading to ursemia
—was not found in man, though albuminuria, with
leucocytes, red blood cells, and casts in the urine, was
often present for a few days. On the other hand, the
frequency of meningitis or meningismus was notable (‘tin
4 out of 12 patients”). The cerebrospinal fluid (¢.s.F.)
was hazy or frankly purulent, usually with polymorphs
predominant. In general, patients exhibited symptoms
like those of influenza with an acute onset, fever, head-
ache, shivering, and muscular pains. Convalescence
was often protracted but occasionally dramatically
-brief. Our patient showed many of these features,
CASE-RECORD —
A boy, aged 11 years, previously healthy, was admitted to
hospital on Sept. 10, 1945, with hematuria, malaise, head-
ache, and pains in the calves for two days. He felt nauseated
but had not vomited. He admitted to. moderate frequency
THE LANCET]
DR. MARGARET BABER, DR. STUART: LEPTOSPIROSIS CANICOLA
[oor. 26, 1946 595
of micturition, and thought his urine had been slightly red
for two or three days. He noticed puffiness of the eyelids
three days before admission.
His past history had been uneventful, except for a slight
sore throat after bathing in the Thames twenty-one days
before. This cleared up in a few days, and he had again
bathed in the Thames twelve days before entering hospital,
No-one else in the family had been il] recently.
He was a well-developed intelligent boy, looking acutely
but not seriously ill. Temperature 102° F, pulse-rate 108,
respirations 22 per min. There was slight but definite puffiness
of the eyelids, chiefly of the upper lids, but no peripheral
cedema. Skin hot and dry, breath foetid, tongue furred, and
mild marginal gingivitis. Throat slightly injected. No
abnormal physical signs in heart’ and lungs. Liver, spleen,
and kidneys not palpable. Except for a suggestion of neck-
rigidity, examination of the central nervous system revealed
nothing unusual. Urine contained visible blood and much
albumin, with numerous cellular and granular casts but no
organisms. Blood-urea 37 mg. per 100 c.cm. Blood-pressure
120/60 mm. Hg. A tentative diagnosis of acute glomerulo-
nephritis was made. l
Next morning the boy seemed better, and his temperature
had fallen to 100° F, but it rose during the night to 104° F
and then fell to normal. Throat-swab culture was negative
for hemolytic streptococci, but a white-cell count showed
8900 cells per c.mm. with polymorphs 73%, lymphocytes
20%, and monocytes 7%.
On the 14th his temperature again rose to 101-8° F and
he still complained of headache. Photophobia was well
marked, but there was no conjunctivitis, Neck-stiffness was
more evident, and slight blurring of the optic disk was seen on
examination of the fundi. A lumbar puncture was performed,
and turbid c.s.F. under raised pressure was obtained; this
contained 690 cells per c.mm. (lymphocytes 70%, polymorphs
30%) but was sterile on culture; chlorides were 690 mg. per
100 c.cm., and an excess of globulin was present.
Leptospirosis was suspected by this time, so penicillin
therapy was begun the same day, 10,000 units being given
intrathecally, followed by the same dose intramuscularly,
the latter being repeated every three hours. In twelve hours
the boy seemed perfectly well, his temperature was normal,
urinary abnormalities had disappeared, and he made a
dramatically swift recovery. Penicillin treatment was dis-
continued on the I7th, after 22 doses (220,000 units) had
been given. On that day, however, the 0.s.F. was still turbid
and contained 300 white cells per c.mm., with lymphocytes
predominating but no excess of globulin. Chlorides were
‘740 mg. per 100 c.cm. Culture was again sterile. Confirmation
had been received from the hospital laboratory of the presence
of antibodies to L. icterohemorrhagie in a specimen of blood
‘TABLE I-—DIRECT RESULTS OF SEROLOGICAL TESTS
Titre of serum obtained on
Strain l Type -=
s Sept. 22 | Oct.15 | Nov. 24
Wijnberg .. L. telero- AB 300 100 100
McIntyre .. hemorrhagie \ B 1000 300 300
Utrecht IV Te eaiieola 10,000 10,000 3000
Berlin 4129 i 10,000 30,000 ` |} 10,000
L.5260 i P ; 30 30 ae
Moscow V... L. grippo-typhosa 0 £2 ee
< ae a pomona Ga 0 ei | an
z - {| L. sejroe.. RA 100 100 30
oe .| L. autumnalis A 0 e Es
ave L. autumnalis B 0 l
oe L. batavie 0
taken on Sept. 18, but the peculiar features of the case sug-
gested the desirability of a more extensive investigation than
was possible locally. This later investigation is described
below.
The patient was discharged from hospital on Oct, 1 quite
well and remained free from symptoms till Nov. 15, when
he was readmitted with a history of slight hematuria. His
main complaint was headache, but his c.s.F. showed no increase
in cells or protein; his urine, however, contained numerous
red blood cells. In hospital he had no symptoms, and in two
days his urine was normal, his blood-urea 41 mg. per 100 c.em.,
and a urea-concentration test gave normal results. Blood-
pressure was not raised. Before his discharge on Dec. 1 a
‘further sample of blood was obtained for serological tests.
Serological Investigation.—Serological tests were carried
out according to Schifiner’s method as described by Davidson
et al. (1934). Both living and formolised culture antigens
were used in parallel tests, but the results were practically
identical. The strains of leptospira used were ‘“‘ Wijnberg,”
a typical “ complete ” strain of L. icteroheemorrhagie (Gispen
and Schifiner 1939); ‘‘ McIntyre,” an incomplete strain
(proved by reciprocal agglutination to be identical with
strains “ Hickey ” and “ Wien I ”); “ Utrecht IV,” a typical
strain of L. canicola used by Prof. W. Schiifiner ; and ‘“‘ Berlin
4129,” another strain of L. canicola, obtained from Professor
Schlossberger. ‘‘L.5260’’ was provided by Prof. A. D.
Gardner, and most of the other strains by Dr. Lépine, of
the Pasteur Institute. Absorption tests were carried out
according to the technique followed by Buckland and Stuart
(1945). Table 1 shows the results of the direct tests on the
patient’s sera, and table m the necessary absorption tests.
Titres are given as the reciprocal of the dilutions in each case,
TABLE II—ABSORPTION TESTS ON SERUM TAKEN SEPT. 22
| Absorbed with
Titre with Unabsorbed "E L. ie ero- 5 T edl
L. iclero. AB .. 300 0 0
L. icter. B .. e 1000 30 30
L. canicola .. | 10,000; 3000 0
L. sejroe | a 0
| 100
The titres with both strains of D. canicola were higher than
the corresponding titres with strains of L. icterohemorrhagie,
and the former tended to rise and the latter to fall as the
disease progressed. The L. canicola antibodies are shown to
be specific by the absorption test, where L. canicola removes
both homologous and heterologous antibodies from the
serum, whereas a L. icterohemorrhagie strain leaves the.
L. canicola antibodies practically intact.
DISCUSSION
Since this is claimed to be the first case of L. canicola
infection discovered in Britain, it is unfortunate that an
opportunity did not arise to isolate the organism from
the patient, but on serological grounds the evidence is
quite definite. Para-specific serum titres to L. canicola,
sometimes greater than to L. tcterohemorrhagie, have
been. encountered occasionally by one of us (R. D. S.)
in the early stages of Weil’s disease and have been -
recorded by Gispen and Schiiffner (1939). Such reactions
are reputedly associated mainly with infections caused
by the “incomplete ” B type of L. icterohemorrhagie,
though there is no evidence that this type has any greater
antigenic similarity to L. canicola than the usual AB
type. Petersen (1938) made the observation that within
the classical type of L. icterohemorrhagie was a subtype
which lacked an antigenic factor present in the others.
Subsequently this “incomplete” subtype was repre-
sented by the letter B, while the “ complete” strains
were indicated by the letters AB. There is apparently
no clinical difference in the diseases caused’ by these
respective strains, but the serological investigation of
cases is often helped considerably by an appreciation of
these antigenic variations. In Weil’s disease the para-
specific serum reactions to L. canicola invariably decline
as the disease progresses, and the specific antibody
response becomes dominant; they are also readily
removed by absorption with a L. canicola culture, which
has little or no effect on the specific antibody. Absorp-
tion of such a serum, however, with a L. icterohemor-
rhagie culture removes both specific and para-specific
antibodies, In the present case the dominance of
L. canicola antibodies throughout the illness, their
resistance to absorption with L. icterohemorrhagie, and
the almost complete absorption of both L. icterohemor-
rhagie and L. canicola antibodies with L... canicola,
leave no doubt that in this instance L. canicola was the
infecting strain. d 2
‘The manner of infection can only be surmised. The
boy did not possess a dog, nor did he play with dogs.
596 THE LANCET]
Most probably the infection was acquired while bathing ;
and, though this is unusual, there are fully authenticated
instances of leptospirosis canicola acquired in this way
(Walch-Sorgdrager 1939, p. 336), There is no reason
against the occurrence of bathing infections with L. cani-
cola; dogs can contaminate water just as effectively as
rats, though one must admit that there are fewer dogs
and a smaller relative percentage of leptospiral carriers.
The last figure is quite unknown. The incidence of canine
infection, however, has been determined, chiefly by
serological methods, in many parts of the world and is
known to be high. In Amsterdam it seems to be greater
than 30% (Walch-Sorgdrager 1939), in Philadelphia it
is about 25% (Raven 1941), and in Glasgow Stuart
(1946) has found antibodies to L. canicola in over
40% of street dogs. Klarenbeek (1938) states that more
than 50% of dogs excrete leptospira for a variable period
following infection ; but since this period is often short,
the percentage of dog “carriers”? at any one time is
probably small.
The clinical features of the present case generally
accord with previous descriptions of leptospirosis cani-
cola. The prominence of the renal symptoms, however,
is noteworthy owing to the similarity of the disease as
it occurs in dogs, but in the human case there is no
evidence of a developing chronic nephritis. One cannot
tell if the brief recurrence of nephritic symptoms is
ascribable to the previous leptospiral disease. The
dramatic change in the clinical condition following
penicillin treatment is interesting and is in accordance
with the experimental work of Larson and Griffitts
(1945). On the other hand, a similar clinical course has
been observed in patients where no specific therapy has
been used. The disease is naturally self-limiting, and
therefore no claim can be made for a specific therapeutic
effect of penicillin.
SUMMARY
A case of leptospirosis canicola in a boy is ascribed to
bathing in the Thames. | l
The diagnosis was established by the demonstration
of a rising serum antibody titre to L. canicola during
the course of the illness and by absorption tests, with
. homologous and heterologous strains of leptospira.
The patient was treated with 220,000 units of peni-
cillin, and dramatic clinical improvement followed.
REFERENCES
Aalvik, T. (1946) Nord. Med. 30, 749.
a vo C. J. W., Snavely, J. R. (1943) J. Amer. med.
e > 5 . Y
Buckland., F. E., Stuart, R. D. (1945) Lancet, ii, 331. ;
Davidson, L. S. P., Campbell, R. M., Rae, H. J., Smith, J. (1934)
Brit. med. J. ii, 1137. as
Dhont, C. M., Klarenbeek, A., Schiiffner, W. A. P., Voet, J. (1934)
Ned. Tijdschr. Geneesk. 78, 5197.
x (1946) Vet. Rec. 58, 1 e g :
Tievsky, G., Schaefer, B. G. (1944) Med. Ann. Dist. Columbia, 13, 11.
Tiffany, E. J., Martorana, N. F. (1942) Amer. J. Hyg. 36, 195.
Walch-Sorgdrager, B. (1939) Bull. Hlth Org. L.o.N. 8, 143.
— Schiiffner, W. (1938) Zbl. Bakt. 141, 97. :
—— — —-- M OO” o a ļŘ—iMl
p
« . . Of course there are important differences between
the medical profession and the university teaching profession.
I think the main difference is that the medical profession has,
on the whole, to work a good deal harder, also it has to work
at less regular hours, and, on the whole, its job is not so
pleasant because there are many patients who are not quite
so attractive to deal with as the young men and young women
in universities. For that very reason, I personally think
you ought to pay the medical profession better than you pay
the teachers. It would be quite easy to do that without
paying them very much.”—Lord BEveERIDGE, Hansard,
Oct. 9, par. 94.
MR. HARGROVE AND OTHERS: MALIGNANT GRANULOMA OF THE NOSE .
negative, and there has.
[oor. 26, 1946
MALIGNANT GRANULOMA OF THE NOSE
. S. W. G. HARGROVE tp eS
M.B. Camb., F.R.CS.E., D.L.O. So
SENIOR SURGEON, EYE, EAR, AND THROAT HOSPITAL,
SHROPSHIRE AND MID WALES i
J. H. FODDEN A. J. Ruopss —
M.D. Leeds M.D. Edin.; F.R.C.P.E.
ACTING PATHOLOGIST, ROYAL LECTURER IN BACTERIOLOGY,
SALOP INFIRMARY, SHREWSBURY LONDON SCHOOL OF HYGIENE
PROGRESSIVE ulceration of the nose, palate, and wall
of the antrum, known to ear, nose, and throat surgeons
as malignant granuloma of the nose (Woods 1921), was
probably first described by McBride in 1896 (see McBride
1926), and about a dozen cases have since been published
(Woods 1921, McKenzie 1922, McArthur 1925, Chatellier
1929, Kraus 1929, Goodyear 1930, Stewart 1933, Hall
1933, Dempsey 1933). _ -E n 4
The lesion begins on the inferior concha or nasal
septum and proceeds to sloughing of the concha and
perforation of the septum and hard palate, the ulcerated
areas having clearly defined margins. An abscess may
form in the soft tissues of the cheek, with perforation
of the anterior wall of the antrum. There is usually no
regional lymphadenopathy. The lesions are not painful.
There is a peculiar odoriferous bloodstained discharge from
the affected nostril. The disease is usually rapidly fatal,
though the precise cause
of death is often obscure. sitet mae a
Bacteriological investi-
gations have not incrimi-
nated any pathogenic bac-
teria, fungi, or protozoa,
and Stewart (1933) re- i
ported negative results on ~ f
animal inoculation. The a
Wassermann and Kahn
tests have always proved
been a complete lack of
response to arsenicals
(McArthur 1925). Apart
from the local lesions in
the nose, mouth, and
antrum, necropsies have
not revealed any specific
changes, though in one of necrotic anterior end of inferior
Hall’s (1933) cases small turbinate bone. :
nodules of reticulum-like
cells were found in the lung and cortex of the kidney.
The histology of the local lesion presents the general
features of invasion by a cellular granulation tissue,
with necrosis of bone and cartilage. .
Muir examined McBride’s (1926) case and stated that the con-
dition did not correspond to any known type of ulceration, and
in particular syphilis, yaws, and tuberculosis could be excluded.
. O’Sullivan, examining Woods’s (1921) case; reported a
zone of granulation tissue extending into the healthy tissue and
breaking down behind.
In McArthur’s (1925) case, Dew stated that the lesion did
not conform to any known type of malignancy though bearing
some resemblance to an atypical spheroidal-celled carcinoma.
Kraus (1929) described infiltration of bone. and. cartilage
by acellular granulation tissue and thought that sarcomatous
change had supervened on an infective granuloma.
With regard to the granulation tissue, Chatellier (1929)
thought there were resemblances to lupus pernio, and Ewing,
examining Wood’s (1931) case, thought that the changes
resembled syphilis though they were not typical. Case,
examining the same material, diagnosed tumour, and Weidman
classified the condition as a granuloma. :
Stewart (1933) described a round-celled infiltration of granu-
lation tissue, engorged vessels, and scattered hemorrhages ;
proliferating blood-vessels showed thickened walls and
endarteritis with hyaline changes. Bone was actively des-
troyed. In one case the appearances suggested a fibroma.
Fig. |—Perforation. of cheek and
anterior wall of antrum ex-
posing lateral wall of nose with
MR. HARGROVE AND OTHERS: MALIGNANT GRANULOMA OF THE NOSE
[oor. 26, 1946 597
Fig. 2—Photomicrograph of section of ulcerated inferior turbinate
bone. Note demarcation between necrosis and slough on the left
and myxomatous connective tissue, with its colonies of fibroblasts
and capillaries on the right. (x 90.)
Qpinion seems to be more or less equally divided
between describing the condition as an infective granu-
loma of uncertain xtiology and attributing the changes
to a tumour growth.
All forms of treatment have been tried, from chemical
cautery and surgical excision to radium implantation
and X rays. Woods’s (1921) second case was healed by
radium needles placed in dental wax upon the ulcer-
perforation. McArthur’s (1925) case derived no benefit
from radium, but showed satisfactory healing after three
full doses of X-ray therapy. All other reported cases
have been resistant to any form of treatment, and death
has usually resulted from a vague cachexia or toxemia
coupled with repeated blood-loss from the lesion.
CASE-RECORD
A farmer, aged 58, was first seen by his doctor in May, 1945,
with a history of a neuralgic pain involving the distribution
of the second division of the 5th nerve. The teeth were
carious, and it was thought that the neuralgia was due to sepsis
in the upper jaw. He did not take his doctor’s advice to have
dental treatment. The first upper right premolar, canine, and
lateral incisor teeth fell out during the next four weeks, followed
by ulceration and necrosis of the adjacent alveolar margin.
> 4 q
AAI A
OT pit
CTS he ee
oa ?
Fig. 3—Photomicrograph showing linear edge between slough on the
upper left and granulation tissue.
Note obliterating endarteritis.
( x 60.)
Fig. 4-Photomicrograph of cellular granulation tissue. (x 320.)
The ulceration spread along the premaxillary region of the
hard palate, destroying the mucosa. This was followed by a
sloughing and necrosis of the bone, with formation of a fetid
sinus opening into the floor of the nose.
On August 29, 1945, the patient was seen at the Royal
Salop Infirmary, when a hole 1 in. in diameter was found in
the premaxillary region of the palate and the alveolar margin.
There was also a tender red swelling over the anterior wall of
the maxilla. A tentative diagnosis of syphilis was made, but
the Wassermann reaction was negative. The patient was
told_to report in a week but did not, and was sent for on
Sept. 17.
On the 19th the patient was seen again as an outpatient.
He was cachectic from toxic absorption, with a very pale
face, and had a temperature of 100° F. He talked with a
nasal voice. The anterior end of the inferior turbinate was
covered with a dirty greyish slough blocking the right nasal
passage. The lateral wall of the nose beneath the inferior
turbinate was eroded, and the whole of the anterior half of
the floor of the nose was absent. Necrosis also involved the
floor of the antrum. The septum was intact, and the disease
was limited to the right nasal cavity. The middle turbinate
was not involved.
After the sloughs had been removed from the nose the
posterior third of the inferior turbinate was seen to be intact.
This was seen with a nasopharyngoscope, it being impossible
aX
BO, A
rare tt. 4 A
> Ys > r
®
: s
, i
FA d
Ta
Fig. 5—Photomicrograph showing almost complete occlusion of two
arteries. Note thick reduplicated external elastic lamina of the
larger artery (orcein stain). (x 115.)
bat PE a TARE Se.
598 THE LANCET]
MR. HARGROVE AND OTHERS: MALIGNANT GRANULOMA OF THE NOSE
`
I
[ocr. 26, 1946
to use a postnasal mirror owing to pharyngitis due to pus
passing downwards. The bone forming the alveolar margin
in relation to the right incisors, canine, and first premolar
teeth, the anterior portion of the floor of the antrum, the
right anterior half of the hard palate, and the medial half of
the anterior wall of the antrum extending into the bony
margin of the right nares and upwards towards the ascending
process of the maxilla were absent. The floor and anteromedial
margin of the orbit were intact.
The antrum contained a blackish-grey slough, which was
removed with hydrogen-peroxide swabs. Beneath the slough
there was a granulating surface with punctate hemorrhages.
The hole in the face (fig. 1) had a punched-out appearance,
and its edges were smooth. The invading edge in the skin
was spreading towards the vestibule of the nose medially,
the spreading edge being hyperemic, with a slough on its
surface.
The ears and larynx were normal, and there were no
glands in the anterior and posterior triangles of the
neck. :
. He was admitted as an inpatient on Sept. 19.
Radiography showed the medial wall of the right antrum
bulging into the right nasal fossa. Illumination of this antrum
by X rays was normal. The remaining sinuses appeared
normal. Radiography of the chest showed kyphoscoliosis
(due to infection in childhood).
Treatment.—The cavity was swabbed three times a day
with hydrogen peroxide to remove the sloughs, and insufflated
with penicillin and sulphanilamide powder.
Fig. 6—Photomicrograph showing hemorrhage and necrosis sur-
rounding spicule of bone. (x 90.)
Intramuscular penicillin 25,000 units was given three-hourly
for three days. On this treatment the spread of the lesion
was arrested, and the patient’s condition appeared to be
improving slightly ; but he caught a “ cold ” and developed
pneumonia, dying ori Sept. 25.
Laboratory Findings.—The Wassermann and Kahn reactions
were negative on two separate occasions, and the Sachs-
Georgi test negative on one occasion. .
Six swabs were taken on the 25th from differont parts of
the affected antrum, with identical results. Films showed
numerous gram-positive cocci and diphtheroid bacilli only.
Cultures gave growths of hemolytic streptococci; a non-
pathogenic Staph..albus (coagulase test negative), and diph-
theroid bacilli of the xerosis type. No evidence of tuber-
culosis, actinomycosis, or mycosis. No growth of anaerobic
bacteria. .
Necropsy (Sept. 25).—Spine : kyphosis and lordosis presum-
ably due to old-standing tuberculosis, with no evidence of
present activity. Brain, skull, and middle ears normal.
Right lung congested ; some serofibrinous fluid in left pleural
cavity secondary to lobar pneumonic consolidation of both
upper and lower lobes. Kidneys small and shrunken; cap-
sules stripped with difficulty, the microscopical appearances
being those of atherosclerosis. Liver showed cloudy swelling.
‘Remaining organs appeared to be normal. The appear-
ances of the maxilla and face have already been described.
wo A
ONE LY J SESS
Fig. 7—Photomicrograph of part of same section as in ng: 6, showing
fibrinoid type of degeneration which was an early lesion found
closely applied to bone (Mállory’s fibrin stain). (x 160.) a
Death was certified ae due to lobar pneumonia and toxemia
from necrosis of right maxilla. | .
Histology.—Several pieces of tissue from the inferior
turbinate bone (fig. 2), the hard palate, and the edge of the
ulcerated area of the antrum were examined. The appearances
throughoùt were similar, but were most pronounced in the
edge of the perforation in the wall of the antrum. The mucosa
was ulcerated away, and the surface was formed by a slough,
consisting of masses of red cells, polymorphs, eosinophils, and
plasma cells. Immediately under this superficial area was a
wide zone of necrosis, where the outline of blood-vessels and
connective tissue was just recognisable. There were no
inflammatory cells in this area. l
There was a sharp line of demarcation (fig. 3) between this
zone and the next, which showed very celular tissue (fig. 4)
composed of closely packed interlacing fibroblasts and a
few capillaries. Deeper still, the fibroblasts were arranged in
long parallel: lines and there was a moderate amount of
collagen. Here also there were tortuous small arteries showing
gross pathological changes. The adventitia was not clearly
demarcated from the surrounding cellular tissue and showed
infiltration with lymphocytes. The media was thickened, and
Fig. 8—Photomicrograph showing start of fibrinoid necrosis preparatory
to sloughing. A spicule of bone is being isolated (Van Gieson). (x 8160.)
` THE LANCET]
MAJOR HALDANE, CAPT. ROWLEY: RAPID PSYCHIATRIC ASSESSMENT ` (ocr. 26, 1946 599
the intima showed irregular proliferation ; so the lumen was
almost completely obstructed (fig. 5). In some of the arteries
the external elastic lamina showed much reduplication
and a peculiar fragmentation.’ Outside the vessel wall were
collections of red cells within a web of necrotic connective
tissue. Isolated spicules of bone were not invaded by the
fibroblasts but were surrounded by œdematous fibrous tissue
undergoing necrosis (figs. 6-8). There was no evidence of
amyloidosis. l
In sections taken from other areas the necrosis was more
clearly seen to involve bone and periosteum. It extended
in bands which surrounded the periosteum of isolated spicules
and was associated with much hemorrhage. Here the struc-
ture of the granulation tissue was much less defined, and
there were isolated colonies of fibroblasts separated by
myxomatous fibrous tissue, in which were several irregular
capillarios. There was no evidence of tuberculosis, syphilis,
or carcinoma, and no protozoal or fungal elements were seen.
Specially stained sections showed the only bacteria to be
gram-positive cocci and scanty gram-positive bacilli in the
outer margin of the zone of sloughing. By similar means the
presence of more pathogenic bacteria, such as B. lepre,
B. mollei, and spirochetes, either in this zone or deeper ones,
was confidently excluded.”
DISCUSSION
There seems to be little doubt that the present case
was one of malignant granuloma of the nose ; the clinical
features correspond closely to those of previously pub-
lished cases. In our case the lesion began near the
base of the carious teeth. The sloughing of the premaxilla,
with perforation of the hard palate, preceded a spread
of the disease to the anterior wall of the antrum and
to the inferior turbinate bone. The absence of bleeding
from the lesions was noteworthy. A slight point of
difference in our case from those previously reported
was the absence of any gross haemorrhages, even when
large adherent sloughs were removed.
The most interesting feature of this condition is its
etiology. As regards the theory that the condition is
infective, no specific organism, protozo6on, or fungus
has ever been incriminated. In our case a hemolytic
streptococcus was isolated, but it is not suggested that
its rôle was more than that of a secondary invader. In
our case, as in the previous ones, the serological tests for
syphilis were negative, and the appearances of the
diseased cartilage and bone did not suggest any known
infection. If the cause is an organism, perhaps a hitherto
unidentified one, as suggested by Dempsey (1933), the
reaction of the tissue is unique among infections, for
there is virtually no evidence of the customary cellular
defence mechanisms. Thus the necrotic area is sharply
defined from the subjacent granulation tissue, but there |
is a complete absence of inflammatory cells at the
interface of these zones. The absence of cellular defence
has been emphasised by Stewart (1933) and well exem-
plified in a case described by Iall (1933).
As regards the theory that the condition is a true
tumour, it may be conceded that there are certain
-~ arguments to support this view. In some published
descriptions specific reference has been made to the
similarity of the tissue to that found in fibromata and
sarcomata. The failure of the usual treatment of a
granulomatous lesion, and the reports of beneficial
effects following the exhibition of X rays or radium,
‘may be cited as evidence in favour.
In our case the noteworthy histological features were
the presence of necrosis and degeneration, the cellular
granulation tissue composed of young fibroblasts, and a
process of obliterating arteritis within and behind this
cellular zone. Though the histological changes appeared
- to suggest a new growth, no such tissue was found; the
whole process seemed to be an erosion of existing normal
tissue. We believe that this can be explained by the
coexistence of two pathological changes keeping pace
, with one another:. (1) a locally spreading lesion, the
cellularity of which indicated the property of new tissue
formation, whether this abnormal tissue be granulomatous
1
physical exhaustion or other minor illness.
or neoplastic ; and (2) the obliterating arteritis, to whieh-
can be attributed the “ fibrinoid ” degeneration of the
connective tissue with its accompanying small hæmor-
rhages, and the complete necrosis of more distant tissue.
The resultant state was one of infarction; and both
normal and abnormal tissues, if the latter were being,
produced, were afterwards lost in the sloughing of the
infarcted area.
| SUMMARY
A case of malignant granuloma of the nose in a man
aged 58 is described.
The main feature was a rapidly spreading ulcerative
condition involving the antrum, nose, and palate.
No specific organism appeared to be responsible, and
serological tests for syphilis were negative.
Necropsy disclosed no specific changes apart from the
local lesion.
The histological picture was that of an acute granuloma
with necrosis.
It is impossible to decide whether the condition was
due to an unidentified infection or to an unusual type
of sarcomatous change.
REFERENCES
Chatellier, L. (1929) Ann. Derm. Syph., Paris, 10, 1213.
Dempsey, P. (1933) Brit. med. J. ii, 194.
Goodyear, H. M. (1930) Ann. Otol., d&c., St. Louis, 39, 598.
Hah, I. S. (1933) J. Laryng. 49, 35.
Kraus, E. J. (1929) Klin, Wschr. 8, 932.
MeArthur, G. A. D. (1925) J. Laryng. 40, 378.
McBride, P. (1926) Proc. laryng. Soc. 4, 18.
Mckenzie, P. (1922) Proc. R. Soc. Med, 15, 28.
Stewart, J. P. (1933) J. Laryng. 48, 657. .
Wood, G. B. (1931) Trans. Amer. luryng. Ass, 53, 63.
Woods, R. (1921) Brit. med. J. ii, 65 :
PSYCHIATRY AT THE CORPS EXHAUSTION
| CENTRE
TECHNIQUE OF RAPID PSYCHIATRIC ASSESSMENT
F. P. HALDANE J. L. ROWLEY
M.B. Glasg., D.P.M. M.B. Bolf.
MAJOR R.A.M.C. CAPTAIN R.A.M.C.
THE corps exhaustion centre was established to prevent
psychiatric casualties from impeding the evacuation and
treatment of the wounded and sick when fighting was
severe; to check secondary deterioration ; and to select
and deal with the relatively few men who would be fit for
early effective return to fighting duties. i
The exhaustion centre is a small medical unit staffed
by a specialist psychiatrist, a psychiatrically experienced
medical officer, and specially trained nursing orderlies.
It is attached to another medical unit and so sited that
patients can reach it within a few hours of being evacuated .
from their units.
In dealing with these patients the principal feature
is the initial psychiatric interview, which usually has to
be restricted to about 15 minutes. Its outcome deter-
mines whether the man has a reasonable prospect of,
effective return to action after not more than four or
five days’ retention at the centre. If there is no such
prospect, he must be evacuated farther.
No elaborate treatment is provided. Arrangements
are made to exclude or mitigate various likely sources
of deterioration, suitable conditions for recuperation
are provided as far as possible, and various adjuvant
systems of medication may be prescribed ; but recovery
is largely spontaneous. :
PSYCHOPATHOLOGY
Cases admitted to the corps exhaustion centre can be
divided into three main groups, although they are
seldom of unmixed type.
(1) Normally Constituted Men who have Broken Down
under Unusually Severe Stress.—Situations sometimes,
arise in battle that render psychologically incapacitated
for the time being any man involved, no matter how
“ tough ”?” he may be. We have known all the unwounded
survivors of some such incident arrive at the centre.
Less intense psychic traumata will break down tempo-
rarily a normal man whose resistance is reduced. by
Repeated
traumata tend to be cumulative. Other factors may
E
600 THE LANOET] ý
coöperate. Many of these men respond well to a few
days’ care at the centre.
of our admissions and are most numerous during heavy
major actions.
| (2) Neurotically Disposed Men who have Developed
Neurotic Symptoms under Stress.—Most of these have
to be evacuated. We will not discuss the psycho-
pathology of these two groups; it has been discussed
fully and often enough elsewhere. '
(3) There remains a third group, which has been some-
what neglected. It is larger than the other two and
often constitutes the majority of our cases at this level.
The men in this group are not ill with a neurosis. They
may even show little or no overt anxiety by the time
they reach the centre. They may be said to have had their
anxiety threshold lowered—a recurrence of the anxiety
reaction facilitated. They may be men whose initial
“anxiety threshold” was not high, or whose ‘“ anxiety
tolerance ” is low. But “low anxiety threshold ” and ‘‘low
anxiety tolerance ” are not neuroses.. Probably some of
these men would develop neurotic symptoms if forced
to continue in fighting duties, but they are not yet
neurotic. They are simply men who have been badly
frightened and are habitually too incapacitated by fear
to be capable of effective action under fire. But their
fear is appropriate to the conditions in which it arises ;
it. is not pathological.
Some stigmatise these men as simply lacking in
“ guts.” While deploring the emotional and subjective
attitude implied in the use of the term ‘“‘ gutlessness,”
we have to admit that the reality concealed behind this
appellation is the central factor in this type of psychiatric
casualty and has to be estimated at the psychiatric
interview. |
These men may be evacuated from the line as casualties
because, during a period of special stress, they have
broken down, weeping and trembling and obviously
unable to control themselves; they may be sent for
psychiatric examination because their officers have
found them to be useless and even burdensome ‘“‘ passen-
gers”; or they may be sent for a psychiatric report
because they are facing trial by court martial for desertion
in face of the enemy. In its crudest form their disability
manifests itself in the following features, which appear
with the presence or threat of severe danger: inability
to advance, inability to refrain from flight, inability to
take appropriate action, inability to refrain from taking
inappropriate action—they may leap from their trenches |
and rush about wildly while mortar bombs are bursting
around, sometimes even rushing towards instead of
away from the enemy’s guns—or inability to appreciate
clearly what is going on round them. These features
- may appear singly. or combined. One or more may
predominate in a given man. They have an impaired
capacity, on the one hand, to maintain contact with
reality and, on the other hand, to control their impulses
in accordance with reality requirements. In other words,
their basic ego-functions are involved. These men suffer
from inadequate development of the ego. That is their
essential disability. Accordingly, the main task of the
psychiatric interview at the centre is to estimate the
strength of the patient’s ego.
TECHNIQUE OF RAPID PSYCHIATRIC ASSESSMENT
We have to provide for men who have no neurotic
illness a 15-minute psychiatric interview which will
reveal any subclinical neurotic trends and enable us to
estimate the strength of the patient’s ego. The taking
of a standard psychiatric case-history is of very limited -
value and takes far too much time.
The ego is developed in childhood, especially in early
childhood. It depends on the strength and constitution
of the instincts, the anxieties and tensions connected
with them, and the mechanisms used to master them,
and is influenced by external conditions, especially the
family pattern, the emotional attitudes and behaviour
of the parents and others, and the social tensions within
the home. But simple information about these external
_ conditions tells us very little about the ego’s development
or of the strengths and weaknesses of the total person-
ality. These external influences do not act in a direct
mechanical way on the growing child. What is important
is to know not that the father was harsh but exactly
MAJOR HALDANE, CAPT. ROWLEY: RAPID PSYCHIATRIC ASSESSMENT
They constitute a. minority.
in any way a questionnaire,
[ocr. 26, 1946 ’
how the child interpreted this harshness; what -phan-
tasies he based on it; with what attitudes of submission
or revenge he reacted; what forms of identifications,
introjections, and projections it stimulated; . what
articular anxieties were aroused, and how they were
dealt with ; how all these and other processes influenced
, one another ; how they influenced the general economic
' situation; .and, in particular, how they advanced or
retarded the adaptation of the ego to reality. These
processes are detailed and complicated. They lie obscurely
buried, largely in non-verbalised forms, in the depths
of the patient’s unconscious. They are protected by
an elastic defence in depth of many and varied resis-
tances, each of which would require painstaking, time-
consuming, and patient efforts to breach. In ‘short,
their thorough assessment would require a prolonged
and. skilled analysis, which is obviously out of the
question at a corps exhaustion centre.
We therefore had to devise a method compatible with
a single interview lasting 10-15 minutes. The method
we have adopted developed from our recognition that,
after working laboriously through our routine examina-
tions, we were really influenced very little by the facts
we elicited from the patient. “What really decided our
disposal of him was our intuitive judgment of his person-
ality, based on his appearance, manner, and behaviour
throughout the interview.
Psychiatric intuition, to be reliable, requires the
maximum of behavioural activity from the patient, so
that its judgments may be adequately grounded. This
in turn requires the establishment of. good rapport—
i.e., some degree of positive transference. The adoption
of any stereotyped systematic technique, approaching
I militates against the estab-
lishment of these necessary conditions; by its rigidity
and its impersonality it reduces transference, and by
increasing the activity of the psychiatrist it reduces
that of the patient. |
On the other hand, the value of intuition has serious
limitations. It will vary from one psychiatrist to another
and even from day to day in the same psychiatrist.
The interview must be so conducted that the patient
will provide the richest display of behaviour suitable for
the stimulation of psychiatric intuition, along with the
maximal content suitable for rational evaluation in
terms of ego strength. — |
The function of the ego is the integration of emotional
attitudes and behaviour so as to ensure the greatest advan-
tages in relation to environment and to avoid painful intra-
psychic tension. Successful function of the ego therefore
depends on extensive and accurate testing of reality and on
competent control of conscious and unconscious psychic forces.
The weak ego manifests its weakness in its relative failure
in these various directions. Contact with reality is too limited,
insufficiently firm, and incoherent ; the individual’s behaviour
is poorly integrated and too strongly swayed by unconscious
motives and instinctual demands. The positive findings
would include, for example, restriction of range of interests ;
deficiency of externally directed activity, either habitual or
in the face of real difficulties ; more or less complete loss of
contact with reality under special stress, followed by undue
delay in full resumption of reality testing ; diffusion of effort
through inconstancy or incompatibility of aims; decreased
ability to postpone satisfaction of desires or-to tolerate their
frustration ; and a general lack of good sense in the conduct
of affairs. Such findings justifiably support the decision that
a patient’s ego is excessively weak.
The interview is simply a short conversation with the
patient, in which we ensure that he does very much
the greater part of the talking. We open it with some
commonplace greeting and let it take its course, guiding
it as unobtrusively as possible to the subjects we think
will be most helpful. So long as the topic is effective in
stimulating affective and other responses from the
patient, we allow or urge him to continue. So soon as
we feel we have exhausted the fruitfulness of any topic,
we intervene, as easily and as naturally as possible, to
change the direction of the deliberately one-sided con-
versation. Any topic may be found suitable. We may
induce him to discuss his sources of pleasure and enjoy-
ment or his difficulties in civil or in Army life, his inter-
ests, his family relationships, other domestic matters, &c.
We do not set ourselves to cover any particular ground,
THE LANCET]
DR. HARRIETTE CHICK, MR. SLACK: MALTED FOODS FOR BABIES
(ocr. 26, 1946 GOL
and in general it is very much better to get a vivid and
detailed account of some limited aspects of his experience
than to spread the inquiry more broadly and so get more
superficial responses.
In our experience one topic has usually occupied the
foreground of our interviews, and it is one that, along
with family matters, is most lable to be spontaneously
introduced by the soldier. It is also especially relevant to
our more specific aims. This is an account of his latest
battle experience. We try to get it as full and as detailed
as possible, trying in particular to gain the maximal
insight into his affective responses to battle, his particular
fears and his defences, and the quality of his behaviour-
on the battlefield. Because of the freshness of our
cases, the affective responses are often more accessible
to study here than they would be farther back along
the line of evacuation; many of our patients, when
they reach the exhaustion centre, still show the tail-end
of the physiological anxiety reactions that were stimu-
lated in battle.
Such an interview gives us information on the existence
and importance of ‘‘ neurotic increments ’’ which may
be indicated by accounts of subclinical neurotic reactions,
such as avoidance of quarrels or excitement, nervousness
„in company, difficulties with superiors, excessive fear-
fulness in the dark, &c. But, most important of all, it
gives us a short simple of the patient’s active living
behaviour, on which we can base our intuitive assessment,
the most decisive factor in deciding our disposal of the
case.
CRITICISM
The technique we have described is open to a number
of objections. We shall mention only three that seem
_ important.
(1) Our intuitive judgment of the patient is not really
a direct assessment of the strength of his ego. What we
gain is an impression of his personality, his externally
perceptible qualities. We do not know what relationship
exists between ego and personality in this sense. We have
‘taken an impression of weakness of this personality as
an indication of the weakness of the ego. This is an
assumption without theoretical backing.
(2) We have treated weakness of the ego as a unitary
condition. It is probably not so. Weakness of one set of
ego functions does not necessarily imply weakness of
all the- others. Thus, because a man has excessive
difficulty in restraining the desire for flight, it does not
follow that he is excessively prone to lose touch with
reality under stress. This is obviously very relevant
to the decision about his disposal.
(3) Finally, weakness of the ego is probably much more
variable than, for instance, weakness of the intellect. The
ego may be fortified by such factors as good unit morale
and leadership. It is therefore difficult to decide what
degree of apparent weakness precludes operational
. effectiveness.
In spite of these and other shortcomings we think
that this is about the best that we are at present able to
do in so short an interview. We get a rough but clearer
and probably more accurate picture of the patient and a
fuller insight into his military effectiveness than results
from adherence to the standard routine of attempting
to take a full psychiatric case-history in the time available.
We hope that the method here described may be of
some use to civilian psychiatrists. With the increased
demand for psychiatric services that seems likely to arise
now that peace has returned, it may well be that, for some
time at least, similar superficial methods may be required.
Even apart ‘from this, occasions arise when we wish to.
gain a quick picture of our patient at our first interview,
and some appraisal of the ego strength is necessary in
deciding the form of therapy ‘and in making a prognosis.
Cases seen at the front are in an emotional state which
renders the “ impressionistic ’’ technique indicated especi-
ally fruitful. This is far less so in cases seen under
ordinary circumstances. However,-it still seems worth
while to draw attention to the ego functions, to the
importance of assessing their effectiveness, and to the
general lines of inquiry along which such an assessment
may be conducted.
- SUMMARY
The nature and functions of the forward military
psychiatric unit (corps exhaustion centre) are described.
Cases seen comprise (tf) normal men who have broken
down under excessive stress, (2) neurotically predisposed
men who have developed neurotic symptoms under
stress, (3) men who merely do not function effectively as
soldiers under stress.
The psychopathology of the third group is discussed.
ea of the ego is considered to be the essential-
efec
The most suitable technique for a psychiatric interview
aimed at assessing ego strength and restricted to 10-15
minutes is discussed. Reliance on psychiatric clinical
intuition as the main decisive factor is recommended.
Our thanks are due to Brigadier J. H. Bayley, p.p.m.s.
5 Corps, for permission to publish this paper. l
MALTED FOODS FOR BABIES
TRIALS WITH YOUNG RATS
_HARRIETTE CHICK E. B. Stack
C.B.1I8., D.Sc. Lond. and Manc. B.A. Camb,
From the Lister Institute of Preventive Medicine, London
A MALTED food for infants to provide a supplement or
substitute for milk, when this is very scarce, was
by Dr. G. Caprino in the laboratories of Peroni’s
brewery in Rome and was called by him ‘ Maltavena.’
His formula was brought to the notice of the health
division of the European Regional Office of UNRRA, at
whose request we have tested on young growing rats
the value of such mixtures as sources of proteins and
B vitamins.
The maltavena preparations supplied to us were of two
types : one containing, on a solids basis, extract of malted
barley about 80%, wheat flour (80% extraction of the
grain) about 10%, and skimmed-milk powder about
10% ; the other containing 10% soya flour in place of the
milk powder. Both the wheat flour and soya flour had
also been subjected to digestion with the enzymes of
malt extract for a short time. Of the materials tested in
the following experiments, two, A and C, were of the
first type, and three, B, D, E, contained soya flour ;
their percentage: composition was approximately as
follows :
Skimmed-
Matlavena Malt Wheat Soya milk
preparation extract flour flour powder
A .. 80 it 10 si 5S os 10
B es 80s 10 oe 10 os —
C Js 80 10 T — . 10
D `.. 80.. AO: os “WO 42 <==
E pa W e 10 .. 10 .. 10
- All were supplied in the dry form and were ground to a
fine powder before being fed to the rats.
EXPERIMENTAL
The criterion adopted was the capacity to support
growth in newly weaned rats. For this purpose, diets
were constructed which consisted mainly of the malted
food to be tested and their:value was estimated in
comparison with that of diets containing a similar per-
centage of protein derived from milk powder. The
proportion of protein, carbohydrate, and fat was similar
in all the diets on which growth was compared.
The following procedure was adopted in all the experi-
ments quoted unless otherwise stated. The young rats
(Lister pied strain) received the experimental diets a few
days after weaning, when their body-weight'was about
40-50 g. Litter mates were divided into groups of equal
average body-weight, with equal distribution of males.
and females, and to these groups were allotted the
different diets to be tested. To provide a standard for
comparison, each experiment included a control group
maintained on a diet containing an equal content of
protein derived exclusively from skimmed-milk powder.
The diets made with the malted foods contained about
90% of these materials, with 2% of a salt mixture
R2
~(McCollum’s no. 185) ;
of dry yeast), to provide B vitamins.
THE LANCET |
602
TABLE I—COMPOSITION OF DIETS (PARTS PER 100 g.)
l Expt. 11 Expt. ui
Material —
Diet | Diet | Diet | Diet | Diet | Diet | Diet
-8 4 §* 6 7 7a 8°
Maltavena C 89 . 85 an
Maltavena D ee 89 85-5 {88
Extra soya flour.. . . 6-1
` Extra milk powder | 10 9 35 11 79 31
Lard 2 3°4 1-83] 0-4f| 4:0
Sucrose ae .. |64 .. | 44 | 4-4 |64
Salt mixturet .. {09 | 0-9 |10 | 0-9 | 0-9 |175| 1-0
Average nitrogen . .
content (% on
air-dry wt.) 1-70 1°77 1:79 | 1:74 | 1-77| 1-67] 1-65
* Milk control. t McCollum’s no.
t These amounts were given P pune the total to Trout 4%;
soya flour contained 22 % fa
§ Extra salt mixture added as diet 7a contained no milk powder.
in some trials extra fat was
added to bring the total up to about 4%. In the experi-
mental diets the malted food provided the protein and the
carbohydrate ; in the milk-powder control diets sucrose
was added to make a corresponding proportion of carbo-
hydrate. The composition of some representative diets
is shown in table 1.
Each rat received daily 2 drops of cod-liver oil, to
supply vitamins A and D, and (except in experiment Iv)
1 c.cm. of a protein-free aqueous yeast extract (=0-5 g.
The proportion of
nitrogen, reckoned on a solids basis, was arranged to be
about the same in the diets compared in any one experi-
ment ; it varied in the different trials from l. 6% to 1-:8%,
representing about 9-5-11:0% of “crude” protein.
_ These amounts are suboptimal for the growth of young
rats and were purposely so arranged to ensure that the
protein content was the factor limiting growth. All
other essential nutrients were present in adequate
amounts.
Expt. 1.—In this test comparison was made of the nutritive
value of the protein and other nitrogenous substances present
in maltavena A and B. The diets 1 and 2, incorporating
products A and B respectively, as fed to the rats, contained
16% of nitrogen, or about 9:69% of crude protein. The
control diet with skimmed-milk powder also contained 1:6%
of nitrogen.
The rats on diet 2 thrived better than those on diet 1, but
less well than those on the control skimmed-milk- powder
diet. The rats on the control milk-powder diet developed a
scaly condition of the skin on paws and tail after about seven
weeks owing to the lack of unsaturated fatty acids. The
condition improved with the addition of 4% of lard. Rats
receiving soya flour (diet 2) had no skin affection, because the
fat in the soya bean contains a high proportion of unsaturated
acids (Durkee 1936).
Expt. u.—The malted products C and D tested in this experi-
ment and in experiment m1 had a total nitrogen content of
1-3-1-5% ,on the dry weight, which is too low for a satis-
DR. HARRIETTE CHICK, MR. SLACK: MALTED FOODS FOR BABIES
ron 26, 1946
factory test with young rats. Accordingly 10% of skimmed-
milk powder was added to each. In this way the percentage
of nitrogen in diets 3 and 4, made with these two. products
respectively, was raised to 1- 7-1- 8% (the crude protein being
10-11%). The milk-powder control diet 5 was arranged to
correspond (see table 1).
This increase: in protein content was accompanied by a
better rate of weight increase than in experiment r. On
diet 4, containing maltavena D with soya flour, the rats
progressed almost as well as on the milk-powder control diet ;
the performance on diet 3 was inferior. The average weekly
weight increase in 32 days on diets 3, 4, and 5 wás,
respectively, 10-0, 13-6, and 13-9 g. (see figure).
Expt. 11.—In this test lard was added to each diet in amount.
to make the proportion about 3-5% in the diet (see table 1).
The performance of the young rats was compared on diets.
6 and 7 (table 1), which contained the malted products C and.
D respectively, after the addition of extra milk powder to each,.
as in experiment m. An additional diet, 7a, was tested, in
‘which 6% of soya flour was added to maltavena D to provide
an amount of nitrogen equal to that in the extra milk powder.
The control diet 8, with all protein derived from the milk.
powder, was included in the experiment.
In all groups the rate of weight increase was satisfactory,.
in view of the low level of protein in the diets for. these rats.
With diets 7 and 7a, containing soya four, growth was as.
good as with the milk-powder control diet 8, the average weekly
weight increases being 15-5, 14-4, and 14-6 g. respectively. On
diet 6, containing malt extract with wheat flour and skimmed
milk powder, the weight increase was less (average weekly
increase 12-8 g.) in spite of the fact that about half of the
protein was derived from milk protein (see table 1m). |
It may be concluded that the growth-promoting value of
the mixture of proteins of malt extract, wheat, soya flour,
and milk as contained. in diet 7, and that of the mixture of
TABLE IlI-——EXPT. IV (DURATION OF TEST 49. DAYS)
ation No,| AY bodys | AN
sition O, ) |W y
Diet 9 | (parts =s of ENG ey
per rats ress f
100 g.) itial |Final|: 52,
Maltavena E 94 ‘With yeast ex- 4 44 139 | 138-6
tract 1 c.cm.
Salt mixture 1 daily š .
Lard ive 4 Without yeast | 4 43 132 12-7
——__—__— extract :
Nitroge
content (%) 1-7
those of malt extract, wheat flour, and soya flour as contained
in diet 7a, were equal to the value of milk proteins.’
Expt. 1v.—Extracts of malted barley and the soya bean are
both known to be good sources of B.vitamins. For this test
. diet 9 was composed of maltavena E with salt mixture and
lard ; the nitrogen content of the diet was 1-7% (see table mn).
A single litter of newly weaned rats was divided into two
groups of 4 rats ; both groups received this diet with the usual
daily dose of 2 drops of cod-liver oil. One group received
additional B vitamins as 1 c.cm. of yeast extract daily ; the
other group received none. After seven weeks there was a
slight, but doubtfully significant, advantage in the average
body-weight of the rats on extra B vitamins, the respective
figures for the two groups being 139 and 132 g. and the average
weekly inorengge 13-6 and 12:7 g.
TABLE II—EXPT. III (DURATION OF TEST 6 WEEKS)
Material tested no.
| (%)
Maltavena C* + extra akimmed-milk powder 10 % 6 | 1°74
Maltavena D* + cxtra skimmed-milk powder 10 % 7 1-77
Maltavena D* +extra soya flour 6% 7a 1°67
1-65
Milk-powder control diet 1: i as su a 8
AV. Protein
Diet ! aitrocen (N x6)
content | content
Percentage (approx.) of protein
Body-weight (av.
derived from— ( )
Ni Av. weekly
(%) | Malt |White| Soya | Skimmed-| rats Patil ong
extract| flour | flour powder (z.)
z 10-4 32 | 10 | .. | 58 | 6 | 396] 12-8
10-6 34 | 11 | 30 | 2% 5 | 390 | 16-5
10-0 34 | 10 | 56 n 6 | 297 | 144
9-9 100 6 | 382 | 14-6
* Seo table I.
x
BOOY -WEISHT (9)
WEEKS
+
Average weight curves of 5-6 rats on diets in which nitrogen was derived
from the malted preparations, compared with those of rats on control
diets containing an equal proportion of nitrogen derived from milk.
For particulars of diets see tables | and ii. Diets 5 and 8 are milk-
powder control diets.
This result indicates that maltavena containing soya flour,
if used for baby food, would not need supplementation with
food yeast or synthetic B vitamins.
DISCUSSION
The results of the tests indicate that a combination of
malt extract about 70 parts, wheat flour about 10 parts,
and soya flour about 16 parts (on a solids basis) possesses
a mixture of proteins whose growth-promoting value for
young rats is about equal to that of the proteins of milk.
When 10 parts of skimmed-milk powder replaced about
half of the soya flour, the growth was not increased to a
° significant extent (experiment 111). It is concluded that
the enhanced worth of the mixture is due to the supple-
mentary action for one another of the proteins contained -
in the different ingredients. The proteins of the soya
bean, in common with those of other legumes, have been
shown to have a supplementary effect for those of rice
or of white wheat flour (Indian Research Fund Associa-
tion 1946; Jones and Divine 1944). We have confirmed
this fact for white wheat flour and the sample of soya
flour used in the manufacture of the foods tested in the
present work (Chick and Slack 1946). It is possible that
the protein in the malt further supplements those in
the wheat and soya flours. Everson et al. (1944) have
shown that the nutritive value of soya protein is increased —
` by germination of the beans. We, however, did not
find any enhancement of the growth-promoting value of
barley after malting.
- With the experimental rats in the present work, better
growth and healthier animals were obtained when the
diet contained about 1-8% of nitrogen or about 11%
of crude protein (on a solids basis) than when the propor-
tion was lower. The human baby, however, with its
-much lower growth-rate, presumably requires less protein
in its diet than the rat, judging from the low proportion
of protein in human milk compared with that of the rat.
But since the biological value of the proteins in human
milk may be greater for the human infant than that of
any artificial mixture, a proportion of about 11% of
protein in the diet would not seem too high.
The composition of these malted foods was originally
so arranged that, when diluted for consumption, it should
DR. HARRIETTE CHICK, MR. SLACK: MALTED FOODS FOR BABIES
focr. 26, 1946 603
equal that of human milk in calorie value and in content
of proteins and total minerals, and the results of our
experiments indicate that the maltavena preparations
containing about 16% soya flour, owing to the supple-
mentation. of the various proteins contained in the
constituents, may meet the protein requirements of an _
infant and provide a sufficient supply of B vitamins.
Maltavena, however, even when compounded with
soya flour in the amount included in diet 7a, is very
deficient in fat (possessing about 1/6 of that in human
milk) and in fat-soluble vitamins. The latter can be
easily supplied by a small dose of cod-liver oil. To
what extent the fat in a food for infants can be replaced
by an isodynamic equivalent of carbohydrate is uncertain.
Owing to milk shortage in Vienna during the war of
1914-18 attempts were made at the University Kinder-
klinik to-feed babies on dilute skimmed cow’s milk to
which sugar was added to bring the calorie value up to
that of human milk. These results were unsatisfactory,
but the importance of fat-soluble vitamins was not
appreciated at that time. As a routine measure the
director, Prof. C. von Pirquet, reduced the fat in the diet
of the babies in the clinic to half and substituted an
amount of cane-sugar of equal energy value. The
infants thrived during the summer on this diet but
developed rickets in the winter; the addition of cod-
liver oil prevented the rickets (Chick et al. 1923). .
Only clinical trials can decide whether the human
infant will thrive on a diet which, though containing
enough good protein, suitable carbohydrate, and the
necessary minerals and vitamins, has a fat content which
is only a small fraction of that in its natural food.
CONCLUSIONS
The nutritive value of the proteins contained in the
different samples of maltavena received, and in modifica-
tions of these, was measured by their power to support
the growth of young newly weaned rats, in comparison
with that of milk proteins.
Of the mixtures tested, the one containing malt extract
70%, wheat flour 10%, soya flour* 10%, and powdered
skimmed milk 10%, with total nitrogen about 1-8%,
proved the most advantageous. The combined supple-
mentary action of the different proteins it contained
rendered the mixture equal in growth-promoting value
to the mixture of proteins in milk, when fed in a diet of
equal nitrogen content. : . l
Though the mixture of malt extract with wheat flour
10% and soya flour 16% was as efficient as that in which
skimmed-milk powder 10% was substituted for about
half the soya flour (experiment 111), it would seem safer,
on general grounds, to include a small proportion of
milk powder in any infant food.
' We wish to thank Glaxo Laboratories Ltd. and Ovaltine
Research Laboratories (A. Wander Ltd.) for the supply, on
behalf of UNRRA, of the maltavena preparations; Mr. G. W.
Flynn for his technical assistance; and Sir Charles Martin
for his hospitality at Roebuck House, Cambridge, where the
work was carried out, and for his constant support. and
helpful criticisrn.
: REFERENCES :
Chick, H., Dalyell, E. J., Hume, E. M., Mackay, H. M. M., Smith,
H. H., Wimberger, H. (1923) Spec. Rep. Ser. med. Res. Coun.,
Lond, no, 77, part It. . E
— Slack, E. B. (1946) unpublished work.
Durkee, M. M. (1936) Industr. Engng Chem, 28, 898.
Everson, G., Steenbock, H., Cederquist, D. O., Parsons, H. T. (1944)
J. Nutril. 27, 225. . l ,
Indian Research Fund Association (1946) Spec. Rep. Indian Res.
Fund Ass. no, 13. ,
Jones, D. B., Divine, J. P. (1944) J. Nutrit. 28, 41.
Mackay, H. M. M. (1940) Arch. Dis. Childh. 15, 1.
* Sova flour is well provided with calcium and phosphorus, con-
taining about two-thirds of the amount present in dried cow’s
milk, but there is less calcium than phosphorus, whereas in
milk the reverse is true. Many workers using soya flour for
infant feeding have therefore added a small amount of a
calcium salt (see Mackay 1940). i
604
THE LANCET]
Reviews of Books aos
Child and Adolescent Life in Health and: Disease
_ W. S. CRAIG, B.so. Glasg., M.D. Edin., F.R.c.P.£., formerly
first assistant in the department of child life. and health,
the University of Edinburgh; with a foreword. by Prof.
Charles McNeil, F.R.c.P. Edinburgh : E. & S. Livingstone.
Pp. 667. 25s.
Tas book appears appropriately at a time when the
child-health services are under review, and when
pediatrics is taking an increasingly important place in
the training of both medical students and postgraduates.
Professor Craig has divided his comprehensive work
into four main sections and a number of appendices.
The first part, which is historical, deals with the early
development of systematised care for children from the
haphazard and often chaotic results of private philan-
thropy and poor-law administration. The second, and
major, part deals with care of child life at the present
time. This section includes particulars of organisations
dealing with homeless children, provisions for juvenile
delinquents and for handicapped children, the mainten-
ance of health, treatment of the sick, and care of children
under conditions of total war. The third section, on
‘* the spirit of future endeavour,” is surprisingly slight
considering the importance of the subject, and barely
touches many of the problems suggested by the subtitles.
Finally there is a first-class summary of the more
important legislation dealing with child health and care.
Where there is so much to praise, it is perhaps mere
carping to suggest that there are rather too many
pleasing studies of child life among the illustrations.
Regarded as a social study, the book is unique at present
and contains a great deal of information not readily acces-
sible elsewhere. It should be useful both to the public-
health worker and the clinician concerned with child health.
The Osseous System
VINCENT AROHER, M.D., professor of roentgenology,
University of Virginia. Chicago: Year Book Pub-
lishers. London: H. K., Lewis. Pp. 320. 33s. _
THis is the fourth of a series of six handbooks on
radiological diagnosis. It is well produced with many
good illustrations of the common bone diseases and.
abnormalities. The text is brief and to the point and
references between text and illustrations are very easy
to follow. These handbooks are a cross between an atlas
and a textbook—a difficult species to breed with success.
This one is a success because rarities are omitted and
emphasis is placed on common mistakes observed over
a period of twenty years in a teaching hospital. The best
` section is on bone abnormalities in childhood, and the `
-book can be heartily recommended to students studying
for a radiological qualification.
Tropical Nutrition and Dietetics
(2nd ed.) Lucrus NicHoLts, M.D. Camb.
Bailliére. Pp. 370. 27s. 6d.
NUTRITION in the tropics differs but little from nutri-
tion in temperate regions as regards the quantity and
the quality of the food which is essential to preserve
health ; the differences lie chiefly in the fact that the
inhabitants of the tropics eat foods which differ in their
composition from those eaten in temperate regions.
There have been very few investigations in the tropics
concerning whether more or less of any dietary con-
stituent is required to maintain the body in a state of
good nutrition, but a book of this kind should review
them. The increased requirement of sodium chloride
in the warmer parts of the tropics is lightly passed over,
however, and the severe deficiency arising in heat
exhaustion is not mentioned. In all who live in the
tropics the basal metabolic rate is believed to be reduced
by some 10%; but none of the published observations
on this important point are specifically mentioned.
The author shares the belief of some other doctors
in the tropics that the indigenous people need less
food, though no colour bar has been detected in the field
of human nutrition. Thus he affirms that an adult
male labourer in the tropics, in view of the fact that he
weighs only 52 kg. (almost certainly because he is poorly
nourished), needs only 1500 calories for basal metabolism,
600 calories for minor activities outside his working
London :
REVIEWS OF BOOKS .
- [oer. 26, 1946
hours, and 400-500 -calories for his work. -- His protein
requirements, however, are set at 65 grammes and his
fat requirements at 50 g.—both liberal estimates. Other
requirements are assessed at calcium 0:5 g., iron 8 mg,
vitamin A 1800 units, nicotinic acid 20 mg., ascorbic
acid 40 mg., and thiamine 0-4 ug. for each non-fat calorie.
Some of these figures are distinctly low when compared
with those which are generally accepted in other parts
of the world. The discussion on the vitamins and
minerals is otherwise detailed and accurate ; the section
on thiamine and beriberi is exceptionally good, largely
because in this field workers in the tropics have made a
unique contribution to knowledge. Such effects of protein
deficiency as nutritional cedema, however, are too briefly.
discussed, and there is almost no mention of necrosis
of the liver or of cirrhosis. Casein hydrolysates and
the administration of plasma: are not mentioned;
kwashiorkor is dismissed as of no account ;
tional iron-deficiency anemia is considered to be almost
an impossibility in the male.
The tables on the analyses of tropical foodstuffs are
useful and accurate, but the approximate wastage in
preparation might have been indicated. .' The discussions
on the different tropical foodstuffs and public-health
aspects of nutrition are some of the best in the book. On
the whole Dr. Nicholls fairly presents what is known in the
field of tropical nutrition, but sometimes fails to_discrimi-
nate between the established facte—all too few—and the
speculations—all too many.
Evolution of Plastic Surgery
MAXWELL MALTZ, M.D., SC.D. New York: Froben Press.
Pp. 368. $5.
It was a happy inspiration of Dr. Maltz to give us
an outline of the history of plastic surgery from primitive
times to the present day. Reparative surgery began in
_ the hard school of war, and today ample scope has
been given for the skill of modern surgeons, especially
in facial plastic surgery—though some of „the new
modern methods are but refinements and improvements
of the old. The Greeks and Arabs made little contribution
to the evolution of plastic surgery. In the 10th century
the Jews gained fame as physicians and surgeons but
in 1267 the Council of Venice prohibited Jews from
practising on the body of any Catholic believer, and
the study of anatomy was likewise forbidden. During
the Middle Ages plastic surgery languished, for the
Fathers of the Church regarded anything pleasing to the
eye as a temptation of the devil. It was only after
the foundation of Salerno University that the Italian `
physicians revived surgical art. in modern Europe.
The University of Bologna followed, where in the 16th
century the great Tagliacozzi—sometimes called the
father of plastic surgery—arose and gave his name to
an operation for rhinoplasty. General and local anss-
thesia have favoured the evolution of modern surgery.
Gillies’s use of the direct-flap method is fully: described,
and the author pays tribute to his brilliant pioneer
work and that of Vilray Blair of the United States.
Pneumoperitoneum Treatment 7
A. L. BANYAI, M.D., F.A.C.P., associate clinical professor
of medicine, Marquette University, Milwaukee. -London :
H. Kimpton. Pp. 376. 33s.
OUTSIDE the world. of pulmonary tuberculosis pneumo-
peritoneum is generally known as an occasional diagnostic
and therapeutic measure. The use of intraperitoneal
oxygen or air in the treatment of tuberculous peritonitis
dates back 50 years, but it is only in the past few years
that the indirect effects of pheumoperitoneum on the
lungs have been used at all extensively. The air in the
abdomen pushes the diaphragm up into the chest, and
thus affects the capacity of the thorax. When used in
conjunction with paralysis of the phrenic nerve the
elevation of the diaphragm can be considerable and isa
valuable addition to collapse therapy. It is usual to use
pneumoperitoneum in conjunction with phrenic-nerve
interruption or artificial pneumothorax, since its effects
alone are not extensive enough to be of great value. Ina
comprehensive and detailed study, Professor Banyai deals
with all aspects of the procedure. Generally speaking
complications are rare, though peritoneal effusion is
sometimes encountered ; the risk of darnage to bowel is
not likely to be overlooked by the operator.
and nutti- a
Serene emer a -ŘE ten a mt
THE LANCET]
THE LANCET
LONDON: SATURDAY, OCT. 26, 1946
A Joint Enterprise
‘MEDICINE and nursing are one art, its aim the care
of the patient. If medicine goes on growing, as it
must, while nursing is suffering a decline, the achieve-
ments of one will be offset by the failures of the other.
However sure the diagnosis, neat the operation, or
apt the drug the patient dies or suffers if he is badly
nursed. Doctors have thus towards the nursing
profession a duty of which nowadays they seem hardly
aware. In the early days of modern nursing the
nurse looked to the doctor for advice and help in
developing her specialty, and the results of that
collaboration have been an example to the world.
Indeed, many of the principles laid down in that
atmosphere of confidence and endeavour have stood
the test of a century of nursing practice. The
founding of the State examination, which placed
nursing finally on the footing of a profession, should
have - strengthened the partnership, doctors and
nurses working together as colleagues. In practice
there has been something of a break, for which both
professions must accept blame. The doctors, probably
from inertia, have lost interest in the training of the
nurse, and the nurses, from a natural wish to cultivate
their own garden, have drawn away from the doctors.
It will not do: any disunity—anything short of
complete and sympathetic collaboration—means too
much risk to the patient.
The neglect of nurses by the doctors has helped
to bring nursing into disrepute with possible candi-
dates. Miss MurirL Epwarps, of the Nursing
Recruitment Centre, tells us that when she talks
in a girls’ school on nursing as a profession she often
has a long queue of eager questioners to answer at
the end; but girl after girl says, “ I want to do some-
thing in a hospital—not nursing, of course.” Asked
what, then, she would like to do, the girl says she
would like to “do therapy.” She does not know
what kind of therapist she wants to be: she hardly
understands the meaning: of the word. All ‘she
knows is that a “ massage”’ student is on a very
different footing—not only with the doctors but
with the general public—from a nurse. To her,
nurses are hack workers of whom little scientific
ability but much domestic work is expected ;
unfortunately the lack of domestic help in hospitals
‘has lately given fresh colour to this old prejudice.
Theory in the present nursing curriculum, illogically
based on the course of the medical student, is wide
in scope and shallow in content, bewildering for the
simple girl, yet leaving the girl with brains unsatisfied.
Nursing should mean an intimate personal study of
the patient; yet bedside nursing, the core of the
whole art, is taught in hasty snatches by a sister
who is fully occupied in other ways, and by a sister-
tutor who is confined to the classroom, and must
somehow invest an unrespohsive dummy with' the
appeal of a living patient. Research in nursing is
unknown under that name; for though many an
ingenious sister contributes impromptu devices to
nursing, there is no recognised way of spreading
A JOINT ENTERPRISE
and ,
the equivalent of 17 litres in fifteen days.
[oct. 26, 1946 605
new methods from one hospital to another, and tech-
niques which might have a universal value are still-
born, or live only. as long as the local need persists.
Again, nurses have no proper control over the equip-
ment they use ; these women, who should be as good
with their hands and as thrifty with their strength
as an old sailor, put up with much pointless exertion
because a nurse is not expected to knock in nails,
rig pulleys, or put screws in the ceiling when these
would make things easier for the patient or for herself.
The very aspect of nursing that should appeal most,
‘alike to the intelligent and to the handy girl, has
been allowed to sink into a hurried routine in which
bedmaking and bedpans, the clock and the sister, have
become dreary phantoms, crowding and diminishing
the patient.
We believe that the medical profession must take
a full and responsible share in restoring nursing to the
position in which FLORENCE NIGHTINGALE placed it :
as an absorbing and stretching career for women
with brains, as well as a satisfying occupation for
women who, though not academic, are physically
and emotionally apt for the care of the sick. And we
think that an important step in this reablement might
be achieved by the founding of an experimental
school of nursing in which new departures in the
curriculum, as well as in the conditions of the nurse’s
life, might be given a fair trial. A large training
hospital might offer the best opportunities for this
venture, and it is possible that funds might be forth-
coming from various sources to meet the expenses :
certainly the Royal College of Nursing was in com-
munication with the Rockefeller Foundation, before
the war, about the establishment of a demonstration
school of nursing, though this was probably dedicated
to another type of experiment.
In this school, we suggest, a medical dean of nursing
should be appointed, to work with the matron,
the sister-tutor, and the ward sisters in devising a
theoretical curriculum oriented to the nurse’s needs—
for example, with less emphasis on anatomy and
physiology and far more on bacteriology and spread
of infection. The school might explore the possi-
bilities of a two-year basic training for all entrants—
in which bedside nursing was given the honourable
place it deserves—and of a senior course, making
good use of the mental capacities of the girl who
wishes to become a sister. The medical dean of
nursing should, in our view, feel himself or herself to
be as much responsible for the proper training of the
nurses as the dean of the medical school is ‘for his.
students, and should bring his or her medical col-
leagues to share more fully in the education of student
nurses, especially by taking ward rounds. An example
of this kind could not fail to benefit the standing
of nursing; besides renewing its standards.
The Bleeding Peptic Ulcer
THE treatment of gastroduodenal bleeding, in
common with other hemorrhagic conditions, has
benefited from the war experience of blood-transfusion.
This has brought home to the surgeon what large
amounts of blood can and often should be given
—one of Loutrr’s! patients, for instance, received
Moreover,
administration has become technically easy and,
1. Pappworth, M. H., Loutit, J. F. Lancet, 1943, ii, 469.
606 THE LANCET]
with reasonable care, hzmatologically safe. The
number of recognised agglutinins, it is. true, is
increasing, but their recognition has made it simpler
` to avoid the dangers of sensitisation. The amount
of blood to be transfused must be based on the
amount lost, but investigations on blood-volume in
shock and hzmorrhage, initiated for gastroduodenal —
bleeding by BENNETT and his collaborators ? * before
the late war, revealed the fallacies of clinical estima-
tions of blood- loss.. It is now clear that after hemor-
- rhage the fluid and corpuscular elements of the
blood are restored to a certain extent independently -
of each other, and at completely different rates.
The hemoglobin level is therefore not in itself a
reliable guide to the blood-loss; moreover, it is usually
impossible to make any allowance for previous
anemia, The level is not immediately altered by
a brisk and heavy bleeding, when corpuscles and
plasma are lost in the same proportions; it is only
later, when the plasma has been replaced and the
patient’s condition therefore improved, that the
hæmoglobin, now lowered, gives some measure of
the seriousness of the hemorrhage. It is true that
hzemodilution usually takes place within a very few
hours, but it may take up to 24 hours,” and the
picture is further complicated if the bleeding continues
or recurs. The patient’s general condition is of course
important in estimating severity, and measurement
of a large hematemesis or melæna will give a rough
minimum estimate of the blood lost; the blood-
pressure is also a valuable clue, particularly if the
normal level is known, and a low pulse-pressure
may help in the recognition of the collapsed hyper-
_ tensive. Nevertheless, accurate criteria of severity
are still Jacking, and without them it is difficult to
confirm and evaluate reports of treatment. What
is most needed is an easy and reliable method of
determining the blood-volume.
The controversy round treatment usually turns
on whether the bleeding from chronic ulceration
should be treated surgically or medically, and, if
surgically, at what stage. Results are best where
coöperation between physician and surgeon is closest. 4
Chronic ulceration accounts for 80% of cases of
gastroduodenal hzmorrhage,> but where hæmate-
mesis or melena is the first manifestation the
differential diagnosis must be considered. The
patient bleeding from an acute erosion or through
cirrhotic congestion or a hemorrhagic disease, such
as purpura, is not a suitable subject for gastric
exploration, though FINSTERER ê believes that when
doubt exists the risk in operating is outweighed
by the danger of leaving a chronic ulcer bleeding.
He even advocates gastrectomy for the gastrostaxis
of multiple erosions, though this is an extreme view
and his quoted fatalities, whether operated on or
not, by modern standards received woefully inadequate
transfusions. On the other hand, his plea for opera-
tion on the known bleeding ulcer within the first
48 hours is well founded. Protracted hemorrhage
is to be anticipated from an ulcer with a big vessel
open in its base; and though, if it is not too severe,
Bennett, T. I., Dow, J., Lander, F. P. L., Wright, S. ‘Ibid,
1938, il, 651.
. Bennett, T. I., Dow, J., Wright, S. Ibid, 1942, ii, 551.
. Gordon- Taylor, G. ‘Brit. J. Surg. 1946, 33, 336.
. Eads, J. T. J. Amer. med. Ass. 1946, 131, 891.
. Finsterer, H. Surg. Gynec. Obstet. 1939, 69, 291.
Cc Gn ie GO 5
THE BLEEDING PEPTIC ULCER
[ocT: 26, 1946
the blood-loss can continually be made good, the
patient’s final condition, with very little of his own
blood left, is not so satisfactory for - operation as
at the beginning. The bleeding often stops, thus
dispelling the need to operate during the period of
hemorrhage; but sometimes it continues, and by
procrastination the surgeon is finally offered a
debilitated poor risk. The problem is to decide in
which case the bleeding will stop.. With a known or
strongly suspected ulcer, if the bleeding i is not appre-
ciably lessening after 24 hours of adequate treatment,
it is wise to step up the transfusion until the heemo-
globin is at least 60%, and then take the patient
to the theatre with the drip running. Where the
diagnosis is in doubt, the best course is probably to
replace blood for blood and to make every effort
consistent with safety to establish a diagnosis. Some
still say that transfusion, by raising the blood-
pressure, will start hemorrhage afresh. This is not
supported by experience with drip methods, and indeed
the bleeding sometimes stops as soon as the first
pint has been absorbed. In any case it may be
essential to raise the blood- ‘pare if life is to be
saved.
. Diet is important, whether the patient BT: -being
treated medically dr surgically. A bland semi-solid
diet, as recommended by Wrrts,’ is perhaps the
most generally useful. There is need to go slow with
feeding for the first 24 hours; for the patients often
feel sick, and vomiting is liable to start the bleeding
again. Opinion i is not yet settled as to the advisability
of emptying the stomach of its blood contents with
a tube; the smooth clot covered with mucus makes
for nausea and interferes with the sealing of the
bleeding vessel. After 72 hours, well-cooked cereals,
custards, junket, soft-boiled egg, and puddings may be
given in greater quantities. Vitamin. C, up to 500 mg.
a day, should be given. Absolute bed rest may be
supplemented by. morphine, which should be . given
in moderate doses since these patients are prone
to serious lung complications. Morphine ‘should be
replaced by barbiturates after 24 hours. In. the
convalescing patient the hæmoglobin and blood-
pressure should be frequently estimated ; the hæmo-
globin should not be allowed to remain low, for a
further hemorrhage would then be disastrous. Packed
corpuscles are at this stage superior to whole blood,
and should be given in repeated small infusions.
When operation is decided on, its nature will
obviously vary with the patient and the surgeon.
To. open the stomach (or duodenum) and insert
mattress sutures over the ulcer is the simplest, and
with bad risks the best, procedure; . and it may be
necessary to combine this with ligature of the bleeding
vessel. With the induration and distortion that is
often present it may not be easy to establish which
vessel. needs tying or to expose it. Here detailed
knowledge of anatomy is essential, and it should
include an understanding of the anomalies of vessels
at the pyloric end of the stomach which .GoRDon-
TAYLOR ® describes. He emphasises that operating
for ulcer hemorrhage is not synonymous with gastrec-
tomy. The object is to stop the bleeding and prevent
its recurrence ; this may in fact be sometimes most
readily attained by gastrectomy, and it is reasonable
: aes itts, L. J. Brit. med. J. 1937, i, 847.
. Gordon- Tay lor, G. Brit. J. Surg. 1937, 25, 403.
THE LANCET]
INFECTED FOOD
foct. 26, 1946 607
to consider this surgical cure if it does not add exces-
sively to the risk. Some of the figures for gastrectomy
show how remarkably results have improved with
adequate transfusion—but it must not be forgotten
that the results of medical treatment have also
improved.
If the physician is to do his best for the patient
he must learn to. differentiate early between the
-case in which there is but a slow intermittent ooze
and the serious hemorrhage from the open large
vessel, unlikely to yield to simple medical measures.
The patients who die are usually those over the middle
_ forties. This is not because of any associated arterio-
sclerotic brittleness of the vessels, but because these
patients have almost certainly had ulcers of long
standing ; the bleeding vessel is encased in a fibrotic
mass and is unable to retract and contract. Throm-
bosis in the vessel is the only hope of stemming the
leak. The case with a long history, and particularly
with. previous bleeding, is the one where the need
for surgery requires strongest consideration. Before
the late war it was generally held that to operate
after 48 hours’ bleeding was nearly always disastrous,
especially as the bowel suture lines seemed to make
no attempt at adequate healing. With the adoption of
massive rapid transfusions this is no longer true,
and results in this country show that such “late ”
surgery is now being successfully undertaken. Never-
theless, cases requiring surgical intervention are
relatively few, and medical management must still
form the first line of treatment.
Infected Food
_ ‘THE increasing incidence of food-poisoning since
the start of the late war may be due, in part, to
_the growing number of residential institutions and
communal feeding centres.
- gation of the toxic form is hampered by the lack of a
susceptible animal. Moreover, no outbreak can be
fully investigated unless it is notified at its very
beginning ; this rarely happens, and anyone working
on the subject is familiar with the disappointment of
arriving to find that all the suspected food has been
thrown away or that only some empty tins remain,
stinking and fly-blown after days in a dustbin. It
is from the comparatively few outbreaks which have
been fully investigated that our understanding of the
condition is derived.
-= Ducks’ eggs have been repeatedly incriminated as
a source of salmonella infection. Lately Salmonella
` typhimurium (ertrycke) of identical phage type was
isolated from a patient who had eaten an egg and from
the duck itself1; and the Ministry of Health’s war
report * records altogether nine outbreaks from this
source. MALLAM and ALHADEFF,? in. recording
another case, urged that ducks’ eggs for eating should
come from healthy birds, be gathered daily, and be
laid in dry and uncontaminated surroundings. The
hen’s egg, in the “ shell-egg ” form, appears to be a rare
source of infection ; the first and only certain example
was reported last year by Warr,‘ who isolated
S. montevideo from eggs of the batch used for the
1. Gorden, R. F., Buxton, A. Mon. Bull. Min, Hlth æ E.P.H.L.S.
1945, 4, 46. ’ Gillespie, E. H. Ibid, 1946, 5, 157.
2. On ioe = tate of the Publio Health during Six Years of War,
Unfortunately, investi-.
mayonnaise from which an outbreak originated.
However, S. pullorum, the cause of bacillary white
diarrhoea, remains the most important source `of
fatal septicemia in young poultry, and other salmonella
organisms pathogenic to man are now causing serious
epidemics in poultry. . It was therefore natural that
dried eggs, which began to arrive here in 1941 and
were first distributed on a large scale in 1942, should
be investigated for this group of organisms. Since
1942 there have, in fact, been outbreaks with many
new types; to S. typhimurium, enteritidis, thompson,
and newport have been added S. oranienburg, monte-
video, sundsvall, meleagridis, and others hitherto
unknown in this country. During 1942 vast nifmbers
of American troops were arriving here; but, though
they mixed with the civilian population, they took
no part in the preparation of its food, and are thus
unlikely to have had any notable effect. Investigation,
in fact, confirmed that dried eggs were the source, for
‘in them the new types, including S. oranitenburg and S.
monlévideo, were identified. During the war altogether
ten outbreaks of salmonella infection in man were
attributed to this source,® although the instructions
for reconstitution had been amended to direct that
the fluid mixture should be used immediately, so as
to minimise the time during which the. organisms
could multiply. |
Cooked-meat products have always been regarded
as an important cause of food-poisoning, especially
because the salmonella group is pathogenic to both
bovines and pigs; S. dublin and S. enteritidis, for
example, are a cause of diarrhoea in cows and may
give rise to symptoms in humans who drink infected
milk. But cooked meat, particularly in brawn and
meat pies, is probably most commonly infected from
extraneous sources, such as food-handlers, rodents,
or flies. The food is commonly harmless when eaten
soon after being prepared, but, by the multiplication
of bacteria in such an admirable medium, may cause
serious illness when consumed a few hours later.
Last year an extensive and explosive outbreak in three
eastern States of the U.S.A.was traced ê to cheese,which
was found to contain S. typhimurium although it had
been stored at 43°-48° F for 302 days after manufacture.
Occasionally, outbreaks of food-poisoning have been
attributed to members of the dysentery group; one
such outbreak, probably due to infected ice-cream,
occurred at Aberystwyth four years ago.5 Whatever
the causative organism, the clinical syndrome is
usually much the same, with headache, upper
abdominal cramps, nausea, diarrhcea, and sometimes
vomiting and fever; recovery is complete within a
week. With severe infection, particularly in the
young and old, the symptoms are more varied, and
meningitis, septicemia, or an acute abdominal
condition may be simulated. |
’ The toxic form of food-poisoning is now - well known
in Britain. Of 296 outbreaks, the toxic products of
bacterial growth were blamed in 115, injurious .
chemicals in 6, and salmonella organisms in 38. The
clinical picture can hardly be mistaken: after a short
incubation period, usually of about 4-hours, there is
an acute onset, with vomiting, abdominal pain, and
usually diarrhoea and prostration, which are followed .
5. Mon, Bull. Min. Hlth & E.P.H.L.S. December, 1942,
4.
6, Tucker, C. B., Cameron, G. M., Henderson, M. P., Beyer, M. R.
J. Amer. med. Ass. 1946, 131, 1119.
608 THE LANCET]
by rapid recovery. The commonest organism is the
coagulase-positive Staphylococcus aureus, whose toxin
is relatively heat-stable and may resist cooking; it
may find its way into the food from handlers with
minor septic hand infections or with heavy nasal
infection. Outbreaks have been traced to other
organisms, including non-hemolytic streptococci, the
proteus group, and various anaerobic bacilli, but no
cases of Clostridium botulinum infection have been
recorded in this country since 1936.
The existence of human carriers of the food-poisoning
organisms has often been denied; but Burt’ has
described a patient who carried 8. typhimurium for
4 years; and TOMLINSON and LinseEtt è found that
convalescents carried S. thompson for up to 6 weeks.
Such people would be dangerous to others if they were
-in charge of food-preparation. Much can be done to
prevent the disease by the education of kitchen /
staffs in personal hygiene and by. suitable arrange-
ments for the washing of hands and utensils. During
the war cook-house personnel of the Army and R.A.F.
were investigated for organisms of the salmonella
group. If this simple investigation were extended to
food-handlers in all the larger feeding centres, carriers
could be identified and diverted to some less dangerous
occupation.
-= Annotations |
te nn A A
CRISIS AND CONSEQUENCES
THE crisis over the capitation fee, which endangered
the chance of good relations between insurance practi-
tioners and the Ministry of Health, has now been resolved.
Up and down the country a great many doctors stood
ready to resign from the National Health Insurance|
service at the call of the Insurance Acts Committee.
The new approach came a fortnight ago from the Minister,
who recognised no doubt how wide was the feeling of
injustice created by his refusal of separate discussions
on the application of the Spens report to’ the current
capitation fee. As a result a formula has been reached
which the I.A.C. is recommending the Panel Conference
to accept. ‘‘ The Minister,” we are now told, “‘ is willing
fully to apply the Spens report to the current capitation
fee with effect from Jan. 1, 1946, the increase of 2s. being
regarded as a payment on account. To this end, he
invites the I.A.C. to enter into discussions on the report
forthwith, with special reference to the current capitation
fee. The discussions will be conducted expeditiously.”
No doubt the Panel Conference (which meets as we
go to press) will find this proposal acceptable. It could
hardly do otherwise, for the Minister has accepted
without qualification the very demand made to him by
the I.A.C.—failing acceptance of which, resignations were
to be invited. That an agreement is within sight is
good, and better still is the promise that discussions will
be started at once and conducted expeditiously. It is to
be hoped that an early and generous settlement can now
be negotiated, that the long frustration which has marred
relations with the Ministry will be removed, and that
the way will thus be cleared for dispassionate considera-
tion of the problems which will crowd upon us with the
enactment of the National Health Service Bill.
Nevertheless the controversy now ending is bound to
have repercussions when the time comes for asking
members of the profession individually whether they
_ favour discussion on the regulations to be made under the
Act. Lest too easy conclusions should then be drawn,
5: Toralins: J. Pathe Bact. 1944, 56, 209.
nson, A ell, Ww. D.
H., Mon. Bull. Min. Huth &
E.P.H.LS. sions’ 117.
CRISIS AND CONSEQUENCES
[oor. 26,. 1946
it would be well to record now, and to remember later,
that the doctors have gained: their point this time
chiefly because they had a case, a-good case, and one on
which they felt genuinely united. It may be, too, that
the Minister has been accommodating because the very
reasonableness of the practitioners’ case, and of its
presentation by the I.A.C., placed him in a vulnerable
position. In the larger issues shortly to bè met the
circumstances will be different. Lord Listowel, speaking
for the Government in the House of Lords, expresaly*
said : ‘‘ We all desire the coöperation of the medical pro-
fession in working out the machinery for the new health
service.” Mr. Bevan, at the annual dinner of the British
Orthopedic Association,
remarked that his relations with the British Medical
Association grow more friendly week by week, and that
before very long, he is sure, they will reach a cordial
understanding and obtain coöperation in carrying out
the great work of the health service. We hope he is.not
being over- -optimistic ; and we believe the profession will
accept his sincere desire to have full coöperation from
its representatives in drafting the regulations which will
shape the new service. It would be a mistake, however,
to suppose that, with his health policy newly endorsed
by both Houses of Parliament, he will be either willing
or able to buy such coöperation by any deviation from
the policy now expressed- in the Bill. The profession
will have much to gain by negotiating liberalising
regulations under the Act when time and opportunity
offer; but it will achieve nothing positive if ite
contribution takes the form of general condemnation
and boycott of the new Act.
TRAINING IN CHILD WELFARE `
THE education of girls has been modelled ` so closely
` on the education of boys that most girls leaving school
at 16 or 18, have little experience of cooking, domestic
management, or the care of children, and moreover have
acquired an impression that time spent on such things
is wasted. (Those who leave school at 14 may have a
‘better chance of learning these basic arts, for they
often come of larger and poorer families where it is
natural for everyone to lend a hand.) Yet the care of
children in the home, as we had occasion to say not
long ago,! i§ at least as important as the care of the
machine in a factory; and the output of the home
takes precedence of the output of industry. —
A group committee of the National Council for
Maternity and Child Welfare have published a report?
on courses of training in the care of healthy children of
all ages, not only for students taking higher posts in
children’s homes and nurseries but also for teachers in the
subject. They contemplate the development of a new
profession of child welfare, having equal status with
nursing and teaching. At present the only recognised
training specifically for child care is the elementary
course for the National Nursery Certificate, planned
for girls Between 14 and 16, and only dealing with
children of nursery age. Those who wish to take
responsible posts in nurseries or nursery schools must
train, after the age of 18, as hospital nurses or nursery-
school teachers; but a nurse’s training, with its bias
towards the care of sickness, is not the ideal background
for holders of these posts, while nursery-school teachers
concentrate mainly on children between the ages of
2 and 6 and learn nothing of the care of children under 2.
The Curtis Committee on the care of children recently
_ suggested ® that there should be training for the house
mothers and house fathers who take charge of residential
1. Lancet, Sept. 28. p
2. Training in Ch
458.
ild Pw elfare. Second Report of ~ Group Com-
mittee ot the the Do trona! Council for Maternit Child Welfare.
Pu ai he National Society of Children's N
117, Piccadilly, London, W.1. Pp. 17. 1s.
See Lancet, 1946, i, 618.
reported on another page, .
4
s Lewis, J
THE LANCET]
foster homes, but this has yet to be started. In Scotland
a new course for nursery workers is about to be instituted.¢
Child welfare must be taught by good teachers; and
these, the committee suggest, should be trained in
_ child-welfare colleges—or departments of existing colleges
—associated with a university, and especially with
university departments of child health and education.
They would also be associated with centres offering
allied courses, such as teachers’ and domestic-science
colleges. Those intending to become teachers would
take the full course, lasting three years, and those wishing
to take posts in nurseries or children’s homes would take
a two years’ course. They would study the child and
his needs in relation to the family, including his physical,
mental, and emotional development from infancy to
adolescence. The course would cover nutrition, from
breast-feeding to a full mixed diet, and clothing, from the
layette to the dress of well-grown young people; there
would be training in home management, lectures on
existing social services in this country and others,
practical work in nurseries, play centres, youth
: organisations, and residential homes, and instruction in
the teaching of child welfare. A six months’ course
would also be provided for those who, having qualified
in an allied profession—as teachers, nurses, or ‘health
visitors—wished to become child-welfare workers or
teachers. The outlines of the syllabus are sketched in an
appendix.
The second part of the report sets out plans for better
instruction in child care in secondary schools and county
colleges. A study of 77 infant deaths at Barnsley 5
shows that among 31 deaths classed as preventable,
19 were attributed to such interrelated factors as poor
social and economic conditions, poor mothercraft, poor
-coöperation by the mother, and poor team-work by the
hospitals or public-health staff. The committee believe
that a gain in children’s health, and ultimately that
of the whole community, would be achieved if girls
were given more instruction in child care—a view
which we warmly share.
RHEUMATISM RESEARCH CENTRES |
In 1945 the Ministry of Health’s medical advisory
committee recommended that a number of diagnostic
-and research centres should be established for the study
of chronic rheumatism and for the improvement of
diagnosis and treatment. The special centres, it was
felt, should be located in university medical schools and
teaching hospitals, and the Nuffield Foundation has now
made a grant of £100,000, spread over ten years, towards.
the establishment of such a centre at the University
-of Manchester. There is to be, first, a diagnostic and
research centre at the teaching hospital, the Manchester
Royal Infirmary, to deal with short-stay inpatients and
outpatients who will be referred from peripheral clinics
in the region. For long-stay inpatients there will also
be a clinic at a nearby base hospital, provided by the
Manchester public-health committee, and a second base
hospital in the country, the Devonshire Royal Hospital
at Buxton.
tions will be carried out and problems of reablement and
resettlement will be studied. This scheme will ensure
ready access to a very large number of cases, especially
those in an early stage. At the centre the work will
cover two main fields—the clinical, sociological, and
industrial aspects of the disease, and the fundamental
study of the rheumatic process. The clinical work will
be directed by a physician, who will have the help of the-
departments of orthopedics and physiotherapy of the
Manchester Royal Infirmary as well as of the university
dental school. The social aspects of rheumatism, and
. Ibid, Oct. 19, p. 585.
> T., Blackwood, M. W. Mom: Bull. Min. Hlth &
£..P.H.L.S. September, 1946, p. 190
RHEUMATISM RESEARCH CENTRES
. per c.mm.
At these base hospitals lengthy investiga- -
, [ocr. 26, 1946 609
its industrial implications, will be studied in coöperation
with the university department of industrial health.
Bone and joint pathology will be investigated under the
direction of a pathologist expert in the subject. It is.
hoped that the scheme will lead to diffusion, of the know-
ledge gained at the university centre.
Readers will recall that the British Legion recently set
up a 50-bed rheumatism research and treatment centre at
Fairfield Hospital, near Letchworth.! This is closely
linked with the parent hospital in London, the Royal Free.
SULPHONAMIDE GRANULOPENIA IN
CHILDREN
THE effects of sulphonamide drugs on the blood-
forming tissues are now well known—hemolytic anzemias,
agranulocytosis, and sometimes aplastic anemia. The
manifestations may be of an allergic type, appearing
suddenly during a first or subsequent course of treatment ;
‘or they may be toxic in character, appearing gradually |
during the treatment. Menten and her associates! have
been watching the effects in children and have noted
that there have been far more cases of aplastic anzmia
and neutropenia—short of agranulocytosis—in a children’s
hospital since sulphonamides became commonly used,
particularly for infections of the upper respiratory tract
and other infections, such as cellulitis. Aplastic anæmia
is uncommon in childhood ; only 1 case was seen in this
hospital between 1928 and 1942 but there were 6 between
1942 and July, 1945. Of these 6 cases, 5 had received
sulphonamide drugs shortly before the diagnosis was
made, and the dose was often on the large side—over
30 g. in children of 6-13 years. All were fatal. Granulo-
penia shows a similar increase,? from 2-9% of admissions
to the hospital in 1939 to 12% in 1944, the peak year ;
the 12% all had at some time less than 3000 granulocytes
per c.mm., and about half of them had less than 2000
In 1945,-when penicillin was beginning to
replace sulphonamides, the incidence fell to 7-6%,
but analysis of the cases showed that in 1944 and 1945
about 20% of all children receiving sulphonamides
developed a definite granulopenia at some stage.
In animals with experimental granulopenia induced
by sulphonamides it had been noted that folic acid
would bring about, or at least accelerate, recovery of the
blood-forming tissues. Menten and Graff? therefore
treated some of their granulopenic children with folic
acid. At first results were negative ; because of favourable
published reports pyridoxine was then added, 150 mg.
being given by mouth daily. The effects were, on the
whole, encouraging; 13 out of 22 children treated
showed a rise of granulocytes towards normal levels; .
the rise was not rapid, most patients requiring treatment
for a week to a fortnight. In some the blood-count
relapsed when the treatment was stopped, and in some
a further dose of sulphonamide produced a. relapse.
The 9 patients who did not respond—or only responded
poorly—were all in hospital for upper respiratory
infections; 3 had had treatment with folic acid alone
for two or three days only (too short a period), 2 were
taken home just when observations might have proved
useful, and 4 showed no definite effect. To give folic
acid and pyridoxine separately is expensive, and an
attempt was made to get results by adding yeast to the
diet ; in practice the attempt failed because the yeast,
either live or in powder, produced too much intestinal
gas and abdominal distension.
Unfortunately no figures are available to show the
speed of recovery of children whose sulphonamide
drug was stopped—as it- was in all cases—and who were
given no other treatment ; experience in adults suggests
1. See Lancet, 1946, i, 870 (Lord Horder), and 1946, i, 947.
- Denny, H. M., Menten, M. L. Amer. £ med. Sci. 1946, 211, 659.
N Menten, M. L., Graff, È. Ibid, p. 666.
3. Ibid, p. 672.
610 THE LANCET]
See te Le ee a ee a
that the recovery would not be much less rapid than
in the patients treated with folic acid and pyridoxine.
Neither of these substances is easy to obtain in this
country, but the combination is clearly worth a trial in
‘persistent cases of granulopenia. Menten’s observations
remind us that toxic depression of hemopoiesis is a
factor to be reckoned with when using sulphonamides in
children’s diseases. : a
THE DEMOBILISED SPECIALIST
THE last few months before demobilisation is for many
medical officers an anxious period, filled with questioning
about their civilian prospects. Of those who want to
be specialists, some already have the qualifications and
experience expected of applicants’ for senior civilian
appointments ; but even for these the way. has not been
easy. Registrarships, supernumerary or otherwise, have
offered a temporary refuge; but the number of posts
_ offering a livelihood to fully qualified specialists has been
far below that of the suitable candidates. At any time
there would have been some delay before all these men
were absorbed; but the extent and the duration of
unemployment and uncertainty: have been magnified |
because most young specialists now expect to receive a
substantial proportion of their income from a hospital,
while the hospitals are disinclined at present to enter
into new commitments. ~ ` | |
Some months ago the Minister of Health showed
himself alive to these circumstances by encouraging
hospitals to create new senior paid appointments, and he
promised to come to their rescue if they should get
into financial difficulties. Perhaps judging its terms
to be too vague, the hospitals showed themselves some-
what unresponsive to this appeal. Now Mr. Bevan
has intervened again with an unequivocal offer :, local
authorities and the larger voluntary hospitals are invited
to increase their senior establishments by creating addi-
_ tional whole-time posts, at salaries of about £1000 a
year, the cost of which is to be charged to the Treasury.
The Minister also proposes to ease the lot of the junior
_ Specialist by increasing the number and the duration of
- Supernumerary registrar appointments, and he has made
the important concession that these appointments shall
be open also to those who were specialists in the Forces,
though they had not previously shown an intention to
specialise.
18 Still under discussion ; the usual practice at the moment
is for them to spend six months in a grade 1 appointment
before being advanced to registrar status. These fresh
. concessions, the need for which we stated last June,}
will prevent many from drifting, through economic
_ necessity, into other fields, where they would be lost to
specialist practice ; and it has doubtless not escaped the
Minister that those who benefit under this scheme will
form a useful nucleus when the new service, with its
unprecedented demand for specialists, begins to operate.
= What of the future general practitioner? The only
word the Minister spares for him is that a grade 1 appoint-
ment will be provided as soon as possible after demobilisa-
tion. Nevertheless, the general practitioner, no less than
the specialist, has his problems, some of which we have
‘already indicated.2 They include the difficulty, if he
takes. a grade r appointment, of managing his affairs
on the salary of a senior houseman; the scarcity of
assistantships ; the reluctance. of principals to accept
new partners or to sell their practices; and the heavy
responsibility of investing capital in a house or practice,
if one can be found. Possibly doctors with panel practices -
may be more ready to employ assistants now that the
capitation fee is likely to be further raised; but even
given an assistant’s salary the man with family responsi-
_ bilities may still wonder how to make ends meet.
eee ee
1. Lancet, 1946, i, 855.
2. Ibid, p. 968.
PRACTICAL NURSES IN CANADA
The continued training of graded specialists _
| oor, 26, 1946
ENCEPHALOMENINGITIS OF VIRUS ORIGIN. _
SooNER or later most practising doctors come across
the healthy young patient who, after a few days’ head- |
ache and malaise, falls acutely ill with fever, headache,
drowsiness or even stupor, and meningism, with or. ,
without increased tendon reflexes and an extensor plantar
response. The first sigh of relief is expressed when the
chloride content of the cerebrospinal fluid is found to
be normal; and the next when the fluid, which may.
be clear or only faintly opalescent, is proved to contain
no organisms. The cells—mostly lymphocytes—number
up to 200 per c.mm., and there is a slight increase in
protein. At the end of a week or so the temperature
falls, the patient embarks on the road to convalescence,
and the doctor’s bewilderment is forgotten in his relief
that the condition, whatever it may have been, has left .
no mark. eg TE ae
‘Even the elect may find it impossible to explain such
an illness. Acute encephalitis lethargica, poliomyelitis,
and acute lymphocytic choriomeningitis must all be borne
in mind during the early days, but the truth seems to'be
that this clinical picture can be produced by a large
variety of viruses, some of which usually, and'some only
rarely, attack the nervous system. . In addition to those
mentioned these include lymphogranuloma . venereum,
psittacosis, infectious mononucleosis, and mumps.
St. Louis encephalitis: and the two: varieties of equine
encephalitis have so far only been observed in the United
States. Doubtless other hitherto unidentified viruses
may also be the cause. Instances of this syndrome
are constantly occurring sporadically, and are seldom
diagnosed until recovery or complications set in. © .
Since June a good many examples of an illness of
this kind have been seen in the London area. The
characteristics of this particular outbreak are its scattered
distribution and the rarity with which two members of
the same family are affected; observation has been
complicated by a concurrent outbreak of poliomyelitis.
In some patients cranial nerve palsies have been recorded,
but fortunately recovery from these as from the other
manifestations has almost always been complete. Little
new light has been thrown on the etiology, though there
is renewed suspicion that the infection may be trans-
mitted through animals, including such domesticated
creatures as the cat. Many of these neurotropic viruses
have been shown to infect animals or birds, from which
they may be transmitted to man by insect vectors such
as mosquitoes or ticks. | 3
PRACTICAL NURSES IN CANADA -
' In 1945 the Province of Manitoba passed an Act to
authorise ‘‘the training, examination, licensing, and
regulation of practical nurses.” The Act defined a
practical nurse to be “a person who being neither a
registered nurse nor a person in training to be a registered
nurse at a school of nursing recognised by the Minister
undertakes nursing for remuneration.” With the
approval of a qualified medical practitioner, a licensed
practical nurse may perform nursing duties ““. (a) during
the convalescence of a patient, (b) after childbirth where
.there are no complications necessitating the services of
a registered nurse, (c) in mild types of illness, (d)-in chronic
illness of long duration not requiring the services of a
registered nurse, or (e) in any other cases prescribed in
the regulations.” : l
The council entrusted with the administration of the
Act contains representatives of the Manitoba Association
of Registered Nurses and anticipates the formation of an
association of practical nurses who will also be repre-
sented on it.. The aid of the various organisations of
registered nurses throughout the Dominion has been
enlisted, and instruction of practical nurses is being
carried out under their direction: The first class for
practical nurses was opened at the beginning of the year
THE LANCET]
BETWEEN TWO CENTURIES
focr. 26, 1946 611
at St. Joseph’s Hospital, Winnipeg. The course, lasting
a year, includes 3 months of classroom work and 9 months’
experience in hospital, of which 1'/, months must be
spent in a tuberculosis sanatorium.
A course in Ontario, lasting 9 months, is divided
into three equal parts, devoted to the classroom work,
supervised practice in the hospital and community, and
practical work in hospital on a small salary.
The Canadian Hospital for September, after surveying
what has been done, raises a number of questions
about possible developments. As regards legislation it is
thought better to have one controlling Act dealing with
all the nursing services than to follow the example of
Manitoba. The risk of competition with registered
nurses is not considered serious; even if there were a
depression, there would be new openings for registered
nurses. A suitable name has been much discussed, and
“ practical nurse” is definitely first favourite. The
‘journal holds that this new grade is likely to be
permanent.
BETWEEN TWO CENTURIES
THE first medical officer of health, Dr. W. H. Duncan,
of Liverpool, was appointed on Jan. l, 1847; and
this approaching centenary was the theme of Sir
Allen Daley’s presidential address to the Society of
Medical Officers of Health on Oct. 17... He found
much to be thankful for. Contrasting the national
statistics of 1847 and 1945, he showed that, while the
birth-rate declined from 31-5 per 1000 to 16-1, the death-
rate fell from 24:7 to 11:4, infant mortality from 164
per 1000 live births to 47, and maternal mortality from
4-52 to 1:84. Against the acute infectious diseases, to
which the public-health service has paid special attention,
considerable success has been attained; but this does
not apply to all of them, and the increase of the tuber-
culosis death-rate early in the war showed the precarious-
ness of our attack. Nor does Sir Allen think that the
increases in the deaths from respiratory and circulatory
diseases and from cancer can be lightly dismissed on the
ground that we must all die of something : ;
“ Many of these deaths are preventable in that they are -
curable if treated earlv. Very many, particularly the respira-
‘tory disorders, occur in young children. Coronary thrombosis
carries off many of our most able citizens in middle age.
Death from rheumatic carditis can be largely reduced, if
not prevented. Cancer is a serious cause of death well
before the age of 65. It is gratifying that increasing
attention is now being given to gerontology, or the study of
old age, and its causes, but we must recall Professor Crew’s
words: the real problem. is not ‘ how to give years to life
but life to years.’ ”’
Unfortunately, continued the president, the M.O.H.
still does not possess the tools needed for his job: he
ought to have complete morbidity figures for his own
area, and, if it is large, for the various sections of it.
In the future every doctor must be imbued with the
principles of preventive medicine, asking himself, for
each patient, “ Why is he ill? Could this illness have
been prevented ? If so, how ? ” Before very long there
will no longer be the two camps of curative and preventive
medicine, for all who look after patients will combine
curative and preventive work. Nevertheless there will
always be room for the specialist in preventive medicine,
and his réle will be increasingly important, covering
communal hygiene, industrial hygiene, epidemiology,
- the care of the convalescent and the disabled, the |
teaching of health, and administration. At the health
centre ‘we will have administrative duties in which
we are all well trained. The duty of an administrator is
to ensure that the proper tools, auxiliary staff, and
accommodation. are provided for the executives to do
the job.” Freedom from the pressing cares of managing
a hospital service will give the M.o.H. more time to
m e
1. To appear in full in the November issue of Public Health. °
ae eee
develop his functions as specialist in reran
medicine.
At the beginning of their second century, Sir Allen
Daley called on his hearers to carry on the torch of
preventive medicine, which should illuminate with
increasing strength the whole medical field.
ANÆSTHESIA IN RETROSPECT 3
THOUGH a hundred years have passed since Robert
Liston operated under ether, we should not, in celebrating
this memorable centenary, ignore many earlier successes.
Prof. Charles Singer, who took the chair at the Royal
Society of Medicine’s meeting on Oct. 16, had the agree-
able task, fulfilled with elegance, of reminding those
present of Adam, of the anxsthetic sponge, of mandra-
gora, henbane, and prickly lettuce, of mesmerism, of
Boccaccio’s Decameron (suitably expurgated), and of the
poet Southey’s view that the atmosphere of the very
highest heaven is composed of laughing gas. Dr.
Barbara Duncum, who had the more mundane duty of
outlining the development of inhalation anesthesia in
the second half of the nineteenth century, contributed
solid facts to an informative afternoon. The modern
development of anzesthesia was confided to Dr. Joseph
Blomfield, who told of the year 1900 when we had
chloroform, ether, and nitrous oxide and nothing else ;
of ethyl chloride, useful for short operations on children ;
of open ether (‘‘ some of you may even have given it ’’) ;
of spinal anzsthesia; of Knapp’s venous congestion,
rectal ether, oral chloroform given with paraffin and
followed by half a glass of port; of premedication, —
endotracheal ether, intravenous anesthetics, and many
another technical advance or experiment.
At the end of the meeting Dr. E. Ashworth Under-
wood startled the company with an original piece of
research, bringing strong evidence to show that Liston’s |
famous amputation was not the first operation in Europe
to be done on a patient under general anzsthesia, but that
two surgeons in his native town of Dumfries, at the
instigation of a fellow Scot, Dr. James Fraser, had
quietly performed an amputation on an etherised patient
about a month or six weeks before Liston got round to
his. Fraser knew Morton in America, and when he
came home on a visit he seems to have persuaded |
Dr. McLaughlin and Dr. Scott, at the Dumfries Infirmary,
to try sulphuric ether on a patient with a fractured
limb—probably some time in November, 1846. Liston,
of course, did his operation on Dec. 21, 1846.
This painstaking piece of historical research, which
seems likely to carry the priority honours from England
to Scotland, was unfortunately delivered at the end of
the session to a closely packed hall whose atmosphere
was itself somewhat anesthetic. More justice was done
to it, however, at the Wellcome Historical Medical
Museum, where an exhibition on the history of anzs-
thesia was opened by Lord Moran later in the afternoon.
Here some of the relevant. documents were well dis-
played, together with early works on analgesics, and —
many types of inhaler used in early experiments. The case
for the patient, too, has been generously included in the
form of a song, to be sung to an air from “‘ The Beggar’s
Opera,” which appeared in the Illustrated London News
of Jan. 30, 1847 :
How happy caid I be with Æther
Were mesmeric charmers away,
But while they perplex me together
The Devil a word can I say.
Sing Robinson, Thomson, and Cooper,
Fol Lol de Rol, Lol de Rol, Lay
There’s nothing like Æther and Stupor
For making a hospital gay.
WE have to record that Dr. T. WARDROP GRIFFITH,
emeritus professor of medicine in the University of Leeds,
died on Oct. 21. He was in his 86th year..
612 THE LANCET]
THE SPIRIT IN WHIOH WE WORK
[oor. 26, 1946
Special Articles
THE SPIRIT IN WHICH WE WORK
THOUGHTS ON ST. LUKE’S DAY *
Sir ALFRED WEBB-JOHNSON, Bt.
PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS
Ir is the tradition of our calling that the poorest
and humblest has just as great a claim on our services
as the highest and most affluent. The measure of their
need is the measure of our help. Thus it was that Sir
Frederick Treves, when his Sovereign, King Edward VII,
thanked him for his life-saving attentions, was able to-
“ Sir, you have had as much care
reply with pride,:
and skill in your illness as the humblest of your subjects.”
Such is the service that it is our privilege and duty
to render, but we have been only too conscious of the
limits of our ability—limits imposed by lack of adequate
facilities. We have known that there were serious gaps
_ in our service, and have realised that those gaps could
only be filled with the help of the State.
The State is about to take a great part in British
medicine. This is not surprising, for medicine is of
wholly unique importance for the very existence of
social life. But, ‘‘ as the master builder must care for
the whole building—so he that undertaketh to set it
out (and use it) must seek out fit things for the adorning
thereof.” This will be our special and immediate task.
We must first ensure that the conditions of service
are such as to allow intellectual freedom, and to give
character as much chance as cleverness. We must
avoid the development of Moliére’s type of doctor,
who thought it more honourable to fail according to rule
than to succeed by innovation.
We must guard against uniformity, for the highest
products of the human mind are the outcome of freedom
and variety rather than of uniform organisation. Inde-
pendence, which inspires fearless advice,
preserved. In fact, if any of the essential freedoms of a
great profession are threatened, then, in the interests
of the people, there must be revision of the plan. Even
when a system has been formed there may still be much
to add, to alter, and to reject.
A PERSONAL SERVICE
The doctor’s work is primarily a personal service,
and his calling exacts the utmost that man can give
/ —full knowledge, exquisite judgment, and skill in the
highest, to be put forth, not at any self-chosen moment,
but daily at the need of others. But illness is-essentially
a personal event. It consists of the individual himself.
The patient is not limited by his outer covering. His
surface is not his real frontier. A man may be more
interested in his environment than in his own body.
His position in the community or some work to which
his passion drives him may appear to be of more
importance than life itself.” Thus it is that the family
doctor has often to be his patient’s confidant and friend,
for, as Francis Bacon said: ‘‘ No receipt openeth the
heart but a true friend to whom you may impart griefs,
joys, fears, hopes, suspicions, counsels and whatsoever
lieth upon the heart to oppress it.”
Then again, in Trotter’s words, “ the well-equipped
clinician must possess the qualities of the artist, the man
of science, and the humanist, but he must exercise them |
only in so far as they subserve the getting well of the
individual patient.” He must feel directly responsible
to his patient, not for him—to someone else. It is a hard
doctrine, but none the less true, that this essential
function of the doctor—the care of the given patient—
may involve the forgoing of exactly scientific diagnosis,
a: vert n an address delivered in Liverpool Cathedral on Oct. 20,
946.
must be.
of the artistic perfecting of an operation, or even of the
interests of society at large. In his care for the individual
the’ method of the doctor is so different from that of
Nature : ;
` “So careful of the type she seems,
So careless of the single life.”
Those of us whose work lies in the hospitals must ‘be
prepared for changes under a new organisation. We
must see to it, however, that we carry into. the national
hospitals the same spirit which inspired us in the great
voluntary hospitals. There we learned ‘to scan gently
our brother man—judging not, asking no. questions,
but meting out to all alike a hospitality worthy of the
Hétel-Dieu, and deeming ourselves honoured in being
allowed to act as its dispensers.
We must keep the souls and individuality of our
hospitals alive, for hospitals are human institutions.
No rigid plan, without margin or elasticity, will suffice
or succeed. Above all, the State must not try to control
development too strictly, for hospitals are also scientific
institutions, and the essence of science is change.
MORAL RESPONSIBILITIES OF SCIENCE —
We are vitally concerned with the application of
scientific discoveries for the benefit of mankind. In our
own time inventions and developments have followed
each other fast as falling leaves, and the great blessing
is that the leaves from the tree of science have been
largely for the healing of the people. Advances have
been achieved by the method of experiment—the
method which, beyond all shadow of doubt, is the most
effective implement for the advancement of knowledge
ever invented by man. Moreover, it satisfies man’s
inveterate instinct not to confide his weight to a branch
until he has tested it.
The greatest discovery in modern medicine is the
detection of the minute bodies which cause many
diseases, and the means by which they are carried.
We now know that the carriers of many death-dealing
diseases are not angels or demons, messengers of wrathful
gods, but common things like flies,, mosquitoes, lice,
and fleas. We have but lately realised that we may
be able to control or destroy these winged vectors of
disease. Millions on millions of lives could be saved and
the morale of native peoples raised by the prevention
of malaria alone.
The millions that are saved must be fed. They must
be reckoned with. This will be a problem for future
generations—our task and duty are clear. As Carlyle
wrote: “ Let a man do his work ; the fruit of it is in the
care of Another than he.” And again: “it is not thy
works, which are all mortal, infinitely little, and the
greatest no greater than the least, but only the spirit that
thou workest in, that can have worth or continuance.”
That is the point—the spirit that thou workest in.
Scientific discoveries are powers for evil as well as for
good. Is it not time that we decided that their use
for the wholesale and indiscriminate destruction of
human life should be outlawed? It is not only physical
and chemical knowledge that can be misapplied, for
biological discoveries might also be used for bacterial
warfare. Is it not more in accord with our traditions
and ideals to follow the example of Jenner, who, when
England and France were at war, sent Woodville to
Paris to help to control an epidemic of smallpox which
was raging in the French capital! To commemorate
this humanitarian action there stands at Boulogne
today a statue to Jenner inscribed: “ À Edward J enner
—La France Reconnaissante.”’
It may be that Man is at the cross-roads. - Will he
proceed higher and further, or will he bring about the
catastrophic ending of the whole human story? Will
he be swept aside by the Great Creator as an experiment
that has failed ? It is for man to decide his own fate.
eis
THE LANCET]
His further and higher development depends on his 3
own conscious efforts.
As more and more secrets are wrested from Nature we
realise more and more clearly that there is no real
conflict between faith and science. The laboratory
-can satisfy many of our needs, but not those of the spirit,
80:
“ Let knowledge grow from more to more,
But more of reverence in us dwell.”
Belief is the healthy act of a man’s mind. And does
not every true man feel that he is himself made higher
by doing reverence to what is really above him ?
In order to realise the moral responsibilities of science
we must look to something higher, and something beyond
our owr little lives. We must turn our minds to things
which have immortality. We inherit ideas and teachings
which are imperishable and everlasting. ~
Our best works are inspired by the thought that we are
making a contribution to the good of our successors, or to
the advancement of ideas, institutions, and causes which
have continuity and permanence. As Lord Balfour said,
at the end of a long life of public service: ‘‘ By so much
as we give of ourselves, our labour, and our loyalty to
things which have immortality, by so much shall we
increase the joy of life and remove the sting from death.”
DOCTORS IN GOVERNMENT DEPARTMENTS
UNIFIED SALARY SCALES
THE different Ministries have hitherto had different
scales of pay for doctors in their employ. With effect
from the beginning of this year these scales have now been
unified in Government departments generally and also in
the principal health departments, including the Ministry
of Health, the Ministry of Education, the Ministry of .
Labour, the Department of Health for Scotland, the
Welsh Board of Health, and the Board of Control.
We understand that the whole subject of salaries for
medical staffs in Government departments may again be
reviewed when the remuneration of other doctors partici-
pating in the National Health Service has been settled.
Meanwhile the scales for London will be :
GENERAL SERVICE.—Medical Officer, £1000 on entry at
age of 35, with annual increases of £30 to £1300, and thence
by £50 increments to £1400. (The starting salary is reduced
by £30 for each year of age under 35, and increased by £30
for each year of age over 35, up to 40.) Principal Medical
Officer, £1400, with annual increases of £50 to £1600. Director,
£1600, with annual increases of £50 to £1800.
HEALTH DEPARTMENTS.—Medical Officer, £1150 on entry
at age of 38, with annual increases of £30 to £1300, and
thence by £50 increments to £1500. (The starting salary is
reduced by £30 for each year of age under 38, and increased
- by £30 for each year of age over 38, up to 40.) Senior Medical
Officer, £1500, rising annually by £50 to £1700. Principal
Medical Officer, £1600, rising annually by £50 to £1800.
Note.—In the Ministry of Health, since changes were
made a few months ago (Lancet, 1946, i, 932), the grade of
` medical officer has included those engaged in the health
services and the regional and deputy regional medical officers
in the insurance service. The grade of senior medical officer
includes the former principal regional medical officers, the
insurance divisional medical officers, and certain former
senior medical officers. Two of the posts of principal medical
officer (insurance and epidemiology) at present carry salaries
of £2000, without increments. The new arrangements make
certain provisions for safeguarding the ‘ expectations ” of
doctors already in Government service.
In about a dozen large provincial towns the London
standard rates. as set out above will be reduced by
£40 per annum on salaries up to £1300, and by £50 on
salaries above that figure. Elsewhere in the provinces
the deductions will be £80 and £100 respectively. Under
present arrangements most of the more senior appoint-
ments in the health departments are in London.
The scales apply equally to men and to women.
/
DOCTORS IN GOVERNMENT DEPARTMENTS
' disabilities ” ;
[ocr. 26, 1946 613
BRITISH ORTHOPEDIC ASSOCIATION
MINISTERS AS GUESTS
A DINNER held in London on Oct. 18. in connexion
with the association’s annual meeting, was attended
by the Prime Minister, the Minister of Health, the
Minister of National Insurance, and a number of overseas
guests. .
Sir HENEAGE OGILVIE, proposing The Association,
outlined the rapid progress of orthopedics from the
time, not so long ago, when its exponents had been
an oppressed minority. Mr. GEORGE PERKINS, replying |
as president, avowed the ‘need in each region for ortho-
pzedic centres, which should be centrally directed by a
consulting orthopedic surgeon; there should also be a
large orthopaedic teaching centre, under a full-time staff.
Salaries should be sufficient not only to attract good men
but to enable orthopsdists to visit other clinics.
Sir REGINALD WATSON-JONES, who proposed The
Guests, welcomed, among others, Dr. Hehry Meyerding
(U.S.A.), the new president of the International Ortho-
pedic Association, and Prof. E. Sorrel (Paris). He
thought it time to end the anomaly by which the man
who breaks his leg on Saturday afternoon receives less
compensation than he would for the same injury sus-
tained at work on Saturday morning; compensation
is, he said, the community’s responsibility and should
be uniform. He declared himself against controls,
preferring the wild English rose to ordered rows of
cultivated tulips.
Mr. C. R. ATTLEE, in his reply, said that “ we have
to be careful today, when our man-power position is
as acute as it was in time of war, that we do not waste
our population, either by leaving unremedied remediable
disabilities, or allowing the unnecessary creation of
and he looked very much to.the work
and influence of the orthopedic surgeon. The National
Health Service Bill would be placed on the statute-
book by Parliament, but its implementation depended
on the whole population. The happiest people, he
suggested, quoting the example of Denmark, are to be
found in the most equalitarian countries. ‘‘ We do not
want to see people regimented; but I believe just as
in a good army, without loss of discipline, there is scope
for initiative and energetic action by individuals, so
in all our health activities there will be freedom, but
freedom on an ordered plan of coöperation.”
Mr. ANEURIN BEVAN contrasted the acrimony amon
politicians with the harmony between doctors. Each
branch of medicine, he had noticed, considered the
others to be its superior. ‘‘ Members of the Royal College’
of Physicians emerge flushed with enthusiasm for the
Royal College of Surgeons; and fellows of the Royal
College of Surgeons regret there is not room for their
college in Trafalgar Square ” ; specialists were concerned
for the general practitioners, and general practitioners
for the specialists. ‘‘ The most eloquent politicians
in Great Britain are to be found in the medical pro-
fession. Indeed, I’ve been learning quite a few tricks
in the last year or two, and I hope to use them for the
benefit of the medical profession.” The politician’s
duty was to universalise the best. He had seen men suffer
because they did not have the benefit of existing know-
ledge: ‘‘ the specialist is not always available when
he is needed.” The health service must be organised |
in the most effective manner. ‘‘ It is not my task to stand
between the doctor and his patient. It is the task of the
public-health services to put the best kind of medical
apparatus in the hands of the profession, and it is for the
profession to use it freely and independently for the
benefit of their patients. ...I am happy. to say that.
enthusiasm grows. My relations with the British Medical
Association grow’more friendly week by week. Before
long I am quite certain that we shall reach a cordial
understanding and obtain coöperation in carrying out this
great work.’’
Mr. JAMES GRIFFITHS said that insufficient attention
had been given to the Industrial Injuries Act which had.
taken the injured person out of the grip of the employer ;
in its field, it was the best thing for half a century.
Miners, he said, deserve special recognition, for’ among
them occur half the country’s industrial injuries.
614 THE LANCET]
_ IN ENGLAND NOW
~
oon. 26, 1946 -
~ LONDON’S VOLUNTARY: HOSPITALS
THE continued practical interest of the public in the
voluntary hospitals of London during 1945 is well demon-
strated in the Annual Statistical Summary for that year
just published by the King’s Fund.' Despite a decrease
of -£67,000 in the income from public authorities, the
total maintenance income of the 164 hospitals reached
a record figure of £6,879,000; in addition £156,000
was given for endowment and £439,000 for building and
equipment, making a grand total of £7,474,000, or
£523,000 more than in 1944. | .
` Income from subscriptions, and donations rose by
£135,000 to £1,276,000; patients’ contributions by
£227,000 to £1,120,000; and contributory schemes
by £175,000 to £912,000. Legacies, a source of income
which many predicted would suffer as the result of death
duties, high taxation, and other adverse economic con-
ditions, rose by £121,000 to £676,000. If ‘‘ free legacies ”’
are included, no less than 74:5 % of the total maintenance
income came from sources other than public authorities.
Maintenance expenditure amounted to £6,466,000. or
£625,000 more than in 1944, leaving a surplus for 1945
of £413,000. i p
The number of new inpatients rose from 206,000 to
236,000, and the average number of beds occupied daily
from 10,447 to 12,797. The number of new outpatients
was VA and the number of outpatient attendances
7,888,000. , l '
INFECTIOUS DISEASE IN ENGLAND AND WALES
WEEK ENDED OCT. 12
Nolificalions.—Smallpox, 0; scarlet fever, 1106;
whooping-cough, 1362; diphtheria, 269; paratyphoid,
6; typhoid, 3; measles (excluding rubella), 2005 ;
pneumonia (primary or influenzal), 351 ; cerebrospinal
fever, 37; poliomyelitis, 22; polio-encephalitis, 1;
encephalitis lethargica, 1; dysentery, 44; puerperal
- pyrexia, 156; ophthalmia neonatorum, 69. No case of
cholera, plague, or typhus was notified during the week.
The number of service and civilian sick in the Infectious Hospitals
ofthe London County Council on Oct. 9 was 835. During the previous
weck the following cases were admitted: scarlet fever, 59; diph-
theria, 22 ; measles, 13 ; whooping-cough, 35.
Deaths.—In 126 great towns there were no deaths
from scarlet fever, 1 (1) from enteric fever, 1 (1)
from measles, 12 (0) from whooping-cough, 5 (0) from
diphtheria, 44 (2) from diarrhosa and enteritis under
two years, and 9 (8) from influenza. The figures in
- parentheses are those for London itself. .
= There were 4 fatal cases of whooping-cough at Manchester.
Liverpool and Manchester each reported 6 deaths from diarrhwa
and enteritis.
The number of stillbirths notified during the week was
258 (corresponding to a rate of 26 per thousand total
births), including 35 in London. | l
King Edward’s Hospital Fund
1. Statistical Summary for 1945:
Pp. 62. 1s. (1s. 6d. post
for London, 10, Old Jewry, E.C.2.
free).
MIDWIVES’ PAY
EMPLOYING authorities have been advised by the Ministry
of Health to adopt new recommendations by the Midwives
Salaries Committee. These include a special service allowance
of £20 at the end of each year’s full-time employment for all
(other than pupil) midwives. It is hoped that this grant may
encourage more women who have the necessary qualifications
to practise. The committee has now completed its review of
all salaries. Under the revised scale a matron of a maternity
hospital with 100—199 beds will receive a salary (inclusive of
emoluments) ranging from £550 to £750, compared with the
old range of £450 to £650 ; and a new inclusive salary ranging
from £600 to £825 is recommended for matrons of institutions
with 200 or more beds. Corresponding increases are recom-
mended for matrons of the smaller hospitals and homes ;
and assistant matrons in institutions with 50 or more beds
will now receive £410 to £485. Resident district midwives will
now have a salary of £290 to £380, compared with the former
£240 to £300. The committee has also recommended that
part-time midwives should be given credit for years of
previous service; and employing authorities are given
discretion to increase the appropriate salaries by 10%.
without it.”
- reach °. oè .?”
In England Now -
A Running Commentary by Peripatetic Correspondents
THE fact that hard-working G.P.s are given the task
of allocating the nation’s milk is certainly not an induce--
ment to take up medicine. True, we are given a list. of
deserving cases entitled to extra milk, and on. the face
of it our task is casy. A pregnant woman gets her 11/, or
2 pints daily; so do sufferers from G.U. or T.B. That
we can understand, but here comes the rub. Why does
a man with a broken arm, being “an active worker on
the pancel,’ get his daily pint while our edentulous old
dears in the 80’s get nothing extra ? Questions like this
are unanswerable. Of course, we may stretch:a point
and give an occasional pint under the all-embracing 2c,
but why do we have to wangle things? Our patients
try to understand our difficulties, but they often make it
worse. In my:most oft-recurring nightmare I sée myself
surrounded hy yellow cards with shadowy voices. There
is the stiff upright card: ‘“ I don’t want treatment,
but I need my milk.” There is the drooping bent card :
“The milkman says he’s got plenty; all he-wants is
a certificate.” There is the crumpled and shabby old
card; ‘‘ I’ve had a glass of milk for. supper all through
the war; the other doctor gave it to me; I can’t sleep
They draw near. They point accusing
corners at me. In my dream I even see the often offered
shilling. Mercifully the phone rings and the dream is
gone, but the question remains. We were never taught
about milk certificates: at our medical. schools. No
examiner questioned us on this knotty point: We are
simple people. We try to be fair to all and we please none.
We are the scapegoats of the Ministry of Food and we.
don’t like it. Z a eS ee
; * x x
Having bought a really new house I was determined
not tó lose it to the anarchists. (I feel sorry for them,
but I am determined to assert myself too !) The house had
. recently been left empty, and pending the move from the
present one into the new one I suggested that my wife
should put up some curtains. ‘‘ Curtains ! ” she scoffed.
“ They wouldn’t keep me out if I were a squatter.”
While I was distempering the empty rooms between
visits the idea arrived—I would get all our friends who
could spare the time during the local rush hour to come |
in and look round and spend as long as they could
offering suggestions. ` p `
One evening this was in full swing, with cars parked
all over the place and a fearful hullabaloo going on,
those in the garden calling to those in the bedrooms,
when a young man walked in through the gate and
produced a notebook. ‘‘ This is it,? I murmured to
myself. He came towards me, as I was the tallest in
sight, and asked, ‘‘ Are the squatters in?” adding, ‘‘ I’m
from the Bull Valley Tribune, the ‘local rag, y’ know.”
“ Young man,” I said, looking as unbalanced as I
could, ‘‘ are you in need of a home, a haven from the
tortures and affliction of the world, where the upward-
licking flames from the fiery furnace below’ cannot -
He seemed to take in the situation in one
terrified glance. ‘‘ No,” he said; ‘‘ not at all, thank
you sir,” and he left hurriedly, without shutting the gate.
Two days later the professional plate which I had
ordered months ago arrived, so I hurried down to the
new house and put it up. Patients and friends alike
(they have long ago forgiven me) agree that the plate
has finally decided the issue between anarchy and order.
“ After all,? they say, ‘‘ when you have your name on
it....’’ Which is saying something, even in these days.
s * *
There ought to be a course of instruction in testi-
monial writing. Just now many of us are enjoying the
exceedingly difficult experience of sitting in judgment
on youthful aspirants to honorary staff appointments.
So erudite, so distinguished do they all appear that they
inspire in us a sense of shame at being accepted as compe-
tent arbiters and a sense of self-congratulation that in
our day competition was less acute. What tests should
we employ in a decision so momentous? How can we
prepare ourselves to hold the scales in fairness to the
claims of the applicant and to the interests of the hospital
and, it may be, of the medical school ? |
~
TRE LANCET]
PSYCHONEUROSIS TREATED WITH ELECTRICAL CONVULSIONS
ocr. 26, 1946 615
I don’t know. Errors in judgment are notorious. I
recall a man who was selected on the most enthusiastic
recommendation of a president of the R.C.P., a president
whose integrity and wisdom were universally accepted
and revered. For thirty years this paragon blocked the
path of anxious, embittered juniors, and during that
thirty years he was a useless encumbrance who taught
nobody anything and made not the smallest contribution |
to medicine. Alternatively every school exhibits its
inability to recognise exceptional potentiality and to
deplore the loss which has proved a rival school’s gain.
To assist us in our deliberations we have—testimonials.
_ In many instances these comprehend no more than a bare
recital of the applicant’s appointments and other details
of his career which we could learn for ourselves by con-
sulting the Medical Directory. The majority of others
consist of platitudinous assurances that ‘‘ he is a sound
physician,” ‘‘has an extensive knowledge of medicine,”
“is hard-working and conscientious,’ ‘‘I think he
would prove a very agreeable colleague,” “ he has read
extensively,” ‘‘is of stirling character ’”’ (yes, the mis-
spelling has appeared on not a few occasians).
Of more value—indeed it ought to be of very great
value—is the personal letter. Now this calls for consider-
able care in its composition unless it leads the recipient
to read between the lines and conclude that it emanates
as a formal response to a request rather than from a
genuine desire to do all possible for the applicant. Look
at these : ; |
“ A. B., who was my house-physician, is applying for the
vacancy of assistant physician at your hospital. Unless you
have somebody outstanding, vou might do worse than select
him.”
“ I have not worked with A. B. personally but I am told he
is a very good physician.” ,
“ Although I can only speak from second-hand experience,
I should say his work in the war was well above average.”
“ As far as I could judge, he was entirely trustworthy.”
“ He is an excellent teacher of the list type.” (I suppose
this interpreted means—you have been warned !)
Being damned with faint praise is bad enough, but
there is a far graver danger to the seeker after testi-
monials. In my early days I encountered a sequence of
failures until a real friend dropped a pretty broad hint that
I would never be selected anywhere so long as I presented
a testimonial from Dr. X. In my innocence I had
congratulated myself on being sponsored by this pros-
-perous and celebrated physician. How was I to know
- that this man whom I had thought to be famous and
distinguished had a reputation among his colleagues
which led them to substitute the adjectives infamous
and notorious, a man whom the ladies called a duck and
other doctors labelled quack ? Presumably the converse
holds good, although I find it difficult to visualise anyone
with the confidence to utilise a testimonial of the opposite
kind because it was written by one ‘‘ of whom,” in the
words of Milton, ‘‘ to be dispraised were no smal] praise.”
% + %
Having just returned from a 1500-mile tour through
Germany; I am happy to be able to announce the cause
and cure of the ‘‘ German problem.” From time to time
the Germans hear rumours that other nations possess
beds in which it is possible to sleep, and, since conquest
is the only means of acquisition known to the German
mentality, they immediately start a war of aggression.
The cure is therefore obvious. Compel the Germans to
manufacture, and make up their beds according to
civilised specifications and they will remain in them
tranquilly ever after. When I think of the tripartite
boards that pose as mattresses, the absence of pillows,
the untucked sheets, the . . . but far abler pens than mine
have spent themselves in vain on that supreme example
of Teutonic masochism. |
% %* *
Talking of the discretion of the British press, a woman
starting a play group in London approached the adver-
tisement manager of a national paper and unfortunately
- mentioned that the group was to be run on psychological
lines. His response was immediate and final. ‘“‘ Psycho-
logy ; no, we cannot touch this. We bar advertisements
dealing with psychology, astrology, racing tips, and
rubber goods.”
Letters to the Editor
PSYCHONEUROSIS TREATED WITH ELECTRICAL
CONVULSIONS - a
Sir,—Dr. Milligan’s interesting paper raises many
issues, but it is particularly towards the presentation of
the material that criticism may be directed. .
New treatments are judged by the careful selection of
material, accurate diagnosis, criteria of recovery, adequate
follow-up, and finally by acceptable presentation. In -
this paper all these points are open to criticism.
1. No criteria are given for the selection of cases, nor is
there evidence of adequate examination preceding treatment.
2. The published case-histories leave room for doubt as to
the correctness of the diagnosis ; for example, case 7 could well
be an involutional melancholia.
3. “Recovery ”’” apparently depends on “stability,” but
we are given no hint of the method adopted in forming this
judgment. |
4. Only case 5 has an adequate follow-up. It is a pity that
some of the cases followed for 5 years have not been included.
These points are a sufficient criticism of the presenta-
tion of results ; but further information is required for
general recognition of this new method of treatment.
Scant consideration is given to the possibility that
these patients have been “ electrically leucotomised.”’
Hypochondriacal features are most noteworthy in the
histories; and the work of Freeman and others has indi-
cated the effects of leucotomy on the chronic complaint
habit. The question of deterioration is also most briefly
considered ; we are given a dogmatic denial of Brodie’s
findings, but no supporting evidence; and the absence of
gross memory disturbance does not rule out deterioration,
as Professor Golla has shown in leucotomy cases.
With the memory of other enthusiastic first reports on
physical methods of treatment in psychiatry and their
subsequent fate, I cannot feel that we are yet justified in
recommending our neurotic patients to enter mental
hospitals for this treatment. Even with electrical
convulsions to ‘* Music While You Work,” the lay public
will, I fear, continue to regard the mental hospital as a
madhouse.
London, W.1. -
P. H. ToOoLBY.
Str,—Dr. Milligan’s article is courageous and impres-
sive. But, despite the recovery-rate, it contains features
that give rise to concern. ;
He advocates this method for selected cases, but
offers no criteria for selection, apart from chronicity—
the duration apparently ranging from 2 to 20 years.
Nor are the “ general lines ” of treatment in case 6 clear ;
surely the treatment prior -to convulsive therapy might
have been described.
Plausible as is the explanation by Brain and Strauss,
is it a sound basis for giving up to four major convulsions
daily, or for producing a condition in which the patient
is reduced to the infantile level, with double incontinence ?
What proof is there that gross damage has not been done
by the repeated severe neuronal disruption ? Even if
sequelæ are not immediately evident, they may still be
forthcoming. ;
Dr. Milligan is indeed fortunate not to have seen
protracted memory defects in these cases. I have under
observation a woman of 25 with an anxiety state, who
had previously been given 18 major convulsions in
6 weeks, and who now has a profound memory-defect
for recent and remote events—a defect that impairs
intellectual work. Though convulsive therapy may have
a place in the treatment of psychoneuroses, its adoption
as recorded by Dr. Milligan cannot be accepted with
unreserved enthusiasm. l
Todmorden. NORTHAGE J. DE V. MATHER.
_Sir,—Of his 100 cases of psychoneurosis treated
intensively by electrical convulsions Dr. Milligan classifies _
52 as recovered on discharge, and he claims that a further
45 or 46 were much improved, most of them symptom-
free. These results might appear to compare favourably
with those of psychotherapy carried out under hospital
conditions, while the amount of the physician’s time
occupied in the administration of treatment seems to
have totalled rather less than five minutes apiece in the
616 THE LANCET] i
MORALE OF THE NATION
ee
i
[00r 26, 1946
7 cases quoted, as against. the many hours required for
psychotherapy. Even the doubtful acceptance of such
results might encourage those who are: planning our
National Health Service to fob off the unfortunate
sufferer from psychoneurosis with some more or less
harmful form of physical treatment, under the pretext
that it is the most modern and effective known to medical
science. Es
I suspect that Dr. Beaton’s treatment is in all secon tials |
a regression to the therapy of the last century, fortified by
_ modern apparatus. :
Some 37 years ago, as a young man in general practice,
I was called out very urgently to a woman said to be on
the point of death. In a poor house in a mean street I
found, in the centre of an excited crowd of neighbours, a
_. married woman of about 35 lying apparently unconscious,
but performing forced respiration with amazing energy.
I could find no signs of physical disease, but my questions
elicited no response of any kind from the patient: Being
satisfied that I had to deal with an exhibition of hysteria,
I turned everyone out of the room and sat down quietly
with notebook and pen to observe the patient, whose
breathing still continued violent and rapid. She probably
noticed the sudden change from eonfused noise to com-
plete silence, and after a minute or two opened her eyes
- and looked at me. I said:: ‘‘ Don’t you think you might
as well stop that performance ? It must be very tiring.”
Her respiration -became normal immediately, and she
began tocry. After about five minutes of this I asked her
whether she felt better ; she said she did. I pointed out
severely that she had caused much unnecessary alarm to
her friends ‘by her behaviour, and left after obtaining her
promise not to do it again. I was quite pleased with my
successful treatment, and,so were the relatives and friends.
- Only the patient seemed to have no sense of relief or
satisfaction, and I remember being struck by her attitude
of quiet despair in contrast with her former excitement ;
but I was not interested in the case except as providing
an opportunity for showing my skill in handling an
hysterical outburst. I did not see her again, but I think
I should have been called by the relatives if there had
been any return of her symptom; the case was probably
cured, by Dr. Milligan’s standards. aa
Ten years later, having begun to learn something of
the causes and treatment of this kind of illness, it occurred
to me that if my understanding had been greater I should
perhaps have encouraged this patient to tell me what was
really troubling her, with the probable result that her
display of emotion would have lasted very much longer
‘while her relatives might have been called upon to
improve their relationship with her. No doubt everyone
‘except the patient would have regarded me as a very
incompetent doctor; yet I might have performed a
service of the greatest importance to the patient. As it
was I had only intimidated her from further self-
expression by a metaphorical bucket of cold water.
Is intensive electro-convulsive treatment really an
advance upon the bucket of cold water which used to be
the treatment for hysterical manifestations most favoured
by bold therapists in the nineteenth century? In
selected cases—and Dr. Milligan’s cases were carefully
selected—it commonly resulted in the complete disappear-
ance of symptoms (sometimes, one gathers, for good), and
results might have been still better if it had been applied
intensively and unemotionally.
I do not deny that intensive convulsive therapy may
be expected to produce more permanent results. It
seems likely from Dr. Milligan’s account that it is followed
regularly by the commencement of a process of mental
deterioration, and it may be that this, like leucotomy,
damages the symptom-producing structures ; but if this
is so, such treatment should be reserved for the most
desperate cases, after careful consideration by a respon-
sible medical board.
Other questions present themselves. Does the theory,
adopted by Dr. Milligan, that Dr. Beaton’s method
obliterates entirely the faulty electrical patterns of the
brain mean that electro-encephalograms recorded before
and after treatment showed the disappearance of
abnormal rhythms ? If not, does it mean anything ? On
what basis were these 100 cases selected for publication
from the larger number of psychoneurotic patients
treated by intensive electro-convulsive therapy ? And
of ‘* belonging ”
does an average dose of ‘180 volts at 0'4 sec.” mean |
anything but a large unmeasured dose? =. =>>
These questions are minor matters, and it may well be
that the intensive method described will prove valuable |
for the treatment of some severe cases which might
otherwise be properly subjected to leucotomy. The
large issue is between the view that the patient should be
treated in the way that is best for him individually, and
the opposed view that treatment should be adapted to
the convenience of those who have to apply it and those
who have to pay for it. I would suggest that the patient
and his human environment should both receive full
consideration. Each should be represented on a beard
which would consider on its merits every case in which
it might be proposed to take action destructive of the
integrity of human life; such actions would include the
termination. of pregnancy for reasons other than the
preservation of the life of the mother, prefrontal leuco-
tomy, and intensive convulsive treatment. -. - :
If the treatment described by Dr. Milligan is considered
. justifiable in the case of ordinary psychoneurotic patients,
it seems to follow that it should be used also on Habitual
criminals, and then on the masses of ex-Nazis whose
re-education is a yet unsolved problem. If Dr. Milligan
is right, the “ obliteration of psychologically unacceptable
patterns of thought and conduct ” can be effected in a
few days, and then someone can carry out the resynthesis
of their personalities along correct lines. One is glad
‘Dr. Milligan sees that this is a task requiring much care
and judgment.
London, W. J. NORMAN GLAISTHR.
MORALE OF THE NATION
SIR, —I was glad to see. that Dr. Kennedy, in the
lecture on Health Education published in your issue of
Sept. 21, emphasises the principle of holism in the
doctrine of positive health. I was less glad to see that,
while he notes the importance of ‘‘ moral discipline,”
he is apparently prepared to leave this fundamental
aspect of the matter to the individual conscience. In so
far as moral discipline affects health, we shauld make an
effort to provide some biological guidance for it.
I suggest that we use the term ‘‘ morale ” instead of
moral discipline. -Even if no more clearly defined, its
various definitions are less likely to be coloured by the
emotional prejudices of different sects. Without dis-
cussing the definition of the concept of morale (which
would only recapitulate what Dr. Kennedy says of the
definition of health), one can, for purposes of discussion,
divide the factors which influence it into components
which foster (a) a sense of security, and (b) a sense of
purpose. The sense of security is essentially the feeling
to a group, and has no implications
about the actual physical conditions. which might be
held to make for security. Its antithesis is the sense of
isolation, or ‘‘ separation anxiety.” .The sense of purpose
is essentially the feeling of ‘‘ worthwhileness,” and can
exist apart from any explicitly stated aim or intention.
These two concepts are both aspects of a state of
mind which is of course largely unconscious and little
subject to deliberate control. Their formulation as
separate entities allows us to estimate the value of any
particular measure as an aid to morale. The sense of
security relates to the individual’s potential, while the
sense of purpose relates to the direction in which the-
potential will be used. Needless to say, a particular
morale factor will have effects on both aspects: thus a
good leader will both provide an adequate motive for
action and enhance his followers’ sense of security, while
the provision of excessive ‘‘ welfare ” facilities may enhance
the feeling of security but confuse the sense of purpose.
In war-time, morale was tackled from both les.
The sense of purpose was fostered by repeated (and not
always effective) efforts to render war aims explicit;
and on a lower but more effective plane by the setting up
of ‘‘ targets ’’—for production, war savings, &c. The
feeling of security was fostered in many ways, by no
means all of them deliberate: ‘‘ One spot of bombing
makes the whole town kin,” and people came into close
contact with their neighbours in a way almost unattain-
able in peace-time. ‘The necessities of the time caused
the State to assume a paternal réle which relieved many
of the day-to-day anxieties of life for the ordinary man
THE LANCET]
PILONIDAL SINUS
[ocr. 26, 1946 617
and woman—for instance, work, food, housing, and
clothes. It was not that these were provided, but that
the individual need not worry about their provision,
which enhanced the sense of security. .
With the end of the war, morale inevitably worsened.
The sudden disappearance of the overriding communal
motive, together with the natural relaxation after a
period of tension, would have sufficed to make a dis-
ruptive social picture even without the loss of the sense
of security resulting from material shortages, the return
of forgotten husbands to homes ‘ otherwise occupied,”
the unconscious guilt of those who left their families,
and the less unconscious (even if still unjustified) guilt
of those who stayed at home.
To restore morale we have to restore both the sense
of purpose and the sense of security. It might be
possible to maintain morale, as the Russians seemed to be
' doing, by inventing new fears of war which would bind
the people together against a common, even if so far a
hypothetical, enemy; but to do this would require a
further denial of democratic government which our
people would fortunately not tolerate. It would in any
event only delay the realisation of the individual’s, as
opposed to the State’s, insecurity.
To return to the problem of health. The sense of
security is to a much larger extent than is generally
realised dependent on interpersonal contact between
members of a community, and to a much smaller extent
on the physical conditions of security. We may therefore
aim at increasing social contact between people. There
is ready to hand an adequate motive for health-giving
activity in a war-weary country: recreation. A blue-
print for action along these lines is, I think, to be found
in the accounts of that admirable social experiment, the
Pioneer Health Centre at Reckham. By laying emphasis
on recreation, a motive is provided which is universally
acceptable and which is persistent. By providing a
focus for interpersonal exchange and communal integra-
tion, and by having the centre run under the guidance
of properly trained biologists, every opportunity is given
for the development of the sense of security. Morale is
improved and a rich soil prepared for the seeds of health
education.
Dr. Kennedy speaks of the need for more recreational
facilities and for more biologists. It is inrportant to
emphasise that these two must be closely linked.
Biology is the science of life; and inasmuch as “ re-
creation ” is a subject for science, it is the biologist’s
responsibility. In conclusion, we may remind ourselves
that medical education—at least up to 1939—used a
fragmentary rather than a holistic approach ; and that
our profession is primarily oriented toward the relief of
illness, secondarily toward the maintenance of health,
and only thirdly toward the enhancement of positive
health. In the nature of medical work, as at present
taught and organised, we see more and think more about
disease than about health. A great deal of hard thinking
and versatility will be required by our profession if we
are to make a real contribution to this problem.
Narborough, Leicestershire. JAMES R. MATHERS.
PILONIDAL SINUS
Sre,—Mr. Patey and Professor Scarff (Oct. 5, p. 484)
make two questionable assertions.
(1) They say there is a world of difference between
sacrococcygeal cysts and tumours of undoubted develop-
mental origin and pilonidal sinus. They claim that the
pilonidal sinus is higher in the natal cleft, but those of
us whose lot it is to see a disproportionate number of
children’s posteriors have seen many more than the 16
cysts and tumours of developmental origin which Raven
collected in London museums. | It is true that some of
these are very near the anus but most are high up and
all grades are seen from the massive dermoid to the
short sinus and dimple. .
(2) They stress the importance of hair in the etiology.
Surely this very fact emphasises the developmental
origin of the pilonidal sinus. The body hair docs not
grow until stimulated by puberty hormone levels, and
it is the young adult in whom the symptoms first develop
most commonly. It is difficult to believe that the tough
tissues of the sacrococcygeal region can be pierced by a
human hair which has been sat on.
One of the reasons for so many failures in treatment
during the war has been that the advent of powerful
chemical bacteriostats has tempted the surgeon to
“ try his luck” and close primarily the gaping chasm
of his wise and wide excision. Healing of the bottom
from the bottom must still remain a fundamental rite.
London. D. F. ELLison Nasa. ©
TUBERCULOSIS FOLLOWING INJECTION
S1r,—Several interesting points emerge from Mr. Ebrill
and Dr. Elek’s account of a tuberculous abscess arising
at the site of a previous intramuscular injection of
penicillin (Sept. 14, p. 379). Although the authors do
not use the term, it is clear that they regard the abscess
as an example of primary tuberculosis (i.e., arising
in a previously uninfected individual, who would have
been tuberculin-negative had he been tested before
the penicillin injection). One cannot, of course, be
dogmatic, but the clinical details given are far more
suggestive of a post-primary tuberculous abscess (i.e.,
arising in a previously infected allergic individual, whose
Mantoux reaction would have been positive previously
had it been tested). Such a post-primary abscess could,
of course, have arisen as a result of introducing virulent
tubercle bacilli during the penicillin injection, but this is
extremely unlikely. Bacili accidentally inoculated into
tuberculo-allergic individuals in this way are usually
effectively dealt with by the body’s defence mechanism,
as was first shown many years ago by Koch when he
described what is now known as the Koch phenomenon.
The most likely explanation is, I think, the one which
Ebril and Elek dismiss as a practical’ impossibility—
namely, that the abscess arose as a blood-borne infection.
Such disseminated tuberculous abscesses are by no
. means rare in sanatorium practice, particularly in the
so-called hematogenous type of disease, and in the case
described the hematoma appears to have acted as a
locus minoris resistantie. The fact that clinical and
radiological examination has revealed no other tuber-
culous focus is, of course, inconclusive; it is quite
common not to find a primary tuberculous focus in
persons undergoing Mantoux-conversion while under
observation (e.g., in sanatorium staff). In such cases
the site of infection may be in the alimentary tract.
Two clinical details would have been helpful. Firstly,
no mention is made of the presence or absence of inguinal
adenitis. With a large primary tuberculous abscess of
the thigh, caseous adenitis of the regional lymph-nodes
would almost certainly have occurred, while ‘‘ drainage ”’
glands of a post-primary abscess, if examined by biopsy,
could have been distinguished histologically by the
relative absence of caseation. Secondly, no mention is
made of the type of bacillus recovered from the pus.
The finding of bovine bacilli would have been a pginter,
admittedly a weak one, to the presence of a bovine
alimentary infection.
It might be of interest. to note that by a curious
coincidence two patients and a possible third have been
admitted to this hospital during the last month, each
with lupus verrucosus of the hand following an injury
involving a breach of skin surface. It is tempting to
picture the very natural reaction of sucking the injured
member (and both patients have active pulmonary
lesions), but it is far more probable that these are also
examples of a hæmic infection of a locus minoris resis-
lantic. The well-known association of injury with other
tuberculous conditions, such as tuberculosis of joints, is
also very much to the point. |
Dr. Marsh’s statement (Oct. 5, p. 508) that ‘‘ tubercle
bacilli are not uncommon in the dust of hospital wards ”’
cannot be allowed to pass unchallenged, since it tends —
‘to perpetuate the erroneous belief that sanatoria and
tuberculosis wards are dangerous places in which to
work because of the risks of infection from dust. Since
Cornet, in 1889, claimed to have found tubercle bacilli
in 40 out of 140 specimens of dust from various German
hospitals, public buildings, and tuberculosis wards,'
belief in the rôle of dust as one of the chief infective
agents in tuberculosis has been widely held, although
few modern tuberculosis pathologists now subscribe to
1. Cornet, G. Z. Hyg. InfektKr. 1889, 5, 191.
618 THE LANCET]
FOLIC ACID IN CŒLIAC DISEASE
[ocr. 26, 1946
this view (e.g., Gloyne ?; a good summary of the
dust v. droplet controversy is given by Topley and
Wilson,*? who point out that the English climate militates
very strongly against the formation of dust containing
living virulent tubercle bacilli). Even if one accepts
Cornet’s work without question, few will deny that
personal hygiene is now vastly improved since his day,
largely as a result of public-health propaganda; our
tuberculous patients no longer spit on the ward floor!
Numerous investigators have failed to find living tubercle
bacilli in the dust of modern hospitals and sanatoria. —
An investigation was recently made at this hospital
into the possible infectivity of occupational-therapy
articles made by patients. One hundred articles of all
types (plastic, wood, wool, felt, &c.) made by patients
with all degrees of lung involvement (many producing
large amounts of positive sputum daily) were examined
carefully in the hospital laboratory, where the technique
of cultural examination for tubercle bacilli has been
brought to a high standard ; not one positive result was
obtained. I am sure that this is in large measure due
to the gareful instruction in the hygiene of cough which
is given to all patients. The danger of infection from
patients with open pulmonary tuberculosis is not from
ward dust but from unrestrained cough. It is clear that
this fact needs to be emphasised at a time when hospital
and sanatorium domestics are at a premium.
A. G. HOUNSLOW.
County Sanatorium, Clare Hall, South Mimms, Barnet.
FOLIC ACID IN CŒLIAC DISEASE
Sir,—The course of coeliac disease in children is often
so protracted, and the prognosis so uncertain, that we
venture to draw attention to its treatment with folic
acid, a procedure which in a particular case has so far
proved dramatically successful.
A boy, aged 17 months, came under the care of one of
us (L. G.) in May, 1946. There was a history of vomiting
and diarrhcea with the passage of numerous pale bulky
and foul-smelling stools during the previous 6 months.
He had been under treatment by another doctor during
this period, with no improvement. o :
He presented the typical appearance of cœliac disease
—pale, apathetic, with a dry skin and distended
abdomen and wasted buttocks, and with the stools as
described above. His weight was 19 Ib. Treatment with
parenteral liver extract 2 c.cm. on alternate days,
together with ascorbic acid and ‘ Benerva’ Compound
tablets by mouth and a fat-free diet was instituted.
Improvement was rapid. The vomiting and diarrhcea
ceased and he gained weight.
The child was taken away on holiday, but after a month
he relapsed and became extremely ill with a return of
his former symptoms. He was admitted to hospital
weighing 21 1b., but after a fortnight’s stay his condition
had deteriorated considerably and he was taken home
weighing only 14'/, lb. He was then seen in consultation
by one of us (H. P. B.) and admitted to hospital
in a serious condition. The picture was typical of
coeliac disease. He was grossly dehydrated and passing
15-16 stools a day. He could take only very small
quantities of skimmed milk with water and glucose. The
blood-count showed a secondary anemia with 52%
hæmoglobin and 4,200,000 red cells per c.mm. The total
fat in the stools was 49%.
Treatment with parenteral liver extract and vitamin-B
complex on alternate days, together with other vitamin
supplements and iron by mouth, was begun, and during
the next week there was no improvement although no
deterioration in his condition and his weight remained
stationary. |
At this stage a supply of folic acid was obtained and
25 mg. per day was administered by mouth. There was
immediate improvement. The following day only 2 stools’
were passed, the appetite returned, and he became
much calmer and brighter. From then on he progressed
rapidly. His appetite became ravenous and he took a
good mixed diet, fat-modified, and passed one or two
pale formed and non-offensive stools each day. At the
end of a week he had gained 7 lb., and 9 days later he
had gained a further 6 lb. At the moment improvement
2. Gloyne, S. R. Social Aspects of Tuberculosis, 1946, p. 23
an C
3. Topley, W. W. C., Wilson, G. S. Principles of Bacteriology
and Immunity, 1936, pp. 1028-29..
has been maintained but there is still considerable
abdominal distension. The dosage of folic acid has
been reduced gradually and he is now taking 10 mg.
per day. All other treatment has been stopped since the
institution of the folic acid.
It is impossible, of course, to draw any general con-
clusions from a single case, but we feel strongly that
improvement in this case can be attributed solely to
folic acid.
No doubt intensive trials in this direction are going on,
but we have so far seen no recorded work on the treatment
of coeliac disease in children with folic acid.
| H. P. BRODY.
Sheffield. L. GORE.
PERFORATED PEPTIC ULCER TREATED
WITHOUT OPERATION |
SIR, —I am anxious to correct two impressions that
Mr. Deitch’s provocative and stimulating letter of
Oct. 19 may give. l
He mentions that for two years I have treated al
cases of acute perforation conservatively and ‘‘ with
uniform success.’ This series was reported at a meeting
of the Leeds Medico-Chirurgical Society in February,
1946. I did not invent the conservative method any
more than Hermon Taylor did. Many surgeons practise
conservative treatment in selected cases, and it was not
until Bedford Turner reported 6 cases (Brit. med. J.
1935, i, 457) that I had the courage to treat all cases
without selection. Further, I have lost 3 cases since the
discussion in February, which makes the mortality
18% in my small series. I agree with your leader of
Oct. 5 that since we have no means of determining which
ulcer will close spontaneously, conservative treatment will
inevitably cause the surgeon’ more anxiety than simple
closure, which, in Mr. Deitch’s hands, carries.a mortality
of only 4%. This remarkable record, extending over
eight years, fully justifies his belief in spinal ansesthesia
and no drainage-tube.
Our experience in York differs from Hermon Taylor’s
in two respects. We found considerable constitutional
disturbance in several cases, the pulse-rate rising to
130 per min. and the temperature to 103° F, falling
gradually to normal by the eighth day, and we had 2
patients who developed subphrenic abscess, a complica-
tion which I had never met after closure without drainage.
We have been more impressed by the results of
prevention of perforation than with the conservative
treatment after the catastrophe has occurred. By
treating all cases of peptic ulcer with severe symptoms
as requiring urgent admission, and by accepting for
surgical treatment all cases who we think are unlikely
to benefit permanently by medical treatment, we have
reduced the incidence of acute perforation by 44%
during the last three years. Acute perforation in the
York area has now become `a rarity; the majority of
cases admitted are visitors to the district, transport
drivers, or passengers in trains. The few locals who
perforate ‘‘out of the blue” will always defeat our
efforts to anticipate, rather than wait for, this dreaded
complication. 7
York. A. HEDLEY VISICK.
PRICE OF POLYTHENE.—In his article of Sept. 14 (p. 380)
Dr. Kent remarked that polythene costs about ls. 2d. per lb.
Imperial Chemical Industries Ltd. point out that the minimum
price of ‘ Alkathene,’ the British grade of polythene they
manufacture, is 3s. 3d. per lb.
SODA-LIME.—Already a familiar laboratory reagent, soda-
lime is now widely used in medical practice for the absorption
of carbon dioxide. Apparatus for closed-circuit anesthesia,
oxygen therapy, and metabolism determination are a few
examples of its uses. Messrs. Sofnol Ltd., Westcombe Hill,
Greenwich, S.E.10, the makers of ‘ Sofnol Brand °’ soda-lime,
claim that their product possesses advantages such as con-
stancy of composition, high absorptive capacity, resistance to
abrasion, and non-heating and non-deliquescent properties.
Their catalogue, illustrated by easily understood graphs,
describes in a simple way the experiments on which these |
claims are based. These tests will be of interest to those
who are unfamiliar with the type of laboratory investigations
to which a specimen of soda-lime must be submitted before its
value as a CO,-absorbent for medical purposes can be assessed.
THE LANCET]
PARLIAMENT
[oct. 26, 1946 619
Parliament
THE LORDS IN COMMITTEE
‘On Oct. 17 the House of Lords resolved into committee
under the chairmanship of the Earl of DROGHEDA to
consider the National Health Service Bill.
POWERS OF THE CENTRAL COUNCIL
Lord MoRAN moved an amendment to clause 2 with
the purpose of strengthening the Central Health Services
Council. The Bill was singularly free from the fault of
trying to meet sectional interests at the expense of the
community, but he thought it unfortunate that member-
ship of the council had been allowed to grow to 41.
This inevitably meant that there must be a number of
' advisory committees, which were to be appointed by the
Minister and to report direct to him, though they would
at the same time report to the council. The amendment
empowered the council to appoint these committees
and laid down that they should report to the Minister
through the council. He thought this vital, for a Minister
faced with a council of 41 and an alternative committee
of 8 or 9 experts would naturally turn to the experts.
Thus the committees would do the real work and the
council would be largely robbed of its chief function.
Did this matter? He thought it did, for at present those
actively engaged in the practice of their profession
played little part in administering the service, and it was
hoped that the council would be a means whereby they
could take an active part, not only once or twice a year
but in every important thing that came before the
Minister concerning health. Lord JowiTr, the Lord
Chancellor, in reply, pointed out that the Minister before
appointing a standing committee must consult with the
Central Health Services Council. He agreed that it was
important that the council should be really effective;
but it was rather an unwieldy body, and for that reason
and not because they wanted to belittle the authority
of the council the Government felt unable to accept
the amendment—which was by leave withdrawn.
ACCESS TO HOSPITALS
The Earl of MUNSTER moved an amendment to clause 4
to ensure that voluntary hospitals should not find after
the passing of the Bill, on instructions from the Minister,
that their small rooms must be abandoned and made
into‘ large wards. Lord JOWITT gave an assurance that
these rooms would not be converted unless it was found
really necessary in the interest of the whole service,
and the amendment was withdrawn.
Lord LLEWELLIN moved an amendment to clause 5
allowing a doctor to follow his patient into a hospital
even though he was not a specialist on the staff of that
hospital. Lord HORDER supported the amendment, for
he declared it was in the interests of the patient that
continuity of treatment should be preserved.
The Earl of LISTQWEL pointed out that the effect of
the amendment would be that a specialist or practi-
tioner who chose to stay outside the public service would
be able to use for his private work hospitals provided
at the public expense. Viscount CRANBORNE suggested
that as the patient had made his contribution to the
scheme presumably he had the right to enter a State
hospital. The clause as it stood allowed any doctor on
the staff of a hospital to treat his private patients in
that hospital, but the man outside the service could not
even arrange for his patients to be treated by someone
else at the State hospitals. He was in favour of a State
service, but he did not believe that there should be this
continual whittling down of private practice so that in
effect it was really useless. Lord ADDISON pointed out
that today medical practitioners who sent their patients
into hospital did not follow them. The patients were
treated by members of the hospital staff. The amend-
ment was withdrawn.
. The Earl of IDDESLEIGH moved an amendment
incorporating the pledge which the Minister had
given that the character of denominational hospitals
would be respected, but withdrew it on Lord Jowrrr
promising to consider the matter before the report
stage.’
HOSPITAL ENDOWMENTS —
Viscount MAUGHAM moved an amendment extending
to the non-teaching hospital the proviso safeguarding the
confiscated endowments of the teaching hospitals
“ Provided that the Board shall, so far as practicable,
secure that the objects of any such endowment are not
prejudiced by the provisions of this section.”
In reply Lord Jowrrr said there was no doubt that by
Act of Parliament any trust could be disturbed. Whether
it should be was another matter, and he agreed that it
should not be done lightly. There was, he pointed out,
a profound difference with regard to the endowments of
the teaching and non-teaching hospitals. In the teaching
hospitals no redistribution was contemplated. The
existing funds remained with the hospital, though the
board of governors was changed. But redistribution was
the very essence of the scheme for the voluntary hospitals.
The scheme would probably cost the public Exchequer
something like £150 milion a year. Approximately
£30 million would come from the insurance contributions,
some £10 million from local authorities, and the remaining .
£110 million from the Exchequer. Of the whole £150
million some £90 million would be expended on hospitals.
The reaction of the Treasury officials to this enormous
expenditure had been: ‘‘ If you are going to call on us
to find out of public funds this vast sum of money, at
least you ought to let us have in return the various
endowments to put against our obligations.” The
Chancellor of the Exchequer had been persuaded to
forgo that claim, for the Government was anxious
that the hospitals should have some cushion between
themselves and the rigours of Treasury control. But it
seemed only fair that this nest-egg should be redistributed
so that all should have a share. The probable capital
value of the endowments was something like £50 million
which at 3% would give something like £1'/, million a
year, and even that figure probably contained a not
inconsiderable element of the endowments of teaching
hospitals. The effect of the amendment would be to
smash up the scheme, for there was hardly an endowment
which had not been given to some specific hospital.
If the scheme became impossible, inevitably the Treasury
would say to a hospital which was richly endowed, ‘‘ You
are so well off that you need not have a large amount of
public funds,” and the whole idea of this cushion would
O.
3 Viscount SAMUEL suggested that a comforts fund would
really fulfil the purpose of the ancient donors of these
endowments, for their only desire was that the sick should
be well cared for and happy, and they would not mind
very much whether the hospital had the name of Saint
So-and-so or was called the Manchester Central Hospital.
Therefore it seemed to him that we were fully entitled
to endorse a change of trusts which arose out of the
different circumstances of our own times. But could not
some words be inserted which would ensure that what
was done was done without detriment to the general
purposes of the endowment and with the intention to
fulfil as far as possible the wishes of the donor? For
example if it were merely a question of a hospital being
named for all time ‘‘ The 1914-18 War Memorial
Hospital ” obviously that sort of trust ought to be ful-
filled. Lord JowIrr replied that he fully accepted
Viscount Samuel’s example, and that where a gift was
attached to a condition—such as the upkeep of a garden—
he was ready to consider an amendment provided it was
limited to such special cases, and did not seek to say that
any money merely because it was left to a particular
hospital should therefore be exempted from pooling and
redistribution. po
REGIONAL BOARDS
Lord ADDINGTON and Viscount BRIDGEMAN moved
amendments to ensure that the local health authorities
should know what plans the regional boards were making
and should have a chance of putting their views to the
Minister before any regional plan was finally accepted.
The Earl of LISTOWEL pointed out that the Minister
must include members of local authorities among the
people he appointed to the regional boards, and they
would no doubt keep their colleagues informed of what
was happening. Viscount SIMON suggested that the
language of the Bill regarding these appointments. might
620 THE LANCET]
be strengthened, and Lord LISTOWEL agreed, for, he
declared, the intention was that representatives of the
local authorities should be included. The amendment
was withdrawn. | l
The Earl of MUNSTER pointed out that the Bill had
now been before Parliament for six solid months and
asked whether the Government could not now give
some information as to the size of the regions. Lord
JOWITT said he wished he could but to be frank he could
not. There was a great deal of negotiation to be done,
and it would be foolish to attempt. anything in a hurry.
FUNCTIONS OF THE HOSPITAL MANAGEMENT COMMITTEES
Lord LUKE moved an amendment seeking to readjust
the functions of the regional boards and the hospital
management committees by omitting the subsection
particularising the duties laid on the boards—to appoint
staff, maintain premises, and acquire equipment and
furniture. Why, he asked, could -not the hospital
management committees have powers from the boards
similar to those enjoyed by the teaching hospitals from
the Minister? The committees would be formed of
trustworthy people appointed by the Minister and be
left. to manage the affairs of the hospitals. The boards
ied
. . would have enough on hand planning their regions and
generally giving guidance. To take the appointment of
staff from the committees would raise difficulties of
divided loyalties and remote control, and put the non-
teaching hospitals at a disadvantage compared with the
teaching hospitals. To have a floating population within
the region capable of being moved at a moment’s notice
might make it difficult for a hospital to get and keep a
team together. If the Minister wanted suitable people to
become members of the committees he must give them
suitable responsibility. | |
Lord JowiTT agreed that if people were to work on
the hospital committees they must be given a real job
to do. The issue was how to achieve this. The Govern-
ment intended to prescribe by regulations that the
hospital management committee should do all things in
regard to the running of their hospital, but that they
should do them on behalf of the regional board. The
appointment of officers—except perhaps senior servants
—should be in the hands of the committee, as would be
all expenditure, other than the building of a new wing
or anything of that sort. The Government expected that
~- the committees would have wide powers covering prac-
tically everything except questions of major policy.
But they thought it better not to impinge upon the
principle that the regional board was the authority and
the hospital management committee the agent acting on
behalf of the board. If there were any dispute between
the two the legal position would then be plain.
. Lord LLEWELLIN thought that all would agree that
as much power as was proper should be left to the
committees. But in the Bill he felt it was being done
in the wrong way. To get good men to serve, these com-
mittees must be made a reality and not just a kind of
camouflage. Their responsibilities must be placed in
the forefront of the shop window and not prescribed
afterwards by regulation. Viscount SIMON pointed out
that in the future these things would be construed not
according to what had been said in the House of Lords
but according to the language of the Bill: while laying
particular duties on the regional boards, Parliament
had not given the hospital management committees any
defined duty. Under this clause it would be lawful for
a Minister to say, ‘‘ Oh, I do not think much of this
hospital committee. I think on the whole that any
regulations it may make should be subject always to the
ratification of the regional board.” The Marquess of
_ READING suggested that it might be some time before
the regulations dealing with the functions of the com-
mittees could be passed. Yet surely to enlist support
for local hospital committees people should know at the
earliest possible moment, in the clearest possible terms,
and by the best possible instrument—which was the
Bill itself—what the functions of the committees were
to be.
Lord JowIrT replied that as part of a codrdinated
scheme the committees were to act as the agents of the
boards. He was anxious that there should be no demarca-
tion disputes and that the boards should have unques-
tioned authority. But he was equally anxious that the
PARLIAMENT
ordinary way.
of the regional boards that they could not be sued. In
[oor. 26, 1946
boards should exercise their powers by leaving a wide
discretion to the committees. “He would discuss the
clause further with his advisers; but to keep the legal
position clear he thought it should -stand, though he
hoped there would be such a wide measure of devolution
as would satisfy the noble Lords. a |
Lord LUKE withdrew his amendment. .
MEDICAL STAFF COMMITTEE
Lord MORAN moved an amendment that a separate
house committee should be set up in each hospital in
every group, and that each hospital should have a medical
staff committee with a right to nominate members to
the hospital management committees. The medical staff
committee which flourished in all our voluntary hospitals
was a unique instrument for keeping the hospital up
to date in practical matters. But in municipal hospitals
its place was taken by a single medical superintendent.
. Lord HORDER thought that the principle was vital but
that the exact relationship between the committee and
the management committee was a domestic matter.
‘‘ If it is not the intention. of the Minister to disallow
the formation of medical staff committees, I think an
assurance to that effect would be satisfactory.”
Lord JOWITT said it was obvious that a hospital board
must be set up to run the individual hospitals under the
jurisdiction of a hospital management committee; and
save in rare cases, such as a fever hospital working with
a general hospital, that would be done. It was also true
that we must have medical staff committees, but-he was
reluctant to mention them in the Bill; for a good many
committees would have to be set up—on nursing and
dietetics, for instance—and if one were singled out it would
look as if there were not to be any others. - _.
In withdrawing the amendment Lord Moran urged
that it was important that in this matter municipal
practice should be brought into accord with voluntary
practice. — l
Lord MORAN moved a further amendment to provide
that in teaching hospitals, facilities for medical teaching
and research as required by the university or medical
school should be supplied. A bed in a teaching hospital
‘might well be more expensive than in another hospital,
and a time might come when a hospital used for teaching
might be accused of extravagance. Professors of medicine
and surgery throughout the country had signed a
memorial on this point, for they felt that of the functions
.of the teaching hospitals were not put down on paper it
might weaken their case later when they came to argue
about the necessary provisions for carrying out teaching
and research. Lord Jowlr? agreed that besides the care
of the sick the teaching hospital had an added function
which might be even more important. He thought the
amendment went a little too far, but he undertook to
consider the matter with a view to drafting suitable
words, and the amendment was withdrawn.
LEGAL STATUS OF HOSPITAL MANAGEMENT COMMITTEES
Lord LLEWELLIN moved an amendment to allow
hospital management committees to sue :or be sued. This
was something, he asserted, that had to be settled at once,
for it could not be altered by regulation afterwards.
Lord Jowrrr recalled that the committees when acting
as principals—in relation to research or in the adminis-
tration of their own property—could be sued in the
It was only when acting as the agents
a codrdinated scheme there must be a chain of authority,
and on this point he was not in a position to make a
concession. The House accordingly divided, and the
amendment was carried by 59 contents to 17 non-
contents.
~ APPOINTMENT OF HOSPITAL OFFICERS
Lord LUKE moved an amendment enabling the Minister
by regulation to empower the hospital management
committees to employ officers other than specialists or
consultants. The Earl of LISTOWEL stated that there
already was power in the Bill to make a regulation of
this kind. Lord MAuGHAM asked how the House could
be expected to decide on this Bill when so much was left
in the air to be determined by regulations. Why was
there nothing in the Bill to show that the main manage-
ment of the hospitals was confined to the management
committee ? The Marquess of READING asked whether
THE LANCET]
the regional boards were to be permitted or obliged to
delegate their powers.
Lord JoWITT admitted that the regulations did not
yet exist, but pointed out that there would be oppor-
tunity to discuss them in Parliament. Broadly, the
_ regulations would lay down that certain matters fell
within the province of the management committees—
for instance, the engaging and dismissal of staff, with the
exception of senior staff. He did not suppose there
would be an appeal to the board if the committee dis-
missed some servant. That would be interfering with
the discretion of the committee unduly. He suggested
that the new system whereby a nurse became a servant
of the regional board, though she could contract to serve
ata particular place if she liked, might lessen the recruiting
difficulties of today.
Lord INMAN,. though he wished to see definite powers
given to the management committee so far as this
amendment was concerned, saw definite advantages in
the Government’s scheme. At his own hospital, to which
several hospitals were affiliated, they had found that the
nurses liked to move from one small hospital to another.
Viscount CRANBORNE asked whether it would not be
possible to distinguish between different types of staff.,
‘ Officer ” was an all-embracing word. Could not the
management committees control staff such as porters,
who were unlikely to want to wander round the region ?
The amendment was negatived.
LOCAL-AUTHORITY SERVICES
- Lord ADDINGTON moved an amendment permitting
a county council on application from a borough to delegate
to it functions relating to the care of mothers, young
children, employment of midwives, health visiting,
home nursing, vaccination, and so forth. The amendment
also gave the borough council the right of appeal to the
Minister if its application was refused by the county
council. Lord O’ILAGAN moved further to extend the
amendment to urban district councils. The amendment,
Lord ADDINGTON declared, would provide n maximum of
local control, attract voluntary effort, and permit the
degree of delegation to vary according to circumstances.
Lord JowITT replied that in the past there had been a
good deal of overlapping and confusion in the exercise
of these functions, and their distribution was chaotic.
Now that a new set of powers were being imposed on
` local health authorities, which it was hoped in the fullness
of time would be performed at health centres, it was a
matter of moment to entrust these duties only to major
authorities, which meant the counties and county
boroughs. The only exception was the care of children,
which would follow the pattern imposed by the new
Education Act. Lord HENLEY thought it would be unfair
to the county councils to take away bits and pieces of
- their areas and spoil the continuity of their services.
Viscount CRANBORNE thought that a proviso should be
. added to the amendment allowing delegation only subject
‘to the approval of the Minister. To this suggestion the
Earl of LISTOWEL promised to give consideration, though
he feared that even so the amendment would undermine
the scheme for coérdinating the services. The amend-
ments were withdrawn. l
METROPOLITAN BOROUGHS
Lord BALFOUR of Burleigh moved an amendment
providing that the London County Council should
delegate the functions cited in the last amendment to
the metropolitan boroughs. Local government in
London, he pointed out, was different from anywhere
else in the country, and the functions relating to maternity
and child welfare had never been exercised by the L.C.C.
Over the past 50 years they had been delegated to the
metropolitan borough councils, and the L.C.C. was still
on record as being in agreement with that position. The
boroughs had a very good record, and he did not think
that under the Bill the services could be maintained at
the same level of efficiency. But for the fact that London
local government was a thing by itself, these great boroughs
. would have been made county boroughs long ago.
Speaking as a Parliamentarian, Lord Jowirr was not
- too much moved by the plea of an agreement reached
between the L.C.C. and the borough councils outside
Parliament. At the time of the agreement the L.C.C.
were going to keep their hospitals, and presumably
PARLIAMENT
[ocr. 26, 1946 621
as they did not want to have too much‘on their plate |
passed these functions to the boroughs. Now the position
was different and the L.C.C. felt that they had time to
conduct these services themselves. '
Lord BALFOUR thought Lord Jowitt had made an
astonishingly good case considering he had not a leg to
stand on, but with 25 years’ experience as a borough
councillor behind him he assured the House that they
would spoil a good service if these functions were trans-
ferred to the L.C.C. The amendment was carried by
.35 contents to 15 non-contents.
FROM THE PRESS GALLERY
When is a Nurse Not a Nurse?
On Oct. 14 in the Commons Mr. ALFRED EDWARDS
moved to annul the Nurses Amendment Regulation
1946. When the Nurses Act of 1913 was under discussion
the Minister of Health. then Mr. Ernest Brown, in a
letter, gave an assurance to the Christian Science. move-
ment that he would provide by regulation that nothing
in the Act should prevent the using of the name or title
of “ Christian Science Nurse” by a member of the
Church of Christ, Scientist, who was, certified by the
church to be qualified for employment as a nurse by
members of the church. Had the movement not received
this assurance they would certainly have moved an
amendment to the Act. Nobody, Mr. Edwards declared,
was entitled to claim a monopoly on a word or name.
There were only 40-50 of these registered nurses in the
country. No-one was allowed to practise as a Christian
Science Nurse who had not completed 5 years’ training
and been recognised by the department. It would be
impossible to engage a Christian Science Nurse in mistake
for a medical nurse. Mr. G. COOPER, who seconded the
motion, pointed out that the words ‘‘ Christian Science
Nurse ”?” were used in the by-laws of the mother church
in Boston, and even if the regulation went through it
would be impossible to prohibit the use of the phrase
in the literature issued by the movement.
Mr. WILSON HARRIS, though admitting he was no
admirer of Mary Baker Eddy, supported the motion,
for he was depressed by the high-handed action of those
estimable people who wished to arrogate a common
English word to their own purposes. He thought it
reasonable to debar anyone from improperly using the
term ‘‘ registered nurse,” but if in the phrase ‘‘ Christian
Science Nurse” the two Archbishops did not object
to the use of the word ‘‘ Christian,” nor the Royal Society
to the use of the word “ science,’ why should anyone
object to the use of the word ‘“‘ nurse” ? Even the
medical profession was less exacting, and the Chancellor
of the Exchequer, though he could only pocket taxes
and could not attack poxes, had the right to be termed
“ doctor.’ Mr. F. MESSER pointed out that those
interested in the question had had no knowledge of the
correspondence taking place between Mr. Brown and
the Christian Scientists, and he refused to be bound
by an undertaking given by a Minister without con-
sultation. The nursing profession was in dire need of
recruits who he thought would only be gained if it won
the status of a real profession. If the door were opened
to the Christian Scientists it would have to be opened
to everyone else.
Mr. A. BEVAN explained that when he took office
he was faced with a prayer to annul Mr. Brown’s pro-
posed regulation giving exemption to Christian Science
Nurses. He therefore withdrew. the regulation in the
hope that a compromise could be reached. This had
not proved possible so he had therefore introduced the
present regulation. He admitted we were attempting
to constrain the English language, but that happened .
whenever we made a charter and gave a specific meaning
to a name. In the care of the sick, nursing, he ven-
tured to suggest, was as important as any other branch
of the medical profession. These women resented that
after an arduous training they were known by a name
which anyone could adopt. AU the other exemptions
to the Act were within the hierarchy of nursing itself.
If he exempted the Christian Science Nurses where
could he stop? He would have a stream of applications
for exemptions and a great body of fine women would
have been deeply and mortally pHended: The motion
was defeated by 245 votes to 43.
622. THE LANCET]
OBITUARY
\
'[oor. 26, 1946
Obituary
CHARLES SAMUEL MYERS
C.B.E., M.A., M.D., SC.D. CAMB., LL.D., F.R.S.
Dr. Myers, one of the first psychologists elected to
fellowship of the Royal Society, died at his home near
Minehead on Oct. 13. A few days earlier he had attended
' the celebration of the 25th anniversary of the National
Institute of Industrial Psychology, of which he was
founder and principal.
Charles Samuel Myers was born on March 13, 1873.
From the City of London School he went to St. Bartholo-
mew’s Hospital for a year and thence to Caius College, |
Cambridge, of which he was later to become an honorary
fellow. He won Foundation and Shuttleworth scholar-
ships, and took `a double first in the natural sciences
tripos, but still found time to exercise his keen interest
in anthropology and in music; and he himself played the
a violin expertly. He returned
to St. Bartholomew’s Hospital
to complete his medical train-
ing, and soon after qualifying
in 1897 he joined McDougall,
Seligmann, Ray, Wilkin,. and
Haddon on the Cambridge
University expedition to the
Torres Straits and Sarawak.
Myers’s part was ostensibly
to study native music, but his
- experience at this time coloured
his subsequent, work in psycho-
logy. On returning to this
country in 1899 he took a
house-appointment at Barts,
but he soon abandoned clinical
medicine. He remained in
London, first as lecturer, and,
after 1906, as professor of
psychology, until in 1909 he
returned to Cambridge as lec-
turer in experimental psychology and director of the
psychological laboratory. In 1911 he became first presi-
dent of the British Psychological Society, whose journal
he edited until 1924. |
The first world war found Myers slightly over age for
the R.A.M.C., but he went to France as a civilian and
became a hospital registrar at Le Touquet. Soon he
worked his way into the Army; he became consulting
psychologist to the B.E.F., and also took a guiding
interest in the training centre set up at Maghull, where
instruction was given in the application of psychological
principles to the war psychoneuroses. The emergency
attracted the energies not only of Myers but of W. H. R.
Rivers, Elliot Smith, and William McDougall—a band of
scientists whose work had previously borne little relation
to clinical medicine. They had an important share in
opening up what was then a new field, and Myers himself
contributed five articles to our own columns during the
war years. He also carried out spare-time research for
the Admiralty on the selection of hydrophone listeners.
The pioneer’s path, however, was not easy, and his book
Shell-shock in France, 1914-18 reflects the sense of
frustration he experienced and his relief when his task
could be relinquished.
The end of his active participation in medical- psycho-
logy was marked by a vigorously controversial letter in
THE LANCET of Dec. 27, 1919, in which he condemned
physical interference in the treatment of hysteria.
“ It is high time that the medical profession should decide
whether it is justifiable for a physician to tell lies to his patient
with the object of effecting a cure by suggestion, and on the
Sport & General Press Agency
basis of such lies to perform a serious operation with that |
object. . . . During the war there were certain physicians who
would explain to a patient suffering from functional hemiplegia
that the cortical cells on one side of his brain were out of
order. ... And they would proceed to tone up the disordered
cells by painful faradism.... I have always been convinced
that such measures are not only needless, but also dangerous.
If the patient is not cured by the electricity or the sham
operation, his latter state is far worse than his previous one,
because henceforth he firmly believes in an ‘ organic’ basis
of his condition. If, on the other hand, he is cured, he may at
any future time fear or fancy a recurrence of his ‘ organic’
malady.” :
He had gained the F.R.s. in 1915, and on his return to
Cambridge had been eager to put his subject even more
clearly on the map. In 1920 he was promoted to a
readership ; but he was denied the support he expected
from scientists and philosophers, and on reflection he
decided to give up his academic life and to join with a
London business man, H. J. Welch, in the foundation of
the National Institute of Industrial Psychology. Here
he found scope for his abilities in his successful teaching
that the humanising of industry by study of the worker’s
comfort, the adjustment of working conditions, and the
fitting of the right man to the right job could be carried
out only with the aid of psychology..
Mr. Alec Rodger writes : ‘‘ The National Institute was
Myers, and Myers was the National ‘Institute; but it
may be questioned whether he was altogether happy
in his new life. In some ways he relished his constructive
task, but now he had little time for teaching, and very
little more for research. Moreover, the support he
obtained from industry was scant. He became too
, preoccupied with financial problems and relationships
with other bodies, public and private, to be able to give
as much attention as he wished to science. Some consola-
tion he undoubtedly gained from his editorship of the
National Institute’s journal, Occupational Psychology, but .
it seems likely that in London as in Cambridge he suffered
disappointment. Nevertheless, he made his outstanding
mark, and it gave him satisfaction to know that most of
the personnel selection procedures adopted by the Navy
and Army in the second world war, in the initial selection
and allocation of recruits, were based directly on those
developed by the institute for civilian purposes. He was
a cultured, generous, kindly affectioned man; proud of
his Jewish race. It is fitting that his last production
should have been a report on Attitudes in Minority
Groups, prepared for the Society of Jews and Christians ;
it is a fine, scholarly work which reflects his deep
insight into anthropology.”
Myers published an Introduction to Experimental
Psychology and other books mostly concerned with the
industrial aspect of psychology, but his influence was
exerted rather through his teaching and organising than
his writings. In later years he was honoured by several
universities, receiving, honoris causa, the D.sc.. at’
Manchester in 1927, the LL.D of Calcutta in 1938, and the
D.sc. at Pennsylvania in 1940. He lived to see the
successful application of principles established thirty
years ago by him and his colleagues. .
He was married and had two sons and three daughters,
who, with his widow, attended a memorial service in
London on Oct. 16.
SYDNEY ARTHUR OWEN
M.D. CAMB., F.R.C.P. o «4
Dr. Sydney Owen had been at heart a children’s
doctor since the days when he served as resident medical
officer at Shadwell, and though he did not drop his work
among adults his appointments showed where his real
interest lay. A pioneer in neonatal pediatrics, he had
been physician to the Queen’s Hospital for Ohildren,
Hackney, since 1910. Physician to the Princess Louise
Hospital for Children from the time of its opening, he was
also on the staff of the City of London Maternity Hospital.
From 1912 to 1937 he was in charge of the psediatric
department of the West London Hospital, where he died
on Oct. 14.
An exhibitioner of Trinity College, Cambridge, he took
a first class in the natural sciences tripos in 1901. At
_ University College Hospital, where he qualified in 1904,
taking his M.B. the following year, he was awarded an
Atchison scholarship, a senior Fellowes medal, and a
medal for midwifery. In 1910 he took his M.D. Camb., and
in 1928 he was elected F-.R.C.P.
Among the pieces of apparatus which he introduced
and carefully tested was the ‘‘ oxygen bell,” a device
for administering oxygen to small infants which is in
regular use in hospitals. But it was characteristic of
Sydney Owen that he himself never published anything
about its use. An excellent teacher, he would have filled
admirably a full-time clinical and academic appointment,
' THE LANCET]
but in his day none existed. Years before the last war
he anticipated its coming and its character better than
most of us, and recommended the provision of hospital
shelters. In 1939 he was due to retire, but instead he
undertook full-time administrative work in the E.MLS.,
where his time-saving orderliness and thoroughness stood
his many medical ‘“‘ clients ” in good stead.
Generous to his juniors, gentle and courteous to his
hospital mothers, a hard worker in spite of indifferent
` health, he would push for others but never for himself,
and medical women owe him much for the doors he
opened on their behalf.
“ Those of us who worked with Owen,’’ writes a
colleague, ‘‘ will always remember him for his keen insight
into the problems which faced him, and his extraordinary
sympathy and tact with little children. No trouble was
too great when dealing with a patient, whether in hospital
or in private, and the careful notes in his small, tidy but
difficult handwriting, were a model of what case-taking
should be. He had a valuable collection of clinical data,
which the retiring nature of his character seemed to
: prevent him from publishing to any large extent.”
His wife, who shared fully in all his interests, is left
with a son and daughter.
IAN MACKENZIE DAVIDSON
M.D. GLASG., F.&.C.S.E.
Dr. Ian Davidson, who died at Carlisle on Oct. 14
at the age of 30, leaves a gap that might have been made
by many an older man, for he had packed much into his
short life. The son of Mr. Norman Davidson, F.R.C.S.E.,
of Glasgow, he entered Glasgow University from Rugby
and graduated m.B. in 1938. After holding a house-
appointment in the Glasgow Victoria Infirmary, he
went as ship’s surgeon to the Far East. At the outbreak
of war, he. volunteered for the R.A.M.C., and after his
discharge on medical grounds served as house-physician
and house-surgeon at the Cumberland Infirmary, Carlisle,
during 1940. The following year, after an interval during
which he wrote his thesis on parkinsonism which was
accepted for the M.D. degree in 1942, he returned to the
Cumberland Infirmary as surgical registrar. | While
holding this post he obtained his Edinburgh fellowship,
and in 1943 he was appointed assistant surgeon to the
Infirmary, later becoming surgeon to the E.M.S., con-
sulting surgeon to the Victoria Cottage Hospital, Mary-
port, and surgeon to the City General Hospital, Carlisle.
He was blessed with unusual gifts of mind and body,
and his engaging charm and genuineness won him many
friends. A sound surgeon, he had a deftness of hand that
reflected a quick and steady brain, and the maturity
of his judgment belied his youth.
His widow, Dr. Josephine Cartwright, D.R.C.O.G.,
of Edinburgh, and their year-old daughter, survive him.
T. MCL. G.
HENRY HANNA
M.A., M.B., B.SC. R.U.I.
Mr. Henry Hanna, who died in Belfast on Sept. 28,-
was widely known throughout the Province, for genera-
tions of medical students had passed under his keen
scrutiny, and he had a large private practice in diseases
of the eye, ear, nose, and throat. For close on 40 years
he had worked at the City Hospital, where he held the
appointment of visiting ophthalmic surgeon at the time
of his death. He retired from the staff of the Royal
Victoria Hospital in 1939.
Born in 1874, he received his early education at Belfast
Royal Academy while his university career was spent
between Queen's College, Belfast, and St. John’s College,
Cambridge. Theold Royal University of Ireland conferred
upon him a B.A. in 1894, and two years later he graduated
M.A., B.Sc. In the following years he worked at
Cambridge but he returned to Ireland to begin his medical
course, and he took his M.B. in 1903. After holding a
resident appointment in the newly built Royal Victoria
Hospital, Belfast, and a demonstratorship in the depart-
ment of anatomy, he spent some time in the eye, ear,
and throat clinics of Vienna before returning to practise
im his chosen specialty at Belfast. He served as presi-
dent of the Irish Ophthalmological Society, the Ulster
Medical Society, and his special section at the British
Medical Association meeting in Belfast in 1937.
APPOINTMENTS—BIRTHS, MARRIAGES, AND DEATHS
But
{ocr. 26, 1946 623
though he had held these offices with distinction he
preferred his own fireside or the company of his friends
whom he delighted with his dry wit.
“ Outside medicine,’ writes J. R. W., “ Hanna’s
interests were varied. He was often to be seen on the
golf links, but perhaps his greatest joy was fishing in
a quiet stream. He had a genuine appreciation of art
and his collection includes many valuable pictures
as well as a beautiful selection of porcelain and old
Irish glass.”
His widow survives him with two daughters.
Appointments
BEATTIE, W: M., M.CHIR. Camb., F.R.C.8.: assistant surgeon, David
POUS. Orern Hospital Branch, Royal Liverpool United
ospital.
FRIPP, A. T., B.M. Oxfd, F.R.c.8.: consultant orthopædic surgeon,
public health department, London County Council.
GUTTMANN, E., M.D. Munich, L.R.F.P.S.: assistant clinical director, .
Maudsley Hospital, Denmark Hill.
LEYs, D. G., D.M. Oxfd, F.R.C.P.: consulting pediatrician, County
Hospital, Farnborough, and North-West Kent.
Lucas, B. G. B., M.R.C.8., D.A.: research assistant in anwsthetics,
University College Hospital medical school, London.
MENDL, K., M.D. Prague, D.M.R.: radiotherapist, Swansea General
and Eye Hospital.
SMITH, A. G., M.D. Glasg., F.R.C.S.: medical referee for dermato-
logical cases under the Workmen’s Compensation Act, 1925,
for county court districts in circuits 32 and 33. .
THOMAs, R. C., F.R.C.S.E., M.R.C.0.G.: consulting obstetrician and
pouecclogists County Hospital, Farnborough, and North-West
ent.
Examining Factory Surgeons :
Bowen, C. E. W., M.B. Vict., D.P.H. : Stretton, Cheshire.
CAMPBELL, A. M., 0.B.E., M.B. Glasg.: Cumnock, Ayr.
GREGSON, A. H., M.B. Manc. : Cromer, Norfolk.
GUTHRIE, G. A., M.B. Glasg.: Nairn.
MAOLEAN, R., M.B. Aberd.: Ullapool, Ross.
MORRISON, D. N. B., M.B. Glasg. : Braemar, Aberdeen.
WATSON, K., M.D. Dubl., F.R.0.8.E. : Redhill, Surrey.
Empire Rheumatism Council : ;
NICHOLSON, D. P., M.B. Lond., M.R.C.P.: registrar at West
London Hospital.
SHIERS, DUNCAN, B.8C., M.B. Wales, M.R.C.P.: registrar at Roya
Mineral Water Hospital, Bath.
Silicosis Medical Board: New Members
FREEBAIRN, N. A., M.B. Glasg.
PIERCE, J. W., M.D. Lond., M.R.C.P.
ROGERS, ENID M., M.D. Wales.
TURNER, G. E. M., M.R.C.8.
WILLIAMS, WYNDHAM, M.B. Edin.
Births, Marriages, and Deaths
BIRTHS
Evans.—On Oct. 17, in London, the wife of Dr. John Evans—a son.
GARROD.—On Oct. 10, in London, the wife of Dr. Oliver Garrod
—a daughter.
GispBs.—On Oct. 12, at Mackenzie, British Guiana, the wife of
Dr. D. S. Gibbs, of Hove—a son.
GLAss.—On Oct. 21, in London, Dr. Norma MacLeod, the wife of
Dr. R. M. Glass—a son.
KERsHAW.—On Oct. 5, at Mansfield, the wife of Dr. Robert Kershaw
—a daughter. p
Lazarnvts.—On Oct. 1, the wife of Dr. Samuel Lazarus, of Glasgow
—a daughter. ,
O’CONNOR.—On Oct. 12, at Abingdon, the wife of Dr. G.F. O’Connor
—a son.
ROSENVINGE.—On Oct. 12, at Harrogate, the wife of Dr. Gerald
Rosenvinge—a son.
SMYTH.—On Oct. 17, at Brighton, the wife of Captain Greville
Smyth, R.A.M.C.—a@ son. ;
THOMAS.—On Oct. 11, at Northampton, the wife of Dr. S. F. Thomas,
M.B.E.—a daughter.
WHEELDON.—On Oct. 15, in London, the wife of Dr. F. T. Wheeldon
—a son. |
WooLLEY.—On Oct. 18, at Derby, the wife of Dr. E. J. S. Woolley
—a daughter.
MARRIAGES
ABRAHAM—CLARK.—On Oct. 15, at Aughton, Everard Cecil
Abraham, M.C., M.D., to Doris Irene Clark, J.P.
BEAL—READE.—-On Oct. 19, John Hugh Bruce Beal, B.M. Oxfd,
F.R.C.S., to Mary Bettina Reade. :
HILL—AKRED.—On Oct. 19, in London, Major Francis E. Hill,
of Loxwood, Sussex, to Alice Akred, M.B.
REaD— BroDIE.—On Sept. 25, at Penang, Malaya, Marten Turner
Read, M.C., M.R.C.8., to Alison Garland Brodie.
THOMAS—GIRVAN.—On Oct. 17, at Pinner, David Francis Thomas,
F.R.C.8., to Jean Isobel Girvan.
DEATHS
DaAvVIDSON.—On Oct. 14, at Carlisle, Ian MacKenzie Davidson,
M.D. Glasg., F.R.C.8.E., husband of Dr. J. A. Davidson (née
Cartwright).
HARRis.—On Oct. 18, Henry Arthur Clifton Harris, M.R.c.8., of
Appledram, Ditchling, Sussex, aged 73.
Howie oe Oct. 14, at Eastbourne, Robert Howie, M.B. Glasg.,
age ;
PHILP.—On Oct. 13, at Preston Hall, Maidstone, James Daniell
Philp, M.R.C.8., aged 29.
TURNEK.—On Oct. 15, at Shirlett Sanatorium, Shropshire,
pears Thomas Turner. M.c., M.R.C.8., medical superin-
endent.
624 THE LANCET]
Notes and News
LIVERPOOL MEDICAL INSTITUTION
‘` AT a large gathering of members of this institution, held
last Saturday, with Dr. G. F. Rawpon Smita, the president,
in the chair, the honorary membership was conferred on
‘Dr. A. E. Barclay, Sir Allen Daley, Dame Louise McIlroy,
Prof. Charles McNeil, Dr. Ivan Magill, and Sir Alfred
Webb-Johnson. The following are extracts from the intro-
ductory speeches delivered by Dr. ROBERT Coors as orator :
DR. ALFRED ERNEST BARCLAY
In medicine’s house there are many mansions. Alfred Ernest
Barclay is one of the pioneers who has helped to build its well-
fitted darkroom, in which men can usefully pursue “ shadows, not
substantial things.” He has given us the work of a master in his
book on the radiology of the digestive tract. With rare ingenuity
he divides light from darkness, and emerges from obscurity to
explain the mechanism of swallowing or to reveal the mysteries of
the foetal circulation, or to startle us with a new and revolutionary
- tale of the blood-flow through the kidneys. Thus he looks upon
the forms of things unknown, turns them to shapes, and gives to
airy nothing a loca] habitation.
To craftsmanship he adds a scholar’s integrity. ... As Socrates
felt about words, so he feels about X-ray shadows: to use them
in an improper sense is not only a bad thing in itself, but it also
generates a bad habit in the soul.
SIR ALLEN DALEY
William Allen Daley—one of our own sons, a former councillor
of this institution—has wandered into a far country, but today
he comes back to us, full of honour and achievement.
There is no problem of preventive medicine on which the Govern-
ment of the day does not turn to him for counsel. He sits almost
by natural right on committees and commissions which consider
matters of medical administration, education, or policy. Since
1939 he has directed the health services of the County of London
t awkward, more than ever ungainly Great Wen. But London
has no terrors for this Merseysider. The man who was brought up
in Bootle. who married a native of Liverpool, whose children were
: born in our midst, who thrived on the smoke and noise of Brownlow
Hill, and who was tempered in the keen air of a provincial medical
society could take London in his stride.
Throughout the war years, when London endured the long-
drawn-out sufferings of bombs and fire and.flying bombs and
rockets, he virtually never left his post, day or night. The ca
and sustained devotion to duty of this modest and homely man
steadied and inspired his team. We welcome him home with pride.
DAME LOUISE MCILROY l
“ England,” wrote Bernard Shaw, “ cannot do without its Irish
-and its Scots, because it cannot do without at least a little sanity.”
Anne Louise McIlroy made doubly sure that we should need her,
first by being born in Antrim, and tben by taking her medical
course in Glasgow. It wanted only the finishing touch of Dublin
to make her irresistible when the Royal Free Hospital looked for a
professor of midwifery. é. @
her ward like a whirlwind: might on
She might sweep through
occasion drive her staff almost to distraction by an inexorable
insistence on detail: might never hesitate to say, forcibly and
without respect of persons, what was in her mind; but however
wild an Irishman may be, he has one eye always on things as they
are. To many problems in her chosen field she brought abounding
enthusiasm, but her final answers had the simplicity of hard
common sense. Her old students have found that she has fixed
enduringly in their minds fundamental principles. She has even
neh to preach that the right place for a baby is with the
mo er. e o
Now in the ripeness of her days, she can look back upon old,
forgotten, far-off battles, and be satisfied: for by what she has
done and by what she is, she has helped to make it natural for
women to take their place in our profession.
PROF. CHARLES MCNEIL
Early in bis medical career Charles McNeil was hard-headed
enough to realise that much may be made of a Scotsman if he be
caught Per Certainly a lifetime’s experience of techy and
wayward infancies has made him a canny clinician and a very
wise man, a senator among pædiatricians: nor has it taken the
edge off a dry and palatable humour.
He has thrown light on many aspects of disease in children,
notably on the respiratory infections of childhood ; but as professor
of child health he more than most men has given to pædiatrica
a positive social content, championing the cause of the newborn
baby, pleading earnestly for prophylactic child-care.
is no affair merely of instruction at medical clinics. He wants a
practical and practisable gospel of child welfare carried right into
the homes of the people.
We hope that it may be long before he needs an epitaph. When
the time comes, however, he will have well earned that which was
once given to another great man: “ When he died, the little
children cried in the streets.”
DR. IVAN MAGILL
Ivan Whiteside Magill came across the water from Northern
Ireland bringing with him a rich brogue and a spirit eager to blaze
new trails. For a brief moment he broke his journey at our own
Stanley Hospital to familiarise himself with a special brand of.
catarrhal upper respiratory tract; but he passed on to the
metropolis, where he now puts even the most uneasy of crowned
heads to sleep. ;
Modern anesthesia owes him much, for he has improved its
techniques and helped to make it safe. Without his skill and
guidance the thoracic surgeon especially might still be unable to
move delicately and with little hazard in a difficult field. Today
the patient condemned to a chest operation is not even allowed
to breathe; his respiratory centre is first poisoned and then ignored,
and with rubber bag and strong right hand the anesthetist breathes
for him. Moreover, Magill has seen to it, by the provision of
ingenious tubes, that the anesthetising vapours are carried to the
innermost shrine of his being.
To him this’
NOTES AND NEWS
‘the advancing edge of their subject.
é
{oor. 26, 1946
SIR ALFRED WEBB-JOHNSON - | ; ;
The glory of a surgeon is a thing of a moment: he. lives only
so long as he is alive. The quick and ready motion of steadfast
hands with experience creates his signature, which no man can
copy; and though it may be read on the bodies of his patients,
they too are mortal. ,
: Some surgeons live on in their students, lighting a candle in
their minds and hearts which can never be put out. Some are
numbered among the few who in various ways help to push forward
Some are remembered for
their leadership in wider issues of medicine and of medical policy.
Alfred Webb-Johnson qualifies on all three counts. What
Manchester trained one day, London received a little breathlessly ~
on the morrow. A born teacher, he never forgets a student, a
houseman, @ theatre sister, a nurse who has been one of his team :
he even knoweth his sheep by name. Medical education and
research have profited by the magic of this modern alchemist who
has solved the mystery of distilling gold from baser metal. And
now he is one of our most trusted medical statesmen, a man for the
times, clear headed, robust in common sense, imperturbable.
After the new honorary members had been formally
admitted by the president, each expressed appreciation and
thanks to the members. In the evening the honorary
members, together with the Lord Mayor of Liverpool. and
other official guests, were entertained to dinner at the
Exchange Hotel. l
COUNCIL FOR THE CARE OF SPASTICS
THE founding of St. Margaret’s School at Croydon! has
marked an entirely new phase in the care of children with
cerebral palsy in this country. Their special needs are now
recognised, and for some time various people and bodies
interested in their care have felt that a council should be
formed on a national basis to provide treatment and education
for them. On Oct. 17 a meeting was held at the London School
of Hygiene and Tropical Medicine, with Mr. G. R. Girdlestone,
F.R.0.s., in the chair, to consider how such a council might
best be founded. Both the Central Council for the Care of
Cripples and the British Orthopedic Association, he said,
have been studying the needs of these children. The Ministries
of Health and of Education have included them in their plans
in a general way, but there is much more to be done, he feels,
in exact diagnosis of the damage done to the brain, -and in
the study of the psychological needs of spastic children. About
a twentieth of them are deaf or have defective hearing. The
exact numbers in the country have yet to be ascertained, but
there are said to be about 7 children born with cerebral palsy
in every .100,000 live births; 1 of these will die during
infancy and 2 of the remaining 6 will be seriously defective
mentally and thus fall outside the group for which the proposed
council is to care. Each child needs the attention of an
orthopedic surgeon, and Mr. Girdlestone estimated that there
should be one physiotherapist and one occupational therapist |
for every 15, and a speech therapist for every 30 children.
The parents need training in the care of their children ; at
St: Margaret’s the mother is is to spend ‘a day at the school
once a week, helping to look after both her own child and
others. The council, Mr. Girdlestone suggested, must help to
develop training institutions, including residential and day
schools, vocational training centres, and perhaps sheltered
factories. In Danish hospitals, it seems, 30% of the secretarial
staff are cases of cerebral palsy, a plan which does well, he
said, as long as those they have to work with remain calm and
serene. Since the only way to convince people that a thing
needs doing is to do it, he suggested that the council, when
formed, should select a small energetic committee to get the
work going. A discussion on the name of the council followed,
in which it was agreed that the work should not be limited
to children, and that an appropriate name would be the
“ Council for the Care of Spastics (and those with allied
conditions).”’ eee
Prof. J. M. Mackintosh was anxious to see the council
formed forthwith, but since many of those present were
unknown to each other it was finally agreed that the meeting
should constitute itself an Association for the Care of Spastics
(and persons suffering from kindred conditions), and should
appoint a committee to draw up recommendations for the
creation of a council. This committee, it was agreed, . should
have power to receive and expend money until they reported
to the association in six or eight weeks’ time, and their running
expenses for that period, up to £400, were guaranteed br
Mr. Paul Cadbury. |
Members of the committee are: Mr. Stephen K. Quarle
(chairman); Mr. H. P. Weston, M.a. (secretary); Mr. E.S.
Evans, F.R.c.s.; Miss M. I. Dunsdon, m.a.; Mrs. W. Lionel
Hitchens; and Mr. N. D. Bosworth Smith, M.A.
1 See Lancet, Sept. 7, 1946, p. 354.
THE LANCET]
7 ROYAL COLLEGE OF SURGEONS OF ENGLAND
- MoNTHLY dinners to which fellows and members of the
college and members of the associations linked with the
college may bring guests have now been held for just over a
year, and the attendance has ranged from 40 to 100. The
dinners always take place at the collego on a Wednesday,
at 7 P.M., and the following are the dates chosen for the
coming session :
1946: Nov. 13, Dec. 11.
1947: Jan. 8, Feb. 12, March 12, April 9, May 7, June 11, July 9.
Applications for tickets, accompanied by a remittance of
one guinea a head, must reach the assistant secretary of the
college, Lincoln’s Inn Fields, London, W. C.2, at least one week
before the date of the dinner.
ADDITIONS TO POISONS LIST
By regulations which came into force on Oct. 15, pethidine
and its salts, and dihydrodesoxymorphine are added to part I
of the Poisons List, and zine phosphide to part 1. These
substances are added to the first schedule of the Poisons
Rules, but rat and mouse poisons containing zine phosphide
are exempted from first schedule requirements and may be
sold by listed sellers of part 11 poisons.
University of Sheffield
Dr. D. H. Smyth has been appointed to the chair of physio-
logy, in the place of Prof. G. A. Clark, who has resigned to
take a post in the Ministry of Health.
Dr. Smyth, who is 38 years of age, graduated B.SC., with first-
class honours, at Belfast in 1929, and M.B. in 1932. After being
house-surgeon at the Royal Victoria Hospital, he was, in 1933,
appointed senior demonstrator in physiology at Queen’s University,
where he worked under Prof. T. H. Milroy and Prof. Henry HKarcroft.
In 1934 he became a M.sc., and in 1935 M.D. With a Musgrave
studentship he studied for a year under Prof. Hermann Kein at
Gottingen, and on returning to this country in 1937 was appointed
lecturer in physiology at University College, London. In 1939
Dr. Smyth went to Shettield to which part of the London Faculty
of Medical Sciences was evacuated, and in 1940 he helped to organise
the department’s work at Leatherhead ; in 1944-45 he acted as
bead of the department in the absence of Prof. Lovatt Evans,
P.R.S., On special war duties. In 1911 he gained the doctorate
of philosophy of London University. Since 1943 he has been sub-
dean and tutor to medical students at University College, and
has made a special study of methods of selecting candidates for
training. This year he became senior lecturer in physiology. His
publications have dealt principally with respiration and metabolism.
As announced last week, Dr. R. S. Illingworth has been
appointed professor in charge of the new department of child
health in the university.
Dr. Illingworth studied medicine at the University of Leeds,
qualifying in 1934. He held resident medical posts at Leeds, and
obstetrical and ear, nose, and throat pusts at Huddersfield, and
spent a period in gencral practice before appointment as resident
medical assistant and clinical pathologist at the Hospital for Sick
Children, Great Ormond Street. He graduated M.D. and became
M.R.C.P. in 1937, and in 1938 obtained the b.P.H., with distinction, and
the D.c.H. In 1939 he won a Nuflieid research studentship in medicine
at the Radcliffe Infirmary, Oxford, and a Rockefeller research
fellowship for travel in the United States. He was in the R.A.M.C.
from 1941 to 1946, serving, with the rank of lieut.-colonel, as
officer in charge of the medical] division of military hospitals in the
Middle East and Northern Ireland. He is at present assistant
to the professor in the Institute of Child Health, London. Dr.
Illingworth has published papers on nephritis, prematurity, infectious
diseases, and other subjects. He isa fellow of the Royal Photographic
Society.
University of Manchester l
On Tuesday, Nov. 19, at 4.15 P.M., Prof. Michael Polanyi,
M.D., PH.D., F.R.S., will deliver the Lloyd Roberts lecture in
the physiology theatre of the university. Professor Polanyi,
who holds the chair of physical chemistry at Manchester, will
speak on the Foundations of Academic Freedom.
Royal College of Surgeons of England
On Oct. 15 Dr. Allen Oldfather Whipple, Valentine Mott
professor of surgery at Columbia University, New York, was
admitted to the fellowship, honoris causa, and was afterwards
entertained to dinner by the council. In the course of his
speech of presentation, Sir Heneage Ogilvie, senior vice-
president, described him as “a great American surgeon, a
pioneer in surgical research, a moving spirit in surgical educa-
tion, a brilliant operator, an inspiring writer, a well- loved
teacher.” He went on:
‘* Wo honour him, not for his many distinctions but for the ability
that earned those distinctions, not for the many important otlices
he holds or.has held but for the outstanding qualities of mind and
character that have earned hiin those appointments. Dr. Whipple’s
namie is printed large on every page of surgical advance, and where
other surgeons are breaking new ground and treading fearfully as
they are today in the surgery of malignant diseases of the pancreas,
there they see Allen Whipple before them saying ‘ Here Iam. This
pares way I have gono, and where I bave tr oudo you may follow
safely.
NOTES AND NEWS
[ocr. 26,1946 625
Royal College of Surgeons of Edinburgh
At the annual meeting of the college on Oct. 16 the follow-
ing oftice-bearers were elected for the ensuing year : president,
Mr. J. M. Graham ; vice-president, Prof. R. W. Johnstone ;
secretary and treasurer, Mr. K. Paterson Brown; members
of the president’s council, Sir John Fraser, Dr. G. Ewart
Martin, Mr. F. E. Jardine, Mr. W. Quarry Wood, Mr. Walter
Mercer, and Prof. J. R. Learmonth; representative on the
General Medical Council, Sir Henry Wade; convener of
museum committee, Mr. W. Quarry Wood; and librarian,
Dr. Douglas Guthrie.
The following were admitted fellows :
Nicholas Alders, M.D. Vienna, M.R.C.8. C. J. B. Anderson,
M.B. Aberd. ; W. G. Birks, M.B. Adelaide; S. K. Burcher,
M.B. NZ; A. G. Sz. Calder, M.B. Edin.; E. A. Chisholm,
M.B. Glasg.; L. M. David, M.B. Witw atersrand; F. W. T. Davies,
M.R.C.S. ; A. J. Freese, M.R.c.8.; G. L. Gale, M.B. Birm.; M. P.
Goradia, M.B. Bombay; J. B. M. Green, M.R.0.8.; F. M. Hanna,
M.B. Dubl. E. L. John, M.B. Lond.; W. G. Kerr, M.B. Edin. ;
J: E Laink, M.B. Edin. ; W. H. S. Liebenberg, M.D. Amsterdam ;
Tobias Levitt, M.R.C.S. A. A. MacGibbon, M.B. Edin.; J. M.
MecInroy, M.B. St. And, T. B. McMurray, M.B. Lpool: J. M.
Matheson, M.B. Edin. ; É. N. Mitra, M.B. Patna; R. F. o’ Driscoll,
M.B. N.U.I. ; G. Osborne, M.B. Lpool; "A. P. R. Pinto,
M.B. Bombay; E. C. Richardson, L.r.c.P.k.: G. K. Riddoch,
M.B. Camb.: L. J. Rov, M.B. N.Z.; A. R. Taylor, M.B. Aberd. ;
D. J. Waterston, M.B. Edin.; Austen Young, M.B. Edin
Royal College of Physicians of Ireland
Dr. Bethel Solomons has been elected president of the
college.
Royal College of Obstetricians and Gynæcologists
The following course of lectures on recent advances affecting
obstetrical and gynæcological practice will be given in the
college house at 5 P.M. on each day: Nov. 1, Prof. J. C. Moir,
Application of Radiology to the Diagnosis of Cephalo-pelvic
Disproportion ; Nov. 15, Dr. J. M. H. Campbell, Heart in
Pregnancy; Nov. 29, Dr. J. F. Loutit, Rhesus Factor ;
Dec. 13, Mr. Victor Bonney, Myomectomy; and Jan. 10,
Mr. F. J. Folley, p.sc., Lactation. Admission is by ticket
only, for which early application should be made ‘to the
secretary.
Leeds and West Riding Medico-Chirurgical Society
Forthcoming lectures to this society include: Nov. 1, Prof.
H. V. Dicks, Rôle of the Family Doctor in Mental Hygiene ;
Nov. 22, Dr. Macdonald Critchley on Sir William Gowers;
Feb. 14, Dr. Peter Bishop, Use of Sex Hormones in Medicine ;
March 8, Prof. C. F. W. ENS Recent Observations on
Peptie Ulcer.
Association of Plastic Surgeons
A meeting of those interested in the secablianinent of an
association of plastic surgeons will be held at the Royal College
of Surgeons, Lincoln’s Inn Fields, W.C.2, on Wednesday,
Nov. 20, at 5 p.m. The President of the Royal College of
Surgeons, welcoming the formation of such a body, has
suggested that it should fall into line with similar associations
already aftiliated to the college.
Gifts from South Africa
Gencral Smuts, prime minister of South Africa, on Oct. 18
handed to Mr. Attlee a bank draft for £196,000 as an offering
to the people of Great Britain from the people of Durban and
the province of Natal. Attached to the gift was a condition
that the money should be spent on a hospital or similar
utilitarian memorial. At the same time General Smuts
presented a gold certificate for £985,000 as a nation-wide
offering from all the people of South Africa and the British
protectorates “ to be vagd for the advantage of the British
people.”
Empire Rheumatism Council
Today, Friday, Oct. 25, Dr. C. W. Buckley will take the
chair at a dinner, to be held at the Euston Hotel, London,
N.W.1, at 7.15 P.M., to welcome the official Swedish delegates
to the celebrations of the tenth anniversary of the foundation
of the council. On Oct. 26, at 11, Chandos Street, W.1, at
ll a.m., Prof. J. A. Höjer, chief medical officer of the Royal
Swedish health department, will give an address on Organisa-
tion of Treatment and Research into Rheumatism in Sweden.
Lord Horder will be in the chair, supported by Mr. M. G. B.
Prytz, the Swedish minister. On Monday, Oct. 28, at 4 P.M.,
Mr. Aneurin Bevan, the Minister of Health, will be present at
a reception to be held at the Apothecaries’ Hall, Black Friars
Lane, E.C.4. On Oct. 29, H.M. Government will give a lunch
at the Savoy Hotel at 1.15 r.m., when Mr. Bevan presides ;
and at 5.30 P.m., the British Council are to hold a reception
at 74, Brook Street, W.1.
626 THE LANCET]
DIARY OF THE WEEK
E
foor. 26, 1946
Medical Research Society
A lecture on the Artificial Kidney will be given ii Dr. W. J.”
Kolff at University College Hospital medical school on
Thursday, Nov. 7, at 5 p.m. Those interested are invited to
attend.
Radiotherapy in Uterine Cancer
A joint meeting of the British Institute of Radiology, the
Faculty of Radiologists, and the radiological section of the
Royal Society of Medicine will be held today, Friday, Oct. 25,
at 5 P.M., at the institute’s house, 32, Welbeck Street, W., to
hear Prof. J. Heyman (Stockholm) speak on Radiotherapy of
Cancer of the Corpus Uteri.
Professional Nurses and Midwives Conference
At the opening of the conference in London last Monday,
Colonel Walter Elliot, F.B.c.P., F.R.S., the deputy president,
traced the history of British nursing since it had broken with
the European tradition of association with religious founda-
tions. Florence Nightingale, he said, though she achieved the
miracle of a ready-made tradition, was herself a rebel. Even
before the start of the late war there had been too fow nurses ;
he blamed overwork and underpay, and the deadening effect
of tradition. Registered nurses now numbered 138,000, and
it was estimated that a further 30,000 nurses were uired—
i.©., three years’ intake without allowing for the 50% wastage.
Better conditions were needed, with a modernisation of the
tradition, but the nurse’s authority must be retained; the
nursing profession must, above all, preserve its charity and
discipline.
London Hospital Dinner
Presiding over the annual dinner on Oct. 17, Sir Henry
Bashford pointed out that in the nine years since it was last
held a whole generation of students had entered the hospital,
qualified, held house-appointments, and gone its way. These
years had seen the death of many members and former
members of the staffi—Mansell Moullin, Hurry Fenwick,
Wilfred Hadley, Percy Kidd, Henry Head, Lord Dawson,
Hugh Rigby, L. A. Smith, H. R. Andrews, Lambert Lack,
E. W. Clapham, James Sherren, William Bulloch, Charles
Miller, Russell Howard, S. G. Scott, F. F. Muecke, Charles
Lindsay, Jack Harris, and Tudor Edwards—and of Sir
William Goschen, the chairman. Of the many retirements
he mentioned only two—those of Prof. Arthur Ellis to the
regius chair of medicine at Oxford, and of Mr. E. J. Burdon,
whom he had supposed to be part of the fabric but who had
in fact been secretary to the medical school for only 37 years
and was still young enough to embark on some entirely new
occupation such as farming or holy orders. During the war
1206 Londoners (including nurses and lay staff) served in the
Forces, winning 73 decorations and 83 mentions in despatches.
Consultants in: the three Services included Robert Milne,
Alun Rowlands, Henry Tidy, James Walton, Hugh Cairns,
J. R. Rees, George Riddoch, Ashley Daly, Charles Donald,
Arthur Lister, R. R. Bomford, and W. J. O’Donovan.
Baronetcies had been conferred on Robert Hutchison and
. Hugh Lett, who were simultaneously president of the Royal
Colleges of Physicians and Surgeons. Dr. Dorothy Russell
and Dr. Clifford Wilson were now professors, and the appoint-
ments to the hospital staff included those of Sir Reginald
-Watson-Jones, Mr. Osmond Clarke, Mr. Vaughan Jackson,
Dr. Frank Filis, Dr. Lloyd Rusby, Dr. Kenneth Perry, Mr.
Vernon Thompson, Dr. Henry Wilson, and Mr. A. Bowen-
Davies: the London had never believed in the closed shop.
There were new departments for X-ray therapy, psychiatry,
and the treatment of accidents: thanks to rehabilitation
“a man coming in with a fractured femur can be discharged
a fortnight later as a fully trained organ-grinder.’’ Rebuild-
ing plans would cost £3 million, and £100,000 was already
being spent on repairs to the hospital, which had had eight
direct hits. With 620 beds in use in London and 320 in the
annexe at Brentwood, it was still (as throughout the war) the
largest voluntary hospital 1 in Britain.
In the medical school, said Sir Henry, women would appear
in October, 1947; and he welcomed among the guests Colonel
C. R. M. Green, 1.M.s. retd., who became a student there
in 1879 and had now entered his grand-daughter. To those
still having trouble with examinations he offered the comfort
of long experience: “either you go on and on and on—or
you don’t. And as one looks at time from the other end,
how little it seems to matter.” Looking at the men the
hospital had produced he could not feel too pessimistic about
the future of medicine. After all, in the golden age of Mead,
Arbuthnot, Radcliffe, and Hans Sloane, physicians earned a
considerable part of their income by selling remedies whose
composition they often kept secret; and a hundred years
hence some of the customs of our own time might equally be
thought inappropriate. Medicine itself, as art and science,
went too deep to be ever chained or bridled by chance
enthusiasts of whatever persuasion. The same was true of
the London Hospital, which represented something too big
and too sane ever to disappear. In the future as in the past
each new generation coming within its influence would absorb
its tradition.
Dr. J. H. Thomas, proposing The Chairman, quoted some
of his early poetry. While disputing a statement contained
in one of his less good books Dr. Thomas felt bound to
commend his steadfastness and his humanity.
Diary of the Week :
| OCT. 27 TO NOV. 2
Monday, 28th
UNIVERSITY OF LONDON
5.30 P.M. (London School of Hygiene, K OppeLEUN niteen W.C.1.) Prof.
Major Greenwood, F.R.8 in Social
Medicine from Percival t “Simon. ( aeth Clark lecture.)
ROTAL, COLLEGE OF SURGEONS OF ENGLAND, Lincoln’s Inn Fielde,
3.30 P.M. Prof. Alexander Lipschutz: Tumorigenic Action of
Steroids and its Implication for the Problem of Cancer.
5 P.M. Mr. R. J. McNeill Love: Surgery of the Gall-bladder and
Common Bile-duct.
ROYAL SOCIETY OF MEDICINE, 1, Wimpole Street, W.1
3 P.M. Field Marshal Montgomery : Morale—with Particular
Reference to the British Soldier. (Llo d Roberts lecture.)
5.30 P.M. Odontology. Prof. H. Stobie: Rôle of Dentistry in
Medicine. (Presidential address.)
MEDICAL SOCIETY OF LONDON, 11, Chandos Street, W.1
8.30 P.M. Mr. Norman Dott, Sir Charles Symonds :
tology and Treatment of Intervertebral Disks.
Tuesday, 29th
UNIVERSITY OF LONDON
5.30 P.M. (London School of Hygiene.) Prof. M. Greenwood :
British Pioneers in Social Medicine;
ROYAL COLLEGE OF SURGEONS OF ENG
3.30 P.M. Prof. A eaeuser Lipschutz : oe Auiitumorianic Action
of Steroids
5 P.M. Mr. G. A. G. Mitchell: Value of Penicillin in Surgery.
LONDON SCHOOL OF DERMATOLOGY, 5 5, Lisle Street, W.C.2
5 P.M. Sir Archibald Gray : Sarcoidosis.
EDINBURGH POSTGRADUATE BOARD FOR MEDICINE
5 P.M. (Royal Infirmary.) Dr. A. C. P. Campbell:
Defence.
Wednesday, 30th
UNIVERSITY OF LONDON
5.30 P.M. (London School of Hygiene.) Prof. M. Greenwood :
_ British Pioneers in Social Medicine.
hore rags ae OF PUBLIC HEALTH AND HYGIENE, 28, Portland
ace A
3.30 P.M. Dr. W. H. Bradley : Methods Adopted in the Detection
of the Carrier.
Thursday, 31st
UNIVERSITY OF LONDON
5 P.M. (University College, Gower Street, W.C.1. ). Sir Joseph
roft, F.R.S. Movements of the ‘Human Fotus.
Prof. M. Greenwood :
Symptoma-
Cellular
- 5.30 P.M. (London School of Hygiene.)
British Pioneers in Social Medicine.
ROYAL COLLEGE OF SURGEONS OF ENGLAND i
5 P.M. Prof. Geoffrey Jefferson: Surgery of Intracranial
. Aneurysms.
LONDON SCHOOL OF DERMATOLOGY
5 P.M. Dr. J Franklin :
Eruptions,
Friday, lst
UNIVERSITY OF LONDON
5.30 P.M. (London School of Hygiene.) Prof. M. Greenwood :
British Pioneers in Social Medicine.
ROYAL COLLEGE OF SURGEONS OF ENGLAND
3.30 P.M. Prof. Alexander Lipschutz: Steroid Balance and tbe
Antitumoral Autodefence.
5 P.M. Prof. C. A. Pannett: Pancreatic Surgery
ROYAL COLLEGE OF OBSTETRICIANS AND GYN EA INES: 58, Queen
Anne Street, W.1
5P.M. Prof. J.C. Motr : Application of Radiology to the Diagnosis
of Cephalo-pelvic Disproportion.
ROYAL SOCIETY OF MEDICINE
10.30 A.M. Otology. Mr. H. V.
eek pie aa Child Welfare.
A.M.
2.30 P.M. Laryngology. Mr. Norman Patterson: Reminiscences
and Reflections. eae address. ) Mr. Lionel
Colledge : ype, veces oo »)
8.15 P.M. Anesthetics. Dr. E. S. Rowbotham: Hundred Years
of Anesthesia. (Presidential address.)
LONDON CHEST HOSPITAL, Victoria Park, E.2
5 P.M. Dr. S. Roodhouse Gloyne: Industrial Diseases of the
Y Lichen Planus and Lichenoid
Forster: Otol in School-
(Presidential ad 8.) Cases
ung
LEEDS AND West RIDING MEDICO-CHIRURGICAL SOCIETY
8.30 P.M. Prof. H. V. Dicks: Rôle of the Family, Doctor in Mental
Hygiene.
Saturday, 2nd
BIOCHEMICAL SOCIETY
11.15 A.M. (London School of Hygiene.) Discussion: Quantitatire
Biochemical Analysis by a OR Ee Response.
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TE DUR
Lancet 42333
SepteCct.,; 1946
lowa State Medical Library
HISTORICAL BUILDING
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