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CHEMOTHERAPY IN CEREBROSPINAL FEVER
BLOOD AND VULCANITE
THE LANCET LONDON:SATURDAY, APRIL 22, 1939
BLOOD AND VULCANITE
anthropologist of investigating the remains of " The
the future, when the inhabitants of
Britain in the first half of the twentieth century, will undoubtedly comment on the large number of young adult skeletons with no teeth."1 No statistics of toothlessness are available, but doctors and dentists in all but the most well-to-do practices will support this prophecy. Who is to blame for these wholesale extractions ? Too often, particularly in the industrial areas, the condition of the teeth of working-class people in the early twenties is such that extraction is the only possible treatment. Apart from the debatable influence of diet and environment, these teeth are being lost because they are inadequately attended to at school and completely neglected in the immediate post-school years. The staffing of the school dental service is insufficient-and in some places grossly insufficient-to carry out the necessary conservative work on permanent teeth ; and, more important, a large proportion of parents, often as many as 60 per cent. in schools where the teachers’ persuasive powers are poor, refuse to have fillings done. On leaving school, at an age when dental caries is particularly prevalent, the working-class adolescent is left for several years without provision for dental treatment, and later he only qualifies for benefit if his approved society has a disposable surplus and he is able to pay half the cost. Many extractions are unavoidable under the present system, but many others are unnecessary and unjustifiable. On another page Mr. L. G. ROBINSON lays some of the blame for these at the door of the medical practitioner. With no real knowledge of dentistry, he says, doctors send their patients to the dentist with a demand for extractions, and unless he is a hospital consultant the dentist can hardly refuse to comply with such orders, backed as they invariably are by the patients themselves. Very many doctors overestimate the importance of dental sepsis as a cause of general disease : faced with a condition such as chronic rheumatism, which may have a septic origin, they are too ready to convict obvious dental sepsis as the cause, at any rate until its removal has proved them wrong. Secondly, they are apt to underestimate the seriousness of extractions : the removal of many teeth, especially if done at one sitting, is far from being a trivial operation, and may activate a smouldering infection and be the stepping-stone from poor health to invalidism; or the toothlessness of subsequent months may precipitate a gastric or duodenal ulcer. Further, many doctors have an exaggerated 1.
Cole, L. B., Dietetics in General Practice, London, 1938, p. 17.
937
faith in dental prosthesis ; no artificial teeth are as efficient as natural ones, and though most people can be made reasonably comfortable, many with unduly sensitive gums or abnormal alveolar arches can never masticate properly with a denture. There can be no doubt, however, that ruthless extraction is encouraged by the less scrupulous members of the dental profession. The removal of all teeth and the provision of complete dentures is the easiest and quickest way of making money where fees are low. Many of the unqualified dentists to whom the Dentists Act of 1921 gave a legal standing were never trained in conservative methods, and their livelihood depends on the teeth they condemn. The approved societies these blood-and-vulcanite encourage practitioners by their low scale of fees, their objection to partial dentures and fillings (often admittedly with reason), and their rules that allow only one ansesthetic fee. Doctor, dentist, and approved society thus all play their part in providing data for the future anthropologist, but fundamentally the attitude of the public themselves is to blame for the loss of countless teeth that might be saved. Even where almost gratuitous treatment is available many parents and adult patients will not spare the extra time and trouble for fillings, but prefer to wait until extraction is inevitable. A large section of the community, moreover, have come to regard it as almost natural to have their teeth out at an early age. Until this attitude changes it will be of little use for the school dental service to be reinforced, for treatment to be provided for adolescents, or for the approved societies to extend their benefits. Much can be done to educate the public in schools and welfare centres, but even more by the medical practitioner ; he must ensure that in this his powerful influence is exerted on the right side.
CHEMOTHERAPY IN CEREBROSPINAL FEVER THOSE whose daily work is facilitated by expert
nursing and lavish equipment may well feel
inclined
to raise their hats to the three officers in the Sudan Medical Service whose experiences in the treatment of cerebrospinal fever are described
elsewhere in this issue. The’word " primitive " seems inadequate to describe the conditions under which their work had to be done, and the expression "field conditions" takes on a new and more literal meaning when the operation of lumbar puncture has to be performed on patients lying on the ground. The only attentions the sick received, apart from the specific treatment with which these papers deal, were those provided by relatives. The treatment itself was primitive in the sense that tablets of sulphonamide compounds are unsuitable for preparing solutions for injection : some of these fluids were necessarily not solutions at all, but suspensions, which even tended to block the needle with which they were injected. In spite of these grave disadvantages, the treatment appears to have been an almost miraculous success. Patients walked home only a few days after it was begun, and local " ’ medicine men ’ forsook their
938
lucrative
practices and used their authority encouraging patients to come .. " : an acknowledgment of the help afforded by these gentlemen is a most unusual postscript to a
own
in
containing eosinophil material in their centre ; they appeared to arise in the ectoderm. Judging from this description they are unlike virus lesions, and although the agent producing them passes through Berkefeld V. and N. filter cells and
scientific paper. These simple facts, and the account given of the candles the fact that it can be cultivated in oxrapid clinical effect achieved, are eloquent testimony serum dextrose broth or on solid media rich in to the efficacy of the treatment. The mortality- serum also marks it off from the viruses. It rates of only 10 and 5 per cent. in two large evidently belongs to the pleuropneumonia group. series of treated cases are also strikingly different SWIFT and BROWN found that mice anaesthetised from that which is apparently normal for this with ether and inoculated intranasally with disease in the Sudan. These papers, however, do rheumatic exudates or with suspensions of the not depend on figures for their interest and value, infected egg-membranes developed pneumonia, and the statistical purist would perhaps look and that this infection could be passed serially askance at them. The impression they may possibly in mice. Both from the pneumonic lesions in give needs to be corrected in some other directions mice and from the lesions on egg-membranes a which are more important. Meningococcal menin- similar micro-organism was grown. Recent work has shown that pleuropneumoniagitis, despite its high mortality in the Sudanese, well like be more amenable treatment in these to organisms are to be found in some stocks of may than follow so the possibility that the micro-organism in if it does not mice, so, people Europeans : that similarly rapid effects are everywhere to be of SWIFT and BROWN came from the inoculated expected, or that equally small doses will always mice and not from the rheumatic material had suffice. In the second place there is no evidence to be faced. The possibility was rendered remote here of the superiority of any one sulphonamide by its isolation from chorio-allantoic membranes compound over another for the treatment of this infected directly with rheumatic exudates, and disease. Dr. SOMERS used M. & B. 693 only; it was altogether removed by obtaining positive Drs. BRYANT and FAIRMAN used this for most of cultures in ox-serum broth directly from rheumatic their cases, and sulphanilamide for the much material. This was achieved with the arthritic smaller number which their limited stock of this exudate from one case and with an excised drug enabled them to treat ; and for what the erythema-nodosum nodule from another, and the fact is worth the recovery-rate on both drugs was cultures thus made were found to have the same 95 per cent. Therapeutic studies,if they are to pathogenicity for animals as the strains recovered have evidential value, must involve one of three by direct inoculation of mice or of egg-membrane. kinds of comparison-supposedly specific treatThere seems to be no doubt then that this ment with merely symptomatic treatment; one pleuropneumonia-like organism was derived from specific treatment with another; or, thirdly, two patients with rheumatic fever, and the question forms of the same specific treatment, one with of its aetiological significance now arises. Microanother. Only the last of these now seems justified organisms of the pleuropneumonia group have in connexion with meningococcal meningitis, and been found in a variety of situations, and the it is to be hoped that future opportunities in the isolation of such an agent from rheumatic exudates Sudan will be used to make a serious comparison by no means implies that it is the prime cause of between the merits of sulphanilamide and M. & B. acute rheumatism. In this connexion, however, 693. While all in this country will sympathise some findings of A. B. Satin2 are pertinent; with those who have to contend with such appalling for he has isolated a pleuropneumonia-like organism conditions, they will also envy such abundance of from mice which on intravenous or intraperitoneal clinical material. Paradoxical as it may sound, injection regularly produced in this species of the circumstances of the Sudan seem ideal for a animal a migratory arthritis. The arthritis became therapeutic study adequate in scale if rather rough progressive and chronic in one or morejoints, in method. leading ultimately to ankylosis, and fusiform swelling of isolated digits was often observed. A MICRO-ORGANISM FROM RHEUMATISM Furthermore the pathological changes, which were SWIFT and BROWN1 of New York report some limited to the joints, consisted in proliferative in the synovial membrane, in the capsule, interesting observations on fluid from the joints changes and in the perichondrium of the articular cartilage. and pleural cavities of patients with acute As SABIN points out, this clinical and pathological rheumatism. They noted first that such fluid, in mice closely resembles rheumatoid inoculated on the chorio-allantoic membranes of picture arthritis in and he recommends search for man, hen’s characteristic eggs, gave rise to developing a in case of human arthritis similar organism these did not appear on primary inoculalesions ; of unknown cause. SWIFT and BROWN’S observation, but by the third to the fifth passage they had in acute rheumatism tions lend additional weight usually become definite and could then be induced to this suggestion. with regularity. On microscopical examination these " pearl-like " lesions were seen to be globular 2. Sabin, A. B., Ibid, March 10, 1939, p. 228. structures surrounded by flattened ectodermal ’
1.
Swift, H. F., and Brown, T. McP., Science, March 24, 1939, p. 271.
THE Norwegian Medical Society in Oslo has elected Prof. Grey Turner a foreign member.
THE LANCET LONDON:SATURDAY, APRIL 22, 1939
BLOOD AND VULCANITE
anthropologist of investigating the remains of " The
the future, when the inhabitants of
Britain in the first half of the twentieth century, will undoubtedly comment on the large number of young adult skeletons with no teeth."1 No statistics of toothlessness are available, but doctors and dentists in all but the most well-to-do practices will support this prophecy. Who is to blame for these wholesale extractions ? Too often, particularly in the industrial areas, the condition of the teeth of working-class people in the early twenties is such that extraction is the only possible treatment. Apart from the debatable influence of diet and environment, these teeth are being lost because they are inadequately attended to at school and completely neglected in the immediate post-school years. The staffing of the school dental service is insufficient-and in some places grossly insufficient-to carry out the necessary conservative work on permanent teeth ; and, more important, a large proportion of parents, often as many as 60 per cent. in schools where the teachers’ persuasive powers are poor, refuse to have fillings done. On leaving school, at an age when dental caries is particularly prevalent, the working-class adolescent is left for several years without provision for dental treatment, and later he only qualifies for benefit if his approved society has a disposable surplus and he is able to pay half the cost. Many extractions are unavoidable under the present system, but many others are unnecessary and unjustifiable. On another page Mr. L. G. ROBINSON lays some of the blame for these at the door of the medical practitioner. With no real knowledge of dentistry, he says, doctors send their patients to the dentist with a demand for extractions, and unless he is a hospital consultant the dentist can hardly refuse to comply with such orders, backed as they invariably are by the patients themselves. Very many doctors overestimate the importance of dental sepsis as a cause of general disease : faced with a condition such as chronic rheumatism, which may have a septic origin, they are too ready to convict obvious dental sepsis as the cause, at any rate until its removal has proved them wrong. Secondly, they are apt to underestimate the seriousness of extractions : the removal of many teeth, especially if done at one sitting, is far from being a trivial operation, and may activate a smouldering infection and be the stepping-stone from poor health to invalidism; or the toothlessness of subsequent months may precipitate a gastric or duodenal ulcer. Further, many doctors have an exaggerated 1.
Cole, L. B., Dietetics in General Practice, London, 1938, p. 17.
937
faith in dental prosthesis ; no artificial teeth are as efficient as natural ones, and though most people can be made reasonably comfortable, many with unduly sensitive gums or abnormal alveolar arches can never masticate properly with a denture. There can be no doubt, however, that ruthless extraction is encouraged by the less scrupulous members of the dental profession. The removal of all teeth and the provision of complete dentures is the easiest and quickest way of making money where fees are low. Many of the unqualified dentists to whom the Dentists Act of 1921 gave a legal standing were never trained in conservative methods, and their livelihood depends on the teeth they condemn. The approved societies these blood-and-vulcanite encourage practitioners by their low scale of fees, their objection to partial dentures and fillings (often admittedly with reason), and their rules that allow only one ansesthetic fee. Doctor, dentist, and approved society thus all play their part in providing data for the future anthropologist, but fundamentally the attitude of the public themselves is to blame for the loss of countless teeth that might be saved. Even where almost gratuitous treatment is available many parents and adult patients will not spare the extra time and trouble for fillings, but prefer to wait until extraction is inevitable. A large section of the community, moreover, have come to regard it as almost natural to have their teeth out at an early age. Until this attitude changes it will be of little use for the school dental service to be reinforced, for treatment to be provided for adolescents, or for the approved societies to extend their benefits. Much can be done to educate the public in schools and welfare centres, but even more by the medical practitioner ; he must ensure that in this his powerful influence is exerted on the right side.
CHEMOTHERAPY IN CEREBROSPINAL FEVER THOSE whose daily work is facilitated by expert
nursing and lavish equipment may well feel
inclined
to raise their hats to the three officers in the Sudan Medical Service whose experiences in the treatment of cerebrospinal fever are described
elsewhere in this issue. The’word " primitive " seems inadequate to describe the conditions under which their work had to be done, and the expression "field conditions" takes on a new and more literal meaning when the operation of lumbar puncture has to be performed on patients lying on the ground. The only attentions the sick received, apart from the specific treatment with which these papers deal, were those provided by relatives. The treatment itself was primitive in the sense that tablets of sulphonamide compounds are unsuitable for preparing solutions for injection : some of these fluids were necessarily not solutions at all, but suspensions, which even tended to block the needle with which they were injected. In spite of these grave disadvantages, the treatment appears to have been an almost miraculous success. Patients walked home only a few days after it was begun, and local " ’ medicine men ’ forsook their
938
lucrative
practices and used their authority encouraging patients to come .. " : an acknowledgment of the help afforded by these gentlemen is a most unusual postscript to a
own
in
containing eosinophil material in their centre ; they appeared to arise in the ectoderm. Judging from this description they are unlike virus lesions, and although the agent producing them passes through Berkefeld V. and N. filter cells and
scientific paper. These simple facts, and the account given of the candles the fact that it can be cultivated in oxrapid clinical effect achieved, are eloquent testimony serum dextrose broth or on solid media rich in to the efficacy of the treatment. The mortality- serum also marks it off from the viruses. It rates of only 10 and 5 per cent. in two large evidently belongs to the pleuropneumonia group. series of treated cases are also strikingly different SWIFT and BROWN found that mice anaesthetised from that which is apparently normal for this with ether and inoculated intranasally with disease in the Sudan. These papers, however, do rheumatic exudates or with suspensions of the not depend on figures for their interest and value, infected egg-membranes developed pneumonia, and the statistical purist would perhaps look and that this infection could be passed serially askance at them. The impression they may possibly in mice. Both from the pneumonic lesions in give needs to be corrected in some other directions mice and from the lesions on egg-membranes a which are more important. Meningococcal menin- similar micro-organism was grown. Recent work has shown that pleuropneumoniagitis, despite its high mortality in the Sudanese, well like be more amenable treatment in these to organisms are to be found in some stocks of may than follow so the possibility that the micro-organism in if it does not mice, so, people Europeans : that similarly rapid effects are everywhere to be of SWIFT and BROWN came from the inoculated expected, or that equally small doses will always mice and not from the rheumatic material had suffice. In the second place there is no evidence to be faced. The possibility was rendered remote here of the superiority of any one sulphonamide by its isolation from chorio-allantoic membranes compound over another for the treatment of this infected directly with rheumatic exudates, and disease. Dr. SOMERS used M. & B. 693 only; it was altogether removed by obtaining positive Drs. BRYANT and FAIRMAN used this for most of cultures in ox-serum broth directly from rheumatic their cases, and sulphanilamide for the much material. This was achieved with the arthritic smaller number which their limited stock of this exudate from one case and with an excised drug enabled them to treat ; and for what the erythema-nodosum nodule from another, and the fact is worth the recovery-rate on both drugs was cultures thus made were found to have the same 95 per cent. Therapeutic studies,if they are to pathogenicity for animals as the strains recovered have evidential value, must involve one of three by direct inoculation of mice or of egg-membrane. kinds of comparison-supposedly specific treatThere seems to be no doubt then that this ment with merely symptomatic treatment; one pleuropneumonia-like organism was derived from specific treatment with another; or, thirdly, two patients with rheumatic fever, and the question forms of the same specific treatment, one with of its aetiological significance now arises. Microanother. Only the last of these now seems justified organisms of the pleuropneumonia group have in connexion with meningococcal meningitis, and been found in a variety of situations, and the it is to be hoped that future opportunities in the isolation of such an agent from rheumatic exudates Sudan will be used to make a serious comparison by no means implies that it is the prime cause of between the merits of sulphanilamide and M. & B. acute rheumatism. In this connexion, however, 693. While all in this country will sympathise some findings of A. B. Satin2 are pertinent; with those who have to contend with such appalling for he has isolated a pleuropneumonia-like organism conditions, they will also envy such abundance of from mice which on intravenous or intraperitoneal clinical material. Paradoxical as it may sound, injection regularly produced in this species of the circumstances of the Sudan seem ideal for a animal a migratory arthritis. The arthritis became therapeutic study adequate in scale if rather rough progressive and chronic in one or morejoints, in method. leading ultimately to ankylosis, and fusiform swelling of isolated digits was often observed. A MICRO-ORGANISM FROM RHEUMATISM Furthermore the pathological changes, which were SWIFT and BROWN1 of New York report some limited to the joints, consisted in proliferative in the synovial membrane, in the capsule, interesting observations on fluid from the joints changes and in the perichondrium of the articular cartilage. and pleural cavities of patients with acute As SABIN points out, this clinical and pathological rheumatism. They noted first that such fluid, in mice closely resembles rheumatoid inoculated on the chorio-allantoic membranes of picture arthritis in and he recommends search for man, hen’s characteristic eggs, gave rise to developing a in case of human arthritis similar organism these did not appear on primary inoculalesions ; of unknown cause. SWIFT and BROWN’S observation, but by the third to the fifth passage they had in acute rheumatism tions lend additional weight usually become definite and could then be induced to this suggestion. with regularity. On microscopical examination these " pearl-like " lesions were seen to be globular 2. Sabin, A. B., Ibid, March 10, 1939, p. 228. structures surrounded by flattened ectodermal ’
1.
Swift, H. F., and Brown, T. McP., Science, March 24, 1939, p. 271.
THE Norwegian Medical Society in Oslo has elected Prof. Grey Turner a foreign member.