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WHOOPING-COUGH TREATED WITH CHLOROMYCETIN
579
suggests that prevention of the anticoagulant effect of a -chemotherapeutic drug is not necessarily desirable, is8 oontained in a statement by Prof. A. St. G. Huggett to the Biochemical Society, that the anticoagulation anti-enzyme action of some trypanocidal dyes may have an analogy to their mechanism as trypanocidal agents. Thus in therapeutic trials with combined P.A.S. and streptomycin it appears worth considering that any Jiypoprothombinsemic effect observed may represent a greater hazard to the tubercle bacillus than to its host. It would then be possible to make a comparison between patients risking hypoprothrombinaemia but safeguarded by serial prothrombin estimations, and those given a .supplement of vitamin K. Rostrevor,
co.
Down.
two-thirds of the insured men reaching minimum pensionable age and nearly one-half of the insured women do not claim their retirement pensions, because they are continuing in regular work until later. F. D. BICKERTON Ministry of National Insurance,
J. A. FISHER.
EMPLOYMENT OF ELDERLY PERSONS
SiR,-The explanation of the conditions on which National Insurance retirement pensions are paid, ’contained in your leading article of Sept. 10, is correct only in respect of persons who reached minimum pensionable .age before July 5, 1948, and accordingly qualified for their pensions under the old Contributory Pension Acts. The effect of the new National Insurance arrangements - on the willingness of elderly people to continue at work is obviously a matter of considerable national importance, and I hope, therefore, that you will allow me to explain the very different arrangements which apply to those Teaching pensionable age after July 5, 1948. Assuming that the contribution conditions are fully satisfied, a man may claim a retirement pension of 26s. from the age of 65 provided he has retired from regular employment, inconsiderable occupations being ignored (for women the qualifying age is 60). A man who does not retire until after age 65 now goes on paying National Insurance contributions in exactly the same way as he did before and remains’ entitled to sickness or unemployment benefit at the same rate as pension, so that any temporary interruption of earnings after minimum pension age provides no temptation to claim the retirement pension. For every 25 contributions paid in employment after his 65th birthday the rate of pension payable from retirement is increased by Is. a week. If the man’s wife has already reached 60 her notional pension-rate (including that payable to her as a widow if her husband dies before her) is also increased by Is. for every 25 contributions he pays. It is possible, therefore, for a man who goes on working until he is 70 to acquire the right to a pension of 36s. a week for himself, and one of 26s. a week for his wife during his lifetime and 36s. thereafter. The increased rates of pension payable in, this way are, taking one case with another, actuarially broadly equivalent in value to the sum of the pension forgone by postponing retirement and the contributions paid after minimum pension age. The arrangements therefore achieve the objective of the suggestion referred to in your, leading article. From age 70 (65 for women) the increased rate of pension earned by postponed retirement is payable unconditionally whether work continues or not. As a reinforcement of the retirement condition, where pension is claimed on retirement before age 70 (or 65, as the case may be), its payment up to that age is regulated by an earnings rule the effect of which is to reduce the pension paid for any week by Is. for every Is. of net earnings over 1:1in that week. The general objective of the provisions of the new National Insurance Act is, of course, to encourage all those who can to continue in regular work wherever possible up to age 70 or even beyond. It may interest your readers to know that at the present time about 8. See
Lancet, 1941, ii, 761.
Chief Press Officer.
London, S.W.1.
VITAMIN E
SIR,-With regard to the letter from Professor Boyd and others (July 16), may I quote experimental data’? R. L. ,Holman1 observed that, in dogs, vitamin E (3 mg. per kg. body-weight) had a significant protective action against hyperlipidic arteritis ; while Tusini2 administered to rats altogether 5 mg. of ergotamine tartrate and found that the ensuing arterial spasm in the tail was, in over 90% of the animals, almost completely- inhibited by giving 20 mg. of vitamin E daily. A synergistic action between vitamin E and vasodilators was also demonstrated, with very interesting therapeutic results. Perhaps these results may lead to clearer judgment of the " etra va.fya.Tit claims Milan.
"
from the S1mt.e Fc)ijtid2tioi-t. V. FERRERO.
WHOOPING-COUGH TREATED WITH CHLOROMYCETIN
SiR,-Your leading article of Sept. 10 prompts
me to what may well be the first case of whooping-cough treated in this country by chloramphenicol (’ Chloro-
report
mycetin ’). My daughter, then aged 51/2 months, developed whoopingcough about the beginning of May this year and was in the early paroxysmal stage towards the middle of the month. Her older brother and sister had contracted the disease at the beginning of April and were by then well advanced in the paroxysmal stage. The infant was fully breast-fed and had been kept away from her brother and sister as much as possible, but of course some contact was inevitable. Although her general condition was good, the attack was becoming fairly severe ; paroxysms became frequent, especially at nights, and during the two nights before treatment was started they occurred about every thirty minutes and often ended in vomiting. As good results with chloromycetin in whooping-cough had been reported from the U.S.A., and as the toxicity of the drug was supposed to be very low, I decided to try its effect while the baby was still in good condition and free from complications. The drug had only come on the market during the previous week, and the dosage recommended was approximately that for typhoid fever-i.e., initially 50 mg. per kg. body-weight, followed by smaller amounts three-hourly. Chloromycetin being made up in 250 mg. capsules, I decided to give one capsule four-hourly as the baby was on four-hourly feeds. Her weight was then about 6-7 kg. Administration proved very difficult, since of course an infant cannot swallow these capsules. We tried to give the powder first in orange juice and then in expressed breast-milk. Both methods proved impossible because of the extreme bitterness of the drug ; the smallest taste of it made the baby retch and cry. We therefore decided to use an oesophageal catheter and found it easiest to introduce this through the mouth ; a good hearty The first time cry assured us that it was in the right place. we attempted this immediately after a feed, and the whole feed was brought up ; after that we gave it half an hour before each feed, when the stomach was presumably empty. This was successful and from that time on the baby retained the full amount of drug given and continued to feed normally. Because of these difficulties we continued to give 250 mg. four-hourly, up to a total of seven doses. Already after twelve hours the effect was noticeable, and the following night paroxysms were down to one every two or three hours. The drug was stopped as it was causing some colic and diarrhcea ; this subsided in twenty-four hours. The effect on the whooping-cough was dramatic. After thirty-six hours the paroxysms stopped completely and the baby was obviously improving. The cough remained, and for many weeks the baby had occasional attacks of coughing, which, however, never gave rise to the slightest anxiety; 1. Proc. Soc. exp. Biol. N.Y. 1947, 66, 307. 2. Atti Soc. Lomb. Sci. Med. Biol.: Meeting of March 11, 1949.
580 she was never sick again, and she continued to make good progress. A smaller dosage after the initial dose and a longer course of treatment might possibly have averted the toxic symptoms and also abolished the cough.
There is no doubt that chloromycetin stopped what seemed to be developing into a severe case of whoopingcough. If this experience is confirmed by others-and I have already heard of one other case treated with good effect-whooping-cough should lose its dread. Its use will probably have to be confined to infants and severe cases at first because of the scarcity and high cost of the drua. D. P. DEGENHARDT. Hounslow, Middx. THE REGISTRAR’S SALARY
Sm,-As
a
junior registrar
about to leave the
services, I should like to draw your attention to
hospital a plight
which I feel must be by no means unique. I qualified just over four years ago, served my houseman’s apprenticeship, and studied for and gained I entered the Services and served my the M.R.c.p. two years. On release I approached an organisation mainly designed to " resettle " the medical ex-Serviceman, and was offered ayear of subsidised cups of tea in a supernumerary capacity. Instead I sought, and took on, a junior registrarship, and in that position have been ruining my health for a net salary of E716s. 2d. weekly, after deduction of emoluments, tax, superannuation, &c. Of this salary 9% must be spent on the books and subscriptions necessary to the maintenance of my standards. I do not pretend to a car-I have only been qualified four years. Now, if I take on a registrarship, my salary will rise to the giddy height of f,775 per annum-i.e., about half the average G.P.’s income and under a quarter of the average dentist’s. But then I become non-resident and must buy and keep up the car I have so long dreaded. As a responsible family man I have gone into my financial prospects and find that my net income, after the usual deductions at source, will be just under f,600. Well, I have remained shabby long enough—I am leaving for the comparative opulence of general practice, where incidentally I shall probably be able to afford an entire half-hour for my meals, and shall get decent food into the bargain. I shall be leaving with some relief ; at least I shall be able to support my wife and child decently. But I shall bear a life-long grudge against the allegedly reformed system that drove me to do so. Yet for all this I can blame no-one but myself and my peers for our cowardice and apathy in preserving a shabby dignity that baulks at organising to fight for our social rights-how else shall we get them ?-and, above all, for our tacit condonation of a system that emphatically does not encourage " ability without means," but unopposedly exploits the competition for academic advancement and imposes on the less fortunate of us the crippling burden of chronic financial worry. A. GEE. London, .V.3.
* * During his training, and until he gained a sufficient reputation, the young specialist has always earned less than he could get by going into general practice ; and men who married soon after qualification have almost always been obliged to abandon their intended specialty unless they had private means. The position has changed to the extent that hospital registrars, instead of receiving .E300—400 or less, as before the war, are now on a scale rising from :E670 to JE1300, and on gaining staff appointments they immediately earn a minimum of :SI400. The fact that this remuneration is lower than that generally obtainable (under quite different conditions) in general practice has to be weighed against the later advantages of the consultant’s life, which include the possibility of a much higher income than that of the practitioner. We must regret, on all grounds, that any
young doctor should feel obliged to enter general practice when his heart is elsewhere ; -but we would point out to our correspondent that under the " allegedly reformed system " he has at least an opportunity of continuing his training, whereas formerly he would have had none. - Fn T,
THE DOCTOR’S PROFESSION
SiR,-In the third article of this excellent series the "
following sentence occurs on p. 338 (Aug. 20) : Although he is no longer normally required to take the Hippocratic Oath, the doctor is bound to respect human life in all its forms." If this basic obligation is to be met the profession must keep clear of bacteriological warfare and other military work. It seems necessary that while a medically qualified person is engaged on such work he should recognisably separate himself from the profession in the way that a doctor does who changes from a medical to a combatant role in the Forces. If this is not done the public will be alarmed and a Government might come which would demand destructive work as part of the profession’s duty. I suggest that doctors who do such work should be, for the time, seconded from the profession with the right to return to it when they have finished destructive work. J. M. ALSTON. London, W.l. RESEARCH
SiR,—With regard to the reference in your leading n
article of Sept. 3 to the use of endowment funds for research purposes, I would like to inform you that the board of governors at this hospital decided, shortly after the introduction of the National Health Service, to earmark for clinical research at least two-thirds of the annual income from endowment-fund investments. Middlesex Hospital,
London, W.1.
DAVID H. PATEY Chairman, Medical Committee.
POLIOMYELITIS AND TONSILLECTOMY
SiR,-Acute anterior poliomyelitis following shortly tonsillectomy may be due to the entry of infection
after
the wounds in the throat. But there is a wider problem. Some evidence shows that the tonsils and other subepithelial lymph-glands can confer some degree of immunity against certain infectious diseases even when the disease itself is not contracted ; and the mechanism by which they could do this has been demonstrated. Whether faucial and nasopharyngeal tonsils function in this way against poliomyelitis where the disease is endemic is a question ripe for investigation. Last year Glover published a valuable collection of evidence on the relation of tonsillectomy to poliomyelitis. But much of the work refers to tonsillectomy recently performed, where infection through the open wounds is a possibility. One would like more figures on the incidence and severity of the disease in patients who have had tonsillectomy performed more than six months
through
previously. The removal of tonsils and adenoids leaves for a time three open wounds through which infection can enter the body. It may also be expected sometimes to cause an almost unnoticeable attack that may confer immunity. It is therefore desirable to know not only whether and when tonsils and adenoids have been removed, but also whether the disease was prevalent locally at the time of removal. Every doctor who has a case of poliomyelitis might make a point of recording these data. The compiling of statistics from such data and the drawing of conclusions from them will be a complicated task requiring much care.
Bromley, Kent. 1. Glover, J. A.
KENELM H. DIGBY. Bull. Min. Hlth, P.H.L.S. 1948, 7, 150.
suggests that prevention of the anticoagulant effect of a -chemotherapeutic drug is not necessarily desirable, is8 oontained in a statement by Prof. A. St. G. Huggett to the Biochemical Society, that the anticoagulation anti-enzyme action of some trypanocidal dyes may have an analogy to their mechanism as trypanocidal agents. Thus in therapeutic trials with combined P.A.S. and streptomycin it appears worth considering that any Jiypoprothombinsemic effect observed may represent a greater hazard to the tubercle bacillus than to its host. It would then be possible to make a comparison between patients risking hypoprothrombinaemia but safeguarded by serial prothrombin estimations, and those given a .supplement of vitamin K. Rostrevor,
co.
Down.
two-thirds of the insured men reaching minimum pensionable age and nearly one-half of the insured women do not claim their retirement pensions, because they are continuing in regular work until later. F. D. BICKERTON Ministry of National Insurance,
J. A. FISHER.
EMPLOYMENT OF ELDERLY PERSONS
SiR,-The explanation of the conditions on which National Insurance retirement pensions are paid, ’contained in your leading article of Sept. 10, is correct only in respect of persons who reached minimum pensionable .age before July 5, 1948, and accordingly qualified for their pensions under the old Contributory Pension Acts. The effect of the new National Insurance arrangements - on the willingness of elderly people to continue at work is obviously a matter of considerable national importance, and I hope, therefore, that you will allow me to explain the very different arrangements which apply to those Teaching pensionable age after July 5, 1948. Assuming that the contribution conditions are fully satisfied, a man may claim a retirement pension of 26s. from the age of 65 provided he has retired from regular employment, inconsiderable occupations being ignored (for women the qualifying age is 60). A man who does not retire until after age 65 now goes on paying National Insurance contributions in exactly the same way as he did before and remains’ entitled to sickness or unemployment benefit at the same rate as pension, so that any temporary interruption of earnings after minimum pension age provides no temptation to claim the retirement pension. For every 25 contributions paid in employment after his 65th birthday the rate of pension payable from retirement is increased by Is. a week. If the man’s wife has already reached 60 her notional pension-rate (including that payable to her as a widow if her husband dies before her) is also increased by Is. for every 25 contributions he pays. It is possible, therefore, for a man who goes on working until he is 70 to acquire the right to a pension of 36s. a week for himself, and one of 26s. a week for his wife during his lifetime and 36s. thereafter. The increased rates of pension payable in, this way are, taking one case with another, actuarially broadly equivalent in value to the sum of the pension forgone by postponing retirement and the contributions paid after minimum pension age. The arrangements therefore achieve the objective of the suggestion referred to in your, leading article. From age 70 (65 for women) the increased rate of pension earned by postponed retirement is payable unconditionally whether work continues or not. As a reinforcement of the retirement condition, where pension is claimed on retirement before age 70 (or 65, as the case may be), its payment up to that age is regulated by an earnings rule the effect of which is to reduce the pension paid for any week by Is. for every Is. of net earnings over 1:1in that week. The general objective of the provisions of the new National Insurance Act is, of course, to encourage all those who can to continue in regular work wherever possible up to age 70 or even beyond. It may interest your readers to know that at the present time about 8. See
Lancet, 1941, ii, 761.
Chief Press Officer.
London, S.W.1.
VITAMIN E
SIR,-With regard to the letter from Professor Boyd and others (July 16), may I quote experimental data’? R. L. ,Holman1 observed that, in dogs, vitamin E (3 mg. per kg. body-weight) had a significant protective action against hyperlipidic arteritis ; while Tusini2 administered to rats altogether 5 mg. of ergotamine tartrate and found that the ensuing arterial spasm in the tail was, in over 90% of the animals, almost completely- inhibited by giving 20 mg. of vitamin E daily. A synergistic action between vitamin E and vasodilators was also demonstrated, with very interesting therapeutic results. Perhaps these results may lead to clearer judgment of the " etra va.fya.Tit claims Milan.
"
from the S1mt.e Fc)ijtid2tioi-t. V. FERRERO.
WHOOPING-COUGH TREATED WITH CHLOROMYCETIN
SiR,-Your leading article of Sept. 10 prompts
me to what may well be the first case of whooping-cough treated in this country by chloramphenicol (’ Chloro-
report
mycetin ’). My daughter, then aged 51/2 months, developed whoopingcough about the beginning of May this year and was in the early paroxysmal stage towards the middle of the month. Her older brother and sister had contracted the disease at the beginning of April and were by then well advanced in the paroxysmal stage. The infant was fully breast-fed and had been kept away from her brother and sister as much as possible, but of course some contact was inevitable. Although her general condition was good, the attack was becoming fairly severe ; paroxysms became frequent, especially at nights, and during the two nights before treatment was started they occurred about every thirty minutes and often ended in vomiting. As good results with chloromycetin in whooping-cough had been reported from the U.S.A., and as the toxicity of the drug was supposed to be very low, I decided to try its effect while the baby was still in good condition and free from complications. The drug had only come on the market during the previous week, and the dosage recommended was approximately that for typhoid fever-i.e., initially 50 mg. per kg. body-weight, followed by smaller amounts three-hourly. Chloromycetin being made up in 250 mg. capsules, I decided to give one capsule four-hourly as the baby was on four-hourly feeds. Her weight was then about 6-7 kg. Administration proved very difficult, since of course an infant cannot swallow these capsules. We tried to give the powder first in orange juice and then in expressed breast-milk. Both methods proved impossible because of the extreme bitterness of the drug ; the smallest taste of it made the baby retch and cry. We therefore decided to use an oesophageal catheter and found it easiest to introduce this through the mouth ; a good hearty The first time cry assured us that it was in the right place. we attempted this immediately after a feed, and the whole feed was brought up ; after that we gave it half an hour before each feed, when the stomach was presumably empty. This was successful and from that time on the baby retained the full amount of drug given and continued to feed normally. Because of these difficulties we continued to give 250 mg. four-hourly, up to a total of seven doses. Already after twelve hours the effect was noticeable, and the following night paroxysms were down to one every two or three hours. The drug was stopped as it was causing some colic and diarrhcea ; this subsided in twenty-four hours. The effect on the whooping-cough was dramatic. After thirty-six hours the paroxysms stopped completely and the baby was obviously improving. The cough remained, and for many weeks the baby had occasional attacks of coughing, which, however, never gave rise to the slightest anxiety; 1. Proc. Soc. exp. Biol. N.Y. 1947, 66, 307. 2. Atti Soc. Lomb. Sci. Med. Biol.: Meeting of March 11, 1949.
580 she was never sick again, and she continued to make good progress. A smaller dosage after the initial dose and a longer course of treatment might possibly have averted the toxic symptoms and also abolished the cough.
There is no doubt that chloromycetin stopped what seemed to be developing into a severe case of whoopingcough. If this experience is confirmed by others-and I have already heard of one other case treated with good effect-whooping-cough should lose its dread. Its use will probably have to be confined to infants and severe cases at first because of the scarcity and high cost of the drua. D. P. DEGENHARDT. Hounslow, Middx. THE REGISTRAR’S SALARY
Sm,-As
a
junior registrar
about to leave the
services, I should like to draw your attention to
hospital a plight
which I feel must be by no means unique. I qualified just over four years ago, served my houseman’s apprenticeship, and studied for and gained I entered the Services and served my the M.R.c.p. two years. On release I approached an organisation mainly designed to " resettle " the medical ex-Serviceman, and was offered ayear of subsidised cups of tea in a supernumerary capacity. Instead I sought, and took on, a junior registrarship, and in that position have been ruining my health for a net salary of E716s. 2d. weekly, after deduction of emoluments, tax, superannuation, &c. Of this salary 9% must be spent on the books and subscriptions necessary to the maintenance of my standards. I do not pretend to a car-I have only been qualified four years. Now, if I take on a registrarship, my salary will rise to the giddy height of f,775 per annum-i.e., about half the average G.P.’s income and under a quarter of the average dentist’s. But then I become non-resident and must buy and keep up the car I have so long dreaded. As a responsible family man I have gone into my financial prospects and find that my net income, after the usual deductions at source, will be just under f,600. Well, I have remained shabby long enough—I am leaving for the comparative opulence of general practice, where incidentally I shall probably be able to afford an entire half-hour for my meals, and shall get decent food into the bargain. I shall be leaving with some relief ; at least I shall be able to support my wife and child decently. But I shall bear a life-long grudge against the allegedly reformed system that drove me to do so. Yet for all this I can blame no-one but myself and my peers for our cowardice and apathy in preserving a shabby dignity that baulks at organising to fight for our social rights-how else shall we get them ?-and, above all, for our tacit condonation of a system that emphatically does not encourage " ability without means," but unopposedly exploits the competition for academic advancement and imposes on the less fortunate of us the crippling burden of chronic financial worry. A. GEE. London, .V.3.
* * During his training, and until he gained a sufficient reputation, the young specialist has always earned less than he could get by going into general practice ; and men who married soon after qualification have almost always been obliged to abandon their intended specialty unless they had private means. The position has changed to the extent that hospital registrars, instead of receiving .E300—400 or less, as before the war, are now on a scale rising from :E670 to JE1300, and on gaining staff appointments they immediately earn a minimum of :SI400. The fact that this remuneration is lower than that generally obtainable (under quite different conditions) in general practice has to be weighed against the later advantages of the consultant’s life, which include the possibility of a much higher income than that of the practitioner. We must regret, on all grounds, that any
young doctor should feel obliged to enter general practice when his heart is elsewhere ; -but we would point out to our correspondent that under the " allegedly reformed system " he has at least an opportunity of continuing his training, whereas formerly he would have had none. - Fn T,
THE DOCTOR’S PROFESSION
SiR,-In the third article of this excellent series the "
following sentence occurs on p. 338 (Aug. 20) : Although he is no longer normally required to take the Hippocratic Oath, the doctor is bound to respect human life in all its forms." If this basic obligation is to be met the profession must keep clear of bacteriological warfare and other military work. It seems necessary that while a medically qualified person is engaged on such work he should recognisably separate himself from the profession in the way that a doctor does who changes from a medical to a combatant role in the Forces. If this is not done the public will be alarmed and a Government might come which would demand destructive work as part of the profession’s duty. I suggest that doctors who do such work should be, for the time, seconded from the profession with the right to return to it when they have finished destructive work. J. M. ALSTON. London, W.l. RESEARCH
SiR,—With regard to the reference in your leading n
article of Sept. 3 to the use of endowment funds for research purposes, I would like to inform you that the board of governors at this hospital decided, shortly after the introduction of the National Health Service, to earmark for clinical research at least two-thirds of the annual income from endowment-fund investments. Middlesex Hospital,
London, W.1.
DAVID H. PATEY Chairman, Medical Committee.
POLIOMYELITIS AND TONSILLECTOMY
SiR,-Acute anterior poliomyelitis following shortly tonsillectomy may be due to the entry of infection
after
the wounds in the throat. But there is a wider problem. Some evidence shows that the tonsils and other subepithelial lymph-glands can confer some degree of immunity against certain infectious diseases even when the disease itself is not contracted ; and the mechanism by which they could do this has been demonstrated. Whether faucial and nasopharyngeal tonsils function in this way against poliomyelitis where the disease is endemic is a question ripe for investigation. Last year Glover published a valuable collection of evidence on the relation of tonsillectomy to poliomyelitis. But much of the work refers to tonsillectomy recently performed, where infection through the open wounds is a possibility. One would like more figures on the incidence and severity of the disease in patients who have had tonsillectomy performed more than six months
through
previously. The removal of tonsils and adenoids leaves for a time three open wounds through which infection can enter the body. It may also be expected sometimes to cause an almost unnoticeable attack that may confer immunity. It is therefore desirable to know not only whether and when tonsils and adenoids have been removed, but also whether the disease was prevalent locally at the time of removal. Every doctor who has a case of poliomyelitis might make a point of recording these data. The compiling of statistics from such data and the drawing of conclusions from them will be a complicated task requiring much care.
Bromley, Kent. 1. Glover, J. A.
KENELM H. DIGBY. Bull. Min. Hlth, P.H.L.S. 1948, 7, 150.