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AN INCREASE IN RHEUMATIC FEVER ?
842
Letters
to
the Editor
AN INCREASE IN RHEUMATIC FEVER ?
SiR,—Between November, 1972,
and
August, 1973,
15
children between the ages of four and thirteen were admitted to the medical ward of Nottingham Children’s Hospital with acute polyarthritis. 5 of these children had evidence of carditis and 10 had definite evidence of preceding streptococcal infection. 5 of the patients, including 2 of those with carditis, had a family history of rheumatic fever and 1, a thirteen-yearold girl, had a bout of rheumatic fever five years earlier. 1 of the children, an eleven-year-old boy, developed erythema marginatum while in hospital. Other causes of polyarthritis were sought in all cases and 1 boy was found to have a rising rubella-antibody titre. When the first patients with polyarthritis were admitted a diagnosis of rheumatic fever was thought so that serial anti-streptolysin titres were not performed. Nevertheless, 10 of the 15 cases conformed to the revised Jones criteria, which require evidence of preceding streptococcal infection, and all 15 cases showed at least one major and two minor manifestations. While not suggesting that all 15 patients had rheumatic fever, it is certain that more cases have been seen in a few months than have been seen for many years. In fact, 4 cases only of possible rheumatic fever were seen in the three years 1970-72. I wonder whether other centres are having the same experience.
unlikely
Nottingham Children’s Hospital, Chestnut Grove, Nottingham NG3 5AF.
M. J. CRAWFORD.
TREATMENT OF APHTHOUS STOMATITIS
SiR,—The xtiology of
aphthous stomatitis is still a matter of controversy. Immunological mechanisms1 are probably involved; light and electron microscopy recurrent
indicates that the lesions are consistent with those of a delayed hypersensitivity reaction.2 In at least one study it was claimed that patients with recurrent aphthous stomatitis have unusually strong skin reactions of delayed hypersensitivity to a-streptococci.3 The same authors suggested that the oral tissues are chronically infected with a pleomorphic transitional L-form of an x-streptococcus.4 As mast cells are present in large numbers in the early lesions,5 the beneficial effects of cromoglycate, as described by Mr Frost (Aug. 18, p. 389), could possibly be explained by the influence of cromoglycate on these cells.6 Mr Frost’s findings prompt us to report observations in patients with recurrent aphthous stomatitis. In 5 patients a D.N.C.B. (2,4-dinitrochlorobenzene) test was performed. Fourteen days after sensitisation with 2 mg. of D.N.C.B., challenge doses of 200, 100, 50, and 25 g.
applied. 2 patients were negative to 200 g.; 1 was 70-year-old man with parkinsonism and the other had associated herpes. 3 patients had a positive reaction up to 25 (J.g., indicating that delayed hypersensitivity is not impaired in all patients with recurrent aphthous stomatitis. In 9 patients with at least a one-year history of recurrent aphthous stomatitis, levamisole (150 mg.) was given daily
were a
Francis, T. C. Oral Surg. 1970, 30, 476. Lehner, T. J. Path. 1969, 97, 481. Graykowski, E. A., Barile, M. F., Lee, W. B., Stanely, H. R. J. Am. med. Ass. 1966, 196, 637. 4. Barile, M. F., Graykowski, E. A., Driscoll, E. J., Riggs, D. B. Oral Surg. 1963, 16, 1395. 5. Brody, H. A., Silverman, S. ibid. 1969, 27, 27. 6. Sheard, P., Blair, A. M. J. N. Int. Archs Allergy, 1970, 38, 217. 1. 2. 3.
for three consecutive days every two weeks. 6 patients remained free of symptoms for a total follow-up of twentyfive months. 1 patient with a follow-up of four months had 2 recurrences which lasted four days, whereas before treatment the mean duration had been ten days and lesions appeared every three weeks. Another patient with a follow-up of three months had recurrences lasting only a few hours, whereas they lasted weeks before therapy, and the last patient still suffers recurrences under treatment but they are of shorter duration. Levamisole, originally described as an antihelminthic,7 was found to restore cutaneous delayed hypersensitivity reactions in anergic elderly subjectsand patients with cancer,8-10 and, after exposure to viable brucella bacteria, it made mice more resistant to subsequent challenges with brucella. 11, 12 It seems likely, therefore, that both eradication of a chronic infective agent and the manipulation of delayed hypersensitivity reactions can play a role in the treatment of aphthous stomatitis. Clinical Research Unit, St. Bartholomeus Hospital, B-2060 Merksem, Belgium.
H. VERHAEGEN J. DE CREE.
Janssen Pharmaceutica, Research Laboratoria, B-2340 Beerse, Belgium.
J. BRUGMANS.
THE NEW N.H.S. CONSULTANT CONTRACT
SIR,-Dr Fearnley (Sept. 22, p. 667) describes the proposed 10-session week as an ingenious plan to increase consultants’ remuneration without seeming to do so, I doubt whether many consultants would object to this, for most appear to be as poorly off as he implies he is. In practically every country of the world extra clinical responsibility is rewarded by extra income, and, as a temporary resident in Britain, I am astonished at the system of remuneration here. Dr Fearnley comments on the reactions of " many junior hospital doctors to extraduty payments. I can only say I have met none who complains about receiving more money for more duty-in fact, the main complaint is that no further payment is given to those who actually have to work when on call, There would be less discontent among specialists if this country adopted a health system similar to most Western European countries, with the doctors’ remuneration coming from insurance funds. Patients should also have a choice of specialist-a little competition never does any harm. The present British system is a false economy: no country can afford to lose doctors through emigration in the numbers Britain does. "
Scartho Road
Hospital,
Grimsby.
JOHN DAVIES.
full-time pathologist of 56 the advent of the fills me with horror. I have always given my full energies to my job; taking on extra work means that the whole is done less well. The most naive administrator must recognise that over every extra committee I attend, How can I ethically demand extra payment for such extras ?
SIR,-As
a
new contract
Thienpont, D., Vanparijs, O. F. J., Raeymaekers, A. H M. Vandenberk, J., Demoen, P. J. A., Allewijn, F. T. N., Marsboom. R. P. H., Niemegeers, C. J. E., Schellekens, K. H. L., Janssen, P. A. J. Nature, 1966, 209, 1084. 8. Verhaegen, H., De Cree, J., Verbruggen, F., Hoebeke, J., De Brabander, M., Brugmans, J. Proceedings of the 79th Tagung der Deutschen Gesellschaft für innere Medizin, Wiesbaden, Germany. 1973 (in the press). 9. Tripodi, D., Parks, L. C., Brugmans, J. New Engl. J. Med. 1973. 289, 354. 10. Hirshaut, Y., Pinsky, C., Marquardt, H., et al. Proc Am. A Cancer Res. 1973, 14, 109. 11. Renoux, G., Renoux, M. C. r. Acad. Sci. Paris, 1971, 272, 349 12. Renoux, G., Renoux, M. J. Immun. 1972, 109, 761. 7.
Letters
to
the Editor
AN INCREASE IN RHEUMATIC FEVER ?
SiR,—Between November, 1972,
and
August, 1973,
15
children between the ages of four and thirteen were admitted to the medical ward of Nottingham Children’s Hospital with acute polyarthritis. 5 of these children had evidence of carditis and 10 had definite evidence of preceding streptococcal infection. 5 of the patients, including 2 of those with carditis, had a family history of rheumatic fever and 1, a thirteen-yearold girl, had a bout of rheumatic fever five years earlier. 1 of the children, an eleven-year-old boy, developed erythema marginatum while in hospital. Other causes of polyarthritis were sought in all cases and 1 boy was found to have a rising rubella-antibody titre. When the first patients with polyarthritis were admitted a diagnosis of rheumatic fever was thought so that serial anti-streptolysin titres were not performed. Nevertheless, 10 of the 15 cases conformed to the revised Jones criteria, which require evidence of preceding streptococcal infection, and all 15 cases showed at least one major and two minor manifestations. While not suggesting that all 15 patients had rheumatic fever, it is certain that more cases have been seen in a few months than have been seen for many years. In fact, 4 cases only of possible rheumatic fever were seen in the three years 1970-72. I wonder whether other centres are having the same experience.
unlikely
Nottingham Children’s Hospital, Chestnut Grove, Nottingham NG3 5AF.
M. J. CRAWFORD.
TREATMENT OF APHTHOUS STOMATITIS
SiR,—The xtiology of
aphthous stomatitis is still a matter of controversy. Immunological mechanisms1 are probably involved; light and electron microscopy recurrent
indicates that the lesions are consistent with those of a delayed hypersensitivity reaction.2 In at least one study it was claimed that patients with recurrent aphthous stomatitis have unusually strong skin reactions of delayed hypersensitivity to a-streptococci.3 The same authors suggested that the oral tissues are chronically infected with a pleomorphic transitional L-form of an x-streptococcus.4 As mast cells are present in large numbers in the early lesions,5 the beneficial effects of cromoglycate, as described by Mr Frost (Aug. 18, p. 389), could possibly be explained by the influence of cromoglycate on these cells.6 Mr Frost’s findings prompt us to report observations in patients with recurrent aphthous stomatitis. In 5 patients a D.N.C.B. (2,4-dinitrochlorobenzene) test was performed. Fourteen days after sensitisation with 2 mg. of D.N.C.B., challenge doses of 200, 100, 50, and 25 g.
applied. 2 patients were negative to 200 g.; 1 was 70-year-old man with parkinsonism and the other had associated herpes. 3 patients had a positive reaction up to 25 (J.g., indicating that delayed hypersensitivity is not impaired in all patients with recurrent aphthous stomatitis. In 9 patients with at least a one-year history of recurrent aphthous stomatitis, levamisole (150 mg.) was given daily
were a
Francis, T. C. Oral Surg. 1970, 30, 476. Lehner, T. J. Path. 1969, 97, 481. Graykowski, E. A., Barile, M. F., Lee, W. B., Stanely, H. R. J. Am. med. Ass. 1966, 196, 637. 4. Barile, M. F., Graykowski, E. A., Driscoll, E. J., Riggs, D. B. Oral Surg. 1963, 16, 1395. 5. Brody, H. A., Silverman, S. ibid. 1969, 27, 27. 6. Sheard, P., Blair, A. M. J. N. Int. Archs Allergy, 1970, 38, 217. 1. 2. 3.
for three consecutive days every two weeks. 6 patients remained free of symptoms for a total follow-up of twentyfive months. 1 patient with a follow-up of four months had 2 recurrences which lasted four days, whereas before treatment the mean duration had been ten days and lesions appeared every three weeks. Another patient with a follow-up of three months had recurrences lasting only a few hours, whereas they lasted weeks before therapy, and the last patient still suffers recurrences under treatment but they are of shorter duration. Levamisole, originally described as an antihelminthic,7 was found to restore cutaneous delayed hypersensitivity reactions in anergic elderly subjectsand patients with cancer,8-10 and, after exposure to viable brucella bacteria, it made mice more resistant to subsequent challenges with brucella. 11, 12 It seems likely, therefore, that both eradication of a chronic infective agent and the manipulation of delayed hypersensitivity reactions can play a role in the treatment of aphthous stomatitis. Clinical Research Unit, St. Bartholomeus Hospital, B-2060 Merksem, Belgium.
H. VERHAEGEN J. DE CREE.
Janssen Pharmaceutica, Research Laboratoria, B-2340 Beerse, Belgium.
J. BRUGMANS.
THE NEW N.H.S. CONSULTANT CONTRACT
SIR,-Dr Fearnley (Sept. 22, p. 667) describes the proposed 10-session week as an ingenious plan to increase consultants’ remuneration without seeming to do so, I doubt whether many consultants would object to this, for most appear to be as poorly off as he implies he is. In practically every country of the world extra clinical responsibility is rewarded by extra income, and, as a temporary resident in Britain, I am astonished at the system of remuneration here. Dr Fearnley comments on the reactions of " many junior hospital doctors to extraduty payments. I can only say I have met none who complains about receiving more money for more duty-in fact, the main complaint is that no further payment is given to those who actually have to work when on call, There would be less discontent among specialists if this country adopted a health system similar to most Western European countries, with the doctors’ remuneration coming from insurance funds. Patients should also have a choice of specialist-a little competition never does any harm. The present British system is a false economy: no country can afford to lose doctors through emigration in the numbers Britain does. "
Scartho Road
Hospital,
Grimsby.
JOHN DAVIES.
full-time pathologist of 56 the advent of the fills me with horror. I have always given my full energies to my job; taking on extra work means that the whole is done less well. The most naive administrator must recognise that over every extra committee I attend, How can I ethically demand extra payment for such extras ?
SIR,-As
a
new contract
Thienpont, D., Vanparijs, O. F. J., Raeymaekers, A. H M. Vandenberk, J., Demoen, P. J. A., Allewijn, F. T. N., Marsboom. R. P. H., Niemegeers, C. J. E., Schellekens, K. H. L., Janssen, P. A. J. Nature, 1966, 209, 1084. 8. Verhaegen, H., De Cree, J., Verbruggen, F., Hoebeke, J., De Brabander, M., Brugmans, J. Proceedings of the 79th Tagung der Deutschen Gesellschaft für innere Medizin, Wiesbaden, Germany. 1973 (in the press). 9. Tripodi, D., Parks, L. C., Brugmans, J. New Engl. J. Med. 1973. 289, 354. 10. Hirshaut, Y., Pinsky, C., Marquardt, H., et al. Proc Am. A Cancer Res. 1973, 14, 109. 11. Renoux, G., Renoux, M. C. r. Acad. Sci. Paris, 1971, 272, 349 12. Renoux, G., Renoux, M. J. Immun. 1972, 109, 761. 7.