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B.P.C. 1959
326
Whereas this phenomenal improvement is undoubtedly largely due to sustained triple-drug therapy, Gale and Kerr also acknowledge the ancillary benefit of certain conservative and reconstructive surgical procedures thereby made possible. They rightly claim, however, that progress in the management of genitourinary tuberculosis during the past ten years ranks paramount among all the remarkable advances in urology within this period.
tuberculosis.
TEMPERATURE REGULATION DURING FEVER
THOUGH fever is a very common accompaniment of disease or tissue damage, elevation of body temperature does not in itself clearly benefit the patient, except perhaps in a few special situations. For this reason fever is sometimes regarded as a manifestation of failure of the normal controlling system; but this is far from the truth. For many years there has been evidence suggesting that the body temperature is controlled at a higher level in disease.
The concept of fever as a change in the setting of a central thermostatic mechanism was first formulated by Von Liebermeister,l and subsequent work by Stern2 substantiated this hypothesis. Stern observed the development of sweating or of shivering in patients with and without fevers, when they were warmed or cooled by gradually changing the temperature of a bath in which they sat. He found that the change in rectal temperature when patients began to sweat or to shiver was the same in the pyrexial and
apyrexial groups. Subsequent experimental work in man Park and has in general confirmed these findings. Palmes3 found that the injection of bacterial pyrogens into normal subjects produced the same elevation of temperature in warm or cold environments. All these findings suggest active regulation of body temperature during fever, though the evidence is not entirely conclusive. Further convincing evidence of active temperature control has been described by MacPherson.4 In a long series of experiments he obtained very complete records of the responses of three normal subjects to standard exercise during environmental heat stress. During these experiments one subject developed a febrile illness characterised by cough and malaise; his temperature was raised by 0-5-1-5°F for six days. During this time the subject was able and willing to continue with the experiment, information.
thereby providing
very
interesting
Before the onset of fever this subject responded to exercise with an increase of rectal temperature which was almost identical with that of his companions. During the fever this pattern was exactly reproduced, at a higher level. The absolute temperature increment due to exercise remained the same. During exercise at moderate environmental temperatures the normal subjects showed a fall of skin temperature, with recovery during the subsequent rest period. This pattern was also reproduced by the febrile- subject, at a higher absolute temperature level. During exercise this subject’s sweat-rate did not differ significantly from that of his companions.
These experiments confirm and extend the previous findings, suggesting that the febrile patient responds to
various thermal stimuli in much the same way as the normal subiect, but at a hisher level of temperature. It is difficult 1. Von Liebermeister, C. Handbuch der Pathologie und Therapie des Fiebers. Leipzig, 1875. 2. Stern, R. Z. klin. Med. 1892, 20, 63. 3. Park, C. R., Palmes, E. D. Medical Department Field Research Laboratory, project no. 6-64-12-06. Fort Knox, Ky, 1948. 4. MacPherson, R. K. Clin. Sci. 1959, 18, 281.
to avoid the conclusion that his temperature is regulated in the same way. If the regulating mechanism is normally active, the temperature rise in fever must be actively produced. Why this happens is unknown.
B.P.C. 1959
edition1 of the British Pharmaceutical Codex is dated 1959-a vintage year for official publications on prescribing costs-and against this background the B.P.C. The conscientious and selecassumes great importance. tive use of the Codex by medical students and doctors would encourage the critical attitude and keener appreciation of the place of pharmacy in relation to therapeutics that can lead to prescribing which is both sound and economical. It is strange that the British Pharmacopceia (published under the xgis of the General Medical Council) continues to be a book of reference used almost exclusively by pharmacists, while the Codex (published by the Pharmaceutical Society of Great Britain) has become one of the most important books available to doctors. The subject matter of the two is, of course, much the same, but there are striking differences in presentation. Thus, the Codex includes paragraphs on the actions and uses of drugs: these are not intended to convert it into a textbook of pharmacology, but they are invaluable in presenting concise information about the effects of drugs and the relative merits of their various preparations. Thus, the Codex is a book of capital importance as an ancillary to standard works on therapeutics. Although drugs, or particular preparations of drugs, which have been deleted from the Plzarmacopceia are likely to disappear also from the Codex, it is the traditional policy of the Codex Revision Committee to retain many of these preparations, if they are widely used, and look at them occasionally during a further period of five years. There is clearly a place for this conservative attitude; for although the factual data of the Pharmacopceia and Codex inevitably have much in common, the books are in many ways complementary. Allowance must also be made for doctors who are not prepared to modify their prescribing habits simply because, for various reasons, certain pharmaceutical preparations are no longer " official ". The additions to the new Codex include 70 new general monographs, and 20 of these refer to drugs already included in the B.P. 1958. Among the monographs which deal with the more specialised materials (biological products, surgical ligatures, and sutures), poliomyelitis vaccine and rabies antiserum deserve mention. The Formulary (part vi of the Codex)-perhaps the most valuable section for the prescriber-contains some 79 new items, but 44 of them represent " salvage " from those deleted from the B.P. There are long lists of deletions under monographs and under formulary. Some 26 preparations suffer total eclipse, in that they no longer appear in either the B.P. 1958 or the Codex 1959. But few doctors will feel their withers wrung by the demise of infusion of quassia, solution of mercuric chloride, and the dilute solution of ammonium acetate. The rise and fall of cream of penicillin (also among the 26 condemned to the twilight of obscurity) may, however, cause some to reflect on the transient glories of therapeutic fame. THE
new
1. British Pharmaceutical Codex 1959. 7th ed. Council of the Pharmaceutical Society of Great Britain. London: Pharmaceutical Press. 195° Pp. 1301. 70s. The Codex comes into force in the United Kingdom on July 1, 1960.
Whereas this phenomenal improvement is undoubtedly largely due to sustained triple-drug therapy, Gale and Kerr also acknowledge the ancillary benefit of certain conservative and reconstructive surgical procedures thereby made possible. They rightly claim, however, that progress in the management of genitourinary tuberculosis during the past ten years ranks paramount among all the remarkable advances in urology within this period.
tuberculosis.
TEMPERATURE REGULATION DURING FEVER
THOUGH fever is a very common accompaniment of disease or tissue damage, elevation of body temperature does not in itself clearly benefit the patient, except perhaps in a few special situations. For this reason fever is sometimes regarded as a manifestation of failure of the normal controlling system; but this is far from the truth. For many years there has been evidence suggesting that the body temperature is controlled at a higher level in disease.
The concept of fever as a change in the setting of a central thermostatic mechanism was first formulated by Von Liebermeister,l and subsequent work by Stern2 substantiated this hypothesis. Stern observed the development of sweating or of shivering in patients with and without fevers, when they were warmed or cooled by gradually changing the temperature of a bath in which they sat. He found that the change in rectal temperature when patients began to sweat or to shiver was the same in the pyrexial and
apyrexial groups. Subsequent experimental work in man Park and has in general confirmed these findings. Palmes3 found that the injection of bacterial pyrogens into normal subjects produced the same elevation of temperature in warm or cold environments. All these findings suggest active regulation of body temperature during fever, though the evidence is not entirely conclusive. Further convincing evidence of active temperature control has been described by MacPherson.4 In a long series of experiments he obtained very complete records of the responses of three normal subjects to standard exercise during environmental heat stress. During these experiments one subject developed a febrile illness characterised by cough and malaise; his temperature was raised by 0-5-1-5°F for six days. During this time the subject was able and willing to continue with the experiment, information.
thereby providing
very
interesting
Before the onset of fever this subject responded to exercise with an increase of rectal temperature which was almost identical with that of his companions. During the fever this pattern was exactly reproduced, at a higher level. The absolute temperature increment due to exercise remained the same. During exercise at moderate environmental temperatures the normal subjects showed a fall of skin temperature, with recovery during the subsequent rest period. This pattern was also reproduced by the febrile- subject, at a higher absolute temperature level. During exercise this subject’s sweat-rate did not differ significantly from that of his companions.
These experiments confirm and extend the previous findings, suggesting that the febrile patient responds to
various thermal stimuli in much the same way as the normal subiect, but at a hisher level of temperature. It is difficult 1. Von Liebermeister, C. Handbuch der Pathologie und Therapie des Fiebers. Leipzig, 1875. 2. Stern, R. Z. klin. Med. 1892, 20, 63. 3. Park, C. R., Palmes, E. D. Medical Department Field Research Laboratory, project no. 6-64-12-06. Fort Knox, Ky, 1948. 4. MacPherson, R. K. Clin. Sci. 1959, 18, 281.
to avoid the conclusion that his temperature is regulated in the same way. If the regulating mechanism is normally active, the temperature rise in fever must be actively produced. Why this happens is unknown.
B.P.C. 1959
edition1 of the British Pharmaceutical Codex is dated 1959-a vintage year for official publications on prescribing costs-and against this background the B.P.C. The conscientious and selecassumes great importance. tive use of the Codex by medical students and doctors would encourage the critical attitude and keener appreciation of the place of pharmacy in relation to therapeutics that can lead to prescribing which is both sound and economical. It is strange that the British Pharmacopceia (published under the xgis of the General Medical Council) continues to be a book of reference used almost exclusively by pharmacists, while the Codex (published by the Pharmaceutical Society of Great Britain) has become one of the most important books available to doctors. The subject matter of the two is, of course, much the same, but there are striking differences in presentation. Thus, the Codex includes paragraphs on the actions and uses of drugs: these are not intended to convert it into a textbook of pharmacology, but they are invaluable in presenting concise information about the effects of drugs and the relative merits of their various preparations. Thus, the Codex is a book of capital importance as an ancillary to standard works on therapeutics. Although drugs, or particular preparations of drugs, which have been deleted from the Plzarmacopceia are likely to disappear also from the Codex, it is the traditional policy of the Codex Revision Committee to retain many of these preparations, if they are widely used, and look at them occasionally during a further period of five years. There is clearly a place for this conservative attitude; for although the factual data of the Pharmacopceia and Codex inevitably have much in common, the books are in many ways complementary. Allowance must also be made for doctors who are not prepared to modify their prescribing habits simply because, for various reasons, certain pharmaceutical preparations are no longer " official ". The additions to the new Codex include 70 new general monographs, and 20 of these refer to drugs already included in the B.P. 1958. Among the monographs which deal with the more specialised materials (biological products, surgical ligatures, and sutures), poliomyelitis vaccine and rabies antiserum deserve mention. The Formulary (part vi of the Codex)-perhaps the most valuable section for the prescriber-contains some 79 new items, but 44 of them represent " salvage " from those deleted from the B.P. There are long lists of deletions under monographs and under formulary. Some 26 preparations suffer total eclipse, in that they no longer appear in either the B.P. 1958 or the Codex 1959. But few doctors will feel their withers wrung by the demise of infusion of quassia, solution of mercuric chloride, and the dilute solution of ammonium acetate. The rise and fall of cream of penicillin (also among the 26 condemned to the twilight of obscurity) may, however, cause some to reflect on the transient glories of therapeutic fame. THE
new
1. British Pharmaceutical Codex 1959. 7th ed. Council of the Pharmaceutical Society of Great Britain. London: Pharmaceutical Press. 195° Pp. 1301. 70s. The Codex comes into force in the United Kingdom on July 1, 1960.