DISSEMINATION OF THE MENINGOCOCCUS

41 social medicine. Taking them all round, the reports are The problem of serum neuritis became more complifurther evidence that the Royal College of Physicians, cated during the late war when a number of cases were reported. Thus from the Middle East Burnard and Fox 6 when it is given the chance, can rise to the occasion as a source of sound well-considered advice. In his introand Spillanerecorded the condition (under the name of localised neuritis of the shoulder-girdle) as occurring duction, Lord Moran, president from 1941 to 1950, points without administration of serum ; in his forty-six cases to its long record of service of this kind, which we hope Spillane found no time-relation between the adminis- and believe will continue and increase. tration of vaccines or sera and the development of DISSEMINATION OF THE MENINGOCOCCUS paralysis. Weinstein 8 recorded sixteen similar cases IN both world wars cerebrospinal fever (meningococcal among American military personnel ; again in none of these had serum been administered within the previous meningitis) became epidemic among recruits in Service establishments. This, together with advances in the three months, but all had had prophylactic injections of 1-12 weeks before the or vaccine onset serological typing of meningococci and the advent of typhus typhoid of the illness. Parsonage and Aldren Turner9 reported chemoprophylaxis, led Aycock and Mueller1 to make a on 136 cases of the same condition, to which they gave long and continuous study, from 1941 to 1945, of carrierrates in relation to the incidence of the disease in two the purely symptomatic name of neuralgic amyotrophy. American army establishments. The record of previous inoculations was investigated in 67 of these ; the number inoculated within the preceding Thirty years ago Glover2 postulated a rise in the four weeks was 11, of whom 6 had been inoculated meningococcal carrier-rate to 20% as a pre-epidemic within the previous fortnight. They found, however, danger-point, and suspected a relation in the army between this rise and overcrowding in sleeping-huts. that in no less than 66 of the 136 cases the condition had developed intercurrently in hospital. Cases of During the inter-war period, however, Dudley and neuralgic amyotrophy without any time-relation to serum Brennan3 found that in Naval establishments persistently or vaccine administration are still occasionally seen high carrier-rates (54%) might obtain without clinical in this country and have also been reported from attacks ; and clinical attacks occurred despite very low carrier-rates. Furthermore, carrier-rates were as high Scandinavia 10 and France." This condition and serum neuritis differ in several among senior ratings with spacious quarters as among whose sleeping accommodation was much recruits ways from anterior poliomyelitis. The onset is afebrile inferior. Early in the late war Fairbrother4 suggested and is not accompanied by the constitutional and meningeal symptoms of poliomyelitis ; the pain at the that fatigue was more important than overcrowding in onset is severe and localised, which is on the whole predisposing to clinical attacks, especially among recruits from rural districts, whose natural immunity was likely uncommon in poliomyelitis, where pain is usually more to be low. even the is generalised subsequent paralysis though Aycock and Mueller discount altogether the effect of localised ; commonly sensation is impaired, particularly in the distribution of C5 segment ; and the cerebrospinal overcrowding. They found that the disease is fairly fluid (c.s.F.) has been normal in the majority of cases uniformly distributed throughout the U.S.A. during years of high and low prevalence alike.. Plotting of reported where it has been examined in the acute stage. The cases during the period 1915-48 showed an undulating of and remain pathology aetiology neuralgic amyotrophy obscure ; but the clinical picture is exactly comparable curve of increases and decreases, each extending over a to that of serum neuritis, and probably the two disorders period of 6-11 years, with peaks in 1918, 1929, 1936, and 1943. This rhythmical variation is a continuing a there a have similar basic pathology. Since is possibility that neuralgic amyotrophy may be precipitated by phenomenon, and is not due to independent seasonal vaccine inoculation, care should be taken, and the epidemics, since the’rhythm during the epidemic season varies with that in the inter-epidemic summer months. C.S.F. examined, before atrophic paralysis following But the pattern of periodicity differs from that of such to anterior poliomyelitis. inoculation is attributed " immunising infections " of childhood as measles, ON THE RECORD is chickenpox, and diphtheria. With these, an epidemic terminated by the " exhaustion of susceptibles " and THE Royal College of Physicians has published in recurs only when enough non-imniunes have once again book form the reports of its fifteen special committees accumulated. Thus Aycock and Mueller deny that which sat between 1942 and 1947 to consider a wide natural of and immunity following exposure shapes the epidemic of professional importance.12 subjects public range These have already had considerable influence, and some pattern of meningococcal meningitis ; season is responsible, they find, only for secondary fluctuations in the of them should have more. The one on medical education longer cyclic curve, and there is no single cause for either. was notable as a bold effort to free the curriculum from the viability of the of from the the accretions obsession Using a method for ages, and in general that a doctor cannot be safely loosed on the public unless meningococcus on nasopharyngeal swabs, similar to that he has had lectures on every conceivable subject-though described by Downie,5 these workers have compared the he need understand nothing. This report was responsible carrier-rate of various serological types amongseasoned for the " pre-registration resident year," which is in due troops and recruits ; and they suggest that the carrierrate among the latter may represent that of the civil course to be introduced under the new Medical Act ; but the college seems to have had in mind an assistant population-a view later supported by swabbings of medical students. In the two military groups Harvard residentship, or scarcely paid post under the supervision the total carrier-rates and their type-composition were of a senior resident ; whereas nowadays the scheme is generally regarded merely as a means of ensuring that essentially the same, and there was no indication of the seasonal variation which obtains for clinical attacks. before undertaking independent practice all doctors shall hold a house-appointment. The report on the design of But, whether in the army or the civilian population, typedwelling-houses starts off in rather pessimistic vein, composition is not stable ; the carrier-rate for one type but in its latter half it proceeds to some first-class may increase while the rates for other types are stationary or declining. Aycock and Mueller believe that these 6. Burnard, E. D., Fox, T. G. N.Z. med. J. 1942, 41, 243. 7. Spillane, J. D. Lancet, 1943, ii, 532. changes, which are not sudden or frequent, are natural

prolonging

8. 9. 10. 11. 12.

Weinstein, E. A. Arch. Neurol. Psychiat. 1947, 57, 369. Parsonage, M. J., Turner, J. W. A. Lancet, 1948, i, 973. Hook. O. Nord. Med. 1949, 42, 1662. Alajouanine, T., Thurel, R., Blatrix, C. Rev. neurol. 1950, 82, 279. A limited number of copies are available on application to the college.

1. 2. 3. 4. 5.

Aycock, W. L., Mueller, J. H. Bact. Rev. 1950, 14, 115. Glover, J. A. Spec. Rep. Ser. med. Res. Coun., Lond. no. 50. 1920. Dudley, S. F., Brennan, J. R. J. Hyg., Camb. 1934, 34, 525. Fairbrother, R. W. Brit. med. J. 1940, ii, 859. Downie, A. W. Lancet, 1940, ii, 36.

42 "

reversals," the mechanism of which is unknown-a akin to that of McLeod,6 who has suggested that the different cultural types of Corynebacterium

hypothesis

diphtherim may be cyclical mutations. An increase in the epidemic type-i meningococcus results from changes in carrier composition and is correlated with the occurrence of meningitis ; but the persistence of a single type in individuals exposed to other types suggests the operation of some general factor in the host. All agree that the relatively high incidence of the disease in the army is due largely to the influx of recruits ; but Aycock and

no evidence that the carrier-rates differed between recruits, seasoned soldiers, and civilians. greatly This susceptibility of recruits to clinical attack is evident only during the first few months of service ; of 3507 cases of meningitis, 78-6% occurred in men with less than six months’ service and 57-6% in men with less than three months’ service. It would therefore not be unreasonable to suppose that Fairbrother was right in attaching importance to fatigue as a contributory factor in attacks among recruits. Fortunately sulphadiazine (and other of the newer sulphonamides) is effective not only in prevention and treatment but also in securing prompt termination of the carrier state. As the result of trials, Aycock and Mueller suggest that the administration of 8 g. of sulphadiazine to recruits upon arrival at the depot would ensure a refractory state throughout

Mueller found

the

period

of

greatest

risk.

AMERICAN HOSPITALS

DESPITE a large Federal construction programme, the U.S.A. is still not within sight of achieving the number of hospital beds it needs. State plans show7 that at the start of 1950 the country had a total of 1,099,493 beds, of which 162,598 were rated as " nonacceptable " ; to replace these and meet the full demand a further 867,833 beds were needed. The upper limits within which the States formulated their estimates were : for general-hospital beds 4-5-5-5 per 1000 population for mental-hospital beds5 per 1000 population ; for tuberculosis beds 2-5 per average annual death in the State over the five-year period 1940-44 ; and for chronic disease 2 beds per 1000 population. The wide discrepancies between different States are reflected in the at the figures for tuberculosis. Whereas Minnesota, " top of the scale, had 2.96 acceptable beds per annual death, Alabama, at the bottom, had only 0-38 ; the national average was 1-43, and in only six States was 2-5 exceeded. (The estimates include beds in hospitals under construction.) These figures do not, of course, indicate the existing special need for more hospitals in the less thickly populated parts. "

TISSUE CULTURE OF HUMAN ENDOMETRIUM THE technique of tissue culture in artificial media has been known for many years, and it is, therefore, surprising that it has not been used more extensively in physiological and pathological research. Randall and his associates 8 seem to be the first to have adopted the technique of Parker 9 and of Medawar 10for the culture of human endometrium in a fluid medium-a method which permits simultaneous study of the effect of the tissue on the medium and of the medium on the tissue. Endometrium is a particularly suitable tissue for this type of work ; it is easily obtained fresh and in quantity by curettage, and it undergoes certain well-defined morphological and functional changes which are only partly understood and whose explanation would be of definite clinical value. 6.

McLeod, J. W. J. Path. Bact. 1950, 62, 137. See Lancet, Dec. 2, 1950, p. 693. 7. Cronin, J. W., Reed, L. S., Baney, A. M. Publ. Hlth Rep., Wash. 1950, 65, 1461. 8. Randall, J. H., Stein, R. J., Stuermer, U. M. Amer. J. Obstet. Gynec. 1950, 60, 711. 9. Parker, R. C. Science, 1937, 85, 292. 10. Medawar, P. B. Quart. J. micr. Sci. 1948, 89, 187.

Randall and his colleagues have already obtained striking results. Thus they found that, whereas proliferative endometrium required, for proper growth, nearly 80% oxygen and 5% carbon dioxide, secretory endometrium survived quite well even under anaerobic conditions. The optimum pH corresponded with these findings : 7-3-7-6 for proliferative endometrium, and 6-7-6.9 for secretory endometrium. Reduction of the temperature greatly prolonged the survival-time of the explanted tissues ; control cultures kept at 37°C began to show evidence of degenerative changes after 10 days, but cultures kept at 4°-5°C were histologically normal On the other hand, at this Ipw even after 35 days. temperature no mitoses were seen in proliferative endometrium, whereas in cultures kept at 25° or 34°C they were numerous. This work opens up a vista of possible on the effects of hormones on the tissue studies-e.g., and its products (which might, incidentally, offer a very neat method of assaying progesterone),; the effects of vitamins, amino-acids, and inorganic ions ; the changes which accompany menstruation ; and the development of inflammatory conditions. some

SYNTHESIS OF COMPOUND F COMPOUND F has been synthesised by research chemists of Messrs. Merck & Co., New Jersey. This, says the New York Tirnes (Dec. 29), was announced at the annual meeting, in Cleveland, of the American Association for the Advancement of Science. Like ’Cortisone’ (Compound E), which was synthesised in the same laboratories, Compound F is made from desoxycholic acid ; the process is completed in 39 stages, compared with 37 for cortisone. Hitherto only small amounts of compound F have been available for trial 1 ; but it is thought to have much the same action as cortisone. The Merck chemists state that, the necessary equipment, substantial amounts of given compound F can be produced within a matter of months. NEW YEAR HONOURS of our profession receiving knightmembers eight hoods,. two are fellows of the Royal Society. Dr. Gordon Holmes has long had so great a name in neurology that a prefix seems almost irrelevant ; and the work on viruses done in Professor Burnet’s institute in Melbourne is known throughout the medical world as that of a mind which can kindle ideas as well as illuminate facts. Mr. Kelsev Fry, with his distinguished record in the Guy’s dental school and as dean of the faculty of dental surgery at the Royal College of Surgeons, has aided the Royal Air Force and the Ministry of Health as consultant. Dr. Selwyn-Clarke, who is appointed K.B.E., is one of the few doctors in the Colonial Service who have become senior administrators : during the war he had the difficult post of director of medical services at HongKong, and his recent efforts, as governor of the Seychelles, to improve the conditions of the people, have likewise called for courage. Also on the Colonial Office list are Dr. F. A. Ibiam (honorary K.B.E.) and Dr. K. A. Abayomi, both of them members of the executive council of Nigeria, and both Scottish graduates. In the Royal Victorian Order, Dr. Daniel Davies and Dr. F. H. Teale are promoted to knighthoods for personal services to the Sovereign and his household. Dr. Davies’s skill as a clinician is based not only on large experience but on patient investigations into the clinical aspects of the pneumonias, anaemias, and dyspepsias ; while Dr. Teale, as former lecturer in bacteriology and head of the immunotherapy department at University College Hospital, has worked on problems of bacterial infection. The-list we print on p. 47 contains also the names of many other men and women who are already honoured in their profession but whose public recognition is none the less welcome to their colleagues.

OF

1. See

Fourman, P., Bartter, F. C., Albright, F., Dempsey, E., Carroll, E., Alexander, J. J. clin. Invest. 1950, 29, 1462.

"