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DOES SODIUM SALICYLATE CURE RHEUMATIC FEVER ?
70 Smith, third of the medical knights, is an adopted but cherished son of Edinburgh who has won enviable reputations as professor of forensic medicine, as dean of the medical school, as acting principal of the university, and as much besides. The many other honours which we, are glad to record on p. 77 include a Privy Counsellorship for Dr. Edith Summerskill, in recognition of her
expertness
as a
parliamentarian. A
LITTLE NURSING ?
Two students write today to protest against the introduction of three weeks’ nursing experience into the medical curriculum as " a ridiculous waste of time." They hope this innovation will not spread to other hospitals, and plead instead for " at least one forceps delivery." Our sympathies are often with students when they criticise the curriculum, but we cannot share this view, which seems to reflect a regrettable bias given to the doctor’s professional outlook by current training. Mr. Carruthers and Mr. Richardson feel that the student, by watching the nurses at work in the wards, can acquire a technique which he should later constantly use and teach to others-that of making people comfortable. It cannot be acquired by observation alone, or, for that matter, by three weeks’ instruction: good nursing comes with practice. But though three weeks will not make the student a good nurse it will at least teach him the rudiments and some of the difficulties of an important side of his job. Other hospitals would do well to follow the London Hospital’s lead. DOES SODIUM SALICYLATE CURE RHEUMATIC FEVER ?
UNDER this title Reidhas published an article in which he postulates that adequate oral administration of sodium salicylate can really cure the disease
rheumatic fever. This assertion is based on observation of 9 adults, and of 3 children with pericarditis. Of the adults 7 were given sodium salicylate 2 g. and sodium bicarbonate 2 g. at four-hourly intervals from 6 A.M. to " 10 P.M.—five doses daily-until complete recovery as indicated by the return of the erythrocyte-sedimentation rate to normal." The other 2 adults received the same amount of sodium salicylate but no alkali. To 2 of the 3 children (aged 14, 12, and 9 years) sodium salicylate 1-3 g. and sodium bicarbonate 1-3 g. were given at the same intervals as for the adults ; the third child received this dosage of sodium salicylate but no alkali. Reid gives evidence that the efficacy of salicylate treatment depends upon the attainment and maintenance of a plasma-salicylate level of 30-40 mg. per 100 ml. ; he also suggests that the urinary concentration of salicylate is a satisfactory guide to the plasma concentration. He found the fall in the sedimentation-rate to be closely correlated with the plasma concentration of salicylate ; failure to respond to salicylates is attributed by him to neglect to maintain a satisfactory plasma-salicylate level and to withdrawal of salicylates at too early a stage. " The practice of giving large doses of salicylate until fever, tachycardia, and joint pains have been relieved and then drastically reducing the dose is condemned." This is a valuable contribution to an ever-vital problem. But the series is small ; and it is perhaps risky to base conelusions upon a study principally of adults, for a first attack of rheumatic fever after the age of 20 seldom causes permanent damage to the heart. (This criticism can also be levelled against some American reports, such as those of Coburn2 and Manchester,3 in which a curative action is claimed for salicylates.) ’The third criticism is that no mention is made of any follow-up. 1. Reid, J. Quart. J. Med. 1948, 17, 139. 2. Coburn, A. F. Bull. Johns Hopk. Hosp. 1943, 73, 435. J. Amer. med. Ass. 1946, 131, 209. 3. Manchester, R. C.
The criterion of cure in this series-the sedimentationrate-was also used by Coburn. Yet there is still no good evidence that the effect of salicylates in lowering the sedimentation-rate implies a parallel beneficial action on the rheumatic process. Rapoport and Guest 4 found in 15 patients with a raised sedimentation-rate, of whom only 4 had rheumatic fever, that the administration of salicylate caused a fall in the sedimentation-rate ; and Homburger5 reported a similar finding in patients with carcinomatosis. The most relevant contribution, however, is that of Harris.6 Using full doses of salicylate (at least 1 grain per pound body-weight) he found that, of 6 patients with pulmonary tuberculosis and 4 with rheumatoid arthritis, 8 showed a fall in the sedimentationrate of the order observed in patients with rheumatic fever under such treatment. In a further series of 6 children with rheumatic fever, chosen because (a) they had leucocytosis, (b) the white-cell count was not affected by salicylate, and (e) there were no manifestations of salicylate toxicity, he found that although the sedimentation-rate fell to normal the white-cell count still reflected continuing activity and there was no definite indication of clinical improvement. Cautiously Harris concludes : " It is very doubtful that massive salicylate therapy suppresses the inflammatory reaction of the rheumatic patient or that the lowering of the E.s.R. in rheumatic patients so treated has the significance attributed to it
by Coburn." The history of salicylates in the treatment of rheumatic fever since they were first introduced for this purpose by Maclagan in 1876, does not suggest that they cure this disease. They have been used so widely and for so long that it is hard to believe that if they had a curative action this would not have been recognised long ago. There certainly would not have been reports, such as those of Miller,’ Ehrstrom and Wahlberg,8 and Master and Romanoff,9 suggesting that the outcome of rheumatic fever in children is alike whether or not salicylates are given. Ehrstrom and Wahlberg’s conclusions were based upon a series of 51,111 cases, while Miller’s were based upon 1907 patients treated with salicylates and 1600 who received no salicylates. Even .the argument that the earlier workers did not use large enough doses is not valid ; as long ago as 1903 Lees 10 suggested doses up to gr. 300 daily, while in 1906 Clarke 11 was giving gr. 240 daily. Recent work indicates that this is more than enough to maintain the optimum plasma-salicylate level. Maggioni 12 has shown that in children the optimum level can be maintained with a dose of gr. 1-1-5 per pound body-weight (0,12-0,18 g. per kg.). THE KING’S HEALTH
LAST Monday the following Buckingham Palace :
bulletin
was
issued from .
Since the bulletin of Dec. 13, 1948, the King has made uninterrupted progress. His general health is entirely satisfactory. On both right and left sides the arterial circulation in the legs and feet is improving slowly. It is not yet sufficient to allow more than strictly limited activity when His Majesty leaves London to continue his convalescence in the
country. .
4. 5.
6. 7. 8. 9. 10. 11. 12.
MAURICE CASSIDY THOMAS DUNHILL HORACE EVANS J. R. LEARMONTH J. PATERSON ROSS MORTON SMART JOHN WEIR.
Proc. Soc. exp. Biol., N.Y. 1946, 61, 43. Homburger, F. Amer. J. med. Sci. 1946, 211, 346. Harris, T. N. Ibid, 1947, 213, 482. Miller, J. L. J. Amer. med. Ass. 1914, 63, 1107. Ehrstrom, R., Wahlberg, J. Acta med. scand. 1923, 58, 350. Master. A. M., Romanoff, A. J. Amer. med. Ass. 1932, 98, 1978, Lees, D. B. Brit. med. J. 1903. ii, 1318. Clarke, T. W. Amer. J. med. Sci. 1906, 132, 429. Maggioni, G. F. Arch. Dis. Childh. 1948, 23, 40.
Rapoport, S., Guest, G. M.
expertness
as a
parliamentarian. A
LITTLE NURSING ?
Two students write today to protest against the introduction of three weeks’ nursing experience into the medical curriculum as " a ridiculous waste of time." They hope this innovation will not spread to other hospitals, and plead instead for " at least one forceps delivery." Our sympathies are often with students when they criticise the curriculum, but we cannot share this view, which seems to reflect a regrettable bias given to the doctor’s professional outlook by current training. Mr. Carruthers and Mr. Richardson feel that the student, by watching the nurses at work in the wards, can acquire a technique which he should later constantly use and teach to others-that of making people comfortable. It cannot be acquired by observation alone, or, for that matter, by three weeks’ instruction: good nursing comes with practice. But though three weeks will not make the student a good nurse it will at least teach him the rudiments and some of the difficulties of an important side of his job. Other hospitals would do well to follow the London Hospital’s lead. DOES SODIUM SALICYLATE CURE RHEUMATIC FEVER ?
UNDER this title Reidhas published an article in which he postulates that adequate oral administration of sodium salicylate can really cure the disease
rheumatic fever. This assertion is based on observation of 9 adults, and of 3 children with pericarditis. Of the adults 7 were given sodium salicylate 2 g. and sodium bicarbonate 2 g. at four-hourly intervals from 6 A.M. to " 10 P.M.—five doses daily-until complete recovery as indicated by the return of the erythrocyte-sedimentation rate to normal." The other 2 adults received the same amount of sodium salicylate but no alkali. To 2 of the 3 children (aged 14, 12, and 9 years) sodium salicylate 1-3 g. and sodium bicarbonate 1-3 g. were given at the same intervals as for the adults ; the third child received this dosage of sodium salicylate but no alkali. Reid gives evidence that the efficacy of salicylate treatment depends upon the attainment and maintenance of a plasma-salicylate level of 30-40 mg. per 100 ml. ; he also suggests that the urinary concentration of salicylate is a satisfactory guide to the plasma concentration. He found the fall in the sedimentation-rate to be closely correlated with the plasma concentration of salicylate ; failure to respond to salicylates is attributed by him to neglect to maintain a satisfactory plasma-salicylate level and to withdrawal of salicylates at too early a stage. " The practice of giving large doses of salicylate until fever, tachycardia, and joint pains have been relieved and then drastically reducing the dose is condemned." This is a valuable contribution to an ever-vital problem. But the series is small ; and it is perhaps risky to base conelusions upon a study principally of adults, for a first attack of rheumatic fever after the age of 20 seldom causes permanent damage to the heart. (This criticism can also be levelled against some American reports, such as those of Coburn2 and Manchester,3 in which a curative action is claimed for salicylates.) ’The third criticism is that no mention is made of any follow-up. 1. Reid, J. Quart. J. Med. 1948, 17, 139. 2. Coburn, A. F. Bull. Johns Hopk. Hosp. 1943, 73, 435. J. Amer. med. Ass. 1946, 131, 209. 3. Manchester, R. C.
The criterion of cure in this series-the sedimentationrate-was also used by Coburn. Yet there is still no good evidence that the effect of salicylates in lowering the sedimentation-rate implies a parallel beneficial action on the rheumatic process. Rapoport and Guest 4 found in 15 patients with a raised sedimentation-rate, of whom only 4 had rheumatic fever, that the administration of salicylate caused a fall in the sedimentation-rate ; and Homburger5 reported a similar finding in patients with carcinomatosis. The most relevant contribution, however, is that of Harris.6 Using full doses of salicylate (at least 1 grain per pound body-weight) he found that, of 6 patients with pulmonary tuberculosis and 4 with rheumatoid arthritis, 8 showed a fall in the sedimentationrate of the order observed in patients with rheumatic fever under such treatment. In a further series of 6 children with rheumatic fever, chosen because (a) they had leucocytosis, (b) the white-cell count was not affected by salicylate, and (e) there were no manifestations of salicylate toxicity, he found that although the sedimentation-rate fell to normal the white-cell count still reflected continuing activity and there was no definite indication of clinical improvement. Cautiously Harris concludes : " It is very doubtful that massive salicylate therapy suppresses the inflammatory reaction of the rheumatic patient or that the lowering of the E.s.R. in rheumatic patients so treated has the significance attributed to it
by Coburn." The history of salicylates in the treatment of rheumatic fever since they were first introduced for this purpose by Maclagan in 1876, does not suggest that they cure this disease. They have been used so widely and for so long that it is hard to believe that if they had a curative action this would not have been recognised long ago. There certainly would not have been reports, such as those of Miller,’ Ehrstrom and Wahlberg,8 and Master and Romanoff,9 suggesting that the outcome of rheumatic fever in children is alike whether or not salicylates are given. Ehrstrom and Wahlberg’s conclusions were based upon a series of 51,111 cases, while Miller’s were based upon 1907 patients treated with salicylates and 1600 who received no salicylates. Even .the argument that the earlier workers did not use large enough doses is not valid ; as long ago as 1903 Lees 10 suggested doses up to gr. 300 daily, while in 1906 Clarke 11 was giving gr. 240 daily. Recent work indicates that this is more than enough to maintain the optimum plasma-salicylate level. Maggioni 12 has shown that in children the optimum level can be maintained with a dose of gr. 1-1-5 per pound body-weight (0,12-0,18 g. per kg.). THE KING’S HEALTH
LAST Monday the following Buckingham Palace :
bulletin
was
issued from .
Since the bulletin of Dec. 13, 1948, the King has made uninterrupted progress. His general health is entirely satisfactory. On both right and left sides the arterial circulation in the legs and feet is improving slowly. It is not yet sufficient to allow more than strictly limited activity when His Majesty leaves London to continue his convalescence in the
country. .
4. 5.
6. 7. 8. 9. 10. 11. 12.
MAURICE CASSIDY THOMAS DUNHILL HORACE EVANS J. R. LEARMONTH J. PATERSON ROSS MORTON SMART JOHN WEIR.
Proc. Soc. exp. Biol., N.Y. 1946, 61, 43. Homburger, F. Amer. J. med. Sci. 1946, 211, 346. Harris, T. N. Ibid, 1947, 213, 482. Miller, J. L. J. Amer. med. Ass. 1914, 63, 1107. Ehrstrom, R., Wahlberg, J. Acta med. scand. 1923, 58, 350. Master. A. M., Romanoff, A. J. Amer. med. Ass. 1932, 98, 1978, Lees, D. B. Brit. med. J. 1903. ii, 1318. Clarke, T. W. Amer. J. med. Sci. 1906, 132, 429. Maggioni, G. F. Arch. Dis. Childh. 1948, 23, 40.
Rapoport, S., Guest, G. M.