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Prevention of Rheumatic Fever
278
patient arrangements, and at the Middlesex Hospital Brigadier HARDY ROBERTS has found it helpful to hold outpatient staff conferences, which can sometimes solve problems previously deemed insoluble. Unfortunately it is very hard to organise improvements in an outpatient department (or in any other concern) which is already overburdened by numbers ; and, though most references to hospital are perfectly reasonable, it is possible that practitioners could help to make conditions better if they exercised their right of consultation a little more sparingly. Sir JAMES SPENCE found that a meeting with general practitioners
was well received, and if B.M.A. meetings were held to consider local problems they would bring out many constructive criticisms and help everyone concerned. Alternatively, the be the could considered local liaison comby subject Another and very imporwhere such exists. mittee, tant means of reducing the pressure on consultative outpatient departments is to provide " direct access " for practitioners to pathological and radiological investigations-an arrangement which is. greatly appreciated and rarely abused. In practice it is found that the special departments have very little extra work to undertake. In all such arranging, the standpoint of the patient needs to be kept in mind. Good signposting is a help to the newcomer, and so is the assistance of receptionists in the entrance-hall to promote the regular flow of patients with their notes. The use of trained nurses for such work is quite unjustifiable, and the duties of outpatient nurses should be restricted to assistance with medical procedures. Wherever to the should come possible departments patient and not vice versa : thus a circuitous journey to the pathological laboratory may be avoided if’accommodation is provided in the outpatient department where the common pathological tests can be made. Similarly ancillary medical staff such as dietitians should have accommodation in the department to enable them to attend various clinics. But the main consideration is that good facilities for outpatient consultation should enable the consultant both to provide guidance to patient and doctor and at the same time to reinforce the patient’s confidence in what is being done for him.
to discuss doctors’ letters
Prevention of Rheumatic Fever RHEUMATIC fever -is a manifestation of infection of the upper respiratory tract with group-A haemolytic streptococci. More than twenty years of epidemiological and immunological investigation support this statement, and, although we know disappointingly little about the details of the relationship, present methods of preventing rheumatic fever are based on the inference that control of streptococcal respiratory infection will reduce the incidence of primary and recurrent rheumatic attacks. The results of clinical trials of prophylaxis with sulphonamides or penicillin suggest that this inference is
justified. In the United States streptococcal infections and rheumatic fever reach a peak during the early spring. The American Heart Association’s committee which has been studying the prevention of rheumatic fever has therefore chosen this moment to publish its -recommendations, which are being widely dis-
tributed to doctors, medical societies, health departments, and medical ancillaries, as part of a general campaign for the prevention of this disease. This statement, which we reproduce on p. 285, is a useful and simple account of the use and hazards of sulphonamides and penicillin in the treatment of streptococcal respiratory =infections in general, and in the prevention of streptococcal infection in rheumatic subjects. In England and Wales the peak of streptococcal infections comes later in the year than it does in the United States : both scarlet fever and rheumatic fever are usually commonest during the last quarter of the year.1 The American statement is none the less a timely reminder of what can be done : the application of a general policy designed to prevent rheumatic fever in this country remains of the first importance, for, quite apart from recurrences induced in rheumatic patients, rheumatic sequeloe probably complicate 1-2% of streptococcal upper respiratory infections. The main points made by the committee are now well established, but they cannot, be given too much emphasis. In the treatof streptococcal infections, ment intramuscular procaine penicillin, given early and continued until the organisms are eradicated from the throat, has amply proved its worth.2 Sulphonamides are not recommended, and oral penicillin gets second place, for though it is known to be useful its reliability for this purpose has not yet been sufficiently widely assessed. In the prevention of streptococcal infection in rheumatic subjects, the population at risk includes all those under the age of 18 who have had rheumatic fever or chorea, and also all those over this age who have had an attack within 5 years, for the risk of The recurrence seems greatest within this period.3 here is a one that of treatmuch than bigger problem ment : prophylaxis should be applied continuously within these age-limits-an expensive businessand partly for this reason the choice of the American Patients authorities has fallen on sulphadiazine. in hospital recovering from acute rheumatic attacks may be successfully launched on their course of sulphadiazine, but their supervision as outpatients afterwards calls for considerable organisation. Toxic effects, though rare after the first 8 weeks of prophylaxis, should be watched for ; routine examination for signs of rheumatic recurrence should be carried out ;-, and it is probably desirable to test the urine occasionally to make certain that thedrug is being taken. Although resistant streptococci have appeared -with devastating results-when mass prophylaxis has been applied to closed communities under Service conditions,4in the individual rheumatic patient taking sulphadiazine at home the risk is not nearly so great. But sulphonamides have their shortcomings, and the superiority of penicillin in exerting a bactericidal rather than bacteriostatic action, in effectively eliminating the streptococcal carrier state, and in
only rarely producing penicillin-resistant streptococci has prompted a search for practicable methods of penicillin prophylaxis. Penicillin has been given orally, but there are disadvantages : it is a more 1. Rowlands, A. B. Brit. med. J. 1938, ii, 15. 2. Wannamaker, L. W., Rammelkamp, C. H., Denny, F. W., Brink, W. R., Houser, H. B., Hahn, E. O., Dingle, J. H. Amer. J. Med. 1951, 10, 673. 3. Bland, E. F., Jones, T. D. Circulation, 1951, 4, 836. 4. Finland, M. Bull. N.Y. Acad. Med. 1951, 27, 199.
279 method and the drug has to be given on an empty stomach. Serious toxic reactions, however, Until lately parenteral penicillin has not are rare. been thought feasible for such long periods of prophylaxis, but the recent introduction of a particu-
costly
larly long-acting preparation (N,N’-dibenzylethylenediamine dipenicillin G) brings penicillin prophylaxis within the bounds of practicability. This drug (benzethacil orBicillin ’) has no significant toxicity, and has the advantage of being very sparingly soluble (its solubility in water is equivalent to about 200 units5 of penicillin per ml.). FLETCHER and KNAPPETT have now investigated the use of this compound, and 6
and RusoFF in New York have of its use as a prophylactic in trial reported rheumatic children in hospital. Both investigations show that it is possible to maintain low serum levels of penicillin continuously in an encouragingly high proportion of individuals by means of simple intramuscular doses spaced at intervals of as long as a fortnight. The serum levels attained are variable, and may be very low or even intermittent. It is possible that this might favour both the emergence of resistant strains and the development of drug hypersensitivity ; but neither of these troubles has In the so far proved to be a serious complication. American trial, the value of the drug as a prophylactic against rheumatic recurrences was not established, for although none occurred, there was only one recurrence in untreated patients in the same hospital during the period of the trial. Further experience is therefore required to estimate its value in prophylaxis. But it might be hard to justify a trial of this kind in Great Britain, where it is widely believed that recurrences of rheumatic fever are quite uncommon-an opinion that cannot be challenged without extensive follow-up data. At all events, it is well to remember, in the light of the American Heart Association’s statement, that there are gaps in our knowledge of the natural history of rheumatic fever in this country. STOLLERMAN a
Law and Public LAWS
are
at best rules of
Feeling
thumb, designed to do,
under average conditions, the "greatest good to the greatest number." There will always be some criminal cases where the outcome leaves the public conscience uneasy. Is it logical to hold an adolescent fully responsible for his actions at 18 but not at 17 ? Naturally not. Many factors influence his stage of maturity, including his genetic endowment, his endocrine development, his education and training, his emotional experiences, and his own choices. Yet the law must rule a line somewhere, and declare that roughlv speaking most people are responsible for what they do at and after such and such an age ; and until we encounter a case such as that of Bentley and Craig we are prepared to accept that this should be so. When the margin is narrowed, however-when a young man of 19 is sentenced to death for inciting another, in a moment of violent excitement, to shoot-we are obliged to ask ourselves whether in holding to the letter of justice we are letting the spirit escape. The issue of the Times which announced the execution 5. Fletcher. A. P., Knappett, C. R. Brit. med. J. Jan. 24, 1953, p. 188. 6. Stollerman, G. H.. Rusoff, J. H. J. Amer. med. Ass. 1952, 150, 1571.
Bentley also carried a report of two boys at Trowbridge who have been stealing from safes and churches, who have used stolen money to buy firearms, knives, and a tent, and who resisted arrest, striking the police of
officer in the face and abdomen. Their ages are 16 and 14, and they have been sent for three years to an approved school, where they will have a 3 to 1 or 4 to 1 chance of reform. The discrepancy between their punishment and that of Bentley (whose offence was of the same order though of greater degree) seems startlingly wide. Against these considerations we have to set another : we are properly proud that our police do not ordinarily carry firearms, and if we ask them to face the risks this entails we must stand by them fully when such arms are used against them. It is generally held that the only way to do this is to deal severely with anyone who attacks them, and that in such cases the prerogative of mercy should not be exercised. According to law and practice,
therefore, Bentley
was
justly hanged.
If
we
think
that nevertheless justice was not done, then we do not like the law or the practice. There is an 18thcentury record of a boy of 11 who wasjustly hanged for a small theft. We have since found that law both intolerable and unnecessary. These perhaps are not directly medical concerns ; but the psychological atmosphere evoked by the recent execution certainly is. What are the motives which bring five hundred people to the gates of a prisonwhere a man is being hanged ? What lies behind the public emotion which this case has excited ? Does such an experience do people good or harm ? Answers to these questions must be largely guesswork, but there are some small pieces of evidence on which to base a guess. The Manchester Guardian correspondent who watched the scene at Wandsworth saw, among those present, members of an association formed for the abolition of capital punishment, who sang a hymn and a psalm ; a woman who had lived in the same street as Bentley ; a man who had attended the last fifteen such occasions, who said
"Nice fresh June morning and a little more sun, that’s what you want really " ; and four people who had taken a taxi from Birmingham in order to be there. Thus this relatively small crowd contained representatives of the types who used to flock to public hangings and burnings : those who used the event to protest against the law as it stood, and who tried to bring the condemned man some message of religion; those who derived a frisson from a macabre occasion ; those whose idle curiosity was not bridled by any and no doubt others who sense of embarrassment ; came to see what it was like, or because a friend had brought them, or because they thought it could not really happen, or because they were passing at the time and saw the crowd, or because they thought we had grown a lot too soft with criminals and things needed tightening up. None of these motives-except the first and the last, which can be defended by an intellectual level-deserves respect : because the country as a whole did not respect them that public executions were given up. Nevertheless it is clear that the same motives still operate, and would doubtless be manifest on a much larger scale if sanctioned and encouraged by public opinion. Restitution of public executions would suffice to restore the audiences.
argument and it
at
was
patient arrangements, and at the Middlesex Hospital Brigadier HARDY ROBERTS has found it helpful to hold outpatient staff conferences, which can sometimes solve problems previously deemed insoluble. Unfortunately it is very hard to organise improvements in an outpatient department (or in any other concern) which is already overburdened by numbers ; and, though most references to hospital are perfectly reasonable, it is possible that practitioners could help to make conditions better if they exercised their right of consultation a little more sparingly. Sir JAMES SPENCE found that a meeting with general practitioners
was well received, and if B.M.A. meetings were held to consider local problems they would bring out many constructive criticisms and help everyone concerned. Alternatively, the be the could considered local liaison comby subject Another and very imporwhere such exists. mittee, tant means of reducing the pressure on consultative outpatient departments is to provide " direct access " for practitioners to pathological and radiological investigations-an arrangement which is. greatly appreciated and rarely abused. In practice it is found that the special departments have very little extra work to undertake. In all such arranging, the standpoint of the patient needs to be kept in mind. Good signposting is a help to the newcomer, and so is the assistance of receptionists in the entrance-hall to promote the regular flow of patients with their notes. The use of trained nurses for such work is quite unjustifiable, and the duties of outpatient nurses should be restricted to assistance with medical procedures. Wherever to the should come possible departments patient and not vice versa : thus a circuitous journey to the pathological laboratory may be avoided if’accommodation is provided in the outpatient department where the common pathological tests can be made. Similarly ancillary medical staff such as dietitians should have accommodation in the department to enable them to attend various clinics. But the main consideration is that good facilities for outpatient consultation should enable the consultant both to provide guidance to patient and doctor and at the same time to reinforce the patient’s confidence in what is being done for him.
to discuss doctors’ letters
Prevention of Rheumatic Fever RHEUMATIC fever -is a manifestation of infection of the upper respiratory tract with group-A haemolytic streptococci. More than twenty years of epidemiological and immunological investigation support this statement, and, although we know disappointingly little about the details of the relationship, present methods of preventing rheumatic fever are based on the inference that control of streptococcal respiratory infection will reduce the incidence of primary and recurrent rheumatic attacks. The results of clinical trials of prophylaxis with sulphonamides or penicillin suggest that this inference is
justified. In the United States streptococcal infections and rheumatic fever reach a peak during the early spring. The American Heart Association’s committee which has been studying the prevention of rheumatic fever has therefore chosen this moment to publish its -recommendations, which are being widely dis-
tributed to doctors, medical societies, health departments, and medical ancillaries, as part of a general campaign for the prevention of this disease. This statement, which we reproduce on p. 285, is a useful and simple account of the use and hazards of sulphonamides and penicillin in the treatment of streptococcal respiratory =infections in general, and in the prevention of streptococcal infection in rheumatic subjects. In England and Wales the peak of streptococcal infections comes later in the year than it does in the United States : both scarlet fever and rheumatic fever are usually commonest during the last quarter of the year.1 The American statement is none the less a timely reminder of what can be done : the application of a general policy designed to prevent rheumatic fever in this country remains of the first importance, for, quite apart from recurrences induced in rheumatic patients, rheumatic sequeloe probably complicate 1-2% of streptococcal upper respiratory infections. The main points made by the committee are now well established, but they cannot, be given too much emphasis. In the treatof streptococcal infections, ment intramuscular procaine penicillin, given early and continued until the organisms are eradicated from the throat, has amply proved its worth.2 Sulphonamides are not recommended, and oral penicillin gets second place, for though it is known to be useful its reliability for this purpose has not yet been sufficiently widely assessed. In the prevention of streptococcal infection in rheumatic subjects, the population at risk includes all those under the age of 18 who have had rheumatic fever or chorea, and also all those over this age who have had an attack within 5 years, for the risk of The recurrence seems greatest within this period.3 here is a one that of treatmuch than bigger problem ment : prophylaxis should be applied continuously within these age-limits-an expensive businessand partly for this reason the choice of the American Patients authorities has fallen on sulphadiazine. in hospital recovering from acute rheumatic attacks may be successfully launched on their course of sulphadiazine, but their supervision as outpatients afterwards calls for considerable organisation. Toxic effects, though rare after the first 8 weeks of prophylaxis, should be watched for ; routine examination for signs of rheumatic recurrence should be carried out ;-, and it is probably desirable to test the urine occasionally to make certain that thedrug is being taken. Although resistant streptococci have appeared -with devastating results-when mass prophylaxis has been applied to closed communities under Service conditions,4in the individual rheumatic patient taking sulphadiazine at home the risk is not nearly so great. But sulphonamides have their shortcomings, and the superiority of penicillin in exerting a bactericidal rather than bacteriostatic action, in effectively eliminating the streptococcal carrier state, and in
only rarely producing penicillin-resistant streptococci has prompted a search for practicable methods of penicillin prophylaxis. Penicillin has been given orally, but there are disadvantages : it is a more 1. Rowlands, A. B. Brit. med. J. 1938, ii, 15. 2. Wannamaker, L. W., Rammelkamp, C. H., Denny, F. W., Brink, W. R., Houser, H. B., Hahn, E. O., Dingle, J. H. Amer. J. Med. 1951, 10, 673. 3. Bland, E. F., Jones, T. D. Circulation, 1951, 4, 836. 4. Finland, M. Bull. N.Y. Acad. Med. 1951, 27, 199.
279 method and the drug has to be given on an empty stomach. Serious toxic reactions, however, Until lately parenteral penicillin has not are rare. been thought feasible for such long periods of prophylaxis, but the recent introduction of a particu-
costly
larly long-acting preparation (N,N’-dibenzylethylenediamine dipenicillin G) brings penicillin prophylaxis within the bounds of practicability. This drug (benzethacil orBicillin ’) has no significant toxicity, and has the advantage of being very sparingly soluble (its solubility in water is equivalent to about 200 units5 of penicillin per ml.). FLETCHER and KNAPPETT have now investigated the use of this compound, and 6
and RusoFF in New York have of its use as a prophylactic in trial reported rheumatic children in hospital. Both investigations show that it is possible to maintain low serum levels of penicillin continuously in an encouragingly high proportion of individuals by means of simple intramuscular doses spaced at intervals of as long as a fortnight. The serum levels attained are variable, and may be very low or even intermittent. It is possible that this might favour both the emergence of resistant strains and the development of drug hypersensitivity ; but neither of these troubles has In the so far proved to be a serious complication. American trial, the value of the drug as a prophylactic against rheumatic recurrences was not established, for although none occurred, there was only one recurrence in untreated patients in the same hospital during the period of the trial. Further experience is therefore required to estimate its value in prophylaxis. But it might be hard to justify a trial of this kind in Great Britain, where it is widely believed that recurrences of rheumatic fever are quite uncommon-an opinion that cannot be challenged without extensive follow-up data. At all events, it is well to remember, in the light of the American Heart Association’s statement, that there are gaps in our knowledge of the natural history of rheumatic fever in this country. STOLLERMAN a
Law and Public LAWS
are
at best rules of
Feeling
thumb, designed to do,
under average conditions, the "greatest good to the greatest number." There will always be some criminal cases where the outcome leaves the public conscience uneasy. Is it logical to hold an adolescent fully responsible for his actions at 18 but not at 17 ? Naturally not. Many factors influence his stage of maturity, including his genetic endowment, his endocrine development, his education and training, his emotional experiences, and his own choices. Yet the law must rule a line somewhere, and declare that roughlv speaking most people are responsible for what they do at and after such and such an age ; and until we encounter a case such as that of Bentley and Craig we are prepared to accept that this should be so. When the margin is narrowed, however-when a young man of 19 is sentenced to death for inciting another, in a moment of violent excitement, to shoot-we are obliged to ask ourselves whether in holding to the letter of justice we are letting the spirit escape. The issue of the Times which announced the execution 5. Fletcher. A. P., Knappett, C. R. Brit. med. J. Jan. 24, 1953, p. 188. 6. Stollerman, G. H.. Rusoff, J. H. J. Amer. med. Ass. 1952, 150, 1571.
Bentley also carried a report of two boys at Trowbridge who have been stealing from safes and churches, who have used stolen money to buy firearms, knives, and a tent, and who resisted arrest, striking the police of
officer in the face and abdomen. Their ages are 16 and 14, and they have been sent for three years to an approved school, where they will have a 3 to 1 or 4 to 1 chance of reform. The discrepancy between their punishment and that of Bentley (whose offence was of the same order though of greater degree) seems startlingly wide. Against these considerations we have to set another : we are properly proud that our police do not ordinarily carry firearms, and if we ask them to face the risks this entails we must stand by them fully when such arms are used against them. It is generally held that the only way to do this is to deal severely with anyone who attacks them, and that in such cases the prerogative of mercy should not be exercised. According to law and practice,
therefore, Bentley
was
justly hanged.
If
we
think
that nevertheless justice was not done, then we do not like the law or the practice. There is an 18thcentury record of a boy of 11 who wasjustly hanged for a small theft. We have since found that law both intolerable and unnecessary. These perhaps are not directly medical concerns ; but the psychological atmosphere evoked by the recent execution certainly is. What are the motives which bring five hundred people to the gates of a prisonwhere a man is being hanged ? What lies behind the public emotion which this case has excited ? Does such an experience do people good or harm ? Answers to these questions must be largely guesswork, but there are some small pieces of evidence on which to base a guess. The Manchester Guardian correspondent who watched the scene at Wandsworth saw, among those present, members of an association formed for the abolition of capital punishment, who sang a hymn and a psalm ; a woman who had lived in the same street as Bentley ; a man who had attended the last fifteen such occasions, who said
"Nice fresh June morning and a little more sun, that’s what you want really " ; and four people who had taken a taxi from Birmingham in order to be there. Thus this relatively small crowd contained representatives of the types who used to flock to public hangings and burnings : those who used the event to protest against the law as it stood, and who tried to bring the condemned man some message of religion; those who derived a frisson from a macabre occasion ; those whose idle curiosity was not bridled by any and no doubt others who sense of embarrassment ; came to see what it was like, or because a friend had brought them, or because they thought it could not really happen, or because they were passing at the time and saw the crowd, or because they thought we had grown a lot too soft with criminals and things needed tightening up. None of these motives-except the first and the last, which can be defended by an intellectual level-deserves respect : because the country as a whole did not respect them that public executions were given up. Nevertheless it is clear that the same motives still operate, and would doubtless be manifest on a much larger scale if sanctioned and encouraged by public opinion. Restitution of public executions would suffice to restore the audiences.
argument and it
at
was