- Email: [email protected]
RESISTANCE TO THE TUBERCLE BACILLUS
232 fall
as
low
as
2 litres per minute. The cardiovascular course, different from the lining of the
endothelium is, of
mouth and is completely insensitive, the subject being any subjective sensation with a catheter in situ. If the catheter tip presses on any point inside the heart, premature beats may be induced; but on slight withdrawal to the middle of the chamber these cease and there is not the -slightest disturbance of contractile function. Remarks on power " and performance are mere verbal quibbling. We try to measure the observablenamely, changes in minute-volume of the circulation and in the degree of venous congestion. We cannot draw any conclusions on the significance of changes in strokevolume, which is a dependent variable resulting from rate and minute output change. We at least know what we mean by change in minute-output, and restoration of this towards the normal is one reliable guide to clinical inmrovement. Postgraduate Medical School of R. I. S. BAYLISS London, W.12. J. MCMICHAEL. unaware of
"
"
"
HEAT CRAMPS
Sin,—With reference to Dr. Ladell’s letter of Jan. 21, I think that the adrenal cortex may be involved but not in the almost immediate relief following intravenous medication. This almost instantaneous easement must, I think, be due to an effect on the motor end-plate(s) or nerve-supply of the voluntary-muscle focus. St. Margaret’s Hospital, Epping, Essex.
FRANK MARSH.
PLACEMENT MEDICAL EXAMINATIONS
SiR,-Recent correspondence prompts me to add a point of view regarding medical examination of
further
for civilian employment. In the interests of industrial morale -and personal contentment, it is most desirable that faithful workers should be confident of their management’s ability to find alternative employment for them if they become permanently unfit for their normal work on account of old age, sickness, or injury. It is wrong for a worker to give the best years of his life to his firm and then be thrown out when he ceases to be fully efficient. In this factory, where most of the men engaged on production are unskilled or semiskilled, and do heavy shift work, the number of jobs available for the aged or infirm is regrettably small. We actually have waiting-lists of our own men who have been recommended by their doctors for light or permanent day work. As long as we continue this policy of filling vacancies in comparatively light unskilled jobs by a process of internal transfer, the only unskilled outsiders we require are those who are capable of heavy shift work ; and they must show every sign of remaining fit for this work for years. We wish to avoid requests for transfer on medical grounds within a few months of starting work, because more often than not in such cases we are unable to comply, and the unfortunate employee leaves, to the annoyance of all concerned. This may explain why some applicants are rejected by the doctor after being approved by non-medical officials. The actual number thus rejected is small, and utterly insignificant compared with the total turned away. At the present moment applicants outnumber vacancies by roughly five to one. R. N. WILSON British Insulated Callender’s
applicants
Cables
Ltd., Prescot,
Lancs.
Assistant Medical Officer.
SiR,-Sometimes a particular instance, rather than generalities, makes it easier to judge a situation more clearly. Would Dr. Todd1 be happy to be a passenger in
a
ship in which one of the 1.
quartermasters had
Todd, J. W. Lancet, 1949, ii, 1229.
a
visual
of 6/36, with a colour-defective navigating officer bridge with him, and where the chief engineer had recently recovered from an attack of hypertensive encephalopathy ? This situation might easily arise if anyone who had previously done a particular job, and felt himself still to be capable of continuing with it, were allowed to do so with no medical screening." As for the individual’s personal liberty, it is surely recognised that in any society some liberties have to be sacrificed for the well-being of the whole.
acuity on
the
"
The
Shipping Federation Ltd., London, E.1.
ALAN WATSON.
EXFOLIATIVE DERMATITIS COMPLICATING
STREPTOMYCIN THERAPY have read with interest the article of Jan. 21 SIR,-I Dr. Harris and Dr. Walley, and note the similarity by between their case and those upon which I have reported.l Since that time a further three cases showing dermatitis, sore tongue, and cheilosis have occurred in this hospital. The incidence of these manifestations of vitamin-B deficiency in this hospital alone is now about 3% of all cases receiving streptomycin. I do not include the skin eruptions, relieved by the administration of ’Benadryl,’ which are much more common but of relatively little importance and certainly do not warrant reconsideration of the advisability of continuing streptomycin administration. The last three cases were rapidly controlled by the administration of’Benerva Compound,’ containing in each tablet 1 mg. of aneurin, 1 mg. of riboflavin, and 15 mg. of nicotinic acid ; three tablets were given thrice daily. Since January, 1949, it has been our policy to administer benerva compound or ’Becosym ’ (Roche) to all patients whether receiving streptomycin therapy or not. No further cases have arisen since then. The reference in my article to the reduction in intestinal organisms by streptomycin administration as an exciting cause of clinical vitamin-B deficiency is shortly to be followed by a more complete report from one of my
colleagues. Harefield Hospital, Middx.
JOHN SUMNER.
RESISTANCE TO THE TUBERCLE BACILLUS
SiR,-As reported in your last issue the British Tuberculosis Association debated on Jan. 20 the following resolution : " That infection, though necessary, is not the major factor in the prevalence of tuberculosis." For lack of time, I could not say all I would have liked to say in support of the motion, and for this I seek the hospitality of your columns. Mass radiography discovers individuals who have always enjoyed good health although their lungs are studded with calcified lesions, which might be the result of successive infections rapidly overcome by resistant tissues. Some of these individuals give a history that one or other parent and one or more brothers or sisters died of pulmonary tuberculosis This raises the question why, after presumably the same exposure to infection, some should survive and others die. Those of us who support the motion would like to know what substance is present or absent in the tissues of those who succumb to tuberculosis. Three years ago a fourth storey was being added to the tuberculosis dispensary at San Sebastian, and the tuberculosis officer told me that in this flat there would be three beds and all the necessary apparatus for investigating the metabolism of tuberculous patients. This seemed a promising line of research. There is also a psychical factor, and most clinicians will agree with Dr. Lionel Houghton who pointed out that anxiety will lower resistance to the tubercle bacillus. There is also the well-established 1.
Tubercle, 1949, 30, 62.
233
fact that in the insane and in mental defectives tuberculosis runs a very sluggish course, as if in harmony with the sluggish faculties of the mind. Those who opposed the motion thought it was futile to attempt to assess the relative importance of seed and soil in the aetiology of tuberculosis. They ignored the case-histories of identical twins which suggest that the soil is the predominating factor in the development of tuberculosis. In my view, little more knowledge can be gained by further research on the tubercle bacillus ; especially since observations by the late Dr. Galenthat, in A.D. 80, those who associated with tuberculous patients were more liable than others to contract the disease-have now been confirmed in the Prophit report. Those of us who support the motion realise that our ignorance of what constitutes resistance is abysmal. Of natural immunity we know no more than the physicians of 1850. Therefore I have said that when Koch discovered the tubercle bacillus, he put the clock back. For this epigram I am regarded as a heretic by those who cannot see beyond the present bacteriological era in medicine. Birmingham Mass HALLIDAY SUTHERLAND. Radiography Centre.
VITAMIN E
SiR,-In their letter of Jan. 7, Dr. W. E. and Mr. E. V. Shute state that we have emphasised the powers of vitamin E as a physiological and safe anticoagulant. This conclusion is a most unfortunate misinterpretation of our communication and imputes to us a suggestion which was neither stated nor implied in our report.1 Despite much careful and thoughtful work the role of the tocopherols in physiological processes is still obscure. Oonclusions regarding their function should be drawn only on the basis of the most rigorously proved observations. Speculations are welcome but should not masquerade as anything more substantial. K. L. ZIERLER D. GROB The Johns Hopkins Hospital, J. L. LILIENTHAL, jun. Baltimore. THE SOCIAL ADAPTATION OF INSTITUTION CHILDREN
,,iR,-Last 0 week’s article by Dr. Bodman and others bases important deductions about the hereditary factor in child maladjustment upon a table of constitutional factors in relatives which merits very close study. The general trend of studies suggesting that the attitudes, and even the apparent intelligence, of institutional children can be environmentally modified does not, of course, rule out the genetic element in maladjustment, but it may lead us to restrict its role. One of the problems of assessing family background is the extreme difficulty of getting unbiased information about " good " homes, and on this score the table seems suspect. Children who are handed over to institutional care bring with them details of delinquency and insanity in the family based on reports by trained or semitrained observers. There is a greatly reduced opportunity for " a social cover-up." The information about the control population in this paper appears to be drawn from sources such as school records based upon interview, and it would be interesting to hear further details of its reliability. Suspicion is strengthened by the fact that the incidence of neurosis and " insanity " in test and control groups show an inverse correlation, while no antisocial individuals are detected in the control group. A certain unavoidable element of selection is likely to be introduced into any series of this kind : testimony that " uncle was a bad lot," or that a relative has been 1. Zierler, K. L., Grob, D., Lilienthal, J. L. jun. 1948, 153, 127.
Amer. J.
Physiol.
freely forthcoming in any case which or is investigated by child-welfare in the better home-group, psychoses organisations : are readily softened to nerves, and- delinquency to " put away "
comes
to
is
court,
"
"
" whereabouts unknown." One would like to ask the authors whether, and to what extent, this factor has proved controllable in their series. ’
Physiology Department, London Hospital, E.1.
ALEX COMFORT.
ARMY MEDICINE IN THE LATE WAR
of statement :
SIR,-In discussing the treatment Dr. Toddmakes the
following
amcebiasis,
"
The difficulties of assessing the value of a remedy for such a disease are very considerable even when it is given alone, and when numerous remedies are given simultaneously are even greater. So far as I know, nobody has yet published the necessary large-scale controlled series in which alternate cases are given a standard combination of remedies and the others this combination plus the preparation to be tested." Much of the information sought by Dr. Todd is to be found in two papers published by us in 1949.23 In these papers we have recorded the effect of most of the drugs .
in use in amcebiasis, given singly and in combination to African patients all of whom suffered from acute amoebic dysentery. In all cases diagnosis and progress were checked by serial sigmoidoscopy and by stool examinations. All cases showed : (1) ulceration of the colon ; and (2) actively motile Entarnaeba histolytica in stools or scrapings. Most of the series in which each drug or combination of drugs was tested numbered 50. In all, the records of some 600 cases were analysed. A .very brief summary of these results is given below. For the sake of objectivity and brevity, we are recording here only the absolute success and failure rates. The latter is the percentage of patients who still showed ulceration and actively motile amoebae twenty days after the institution of a test drug. The discrepancy in the percentages is made up of doubtful " cases in which open but healing ulcers were still present, but which showed no amoebae in stools or scrapings. Unfortunately these figures give no information of the relapse-rate
commonly
"
since follow-up
was impossible. They are an indication immediate cure and failure rates in African with an unusually severe and acute form of the .. disease. An abbreviated table is set out below :
only of patients
1. Todd, J. W. Lancet, 1949, ii, 1143. 2. Armstrong, T. G., Wilmot, A. J., Elsdon-Dew, R. Trans. R. Soc. trop. Med. Hyg. 1949, 42, 597. 3. Armstrong, T. G., Elsdon-Dew, R., Marot, R. J. S. Afr. med. J. 1949, 23, 369.
as
low
as
2 litres per minute. The cardiovascular course, different from the lining of the
endothelium is, of
mouth and is completely insensitive, the subject being any subjective sensation with a catheter in situ. If the catheter tip presses on any point inside the heart, premature beats may be induced; but on slight withdrawal to the middle of the chamber these cease and there is not the -slightest disturbance of contractile function. Remarks on power " and performance are mere verbal quibbling. We try to measure the observablenamely, changes in minute-volume of the circulation and in the degree of venous congestion. We cannot draw any conclusions on the significance of changes in strokevolume, which is a dependent variable resulting from rate and minute output change. We at least know what we mean by change in minute-output, and restoration of this towards the normal is one reliable guide to clinical inmrovement. Postgraduate Medical School of R. I. S. BAYLISS London, W.12. J. MCMICHAEL. unaware of
"
"
"
HEAT CRAMPS
Sin,—With reference to Dr. Ladell’s letter of Jan. 21, I think that the adrenal cortex may be involved but not in the almost immediate relief following intravenous medication. This almost instantaneous easement must, I think, be due to an effect on the motor end-plate(s) or nerve-supply of the voluntary-muscle focus. St. Margaret’s Hospital, Epping, Essex.
FRANK MARSH.
PLACEMENT MEDICAL EXAMINATIONS
SiR,-Recent correspondence prompts me to add a point of view regarding medical examination of
further
for civilian employment. In the interests of industrial morale -and personal contentment, it is most desirable that faithful workers should be confident of their management’s ability to find alternative employment for them if they become permanently unfit for their normal work on account of old age, sickness, or injury. It is wrong for a worker to give the best years of his life to his firm and then be thrown out when he ceases to be fully efficient. In this factory, where most of the men engaged on production are unskilled or semiskilled, and do heavy shift work, the number of jobs available for the aged or infirm is regrettably small. We actually have waiting-lists of our own men who have been recommended by their doctors for light or permanent day work. As long as we continue this policy of filling vacancies in comparatively light unskilled jobs by a process of internal transfer, the only unskilled outsiders we require are those who are capable of heavy shift work ; and they must show every sign of remaining fit for this work for years. We wish to avoid requests for transfer on medical grounds within a few months of starting work, because more often than not in such cases we are unable to comply, and the unfortunate employee leaves, to the annoyance of all concerned. This may explain why some applicants are rejected by the doctor after being approved by non-medical officials. The actual number thus rejected is small, and utterly insignificant compared with the total turned away. At the present moment applicants outnumber vacancies by roughly five to one. R. N. WILSON British Insulated Callender’s
applicants
Cables
Ltd., Prescot,
Lancs.
Assistant Medical Officer.
SiR,-Sometimes a particular instance, rather than generalities, makes it easier to judge a situation more clearly. Would Dr. Todd1 be happy to be a passenger in
a
ship in which one of the 1.
quartermasters had
Todd, J. W. Lancet, 1949, ii, 1229.
a
visual
of 6/36, with a colour-defective navigating officer bridge with him, and where the chief engineer had recently recovered from an attack of hypertensive encephalopathy ? This situation might easily arise if anyone who had previously done a particular job, and felt himself still to be capable of continuing with it, were allowed to do so with no medical screening." As for the individual’s personal liberty, it is surely recognised that in any society some liberties have to be sacrificed for the well-being of the whole.
acuity on
the
"
The
Shipping Federation Ltd., London, E.1.
ALAN WATSON.
EXFOLIATIVE DERMATITIS COMPLICATING
STREPTOMYCIN THERAPY have read with interest the article of Jan. 21 SIR,-I Dr. Harris and Dr. Walley, and note the similarity by between their case and those upon which I have reported.l Since that time a further three cases showing dermatitis, sore tongue, and cheilosis have occurred in this hospital. The incidence of these manifestations of vitamin-B deficiency in this hospital alone is now about 3% of all cases receiving streptomycin. I do not include the skin eruptions, relieved by the administration of ’Benadryl,’ which are much more common but of relatively little importance and certainly do not warrant reconsideration of the advisability of continuing streptomycin administration. The last three cases were rapidly controlled by the administration of’Benerva Compound,’ containing in each tablet 1 mg. of aneurin, 1 mg. of riboflavin, and 15 mg. of nicotinic acid ; three tablets were given thrice daily. Since January, 1949, it has been our policy to administer benerva compound or ’Becosym ’ (Roche) to all patients whether receiving streptomycin therapy or not. No further cases have arisen since then. The reference in my article to the reduction in intestinal organisms by streptomycin administration as an exciting cause of clinical vitamin-B deficiency is shortly to be followed by a more complete report from one of my
colleagues. Harefield Hospital, Middx.
JOHN SUMNER.
RESISTANCE TO THE TUBERCLE BACILLUS
SiR,-As reported in your last issue the British Tuberculosis Association debated on Jan. 20 the following resolution : " That infection, though necessary, is not the major factor in the prevalence of tuberculosis." For lack of time, I could not say all I would have liked to say in support of the motion, and for this I seek the hospitality of your columns. Mass radiography discovers individuals who have always enjoyed good health although their lungs are studded with calcified lesions, which might be the result of successive infections rapidly overcome by resistant tissues. Some of these individuals give a history that one or other parent and one or more brothers or sisters died of pulmonary tuberculosis This raises the question why, after presumably the same exposure to infection, some should survive and others die. Those of us who support the motion would like to know what substance is present or absent in the tissues of those who succumb to tuberculosis. Three years ago a fourth storey was being added to the tuberculosis dispensary at San Sebastian, and the tuberculosis officer told me that in this flat there would be three beds and all the necessary apparatus for investigating the metabolism of tuberculous patients. This seemed a promising line of research. There is also a psychical factor, and most clinicians will agree with Dr. Lionel Houghton who pointed out that anxiety will lower resistance to the tubercle bacillus. There is also the well-established 1.
Tubercle, 1949, 30, 62.
233
fact that in the insane and in mental defectives tuberculosis runs a very sluggish course, as if in harmony with the sluggish faculties of the mind. Those who opposed the motion thought it was futile to attempt to assess the relative importance of seed and soil in the aetiology of tuberculosis. They ignored the case-histories of identical twins which suggest that the soil is the predominating factor in the development of tuberculosis. In my view, little more knowledge can be gained by further research on the tubercle bacillus ; especially since observations by the late Dr. Galenthat, in A.D. 80, those who associated with tuberculous patients were more liable than others to contract the disease-have now been confirmed in the Prophit report. Those of us who support the motion realise that our ignorance of what constitutes resistance is abysmal. Of natural immunity we know no more than the physicians of 1850. Therefore I have said that when Koch discovered the tubercle bacillus, he put the clock back. For this epigram I am regarded as a heretic by those who cannot see beyond the present bacteriological era in medicine. Birmingham Mass HALLIDAY SUTHERLAND. Radiography Centre.
VITAMIN E
SiR,-In their letter of Jan. 7, Dr. W. E. and Mr. E. V. Shute state that we have emphasised the powers of vitamin E as a physiological and safe anticoagulant. This conclusion is a most unfortunate misinterpretation of our communication and imputes to us a suggestion which was neither stated nor implied in our report.1 Despite much careful and thoughtful work the role of the tocopherols in physiological processes is still obscure. Oonclusions regarding their function should be drawn only on the basis of the most rigorously proved observations. Speculations are welcome but should not masquerade as anything more substantial. K. L. ZIERLER D. GROB The Johns Hopkins Hospital, J. L. LILIENTHAL, jun. Baltimore. THE SOCIAL ADAPTATION OF INSTITUTION CHILDREN
,,iR,-Last 0 week’s article by Dr. Bodman and others bases important deductions about the hereditary factor in child maladjustment upon a table of constitutional factors in relatives which merits very close study. The general trend of studies suggesting that the attitudes, and even the apparent intelligence, of institutional children can be environmentally modified does not, of course, rule out the genetic element in maladjustment, but it may lead us to restrict its role. One of the problems of assessing family background is the extreme difficulty of getting unbiased information about " good " homes, and on this score the table seems suspect. Children who are handed over to institutional care bring with them details of delinquency and insanity in the family based on reports by trained or semitrained observers. There is a greatly reduced opportunity for " a social cover-up." The information about the control population in this paper appears to be drawn from sources such as school records based upon interview, and it would be interesting to hear further details of its reliability. Suspicion is strengthened by the fact that the incidence of neurosis and " insanity " in test and control groups show an inverse correlation, while no antisocial individuals are detected in the control group. A certain unavoidable element of selection is likely to be introduced into any series of this kind : testimony that " uncle was a bad lot," or that a relative has been 1. Zierler, K. L., Grob, D., Lilienthal, J. L. jun. 1948, 153, 127.
Amer. J.
Physiol.
freely forthcoming in any case which or is investigated by child-welfare in the better home-group, psychoses organisations : are readily softened to nerves, and- delinquency to " put away "
comes
to
is
court,
"
"
" whereabouts unknown." One would like to ask the authors whether, and to what extent, this factor has proved controllable in their series. ’
Physiology Department, London Hospital, E.1.
ALEX COMFORT.
ARMY MEDICINE IN THE LATE WAR
of statement :
SIR,-In discussing the treatment Dr. Toddmakes the
following
amcebiasis,
"
The difficulties of assessing the value of a remedy for such a disease are very considerable even when it is given alone, and when numerous remedies are given simultaneously are even greater. So far as I know, nobody has yet published the necessary large-scale controlled series in which alternate cases are given a standard combination of remedies and the others this combination plus the preparation to be tested." Much of the information sought by Dr. Todd is to be found in two papers published by us in 1949.23 In these papers we have recorded the effect of most of the drugs .
in use in amcebiasis, given singly and in combination to African patients all of whom suffered from acute amoebic dysentery. In all cases diagnosis and progress were checked by serial sigmoidoscopy and by stool examinations. All cases showed : (1) ulceration of the colon ; and (2) actively motile Entarnaeba histolytica in stools or scrapings. Most of the series in which each drug or combination of drugs was tested numbered 50. In all, the records of some 600 cases were analysed. A .very brief summary of these results is given below. For the sake of objectivity and brevity, we are recording here only the absolute success and failure rates. The latter is the percentage of patients who still showed ulceration and actively motile amoebae twenty days after the institution of a test drug. The discrepancy in the percentages is made up of doubtful " cases in which open but healing ulcers were still present, but which showed no amoebae in stools or scrapings. Unfortunately these figures give no information of the relapse-rate
commonly
"
since follow-up
was impossible. They are an indication immediate cure and failure rates in African with an unusually severe and acute form of the .. disease. An abbreviated table is set out below :
only of patients
1. Todd, J. W. Lancet, 1949, ii, 1143. 2. Armstrong, T. G., Wilmot, A. J., Elsdon-Dew, R. Trans. R. Soc. trop. Med. Hyg. 1949, 42, 597. 3. Armstrong, T. G., Elsdon-Dew, R., Marot, R. J. S. Afr. med. J. 1949, 23, 369.