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SCOTTISH REGIONAL BOARDS
143
The
the organism was allowed to develop in the before treatment began, therefore, the greater the
longer
body subsequent immunity in the animals surviving. Infection of guineapigs and mice by subcutaneous inoculation with Past. pestis produces an infection closely resembling bubonic plague in man ; intraperitoneal inoculation results in a more acute type of infection, corresponding more closely to septicamic plague. According to Herbert, D. W. Henderson has produced lung infections in animals closely resembling pneumonic plague in man by exposing them to aerosols containing Past. pestis. In this type of infection streptomycin was also highly effective. One remarkable feature of streptomycin therapy in experimental plague is the good results obtained with short periods of treatment ; even single doses produce some effect. Sulphathiazole was also found by Herbert to be effective, but it had to be given If the results of these experiments over long periods. are applicable to man it seems that if streptomycin is going to be effective in human plague it must be given within a day or so of the onset, or at any rate very early. Owing to the relative scarcity and expense of the drug it ,is unlikely to be tried on a large scale for the treatment of plague yet awhile. At the moment the most successful readily obtainable remedy appears to be sulphadiazine, which is superior to the other sulphonamides for this purpose. This was established by extensive field trials carried out in India at Latur and Poona from 1940 to 1944 under the auspices of the Indian Research Fund Association.13 On the basis of experimental work reported by Sokhey and Dikshit 14 in these columns in 1940, over 1600 patients were treated with various sulphonamides. The group treated with sulphadiazine had the lowest mortality, 21 %, compared with 91 % in the control cases. The value of sulphadiazine in plague has also been demonstrated by other workers in India.1s FATTY HERNIATION IN LOW BACK PAIN IN 1944 Copeman and Ackerman 16 reported a series of cases in which low back pain appeared to be due to herniation of lobules of whatthey called " basic fat " through the superficial fascia in the region of the iliac crests. Such herniations, occurring at weak points, and symptomless until made turgid and cedematous -e.g., by injury or confinement to bed-they considered to be the cause of a proportion of low back disabilities, and a number of patients were relieved by their surgical excision. Herz 17 now reports 37 cases treated in this way with satisfactory results. He agrees that the of a tender nodule, injection of which with local anaesthetic relieves the’ pain, is diagnostic, and that later severe and long-standing pain ceases after the surgical removal of the protrusion. There are difficulties in the way of accepting this work without reservation. In the first place, there is a lack of anatomical evidence as to the existence of Copeman and Ackerman’s basic fat pattern. Secondly, as was mentioned in the discussion on Herz’s paper,18 subcutaneous fatty nodules are to be found in over 50% of persons not complaining of backache. Thirdly, the mere administration of a general anaesthetic for the removal of tender nodules will also, as Elliott 19 has shown, relieve the painful reflex foci of muscular spasm found in cases of low back pain and sciatica due to prolapsed intervertebral disks. Moreover, these views conflict with those of surgeons like Burns and Young,20 who believe that the prolapsed disk is the cause of most cases of persistent low back pain. This conflict is certainly no reason
discovery
13. 14. 15. 16. 17.
Sokhey, S. S., Wagle, P. M. Indian med. Gaz. 1946, 81, 343. Sokhey, S. S., Dikshit, B. B. Lancet, 1940, i, 1040. Simeons, A. T. W., Chhatre, K. D. Indian. med. Gaz. 1946, 81, 235. Copeman, W. S. C., Ackerman, W. L. Quart. J. Med. 1944, 13, 37. Herz, R. Ann. rheum. Dis. 1946, 5, 201. 18. Hench, P. Ibid, p. 205. 19. Elliott, F. A. Lancet, 1944, i, 47. 20. Burns, B. H., Young, R. H. Ibid, 1947, i, 623.
dismissing the evidence for fat herniation as a cause of symptoms, but it is essential to have detailed records of the physical and neurological findings in such cases. In one of the two cases Herz 17 mentions in detail, the referred pain in the leg, the hypoalgesia, wasting, and decreased reflexes might be attributed to disk prolapse, and the few months of relief recorded after general anaesthesia for the mass removal of a large quantity of fatty tissue is not conclusive. for
TREATMENT OF THE
DISSEMINATED SCLEROSIS
pittaiis awaiting
those who
seek
an
enective
treatment for disseminated sclerosis are now clearly mapped ; and in his Humphry Rolleston lectures at the Royal College of Physicians last week Prof. P. C. P. Cloake marked them anew. Despite his caution there seems to be real promise that the treatment which he has practised for the last 17 years is an advance on existing alternatives. Broadly, it is based on repeated courses of T.A.B. pyrotherapy along with alternating courses of intravenous organic arsenic and oral inorganic arsenic. These remedies, as Professor Cloake said, have been used before in disseminated sclerosis ; the novelty lies in his insistence that their administration must be continued for at least five if not ten years. Out of 422 cases observed, 312 have been followed up. Of 64 slight cases that received adequate treatment, 39 are today well, 20 are improved, and 5 are unchanged ; none is worse. Among the moderately severe cases, only 1 is materially worse. It is all too easy, as Professor Cloake indicated, to draw over-optimistic conclusions from these results ; for example, the patient who felt that he was not benefiting from treatment may not have stayed the course, and will thus have been lost to the follow-up. This does not alter the central fact that for all their deficiencies the figures seem better than those obtainable with other forms of treatment. SCOTTISH REGIONAL BOARDS
CHAIRMEN of the five regional hospital boards for Scotland have now been appointed. They are : Northern region, Mr..Donald Macpherson, convenor of Inverness public-health committee ; North-eastern region, Dr. May Baird, convenor of Aberdeen city public-health committee ; Eastern region, Mr. William Hughes, treasurer of Dundee corporation ; South-eastern region, Dr. J. R. Greenlees, chairman of the Royal Hospital for Sick Children, Edinburgh ; and Western region, Prof. E. P. Cathcart, F.R.S., recently retired from the chair of physiology in the University of Glasgow, and formerly chairman of the Scottish Health Services Committee. THE 17th International Physiological Congress, under the presidency of Sir Henry Dale, o.M., opened at Oxford last Monday. The meeting is being attended by nearly 1200 physiologists representing almost every country in the world except Germany and Japan. The congress has only twice before met in Britain-at Cambridge in 1898 and at Edinburgh in 1923. THE chief medical officer of the National Coal Board is to be Dr. E. H. CAPEL, of Birmingham. Details of the will be found in our news columns. Sir ARTHUR RUCKER has been appointed deputy executive secretary of the preparatory commission of the International Refugee Organisation. As deputy secretary to the Ministry of Health since 1940, he has taken a constructive part in the preparations of successive Governments for a National Health Service, and in discussions with representatives of the medical profession. To his new work he brings experience of relief and refugee administration gained in 1941-43 when seconded for special service as secretary to the office of the Minister of State in Cairo. In the preparatory commission his senior will be Mr. William Hallam Tuck, of the United States.
appointment
The
the organism was allowed to develop in the before treatment began, therefore, the greater the
longer
body subsequent immunity in the animals surviving. Infection of guineapigs and mice by subcutaneous inoculation with Past. pestis produces an infection closely resembling bubonic plague in man ; intraperitoneal inoculation results in a more acute type of infection, corresponding more closely to septicamic plague. According to Herbert, D. W. Henderson has produced lung infections in animals closely resembling pneumonic plague in man by exposing them to aerosols containing Past. pestis. In this type of infection streptomycin was also highly effective. One remarkable feature of streptomycin therapy in experimental plague is the good results obtained with short periods of treatment ; even single doses produce some effect. Sulphathiazole was also found by Herbert to be effective, but it had to be given If the results of these experiments over long periods. are applicable to man it seems that if streptomycin is going to be effective in human plague it must be given within a day or so of the onset, or at any rate very early. Owing to the relative scarcity and expense of the drug it ,is unlikely to be tried on a large scale for the treatment of plague yet awhile. At the moment the most successful readily obtainable remedy appears to be sulphadiazine, which is superior to the other sulphonamides for this purpose. This was established by extensive field trials carried out in India at Latur and Poona from 1940 to 1944 under the auspices of the Indian Research Fund Association.13 On the basis of experimental work reported by Sokhey and Dikshit 14 in these columns in 1940, over 1600 patients were treated with various sulphonamides. The group treated with sulphadiazine had the lowest mortality, 21 %, compared with 91 % in the control cases. The value of sulphadiazine in plague has also been demonstrated by other workers in India.1s FATTY HERNIATION IN LOW BACK PAIN IN 1944 Copeman and Ackerman 16 reported a series of cases in which low back pain appeared to be due to herniation of lobules of whatthey called " basic fat " through the superficial fascia in the region of the iliac crests. Such herniations, occurring at weak points, and symptomless until made turgid and cedematous -e.g., by injury or confinement to bed-they considered to be the cause of a proportion of low back disabilities, and a number of patients were relieved by their surgical excision. Herz 17 now reports 37 cases treated in this way with satisfactory results. He agrees that the of a tender nodule, injection of which with local anaesthetic relieves the’ pain, is diagnostic, and that later severe and long-standing pain ceases after the surgical removal of the protrusion. There are difficulties in the way of accepting this work without reservation. In the first place, there is a lack of anatomical evidence as to the existence of Copeman and Ackerman’s basic fat pattern. Secondly, as was mentioned in the discussion on Herz’s paper,18 subcutaneous fatty nodules are to be found in over 50% of persons not complaining of backache. Thirdly, the mere administration of a general anaesthetic for the removal of tender nodules will also, as Elliott 19 has shown, relieve the painful reflex foci of muscular spasm found in cases of low back pain and sciatica due to prolapsed intervertebral disks. Moreover, these views conflict with those of surgeons like Burns and Young,20 who believe that the prolapsed disk is the cause of most cases of persistent low back pain. This conflict is certainly no reason
discovery
13. 14. 15. 16. 17.
Sokhey, S. S., Wagle, P. M. Indian med. Gaz. 1946, 81, 343. Sokhey, S. S., Dikshit, B. B. Lancet, 1940, i, 1040. Simeons, A. T. W., Chhatre, K. D. Indian. med. Gaz. 1946, 81, 235. Copeman, W. S. C., Ackerman, W. L. Quart. J. Med. 1944, 13, 37. Herz, R. Ann. rheum. Dis. 1946, 5, 201. 18. Hench, P. Ibid, p. 205. 19. Elliott, F. A. Lancet, 1944, i, 47. 20. Burns, B. H., Young, R. H. Ibid, 1947, i, 623.
dismissing the evidence for fat herniation as a cause of symptoms, but it is essential to have detailed records of the physical and neurological findings in such cases. In one of the two cases Herz 17 mentions in detail, the referred pain in the leg, the hypoalgesia, wasting, and decreased reflexes might be attributed to disk prolapse, and the few months of relief recorded after general anaesthesia for the mass removal of a large quantity of fatty tissue is not conclusive. for
TREATMENT OF THE
DISSEMINATED SCLEROSIS
pittaiis awaiting
those who
seek
an
enective
treatment for disseminated sclerosis are now clearly mapped ; and in his Humphry Rolleston lectures at the Royal College of Physicians last week Prof. P. C. P. Cloake marked them anew. Despite his caution there seems to be real promise that the treatment which he has practised for the last 17 years is an advance on existing alternatives. Broadly, it is based on repeated courses of T.A.B. pyrotherapy along with alternating courses of intravenous organic arsenic and oral inorganic arsenic. These remedies, as Professor Cloake said, have been used before in disseminated sclerosis ; the novelty lies in his insistence that their administration must be continued for at least five if not ten years. Out of 422 cases observed, 312 have been followed up. Of 64 slight cases that received adequate treatment, 39 are today well, 20 are improved, and 5 are unchanged ; none is worse. Among the moderately severe cases, only 1 is materially worse. It is all too easy, as Professor Cloake indicated, to draw over-optimistic conclusions from these results ; for example, the patient who felt that he was not benefiting from treatment may not have stayed the course, and will thus have been lost to the follow-up. This does not alter the central fact that for all their deficiencies the figures seem better than those obtainable with other forms of treatment. SCOTTISH REGIONAL BOARDS
CHAIRMEN of the five regional hospital boards for Scotland have now been appointed. They are : Northern region, Mr..Donald Macpherson, convenor of Inverness public-health committee ; North-eastern region, Dr. May Baird, convenor of Aberdeen city public-health committee ; Eastern region, Mr. William Hughes, treasurer of Dundee corporation ; South-eastern region, Dr. J. R. Greenlees, chairman of the Royal Hospital for Sick Children, Edinburgh ; and Western region, Prof. E. P. Cathcart, F.R.S., recently retired from the chair of physiology in the University of Glasgow, and formerly chairman of the Scottish Health Services Committee. THE 17th International Physiological Congress, under the presidency of Sir Henry Dale, o.M., opened at Oxford last Monday. The meeting is being attended by nearly 1200 physiologists representing almost every country in the world except Germany and Japan. The congress has only twice before met in Britain-at Cambridge in 1898 and at Edinburgh in 1923. THE chief medical officer of the National Coal Board is to be Dr. E. H. CAPEL, of Birmingham. Details of the will be found in our news columns. Sir ARTHUR RUCKER has been appointed deputy executive secretary of the preparatory commission of the International Refugee Organisation. As deputy secretary to the Ministry of Health since 1940, he has taken a constructive part in the preparations of successive Governments for a National Health Service, and in discussions with representatives of the medical profession. To his new work he brings experience of relief and refugee administration gained in 1941-43 when seconded for special service as secretary to the office of the Minister of State in Cairo. In the preparatory commission his senior will be Mr. William Hallam Tuck, of the United States.
appointment