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SERUM AND SULPHAPYRIDINE
700
highly important questions at all times but especially so under blackout conditions. The screening of windows and skylights is bound to reduce ventilation to an undesirably low level unless special steps are taken to allow entry and exit of air. Various methods are here suggested. Under different varieties of undesirable environmental conditions accidents, too, have been found to increase, as they do also when the number of inexperienced workers rises. During the war the proportion of such workers is certain to go up and special supervision will therefore be called for, as well as methods for detecting the accidentprone and as far as possible placing them where they will do no harm to themselves or others. Such, in outline, is a report that should have a wide circulation, for the need at the moment is for application of knowledge previously gained rather than for new both
researches. Where recommendations are made which seem to war-time managers or employers impracticable or needing further research before they can be applied, or where new problems present themselves, the board hopes to be consulted at once. ANOTHER TEST FOR OBSTRUCTIVE JAUNDICE
THE
name
of biochemical tests intended to dis-
tinguish between obstructive and toxic or infective jaundice is legion. Most of them are based on some recognised function of the liver. Those in most common use are probably the van den Bergh reaction, the tests for bile in stool and urine, the galactosetolerance test, and lately the estimation of plasma phosphatase. The rationale behind these tests is fairly1 well understood. A new test emanating from France is not so well founded in theory, but it claims such a sharp differentiation between obstructive and toxic jaundice that it may prove a useful adjunct to the investigation of these cases. The blood-serum is heated with sulphuric acid and then phosphoric acid and vanillin are added. A colour develops which is of cases of obstructive with those of toxic and much less intense jaundice jaundice. The authors are not certain what substance or substances are responsible for the reaction, but they are in no doubt as to its clinical usefulness. So many claims have been made in the past, however, for tests for obstructive jaundice, that more information will be required, with trials by other investigators, before the "reaction sulpho-phospho-vanillique" can be regarded as of established value in the differential diagnosis of jaundice.
very intense with the
sera
SERUM AND SULPHAPYRIDINE
Two papers by Finland2 and colleagues at the Boston City Hospital serve, if only by repetition, to underline certain principles which may easily be forgotten in the clinical application of the sulphonamide group of drugs. Using blood-broth or denbrinated human and rabbit bloods as their media, to which were added 5 and 10 mg. per cent. of sulphapyridine, they confirmed earlier observations that whatever the number of pneumococci (they used types i, in and v) in the inoculation and whatever the concentration of the drug there is always a preliminary phase of growth of the organism, and, what is equally important, the organism must multiply before the drug can act. Afterwards the fate of the pneumococcus depends mainly on three factors-the size of the inoculum, the concentration of the drug, and the susceptibility of Charonnat, R. and Blanchard, J., Pr. méd. Feb. 13, 1940, p. 177. W. C. Spring, Jr., Lowell, F. C. and Finland, F. J. clin. Invest.
1. Chabrol, E.,
2.
January, 1940, p. 163 ; Finland, Spring p. 179.
and
Lowell, Ibid,
the strain-strains of the same type varying in sensiThe natural inferences are that a certain tivity. concentration of the drug in the blood (Finland suggests 5 mg. per cent.) is required to deal with a generalised infection, and that in severe septicaemias no amount of the drug will per se save the patient. The next point demonstrated was that sulphapyridine exerts its delayed bacteriostatic or bactericidal action on the pneumococcus in the presence of considerable amounts of the homologous specific polysaccharide, a substance which has a direct neutralising effect on antiserum. Thus the drug might be expected’to do good in the late stages of a pneumonia when antiAntiserum by serum is admittedly less effective. itself was found to have a rapid pneumococcidal action which was completed before the sulphapyridine began to act. Lastly, Finland confirmed the "summation" effect of serum and sulphapyridine when used together. These findings from in-vitro tests were confirmed by tests carried out on the blood of pneumonia patients under treatment with sulphapyridine or serum, and they substantiated the clinical impression that a combination of serum and sulphapyridine produces the most rapid amelioration of symptoms. No-one would suggest that every case of pneumonia should be treated with both remedies, but in severe infections, whether with the pneumococcus or other pathogen, there are firm grounds for using a combination of serum- and chemotherapy whenever possible, and at the moment this dictum is particularly applicable to epidemic cereThe drug seems to act directly brospinal fever. 3 on the organism or its enzymes (Prof. H. N. Green on thrown some its mode of whereas has action) light antiserum neutralises the toxins or specific substances of the organism. Together the two remedies pave the way for the third factor-the body’s natural defences -to complete the destruction of the invading
pathogen. IF EVACUATION
HAS COME TO STAY
ENGLAND has probably had more experience of evacuating children than any other country, for the
children of our so-called upper classes have traditionally spent the greater part of their childhood in boarding-schools. We may learn from this peculiarly English custom that children and parents will accept prolonged separation if the children live in communities where they are cared for and educated by professionals, where there is not the competition of " another home," and where there is opportunity for regular visits. Dr. Alison Glover (on p. 693) tells a convincing story of the success of the September evacuation, but the results of the new registration are said to be disappointing. Perhaps that is because we have begun at the wrong end. The best stimulus to evacuationshort of actual bombs-would be an improvement of conditions in the reception areas. In September people rose to the occasion and accepted household billeting as a temporary measure. As a permanent scheme it arouses resentment. The A.R.P. Co-ordinating Committee, of which Prof. J. B. S. Haldane, F.R.S., is chairman, in a memorandum to the Minister of Health and the President of the Board of Education stigmatises household billeting as the greatest single cause for the failure of evacuation. In this the committee put forward as an alternative plan that our unemployed builders should be set to work at once on a two-year programme to build camp schools for the older children, and nursery centres and hostels for the The committee have mothers and young children. estimated that this scheme would cost E104 million, 3. Brit. J. exp. Path.
February, 1940,
p. 38.
‘
highly important questions at all times but especially so under blackout conditions. The screening of windows and skylights is bound to reduce ventilation to an undesirably low level unless special steps are taken to allow entry and exit of air. Various methods are here suggested. Under different varieties of undesirable environmental conditions accidents, too, have been found to increase, as they do also when the number of inexperienced workers rises. During the war the proportion of such workers is certain to go up and special supervision will therefore be called for, as well as methods for detecting the accidentprone and as far as possible placing them where they will do no harm to themselves or others. Such, in outline, is a report that should have a wide circulation, for the need at the moment is for application of knowledge previously gained rather than for new both
researches. Where recommendations are made which seem to war-time managers or employers impracticable or needing further research before they can be applied, or where new problems present themselves, the board hopes to be consulted at once. ANOTHER TEST FOR OBSTRUCTIVE JAUNDICE
THE
name
of biochemical tests intended to dis-
tinguish between obstructive and toxic or infective jaundice is legion. Most of them are based on some recognised function of the liver. Those in most common use are probably the van den Bergh reaction, the tests for bile in stool and urine, the galactosetolerance test, and lately the estimation of plasma phosphatase. The rationale behind these tests is fairly1 well understood. A new test emanating from France is not so well founded in theory, but it claims such a sharp differentiation between obstructive and toxic jaundice that it may prove a useful adjunct to the investigation of these cases. The blood-serum is heated with sulphuric acid and then phosphoric acid and vanillin are added. A colour develops which is of cases of obstructive with those of toxic and much less intense jaundice jaundice. The authors are not certain what substance or substances are responsible for the reaction, but they are in no doubt as to its clinical usefulness. So many claims have been made in the past, however, for tests for obstructive jaundice, that more information will be required, with trials by other investigators, before the "reaction sulpho-phospho-vanillique" can be regarded as of established value in the differential diagnosis of jaundice.
very intense with the
sera
SERUM AND SULPHAPYRIDINE
Two papers by Finland2 and colleagues at the Boston City Hospital serve, if only by repetition, to underline certain principles which may easily be forgotten in the clinical application of the sulphonamide group of drugs. Using blood-broth or denbrinated human and rabbit bloods as their media, to which were added 5 and 10 mg. per cent. of sulphapyridine, they confirmed earlier observations that whatever the number of pneumococci (they used types i, in and v) in the inoculation and whatever the concentration of the drug there is always a preliminary phase of growth of the organism, and, what is equally important, the organism must multiply before the drug can act. Afterwards the fate of the pneumococcus depends mainly on three factors-the size of the inoculum, the concentration of the drug, and the susceptibility of Charonnat, R. and Blanchard, J., Pr. méd. Feb. 13, 1940, p. 177. W. C. Spring, Jr., Lowell, F. C. and Finland, F. J. clin. Invest.
1. Chabrol, E.,
2.
January, 1940, p. 163 ; Finland, Spring p. 179.
and
Lowell, Ibid,
the strain-strains of the same type varying in sensiThe natural inferences are that a certain tivity. concentration of the drug in the blood (Finland suggests 5 mg. per cent.) is required to deal with a generalised infection, and that in severe septicaemias no amount of the drug will per se save the patient. The next point demonstrated was that sulphapyridine exerts its delayed bacteriostatic or bactericidal action on the pneumococcus in the presence of considerable amounts of the homologous specific polysaccharide, a substance which has a direct neutralising effect on antiserum. Thus the drug might be expected’to do good in the late stages of a pneumonia when antiAntiserum by serum is admittedly less effective. itself was found to have a rapid pneumococcidal action which was completed before the sulphapyridine began to act. Lastly, Finland confirmed the "summation" effect of serum and sulphapyridine when used together. These findings from in-vitro tests were confirmed by tests carried out on the blood of pneumonia patients under treatment with sulphapyridine or serum, and they substantiated the clinical impression that a combination of serum and sulphapyridine produces the most rapid amelioration of symptoms. No-one would suggest that every case of pneumonia should be treated with both remedies, but in severe infections, whether with the pneumococcus or other pathogen, there are firm grounds for using a combination of serum- and chemotherapy whenever possible, and at the moment this dictum is particularly applicable to epidemic cereThe drug seems to act directly brospinal fever. 3 on the organism or its enzymes (Prof. H. N. Green on thrown some its mode of whereas has action) light antiserum neutralises the toxins or specific substances of the organism. Together the two remedies pave the way for the third factor-the body’s natural defences -to complete the destruction of the invading
pathogen. IF EVACUATION
HAS COME TO STAY
ENGLAND has probably had more experience of evacuating children than any other country, for the
children of our so-called upper classes have traditionally spent the greater part of their childhood in boarding-schools. We may learn from this peculiarly English custom that children and parents will accept prolonged separation if the children live in communities where they are cared for and educated by professionals, where there is not the competition of " another home," and where there is opportunity for regular visits. Dr. Alison Glover (on p. 693) tells a convincing story of the success of the September evacuation, but the results of the new registration are said to be disappointing. Perhaps that is because we have begun at the wrong end. The best stimulus to evacuationshort of actual bombs-would be an improvement of conditions in the reception areas. In September people rose to the occasion and accepted household billeting as a temporary measure. As a permanent scheme it arouses resentment. The A.R.P. Co-ordinating Committee, of which Prof. J. B. S. Haldane, F.R.S., is chairman, in a memorandum to the Minister of Health and the President of the Board of Education stigmatises household billeting as the greatest single cause for the failure of evacuation. In this the committee put forward as an alternative plan that our unemployed builders should be set to work at once on a two-year programme to build camp schools for the older children, and nursery centres and hostels for the The committee have mothers and young children. estimated that this scheme would cost E104 million, 3. Brit. J. exp. Path.
February, 1940,
p. 38.
‘