SULPHANILAMIDE IN TYPHOID FEVER

1401

LETTERS

TO THE EDITOR

SULPHANILAMIDE IN TYPHOID FEVER

SiB,—In your last issue Dr. Harries and his

colleagues describe the treatment of seven cases of typhoid fever with the sulphonamides-sulphanilamide and M. & B. 693. Although they are cautious in making claims for this treatment, the impression to be gained from their article is that sulphonamides should be used in similar cases. Thus they state that sulphanilamide can exercise a bacteriostatic effect on B. typhosus in the blood-stream, though from the next sentence it seems that the reference is actually to M. & B. 693 (which is not sulphanilamide). I have seen two patients with typhoid fever who had been treated, the one with sulphanilamide, the other with M. & B. 693, before the establishment of the diagnosis. The first was a man aged 75 years, whose symptoms started on Dec. 28, 1928. He was given sulphanilamide, 3 grammes daily, from Jan. 8 to 16. The

temperature throughout this period varied from 101° to 103° F., and the general condition, including the development of nocturnal delirium, was exactly that which would be expected at this stage of the disease. I advised withdrawal of the drug. The

fever lasted for five weeks and recovery followed. A more striking instance of the uselessness of sulphonamides for typhoid fever was presented by a female aged 43, whose first symptoms arose on Dec. 8, 1938. She was given M. & B. 693 in 1-gram.m.e doses five times daily from Dec. 14 to 23 inclusive. For the first twenty-four hours of this treatment the temperature fell from 103°to 990; and then it rose to a daily swing of 101° to 104°. Blood taken on Dec. 20 and 23, when she was saturated with M. & B. 693, and was deeply cyanosed as a result, gave positive cultures of typhoid bacilli. The illness was a severe one, the pyrexia lasting for seven weeks. Here then are two instances in which sulphonamide treatment, even in large doses, was powerless to influence the course of typhoid fever. In view of the great natural variations in the manifestations of the disease, I question whether a case has been made out for the employment of drugs which are by no means devoid of danger. I am, Sir, yours faithfully, A. H. DOUTHWAITE. Harley Street, W.1, June 12. THE APPENDIX MASS

SiR,—Mr. McNeill Love in his article on the appendix mass in your issue of June 3 raised the perennial but extremely important question of treatment. In my own opinion the " mass " due to an inflamed retrocsecal appendix is the only one which can be treated expectantly with any safety. It is due to the induration of the caecal wall, and the appendix is " as a rule well " shut off from the general peritoneal cavity. This is the commonest position in which to find the appendix at the subsequent interval operation. Where the appendix is not in this position the " mass " is formed by adherent omentum and coils of small bowel, and is lying in the general peritoneal cavity or in the pelvis. In these cases I believe great risk is incurred in adopting expectant treatment. The main difficulty is the correct diagnosis of the origin of the " mass," and if this is appendiceal, of the position of the appendix. The latter may be known from a previous barium meal or enema examination. The character of the symptoms and signs, which I have discussed fully elsewhere, may

retrocaecal position. When a patient is after the third day of the attack and has a palpable " mass " in the right iliac fossa, and the evidence is in favour of retroeaecal appendicitis, but without signs of suppuration, then expectant treatment rather than immediate operation is advisable, except in children. If the appendix perforates, a retroc2ecal abscess

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forms, which, as a rule, readily localises ; but spread to the subphrenic region is possible and a perforation near the base of the appendix may result in immediate general peritonitis. If the evidence points to the presence of or the development of a localised retrocaecal abscess (leucocytosis, true rigidity in the loin, palpably 11 mass" in the right iliac fossa), then operation is generally indicated; but great care is necessary in estimating the optimum time for interference, especially in middle-aged and elderly patients. These are often surprisingly well, especially if not seen until 7-10 days after the onset of the attack; yet simple drainage of their abscess may end fatally owing to such complications as secondary heamorrhage, paralytic ileus and portal pyaemia. Although the appendix is undoubtedly the commonest source of a " mass " in the right iliac fossa, yet occasionally errors in diagnosis are made. Apart from the difficulty of subsequent explanation to the friends and relatives, the prognosis may be affected adversely by the delay. I have found the following conditions, admittedly rare, simulating an appendix mass : (1) inflamed Meckel’s diverticulum ; (2) inflamed solitary diverticulum of the caecum ; (3) tuberculoma of the ileum ; (4) tuberculous hyperplastic caecal tumour; (5) abscess of external iliac lymphatic glands. I am, Sir, yours faithfully, Harley Street, W.1, June 12.

CAMERON MACLEOD.

THE PROBLEM OF MEDICAL LITERATURE

SIR,-No-one can deny that the present state of medical literature is simply chaotic, nor is there any prospect of improvement. The general problem is nobody’s business and so it drags on with the result that thousands of pounds are wasted and there is much delay in bringing the fruits of research to the

public benefit. Take the position of the average doctor who has idea and wants to find out what has been done the subject already. If he has been able to afford five guineas he writes to the Royal Society of Medicine and asks the question. The non-medical librarians of this excellent institution consult the Cumulative Index and the Surgeon-General’s Catalogue, both American publications, and in due course a list of possibly some hundreds of references arrives. They are in all manner of languages; some are relevant, many are not. He next tries to find where the journals are and he will, if he is lucky enough to locate them at all, find they are scattered all over the libraries of Britain ; some are already on loan, some are in libraries which do not lend. He will discover that many libraries take in the same journals and that most have had to restrict their intake to what they can afford. They continue the old classics because they do not wish to spoil their existing sets. Having obtained a journal-which journal may be in Hungarian-he has to find a translator and having had it translated he may find that the paper is not relevant after all. And so he goes on until any enthusiasm he has had becomes melted. Too often an on