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SULPHATHIAZOLE IN IMPETIGO
511 the 1914-18 war. He reported it in an article on Gunshot Wounds and other Affections of the Chest In a subsequent published in The Lancet (1919, i, 697). " I therefore always letter (1926, i, 834) he wrote :
paste is applied to the lesions and allowed to dry. No covering is used. This procedure is carried out twice
an empyema to lie on the back, described, or on the side where the rib has been resected; both from the drainage point of view and for expansion of the lung" (italics mine). Those of us who know Mr. MacMahon’s work have always given him the credit for this original observation.
removed, but raw areas are " touched little of the paste. The scabs come off in from five to seven days leaving the area healed. I have probably been lucky, but so far I have seen no case of BRIAN LEES. LUMBAGO AND SCIATICA SiB,—While everyone must admire any coordinated efforts to throw light on the cause of such disabling affections as lumbago, I should like, as an intermittent sufferer, to sound a note of caution to enthusiasts ready to accept a single cause for this common ailment. Dr. Cyriax does not give any diagnostic criteria for his hypothesis of abnormality of a low lumbar intervertebral disk, except to say that radiology is of no use. He describes " agonisingly painful coughing " as a well-attested sign of intraspinal lesions. Apart from the word " agonising," which is almost pathognomonic of the hysteric, one can think of several other well-attested causes of pain in the back on coughing. What would influence me chiefly against so simple a hypothesis as he puts forward is the fact that the lumbar region is not the only seat of " rheumatic " pain. Bad as have been my attacks of lumbago, I have had worse attacks of intercostal pain, a painful, joint or two, and frequent stiff necks since childhood. Still, such disabilities are not crippling. After relative immobilisation of the painful muscles by strapping, with citrates and citric acid and occasional purges, I am much better than I was 20 years ago-even for lawn tennis. I should like to recommend to some enterprising editor a collection of articles entitled " The successful treatment of illness in ourselves," to be contributed by patients who are also doctors.
advise patients with as
GEOFFREY EVANS. GAS-GANGRENE SlE.,—We have read with great interest Dr. A. H. T. Robb-Smith’s article in your issue of Sept. 22 on the tissue changes induced by Cl. welchii type A filtrates. In this field our work has been essentially concerned with observations on the effects of these toxins on the lipid elements of a number of body tissues and fluids (Lancet, 1945, i, 457, 487), which forms a part of a more extensive investigation into the aetiology of fat-embolism which is London, Wl.
now
nearing completion.
The first sentence of the last paragraph of Dr. RobbSmith’s article might be thought to indicate that we attributed fat-embolism in guineapigs and rabbits, following injection of Cl. welchii toxin, to the splitting of lipoprotein complexes in the plasma. This is not the case. In fact, we have presented evidence showing the improbability of this origin of the embolic fat in these animals. Later in this paragraph Dr. Robb-Smith refers to the occurrence and significance of fat-embolism in human cases of gas-gangrene. The dangers of confusing post-mortem changes of fat distributionwithfat-embolism In all our animal experiments are, of course, obvious. extensive control groups were investigated and autopsy was carried out immediately. In our human cases autopsy was performed at the earliest possible moment .(in one case, uncomplicated by fracture, within two hours of death) ; there were no local signs of fat displacement by gas formation ; nor was there evidence of any extensive breakdown of blood lipoprotein complexes. The associated changes in the lung were compatible with the conception that the fat was embolic. We concluded, therefore, that fat-embolism had occurred in our animals, and in the human cases we were able to investigate. We agree with Dr. Robb-Smith that fat-embolism is probably only a contributory factor in the fatal outcome in cases of gas-gangrene. We were not able, however, to conclude from our limited number of cases what part fat-embolism might play in the production of the systemic reaction. We have regarded this particular variety of fat-embolism more as an index of the dispersal of a number of tissue breakdown products than as a separate entity. Because of this, and other observations, we suggested in our paper (194S’, i, 487) " that products of tissue breakdown may be a more important factor in the systemic reaction than circulating toxin "-a view expressed independently at the same time by Macfarlane and MacLennan. A. C. FRAZER. A. D. T. GOVAN. J. J. ELKES. W. T. COOKE. Birmingham. much interested to see the figures published by Brigadier MacKenna and Captain CooperWillis in your issue of Sept. 22. My own experience in treating several hundred cases of impetigo entirely supports their conclusions. In 1942 microcrystalline sulphathiazole (15%) was issued to commando troops to be used as a wound prophylactic. At that time we had a number of troublesome cases of impetigo in the unit, and I misappropriated one tube of this preparation as an experimental remedy. It proved far superior to any other I had tried, but as it, was in short supply I did not feel justified in continuing to use it for this purpose, and so tried ordinary’ sulphathiazole instead. The results were almost as good, and I have used the treatment exclusively ever since, both at home and abroad. The time required for cure has rarely exceeded a week. From the practical standpoint the treatment has been easy to apply. One tablet of sulphathiazole of standard make is made into a paste with some boiled water from my MI-room steriliser. Crusts are cleaned off, and the
SiB,—I
was
day for a couple of days, and thereafter once a day until weeping has ceased (usually the fourth day), after which a
the scabs up
"
are
not
daily with
a
-
-
--
MARTIN U. RAVEN.
Broadstairs.
HEALTH CENTRES
SIR,-Attempts at constructive discussion on health centres are frequently handicapped by the very varied, and often very nebulous, mental pictures different people have of what each means by a health centre. For this reason illustrated articles, such as the one you published last week, are to be welcomed, and I hope this article will be followed, whenever possible, by other suggestions of designs for possible centres. This present plan, however, can hardly be regarded as the last word in health-centre design, even if it is only meant as a temporary centre. As a matter of experience, temporary structures have an awkward habit of acquiring permanence, and it would be unwise to accept lower standards of building and equipment for them merely because they are intended to be temporary. Nor must it be forgotten that it will be upon the first centres built or adapted that the judgment both of the doctors and of their patients will be given as to the desirability of this new form of practice. This makes it doubly important not to begin with any scamped or illconceived design.
’
This present design, examined with these principles in mind, appears at once too extravagant and too scamped. It is extravagant (as you have already pointed out) in its use of land, and yet scamped in the accommodation it
each doctor and his patients. The centre seems to be designed to combine the publichealth provision of child-welfare, maternity, and dental services with that of a general-practitioner service employing at least 12 and possibly 16 doctors. X-ray, physiotherapy, and rehabilitation sections are also provided. Such a centre could not unreasonably be expected to serve an urban population of some 30,000 people. Indeed, it would not be economically possible to suggest at present such extensive provision for an appreciably smaller community. Yet the suggested layout requires a site of approximately 450 x 200 ft., and few towns now could afford to supply so large a site for a health centre in a position sufficiently central to be reasonably accessible to all the patients for whom it is intended. When we come to examine the sketch plan for the unit of doctors’ consulting-rooms, we find that little has been
provides for
paste is applied to the lesions and allowed to dry. No covering is used. This procedure is carried out twice
an empyema to lie on the back, described, or on the side where the rib has been resected; both from the drainage point of view and for expansion of the lung" (italics mine). Those of us who know Mr. MacMahon’s work have always given him the credit for this original observation.
removed, but raw areas are " touched little of the paste. The scabs come off in from five to seven days leaving the area healed. I have probably been lucky, but so far I have seen no case of BRIAN LEES. LUMBAGO AND SCIATICA SiB,—While everyone must admire any coordinated efforts to throw light on the cause of such disabling affections as lumbago, I should like, as an intermittent sufferer, to sound a note of caution to enthusiasts ready to accept a single cause for this common ailment. Dr. Cyriax does not give any diagnostic criteria for his hypothesis of abnormality of a low lumbar intervertebral disk, except to say that radiology is of no use. He describes " agonisingly painful coughing " as a well-attested sign of intraspinal lesions. Apart from the word " agonising," which is almost pathognomonic of the hysteric, one can think of several other well-attested causes of pain in the back on coughing. What would influence me chiefly against so simple a hypothesis as he puts forward is the fact that the lumbar region is not the only seat of " rheumatic " pain. Bad as have been my attacks of lumbago, I have had worse attacks of intercostal pain, a painful, joint or two, and frequent stiff necks since childhood. Still, such disabilities are not crippling. After relative immobilisation of the painful muscles by strapping, with citrates and citric acid and occasional purges, I am much better than I was 20 years ago-even for lawn tennis. I should like to recommend to some enterprising editor a collection of articles entitled " The successful treatment of illness in ourselves," to be contributed by patients who are also doctors.
advise patients with as
GEOFFREY EVANS. GAS-GANGRENE SlE.,—We have read with great interest Dr. A. H. T. Robb-Smith’s article in your issue of Sept. 22 on the tissue changes induced by Cl. welchii type A filtrates. In this field our work has been essentially concerned with observations on the effects of these toxins on the lipid elements of a number of body tissues and fluids (Lancet, 1945, i, 457, 487), which forms a part of a more extensive investigation into the aetiology of fat-embolism which is London, Wl.
now
nearing completion.
The first sentence of the last paragraph of Dr. RobbSmith’s article might be thought to indicate that we attributed fat-embolism in guineapigs and rabbits, following injection of Cl. welchii toxin, to the splitting of lipoprotein complexes in the plasma. This is not the case. In fact, we have presented evidence showing the improbability of this origin of the embolic fat in these animals. Later in this paragraph Dr. Robb-Smith refers to the occurrence and significance of fat-embolism in human cases of gas-gangrene. The dangers of confusing post-mortem changes of fat distributionwithfat-embolism In all our animal experiments are, of course, obvious. extensive control groups were investigated and autopsy was carried out immediately. In our human cases autopsy was performed at the earliest possible moment .(in one case, uncomplicated by fracture, within two hours of death) ; there were no local signs of fat displacement by gas formation ; nor was there evidence of any extensive breakdown of blood lipoprotein complexes. The associated changes in the lung were compatible with the conception that the fat was embolic. We concluded, therefore, that fat-embolism had occurred in our animals, and in the human cases we were able to investigate. We agree with Dr. Robb-Smith that fat-embolism is probably only a contributory factor in the fatal outcome in cases of gas-gangrene. We were not able, however, to conclude from our limited number of cases what part fat-embolism might play in the production of the systemic reaction. We have regarded this particular variety of fat-embolism more as an index of the dispersal of a number of tissue breakdown products than as a separate entity. Because of this, and other observations, we suggested in our paper (194S’, i, 487) " that products of tissue breakdown may be a more important factor in the systemic reaction than circulating toxin "-a view expressed independently at the same time by Macfarlane and MacLennan. A. C. FRAZER. A. D. T. GOVAN. J. J. ELKES. W. T. COOKE. Birmingham. much interested to see the figures published by Brigadier MacKenna and Captain CooperWillis in your issue of Sept. 22. My own experience in treating several hundred cases of impetigo entirely supports their conclusions. In 1942 microcrystalline sulphathiazole (15%) was issued to commando troops to be used as a wound prophylactic. At that time we had a number of troublesome cases of impetigo in the unit, and I misappropriated one tube of this preparation as an experimental remedy. It proved far superior to any other I had tried, but as it, was in short supply I did not feel justified in continuing to use it for this purpose, and so tried ordinary’ sulphathiazole instead. The results were almost as good, and I have used the treatment exclusively ever since, both at home and abroad. The time required for cure has rarely exceeded a week. From the practical standpoint the treatment has been easy to apply. One tablet of sulphathiazole of standard make is made into a paste with some boiled water from my MI-room steriliser. Crusts are cleaned off, and the
SiB,—I
was
day for a couple of days, and thereafter once a day until weeping has ceased (usually the fourth day), after which a
the scabs up
"
are
not
daily with
a
-
-
--
MARTIN U. RAVEN.
Broadstairs.
HEALTH CENTRES
SIR,-Attempts at constructive discussion on health centres are frequently handicapped by the very varied, and often very nebulous, mental pictures different people have of what each means by a health centre. For this reason illustrated articles, such as the one you published last week, are to be welcomed, and I hope this article will be followed, whenever possible, by other suggestions of designs for possible centres. This present plan, however, can hardly be regarded as the last word in health-centre design, even if it is only meant as a temporary centre. As a matter of experience, temporary structures have an awkward habit of acquiring permanence, and it would be unwise to accept lower standards of building and equipment for them merely because they are intended to be temporary. Nor must it be forgotten that it will be upon the first centres built or adapted that the judgment both of the doctors and of their patients will be given as to the desirability of this new form of practice. This makes it doubly important not to begin with any scamped or illconceived design.
’
This present design, examined with these principles in mind, appears at once too extravagant and too scamped. It is extravagant (as you have already pointed out) in its use of land, and yet scamped in the accommodation it
each doctor and his patients. The centre seems to be designed to combine the publichealth provision of child-welfare, maternity, and dental services with that of a general-practitioner service employing at least 12 and possibly 16 doctors. X-ray, physiotherapy, and rehabilitation sections are also provided. Such a centre could not unreasonably be expected to serve an urban population of some 30,000 people. Indeed, it would not be economically possible to suggest at present such extensive provision for an appreciably smaller community. Yet the suggested layout requires a site of approximately 450 x 200 ft., and few towns now could afford to supply so large a site for a health centre in a position sufficiently central to be reasonably accessible to all the patients for whom it is intended. When we come to examine the sketch plan for the unit of doctors’ consulting-rooms, we find that little has been
provides for