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TUBERCULOSIS OF THE LARYNX.
908 It needs as a means of controlling the outbreak. SCHOOL CLOSURE FOR INFECTIOUS of the casuist to draw any clear distinction something DISEASE. between the school medical officer acting on such a FROM time to time the parents of children away at basis and the headmaster of a boarding school who his school on account of infectious disease. boarding schools are agitated by the intimation
closes
that infectious disease has occurred at the school, Is there not scope for both to review their methods and that in consequence the school will be closed and to define the procedure which will make for the before the date on which the term should end. No greatest good of the children under their supervision ? doubt in individual and exceptional instances such a precaution as school closure may prove to be the smaller of two evils. We doubt, however, whether TUBERCULOSIS OF THE LARYNX. the occasions for its application are nearly as frequent as headmasters, through their own anxiety or through THE Medical Research Council has just published1 the cautious counsels of their medical advisers, would an instructive account by Sir STCLAIR THOMSON lead us to believe. of his experience of laryngeal tuberculosis at the The experience of the school medical service of this King Edward VII. Sanatorium at Midhurst over a country appears steadily to be crystallising in a form period of ten years. During this period 2541 cases opposed to the use of school closure as an instrumentt of pulmonary tuberculosis were admitted, and for the control of infectious disease. The arguments among them were 477 cases of tuberculous invasion which apply to the procedure in its relation to the of the larynx. The author adopted the public elementary schools, both urban and rural, in method of passing all his case-cards and notes happy to an this country seem to have special point in respect of Dr. D. A. HUTCHESON, who worker, independent boarding schools. The closure of the school involves compiled the figures, tables, and averages without a general dispersal of the occupants to families or any suggestion from anyone as to the conclusions communities, in many of which they will not be under which might be anticipated, thus avoiding to a very any degree of careful supervision ; the one original great extent the personal bias inevitable in all human focus of infection may thus multiply itself in a number The conclusions to be drawn from the of different localities. Had the school been kept open, undertakings. statistics thus analysed do not, as a whole, differ and had the daily medical and nursing supervision from the many similar figures which have been adequate, each fresh case as it arose could, in greatly been compiled. In one respect, however, previously most of the infectious diseases, have been detected there is a marked difference ; while numerous tables at a stage before infectiousness had developed to a to ten compiled up years ago show that laryngeal’ material degree. Moreover-and this is an aspect invasion was two to three times more common in which appeals to the long-suffering parent, though he men than in women, the Midhurst figures make the accepts the prevailing practice with singularly little incidence almost exactly equal. Sir STCLAIR THOMSON grumbling-the child would receive the term’s schooling points out that most of the women admitted to contracted for and paid for, but only in part received Midhurst are wage-earners who follow the same, or under conditions of premature closure. Undoubtedly as the men-viz., clerks, typists, similar, employments the present practice is based, not on closure as a true &c.-and concludes that any increased teachers, means of controlling infectious disease, but on the of the male is due to social, and not to lack of pains taken in many boarding schools to susceptibility differences. Before 1905 the post-mortem sexual, evolve an effective machinery for the daily super- records at the Brompton Hospital showed twice as vision of the health of the pupils. The happy-gocases of tuberculous laryngitis in men as in many lucky attitude which enters so much into the spirit women, but since 1908 the proportion has been almost of the recreations of the boarding school permeates identical ; the question arises, is this the result of the attitude of the principal and of the staff towards the of habits and occupation among women? the physical health of the inmates. Probably quite a For change the last five years of this investigation, involving small proportion of the masters have any knowledge 1456 notes were made of the condition of the symptoms and signs of infectious disease of thepatients, nares and pharynx ; the conclusion is that approaching that acquired by the elementary school affections of this region are no more common in teacher, while the school nurse, with a thorough those with laryngeal invasion than in those whose grounding in infectious disease, who is so closely disease is limited to the lungs ; also, though it would linked up with the public elementary school, is, on be to make a comparison of the nose and difficult the whole, distinctly more expert in this subject pharynx in sanatorium patients with an equal number than is the average matron at a boarding )f the public, the author’s impression is that We believethat some degree of concentration onroublehealthy in these regions is no more common in a this aspect of the control of infectious disease in ianatorium than out of it. Three cases of intrinsic residential schools would result in a material drop in (;ancer in phthisical patients provide interesting the frequency of premature closure. E’xamples of the difficulty of differential diagnosis. But while the experience of school medical officers 1Fhe author concludes that epithelioma of a vocal in the service of local authorities is in general increasciord is a very slow-growing tumour ; if it is so limited ingly unfavourable to closure as a preventive measure ,s to be difficult to recognise, a delay of two or three against the spread of disease, it must be confessed nonths in clearing up the diagnosis can do little harm. that their practice does not always march with their rj’here is also a case of aspergillosis of the lungs precept. It is not uncommon for school medical and larynx, theunique latter presenting a typical picture of officers to advise closure of an elementary uberculosis ; recovery was rapid under sanatorium department on account of infectious disease when the reatment. attendance drops to a low level-perhaps in So much for the pathology of laryngeal tuberculosis. neighbourhood of 50 per cent. of the normal-such rr’he chief feature, and the great value, of Sir STCLAIR closure being largely for the convenience of the educa- T’HOMSON’s lies in the emphasis laid on the report tion authority, and to save loss of grant from the rf3markable benefit which the tuberculous larynx Treasurv on account of low attendance rather than because the medical officer has any faith in closure t 1 Special Report Series, No. 83. H.M. Stationery Office. 2s. 6d. "
"
,
,
,.,
"
I
..,
’
school.
a
school;
thet
’
909 air, hundred experiments their best yield obtained by o,f control aqueous extraction was only a quarter of that regular by their alcohol process. Two causes of and tobacco. Th e obtained cough, and cessation of alcohol arise : (1) The inhibition of tryptic action; difficulty clinic in a town as seen tuberculous larynx, among (2) efficient separation of insulin from the relatively dwellers, is usually in a condition of general congestion enormous mass of protein. The authors state that the which makes it difficult to distinguish the deposits o:is first cause of loss was reduced, and the second diffidisease, angry granulations being bathed in abundaniculty completely overcome, by the method described pus. All this subsides in sanatorium without loca:1 by them in our columns. Summarised briefly, the treatment, and it soon becomes evident that 2() method consisted in extracting the pancreas with to 50 per cent. of the unhealthy appearances were1per cent. formic acid, and precipitating the proteins added conditions, the result of hygienic unrighteous-and insulin from the resulting solution by means of acid. The picrates were then extracted with ness. Practically all the laryngeal cases at Midhursttpicric acetone. This separates the insulin picrate from the were " put on whispers " ; the patient is told to speak proteins, the acetone dissolving out the former and only on the lips, and is warned against using a forced.l leaving the latter undissolved. The acetone solution whisper or speaking at all out of doors or at table. was then diluted with equal volumes of saturated Of the 477 laryngeal cases, 336 had no other specialaqueous picric acid and water, when the insulin treatment, and of these 50 cases were cured. Completepicrate separated. This was collected, washed, and silence, with the use of writing block and pencil, converted to the hydrochloride by Dudley’s method. is rightly recognised to be a severe measure; it was; The average yield by this method was in the neighbourreserved for recent and acute cases, especially of, hood of 300 rabbit-units per kilo of pancreas. This found to be difficult on a large scale the glottic margin, and only for such as offered a processtowas the time expended on the separation of the owing : fair prospect of cure ; it was seldom prescribed for solid pancreatic tissue in the first stage. Also, in a longer period than six months, for if the conditionview of later experiments, it became obvious that did not clear up within that time it was recognised about 40 per cent. of the yield was lost by the incom" " as unpromising and put on to whispers or, in plete precipitation of the picrate by dilution. In some cases, treated by the galvano-cautery. Silence order to improve the process it was necessary (1) to was prescribed for 67 patients, of whom 23 were include some powerful tryptic inhibition to the cured. The only active method of local treatment extracting substance; (2) to adopt the removal of the acetone by distillation, before precipitating the employed was galvano-cautery puncture ; this was picrate. Many substances are known to inhibit the used when the general conditions were favourable action of but the majority also act upon trypsin, and the spontaneous healing, after making progress, insulin and impair its activity. Paraldehyde is free appeared to be slow or stationary. Local anaesthesia from this objection, and its addition was found to be and the " indirect " method were always employed, advantageous. The modified method differs from two to six punctures were made at a sitting, and never that described in THE LANCET only in the addition more often than once a month. In all, 74 cases were of 5 per cent. of paraldehyde to the extracting fluid. considered suitable for this method of treatment, Although paraldehyde is immiscible with water in this an emulsion is formed on mincing and of these a cure was obtained in 46. Thus of the with proportion, the pancreas. The result of a typical experiment 477 cases of laryngeal tuberculosis, 119 (24-9 per cent.) was a yield of 535 rabbit-units per kilo, as compared were cured, 73 by restriction of voice use, and 46 by with 300 by the original process. As to distillation, cautery puncture, in addition to the sanatorium some investigations on the properties of the picrate regime. This is, as Sir STCLAIR THOMSON remarks, have shown the incompleteness of the precipitation from acetone solution obtained by the dilution a result which is very encouraging, when compared with Sir MORELL MACKENZIE’S statement of 50 years method. It was thus clear that an increased yield be obtained. as a result of distilling off the ago that " of all the cases that I have ever seen, acetone. This procedure was adopted with good I only know of four in which I have reason to believe and the next step was to combine both of results, that the disease was entirely arrested." The direction these modifications, and this was done, the yield of can be made lies chiefly a in which further typical experiment being equivalent to 1040 rabbitin earlier diagnosis and more prompt resort to sana- units from 1 kilo of pancreas. Although the results torium, and especially in a general recognition of obtained by this process were consistently good, and the fact that persistent hoarseness requires expert the time factor was reduced to two days, there was still the objection that the first filtration was troubleinvestigation. A comment upon a sentence in a some on a large scale, owing to the gelatinous nature our in columns is for this recent annotation curious, of the material. In view of the ready solubility of report lays stress on the difference between present- insulin picrate in 70 per cent. acetone and the day methods and results when compared with the insolubility of protein picrates, it was an important narrow outlook and hopeless results:of a generation ago. point to ascertain whether this preliminary aqueous extraction of the pancreas was necessary, and whether picrates could not be prepared simply by grinding
derives from sanatorium
regime, including good
rest, diminution of voice
use,
-
f
"
-
,
.
should
progress
I
pancreas with solid picric acid. The application of AN IMPROVED ACETONE-PICRATE PROCESS picric acid to the original tissue, as a step in the extraction of insulin, was discussed by the authors FOR INSULIN. with Dr. H. 11’. Dudley, who informed them that it CERTAIN modifications of the acetone-picrate was already under trial by him for fish islets. After process for the preparation of insulin, described by a series of experiments on these lines, the authors
Dr. E. C. Dodds and Dr. F. Dickens in THE LANCET evolved a method, of which full details ae given in of Feb. 16th, 1924, p. 330, have been published by the article, whereby the average yield of hydrochloride these authors in the April number of the British was equivalent to about 1000 rabbit-units from 1 kg. Journal of Experimental Pathology. That watery of pancreas, and had a rabbit-unit of 0-5 to 1 mg. extracts of the pancreas could yield active material In one experiment (Experiment 24), in which 8 kilos was known from the beginning of work on insulin, of pig pancreas were worked up by this method, since Banting and Best’s original method consisted the high yield of 3-690 g. was obtained, the rabbit-unit in a watery extraction of pancreas, and the first of which was 0-25mg., thus giving a total yield of preparation of active substance was obtained in this 14,760 rabbit-units, or 1845 rabbit-units per kg. of manner. When tried on a large scale, however, the pancreas. So far as the authors know, this is the yield was so poor as compared with the alcohol highest vield of insulin recorded. The authors’ extraction process that the method had to be comments on the method are as follows: 1. The use abandoned. Best and Scott state that out of some of solid picric acid not only renders the first tedious
’
closes
that infectious disease has occurred at the school, Is there not scope for both to review their methods and that in consequence the school will be closed and to define the procedure which will make for the before the date on which the term should end. No greatest good of the children under their supervision ? doubt in individual and exceptional instances such a precaution as school closure may prove to be the smaller of two evils. We doubt, however, whether TUBERCULOSIS OF THE LARYNX. the occasions for its application are nearly as frequent as headmasters, through their own anxiety or through THE Medical Research Council has just published1 the cautious counsels of their medical advisers, would an instructive account by Sir STCLAIR THOMSON lead us to believe. of his experience of laryngeal tuberculosis at the The experience of the school medical service of this King Edward VII. Sanatorium at Midhurst over a country appears steadily to be crystallising in a form period of ten years. During this period 2541 cases opposed to the use of school closure as an instrumentt of pulmonary tuberculosis were admitted, and for the control of infectious disease. The arguments among them were 477 cases of tuberculous invasion which apply to the procedure in its relation to the of the larynx. The author adopted the public elementary schools, both urban and rural, in method of passing all his case-cards and notes happy to an this country seem to have special point in respect of Dr. D. A. HUTCHESON, who worker, independent boarding schools. The closure of the school involves compiled the figures, tables, and averages without a general dispersal of the occupants to families or any suggestion from anyone as to the conclusions communities, in many of which they will not be under which might be anticipated, thus avoiding to a very any degree of careful supervision ; the one original great extent the personal bias inevitable in all human focus of infection may thus multiply itself in a number The conclusions to be drawn from the of different localities. Had the school been kept open, undertakings. statistics thus analysed do not, as a whole, differ and had the daily medical and nursing supervision from the many similar figures which have been adequate, each fresh case as it arose could, in greatly been compiled. In one respect, however, previously most of the infectious diseases, have been detected there is a marked difference ; while numerous tables at a stage before infectiousness had developed to a to ten compiled up years ago show that laryngeal’ material degree. Moreover-and this is an aspect invasion was two to three times more common in which appeals to the long-suffering parent, though he men than in women, the Midhurst figures make the accepts the prevailing practice with singularly little incidence almost exactly equal. Sir STCLAIR THOMSON grumbling-the child would receive the term’s schooling points out that most of the women admitted to contracted for and paid for, but only in part received Midhurst are wage-earners who follow the same, or under conditions of premature closure. Undoubtedly as the men-viz., clerks, typists, similar, employments the present practice is based, not on closure as a true &c.-and concludes that any increased teachers, means of controlling infectious disease, but on the of the male is due to social, and not to lack of pains taken in many boarding schools to susceptibility differences. Before 1905 the post-mortem sexual, evolve an effective machinery for the daily super- records at the Brompton Hospital showed twice as vision of the health of the pupils. The happy-gocases of tuberculous laryngitis in men as in many lucky attitude which enters so much into the spirit women, but since 1908 the proportion has been almost of the recreations of the boarding school permeates identical ; the question arises, is this the result of the attitude of the principal and of the staff towards the of habits and occupation among women? the physical health of the inmates. Probably quite a For change the last five years of this investigation, involving small proportion of the masters have any knowledge 1456 notes were made of the condition of the symptoms and signs of infectious disease of thepatients, nares and pharynx ; the conclusion is that approaching that acquired by the elementary school affections of this region are no more common in teacher, while the school nurse, with a thorough those with laryngeal invasion than in those whose grounding in infectious disease, who is so closely disease is limited to the lungs ; also, though it would linked up with the public elementary school, is, on be to make a comparison of the nose and difficult the whole, distinctly more expert in this subject pharynx in sanatorium patients with an equal number than is the average matron at a boarding )f the public, the author’s impression is that We believethat some degree of concentration onroublehealthy in these regions is no more common in a this aspect of the control of infectious disease in ianatorium than out of it. Three cases of intrinsic residential schools would result in a material drop in (;ancer in phthisical patients provide interesting the frequency of premature closure. E’xamples of the difficulty of differential diagnosis. But while the experience of school medical officers 1Fhe author concludes that epithelioma of a vocal in the service of local authorities is in general increasciord is a very slow-growing tumour ; if it is so limited ingly unfavourable to closure as a preventive measure ,s to be difficult to recognise, a delay of two or three against the spread of disease, it must be confessed nonths in clearing up the diagnosis can do little harm. that their practice does not always march with their rj’here is also a case of aspergillosis of the lungs precept. It is not uncommon for school medical and larynx, theunique latter presenting a typical picture of officers to advise closure of an elementary uberculosis ; recovery was rapid under sanatorium department on account of infectious disease when the reatment. attendance drops to a low level-perhaps in So much for the pathology of laryngeal tuberculosis. neighbourhood of 50 per cent. of the normal-such rr’he chief feature, and the great value, of Sir STCLAIR closure being largely for the convenience of the educa- T’HOMSON’s lies in the emphasis laid on the report tion authority, and to save loss of grant from the rf3markable benefit which the tuberculous larynx Treasurv on account of low attendance rather than because the medical officer has any faith in closure t 1 Special Report Series, No. 83. H.M. Stationery Office. 2s. 6d. "
"
,
,
,.,
"
I
..,
’
school.
a
school;
thet
’
909 air, hundred experiments their best yield obtained by o,f control aqueous extraction was only a quarter of that regular by their alcohol process. Two causes of and tobacco. Th e obtained cough, and cessation of alcohol arise : (1) The inhibition of tryptic action; difficulty clinic in a town as seen tuberculous larynx, among (2) efficient separation of insulin from the relatively dwellers, is usually in a condition of general congestion enormous mass of protein. The authors state that the which makes it difficult to distinguish the deposits o:is first cause of loss was reduced, and the second diffidisease, angry granulations being bathed in abundaniculty completely overcome, by the method described pus. All this subsides in sanatorium without loca:1 by them in our columns. Summarised briefly, the treatment, and it soon becomes evident that 2() method consisted in extracting the pancreas with to 50 per cent. of the unhealthy appearances were1per cent. formic acid, and precipitating the proteins added conditions, the result of hygienic unrighteous-and insulin from the resulting solution by means of acid. The picrates were then extracted with ness. Practically all the laryngeal cases at Midhursttpicric acetone. This separates the insulin picrate from the were " put on whispers " ; the patient is told to speak proteins, the acetone dissolving out the former and only on the lips, and is warned against using a forced.l leaving the latter undissolved. The acetone solution whisper or speaking at all out of doors or at table. was then diluted with equal volumes of saturated Of the 477 laryngeal cases, 336 had no other specialaqueous picric acid and water, when the insulin treatment, and of these 50 cases were cured. Completepicrate separated. This was collected, washed, and silence, with the use of writing block and pencil, converted to the hydrochloride by Dudley’s method. is rightly recognised to be a severe measure; it was; The average yield by this method was in the neighbourreserved for recent and acute cases, especially of, hood of 300 rabbit-units per kilo of pancreas. This found to be difficult on a large scale the glottic margin, and only for such as offered a processtowas the time expended on the separation of the owing : fair prospect of cure ; it was seldom prescribed for solid pancreatic tissue in the first stage. Also, in a longer period than six months, for if the conditionview of later experiments, it became obvious that did not clear up within that time it was recognised about 40 per cent. of the yield was lost by the incom" " as unpromising and put on to whispers or, in plete precipitation of the picrate by dilution. In some cases, treated by the galvano-cautery. Silence order to improve the process it was necessary (1) to was prescribed for 67 patients, of whom 23 were include some powerful tryptic inhibition to the cured. The only active method of local treatment extracting substance; (2) to adopt the removal of the acetone by distillation, before precipitating the employed was galvano-cautery puncture ; this was picrate. Many substances are known to inhibit the used when the general conditions were favourable action of but the majority also act upon trypsin, and the spontaneous healing, after making progress, insulin and impair its activity. Paraldehyde is free appeared to be slow or stationary. Local anaesthesia from this objection, and its addition was found to be and the " indirect " method were always employed, advantageous. The modified method differs from two to six punctures were made at a sitting, and never that described in THE LANCET only in the addition more often than once a month. In all, 74 cases were of 5 per cent. of paraldehyde to the extracting fluid. considered suitable for this method of treatment, Although paraldehyde is immiscible with water in this an emulsion is formed on mincing and of these a cure was obtained in 46. Thus of the with proportion, the pancreas. The result of a typical experiment 477 cases of laryngeal tuberculosis, 119 (24-9 per cent.) was a yield of 535 rabbit-units per kilo, as compared were cured, 73 by restriction of voice use, and 46 by with 300 by the original process. As to distillation, cautery puncture, in addition to the sanatorium some investigations on the properties of the picrate regime. This is, as Sir STCLAIR THOMSON remarks, have shown the incompleteness of the precipitation from acetone solution obtained by the dilution a result which is very encouraging, when compared with Sir MORELL MACKENZIE’S statement of 50 years method. It was thus clear that an increased yield be obtained. as a result of distilling off the ago that " of all the cases that I have ever seen, acetone. This procedure was adopted with good I only know of four in which I have reason to believe and the next step was to combine both of results, that the disease was entirely arrested." The direction these modifications, and this was done, the yield of can be made lies chiefly a in which further typical experiment being equivalent to 1040 rabbitin earlier diagnosis and more prompt resort to sana- units from 1 kilo of pancreas. Although the results torium, and especially in a general recognition of obtained by this process were consistently good, and the fact that persistent hoarseness requires expert the time factor was reduced to two days, there was still the objection that the first filtration was troubleinvestigation. A comment upon a sentence in a some on a large scale, owing to the gelatinous nature our in columns is for this recent annotation curious, of the material. In view of the ready solubility of report lays stress on the difference between present- insulin picrate in 70 per cent. acetone and the day methods and results when compared with the insolubility of protein picrates, it was an important narrow outlook and hopeless results:of a generation ago. point to ascertain whether this preliminary aqueous extraction of the pancreas was necessary, and whether picrates could not be prepared simply by grinding
derives from sanatorium
regime, including good
rest, diminution of voice
use,
-
f
"
-
,
.
should
progress
I
pancreas with solid picric acid. The application of AN IMPROVED ACETONE-PICRATE PROCESS picric acid to the original tissue, as a step in the extraction of insulin, was discussed by the authors FOR INSULIN. with Dr. H. 11’. Dudley, who informed them that it CERTAIN modifications of the acetone-picrate was already under trial by him for fish islets. After process for the preparation of insulin, described by a series of experiments on these lines, the authors
Dr. E. C. Dodds and Dr. F. Dickens in THE LANCET evolved a method, of which full details ae given in of Feb. 16th, 1924, p. 330, have been published by the article, whereby the average yield of hydrochloride these authors in the April number of the British was equivalent to about 1000 rabbit-units from 1 kg. Journal of Experimental Pathology. That watery of pancreas, and had a rabbit-unit of 0-5 to 1 mg. extracts of the pancreas could yield active material In one experiment (Experiment 24), in which 8 kilos was known from the beginning of work on insulin, of pig pancreas were worked up by this method, since Banting and Best’s original method consisted the high yield of 3-690 g. was obtained, the rabbit-unit in a watery extraction of pancreas, and the first of which was 0-25mg., thus giving a total yield of preparation of active substance was obtained in this 14,760 rabbit-units, or 1845 rabbit-units per kg. of manner. When tried on a large scale, however, the pancreas. So far as the authors know, this is the yield was so poor as compared with the alcohol highest vield of insulin recorded. The authors’ extraction process that the method had to be comments on the method are as follows: 1. The use abandoned. Best and Scott state that out of some of solid picric acid not only renders the first tedious
’