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months, and an equal number were used as controls. Sosuccessful were the results that the streptococcal infec-tion-rate was reduced by 85%, and in the treated groupthere was only 1 case of rheumatic fever for every 14among the controls. Since these latest figures haveappeared, the feeling among workers in the United Statesis that sulphadiazine is at present the drug of choice, butthat sulphamerazine may eventually supersede it.

DOSAGE

This varied in the different series from 0-6 g. to 3-0 g.daily. In the naval experiment, the patients beingadults, sulphadiazine 1 g. was given daily in two dosesof 0-5 g. Thomas 2 found 1 g. daily of sulphanilamidea suitable dose. Chandler and Taussig 8 treated a groupof children with sulphanilamide 0.6 g. daily, and toxicreactions were few and mild.

LENGTH OF TREATMENT

All investigators agree that prophylaxis must continueas long as relapses are likely-i.e., until adolescence.This will involve taking the drug in most cases for aminimum period of five years and probably longer. Inthe early series the drug was given only during the wintermonths, but Thomas 2 encountered relapses during thesummer and later elected to give the drug all the yearround. Protection was not prolonged after cessation oftreatment, and patients again became liable to relapse.

CONTRA-INDICATIONS TO PROLONGED THERAPY

The toxic manifestations could be divided into twogroups, minor and major. The first consisted of rashes,fever, gastro-intestinal disturbances, and moderateleucopenia, which did not in most cases necessitatestopping treatment. The only major toxic effectencountered was agranulocytosis. These symptomsappeared only during the early weeks of treatment,between the 14th and 49th days; none was observed onceBhis danger period was passed. It was quite common tofind a leucopenia of 2500-4500 per c.cm., with or withouta relative granulocytopenia, during the early weeks, whichsubsequently returned to normal without interruptingtreatment. Severe degrees of agranulocytosis were

sometimes preceded by other toxic symptoms but alsodeveloped without warning and seemed to be unrelated tothe dosage of the drug. Stowell and Button found thetoxic effects more troublesome than did other workers ;half their patients had to give up treatment during thefirst year and 9 out of 32 during the first two months ofthe second year. They also reported 1 death fromagranulocytosis. This is the only death recorded inthese studies. They concluded that this form of therapywas too dangerous to be continued.The toxic manifestations of sulphadiazine used in the

naval experiments were not severe : 0-3-0-6% of patientsdeveloped mild transient reactions, such as skin erup-tions ; serious symptoms, such as exfoliative dermatitisand agranulocytosis, were exceedingly rare. Statistic-ally therefore the danger from toxic reactions is verysmall. French and Weller 9 found changes in the heartmuscle in patients who died shortly after taking sulphon-amides in therapeutic doses. These changes consistedof perivascular infiltration with eosinophil cells through-out the myocardium. Bearing in mind the possibleeffects on the heart muscle, Hansen et al.5 took repeatedelectrocardiograms on prophylactically treated anduntreated children. They found no evidence thatsulphanilamide produced any deleterious effect on

the electrocardiogram ; in fact many tracings showedimprovement during treatment.

PRECAUTIONS TO BE TAKEN

The choice of suitable subjects for treatment was foundto be important ; only those who are willing and able toattend clinics regularly should be chosen for prophylactictherapy. Treatment should not be started until theacute attack of rheumatic fever has subsided, but it isnot necessary to wait for the sedimentation-rate tobecome normal. It was found desirable to start adminis-tering the drug a few days before the patient left hospitalor convalescent home, as a relapse often quickly followedreturn to the old environment.

9. French, A. J., Weller, C. V. Amer. J. Path. 1942, 18, 109.

In the naval experiment it was noticed that recruits inpoor general health suffered more from toxic manifesta-tions than did the seasoned personnel ; it is thereforenecessary to attend to the patients’ nutrition and generalwell-being while under treatment.

Blood-counts and haemoglobin estirnations were madefrequently during the early weeks, but later were requiredmuch less often. If toxic reactions of any degree ofseverity arose, treatment was temporarily discontinued,and on starting it again it was found advisable to beginwith a dose as small as 0-3 g. daily, increasing graduallyup to the full maintenance required. It was also sug-gested that this might be the best way to initiatetreatment in all cases.

CONCLUSIONS

There seems to be no doubt that sulphonamides are ofreal value in the prophylactic treatment of rheumaticfever. The real problem is whether the difficulties in theprolonged administration of a toxic drug outweigh theproven advantages. We feel that the reports herereviewed are so promising as to encourage the promotionof similar trials in this country. Sulphamezathine, adrug effective against the haemolytic streptococcus, is theleast toxic of the sulphonamide drugs so far used overhere, and might therefore be employed with advantage.

SUMMARY

The prophylactic use of the sulphonamides in rheumaticfever as carried out in the United States is described.The results of six trials involving 500 patient-seasons

show a relapse-rate of 1-2% compared with 19-8% in 500controls. Sulphanilamide was used in almost all cases.It was concluded that therapy must be continued untiladolescence, probably for a minimum period of five years.The toxic effects generally were mild ; there was 1

death from agranulocytosis, but 4 deaths took place inthe same series among untreated controls.Some figures from the United States Naval programme

using prophylactic sulphadiazine for recruits are cited.

AFTER-TREATMENT OF HEAD INJURY

THE Nuffield Provincial Hospitals Trust, the Ministryof Pensions, and the Radcliffe Infirmary, Oxford, haveduring the past eighteen months been considering thepossibility of devising some scheme to deal with theafter-treatment of head-injury cases, and they havenow issued the following statement. The Nuffield Trustand the Radcliffe Infirmary have become ’interested inthis subject because of the large share taken by membersof their staffs in the work done at the Military Hospitalfor Head Injuries at St. Hugh’s, Oxford. The interestof the Ministry of Pensions flows naturally from itsresponsibility for the treatment of disability arisingfrom the war, and includes cases of head injury treatedat special centres of the Emergency Hospital Scheme aswell as those treated in military hospitals.As a result of modern neurosurgery and chemo-

therapy, men with brain wounds have survived this warwho formerly would have died. Many have regainedmuch of their lost brain function ; speech, sight, andmental faculties have returned, paralysed limbs havemoved again. These results have not been achievedwithout courage and perseverance on the part of thepatients, a favourable environment, and the guidanceand help of a skilled team of workers. But neverthelessrecovery is often incomplete, and sometimes the perma-nent disability is severe. Inability to cope with ordinaryconditions when they return to civilian life, coupled withthe fear of being a drag on their families, causes suchpatients anxiety, disappointment, and frustration.

If these men are to make their contribution to the

community within the limitations imposed on them bytheir disabilities, their physical, mental, and vocationalcapacities for work must be accurately assessed whilethey are in hospital. Liter, they must be given facilitiesfor simple training in various forms of work, which aremore advanced than occupational therapy and theref(remore likely to satisfy their anxiety to be useful. Finally,for the gravely disabled, a permanent centre must beprovided which will give medical care and treatmenttogether with appropriate and selected forms of usefulwork and activities, in and around which these men

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can live with their families under the protection whichthey need.

The Ministry of Pensions recognises that head-injurypatients comprise a group for which special provisionmust be made. In addition to the routine treatmentwhich the Ministry will provide, there is need for researchinto the best methods of rehabilitation and into otherproblems of head injuries. To carry out this researchwork the Radcliffe Infirmary, with the aid of the dona-tion of 220,000 from the Nuffield Provincial HospitalsTrust, has appointed a neurologist,who will work in closecollaboration with the departments of Oxford Universitywhich are already studying lesions of the nervous system.One of his primary duties will be to provide specialisedassistance and advice to the Ministry of Pensions. Bythese means the latest methods of treatment will bemade available for pensioners.As was announced in these columns on lTOV. 3 (p.

584), the holder of this appointment is Dr. W. RitchieRussell, FRCP, who before the war was lecturer inneurology at Edinburgh University and during the warworked at the Military Hospital for Head Injuries, Oxford.

GENERAL MEDICAL COUNCILWINTER SESSION, NOVEMBER 27-30

AT the conclusion of the President’s address, reportedin these columns last week, a vote of thanks was proposedby Prof. SYDNEY SMITH and seconded by Dr. J. W.BONE. Prof. R. M. F. PicKEN was introduced as

representative of the University of Wales for one year.The name of William Laird was restored to the

Dentists Register after penal erasure.Penal Cases

The Council considered a recommendation by theDental Board that the name of Colin Newton, registeredas of 2, Wigan Road, Ormskirk (Dentists Act, 1921),should be erased from the Dentists Register. TheBoard had found that he had fraudulently claimed sumsamounting to about ;f:4 by dental letters to approvedsocieties for anaesthetics purporting to have been givenby his brother but really given by himself. Mr. Newtondid not appear before the Council, on the ground of illhealth, but was represented by Mr. Samuel Bieber,solicitor, of Manchester, who said that Mr. Newton hadnot gained personally by the fraud and that the docu-ments had been signed some months after the work wascarried out. The offence was due to carelessness andnot deliberate deception. The Council directed theregistrar to erase Mr. Newton’s name.Ewen L01.’at Fraser, registered as of 130, Goring Road,

Worthing, Sussex, LRCPE (1928), appeared before theCouncil in accordance with a decision made in Novem-ber, 1943, when judgment was suspended for two years.The Council now decided that they would not direct theerasure of his name.Graham George Robertson, registered as of 25, Mariners

Lane, Tynemouth, MB Edin. (1934), appeared beforethe Council in consequence of a decision in May, 1944,when judgment was postponed for a year. The Councilpostponed their decision for another year.Ronald Alexander Paton, registered as of 36, Lulworth

Road, Birkdale, Southport, LRCPE (1927), appearedcharged with having undergone during the last thirteenyears fcur convictions involving drunkenness, two ofthem while in charge of a motor-car. He was accom-panied by Mr. Lester Davidson, solicitor, of Liverpool,who said that Dr. Paton remembered very little of thecharges in 1932 and 1939. Since 1938 he had sufferedfrom diabetes, and at the time of the third charge in1943 he had been suffering from severe nervous depres-sion and insomnia after his ship had been torpedoed andhe had been taken prisoner. He had incurred the fourthcharge through drinking too much just before he wentto sea at a time when many ships were being sunk by theenemy. Dr. Paton himself said that on the third andfourth occasions he had been suffering from overdoses ofinsulin. He produced testimonials from the chief officerof his ship and from a medical practitioner. He saidhe had abstained from alcohol for the last six months.The Council decided not to erase his name.John Gray Gilmour, registered as of 188, Hyndland

Road, Glasgow, W2, MB Glasg. (1920), appeared inconsequence of four convictions for drunkenness, two

of them while in charge of a motor-car. Mr. OswaldHempson, solicitor, who accompanied him, said that Dr.Gilmour had suffered from domestic unhappiness andhad been obliged to give up general practice during thewar as he had been unable to drive his car under blackoutconditions. The Council decided that his name shouldnot be erased.John Corboy, registered as of Willoughbys, Astley,

Manchester, MB NUI (1939), appeared for two convic-tions this year of driving a motor-car under the influenceof drink. He pleaded that he was not used to alcoholand was sensitive to it. The Council postponed judg-ment for a year subject to the usual provisos.

Bernard Maguire, registered as of 366, WilbrahamRoad, Chorlton, Manchester, MB NUI (1927), appearedfor two similar convictions, one last year and one thisyear. He said he had suffered from an anxiety neurosisbut was now cured, and he would not be overworked nowthat his partner had returned. Judgment was post-poned for two years.

NO PROFESSIONAL RELATIONSHIP

The case of Charles Gibson Auld, registered as of Sunny-mead, Bromsgrove, Worcs., MB Edin. (1921), whoappeared on the charge of abusing professional relation-ship by committing adultery with Mrs. Mabel BlakewayAdie. The complainant was her former husband,Mr. P. C. Adie. The couple were divorced this year,with Dr. Auld as co-respondent. He was accompaniedbefore the Council by Mr. G. Russell Vick, KC, andMr. A. A. Pereira, of counsel, instructed by Messrs.Evershed and Tomkinson, solicitors, of Birmingham.Mr. Adie was represented by Mr. Leslie Tucker, solici-

tor, of Messrs. Tyndall, Nichols and Hadfield, who saidthat the adultery was not disputed. Mrs. Adie had beena VAD nurse at Bromsgrove Cottage Hospital where Dr.Auld was an honorary member of the staff. Theevidence of professional relationship was that Dr. Auldhad treated her for a sprained ankle, and had advisedand performed the operation of curettage. Mr. Adieknew nothing of their association until the end ofJanuary, 1944, when she went away with Dr. Auld. InFebruary the three made an undertaking by which Mrs.Adie and Dr. Auld promised to hold no communicationfor six months, and Mr. Adie to take no proceedings.The lovers had kept this undertaking until August,when Dr. Auld was ordered overseas and, after difficultyin finding her address, had met her to say goodbye, andinformed the husband’s solicitors. She was now livingwith him as his wife, and had changed her name to his bydeed poll. Mr. Adie admitted in evidence that he hadsaid he " would smash Dr. Auld," but declared that hewas not vindictive and now did not care, but consideredit his duty to put the facts before the Council. Hiswife had throughout had her own regular medicalattendant ; she had consulted Dr. Auld about the

sprained ankle to avoid a long motor journey to herhome. The curettage was performed with his approval.

Dr. Auld said in evidence that he had been woundedoverseas and lost a leg. He had first met Mrs. Adiewhen both were serving at the hospital, and a year and ahalf later had met her socially at her house. Intimacyhad begun about six months after this time, and therelationship was a permanent one. The bandaging of thesprained ankle was an isolated incident, and Mrs. Adiehad consulted him about her pelvic symptoms as a lovernot as a doctor. He had not sent in an account.The Council found that no professional relationship

had existed between the respondent and Mrs. Adie, andthat therefore he had not been guilty of "infamousconduct."

RestorationThe Council restored the following names to the Medical

Register after penal erasure : Humphrey Manly Hamil-ton Ashwin, John Black, Patrick Joseph Conlin, AlanGray, William Lyle Paterson, and William AlexanderStevenson Welsh.

CommitteesMost of the Council’s educational work was done in

private session this autumn, but the chairman of thePharmacopoeia Committee (Prof. DAVID CAMPBELL)reported the sale to date of over 135,000 copies of theBritish Pharmacopoeia and its addenda. The new edi-tion could not, he said, be ready for several months yet.