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Annotations

HOSPITAL APPOINTMENTSUp till now in non-teaching hospitals the appointment

of registrars has been the responsibility of the hospitalmanagement committee. But the posts of registrarand senior registrar are important steps in the trainingof consultants, and experience has shown that theuniversities, the medical schools, and postgraduateinstitutions could with advantage be drawn more closelyinto the task of selecting the right men for these jobs.A change in the present procedure would also, as we

suggested last year,l foster a healthy interchange betweenteaching and non-teaching hospitals and allow the

consultant-in-training to move more freely betweenthe hospitals in a region. On all these heads the transfercf’tfiesponsibility for these appointments to the regional:hospital boards 2 on Sept. 1 will therefore be welcome.The hospital management committees will, of course,

still-play an important part in selection and will continueip appoint the junior registrars. No change will bemade in the arrangements for the payment of the

registrars’ salaries in the present financial year., These registrar posts will not come within the scopeof the committees that advise the regional hospital boardson the appointment of consultants, and the Ministry islaying down- no precise machinery for making registrarappointments. It is suggested, however, that theselection might appropriately be made by a committeeconsisting of a standing nucleus of one medical and onelay member appointed by the regional hospital board,one lay member appointed by the board of governors,arid two medical members appointed by the university.To these, two or three members would be added by thehospital concerned, one of whom would normally be theregistrar’s future chief. A member of the specialtyconcerned would also be appointed by the regionalhospital board or by the university.Some smaller changes have been made in the procedure

for the appointment of fully fledged consultants,3 butthese mostly concern the powers and composition of theadvisory committees which submit recommendationsto the boards. Some of these appointments-such asof members of professorial units who receive no remunera-tion from hospital boards, some clinical teachers, someresearch-workers, retiring consultants continuing workin an honorary capacity, and distinguished visitors fromoverseas-will no longer be considered by these advisorycommittees, though the actual appointment will still bemade by the boards. The duration of the appointmentneed no longer be stated in an advertisement for oneof these senior posts. When there is no applicant ofconsultant standing the advisory committee may nolonger recommend that one of the candidates should beappointed with the grade of senior hospital medicalofficer. The constitution of these committees has alsobeen slightly varied-for a teaching hospital the com-mittee will now have 8 members. Members from outsidethe region who represent the specialty concerned will beappointed after consultation with one of the RoyalColleges.The procedure for the appointment of consultants was

designed with the laudable intention of preventinginbreeding. At the time we foresaw that it mightbring new difficulties to replace those it avoided ; andat least one London teaching hospital has found that amechanism which looks fair and easy on paper is in

practice clumsy and expensive in time, labour, and

money. The new constitution will do nothing to easethis administrative burden.

1. Lancet, 1949, ii, 949.2. S. I. 1950, no. 1260.3. S. I. 1950, no. 1259.4. Lancet, 1948, ii, 101.

THIOSEMICARBAZONE IN LEPROSYTHE German drug Tliioseiiii6atbaone" or 4-acjetyl-

aminobenzaldehyde thiosemicarbazone, is now beingextensively tested in the United States and this countryas a treatment for tuberculosis, in which it seems to beabout as active as p-amiiiosalicyli6 acid (r.A.s.). LikeP.A.s., too, it is being used both alone and as an adjunctto streptomycin. Since other drugs that inhibit the

growth of jtfyco. tuberculosis have proved effective againstthe closely similar acid-fast organism, fflyco. leprce,Dr. Gordon Ryrie, of the British Empire Leprosy ReliefAssociation, has undertaken a clinical trial of thiosemi-carbazone in leprosy. Of the 10 cases so far treated,8 were examples of the virulent lepromatous type andtwo had chronic tuberculoid leprosy. The preliminaryresults, reported on p. 286, seem promising, though,as Dr. Ryrie freely admits, the value of the drug cannotbe assessed after only four months’ study on 10 patients.All have improved clinically and most have shown somebacteriological improvement. In Dr. Ryrie’s opinionthey have improved more rapidly than they would havedone with sulphones, and there has been less mentaldepression. The dose of thiosemicarbazone, given bymouth in 25 mg. tablets of Messrs. Boots’s preparation’ Thiacetazone,’ was gradually increased to 150 mg.daily. At this dose-level no toxic effects were recorded,but the German workers have found the drug potentiallytoxic and have reported anorexia, malaise, headache,vomiting, anaemia, conjunctivitis, jaundice, and granulo-cytopenia in tuberculous patients given the drug for along period. The leprosy patients may have escapedside-effects because they were not treated long enoughand did not have a second course of the drug-somedrug reactions occur only when there has been a previouscourse to produce sensitisation. Toxic effects would beparticularly likely to arise in poorly nourished, anaemic,and infested lepers, and they may well be troublesomewhen a larger group of patients is treated.

AMBULANCESTHE free ambulance service provided under the

National Health Service Acts is operated in Englandand Wales by local health authorities, which recoverhalf of the cost from the Ministry of Health. In Scot-land, on the other hand, the service is operated entirelyby the Department of Health, and the whole cost isborne centrally ; the Select Committee on Estimates,in reviewing these services,2 points out that none of thecost falls on the Scottish ratepayers, and in effect " theambulance service in Scotland is mainly paid for bythe taxpayers of England and Wales."For the present financial year the total cost of the

ambulance services to the nation is estimated at

7,986,000. The cost is rising as the demand increases:in England and Wales the number of patients carriedin ambulances and sitting-case cars rose during 1949from 365,859 in January to 488,899 in December. TheSelect Committee finds that a large local health authorityneeds to maintain one ambulance or sitting-case car toabout 10,000 people ; but in a small and sparselypopulated area the proportion may be much higher-thus in December, 1949, Huntingdonshire required oneambulance or car for every 3765 of its population. For

England and Wales as a’whole about 10% of the popula-tion are transported in this way each year ; but hereagain local differences are wide. There are also widedifferences in running costs : among three authoritieswhich submitted evidence on this point, the cost permile run ranged from 2s. to 3s. The committee, while notadvocating more centralised control, suggests that theMinistry of Health should interest itself more " in the1. See leading article Lancet, 1950, i, 264.2. Third Report from the Select Committee on Estimates : Session

1950. Ambulance Services. H.M. Stationery Office. Pp. 99.4s.

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wide variations which exist in the services supplied bydifferent local health authorities." General criteria ofneed would help to check abuse. " It is clear," says thereport, " that the Ministry of Health are paying publicmoney to some local health authorities for ambulanceservices in circumstances where other local authoritiesfeel that they should not be provided and where they donot provide them." The Ministry should cooperate inironing out this unevenness ; after consultation it shouldcirculate rules for the use of ambulances. At present,one of the more striking differences is in the authorityrequired before the service may be used. The committeewas favourably impressed by the practice, followed insome parts, whereby drivers -are forbidden to carryanyone (except in an emergency) without a medicalcertificate, and it also applauds the London CountyCouncil’s general rule that hospitals rather than doctors

‘

should order ambulances ; in London this has preventedpatients being carried to hospitals where no bed is to behad. The committee recommends that, before admittinga patient from a distant place, hospitals should demanda certificate that the necessary treatment cannot reason-ably be obtained at a nearer hospital ; and that for longjourneys the railways might more often be used. Itseems that outpatients sometimes continue to be carriedto and from hospitals after they have become fit totravel by ordinary means. The report urges all largehospitals to appoint a transport officer, who will bedirectly responsible to the senior administrative officer.Finally, it proposes a tightening-up in the regulationsfor the use of the voluntary Hospital Car Service.

ANTIMALARIAL DRUGS

IT is not surprising that W.1l.O.’s expert committeeon malaria 1 finds that no existing antimalarial drughas all the desired qualities. Their ideal drug would bea causal prophylactic against all species of humanmalaria parasites, would have a definite curative valueand low toxicity, and would be cheap: If such a producthas not yet been produced, one must remember thatdifferent geographical strains of malaria parasitesdiffer in their reactions to both prophylaxis and therapy,and that the degree of premunition of the-host mayaffect their action. The efficacy of specific drugs is byno means the same everywhere.As the committee say, the treatment of malaria is

firmly connected in the public mind with the use of

quinine, and for malarial emergencies injections of

quinine are still generally recommended. The evidence

they adduce in favour of their opinion that certain

synthetic drugs may possibly be equally effective forthis purpose is not perhaps entirely satisfactory ; andthe same is true of the observations they quote onrestriction of the field of vision attributed to a toxicaction of quinine. These observations were made byCoatney et a1.2 in a United States penitentiary where5 white male volunteer prisoners took 0’5 g. quininesulphate daily, and 5 others 0-25 g., for twenty-fiveconsecutive days. Later 3 were found to have con-stricted visual fields ; but, as their eyes were not examinedbefore treatment, their vision may possibly have beenabnormal previously. Quinine amblyopia as such is

generally considered exceedingly rare, and this isolatedAmerican observation conflicts with experience in WestAfrica and other parts of the tropics where Europeanshave been in the habit of taking large doses of quinineover many years without untoward effect. In linkingquinine with the causation of blackwater fever, thecommittee have, of course, ample precedent. But itwould be wrong to assume that blackwater has dis-

1. Report on the third meeting of the committee. World HealthOrganisation, Geneva. Technical Report Series no. 8. May,1959. Pp. 48. 2s. 3d.

2. Coatney, G. R., Cooper; W. C., Ruhe, D. S. Amer. J. Hyg.1948, 47, 113.

appeared from West Africa since the almost universalapplication of mepacrine (atebrin), first as a causal

prophylactic and later as a remedy for subtertian malaria.There seems, in fact, to be no evidence that the incidenceof blackwater after quinine is greater than that aftermepacrine therapy.On mepacrine in general perhaps it would be true to

say that the committee tend to say more about its virtues

than its vices. Thus they do not comment on the riskof mental disturbances arising from the increasinglyhigh doses that have become customary since the war,or on the lichenoid eruptions of the skin it sometimesproduces. Their conclusions about chloroquine andclosely related compounds are necessarily rather vague,because relatively few systematic observations havebeen made on treatment with this drug ; but they allowthemselves to state that as a suppressant its action ieunsurpassed by any other. This is especially true inPlasmodium vivax infection, which can be completelysuppressed by giving 0-5 g. of chloroquine once a weekfor six months. Chloroquine does not stain the skin oreyes and seems to have no undesirable side-effects ; butit has a smaller margin of safety than proguanil (’ Palu-drine’) and is relatively expensive. On proguanil therenow seems to be some real unanimity. Its main meritis that it is a causal prophylactic against P. falciparurn-a property not possessed by quinine, mepacrine, or the4-aminoquinolines. Its therapeutic action differs indifferent parts of the world and in different races ; butall agree that it is slower in action than quinine,mepacrine, or chloroquine, and therefore cannot berelied on in the treatment of malarial emergencies wherespeed is essential. Moreover, when given alone, itcannot be relied on to cure infection by certain strains ofP. falciparum. Another disadvantage of proguanilis the ease with which malaria parasites become resistant.Apparently this resistance is increasing, especially inWest Africa. Of the various remedies considered.pamaquin and the related 8-aminoquinolines are the mosttoxic and hence have little practical application.Pamaquin appears to be the most poisonous, but is

closely followed by pentaquine and isopentaquine.The committee’s very thorough report also covers the

organisation of training, and antimalarial measures ingeneral, on all of which valuable advice is offered.

TUBERCLE BACILLI IN THE C.S.F.

THE finding of tubercle bacilli in the cerebrospinalfluid does not necessarily mean that there is a diffusetuberculous meningitis. McGregor and Green in 1937cultured tubercle bacilli from the c.s.F. of patients withprimary tuberculosis in whom there was no clinical orpathological evidence of meningitis. They also demon-strated by animal inoculation the presence of tuberclebacilli in the c.s.F. of three patients with positive tuber-culin skin tests and the clinical picture of meningealirritation, without evidence of tuberculosis elsewhere.Lincoln in 1947 drew attention to the occurrence of" serous tuberculous meningitis

"

during the course of aprimary infection. Tubercle bacilli were not found in thec.s.F. in her cases. The fluid was under increased

pressure and its cell-count was raised, but it was other-wise normal. In two patients who died after recoveryfrom the meningitis, post-mortem examination showedhealed non-specinc meningitis. The view that caseoustuberculous meningitis arises by rupture of corticalfoci into the subarachnoid space was put forward in1933 by Rich and AleCordock.3 Lincoln suggested thatthe clinical picture in

" serous tuberculous meningitis

"

was due to perifocal reactions around unrupturedtuberculous lesions in the brain.

1. McGregor. A. R., Green, S. A. J. Path. Bact. 1937, 45, 613.2. Lincoln, E. M. Amer. Rev. Tuberc. 1947, 56, 95.3. Rich, A. R., McCordock, H. A. Bull. Johns Hopk. Hosp. 1933,

52, 5.