954

mite, not unlike our own " harvester " that picnicparties encounter in the September corn stubble, butpicked up in the tropics by walking through thelalang grass. The overgrown rubber plantations arenow being cleared after the Japanese occupation,and the disease, always endemic, is being encounteredagain among the native workers. So far 25 patientshave been treated with the drug, while a controlgroup of 12 untreated cases have been observedduring the same period. The treated and untreatedcome from the same areas and in some cases fromthe same plantations, so the strains of R. tsutsugamushiare likely to be of similar virulence. The mean agesof the two groups-an important factor in any typhusinfection-were the same. The diagnosis was provedin each instance, either by recovering the rickettsiafrom the blood or by demonstrating satisfactorytitres for agglutination against an OXK strain ofProteus. In the treated group nobody developedcomplications or died ; the average duration of feverafter the first dose was 31 hours, and the average total

febrile period 7.5 days ; one man, treated on the 3rd dayof the disease, was discharged for light work on the9th day after onset. In the untreated group of 12,2 patients developed serious complications and 1 ofthese died, while the mean duration of fever was18-1 days. The chloromycetin was given by mouth,initially in large doses; but these were graduallyreduced, and the last 7 cases were given the drugfor only 24 hours, receiving a total of 6 g., with anequally satisfactory response. Half the patients weretreated on estate hospitals where nursing conditionsare necessarily somewhat primitive.To those who have had experience of scrub typhus

in the Burma campaign these results will be morethan striking ; they will alter the whole pictureof a disease. From the laboratory work it is not toomuch to hope that this new antibiotic will proveequally effective against other rickettsial diseases.If so, the future history of the typhus group ofdiseases will depend on how far the demand forchloromycetin can be met.

Annotations

TREATMENT OF ARTERIAL EMBOLISM

ARTERIAL embolism is a complication of cardiac orvascular disease, and its effects depend on the site and sizeof the embolus as well as on the severity of the primarydisease. The variation of these three factors offerssuch a formidable range of combinations that anystatistical analysis of the results of treatment is almostforedoomed to failure. A surgeon who is called in during

the course of a disabling disease to treat a complicationmay be forgiven some preoccupation with that complica-

tion, but his claims for the value of treatment must bebased on their effect on the patient as a whole. Inthe case of embolism affecting a limb artery the surgeon’saim is usually to save the limb, and there is a tendencyto assess results purely on the rate of limb survivalwithout reference to its usefulness to the patient.Warren and Linton,l analysing experience of arterial

embolism at the Massachusetts General Hospital, con-clude that arterial embolectomy is the treatment ofchoice in embolism of a peripheral artery, mainly on thegrounds that the cases operated on show a higher pro-portion of limb survival than those treated by conserva-tive methods. It is difficult to judge the validity of theirclaim because it is not clear what determined the choicebetween operation and other methods, but since all

surgeons insist on the importance of the time intervalit is reasonable to suppose that this plays some part inselection. Apart from one case operated on at 60 hours,their longest interval between onset and operation was11 hours. It must also be supposed that the patient’sgeneral condition was also a criterion in selection, thoughit is recorded that two patients selected for surgerydied on their way to the operating-theatre. If anyuseful comparison is to be made between surgery andconservative treatment, both should be tried in the mostfavourable cases-i.e., those with a brief interval sincethe embolism and a reasonable prognosis for the cardiaccondition. Experimental work on heparin encouragesthe view that this should be the treatment of choice,since it has been shown by Rabinowitch and Pines 2and confirmed by Loewe et al. 3 that heparin not onlyprevents thrombosis but also assists in the resolutionof clot already formed. The secondary coagulation

1. Warren, R., Linton, R. R. New Engl. J. Med. 1948, 238, 421.2. Rabinowitch, I., Pines, B. Surgery, 1943, 14, 669.3. Loewe, L., Hirsch, E., Grayzel, D.M. Ibid, 1947, 22, 746.

thrombosis extending peripherally after embolism isthe chief obstacle to the success of embolectomy. Thecombination of surgery and heparin is attractive in

theory but hazardous in practice. The patient naturallyabhors amputation, but this may sometimes be the mosthumane treatment even when there is a chance thatthe limb can be saved. There have been very few longsurvivals of an affected limb after embolectomy, andstill fewer with a symptomless limb. The embolismitself carries a risk to life because of the poor state of thepatient. Warren and Linton report a case-mortalityof 38-7% (but this includes embolism in sites other thanlimbs) and quote other rates of 50% and over.Whatever pleas are made for special forms of treat-

ment it is clear that none has any outstanding advantageover the others. The choice of treatment at presentmust be an individual one, and it must depend on theprognosis of the cardiac disease and on the prospect ofthe future usefulness of the limb.

CANCER IN CHILDREN

CANCER, in general, is a disease of the elderly, butit sometimes appears in a child, and the doctor’s philo-sophy and understanding may then be strained to theutmost. Often no cure is possible from the first, themiseries of the child are hard for parents to bear, andsymptomatic relief may be temporary and incomplete.A small gleam of light is provided by Dargeon, of NewYork, in a paper sponsored by the American MedicalAssociation and the American Cancer Society. The

importance of the subject can be gauged by the factthat in New York, in the three years 1942-44," cancer and other tumours " accounted for 215 deaths inchildren, against 291 for tuberculosis, and in the U.S.A.as a whole " cancer and allied diseases" was the thirdhighest cause of death between 3 and 10 years,and the sixth at 10-14 years. The commonest sitesfor juvenile cancer are the bones, kidneys, eye andorbit, and the lymphatic and blood-forming organs;tumours may also arise in the nervous system, muscle, andother connective tissues. The detailed recognition andmanagement of these different kinds of new growth aresystematically described by Dargeon, and he emphasisesthe fact that although many of the tumours have anunfavourable prognosis from the beginning, this is notan invariable rule-for example, osteochondromas andgiant-cell tumours of bone only become malignant withthe advance of time ; there have been several instances

1. Dargcon, H. W. J. Amer. med. Ass. 1948, 136, 459.

955

of children surviving for more than ten years after treatment for cancer of bone. Our general attitude towardso-called -benign tumours, he thinks, should be revisedwithout delay.The universal desideratum is early and correct

, diagnosis, followed immediately by suitable treatment ;the sooner surgical operations are done, the less mutilat-ing they are likely to be and the better the chances ofpermanent cure. To secure quick recognition, Dargeonrecommends that every child should be examined

monthly during the first year, quarterly from 1 to 6

years, and every six months thereafter. Biopsy should bedone at once on every swelling of non-traumatic originas well as on those which, though following injury,have persisted unusually long ; all potentially malignantgrowths, including melanomas, teratomas, dermoids, andneuromas, ought to be excised without delay. Evenan atypical symptom-complex demands thorough investi-gation, for the cause may be a hitherto undetected

neoplasm. The essential change required is that doctorsexamining children should keep malignant disease inmind as a possibility and not exclude it automaticallyon grounds of age.

SAFETY IN SHELL-FISH

THERE is no legal standard in this country for thebacteriological cleanliness of shell-fish. Most of the

popular types are cooked, but oysters and sometimesmussels are eaten raw. In fifteen years there are saidto have been over 100,000 cases of typhoid fever inFrance caused by contaminated shell-fish, and we havehad large outbreaks in this country from this cause.There is less evidence that other types of salmonellainfection are conveyed in this way, possibly becausethe infecting dose of bacteria is considerably greaterthan in typhoid fever. But shell-fish are now beingeaten by more people than ever before and many medicalofficers of health feel that a bacteriological safeguard isneeded. Ever since Captain Vancouver’s men landedin Poison Cove on the Pacific Coast of Canada’mussels have been known to cause a severe type of

paralytic food-poisoning, and such places as the Bayof Fundy are out of bounds to the fisherman for thisreason. The source of the paralytic poison is a speciesof dino-flagellate on which the mussels feed, and ordinarymethods of cooking may not destroy the poison. Inthe British Isles the chief danger is typhoid fever, formany of our shell-fish lays are in estuaries where rawsewage enters the’ sea or on shores swept by heavilypolluted tidal water. In a four-hour shift an oystercan filter some two gallons of sea-water, and pathogenicorganisms may be filtered off ’and left behind in its gut.It has been shown that shell-fish can be made safe

by treating them in chlorinated sea-water, and thismethod is likely to be widely used. The bacterio-

logical control of shell-fish for human consumptiondepends on counting numbers of coliform bacilli-atest which appears simple and accurate but is technicallydifficult and misleading. Of the many standards used,that of the Fishmongers’ Company allows about 100coliform organisms per oyster in 40% of the specimensexamined. A more satisfactory test has now been

suggested by Clegg and Sherwood, who measure thedegree of contamination by faecal coli in a single testwhich does not require subsequent confirmation. Theyinoculate roll-tubes of a modified MacConkey agar withmaterial from the shell-fish and incubate the tubes at44°C, a temperature which inhibits the non-faecal coli.If four out of five samples from the same source are freefrom faecal coli in 1 ml. quantities of tissue such shell-fish are said to be fit for food. If there are two orthree faecal coli per ml. of shell-fish in any sample further1. Clegg, L. F. L., Sherwood, H. P. J. Hyg., Camb. 1948, 45, 504.

investigation is required. This suggested standard willnot be easy to reach unless the newer methods of shell-fish purification are used, but outbreaks of infectionfrom shell-fish will continue unless some such standard is

adopted and enforced. Those who do their own cocklingwill no doubt ignore bacteriological standards, but therest of us will be happier if we know that our oystersand mussels are free from fecal contamination.

PLAIN ENGLISH

A SERIOUS effort is being made to improve the standardof written English, especially to clear away the verbiagewith -which official and commercial phraseology befogplain meaning. Mr. Churchill expressed it all in a

characteristically forceful way when he said : " this isthe sort of English up with which I will not put."Government departments’ today have much more

direct contact with the general public than they had tenyears. ago ; they circulate to every citizen informationand directions about social services ’and about all the

unpleasant restrictions that are still with us ; theirofficials have to write innumerable letters to membersof the public as well as to other officials. The ordinarycitizen who receives a letter of the " I am directed ... Iam to add..." type tends to throw it straight into thewastepaper basket, and this habit has become known inWhitehall. The daily press have not been tardy in

emphasising the sense of despair produced by the attemptto get any meaning at all from the slabs of jargon thatsome Ministries issue as directions or " explanations."In the Observer Mr. Frank Watkins 1 has pleaded forputting business English in order. He would like to seean end of same,’inst., prox., and ult., herewith, favour,and all the jargon of opening and closing phrases thatmake most business letters " at least one-tenth too long."

Several important Government departments have madea real effort to rid their pamphlets and letters of jargon

-

and to say quite clearly-when the Minister has any clearideas-what they want ; the explanatory leaflet thatcomes with the income-tax assessment form is a notable

example of successful redrafting. The Treasury askedSir Ernest Gowers to write, for the benefit of civil servants,an up-to-date guide to the use of English, and this hasnow been published in a booklet entitled Plain Words.2It is primarily designed for officials, and most of theexamples-good and bad-are taken from official sources.On the first page there is a quotation from Robert LouisStevenson : " The difficulty is not to write but to writewhat you mean, not to affect your reader, but to affecthim precisely as you wish." The solution of this difficultyis the theme of the book. And it is of vital interestnot only to officials but also to every doctor who writesletters or sends articles to the press. Not everyone hasthe time to study Fowler’s Modern English Usage,but no doctor, however experienced, will fail to benefitfrom studying the 94 pages of Plain Words. In facthe will find (on page 30) a special reference to the medicalprofession who, it appears, are becoming increasinglyaddicted to " puddery." Pudder is a disease contractedin early manhood and leads the victim to write phraseslike " concerned with the aetiology of the disease and withprescribing some general regimen...." If we lookabout, most of us will find some symptom of the diseasein our own writings.

Sir Ernest Gowers deals sensibly with the splitinfinitive, the preposition at the end, the use of dashes,and other punctuation troubles. He points out manysigns of slovenly thinking and writing that have creptinto technical and official writing : " It may safely besaid that the design of sanitary fittings has now reacheda high degree of perfection " (qualification of an absolute);" These claims are of a very far-reaching character "

1. May 23, 1948.2. H.M. Stationery Office. 1948. Pp. 94. 2s.