707CHEMOTHERAPY IN ACUTE OSTEOMYELITIS

out in 1927- in the v’onduct of Medical Practice, thatneither under the act of 1926 nor any other act isthere any legal obligation upon the medical man toinform the coroner. The earliest operative words inthe Coroners Act of 1887 are " When a coroner isinformed " ; the coroner is not put upon inquiryuntil he is informed of the death. The existence ofa legal duty may be tested by the evidence of itsenforcement. Isthore any precedent for the prosecu-tion of a practitioner for the supposed common-lawmisdemeanour of failing to report a death to thecoroner ? 1Deaths in certain particular circumstances-e.g., in

prisons, asylums or inebriate homes-cast a specialstatutory duty upon persons in charge. Otherwiseit is clear that Parliament deliberately made notifica’-tion the responsibility of the registrars of deaths. Asis well known, the registration regulations of 1927require the registrar to tell the coroner of the followingdeaths before registering them : those where thedeceased was not attended by a registered medicalpractitioner during his last illness or where a dulycompleted medical certificate in the prescribed formis not forthcoming ; those reasonably believed to beunnatural or due to accident, violence or neglect, orattended by suspicious circumstances, or due to somecause apparently unknown ; those due to abortionand certain specified diseases, particularly variousforms of poisoning ; those occurring after " an opera-tion necessitated by injury or occurring under anoperation or before recovering from the effects of theanaesthetic " ; those where the deceased was appar-ently not seen by the certifying doctor either afterdeath or within 14 days beforehand ; and lastly thosealleged stillbirths where there is reason to think thechild was born alive. Notification of the coronerin these instances does not, of course, mean that aninquest will inevitably follow.

Coroner and practitioner alike desire that allnecessary inquiries should be undertaken and com-pleted with the least possible discomfort to thepublic. The coroner may request, though he cannotrequire, that certain deaths (for example, those

taking place in hospital within 24 hours of admis-sion or within 24 hours of administration of anansesthetic) be reported to him by the medicalauthorities ; but he generally does this because he isaware that it is the relatives who suffer by uncertaintyand delay. Prompt reports from hospitals may spareanxiety to the family of the deceased; the relativesare occasionally pained by the coroner’s interruptionof their arrangements for the funeral. As was wellstated in the letter published last week, medicalpractitioners .(like other members of the community),have social, public and moral duties, not enforceableby law, to assist the coroner. * In the past they havecollaborated harmoniously for the public good. The

very existence of the uncertainty lately emphasised isremarkable evidence of the reasonable spirit mutuallydisplayed between the medical profession and thatancient office of coroner which the profession at largehas as little desire as the rest of the community to see,abolished.

Mr. BASIL GRAVES will talk on the cult of the eye andthe quest of reality at the Royal Eye Hospital ClinicalSociety on Friday, Dec. 17, at 4.30 PM.

Annotations

CHEMOTHERAPY IN ACUTE OSTEOMYELITISSiNCE sulphathiazole was introduced there have been

a good many isolated case-records of acute haemato-genous osteomyelitis treated with this drug, but untilrecently no adequate series has been published. Toassess the effects of chemotherapy in osteomyelitis isdifficult because there are generally two separate con-ditions to be considered-the staphylococcal septic-semia and the bony lesion. A drug may affect the oneand not the other. Butler,t reviewing 500 cases un-treated by chemotherapy, found a mortality of 25%.The cause of death was always staphylococcal septic-semia and the death-rate was uninfluenced by the typeof operation ; but of 31 cases in which no operation wasperformed, because the patient was considered too illfor it, 26 were fatal. To lower the mortality of thisdisease sulphathiazole must be able to deal with a severeblood infection. The severity of the infection, and theprognosis, can be judged on. the results of repeatedquantitative blood-cultures: Valentine and Butler 2

showed that of 17 patients whose colony counts rose toover 30 per c.cm. of blood only 3 lived; 5 of the 17received sulphathiazole, but all died save one. Of12 patients whose colony counts were under 20, all but2 recovered, though only 2 had sulphathiazole. Similarfigures are given by McLellan and Goldbloom.3

Robertson 4 now records 89 cases of acute hsemato-genous osteomyelitis with only 4 deaths. Blood-cultureestimations are not given, so it is impossible to assess theseverity of the infections, but the series provides one ofthe lowest death-rates yet recorded for the disease.Robertson believes that operation is hardly ever requiredand supports this claim with an account of 25 casestreated with sulphathiazole alone, despite the fact thatsome of them developed sinuses. He does not approveof immobilisation and uses no splinting of any kind saveextension where the joint is infected. In his experiencesulphathiazole given early in the disease and in adequatedosage (8-10 grammes daily) not only lowers the mor-tality, but also limits the bone infection. McKeown,5who has concentrated on the effects of sulphathiazoleon the bone’lesion, found in a small series of 25 cases thatthe best results came from adequate chemotherapyreinforced by drilling the infected bone. He maintainsthat with this treatment he was able to out short theillness and to get a better final result than with casesuntreated by chemotherapy. Like Robertson, he em-phasises the necessity for using sulphathiazole soon.

If it is given when infection is well established in thebone no clinical improvement can be expected.

DETENTION BARRACKSAFTER the trial of two warrant officers for the man-

slaughter of Rifleman Clayton, the Prime Ministerappointed Mr. Justice Oliver, the Bishop of Readingand Lord Moran, rBCP, to inquire into the treatmentof men under sentence in naval and military prisonsand detention barracks. The committee, on whichDr. H. E. A. Boldero served instead of Lord Moran,have issued a frank and useful report which admits-deficiencies, especially earlier in the war, but expressesthe opinion that men in detention are not now exposedto calculated brutality. A certain amount of shouting," chasing," and bad language is still encountered, andthe committee discuss the awkward problem of findingthe right kind of staff. The present medical arrange-ments on the whole impressed them very favourably.In some places separate accommodation for the mildly1. Butler, E. C. B. Brit. J. Surg. 1940, 28, 261.2. Butler, E. C. B. and Valentine, F. C. O. Lancet, 1943, i. 194.3. McLellan, N. W. and Goldbloom, A. Canad. med. Ass. J. 1942,

146, 136. 4. Robertson, D. E. Ann. Surg. 1943, 118, 318.5. McKeown, K. C. Brit. J. Surg. 1943, 31, 13.

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ill is needed because they lie in their usual beds. Itwould also be best to have a whole-time medicalofficer for each detention barracks, but the shortageof doctors is an obstacle to this, and special aptitudefor the work is important. The onus on the medicalofficer would be lightened " if days spent comfortablyin hospital did not count towards the completion of thesentence." Changes of medical officer have sometimesbeen far too frequent, but " it would not be right tokeep a young man at this work year after year." Thecommittee’s strongest criticism of military institutionsis made against the sanitary arrangements at most ofthose they visited : the men may be locked in their

sleeping rooms from 4 or 5 PM onwards with no sanitaryfacilities except buckets which cannot be Bushed;and for prisoners in cells more latrine parades are needed.Their sharpest comment, however, is reserved fornaval detention quarters, where " the discipline andgeneral life of offenders are in many respects far hardereven than in the military prisons." During his entiresentence the sailor has no communication at all with hisfellows ; for at least a fortnight he has to lie at nighton bare boards without blankets (except in cold weather)and may neither send nor receive letters. In the Navy,moreover, little seems to be attempted towards occupy-ing the men’s minds and improving their characterswhile undergoing detention. In all the Army establish-ments there is at least one education room, and oftenan information room as well, with cuttings from theillustrated papers, war maps and so forth ; the cinemaand wireless are used for educational purposes, andcommonly there are regular courses of lectures oncurrent topics, with brains’ trust meetings. Welfareservices are also valuable, but tend to come too late.The committee remark that if the Adjutant-General’sadmirable notes on The Soldier’s Welfare were fullycarried into effect, particularly by company and platoonofficers, perhaps as many as half those now under sen-tence would never have been committed to detention.

IMMUNITY TO TRICHINA

THERE has lately been a good deal of discussion onthe stage of infestation with Trichinella spiralis at whichimmunity is developed by the infested person or animal.Is it during the phase when the adult trichinse areharboured in the intestinal canal, or when the larvsemigrate throughout the body and encyst in the muscles ’IThe work of Roth 1 seems to indicate that intestinalinfestation alone may suffice to confer a persistentimmunity of more or less pronounced degree to rein-festation. This he attained by feeding guineapigs withlarvae of one sex only, preventing therefore the repro-duction of the adult worms and the dissemination ofdaughter larvae into the guineapig’s body. Guineapigsthus treated later survived a lethal dose of infectivelarv2e of both sexes and showed in the muscles con-siderably fewer encysted worms than the controlanimals. The differentiation of male and female larvae 2

although rather difficult and tedious is quite feasibleand apparently successful in most cases. Others 3

have shown that immunity can be acquired not onlyactively by means of a sublethal dose of the infestingagent but also by parenteral introduction of trichinaantigen and by passive transfer of immune serum.Immune bodies produced by metazoa like trichina, asin the case of bacteria and .protozoa, are associatedwith the globulin fractions of the serum.4 An inter-esting feature noted in some of these investigations wasthe response occasionally arising in immunised animalsafter the reinfesting dose. This response appeared tobe of an anaphylactic type with symptoms of " allergicenteritis," often terminating in the death of the animal.

1. Roth, H. Amer. J. Hyg. 1943, 38, 99.2. Bugge, G. Arch. wiss. prakt. Tierheilk. 1934, 68, 24.3. Culbertson, J. T. J. Parasit. 1942, 28, 197.4. Mauss, E. A. Amer. J. Hyg. 1941, 34, 73.

The hypersensitive immune response to the trichina sub.stances has apparently been observed also in human

beings.5 This has to be borne in mind in view of thefact that a certain proportion of the population bothhere and in America are known to have suffered fromsubelinical infestation with Trichinella spiralis and skintests have shown that they carry antibodies againsttrichina antigen.

EXPLAINING MENTAL ILLNESS

EVERY psychiatrist and indeed every doctor has toexplain to relatives what mental illness and admissionto a mental hospital really entails. It is a difficult task,but the rewards for executing it well are great. Oftenhowever those to whom the explanation and reassuranceare addressed are too deeply stirred, or too much in-fluenced by common prejudices about insanity, to beable to grasp what has been told them ; often, too, thedoctor lacks the time, and perhaps the skill, to allay alltheir fears and doubts. Mrs. Stern’s book will, to agreat extent, fulfil the task for him. It is so arrangedthat the successive stages and problems which willconfront relatives are dealt with seriatim. The firstfew chapters cover the attitude towards mental illness,the need for hospital treatment, desirability of 4 publieor a private hospital for the patient, procedure of ad-mission, getting the patient to the hospital, and the firstfew weeks there. The latter part of the book describeslife in the mental hospital and gives advice about letters,visiting, parole, attitude after discharge from hospital,and finally about the responsibility of all citizens for themental health services in their community. Medicaldetails are eschewed ; there are no descriptions ofsymptoms, helps to diagnosis, or names of diseases.Here and there differences of an unessential kind betweenAmerican procedures and ours will occur to the Englishreader, but they do not reduce the great usefulnesswhich such a manual could have in modifying theattitude of the public in this country and lessening theavoidable misery incident to mental illness. Sensible,clear, unsentimental and humane, the book is a modelinstrument of public health education. It would be a,very suitable use of the funds and influence of theNational Council for Mental Hygiene if it could subsidiseor otherwise promote the publication of the book here,where it is at present virtually unprocurable.

SOCIAL REFORM IN CANADA

OUR Canadian correspondent last week referred to

plans for social security in Canada. A committeeappointed by the Canadian House of Commons has beenconsidering a general report on social security, preparedby Dr. L. C. Marsh, and a report on health insurancecontaining the drafts of Dominion and provincial billsto establish universal health insurance and improvedpublic health services.9 The medical profession inBritain will be particularly interested in the parts of thescheme relating to medical and sickness benefit. Forthe extension of medical services the Canadian plannersrely chiefly on the insurance principle and insurancemachinery. Health insurance, including medical benefit,will be mainly self-supporting. All insured persons andtheir dependent children will be entitled to medical,surgical and maternity benefits, dental benefit, pharma-ceutical benefit, hospital benefit and nursing benefit, ithese are expected to include adequate measures forthe prevention of disease and all necessary diagnosticand curative procedures. ’ The scheme also embodiesimportant measures of occupational readjustment-5. Bercovitz, Z. cited by Culbertson.6. Meleney, H. E. Amer. J. Hyg. 1941, 34, 18.7. Shapiro, M. M., Crosby, B. L. and Sickler, M. M. J. Lab. clin.

Med. 1938, 23, 681.8. Mental Illness: A Guide for the Family. Edith M. Stern. Oxford

University Press. Pp. 134. 6s.9. Summarised in Social Security Planning in Canada, Inter-

national Labour Office, Montreal, 1943 (obtainable from thebranch office of the ILO : 38, Parliament Street, London, S.W.1).