402

overestimated. Denison and Dowling 4 for instance,reported 48 cases of rabies in nearly half of which promptand adequate prophylactic treatment had apparentlybeen given. Ratcliffe 5 found that of 40 fatal cases ofrabies 12 had received Pasteur treatment. Y-ft haslately recorded that from July, 1923, to August, 1940,383 patients attended the medical department of PeipingUnion Medical College -because of dog bites ; of thisseries 201 were- vaccinated and 182 were not, eitherbecause they refused or because they were bitten by dogswhich were proved to be normal. Among the 201vaccinated people there were 9 (4-5%) cases of rabies ;among the 182 unvaccinated 18 (9.8%). In 2 of thevaccinated people in whom rabies developed vaccinationwas started a fortnight after the bite, possibly too late.The failure of the immunisation could not in the’ othersbe ascribed either to delay in treatment or to severityof the wounds ; neither could the viruses obtained beidentified as reinforced viruses in the sense used byKoritschoner, although in all the cases the first symptomsappeared within 14 days after inoculation and the virusesisolated became fixed after from 3 to 10 passages.Even when no cases of rabies develop the value of thePasteur treatment is not absolutely proved. Thus in

Shanghai Lieou reported that 402 complete Pasteurtreatments were given from 1937 to 1939 ; no case ofrabies was observed. However, of the supposedly rabidanimals 249 were definitely proved to be free fromrabies, 106 were suspected on various grounds of havingrabies, 10 had clinical symptoms of rabies and only 37were proved experimentally to be rabid. Of the 37

people who were associated with the animals proved tobe rabid only 17 were actually bitten, 9 had had theirhands covered with saliva and 11 were licked by therabid dogs. It is known that rabies can be contractedby contact with the saliva of a rabid animal but there islittle or no evidence to show how often this happens,while according to Kelser 8 only about 25% of peoplebitten by rabid dogs actually develop rabies. It seemsthen that in less than 5 out of 402 patients is there anyactual proof that rabies was prevented. Similarly 442people received the Pasteur treatment in Paris in 1937 7but in only 2 instances was the diagnosis established byhistological examination of the dogs’ brains. Beforethe value of the Pasteur treatment can be fully assessedmuch further work will have to be carried out both

experimentally in the laboratory and in man. Statisticsmust be based only on cases which can be proved tohave been, bitten by rabid animals, while the character-istics of the viruses isolated must be carefully studied.If after thorough investigation the present method ofimmunisation is found to,be inadequate it should be

scrapped. Pasteur would be the first to encourage us tofind a better.

’

JOINT RENOVATION

ANY contribution is welcome that tends to lessen thefeeling of helplessness in dealing with severe osteo-arthritis. Magnuson’s 9 results with operative treatmentbased on purely mechanical considerations are parti-cularly encouraging. He confirms the experimentalfindings of Bauer and Bennett 10 that the pathologicalchanges are probably the result of frequent minortraumata and that the typical marginal exostoses -areproduced in the effort to stabilise a joint which hassuffered ligamentous injury or damage to articular

cartilage. Once these exostoses are formed they limitmovement and a vicious circle of recurrent trauma andnew peripheral bone formation is set up. Clinically,4. Denison, G. A. and Dowling, J. D., J. Amer. med. Ass. 1939,

113, 390.5. Ratcliffe, A. W. Arch. intern. Med. 1940, 66, 478.6. Yü, T. F. Chin. med. J. 1941, 59, 326.7. Lieou, T. C. Bull. med. Université L’Aurore, 1940, 5, 84.8. Kelser, R. A. Harvard Symposium on Virus and Rickettsial

Diseases. Cambridge, Mass. 1940. P. 642.9. Magnuson, P. B. Surg. Gynec. Obstet. 1941, 73, 1.

10. Bauer, W. and Bennett, G. A. J. Bone Jt Surg. 1936, 18, 1.

operation aiming at complete removal of mechanicalirritants from the joint surfaces was performed on 62cases with entire relief in 60 ; no formal synovectomy wascarried out since this does not appear to be called for innon-rheumatoid cases. In the hip, where old Perthes’sdisease or slipped epiphysis is often the primary lesion,removal of marginal osteophytes and the overhangingacetabular lip gave gratifying results ; in the elbow,after wide exposure with reflexion of the ’olecranon, thesmoothing down of transverse ridges lying in the sigmoidnotch was often necessary. The knee was most com-

monly involved and an extensive toilet is advocated inwhich the condylar margins are excised, all degeneratedcartilage removed down to firm fibrocartilage or ebur- *

nated bone, the menisci dealt with if injured, and thepatella shaped with the chisel to glide unobstructedbetween the femoral condyles. Movement was begunon the fourth post-operative day, with gentle passiveencouragement and muscle re-education, and weight-bearing by the tenth day. It is then of cardinal import-ance for the patient to hold the joint quite straight andto use sticks only ; the pain of walking on the slightlyflexed knee or the use of crutches will defeat the surgeon’sendeavours. Magnuson’s results give point to theobservation of Kelikian 11 that trauma and trauma aloneis the primary affection of articular cartilage and thatmetabolic or endocrine factors are only secondarilyassociated with osteo-arthritis. They are encouraging,too, since operations of this type, as opposed to arthro-desis or arthroplasty, have not been very popular. It

may well be that such a careful removal of mechanicalirritants is better than a formal synovectomy or capsulo-tomy, or the casual removal of osteophytes ; but theoperation is not a minor one and, unless the patient giveswhole-hearted cooperation, may leave him worse thanbefore.

FIBROIDSIN reviewing the cases of myomata treated in their

wards Mahfouz and Magdi 12 of Cairo discuss almost

every aspect of this common tumour including the

history of its surgery. Avicenna in the llth centurydescribed and advocated the excision and avulsion of

vaginal polypoid myomata with or without ligation ofthe pedicle, and he seems to have been the first to ap-proaeh the problem of myomata from a purely surgicalstandpoint. All sorts of procedures were tried by theearlier surgeons, including ligation of the uterine vesselsand ovarian castration, in an effort to diminish the blood-supply to the tumour. The name of Lawson Tait will

always be associated with this latter procedure; heclaimed that the " whole merit of the thing, howevermuch or little it may be, belongs to British surgery,"for there was considerable competition from the UnitedStates and the Continent to establish a prior claim forits invention and successful performance. Tait’s firstsuccessful ovarian castration was performed in 1872.A few years before this, in 1863, Spencer Wells had per-formed the first two abdominal myomectomies, and inthe same year Charles Clay of Manchester performedthe first successful supravaginal hysterectomy in Europe.Clay ligated the whole uterine stump with three strandsof Indian hemp and only took fifteen minutes for thewhole operation. The patient left hospital 35 days later.

In their series of 931 cases of myoma all treated byoperation Mahfouz and Magdi note some interestingfacts : 86% were multiple, 14% single ; 58% intramural,24% submucous and 18% subserous ; only 2% werecervical in situation. Ovarian cysts were associated in16% of their cases and inflammatory disease of the adnexain 28%. This latter complication they regard as a

serious one in that it considerably increases the fatality,the commonest cause of death being peritonitis in 52% of

11. Kalikian, H. Surg. Gynec, Obstet. 1940, 71, 416.12. Mahfouz, N. P. and Magdi, I. J. Obstet. Gynœc. June, 1941, p. 293.

403

the fatal cases. Axial rotation of the tumour occurredin 5 patients, the cause being a pedunculated subserousfibroid. Various degenerations were noted in 18%of the tumours removed and red degeneration in 6 cases.In 3 cases the tumours had become detached entirelyfrom the uterus and gained a new parasitic foothold onthe omentum. Malignant degeneration was encounteredin 3 cases-a low incidence, for in England the generallyaccepted figure is 1%. The operations performed were :subtotal hysterectomy in 459 cases with 9 deaths;abdominal myomectomy in 362 cases with 5 deaths (avery creditable achievement, for myomectomy in thiscountry is recognised to carry a fatality of 5% and sub-

total hysterectomy 2%) ; vaginal myomectomy in 93cases with 4*deaths (this high fatality is explained by thelarge infected masses impacted in the vagina after yearsof ill health and haemorrhage) ; and finally total hysterec-tomy in 18 cases with 3 deaths (a high figure, explainedas due to tubo-ovarian infection resulting in peritonitis).The number of myomectomies is large. The reason forthis in Egypt is largely a social and religious one, forfertility is of tremendous importance there, but at thesame time it does the surgeons concerned great creditfor holding a conservative outlook. Here Victor Bonneyhas preached just such a doctrine for years. Its soundnessis illustrated by one of the cases in the Cairo series, awoman of 38, married ten years without issue, in whomthey enucleated 52 myomata. This lady was 161monthslater delivered of an heir. How many surgeons wouldhave sacrificed the uterus ? Mahfouz and Magdi put therecurrence figure after myomectomy at 5%. Theyregard the operation as dangerous if the cavity of theuterus has to be opened or if multiple incisions are neededfor the enucleation of many tumours. The incidenceof stump carcinoma in the cervix after subtotal hysterec-tomy was nil. The work of these two surgeons is a

strong plea for conservatism and a wider adoptionof myomectomy whenever myomata are encounteredin a uterus that is still potentially capable of beingimpregnated. They undoubtedly favour the subtotaloperation as against the total in hysterectomy and thiswill give many English and American gynaecologists foodfor thought.

MEDICAL REPORTS AND CERTIFICATES

THE legal position and usual practice with regard tomedical reports and certificates is succinctly set out inmemorandum No. 156, issued by the Central Bureau ofHospital Information.1 Legally neither a hospital norits medical staff is obliged to give reports or certificatesto any third party outside. The only legal method ofextracting information from the medical officer is to

subpoena him to give evidence in a court of law. Thisdoes not oblige him to say anything tg anyone outsidethe court, and even in court he can object that theinformation is confidential, although the tribunal maydecide to overrule his protest that disclosure would bea breach of professional secrecy. The patient’s consentshould always be obtained before giving a report or

certificate; one large London hospital refuses all reportsunless application is made on a particular form (appendedto the bureau’s memorandum) ; this form contains a

space for the patient’s express consent in writing.The memorandum usefully sets out the usual practice

.about fees. Hospitals generally allow a medical officerto receive the fee charged for a report ; they sometimescollect the fee for him. The fee does not commonlyexceed two guineas ; it may be less (according to thecircumstances or the patient’s means) or nothing at all.In road-accident cases one large London hospital chargesa fee of two guineas to an injured patient who wants amedical report to support his claim for compensation.’This fee is collected only if the claim succeeds (presum-1. Obtainable from the director of the bureau, 12, Grosvenor

Crescent, S.W.1. 31/2d. post free.

ably because in that case the plaintiff recovers it fromthe defendant) ; it is then handed over to the medicalofficer who made the report ; if the claim fails the

hospital itself pays the doctor a fee of 10s. 6d. Where apatient wants a medical certificate in order to recovernewspaper insurance compensation, the fee is usually5s., as the amount recovered is small. Where a medicalcertificate (usually the confirmatory certificate) is givenby a hospital medical officer under the Cremation

Regulations, the usual fee is a guinea. It may berecalled, in passing, that regulation 8 of the 1930

regulations, requiring certificates from the deceased’smedical attendant and the confirmatory certificate fromanother practitioner, is suspended by Defence Regula-tions where the registrar has certified that death hasbeen registered as due to war operations. Hospitalssometimes charge Is. for " admission and discharge"certificates ; more often they are given free. Nor is itusual to charge for an "unfit to work" certificate.Forms of " unfitness to work " and " admission and dis-charge " certificates are appended to the memorandum.There is also a simple form of general informationcertificate. This is useful where a rough idea of thedisability is needed, rather than the medical details-for example, where a workman is in hospital and theemployer wants to know whether the injury is so seriousthat another workman had better be engaged in his place.

HISTIDINE AND HISTAMINE

SUBSTANCES which give specific chemical reactions aremuch more easy to follow and investigate than thosewhich do not, and this generalisation is well illustratedby the amin1>-acids. Most of those with closed rings orunusual chemical groupings in their molecules can beinduced to react in some way which betrays their

presence whatever the circumstances, and this hasfavoured their isolation and investigation. Those with

straight chains are much more difficult to characterise,and, although progress is always being made, much lessis known about their occurrence and distribution. Indeedthreonine was only detected, and that quite recently,because an elaborate investigation led to the discoverythat rats would not grow on a synthetic mixture whichdid not contain it. The amino-acid which is known tothe biochemical fraternity as histidine and to their purerchemical cousins as &bgr;-iminazole-ex-aminopropionic acidgives colour reactions with bromine which enable it tobe detected and estimated in minute quantities in thebody fluids ; and histamine, the primary amine formedfrom it by decarboxylation, has equally striking pharma-cological properties by which it can be traced. Boththese substances have been stated to occur in urine, andtheir presence there has recently been proved by elaboratechecking and rechecking of the methods by which thecompounds were first detected and estimated. It hasbeen shown that histidinel is a constituent of normalurine, and up to 80 mg. per 100 c.cm. have been foundthere. Larger amounts are excreted during pregnancy.The quantity depends partly on the subject and partly onthe food, and although there are other factors regulatingthis excretion which have not been exactly defined thehistidine appears soon after conception and its elimina-tion seems to be related in some way to the increasedexcretion of the gonadotropic hormones. Pregnantanimals do not excrete histidine in this way-a goodexample of the biochemical differences which existbetween animal species and add such zest to comparativephysiology. During the severe toxaemias of pregnancyhistamine is excreted ; it must be formed from histidine,but why the toxaemias should bring about the appearanceof this highly reactive body, and whether it plays anypart in the production of the toxaemic syndrome is stillobscure. It is evident that we have still much to learn

1. Racker, E. Biochem. J. 1941, 35, 667 ; Kapeller-Adler, R. Ibid,p. 213.