519

followed by firm bony union. In the adult, however,bony union is uncommon and occasionally a late para-plegia follows. Although this complication usuallyappears within the first year after injury, it has been

reported as long as 28 years later. If the paraplegia isdue to instability, then early spinal fusion might be

expected to lessen its incidence. ’

The early treatment of the fracture demands traction,and the skull calliper is undoubtedly the best method.Careful positioning may assist reduction if the frag-ment is displaced, and by flexing or extending the headaccurate alignment of the fragments is possible. Evenfor the undisplaced fracture, light traction affords a

convenient method of immobilisation. If the fracturecan be maintained in a good position for 3 months itmay well unite, although even then fibrous union is notuncommon. Such a result is compatible with goodfunction and freedom from pain, but nervous complica-tions may ensue.

1. Rubin, L., Slepvan, A. H., Weber, L. F., Neuhauser, I. J. Amer.med. Ass. 1956, 162, 953.

DEODORANTS AND THE SKIN

DEODORANTS are amongst the most commonly usedcosmetic preparations, and they are marketed in the formof liquids, creams, pastes, powders, or sticks. They areof two types : substances which destroy or obscure theodour and those which, being astringents, diminish theflow of perspiration. Most preparations contain a pro-portion of each type. The first group includes suchsubstances as sodium perborate, zinc peroxide, hexa-

methylenetetramine, chloramine-T, chlorothymol, oxy-quinoline sulphate, perfumes, and essential oils. Amongtheastringents, which act by precipitating skin proteins, thusblocking the ostia of the sweat-ducts, are formaldehyde,aluminium chloride, sulphate, and phenolsulphonate,zinc salicylate and phenolsulphate, tannic acid, and thetannates. Formaldehyde is now rarely used, since, in aneffective strength, it is a primary irritant. The veryefficient aluminium salts are often used in liquid prep-arations ; they are also primary irritants and sensitisers,but their irritant effect can be eliminated by bufferingthe solution with urea.Dermatitis caused by deodorants is usually confined

to the axillse, where it takes the form either of a sharplylimited erythematous vesicular eruption or a folliculitis.Patch testing will confirm the cause of the eruption anddistinguish it from dress-shield dermatitis. Rubin et al.1have lately described a new type of local skin reactionin the axilla after the use of certain deodorants. Theyrecord 4 cases in detail and they mention that they havealready seen 11 other similarly affected patients. Ofthe first 4 patients, 3 had used stick deodorants and 1 aliquid preparation. After periods varying from two daysto a month, irritation and an eruption suddenly appearedin the axillae. The rash consisted of dusky reddish-browndiscrete papules 1-4 mm. in diameter. They wereclosely set in the domes of the axillae and more sparselyplaced at the periphery. The lesions looked semi-translucent but no fluid could be extracted by puncture.An " apple-jelly " appearance was produced by diascopy.Treatment with superficial X rays and topical hydro-cortisone had little effect except for a slight yellowing incolour and moderate scaling.

Histological" sections from a biopsy specimen of anaxillary papule from each patient showed a tuberculoidgranuloma situated in the corium. It consisted ofepithelioid cells and Langhans giant cells surrounded bylymphocytes in typical tuberculoid pattern. Necrosiswas absent. The sharp delineation of tubercles as seenin sarcoidosis was lacking. The infiltrate lay along thecourse of the blood-vessels. Foreign bodies could notbe detected by polaroscopic examination. The stickdeodorant used by 3 patients contained, apart from the

commonly used ingredients, sodium zirconium lactate,but this substance could not be dernonstrated spectro-graphically in the biopsy specimen from 1 patient. Thelotion used by the 4th patient contained chlorhydroxy-aluminium sulphate but no zirconium.Rubin et al. say they cannot be certain of the cause

of this granulomatous eruption. They mention a lineardistribution of lesions and they are now investigating thepossible role of razor abrasions. They do not say whetherany or all of their patients wore dress shields and if sowhether sensitivity to them had been excluded. In anycase, this type of granulomatous reaction is unusual andfurther observation is needed.

1. See Poumon, 1954, 10, 465, and the next 7 articles.2. Hobby, G. L., Auerbach, O., Lenert, T. F., Small, M. J., Comer,

J. V. Amer. Rev. Tuberc. 1954, 70, 191.3. See leading article, Lancet, 1955, i, 599.4. Auerbach, O. Transactions of the 12th Conference on Chemo-

therapy of Tuberculosis, U.S. Veterans Administration, 1953 ;p. 224. Medlar, E. M. Amer. Rev. Tuberc, 1955, 71, part II, 92.

5. Auerbach, O. Amer. Rev. Tuberc. 1955, 71, 165.6. Thomson, J. It. Ibid, 1955, 72, 158, 601.7. Allen, A. R. Arch. intern. Med. 1956, 98, 463.8. Keers, R. Y., Riddell, R. W., Reid, L. Tubercle, Lond. 1956,

37, 404.

OPEN HEALING OF TUBERCULOUS CAVITIESEVEN after long periods of chemotherapy for chronic

pulmonary tuberculosis, tubercle bacilli can often becultured from the walls of cavities in resected specimensby simple 1 or elaborate 2 methods ; and we havereferred 3 to some of the changes in the lesions afterchemotherapy. Perhaps the most important, and

certainly one of the most interesting, aspects of chronictuberculosis is open cavity healing in the lings-a typeof healing recognised as very rare before the days ofchemotherapy.4 Auerbach 5 pointed out that open cavityhealing was commoner after chemotherapy (his examplesreferred to treatment with streptomycin plus p-amino-salicylic acid), that the cavity walls were thinner thesooner treatment was begun, and that the drainingbronchus was re-epithelialised. Thomson s showed thatthe incidence of open cavity healing had risen remarkablywith the introduction of isoniazid, and that two-thirdsof such cavities became completely healed, though areasof minute ulceration were still present in the other third.No tubercle bacilli could be seen in sections of the walls.In resected lesions including more than cavities, Allen 7found that over 10% were positive on culture and 10%on smear. In 10% of Allen’s patients the disease becameactive again after chemotherapy, even after conversion(by a combination of all three drugs) of gastric washingsand sputum ; and Allen recommends surgery afterthree or four months’ chemotherapy, especially for thick-walled cavities, caseous masses over 2 cm. in diameter,and bronchial stenosis or bronchiectasis.A careful clinical, pathological, and bacteriological

study of persistent thin-walled cavities has lately beenreported by Keers et al.8 From the first 10 out of 14

patients who had such cavities and whose sputum hadbeen converted by a few months’ chemotherapy ofvarious combinations, the lesions were resected after afurther four months’ or more chemotherapy. The wallsof the cavities were sometimes uniformly smooth andsometimes trabeculated ; and others showed large or

small granular areas with or without caseous material orthin pus. Histologically, the picture was just as variable,and there was evidence of activity even in cavities whichlooked smooth and shiny. None of the cavities showed

complete epithelialisation, though in several of them

epithelium had grown from the junction between cavityand bronchus for 2 or 3 cm. along the cavity wall. Else-where a smooth fibrous wall sometimes seemed to havea surface layer of flattened fibroblasts. Tubercle bacilliwere identified (4 times by culture and 4 times by smear)in 5 out of 9 cavities from 8 patients. Altogether 11

positive cultures were obtained from 3 patients (4

520

cavities), and of these, three strains from 1 patientwere found to be resistant (two completely to P.A.S.

and partially to streptomycin, one partially to

streptomycin), but all were sensitive to isoniazid and allwere sensitive to a combination of the three drugs. Theseresults suggest that the common finding in America 9 oforganisms sensitive to isoniazid after treatment with

streptomycin.. and isoniazid is due not so much to theantagonism to streptomycin of the desoxyribonucleic acidin the cavity contents as to the low dose of streptomycin(I g. every third day), which means that the streptomycinand isoniazid cannot exert their mutual protection. Keersand his colleagues combine their observations to showthat only one of the cavities in their series could bedescribed as " healed " and even then there was activetuberculosis elsewhere in the lungs. They have 4 othercases with similar lesions under chemotherapy, and theypoint out that, while resection gives valuable information,more conclusive evidence can come only from longclinical follow-up of such patients treated by chemo-therapy alone.

Stewart et al.1o investigated bacteriologically and

histologically 71 resected specimens of lung tissue,including 50 pulmonary cavities. 11 were described as

having smooth shiny walls ; and no tubercle bacilliwere cultured from 9 of them. The 2 patients from whombacilli were recovered had had less than twelve months’effective chemotherapy before operation. The most

important conclusion of this detailed investigation wasthat drug resistance and the duration of effective chemo-therapy were the main factors affecting healing. Viablebacilli were obtained from 96% of caseous foci and 95%of cavities in these patients in whom drug-resistantbacilli had been demonstrated in the sputum at any time ;but the corresponding figures for the drug-sensitivegroup were 9% and 17%. Only 2% of the lesions frompatients who had had twelve to eighteen months’treatment were positive. Stewart et al. claim that

chemotherapy can sterilise tuberculous lesions and thatopen healing of cavities can be achieved providedthat only those combinations of drugs known to preventthe emergence of resistant bacilli are used and thattreatment is continued for at least twelve months.Even longer treatment may give greater chances of

healing ; and two years would not now be consideredout of the ordinary. Stewart et al. suggest that a longperiod of chemotherapy may often prove a satisfactoryalternative to surgical treatment. This possibility is

attractive ; but some may feel that the evidence doesnot yet justify looking at ring shadows in the radiographwith anything but disfavour.The introduction of isoniazid is one of the reasons

why it has been possible to collect so large a series ofpersistent thin-walled cavities as Keers et a1.B have done.The fact that isoniazid was part of the treatment of 11 oftheir 14 patients, and in 12 of them radio-opaque materialentered 13 cavities, supports Thomson’s finding thatopen healing of cavities is commonest after isoniazid.Further support for this view comes from a study ofurinary tuberculosis with cystitis ; Borthwick 11 showedthat the three combinations of streptomycin, isoniazid,and P.A.S. all gave good results, but streptomycin plusP.A.S. was more likely to lead to severe bladder con-tracture, isoniazid plus P.A.S. was followed by practicallyno bladder contracture, and streptomycin plus isoniazidcame in between the two in this respect. Thus, if the aimis to produce fibrosis in any tuberculous lesion, strepto-mycin, especially with p..s., may be the best treatment(though the evidence that streptomycin promotes fibrosisis by no means complete) ; and to avoid fibrosis and

9. Russell, W. F. jun., Dressler, S. H., Middlebrook, G., Denst, J.Amer. Rev. Tuberc. 1955, 71, 441.

10. Stewart, M., Turnbull, F. W. A., MacGregor, R. Tubercle,Lond. 1956, 37, 388.

11. Borthwick, W. M. Ibid, p. 120.

promote as much resolution as possible, isoniazid plusP.A.S. may be the choice. And it may turn out that thesame principle applies to lung cavities according to thedensity of their walls and the possibilities of drainage:for thick-walled cavities which would never resolve butcould be sealed off, streptomycin plus r.A.s. may bebest ; for thin-walled cavities, to get as much drainageand then resolution as possible, a combination includingisoniazid may be most effective. At present, however,the choice of drugs cannot be based on these possibilities:for one thing, they are little more than speculations,and for another, different types of lesion are often foundin the same patient.

1. See Lancet, 1956, ii, 929.2. Ibid, 1953, ii, 815.3. Bagnall, H. H., Stock, F. G. Pharm. J. 1956, 177, 411.4. British Pharmacopœia London, 1953; p. 555.

OFFICIAL OR PROPRIETARY?FEW people have welcomed the Government’s action

in multiplying the prescription charges.l A less unpopularline of attack on the National Health Service drug billhas been the effort to dissuade doctors from prescribingproprietary drugs, which are often (though not always 2)more expensive than similar drugs supplied under theofficial title. Many doctors agree in principle, but feelthat certain proprietary preparations have an advantagein practice over the corresponding official preparations,even though their content is apparently identical. Thisview is supported by the findings of Bagnall and Stock,3who subjected 343 samples of barbiturate tablets to testsspecified in the British Pharmacopaeia. The two mostimportant of these are the disintegration test, whichmeasures the capacity of the tablet to break up in thestomach, and the uniformity test, which measures theweight of the drug in the tablet.4 Thus the uniformitytest determines whether the patient is receiving theintended dose, ana the disintegration test is a guide towhether or not the drug will be absorbed. Of the 343samples, which included drugs marketed under bothofficial and proprietary titles, 79 failed to conform to

pharmacopopial standards ; most failures were in the

disintegration test. 11 of the samples were proprietarymixtures which need not have complied with the B.P.requirements, but in fact all did so. ,

Bagnall and Stock point to the startling difference inquality between the tablets of different manufacturers.No fault was found in the 83 samples which representedfour firms, but of the 67 samples representing two otherfirms no fewer than 42 were below standard. The ageof a tablet influences its disintegration, but 5-year-oldtablets from some firms behaved better than 5-week-oldtablets made by others ; and even 18-year-old tabletsmade by one firm still fulfilled the B.P. requirements.There were some surprising variations in the dose ofactive material among tablets of a given batch (up to25%); and l/2,grain tablets were found in a tin labeUedll,/2 grains.Some drug manufacturers, on both sides of the Atlantic,

spend a lot of money on research which is important,even indispensable. Other firms with lower standardsmake no such contribution, and they can thus underselltheir competitors, but their products may be inferior.Though a higher price does not guarantee a better

product, a lower price often means a poorer one, eventhough both preparations carry the same pharmaeopcoialname. If a doctor’s experience has convinced him thatcertain proprietary medicines are better than those whichmay be supplied as official equivalents, it is clearly hisduty to reject what he considers an inferior substitute.Until stricter control has ensured that the B.P. standardsare maintained and that preparations which do not

satisfy them arc rarely if ever supplied, the Governmentcannot assure prescribers that official preparations areinvarÙtbly as effective as the corresponding proprietaries.