33

and venous pressure is increased. There is no significantchange in glomerular-filtration rate, and the specificgravity of the urine is increased. Impaired kidneyfunction is not a contra-indication, and in normal subjectsthere is no diuresis. There is no clinical evidence thatdextran damages the liver, and liver disease is, notaggravated by it., W. McK. CRAIG and his group in Rochester, Minn.,have used 6% dextran in isotonic saline in over 2000cases since 1946, and have found it of " tremendousvalue." They make it clear that dextran is not asubstitute for blood, but it is a valuable adjunct.: Colonel E. J. PULASKI, of San Antonio, Texas, hasestablished that dextran is antigenic to heavily immunisedsoldiers and " veterans;" in whom swelling of the faceand some anaphylactic phenomena have been observed.These complications occurred with Swedish dextran, butnot with the American product ; and they did not

develop in anaesthetised patients.Dextran is valuable in the hypotensive state of anuria,

and it has the advantage of not raising the level of theblood-urea. Twice the volume of 3% dextran is moreeffective than one volume of 6%..FRANK W. HARTMAN, of Detroit, reviewed the tissuechanges following the administration of dextran toanimals and man. The animals received 1-8 g. of dextran.per kg. body-weight every 3 days for seven injections.Vacuolar degeneration of the interstitial tissues, compar-able with sucrose necrosis, was found. Foam-cells developedin liver and kidneys. The blood-vessel walls, especially inthe lungs, were infiltrated, and terminal chemical pneu-monia might ensue. There was some desquamation andswelling of the convoluted tubules of the kidney. These

changes are reversable in a few days. It is estimatedthat 38% of the dextran is excreted within 24 hours.One worker found that in man 1-2 litres of dextran dailyfor 3 days caused a 20% impairment of renal functionAnother worker found in tissue studies nothing significant,other than some temporary swelling of areolar tissue.Some of the dextran is phagocytosed by the reticulo-endothelial system, and it infiltrates the tissues of theliver, spleen, lymph-nodes, and kidneys, mainly theendothelium of the blood-vessels.There is some doubt whether dextran is degraded in

the tissues and metabolised. After two weeks no dextranremains in the body. (It seems certain that P.V.P.

is not metabolised, and the fate of this substance is in

doubt.)Within 3 hours of the injection of dextran, its con-

centration in the thoracic duct is almost equal to that inthe blood. Its clinical value in maintaining plasma-volume seems to continue even when half the materialis in the extravascular fluid. Electrophoretic studies

of plasma and urine have showed no significant changesfollowing dextran injection. Haemodilution takes place,as would be expected, and continues for 6 hours.

Brevities

Under the age of 5 years more than half the cases of

hepatitis do not have jaundice-J. STOKES, jun.,Columbus, Ga.Methods such as suspension for retroversion of the

uterus and cauterisations of the cervix have littleplace in the treatment of infertility-F. B. CORDER,Durham, N.C.

’Azopyrin,’ a combination of sulphapyridine andsalicylates, is one of the best sulpha drugs for ulcerativecolitis-J. A. BARGEN, Rochester, Minn.

In a group of 1000 doctors examined as patients inTennessee, 68 cases of neoplastic disease were found.The time-lapse between the onset of clinical manifesta-tions and the beginning of treatment compared unfavour-ably with that of the general population-B. F. BIRD,Nashville, Tenn.

The introduction of antibiotic therapy has changedthe primary function of the infectious-disease laboratory.The question that now requires an answer is : Whatantibiotic is most likely to be effective ? 1 The filter-

paper disc method of study of susceptibility can usuallysupply the answer.-E. H. SPALDING, Philadelphia.The gap between retirement and death now stands

at 51/Z years. This is double what it was in 1900. Ifthe present trend continues it will be triple in 1975.Unless retirement policies are changed the individualworker will be faced with increased years of inactivityand with a drastically reduced income, under conditionswhich are physiologically and physically degenerative.-S. C. FRANCO, New York.The air-evacuation aeroplane will play an increasingly

important role in military planning operations. Its

great speed, and ability to support sudden and unfore-seen military evacuation requirements, are unmatchedby surface means. It can make a major contributionto the lowering of mortality-rates.-Brigadier-GeneralW. F. HALL, Washington.

’

Chemotherapy in massive tuberculous pneumonia hascompletely altered the outlook in that serious condition.Patients with minimal pulmonary tuberculosis shouldnot receive chemotherapy, because they will do as wellwith ordinary methods of treatment. Chemotherapyhas exerted a particularly beneficial effect in tuber-culous tracheobronchitis.—W. S. SCHwARTZ, Oteen, N.C.Washing powders, drainpipe cleaners, and some paint

removers are serious poisoning hazards for childrenbecause they contain caustic soda. Less well recognisedhazards are lactic acid, candy and chocolate cathartics,barbiturates, aspirin, aniline markings on diapers,crayons, shoe polish, moth-balls, and lead toys.-J. M.ANENA, Durham N.C.

Shielding of the spleen from atomic radiation retainsthe activity of a splenic factor which favourably influencesthe recovery of the bone-marrow and the gastro-intestinalmucosa.-Prof. C. McLEAN, Chicago.

Public Health

TUBERCULOSIS IN BUCKINGHAMSHIRETHE tuberculosis problem varies greatly from one part of

the country to another. The crowded industrial cities ofthe Leeds region, described in our issue of June 23, presenta very different picture from Buckinghamshire, packedwell into the heart of England, with no large industrialcities, plenty of high ground, and a mainly rural com-munity. This description applies to all but the southern-most part of the county, where Slough, indeed, presentsa manufacturing community ; but the Slough area

belongs to the North West Metropolitan Region, and thisarticle deals with the rest of the county, which comesunder the Oxford Regional Hospital Board.

In the County Offices at Aylesbury, every patient withtuberculosis in this, the greater part of the county, isshown on a map by means of a coloured pin, put in athis dwelling-place (fig. 1). Besides showing that thebulk of the cases are in the towns, as would be expected,this map reveals at a glance the unexpected black spots-the village with a cluster of 8 or 9 cases, the camp fordisplaced persons where the rate is greater than theaverage.

FOR ALL WHO COME

One thing about this county is exceptional. It is

possible to lay a finger at random on any pin in the mapand say : " This patient will never have to wait if heneeds a hospital bed." This unusual state of affairshas been achieved in the course of the last five years,during which an effective tuberculosis scheme has beensteadily developed. Prospects of a bed were not always.

34

so good. At one time the chest physicians of the areahad no beds at all under their own control; and any policyof short-term hospital treatment and subsequent homecare was therefore out of the question. That has nowbeen remedied. An unused block in the isolation hos-pital at Aylesbury was made over to the chest team,thus putting at their disposal 15 beds in two

well-appointed wards. They have also been given 4beds in Tindal Hospital, Aylesbury, 4 at Amersham, and4 at High Wycombe-27 beds in all, most of which areused for short-term treatment. It is the practice inBucks, however, to put one or two chronic cases amongthe short-term patients. These may be homeless people,or those who cannot be nursed adequately at home.The chest physicians believe that the company of recover-ing patients puts heart into those with chronic disease,while the sight of a bad case is salutary for those who arelightly affected. A ward full of chronic cases, in contrast,is a mournful place, for patients and nurses alike. Everytuberculosis ward in the country, the team hold, shouldcarry its share of a few chronic cases.The number of short-term beds is not excessive for a

population of 280,000 ; many more could probably befilled if they were available ; but it has proved possibleto use these 27 beds in such a way that when an earlycase needs a pneumoperitoneum or a phrenic crush hecan be taken in within a week. Those requiring moreextensive procedures or long-term care can be sent toPeppard Sanatorium where some 60 beds are allocatedto Buckinghamshire. All those needing chest surgeryare treated there.

CHALETS

After the necessary treatment has been given in hos-pital the patient returns home for domiciliary care:Sometimes it happens that a room in his home can be set

Fig. I-Tuberculous patients in Bucks. Each dot represents a patient.

. Fig. 2-A chalet in the garden.

aside for him : and the council will arrange to carry out

any necessary adaptations or alterations. If no roomis suitable the architect, after consulting with the patient,will arrange for the council’s contractors to put up forhim and maintain, at the council’s, expense, a neat andpleasant chalet (fig. 2). These little prefabricatedboxes are scattered about the county-in back gardens,alongside the slightly larger houses of a

"

prefab "

village, and even attached, by short well-lighted coveredways, to the wards of hospitals, where they serve as

isolation units. They are quite small-about 7 ft. by8 ft.-and raised clear of the ground on two strips ofconcrete, with windows in three sides in the earliermodels, and in every side of those of more recent design.The grooved and overhanging eaves shed rain and snowwell clear of the windows, and the inside, lined withEssex board, is warm and dry. In each chalet there isroom for a bed, a table, a comfortable chair or so forvisitors, and a shelf carrying a curtain, which serves as asimple wardrobe. Each chalet is fitted with an electric

light above the bed, and a power-point which serves awireless set and an electric fire. The patients take

kindly to these pleasant little bungalows, and theirrelations find them easy to keep clean and tidy. Theyensure for the tuberculous modified segregation andplenty of fresh air, at the reasonable cost of noo apiece.

Occupational therapists attached to the service keeppatients supplied with handicrafts or other occupationaltherapy in their homes, and have lately been getting themoutwork from local factories. At present this is difficultto arrange, because the managements are not used to theidea; but they are beginning to take an interest in it,and the opportunity to earn a few shillings a week givesa great fillip to a patient’s spirits. Care committees,subsidised by the council, help patients whose meansare straitened by lending them such things as beds,bedding, and electric fires. They also administer anextra-nourishment scheme.While being treated at home, patients may be getting

courses of streptomycin (given by the district nurse)or P.A.3., and are under the day-to-day care of their

family doctors. Apart from this, not much treatmentis given directly in the home, since it has been foundbetter to bring patients in to the clinics by means of ahospital car service, provided by the county council

through the Women’s Voluntary Services. As the

county is small and the clinics well placed (as the mapshows) no patient has to be taken very far.

35

THE CLINICS

The clinics at Amersham and Aylesbury, being in

general hospitals, are convenient and sufficiently roomy-though with little room to expand should this be necessary.The High Wycombe clinic, at present in poor quarters,is about to be moved into the general hospital. Clinics

at Bletchley and Wolverton, though not in hospitals,are well housed, the one at Bletchley in a small butsatisfactory school clinic, and the Wolverton clinic,which is particularly good,1 in its own building. A thirdoutlying clinic, at Buckingham, is badly housed in anold public-assistance institution. Sessions are held on oneor two days a week in these three outlying clinics, oneof the chest physicians attending for the purpose. Allthe clinics have X-ray equipment, usually employed forscreening, though the sets can also be used for taking films.

THE SOCIAL WORKERS

The chest service has the help of three almoners (herecalled welfare officers) and 28 health visitors. There areno health visitors seconded to tuberculosis work only,however, and this is causing the sort of inconveniencesabout which chest physicians up and down the countryare protesting. Instead of a few health visitors workingregularly with the physicians in the clinics, visiting thetuberculous patients in their homes, and making a directreport to the responsible physician, all the health visitorsin the area have a share of tuberculous patients on theirlists. They will always furnish a report to the physicianon request, but seldom or never meet him face to face,and it is felt that few of them acquire the same keeninterest in the tuberculous as do health visitors workingonly as part of a chest team. The three welfare officersare not concerned strictly with tuberculosis, either, butthey cover all long-term illnesses in patients in theirhomes; and since tuberculosis is one of the most

important of these, their interest-unlike that of thehealth visitors-is deeply engaged.

CHANGING STATISTICS

Like other parts of the country, Bucks has shown adecline in the death-rate from respiratory tuberculosis,the figures for the whole county having fallen from0-40 (146 cases) in 1940 to 0-30 in 1949 (112 cases) per1000 population. Provisional figures for 1950 suggestthat the rate has again fallen-by more than half-theestimated deaths being only 50-odd. Moreover, not onlyare fewer people dying of the infection in this county, butthey are dying at a later age than is commonly expectedof the tuberculous. Thus of 51 patients who died lastyear, only 8 were under 30 ; 2 of these were children under5 who presumably died of meningitis. There were

8 deaths among those aged 40-50 ; and no less than 29of the deaths-nearly three-fifths of the whole number-were of people over 50. Nor had many of the patientsbeen invalids for long periods before they died. Itseems likely that better case-finding and modern methodsof treatment, including streptomycin, are changing thefamiliar picture of the disease rather rapidly, though itis still too early to say what the final pattern will be.

Better case-finding was probably largely responsiblefor an abrupt rise in the number of notifications between1946 and 1948, when the figure rose from below 250 to theregion of 375. Last year new notifications numbered383 for the whole county, and 259 for the part comingunder the Oxford region. Most of these 259 were foundamong suspected cases referred to the clinics, and amongcontacts. The ratio of cases diagnosed to suspectsreferred is I : 5 or 6, showing that the local generalpractitioners are willingly sending up all those aboutwhom they feel at all doubtful. Of 844 contacts examinedin the Oxford area of the county during 1950, 14 provedto have tuberculosis..The figure 844 represents an

average of 3-3 contacts examined per new patient. The

1. See Tubercle, 1949, 30, 86.

aim is to examine the immediate household ; for it is felt-that those outside it who may have been infected by thepatient are so few that they are better picked up inother ways-by mass radiography at the patient’s placeof work, for example.The team believe that mass radiography is best used

in this way, on groups likely to give a good yield ofcases ; and a project is in the air to form an epidemio-logical team who would investigate such selected groupsnot only by mass radiography but by Mantoux testing,and then follow up their findings with B.C.G. vaccination..Such a team could investigate, for example, the workers ina telephone-exchange where a case had developed,residents in hostels for displaced persons (and there were39 cases in 13 Polish hostels in Bucks last year), or invillages which appear from the map to be black spots.B.c.G. is already being given to nurses and laboratoryworkers throughout the county ; and a special trial is

being made at an epileptic colony where half the patientshave been given B.C.G. and half vole bacillus. So farthere have been no serious reactions, and every personvaccinated; except one laboratory worker, has converted.The picture in Bucks, then, is of a controllable disease

being brought under control by able planning; butwhat can be done in a mainly rural community may bequite impossible to achieve in an overcrowded industrialcity. There all the curative and preventive measuresnow to hand must be used in conjunction with an advancedhousing policy.

PoliomyelitisIn England and Wales notifications of poliomyelitis

in the week ended June 23 were as follows : paralytic44 (25), non-paralytic 35 (25) ; total 79 (50). This is anincrease of 29 compared with the previous week, forwhich the figures are in parentheses.Up to and including the week ending June 16 the

over-all notification-rate since the start of this yearwas 1.5 per 100,000, with the highest rates in the Midlandand South Western regions (2-28 and 2-26 per 100,000)and the lowest in the East and West Ridings ofYorkshire and the North Western region (0-97 and 1-08).

Parliament

Adulteration of FoodIN raising this subject on the adjournment on June 25,

Dr. BARNETT STROSS admitted that since time immemorialfood had been processed, preserved, and sophisticated;but in recent years, he pointed out, additions of chemicalsto food had greatly increased. A great spate of newsubstances had become available, and he was disturbedthat as the law now stands any manufacturer may adda substance to food without having to prove that it isharmless. The cumulative effects of apparently harmlesssubstances must also be considered. Did the Food andDrugs Act of 1938 give the Minister of Food sufficientpowers, Dr. Stross asked, to protect the public, andwere these powers adequately used ? Did the Ministerconsider that the Act placed on the manufacturer theonus of proof that an added substance is harmless ? Ina parliamentary answer * the Minister had admittedthat though manufacturers often sought the advice of theMinistry there was no more direct control over the use ofsubstances which are not known to be harmful. Dr.Stross thought it was not a happy situation when theMinistry had to bring an action against a manufacturerwho was thought to be at fault. The case was then heardin a court of law with conflicting points given by expertsbefore an arbitrator who was not himself an expert.Would it not be better to use the American techniquewhereby written evidence was given by experts withoutthe tension caused by opposing views ? ?-

Dr. Stross also reminded the Minister that the best-qualified food scientists were not only skilled chemistsbut were also medically trained. As examples of thedoubtful substances Dr. Stross cited mineral oils whichwere used’during the war in cakes and in salad dressing.

* See Question Time.