928 STREAKY BLOOD FILMS SIR,—The observations of Boveri, Waterfield, and Newman, recorded in your issue of Dec. 6, appear to be related to some unexplained observations I made on the bloods of Africans suffering from gambian trypano- son-liasis. In these bloods the plasma albumin-globulin ratio is usually reversed. There is intense rouleaux formation and the blood-sedimentation* rate (B.s.R,.) is much increased. I do not know if the plasma-fibrinogen is usually altered. If the i3.s.R. is performed with whole citrated blood and repeated after remixing one hour later the two results are almost- identical. If, however, defibrinated blood is used with or without citrate, the first B.s.R. reading is only slightly less than that of whole blood, but on remixing at the end of one hour both sedimentation and rouleaux formation have entirely disappeared. This occurs at blood temperature and at 0°C. One part of a 10 % solution of suramin to 4 parts of blood is an excellent anticoagulant, and it also prevents rouleaux formation and sedimentation. These properties might be of Dractical use in hæmatology. Dorchester. C. HOLLINS. PROLONGING THE EFFECT OF INJECTED SUBSTANCES SIR,—Sir Alexander Fleming, F.R.S., discussing the properties of penicillin at the International Conference of Physicians, is reported in your issue of Sept. 13 to have said : "Lately the main objection to the oil- beeswax mixtures-that they solidify on cooling-has been overcome ; but prolonged action can equally well be obtained by injecting very large doses of a watery solution." At the Hamburg meeting of the German pharmaco- logists on Aug. 23 I showed, on the basis of experiments with R. Kindler, that the effect of morphine injected subcutaneously into dogs (1 mg. per kg. body-weight) could be greatly increased in duration by increasing the dilution of the morphine solution. The implications of this observation for general pharmacology are discussed in an article which is to appear in the Zeitschrift für Naturforschung. Sir Alexander Fleming’s statement reflects the bearing on clinical medicine of this finding. Institute of Pharmacology, University of Hamburg. KLAUS SOEHRING. INTENSIVE TREATMENT OF KALA-AZAR WITH SODIUM ANTIMONYL TARTRATE SIR,—I read with considerable interest the article by Dr. Adams and Dr. Seaton (Oct. 18), and noted that the authors were most careful not to make extravagant claims for this treatment. Nevertheless, I have subse- quently heard several comments on this paper which suggest that it may have conveyed a wrong impression, and, as there are few today who have had much experience with the antimonyl tartrates in the treatment of kala- azar, some cautionary remarks would not, I feel, be out of place. I used,sodium antimonyl tartrate from 1917 until 1923. almost exclusively, in the treatment of oriental sore and kala-azar. In 1923 I obtained large samples of a variety of pentavalent antimony compounds for trial in kala-azar, and, finding that even the least effective of these gave better results than sodium (or potassium) antimonyl tartrate, we abandoned the latter drug for use among inpatients ; but, as we always had between fifty and a hundred outpatients under treatment, we had to continue to use the antimonyl tartrates among these, for several years. Before the introduction of the treatment by the antimonyl tartrates, kala-azar was a fatal disease ; possibly between 5 % and 10 % of patients recovered spontaneously while under treatment, but there was little evidence that any special tieatment was responsible for these recoveries. Therefore, a drug that produced a 75 % cure-rate was naturally received with enthusiasm, and the disadvantages and dangers associated with the treatment were accepted as relatively unimportant. Actually, they were considerable, and frequently com- pelled us to modify the prescribed course of injections. The most troublesome by-effects were violent coughing. vomitina, and joint pains. In addition to this there was always a, high mortality among patients under treatment. In a series of 139 hospital patients treated by sodium antimonyl tartrate, which r reported in 1924. 14’4% died. This was a lower dea,th-rate than that reported by Knowles in 1920. Pneumonia, was a common cause of death. When the pentavalent compounds came into use deaths during treatment became rare and pneumonia was practically unknown. A variety of strengths of sodium antimonyl tartrate were used, but as no differences in the effects of the various strengths could be detected, a 2 % solution became the standard strength. We never attempted to give a concentrated course on the lines adopted by Adams and Seaton, but it seems unlikely that this concentration would diminish the unfavourable by-effects of this drug. The two advantages claimed for this course are rapidity and cheapness. The latter must be granted, but, if experiments are to be made with concentrating the course, would it not be better to use one .of the benign pentavalent drugs such as ’ Neostibosan’ or sodium stibogluconate ? The former has been used in daily (divided) doses of 1.5 5 g. in the treatment of filariasis.- When the results achieved by Adams and Seaton are critically analysed, they amount to the fact that, of 6 patients, 3 were followed for only a short time and may or may not have been cured ; on 1 the treatment had no effect ; 1 relapsed but was apparently cured by a second course ; and 1 was apparently cured by a single course. It is also of interest that 1 developed pneumonia. The only conclusion that can be drawn from the results in this small series is that it is possible to cure kala-azar with a two-day course of sodium antimonyl tartrate. I have cured patients with two injections ofneostibosan given on consecutive days, but I would not recommend that course. Finally, I do not think that any extension of the series would be iustiflable. London, W.I. L. EVERARD NAPIER. Public Health Future of Public-assistance Institutions THE National Health Service Act provided for the transfer to the Minister of Health (and for administration by regional hospital boards) of those parts of public- assistance institutions used for hospital purposes, and for the apportionment of premises used partly for hospital and partly for other purposes. Since dual ownership and control might give rise to difficulties provision is being made under the National Assistance Bill for each public-assistance institution to be treated as a single unit, the future ownership and management being determined by its predominant user. There will thus be no apportionment of premises. Responsibility for the care of the sick in institutions remaining with a local authority will, however, rest with the regional board ; while the care of the non-sick in institutions vesting in the Minister of Health will rest with the local authority. In a circular (172/47) the Minister urges local authorities to determine, by negotiation with regional hospital boards, which institutions should be vested in the Minister. ’ Poliomyelitis Notifications, which totalled 103 in the previous week, numbered 70 in the week ended Dec. 6. This is the first time since the week ended July 5 that notifications have been below the peak figure for 1938-85 notifica- tions in the week ended Oct. 22. The fall from 103 to 70 maintains the more rapid decline which has been notice- able since the week ended Nov. 15 ; and if this rate continues notifications should be reaching the normal winter level of 4-5 cases a week by the middle or end of January.
Transcript
928
STREAKY BLOOD FILMS
SIR,—The observations of Boveri, Waterfield, andNewman, recorded in your issue of Dec. 6, appear to berelated to some unexplained observations I made on thebloods of Africans suffering from gambian trypano-son-liasis.
In these bloods the plasma albumin-globulin ratio isusually reversed. There is intense rouleaux formationand the blood-sedimentation* rate (B.s.R,.) is muchincreased. I do not know if the plasma-fibrinogen is
usually altered. If the i3.s.R. is performed with wholecitrated blood and repeated after remixing one hourlater the two results are almost- identical. If, however,defibrinated blood is used with or without citrate, thefirst B.s.R. reading is only slightly less than that of wholeblood, but on remixing at the end of one hour bothsedimentation and rouleaux formation have entirelydisappeared. This occurs at blood temperature andat 0°C.One part of a 10 % solution of suramin to 4 parts of
blood is an excellent anticoagulant, and it also preventsrouleaux formation and sedimentation. These propertiesmight be of Dractical use in hæmatology.
Dorchester. C. HOLLINS.
PROLONGING THE EFFECT OF INJECTEDSUBSTANCES
SIR,—Sir Alexander Fleming, F.R.S., discussing theproperties of penicillin at the International Conferenceof Physicians, is reported in your issue of Sept. 13 tohave said : "Lately the main objection to the oil-beeswax mixtures-that they solidify on cooling-hasbeen overcome ; but prolonged action can equally wellbe obtained by injecting very large doses of a waterysolution."At the Hamburg meeting of the German pharmaco-
logists on Aug. 23 I showed, on the basis of experimentswith R. Kindler, that the effect of morphine injectedsubcutaneously into dogs (1 mg. per kg. body-weight)could be greatly increased in duration by increasing thedilution of the morphine solution. The implications ofthis observation for general pharmacology are discussedin an article which is to appear in the Zeitschrift fürNaturforschung. Sir Alexander Fleming’s statementreflects the bearing on clinical medicine of this finding.
Institute of Pharmacology,University of Hamburg.
KLAUS SOEHRING.
INTENSIVE TREATMENT OF KALA-AZAR WITHSODIUM ANTIMONYL TARTRATE
SIR,—I read with considerable interest the article byDr. Adams and Dr. Seaton (Oct. 18), and noted that theauthors were most careful not to make extravagantclaims for this treatment. Nevertheless, I have subse-quently heard several comments on this paper whichsuggest that it may have conveyed a wrong impression,and, as there are few today who have had much experiencewith the antimonyl tartrates in the treatment of kala-azar, some cautionary remarks would not, I feel, be outof place.
I used,sodium antimonyl tartrate from 1917 until1923. almost exclusively, in the treatment of orientalsore and kala-azar. In 1923 I obtained large samplesof a variety of pentavalent antimony compounds fortrial in kala-azar, and, finding that even the least effectiveof these gave better results than sodium (or potassium)antimonyl tartrate, we abandoned the latter drug foruse among inpatients ; but, as we always had betweenfifty and a hundred outpatients under treatment, wehad to continue to use the antimonyl tartrates amongthese, for several years.
Before the introduction of the treatment by the
antimonyl tartrates, kala-azar was a fatal disease ;possibly between 5 % and 10 % of patients recoveredspontaneously while under treatment, but there waslittle evidence that any special tieatment was responsiblefor these recoveries. Therefore, a drug that produceda 75 % cure-rate was naturally received with enthusiasm,and the disadvantages and dangers associated withthe treatment were accepted as relatively unimportant.
Actually, they were considerable, and frequently com-pelled us to modify the prescribed course of injections.The most troublesome by-effects were violent coughing.vomitina, and joint pains. In addition to this therewas always a, high mortality among patients undertreatment. In a series of 139 hospital patients treatedby sodium antimonyl tartrate, which r reported in 1924.14’4% died. This was a lower dea,th-rate than that
reported by Knowles in 1920. Pneumonia, was a commoncause of death. When the pentavalent compoundscame into use deaths during treatment became rare andpneumonia was practically unknown.A variety of strengths of sodium antimonyl tartrate
were used, but as no differences in the effects of the variousstrengths could be detected, a 2 % solution became thestandard strength. We never attempted to give a
concentrated course on the lines adopted by Adams andSeaton, but it seems unlikely that this concentrationwould diminish the unfavourable by-effects of this drug.The two advantages claimed for this course are
rapidity and cheapness. The latter must be granted,but, if experiments are to be made with concentratingthe course, would it not be better to use one .of thebenign pentavalent drugs such as ’ Neostibosan’ or
sodium stibogluconate ? The former has been used indaily (divided) doses of 1.5 5 g. in the treatment offilariasis.-When the results achieved by Adams and Seaton are
critically analysed, they amount to the fact that, of6 patients, 3 were followed for only a short time and mayor may not have been cured ; on 1 the treatment hadno effect ; 1 relapsed but was apparently cured by asecond course ; and 1 was apparently cured by a singlecourse. It is also of interest that 1 developed pneumonia.The only conclusion that can be drawn from the resultsin this small series is that it is possible to cure kala-azarwith a two-day course of sodium antimonyl tartrate.
I have cured patients with two injections ofneostibosangiven on consecutive days, but I would not recommendthat course.
Finally, I do not think that any extension of the serieswould be iustiflable.London, W.I. L. EVERARD NAPIER.
Public Health
Future of Public-assistance Institutions
THE National Health Service Act provided for thetransfer to the Minister of Health (and for administrationby regional hospital boards) of those parts of public-assistance institutions used for hospital purposes, andfor the apportionment of premises used partly forhospital and partly for other purposes. Since dualownership and control might give rise to difficultiesprovision is being made under the National AssistanceBill for each public-assistance institution to be treatedas a single unit, the future ownership and managementbeing determined by its predominant user. There willthus be no apportionment of premises. Responsibilityfor the care of the sick in institutions remaining with alocal authority will, however, rest with the regionalboard ; while the care of the non-sick in institutionsvesting in the Minister of Health will rest with the localauthority.
In a circular (172/47) the Minister urges local authoritiesto determine, by negotiation with regional hospitalboards, which institutions should be vested in theMinister. ’
PoliomyelitisNotifications, which totalled 103 in the previous week,
numbered 70 in the week ended Dec. 6. This is thefirst time since the week ended July 5 that notificationshave been below the peak figure for 1938-85 notifica-tions in the week ended Oct. 22. The fall from 103 to 70maintains the more rapid decline which has been notice-able since the week ended Nov. 15 ; and if this ratecontinues notifications should be reaching the normalwinter level of 4-5 cases a week by the middle or endof January.
929
Infectious Disease in England and WalesWEEK ENDED DEC. 6
Notifications.—Smallpox, 0 ; ; scarlet fever, 2027 ;whooping-cough, 1488 ; diphtheria, 205 ; paratyphoid,8 ; typhoid, 0 ; measles (excluding rubella), , 2799 ;pneumonia (primary or influenzal), 530 ; cerebrospinalfever, 46 ; poliomyelitis, 70 ; polioencephalitis, 6 ;encephalitis lethargica. 0 ; -, dysentery, 93 -, puerperalpyrexia, 112 ; ophthalmia neonatorum, 45. No case ofcholera, plague, or typhus was notified during the week.Deaths.-In 126 great towns there were no deaths
from enteric fever or scarlet fever, 1 (0) from measles,4 (0) from whooping-cough, 3 (1) from diphtheria, 59 (2)from diarrhoea and- enteritis under two years, and 19 (3)from influenza. The figures in parentheses are thosefor London itself.The number of stillbirths notified during the week
was 210 (corresponding to a rate of 26 per thousandtotal births), including 24 in London.
Parliament
FROM THE PRESS GALLERY’
Medical Practitioners and Pharmacists BillAT the committee stage of this Bill in the House of
Commons on Dec.. 9 Mr. JOHN EDWARDS, parliamentarysecretary to the Ministry of Health, moved a series ofamendments to clause 3 to include alien doctors, who,although they had not served in His Majesty’s Forces,had given valuable ’service in a civilian medical capacityoverseas. The Bill as amended -was read the third timeand passed.
QUESTION TIMEGrants to Industrial Health Research
Mr. F. J. ERROLL asked the Lord President of the Councilwhat was the total amount of Government grants given inthe last four years to the Industrial Health Research Board ;the number of reports issued during the same period ; andwhat was the future policy for the board.-Mr. H. MORRISONreplied : The expenditure of the Medical Research Council onthat part of their programme in which they are advised bythe board amounted to £161,520 over the last four financialyears. During the same period 12 reports on this work werepublished officially, and 46 other reports as contributions toscientific journals. The policy is to continue the expansionwhich has already taken place on a considerable scale sincethe war.
Answerable for the Regional Hospital BoardsColonel M. STODDART-SCOTT asked the Minister of Health if
the Government’s decision with regard to Ministers’ repliesto Parliamentary inquiries about nationalised industries alsoreferred to nationalised hospitals and the specialist and otherservices administered by regional hospital boards.—Mr. A.BEVAN replied : No. The Health Ministers will be answer-able for these services and therefore for their administrationby the local or regional bodies set up for the purpose. Butit is to be hoped that the proper responsibilities of those bodieswill not be diminished by too many inquiries on detailedday-to-day matters unless some point of general importanceis involved.
Analgesia for MothersMr. R. W. SORENSEN asked the Minister to what extent
progress was being made in providing analgesia for women inconfinement.-Mr. BEVAN replied : The number of cases
where it was provided by domiciliary midwives increasedfrom 7262 in 1945 to 20,507 in 1946. Also the number ofmidwives trained to give it has doubled in the current year.I am not yet satisfied with the progress. It is substantialbut there is still a very large number unable to avail them-selves of it.
Production of AudiometersMr. EDWARD EvaaNs asked the Minister whether he had
arranged for the purchase of a sufficient number of pure-toneaudiometers for testing purposes in the scheme for thesuitable allocation of hearing-aids under the National HealthInsurance Act.-Mr. BEVAN replied : I am arranging for theproduction of a new type of pure-tone audiometer which canbe used after a short and simple training. This will be given asmay be necessary to the staff of hospitals providing the service.
ObituaryROBERT ALEXANDER FLEMING
, M.A., M.D. EDIN., LL.D., F.R.C.P.E.
Dr. R. A. Fleming, the oldest fellow of the RoyalCollege of Physicians of’Edinburgh, died on Dec. 6.The son of a Dundee merchant, he was born in 1862;and from Craigmount School he entered the Universityof Edinburgh where he graduated M.A. in 1884. and az.B.with first-class honours four years later. In 1896 he wasawarded a gold medal for his M.D. thesis.As was the custom at that time, he was pathologist to
Edinburgh Royal Infirmary for several years before hewas appointed to the staff. He also lectured on thepractice of medicine, and he was an examiner for Edin-burgh and Aberdeen Universities. As a territorial heserved in the war of 1914-18 in the 2nd Scottish GeneralHospital, and later, with the rank of major, was in’charge of the medical division of the 42nd General Hos-pital at Salonika. He was a member of that select body,the King’s Bodyguard for Scotland, the Royal Companyof Archers, which he also served as surgeon. He becamea fellow of the Royal College of Physicians of Edinburghin 1899, and in 1928 he was elected president. In thesame year the university conferred on him the degreeof LL.D. He was also a fellow of the Royal Society ofEdinburgh.But perhaps the duties which gave him most pleasure
and interest were his appointment as physician to thetwo Royal Edinburgh Hospitals for Incurables, which hevisited at least once each week, always making a pointof speaking to the patients, and his post as -medicaladviser to the Prison Department for Scotland. Invisiting the prisons he showed a deep concern for thewelfare and reformation of the prisoners, and for hisMorison lecture of 1934 he chose as subject the MentalElement in Crimes and Criminals. Kindness and con-sideration for others were characteristic of the man, andhe earned the affection of all with whom he came incontact. Fond of fishing and shooting, he spent muchof his holidays at his shooting-lodge in Perthshire,where he went a few months ago in the hope that incountry surroundings his health might improve ; andthere he died.
Dr. Fleming lately celebrated his golden wedding toEleanor Mary, a daughter of the late Canon W. L. Holland,rector at Cornhill-on-Tweed. She survives him withthree sons and a daughter. ,
THE LATE DR. BOLTONProf. G. Payling Wright writes : In many ways
Charles Bolton was fortunate in the unconventionalitvof his medical training. Long before he began the formalscientific discipline, he had acquired much medical know-lodge and skill in observation through his apprenticeshipto a general practitioner. Having this practical experi-ence for his background, he was suddenly thrown intothe great London medical school which saw the renais-sance of physiology in this country. With the problemsand difficulties of practical clinical medicine he wasalready familiar ; it was hardly surprising, therefore,that his finding in the sciences of physiology andpathology, the solutions to many of his former per-plexities, should instil in him a deep urge to followmethodically in the footsteps of the active group of
investigators whose steady flow of discoveries had alreadydisclosed so much and held out even higher hopes forthe future.The large number of Bolton’s contributions to medicine
can only be fully appreciated by any one who has. gonecarefully through the list of his published writings.While it is difficult to discriminate in value between the
three main phases into which his researches fell-the complica-tions of diphtheria, the genesis of peptic ulcers, and thepathology of œdema—it is likely that the last was the mostimportant contribution that he made. In his study of thisproblem, he was fortunate in having his friend Starling’sresearches into lymph formation to guide him. But Boltonhad a strongly independent nature, and while he fully appre-ciated the importance of the advances made by Cohnheimand Starling, he was unable to accept in their entirety theapplicability of their conclusions to the clinical problem of
