333

during the hyaluronidase period, and in four of them

existing stones have become smaller and less dense

radiologically. At least some of the five failures, it

seems, may have been caused by incorrect administra-tion of the drug. During the experiment no otherform of treatment was used. Most patients had aninjection every 24-48 hours ; and Butt et al. pointout that the site of injection should be changed so thatthe same area is not injected more often than once in4 days. Frequent injections are clearly a drawback ,but if they can really help a patient threatened byrecurrent stones, then he will accept the irksome routineas cheerfully as most diabetics do.

1. Levin, M. J. Neurol. Psychopath. 1933, 14, 1.2. Weitzner, H. A. Arch. Neurol. Psychiat. 1952, 68, 835.

TREATMENT OF SLEEP PARALYSISSLEEP paralysis is a rather rare disorder of the normal

change of consciousness from waking to sleeping or

sleeping to waking. It seems to be rather commoner on

waking than on falling asleep, although the so-called

night-nurse’s paralysis may possibly be predormitialsleep paralysis. Those who experience this disorder saythat they are quite conscious and their sensory powersare complete, but they are unable to move or speak.This rather frightening state may last for as long as tenminutes. Sometimes sleep paralysis is associated withnarcolepsy.1Our understanding of sleep itself makes little headway.

Some attribute sleep to general cortical processes, andothers to the special action of a localised area of theposterior hypothalamus which is variously regarded as awaking centre, a sleep centre, or even a combination ofthese two. Narcolepsy and hypersomnia arise inassociation with many different organic conditions of thebrain, but structural involvement of the hypothalamicregion is generally regarded as the commonest cause.This does not necessarily prove, however, that we oweordinary sleep to the hypothalamus ; for the sleep ofnarcolepsy and of hypersomnia may differ from the

physiological form.Weitzner,2 who has successfully treated sleep paralysis

by insulin hypoglycemia, obviously has no doubt thatit is the hypothalamus-be it sleep or waking centre-that is involved in this syndrome ; he asserts that insulinhypoglycæmia increases the power of the hypothalamusto regulate sleep, and he recalls that usually one ofthe first benefits that patients with rheumatoid arthritisderive from treatment by insulin hypoglycaemia is arelaxed and uninterrupted night’s sleep. Weitzner’sideas will perhaps not be accepted by all ; but his findingsmay form a useful basis for further observations.

A SUBSTITUTE FOR LYSOLOF the disinfectant compounds derived from the

distillation of coal-tar at rising temperatures, phenol hasthe lowest boiling-point and is most highly destructiveto tissue. It is followed by the cresols, which are muchmore bactericidal and rather less toxic ; being lesssoluble, they are put up in solution in soap. Lysol,which is a 50% solution of cresols, has a wide range ofactivity on bacteria and fungi, and has long been popularas an economical disinfectant for general use. It hasthe disadvantage, however, that its bactericidal valuevaries with the different oils and fatty acids which maybe used in its preparation. Furthermore, it has anirritant or even necrotic action on the skin. LeonardColebrook, who observed this with concentrationsnecessary to destroy the hæmolytic streptococcus,condemned lysol for midwifery and suggested that

chloroxylenols should be used ; these, however, haveonly a limited action on staphylococci and Pseudonionaspyocyanea, and they lose much of their value when

organic matter is present.The skin irritation from lysol is due to the cresols

contained in it ; and refractionation of the higher

phenolic homologues will yield a fraction or 14 cut "

which contains no cresols but is close enough to them togive, when formulated, a disinfectant with most of thedesirable qualities of lysol and, in effective concentrations,no damaging action on the skin. The properties of amaterial of this sort, marketed as ’ Sudol,’ have beeninvestigated by Finch.1 It contains 50% of phenols,and a blend of vegetable fatty oils is used as the basisof the soap. It forms a clear solution with distilledwater and gives a slight opalescence without scum intap-water. Its activity against seven -representativebacterial species-mainly pyogenic and intestinal organ-isms-was compared with that of carbolic acid in Rideal-Walker and Chick-Martin tests, and with lysol and thesolution of chloroxylenol B.P. in modified tests with andwithout organic matter.We have already noted the serious limitations of these

tests.2 The comparative figures reported by Finch seem,however, to show clearly the greater bactericidal effectof the lysol substitute, and its greater activity againstnon-sporing organisms in the presence of organic matter,especially when compared with chloroxylenol solution.In working concentrations, and even for a few minutesundiluted, it does not burn the hands. Further workwill no doubt be done to assess its value as a skin dis-infectant, and, diluted with equal parts of water, forsuch purposes as the sterilisation of instruments andbaths. The fraction has no doubt been carefully selectedto exclude the known carcinogenic components of thedistillates. This precaution has to be kept clearly inmind in the search for better disinfectants among the

higher " cuts."

1. Finch, W. E. Pharm. J. 1953, 170, 59.2. Lancet, 1951, ii, 575.

THE RESURGENT STREPTOCOCCUS

IN the past two decades the outstanding successes ofchemotherapy against bacterial infections have perhaps-lulled us into a false sense of security. On an earlier pageof this issue will be found an account by Dr. Gibson andDr. Caiman of an outbreak which shows us that thehaemolytic streptococcus has not lost its sting.

Between Nov. 1, 1952, and Jan. 3, 1953, the laboratoryat Queen Charlotte’s Hospital received 38 swabs fromwhich group-A &bgr;-hæmolytic streptococcus was isolated..It was found that 26 of the strains isolated belonged toserological type 13 (3/B3264) : of these, 1 came from a.

throat-swab and 13 from vaginal swabs of patients, 11were from throat-swabs of nurses and orderlies, and 1was from ward dust. The first recognised case of strepto-coccal infection was in November, 1952, when a nursecomplained of sore throat. She was sent off duty untilher " throat was clear." A fortnight later a baby devel-oped erysipelas, and although this baby was immediatelytransferred to another hospital streptococcal infection-appeared sporadically in patients and staff. At first allthe cases were in one ward, but later cases occurred inwards on other floors. By last month it was evidentthat the epidemic type of &bgr;-hæmolytic streptococcus(type 13) had become well established. In 11 out of 14infected patients the illness was mild ; the other 3,.however, were acutely and seriously ill with temperatures-of up to 105°F with rigors. Of 3 later cases 1 was mild,1 was the most severe genital-tract infection of the wholeoutbreak, and 1 was a streptococcal meningitis in aninfant who was critically ill.

Dr. Gibson and Dr. Calman emphasise that " thisoutbreak of puerperal infection was far larger than any-thing experienced in recent years." They give reasons forthinking that it was not due either to relaxation of

antiseptic methods (which have not been changed in thelast five years), or to an increased infection-rate in the-surrounding population. They are inclined to think thatthe great increase in the number of cases and the severityof some of them may herald an increase in the patho-

334

genicity of the hsemolytic streptococcus. Be that as it

may, the epidemic illustrates the difficulty of effectivelycontrolling the spread of streptococcal infection whilecontinuing to admit patients. Undoubtedly one reasonis that the causal organism remains viable in dust for along time and may defy disinfection with formaldehydeor other chemicals. Dust is likely to be especiallydangerous if it is being continuously reinfected from areservoir of streptococci , and the work of Hamburgerand others 1 2 has shown that often a heavy nasal carrierof &bgr;-haemolytic streptococci can be found, and that freshcases cease when this reservoir is removed. Meanwhile,Dr. Gibson and Dr. Caiman are right to warn thoseresponsible for maternity units against the possibilityof similar severe puerperal infections.

1. Hamburger, M. jun., Hamburger, V. G. J. infect. Dis. 1945,77, 68, 96.

2. Cook, G. T., Munro-Ashman, D. Brit. med. J. 1949, i, 345.3. Living with Cancer. London : Gollancz. 1953. Pp. 160. 8s. 6d.

LIVING WITH CANCER

Mrs. Edna Kaehele, who has had inoperable cancer forsix years, has written a remarkable little book about

living with this disease.s The dust-jacket asserts plainlythat the title " does not mean that you can survive for

longer than you thought when you have cancer : butthat, in spite of having cancer, you can live life abun-dantly." Mrs. Kaehele herself, however, has survived forlonger than she thought ; and believes it has been, insome part at least, a spiritual victory. Her story has aspecial interest, because it may throw some fresh lighton the natural history of this disease. Most patients whoare beyond successful treatment die, as it were, beforethey have time to rally. Mrs. Kaehele failed to die atthe appointed time ; and she has rallied. Perhaps hercancer would have regressed in any case, as a few do ;but she certainly passed and survived a point at whichmost patients would have died, and that in itself isinteresting.The growth was beyond operation when diagnosed in July,

1946 ; and by Dec. 3 she had received " fifty-six X-ray treat-ments, the radium operation, radon implants, as well as

biweekly injections of liver extract and countless shots ofvitamins to replace the ones destroyed by radiation." Shedid not feel as though she had profited from this exhaustingcourse of treatment-though it may, in fact, have slowed therate of growth of the tumour, and given her body time tomanceuvre. Her weight had gone down from well over 10 st.to less than 7 st. and she had much pain, and hardly strengthenough to stand. She was given a blood-transfusion and senthome on the understanding that she would be dead before theNew Year. That she did not fulfil this engagement she attri-butes largely to the determination of her family, and especiallyof one sister. On Jan. 17, 1947, as she was still alive, a courseof radium chloride therapy was begun. " It was tastelessand painless, and when the series was finished seemed to havebeen useless as well." However, if not gaining she was losingground more slowly, and in February she was given anothertransfusion, and received two more in the course of the follow-ing months. In July, a year from the date of diagnosis, shebegan a second course of radium chloride treatment, andafter that her doctors were at the end of their resources.

So much for the medical delaying tactics ; she doesnot underrate their value. " I beg you," she says to herreaders with cancer, "to search out the best cancer

specialist you can find and to make full use of the mostadvanced resources available."

Nevertheless for a long time after her treatment ended sheremained very ill, and her weight, though she had stoppedlosing it, remained at 6-7 st. She considers she was greatlysupported, however, by the general determination that sheshould live and by her own strong religious faith. She wasbedridden for a long time, and for several months food " wasnot only unwelcome but became unbearable." Her familykept her going by adding gelatin to her coffee, and by per-suading, bullying, and nagging. Then came a turning-point,surely of much clinical interest, when she began to eat

ravenously, as though the body so recently rebelling against

food was now " crying out in starved desperation." Her

weight began to rise, and by the autumn 6f 1947 she wasbeginning to come " back to life." By Christmas she wasgoing out again and doing her own shopping. It was anemotional as well as a physical reorientation, and she naturallywrites of it with emotion.

She has put on 2 st. in weight, and is now engaged inbreeding dogs. She needs hardly any medication forpain, which is much less insistent. To others with cancershe offers two useful pieces of advice : have faith in"

your doctor, your God, yourself-faith in something " ;and eat well, " stuff the body with protein to rebuild theravaged tissues and saturate it with vitamins to revitaliseit." On the subject of pain she is reassuring :

" I musthave suffered just about all that one suffers from deathby cancer, and I wish to shout it from the housetopsthat my greatest agony was in waiting expectantlytwenty-four hours a day for the unbearable pain I

confidently expected to beginany minute."Her message to doctors is probably equally well chosen.

If we kill the patient’s hope stone dead by inviting himto die at a given time, die he probably will, at the

appointed moment, out of a combination of despair andgood manners. She also writes feelingly of the Americanpatient who delays coming for treatment until too latesolely because of the expense. The National HealthService has surely done a good thing in removing thiscause of death from our statistics.

1. See Lancet, 1946, i, 241.

STUDENT HEALTH SERVICES

IN fact and tradition, students seldom have the meansor indeed the inclination to provide themselves withgood food and lodgings, and for one reason or anotherthey are often slow to seek medical advice. Theoretically,the National Health Service has overcome the student’sdifficulty of finding the money to meet ill health ; but,as the Social and Preventive Medicine Committee of the

Royal College of Physicians points out in a progressreport on Student Health Services published last month,this solution does not always work out in practice. Astudent is often not registered with a doctor in the

university town because his home is elsewhere ; and theNational Health Service does not provide for the regularexaminations which the committee recommended in19461 and which are now required by many universitiesand colleges. To overcome these difficulties, the com-mittee would like to see more general practitioners fittedinto the organisation of student health services, not

only to help the student when he is ill in his " digs " butto take on the wider role of adviser in health.

Looking back on the development of student healthservices since 1946, the committee finds that the positionin the universities outside London, with the notable

exception of Oxford, is now largely in agreement withtheir earlier recommendations in the matters of medicaland nursing care, lodgings, and food. In Oxford certaincolleges have their own arrangements, which in somecases amount to an organised health service, but theuniversity recently set aside a proposal for a servicecovering the student population as a whole. The situationin London is unsatisfactory, particularly for the non-medical students. Nearly all the medical schools insiston regular X-ray examinations, and students can alwaysobtain advice and treatment from members of the hospitalstaff ; but their colleagues in other faculties are oftenpoorly provided for. True, University College has anexcellent scheme ’run by its student health association,to which the Royal Veterinary College and the LondonSchool of Hygiene and Tropical Medicine are affiliated ;and Imperial College is also well equipped to look afterits students. But the other non-medical schools andcolleges, with a student population of 6000, have donelittle to follow the committee’s advice. Most of them