707CHEMOTHERAPY IN ACUTE OSTEOMYELITIS

out in 1927- in the v’onduct of Medical Practice, thatneither under the act of 1926 nor any other act isthere any legal obligation upon the medical man toinform the coroner. The earliest operative words inthe Coroners Act of 1887 are " When a coroner isinformed " ; the coroner is not put upon inquiryuntil he is informed of the death. The existence ofa legal duty may be tested by the evidence of itsenforcement. Isthore any precedent for the prosecu-tion of a practitioner for the supposed common-lawmisdemeanour of failing to report a death to thecoroner ? 1Deaths in certain particular circumstances-e.g., in

prisons, asylums or inebriate homes-cast a specialstatutory duty upon persons in charge. Otherwiseit is clear that Parliament deliberately made notifica’-tion the responsibility of the registrars of deaths. Asis well known, the registration regulations of 1927require the registrar to tell the coroner of the followingdeaths before registering them : those where thedeceased was not attended by a registered medicalpractitioner during his last illness or where a dulycompleted medical certificate in the prescribed formis not forthcoming ; those reasonably believed to beunnatural or due to accident, violence or neglect, orattended by suspicious circumstances, or due to somecause apparently unknown ; those due to abortionand certain specified diseases, particularly variousforms of poisoning ; those occurring after " an opera-tion necessitated by injury or occurring under anoperation or before recovering from the effects of theanaesthetic " ; those where the deceased was appar-ently not seen by the certifying doctor either afterdeath or within 14 days beforehand ; and lastly thosealleged stillbirths where there is reason to think thechild was born alive. Notification of the coronerin these instances does not, of course, mean that aninquest will inevitably follow.

Coroner and practitioner alike desire that allnecessary inquiries should be undertaken and com-pleted with the least possible discomfort to thepublic. The coroner may request, though he cannotrequire, that certain deaths (for example, those

taking place in hospital within 24 hours of admis-sion or within 24 hours of administration of anansesthetic) be reported to him by the medicalauthorities ; but he generally does this because he isaware that it is the relatives who suffer by uncertaintyand delay. Prompt reports from hospitals may spareanxiety to the family of the deceased; the relativesare occasionally pained by the coroner’s interruptionof their arrangements for the funeral. As was wellstated in the letter published last week, medicalpractitioners .(like other members of the community),have social, public and moral duties, not enforceableby law, to assist the coroner. * In the past they havecollaborated harmoniously for the public good. The

very existence of the uncertainty lately emphasised isremarkable evidence of the reasonable spirit mutuallydisplayed between the medical profession and thatancient office of coroner which the profession at largehas as little desire as the rest of the community to see,abolished.

Mr. BASIL GRAVES will talk on the cult of the eye andthe quest of reality at the Royal Eye Hospital ClinicalSociety on Friday, Dec. 17, at 4.30 PM.

Annotations

CHEMOTHERAPY IN ACUTE OSTEOMYELITISSiNCE sulphathiazole was introduced there have been

a good many isolated case-records of acute haemato-genous osteomyelitis treated with this drug, but untilrecently no adequate series has been published. Toassess the effects of chemotherapy in osteomyelitis isdifficult because there are generally two separate con-ditions to be considered-the staphylococcal septic-semia and the bony lesion. A drug may affect the oneand not the other. Butler,t reviewing 500 cases un-treated by chemotherapy, found a mortality of 25%.The cause of death was always staphylococcal septic-semia and the death-rate was uninfluenced by the typeof operation ; but of 31 cases in which no operation wasperformed, because the patient was considered too illfor it, 26 were fatal. To lower the mortality of thisdisease sulphathiazole must be able to deal with a severeblood infection. The severity of the infection, and theprognosis, can be judged on. the results of repeatedquantitative blood-cultures: Valentine and Butler 2

showed that of 17 patients whose colony counts rose toover 30 per c.cm. of blood only 3 lived; 5 of the 17received sulphathiazole, but all died save one. Of12 patients whose colony counts were under 20, all but2 recovered, though only 2 had sulphathiazole. Similarfigures are given by McLellan and Goldbloom.3

Robertson 4 now records 89 cases of acute hsemato-genous osteomyelitis with only 4 deaths. Blood-cultureestimations are not given, so it is impossible to assess theseverity of the infections, but the series provides one ofthe lowest death-rates yet recorded for the disease.Robertson believes that operation is hardly ever requiredand supports this claim with an account of 25 casestreated with sulphathiazole alone, despite the fact thatsome of them developed sinuses. He does not approveof immobilisation and uses no splinting of any kind saveextension where the joint is infected. In his experiencesulphathiazole given early in the disease and in adequatedosage (8-10 grammes daily) not only lowers the mor-tality, but also limits the bone infection. McKeown,5who has concentrated on the effects of sulphathiazoleon the bone’lesion, found in a small series of 25 cases thatthe best results came from adequate chemotherapyreinforced by drilling the infected bone. He maintainsthat with this treatment he was able to out short theillness and to get a better final result than with casesuntreated by chemotherapy. Like Robertson, he em-phasises the necessity for using sulphathiazole soon.

If it is given when infection is well established in thebone no clinical improvement can be expected.

DETENTION BARRACKSAFTER the trial of two warrant officers for the man-

slaughter of Rifleman Clayton, the Prime Ministerappointed Mr. Justice Oliver, the Bishop of Readingand Lord Moran, rBCP, to inquire into the treatmentof men under sentence in naval and military prisonsand detention barracks. The committee, on whichDr. H. E. A. Boldero served instead of Lord Moran,have issued a frank and useful report which admits-deficiencies, especially earlier in the war, but expressesthe opinion that men in detention are not now exposedto calculated brutality. A certain amount of shouting," chasing," and bad language is still encountered, andthe committee discuss the awkward problem of findingthe right kind of staff. The present medical arrange-ments on the whole impressed them very favourably.In some places separate accommodation for the mildly1. Butler, E. C. B. Brit. J. Surg. 1940, 28, 261.2. Butler, E. C. B. and Valentine, F. C. O. Lancet, 1943, i. 194.3. McLellan, N. W. and Goldbloom, A. Canad. med. Ass. J. 1942,

146, 136. 4. Robertson, D. E. Ann. Surg. 1943, 118, 318.5. McKeown, K. C. Brit. J. Surg. 1943, 31, 13.