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ANNOTATIONS

TREATMENT OF MENINGOCOCCAL MENINGITIS

SEVERAL previous reports on small numbers ofcases have agreed in commending sulphanilamide as aremedy for cerebro-spinal fever. The vast resourcesof the London County Council hospital system havemeanwhile enabled Dr. H. Stanley Banks to study thetreatment of this disease on a scale impossible any-where else in this country, and an account of hisresults will be found on p. 7. The total of 113cases is divisible into three groups, treated respec-tively with serum alone, with serum and sulphanil-amide, and with sulphanilamide alone. These arementioned in a descending scale of mortality, fromwhich it may be concluded that sulphanilamide ismore efficient than serum. It would be interesting,though of course it is impossible, to know what themortality would have been in cases receiving neither,for the only element of doubt remaining concernsthe value of serum, and whether it should be givenin addition to sulphanilamide. Walsh,1 analysinglarge-scale American statistics, concludes that the

mortality during the past sixteen years has variedbetween 38 and 67 per cent., and that it has beenlittle influenced by treatment.

In assessing the value of serum, it is necessary totake account not only of the type of serum used butof the method of its use, and Dr. Banks’s policy ofmassive intravenous dosage may well be an importantfactor in success. The theory underlying the produc-tion of so-called meningococcus antitoxin has been asubject of some dispute, and the relative merits ofthis serum and those produced by immunisation withwhole meningococci have never been satisfactorilysettled. Whatever the method of preparation,different batches vary in potency, and the only con-clusive test of efficacy is that of clinical trial. It has

lately been suggested from an authoritative quarterin the United States 2 that an attempt should be made,by correlating clinical effect with the results of

laboratory test, to define some means of ensuringmore constant efficacy. In some ways it is astonishingthat while other forms of serum treatment havesteadily increased in reliability and precision, the

production of antimeningococcal serum should still beclouded with so much uncertainty.

It is a relief to turn from this difficult question tothe simplicity and certainty of sulphanilamide treat-ment. Here the work of Dr. Banks and his associatesfurnishes important information on one point thatwas still obscure: it now seems clear that when thedrug is given by the mouth an adequate concentra-tion appears in the cerebro-spinal fluid ; indeed withthe massive dosage used some of these concentrationsare higher than any hitherto recorded. The clearestand most emphatic conclusion to be drawn fromthese valuable observations is that every case of

meningococcal meningitis should be given largedoses of sulphanilamide at the earliest possiblemoment. Whether the intrathecal route of adminis-tration is unnecessary, as is suggested here, and whatare the indications, if any, for combined serum

treatment, are subsidiary questions which furtherexperience will doubtless settle. Another matterinto which inquiry might well be made is the effectof chemotherapy on the infection in the nasopharynx.This could readily be studied in cases of meningitis,or alternatively in carriers, for whom the treatment

1 Walsh, G., J. Amer. med. Ass. June 4th, 1938, p. 1894.2 Branham, Sarah E., Publ. Hlth Rep., Wash. April 29th,

1938, p. 645.

may solve a previously very difficult problem. Sincesulphanilamide has been found in every one of thebody fluids in which it has been looked for duringthe administration of the drug, including even

prostatic secretion, it presumably appears in the

nasopharyngeal mucus. If it should be found tocause the disappearance of meningococci from thissituation as rapidly as from the meninges, the carriercondition will for the first time be capable of readycontrol.

LEPROSY IN WESTERN EUROPE

FOR many years the medical profession in countriessuch as England and Wales has been happy in thebelief that leprosy was not contagious under WesternEuropean conditions. It was believed to be almostexclusively a colonial problem and-apart fromconcealing in decent obscurity those victims of

leprosy acquired abroad who had managed to slip backto the mother country-it was held to present noproblems for those European countries in which thesocial and hygienic standards were reasonably good.Certain facts set out by Prof. Charles Flandin in theProsser White oration reported on another pagesuggest that this complacent attitude may no

longer be justified. Prof. Flandin is in charge of aleprosy ward at the Hopital Saint Louis in Paris andhis sympathetic interest in lepers has led him todiscover 10 cases in the past three years which werebeyond dispute of indigenous origin, all in adultwhite French citizens who had never left France.Moreover the length of time between the first exposureto infection and the establishment of the diagnosiswas in some instances considerably shorter than hadhitherto been considered possible. In this country,according to an answer given by the Minister ofHealth in December, 1937, in the House of Commons,only 4 cases of possible indigenous origin have beendiscovered over a long period of years. As to thetotal number of lepers in England and in France,little is known. In France notification is compulsoryand 95 lepers have been traced in Paris alone. ButProf. Flandin thinks that the number may be consider-ably larger, since notification has proved a deterrentrather than an aid to ascertainment. In Englandand Wales-as appears from the Parliamentaryanswer quoted above-38 cases are known to theMinistry of Health.

Such are the facts. Has there been merely betterascertainment of indigenous cases in recent yearsor is Prof. Flandin right in his suspicion that a realincrease in indigenous cases is occurring ? If so, isthis due to an increased virulence of the disease orto a decrease in resistance in the host ? Since thelast native case of leprosy in Great Britain is supposedto have died in the Shetland Islands in 1798, it seemsdifficult to see why racial immunity, if any, shouldmaintain itself for a century or so and then

suddenly diminish: nor does it seem likely that the.number of those " exposed to risk " have increasedof recent years. Travelling facilities have certainlyimproved but the total number of lepers returningfrom abroad is not likely to have altered substantiallyin either England or France. If the increase in

indigenous cases is a real one-and this is by no meanscertain-the most likely explanation seems to liein a rise in virulence of the organism.A hopeful aspect of the situation is that Prof.

Flandin’s experience has not led him to reject orthodoxopinion on the conditions necessary for infection.

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To imagine. as the public does, that casual contactmay cause leprosy is, in his view, quite unjustifiable,and all his cases have arisen from close and prolongedcontact with a leper, as in the intimacies of familylife. Since notification and official action seem tobe definitely contra-indicated and since real hardshipand cruelty might be. and indeed have been,caused by ill-advised publicity, what can be done ?First, the possibility of leprosy must be borne in mindby the diagnostician and some sort of organisationfor the ascertainment of cases should be set on footto take the place of compulsory notification ; secondly,the public must learn to realise that there is no more-and no less-reason for a leper to be an outcast fromsociety than there is for a tuberculous person; and

thirdly, such cases of leprosy as require institutionaltreatment should be able to obtain it. In this countrythere exists but one institution for the receptionof lepers, the Homes of St. Giles, supported entirelyby voluntary contributions. Should the publicfail to provide all that is required from voluntarysources, here is a strong case for official subsidy.

INTESTINAL STASIS DUE TO

HYPOPROTEINÆMIA

HAVING shown 1 2 that stasis in the stomach follow-

ing Billroth operations Types I and II is associatedwith a low percentage of protein in the plasma,Barden and his associates 3 have now studied theeffects of artificially produced reduction of plasmaprotein on the mobility of the small intestine of

dogs. The reduction was obtained by feeding on aprotein-free diet or by bleeding and returning thecells only to the circulation, the plasma being removed.In each animal tested slowing of the intestinal move-ments could be demonstrated by X rays, and couldbe cured by raising the plasma protein to a normallevel, either by a high protein diet or by returningto the circulation the plasma which had previouslybeen withdrawn. The stasis was thought to be dueto oedema, which is recognised as a possible cause ofobstruction after operations on the stomach. These

findings suggest that an estimation of plasma proteinmight be a wise precaution before major abdominaloperations, particularly where the patient has beenon a restricted diet.

A METHOD OF PREVENTING OR ENDING

LACTATION

ACCORDING to Ramos and Colombo 4 of BuenosAires the artificial termination of lactation is achievedwith greatest certainty and safety by means of cestrin.They argue that after the breasts have enlarged duringpregnancy the final changes leading to the secretion ofmilk are inhibited by the oestrin circulating in theblood ; during the first three days of the puerperiumthe circulating oestrin rapidly disappears and milksecretion then begins. In the past two years they haveapplied this hypothesis to 50 cases in which inhibitionof milk secretion was required. The preparation

employed was oestradiol benzoate in an oilysolution, and the dose 10,000 units by intramuscularinjection at twelve-hourly intervals for three and

exceptionally for four doses, beginning when thestate of the mother or the death of the child made itadvisable that lactation should be suppressed. ’If

1 Barden, R. P., Ravdin, I. S., and Frazier, W. D., Amer. J.Roentgenol. 1937, 38, 196.

2 Mecray, P. M., Barden, R. P., and Ravdin, I. S., Surgery,1937, 1, 53.

3 Barden, R. P., Thompson, W. D., Ravdin, I. S., andFrank, I. L., Surg. Gynec. Obstet. 1938, 66, 819.

4 Dtsch. med. Wschr. May 27th, 1938, p. 782.

the injections are begun immediately after deliveryno other treatment is required, and the mother, itis stated, has no obvious discomfort or congestionof the breasts to remind her of the loss of her child.When milk secretion has begun it is advisable, besidesgiving the injections, to empty the breasts

mechanically between the second and third doses ofcestrin so that the third, or if necessary the fourth,dose can produce complete suppression. A curiousfeature of the success claimed for this method is thatonce the lactation has been stopped it does not

begin again unless a new pregnancy starts. Ramosand Colombo explain this by comparing the largedoses of oestrin they use with the much smaller amountsrecoverable from the blood of women during the earlypuerperium. They also believe that the oily secretionused is but slowly absorbed and thus maintains itseffect long enough to promote retrograde changes inthe secreting tissues in the breasts. Measurableamounts of oestrin could be detected in the patientsas long as twenty days after injection of the oilypreparation.As a sidelight, so to speak, Ramos and Colombo

offer a warning against the use of cestrin to inducelabour. They have observed gross interference withlactation during the first week of the puerperiumin three patients thus treated-an observation whichhelps to confirm the value of their method of suppress-ing lactation when this object alone is desired.

VITAMIN VALUES FOR FOODSTUFFS

A FEW months ago the issue of a monographby Miss Katherine Coward, D.Sc., on the biologicalstandardisation of the vitamins provided an importantmilestone in the science of nutrition. Another hasbeen reached with the publication of a new set oftables of the vitamin values of foodstuffs, in the

compilation of which a very important principle hasbeen applied. The tables are published as part ofVol. 7, Part 4 of Nutrition Abstracts and Reviews ;they can also be obtained separately (price 2s. 6d.)from the Imperial Bureau of Animal Nutrition,Rowett Institute, Aberdeen. They have been pre-pared by two competent workers in the vitaminfield of nutrition, Miss Margaret Boas Fixsen, D.Sc., andMiss M. H. Roscoe, Ph.D. The values have been collectedfrom the vast literature of the subject and have beencritically sifted, with a sieve woven, as it were, fromthe principles in Dr. Coward’s book. Only thosevalues have been admitted which have been obtained

by chemical or spectroscopic methods, or by approvedmethods of biological standardisation, that is, methodswhich include a simultaneous test against the inter-national standard, and yield results expressed ininternational units. No values expressed in purelybiological units of animal response have been accepted,and values obtained by converting such biologicalunits into international units by means of a fixedconversion factor have been rigorously excludedas being too variable to be reliable.The tables are the first of their kind to embody this

principle and they will be doubtless widely usedin dietary surveys to work out the vitamin values ofdiets after the data have been collected in the field.Those engaged on this intricate task may be warnedthat they will be disappointed if they hope to finda tidy, fixed value for each foodstuff in these tables.Instead they will be confronted with a very wide rangeof values, and will find it hard to decide which tochoose. The uncomfortable truth must be facedthat the vitamin values of foods do, in fact, vary verymuch even in the raw state, according to soil and