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arteries in tuberculous meningitis and commentedfor the first time on the fibrinoid swelling of theintima, a finding stressed by most subsequent writers.At one time it was believed that the arteries wereinvolved from within by the haematogenous spread oftubercle bacilli, 9 but later histological evidenceshowed convincingly that they were affected fromthe outside in their passage through adjacent meningealexudate.1O More recently, WINKELMAN and MOORE 11in America gave an excellent description of thediverse pathological changes in the basal vessels ofthe brain, and in this country SMITH and DANIEL,12anticipating the introduction of streptomycin andother chemotherapeutic agents against tuberculosis,dealt with the clinical and pathological aspects ofcentral nervous system involvement. SMITH andDANIEL emphasised the destructive changes in themeningeal and smaller penetrating vessels of thebrain, which they felt were a sufficient basis forthe softening commonly found. They rightly pointedout that if the treatment of tuberculous meningitisis to achieve recovery and not mere survival it mustbe started before these vascular changes produceischsemic lesions and their accompanying cripplingeffects. Their timely warning must be taken toheart if permanent sequelae are to be avoided.The latest study is that of DomrAOH,i3 who confirmsthe findings in the meningeal vessels in acute untreatedtuberculous meningitis and contrasts the histologicalchanges with those found in unsuccessfully treatedchildren under the age of 7 years who had survivedfor periods ranging from a few weeks to just over oneyear. Some of his cases had relapsed after completinga course of streptomycin. Scarring of the basalvessels with reduction or obliteration of their lumenwas the most striking change in cases which had sur-vived for ten weeks or more. In treated cases dyingwithin a month of onset the picture was essentiallysimilar to that in the untreated controls. There was

nothing to suggest that the streptomycin introducedintrathecally was responsible for the vascular effects ;they could all be explained in terms of the prolongationof life. Indeed, similar changes have been recordedbefore in untreated cases where life had been prolongedseveral weeks after the appearance of meningealsigns.11 In both the untreated and treated groupsthe medial coat of an involved vessel seemed to playa purely passive rôle, and, though sometimes har-bouring a few migrating cells, usually preserved anormal appearance between the affected intima andadventitia. Occasionally, all three coats and thelumen were involved in a caseous necrosis whichformed part of a more extensive meningeal lesion.In the relapse group scarred vessels imbedded in oldfibrous exudate were associated with acutely inflamedvessels caught in fresh exudate.

Experience with the treatment of tuberculous

meningitis has shown that cases presenting with focalsigns in the nervous system usually carry a bad

prognosis, and that the relapse-rate in patients whorespond to an initial course of treatment is high9. Hektoen, L. J. exp. Med. 1896, 1, 112.

10. Rich, A. R., McCordock, H. A. Bull. Johns Hopk. Hosp. 1933,52, 5.

11. Winkelman, N. W., Moore, M. T. Amer. Rev. Tuberc. 1940,42, 315

12. Smith, H. V., Daniel, P. Tubercle, 1947, 28, 64.13. Doniach, I. J. Path. Bact. 1949, 61, 253.

when there are residual neurological signs. The

pathology of untreated and treated cases provides arational basis for this clinical observation and alsounderlines the need for early diagnosis and earlytreatment. Our aim must be to give streptomycinbefore exudate and adhesions have formed in thesubarachnoid space, and if we accept the work ofMACGREGOR and GREEN 14 this is a comparativelylate event. Once this basal exudate becomes exten-sive the normal now of cerebrospinal fluid to theabsorbing area at the vertex may be obstructed,causing hydrocephaly; the free circulation of

streptomycin introduced into the subarachnoid path-ways from below may be impeded, so that its accessto all the sites of infection becomes difficult or

impossible ; various cranial nerves in relation to thebase of the brain may be constricted and damaged,leading to blindness and permanent nerve palsies ;and lastly, as we have seen, irreversible changes maybe induced in the basal meningeal vessels coursingthrough the tuberculous exudate.

Annotations

WATER ! WATER!

THE warning given last month by a working party ofexperienced water engineers 15 has received too littleattention. They tell us that supply cannot meet demand.The population increases ; agriculture and industry,working at high pressure, need quantities of water;housing schemes are pressed forward as fast as presentconditions permit ; new towns are springing up ; greaterdomestic comfort and convenience are expected ; villagescry out for piped supplies ; indoor sanitation and propersewerage must follow ; progressive municipalities nowa-days ask Parliament for powers to furnish hot waterto householders—indeed, in the last few days the earlystages of next year’s local legislation have revealed thatseven more local authorities are petitioning for thisfashionable form of civic enterprise. All these phenomenamay be matter for admiring congratulation, but they alldemand more and more water. The water is not there.

In the ten years from 1938 consumption has gone upby 20% in England and Wales and by 10% in Scotland.Statistics indicate that, if the rate of increase continues,water undertakings will be faced in 1970 with a demandfor twice the amount consumed in 1938. Water under-takers are several years behindhand in the normal

expansion of their works. The war prevented capitalexpansion and deferred the tasks of maintenance ; post-war shortages of labour and materials obstruct themaking good of arrears. Water-supply is linked withsewage disposal. " Here again," say the engineers,

" theforeseeable demands far exceed potential resources."

They anticipate increasing competition from the new

hospital and health services, and from local governmentneeds, for the labour and materials allocated to the healthdepartments of England and Scotland ; and all these

requirements " must be related to those of coal, gas, oil,transport, power and the export trades." Things mayright themselves in time, but meanwhile there is some-thing like a crisis in the short-term prospect.Can anything be done ? Well, at least, say the

engineers, we can try to eliminate waste. Mr. G. M.McNaughton, chief engineer to the Ministry of Health,stated recently that, if a figure of eight gallons per headwere taken as the daily waste, it represented approxi-11. Macgregor, A. R., Green, C. A. Ibid, 1937, 45, 613.15. Interim report of the Comittee on Causes of Increase in Con-

sumption of Water : Ministry of Health.

1092

mately the whole supply to London or the supply tosix towns the size of Manchester. The engineers’ reportdevotes several pages to technical methods of detectingand preventing waste. As most of our urban systems areabout a century old, plant must be looked to. Extremesof weather, traffic vibration, soil subsidence, air-raidconcussion, and the use of the " booster " will have

damaged mains and service pipes. In one recent instancea serious drop in the level of a reservoir was traced to aleak from which over 40,000 gallons had been escapingdaily for a long period into an underground cavity.Undertakings are advised to review their system of

inspection-is closer supervision wanted, is existingman-power properly used, ought more inspectors to beappointed, is their training adequate, are records of

supply and consumption (including night flow) kept,can waste-water metering be adopted or extended, areall physical measures against corrosion, faulty fittings,and bad workmanship being applied, can water suppliedfor industrial use be recirculated ? ‘1 Above all, can

consumers be induced to cooperate 1 Can they be madeto realise that, before the finished product reaches thetap, expensive steps have to be taken to collect it, storeit, treat it, and distribute it 1 The cottager who carrieshis supply in a bucket from a well is naturally morethrifty than the folk who have been brought up in acomplacent world where a tap is turned on and watergushes forth abundantly. Some better propaganda iswanted than the mere repetition of injunctions not towaste water. During the next few years there will be aformidable menace to our improving standards of publichealth and personal hygiene. What are we doing about it? ‘

THE CHRONIC WARDS REVIEWED

3TUDIES 01 the agea sick in Hospital are multiptyrngas our understanding of what can be done for these oldpeople grows. Last week we published a review, byDr. J. M. Greenwood, of 399 patients in the chronicwards of a general hospital in Manchester ; and thisweek Dr. G. F. Adams gives an account of 310 patientstreated in the chronic wards of the Belfast City Hospitalbetween August, 1948, and July, 1949. A report on701 patients in Bradford hospitals, by Mr. PeterMcEwan and Dr. S. G. Laverty, has also appeared, andwe reprint some of their conclusions. All three studiesserve to drive home once more the lesson that a verylarge proportion of cases formerly thought to be hope-less can be expected to respond well to treatment. AtManchester 205 out of the 399 were adjudged likely tobenefit. At Belfast 58 of the 310 patients were classedas " elderly infirm," 67 as remediable sick, 107 as

irremediable sick, and 78 as psychiatric cases ; but atthe end of a year 14 who had been classed as irremediableand bedfast had advanced to the ranks of the elderlyinfirm-i.e., they were up, dressed, and walking for thebest part of the day-and 10 more " irremediables "

had benefited enough to go home or to be transferredto resident homes. Against this must be set the factthat 15 who were expected to respond to treatment hadnot done so. In all, however, 76 patients had responded.The Bradford survey is not concerned with treatment,but is a careful estimate of the physical state of the

patients-" the final result of the hospital system of thepast, which is now, it is to be hoped, nearly at an end."Even for these old people, decrepit in body and mind,much can be done ; but the chief aim of the geriatricservice, in McEwan and Laverty’s opinion, must be tokeep other old people from falling into a like state.

All the writers agree that this can only be done if

enough resident homes are provided into which the

hospitals can transfer reabled old people who are home-less, or whose homes are unsuitable for their return.Such homes will free hospital beds for those who needactive treatment ; and the old atmosphere of stagna-

tion in chronic wards can be exchanged-as pioneershave shown already-for a spirit of liveliness and hope.Dr. Adams reminds us of Mr. L. Z. Cosin’s findingsthat among patients over sixty admitted to chronicwards, 40% may be expected to die within a year, but40% can be made fit enough to be discharged, and only20% will need continued care in a long-stay annexe.By treating such old people actively Dr. Marjory Warrenhas been able to empty beds long filled, and to substitute200 beds with a turnover for 700 beds with stagnation.

RETICULOCYTES AND LIVER ACTIVITY

WHEN a potent liver preparation is given by any routeto a patient with pernicious ansemia in relapse, thefirst striking change to be seen in the peripheral bloodis an increase in reticulocytes ; the proportion of reticulo-cytes rises steadily for a few days to a peak and thenfalls, though to a still elevated level. The rise andfall takes about a fortnight, at the end of which thered-cell count and haemoglobin level are found to be raised,and this rise is sustained if further treatment is given.The " reticulocyte peak " was one of the earliest observa-tions made when liver treatment for pernicious anaemiawas introduced, and it was noted that the peak per-centage of reticulocytes reached was roughly inverselyproportional to the initial red-cell count-i.e., the lowerthe red-cell count before treatment the higher the

reticulocyte peak produced by a given dose of a certainliver preparation. It is not surprising therefore thatmany attempts have been made to devise formul2efrom which the height of the reticulocyte peak or the risein red cells and haemoglobin could be predicted from theinitial red-cell and haemoglobin levels. With a reliableformula of this kind the actual results produced by abatch of liver extract could be compared with the expectedresults and the comparison used as an estimate of thepotency of the batch.

This game of formula-devising has now gone on forsome twenty years with indifferent success. No formula-has been generally accepted or has recommended itselfto interested official bodies in this country. Muchdestructive criticism has been levelled at them, and inour last issue Dr. Kohári-Kuchárik quoted some of thedisadvantages and proposed another remedy. Lately,Clark 1 collected a vast amount of information from therecords of 228 pernicious-anaemia patients in the U.S.A.He found that less than half of the reticulocyte peaksobtained reached the standards calculated accordingto those used by the U.S. Pharmacopoeia anti-anaemiapreparations advisory board. And closer investigationrevealed three serious difficulties : (1) that the same lotof liver extract given to patients with very similar initialred-cell counts could produce widely differing reticulo-cyte peaks ; (2) that there could be a good reticulocytepeak and yet a poor subsequent rise in red cells andhaemoglobin ; and (3) that there could be almost noreticulocytosis and yet the red cells and haemoglobinrose at maximum rate. Della Vida 2 sought to over-

come these difficulties by eliminating the reticulocyte-count altogether from the calculations and basinghis assay on the initial red-cell count and the averagerise in red cells during the first fortnight after treat-ment ; but his formula too does not overcome the

disadvantages inherent in such methods.These findings will surprise few workers who have

had long experience in observing the effect of liverextracts on pernicious anaemia. In fact, individualvariation of response can cause so much confusion thatthe surprising thing is not that these formulae are

criticised but that their results were ever consistentenough for them to be seriously considered. With ananimal test, the variations could perhaps be minimised

1. Clark, G. W. Amer. J. med. Sci. 1948, 216, 71.2. Della Vida, B. L. Lancet, 1942, ii, 275.