28

Central Health Services Council, which was intendedto play a really important part as the accessory

. brain and the voice of the service. Somehow or bysomeone, the large view must be taken, and we mustall be made to feel (as we should) that, amidunavoidable confusion and disappointment and hard-ship, we are progressing towards a service of highquality, soundly balanced. In the words of Prof.I. G. DAVIES 3 :

" Looking back on 1948 and the year subsequent,there is discernible a vast national system of medico-social services administered bv a number of differenttypes of authority and run by different kinds of adminis-trative machinerv. Not even the kindliest critic of thismachine could say that it worked smoothly or that itscomponents were properly synchronised with each other.. Is it too much to hope that some method will bedevised of integrating these different parts into one of thefinest national medico-social services yet seen ? The

parts are all there-it would be a pity to leave them asthey are."

Risks of Anti-histamine MedicationTHE introduction and development of anti-histamine

drugs in the last dozen years has been a notableadvance in theraputics, and their success in

allergic diseases has naturally led to their trial inailments on or beyond the borders of the allergicgroup. Since they have been particularly valuable inparoxysmal rhinorrhoea, it was inevitable that theyshould be tried in the common cold. In medicine,we are told, sensible experimentation is preferableto speculation, so such trials were obviously desirable.The aetiologies of the two conditions are generallyagreed to be quite different-the one allergic and theother a virus infection-but it was argued that thesymptoms of the early coryzal and congestive phasesof a cold might be allergic in origin and that at thisstage an anti-histamine drug might abort the coldbefore secondary infection had occurred.4 Individualpractitioners who have experimented on themselvesseem to agree that the anti-histamines afford some

symptomatic relief, and BREWSTER’s 5 trial in theU.S, Navy was encouraging so far as it went, thoughthe plan was subject to serious criticism. 6 On theother hand, PATON, FuLTON, and ANDREWES,7who emphasised the difficulty of assessing " coldcures," reported a small but carefully controlled

experiment to test the value of Anthisan’ andconcluded that the results did not show any dramaticeffect of this drug on the common cold. They addedthis rider concerning their findings :

" We do not bring them forward as evidence thatthere is no beneficial action, but only to draw attentionto the necessity for rigorous control of any test of aremedy for colds ; the need to depend on subjectivejudgmen,ts; by patient and clinician alike make suchtests particularly difficult."A cautious attitude on the part of doctors

is highly desirable, if only because the Poisons Boardhas not, so far, taken steps to prevent the publicfrom buying these toxic drugs over the counter.It is said. that by the Monday evening after an articlehad appeared in a Sunday newspaper on the virtuesof anti-histamines as a cold cure, stocks of them inthe chemists’ shops were almost exhausted. It seems

3. Medical Press, Dec. 14, 1949, p. 555.4. Cort, F. Brit. med. J. 1948, i, 758.5. Brewster, J. M. Nav. med. Bull., Wash. 1949, 49, 1.6. Annotation, Lancet, 1949, i, 489.7. Paton, W. D. M., Fulton, F., Andrewes, C. H. Ibid, p. 935.

likely that of the thousands of people who boughtthese drugs at least a third would experience sometoxic effect, such as drowsiness, giddiness, or the

peculiar psychological states of unreality and disorienta-tion. Trivial as this may appear, there will certainlybe tragic consequences if drivers of cars and publictransport dose themselves indiscriminately withanti-histamines. The decision not to include these

drugs in the Poisons Schedules was doubtless made ata time when it could reasonably be assumed that thepeople taking them would normally be under imme-diate medical supervision. Today this applies onlyto a minority, and the change of circumstances hascreated a potential danger which merits immediateintervention by the Ministry of Health. The possi-bility that a labyrinthitis may develop on withdrawalof anti-histamine therapy, of which three examplesare reported by CHERRY 8 for South Australia, alsodeserves consideration.

According to reports reaching this office severalchildren have died from eating sugar-coated anti-histamine tablets as sweets. In cases of acute

poisoning by anti-histamines the obvious antidote ishistamine acid phosphate, injected subcutaneouslyin doses of 0’1 mg. per kg. of body-weight. Tabletswhich are vividly coloured and sweet to taste canscarcely be resisted by a normal child, and we havethe unfortunate experience with ferrous sulphatetablets as evidence of this fact. Responsibility forsafe disposal of poisons in the household rests withits adult members ; but manufacturers might con-sider whether the time has not come to incorporateinto the coating of these tablets a trace of some bittersubstance which would discourage a child without

causing undue hardship to adults.

Prognosis in Myocardial InfarctionTHE mortality from coronary disease appears to be

increasing. In his Harveian oration of 1946, CASSIDY 9voiced his conviction that the increase could not be

explained by more accurate certification ; and hepointed out that relatively few cases were seen by thegreat physicians of the past, such as MACKENZIE andOSLER, or by the astute morbid anatomists of thosedays, though they were fully alive to the existenceof the condition. According to the Registrar-General’sreturns, deaths in England and Wales from coronarydisease numbered 1880 in 1926, 25,012 in 1945, and33,168 in 1947. This is a startling increase ; andRYLE and RussELL., after allowing for changingfashions in diagnosis, amendments to the inter-national classification of causes of death, and thelengthening span of life, conclude that the increase isreal. Similar figures have in fact been publishedin the U.S.A., where 28,286 fatal cases were recordedin 1930; 101,467 in 1940, and 113,636 in 1942."And at the Royal Adelaide Hospital,12 in Australia,the proportion of necropsies showing cardiac infarctionrose from 1-1% in 1935 to 45% in 1946

In myocardial infarction death often follows imme-diately on the onset of symptoms, or it may comewithout any warning at all; probably some 30%of all natural sudden deaths are due to coronary-

8. Cherry, A. Med. J. Aust. 1949, ii, 540.9. Cassidy, M. Lancet, 1946, ii, 587.

10. Ryle, J. A., Russell, W. T. Brit. Heart J. 1949, 11, 370.11. U.S. Bureau of the Census : Vital Statistics 1942, Part I.

Washington, 1944.12. Cleland, J. B. Med. J. Aust. 1949, ii, 733.

29

artery disease.13 Statistics on prognosis are unsatis-factory for several reasons. There are inevitablevariations between cases admitted to hospital andthose treated at home. Some patients will be regarded-as too ill to be moved to hospital, or will refuse to go ;others will be regarded as too ill to be nursed at home,or circumstances may make home nursing impossible.On the whole, however, the more serious cases willbe treated in hospital, and it is on hospital groupsthat most reports are made. On the other hand, hos-pital treatment may well be more effective, especiallyin these days of anticoagulants. Some years agoPARKINSON and BEDFORD 14 reported that of 100

patients who did not die immediately, 23 died withinsix months and a further 7 within two years. CONNERand HOLT 15 found shortly afterwards that of 209cases about 16% died in the first attack ; of those whosurvived this, 75% were alive at the end of a year,- 56% at the end of two years, 21 % at the end of fiveyears, and 3-5% at the end of ten years. In 1931WHITE and BLAND 16 recorded that 10% died withina month and a further 17% within a year. In 1935BEDFORD 117 remarked that the outlook is alwaysuncertain until the danger period of the first threeweeks is past, though the chances are definitelyin favour of recovery ; that 25% of cases died within6-8 weeks ; and that thereafter there was a good,chance of fair health and activity for some years,and a possibility of surviving more than five years.PALMER 18 found that of those who survived thefirst three months 75% were alive after five years.and almost 40% after ten years. LsviNE and RosEN-BAUM,19 however, observed that the average expectationof life was only 31/2 years. In a recent investigation of866 cases in Servicemen under 40 years of age, YATERand his colleagues 20 found that of 450 who died noless than 83% did so within twenty-four hours of theonset of symptoms. How grave myocardial infarctioncan be in a hospital series has lately been illustratedby KATz and his colleagues 21 of the Michael ReeseHospital, Chicago, who analysed 488 cases admittedto a general hospital. About a quarter of these patientsdied in the first two months, about half had died bythe end of a year, about two-thirds by the end. of thethird year, and about four-fifths by the end of fiveyears. Thus the survival-rate fell from 72% at twomonths to 55% at a year and to 16% at five years.

It is now realised not only that infarction may bepainless but that coronary occlusion often takes placewithout infarction and infarction without occlusion. 22 23It is generally conceded, too, that the prognosis forpatients with angina pectoris is better than for thosewith clinically manifest infarction. Among 3000cases of angina which were followed up by PARKERand others,24 the average five-year survival-rate was71% for women and 58% for men, and the average13. Rabson, S. M.. Helpern, M. Amer. Heart J. 1947, 35, 635.14. Parkinson, J., Bedford, D. E. Lancet, 1928, i, 4.15. Conner, L. A., Holt, E. Amer. Heart J. 1930, 5, 705.16. White, P. D., Bland, E. F. Ibid, 1931, 7, 1.17. Bedford, D. E. Lancet, 1935, i, 223.18. Palmer, J. H. Quart. J. Med. 1937, 6, 49.19. Levine, S. A., Rosenbaum, F. F. Arch. intern. Med. 1941,

68, 1215.20. Yater, W. M., Traum, A. H., Brown, W. G., Fitzgerald, R. P.,

Geisler, M. A., Wilcox, B. B. Amer. Heart J. 1948, 36, 334.21. Katz, L. N., Mills, G. Y., Cisneros, F. Arch. intern. Med.

1949, 84, 305.22. Blumgart, H. L., Schlesinger, M. J., Zoll, P. M. J. Amer.

med. Ass. 1941, 116, 91.23. Ravin, A., Gerver, E. F. Arch. intern. Med. 1946, 78, 125.24. Parker, R. L., Dry, T. J., Willius, F. A., Gage, R. P. J. Amer.

med. Ass. 1946, 131, 95.

ten-year survival-rate was 49% for women and 33%for men. Questioning of patients with angina oftenelicits the history of an episode suggesting myocardialinfarction some time-perhaps years-previously ;and electrocardiography commonly brings to lightunequivocal evidence of previous infarction. Someof these patients have kept on with their work, orgone back to it in a few days, after what in retrospectwas clearly an infarction ; but others seek advicefor even minor pain and have thus been put to bedat home or admitted to hospital. There can be all

grades of infarction, from the death of a small areaof myocardium, or even of a few fibres, to extensivenecrosis of large areas of ventricular wall. Suitabletreatment may make all the difference to the outcome.Rest- and relaxation are of paramount importance.Some patients will need oxygen and others treatmentfor shock. Continued pain demands relief, and thoughmorphine is the usual standby GIBSON 25 emphasisesthe value of aspirin. If a serious arrhythmia develops,quinidine may be life-saving, or it may be useful

prophylactically. Digitalis will be needed for congestivefailure. Above all, perhaps, there are the possibilitiesof anticoagulant therapy.The causes of death in the first two months are

worth considering in detail. In KATZ’s 21 series,further myocardial infarction was responsible for

65% of the deaths and in that of LEVINE andROSENBAUM 19 for 40%. Next in importance is pul-monary infarction, and then peripheral arterialembolism, which may involve vital areas such as thebrain or mesentery. In an analysis of 1605 clinicalcases of myocardial infarction collected from elevenreports, HELLERSTEIN and MARTIN 26 found that

11.5% had clinically detectable lesions due to throm-bosis or embolism. In their own series of 160 necrop-sies, infarction was found in 45% ; in 12% of thesecases this was held to be the main cause of death andin a further 15% a contributory cause. Here then isa promising field for anticoagulant therapy. Heparinand dicoumarol might well be expected to lower theincidence of mural thrombosis over the site of infare-tion in the ventricles and hence of arterial embolism.

They help to prevent peripheral venous thrombosis,with its risk of subsequent pulmonary infarction ;they probably limit the " build-up " of further throm-bus behind the obstructed coronary artery; and theymay also reduce the likelihood of further coronarythrombosis in other vessels during the period of hospitaltreatment. The American Heart Association set upa committee in 1946 to collect data on this subjectfrom teaching centres, and the resulting seriesof 800 cases was divided into two groups. One groupwas treated in a standard way with dicoumarol, some-times plus heparin, and the other served as controls.A preliminary report 27 showed encouraging results,which have been confirmed by other workers. Overthe six weeks’ period of observation, the death-ratein the treated group was 14-9%, compared with 24%in the untreated group. The incidence of thrombo-embolic complications was 11% compared with 25%.Moreover, about half the treated series experiencedcomplications before the anticoagulant drugs had had25. Gibson, P. C. Lancet, 1949, ii, 1172.26. Hellerstein, H. K., Martin, J. W. Amer. Heart J. 1947, 33,

443.27. Wright, I. S., Marple, C. D., Beck, D. F. Ibid, 1948, 36,

801 ; J. Amer. med. Ass. 1948, 138, 1074.

30

time to become fully effective. Since the risk of these

complications is greatest in the first four weeks andthereafter decreases rapidly, the prospects for suchtreatment influencing prognosis are bright. This formof treatment cannot be undertaken in the patient’shome and is possible only in a hospital with sufficientlaboratory resources. The necessary estimations of

prothrombin-time with a daily control require parti-cular care and involve dangers for the unwary. Thisraises the question whether myocardial infarctionshould not be regarded as an indication for urgentadmission to hospital. With prompt hospital treat-ment (not to mention inclusion of the many moreminor cases which can now be diagnosed) the resultsof the future may be a good deal less gloomy.

Intestinal IntubationDECOMPRESSION of the obstructed small intestine

by aspiration through swallowed tubes is a valuableand widely used measure. Like all potent remedies inmedicine it has its snags and dangers. The intestineis intubated with more difficulty than the stomachbecause the pylorus often refuses to pass the bulkytip of a Miller-Abbott or similar tube. The sub-stitution of a bag containing mercury for the moreusual air balloon on the end of these long tubes isone of the devices used to facilitate their trans-mission through the pylorus, and HARRIS and GORDON 1have lately- recorded their experiences with such atube. Its advantages are that, as it requires only onelumen, the whole diameter of the tube can be used forits primary purpose of aspiration; and that it passesthe pylorus more easily than its double-lumen pre-decessors, especially if, once its tip is in the stomach,it is left to descend spontaneously and unaided bywell-intentioned hands. Rupture of the bag containingthe mercury in 4 cases caused HARRIS and GORDONsome alarm, but those familiar with the writings ofthe late Dr. THOMAS DOVER 2 will recall his habit of

prescribing metallic mercury in daily doses of an ouncefor 4 variety of disorders, and will know that mercuryin the intestine seemed to do his patients no harm.One of them, Captain CoLT, =writing about the year1740, estimated that he had swallowed 120 lb. of

quicksilver over a period of nine years, with completerelief of his gout !

’

The usual trouble with an intestinal tube is that itwill not go far enough ; but on occasion it maygo too far. Not only is a tube whose tip lies in thecolon useless- for decompressing the small intestine,but apparently it may irritate the small intestineto the point of aggravating the ileus it is supposed torelieve. In our present issue Dr. FRANK reportsan extraordinary case in which the balloon of a10 ft. tube was seen at the anus when over 3 ft. ofthe suction end still protruded from the nose ; the

patient’s ileus passed off spontaneously when thetube was removed per rectum. HARRIS and GORDONadvise that if a long tube passes through the ileo-csecal valve it should be cut off at the nose and leftto, be evacuated per rectum, since attempts to pullit back may damage the bowel. They think that theposition of the tip of a tube should be checked byX-ray examination when the 3 ft. mark has reached1. Harris, F. I., Gordon, M. Surg. Gynec. Obstet. 1948, 86, 647.2. Dover, T. The Ancient Physician’s Legacy to his Country.

7th ed., London, 1762; p. 37 et seq.

the nose, and that only 2-3 ft. of tube in the smallintestine is needed for satisfactory decompression.They believe that 6 ft. is the proper length for anintestinal tube. A curious difficulty they encounteredwas swelling of the mercury-filled bag in tubes whichremained in situ a long time-a swelling due to thepermeability of rubber to carbon dioxide. In a single-lumen tube the added - carbon dioxide cannot beevacuated and may make it impossible to with-draw the tube. On three such occasions the tube

passed per rectum, but in a fourth case operationwas required. POOL has recorded another curiousoccurrence, in a patient with a gastro-enterostomy.A long tube was passed into the jejunum via theduodenum, re-entered the stomach through theartificial stoma, and continued on this merry-go-roundfor three revolutions, knotting itself in the process.It had to be removed by operation. (The case of thedisappearing mercury bougie, recorded on anotherpage, is simple compared with these others, butnone the less instructive to those who use such things.)None of the papers mentioned deal with the rare

pressure necrosis which long residence of a tube maycause in the nose, behind the larynx, or above thecardia ; nor do they refer to the slight but definiteinterference with post-anaesthetic coughing. Thebiochemical difficulties which the body encountersthrough continuous removal of gastro-intestinal juicesmust also be reckoned on the debit side. Thoughundoubtedly a great blessing, intestinal aspirationis by no means foolproof.

Annotations

HOW TO TEACH HEALTH PRINCIPLES

CONVINCING arguments are wasted on those whochoose not to hear them. Dr. lago Galdston,4 reviewingthe history of health education, recalls the early anti-tuberculosis campaigns, in which plain facts given as

starkly as possible were expected to raise standards ofsanitation and cleanliness. But people were not reallyinterested-partly, as he points out, because this wasdisease education rather than health education. An eraof jolly little health rhymes and animated cartoons hasfollowed, and is doing rather better ; but these toofail with most people because they are minatory andinstructive. - They try to condition the reader to betterhabits ; but it is impossible to condition anyone whoseinterests are not in some way engaged. Pavlov’s dog,when his mouth watered in obedience to the bell, wasinterested in his dinner ; but health education has noimmediate appeal to any of the body’s instincts. Dr.Galdston thinks that nobody except a hypochondriac" wants " health in a positive way ; the ordinary personwants not to be bothered bv bad health and wants totake his good health for granted without having tothink about it. He also wants many things for whichgood health is essential-to eat, move, rest, and servehis body’s needs-but he puts them first and healthnowhere, for he will often pursue them at the expenseof health. Though the growing boy will govern and directhis appetite when he is in training, he does it not onaccount of any abstract ideal of health but because hewants his side to win.Well then, Dr. Galdston suggests, we must approach

people through their living interests if we want to

improve their health..Unfortunately he does not give3. Pool, R. M. Ann. Surg. 1949, 130, 267.4. Amer. J. publ. Hlth, 1949, 39, 1276.