of 1 /1
1320 ment seemed possible: fewer tubercle bacilli might be excreted; those excreted, especially if resistant to isoniazid (on the analogy of animal experiments), might be less able to produce infection; or the general hygienic measures recommended to every patient might be having some effect. In view of the national habit of spitting, this last seemed improbable, but each factor probably played a part. As was expected, strains of tubercle bacilli resistant to isoniazid have appeared over and above the 4% found before this campaign began, but so far they have not spread widely. The testing of the drug sensitivity of the organisms isolated from newly discovered cases must be pursued indefinitely to give some warning of an accumula- tion of resistant strains. Subclinical infections due to these may be the gravest difficulty which this programme meets. A similar experimental eradication scheme, involving different drugs, is in progress in East Africa.4 No-one has yet cared to forecast how long these projects must con- tinue ; but at the end of ten years it may be safe to say, not that tuberculosis is eradicable, but that the tide has turned. RECURRING ULCERS OF THE MOUTH THE unpleasant disorder of recurring ulceration of the mouth is sometimes called aphthous ulcers or canker sores -terms of little value. Many people have these ulcers at some time or other, but only those who have had frequent recurrences know how much distress they can cause. Ulcers appear on the buccal mucosa inside the lips and opposite the molars, on the tongue, and on the soft palate and anterior pillars of the fauces. They are extremely painful but usually heal within a few days, although in some attacks one or two ulcers take a few weeks to heal, with prolonged pain and scarring, probably because of secondary infection. The epidemiology is best studied in general practice where there are many opportunities to observe the natural history of the condition. Usually the trouble starts in the late teens or early twenties, and women are more likely to be affected than men. In a few women the onset may be delayed until the menopause. In a large group of patients recurrences come fairly regularly every two to four months, though in many others attacks are as rare as every few years. Ultimately after some twenty or thirty years, the attacks subside, and it is distinctly rare to see this con- dition over the age of 60. Probably therefore, like some psychosomatic conditions, such as asthma, duodenal ulcer, and migraine, the condition " burns itself out". There are probably many causes. Attacks may be related to menses, to mental stress, to local trauma, and to certain foods, such as nuts and chocolate. Although recurrent aphthous ulcers have been commonly supposed to be due to a virus, no virus has ever been isolated from scrapings; and these ulcers run a different clinical course from those other common conditions of the mouth and lips-recurrent cold sores and herpes simplex. As might be expected, treatment is very unsatisfactory. The many suggested remedies include hormones for menstrual episodes, and even systemic steroids in severe cases, hydrocortisone tablets dissolved in the mouth, antibiotics, and (indefensibly) local radiotherapy. Nothing has proved to be anywhere near the consistent answer. We draw attention to this situation because we received 4. East African/British Medical Research Council. Tubercle, Lond. 1963, 44, 301. See Lancet, Oct. 19, 1963, p. 817. a letter from a patient who had long been seeking relief from recurrent ulcers. Her experience and our researches suggest that it is best, at present, to say plainly to the patient that this is a minor illness for which we have no effective treatment. NUTRITION EDUCATION PROTEIN deficiency is the most important nutritional disorder in the world today. It affects the health of hundreds of millions of people in the underdeveloped countries, and is responsible for a high mortality in pre- school children. Foods rich in protein, especially animal protein, are expensive, and poverty is an important cause of diets being inadequate in protein. Nevertheless physicians who work in the rapidly growing big cities in countries in Asia, Africa, and Latin America see severe kwashiorkor in children whose parents have incomes which allow them to enjoy some of the amenities and minor luxuries of urban life. Many of the mothers have migrated from the countryside. In their old homes the traditional way of life, based on peasant agriculture, usually provided a diet at least adequate in protein, except in seasons of scarcity. In the towns these young people have to become accustomed to changed dietary habits with many new foods which they have to buy. Further, urban mothers, often owing to the necessity to go out and work, tend to wean their infants early and so cut them off from a supply of protein which, even if small in quantity, is always of high quality. The need for education in how to spend money on food is very great in many parts of the world. F.A.O. have produced a useful little manual 1 which describes how to run an educational campaign to increase consumption of protein. The details are almost entirely concerned with fish promotion (it is proper to take a word from the advertising business) in countries in Latin America and North Africa But the general principles can be applied in other places and to other types of protein-rich food. This report is profusely illustrated with pen-and-ink drawings, many of which are very funny, and with photographs, some of which are very beautiful. The author, John Fridthjof, is clearly a man of imagination. All health educationists would probably like to see his book, even if they are not concerned with his special problems. CENTRAL HEALTH SERVICES COUNCIL IT seems a long time since July 27, 1949, when this Council held its first meeting and " Mr. F. Messer, M.P., was elected chairman and Prof. Henry Cohen vice-chair- man ". Lord Cohen of Birkenhead, who succeeded to Sir Frederich Messer’s post in 1957, can look back on fourteen years of solid, thoughtful, and discerning public service with the Council, through which the Ministry of Health and the N.H.S. have benefited from professional opinion on a great number of topics, from the small to the very large. As chairman of the C.H.S.C. he is suc- ceeded by Sir Howard Collingwood (chairman of the Newcastle Regional Hospital Board), while as chairman of the Standing Medical Advisory Committee-an appointment he has held since the beginning of the N.H.S.-he is followed by Prof. R. E. Tunbridge. The vice-chairman of this committee is now Prof. Hedley Atkins. 1. Encouraging the Use of Protein-Rich Foods. Rome: Food and Agri- cultural Organisation. Obtainable from H.M. Stationery Office, P.O. Box 569, London, S.E.1. Pp. 103. 5s.

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ment seemed possible: fewer tubercle bacilli might beexcreted; those excreted, especially if resistant to isoniazid(on the analogy of animal experiments), might be lessable to produce infection; or the general hygienic measuresrecommended to every patient might be having someeffect. In view of the national habit of spitting, this lastseemed improbable, but each factor probably played apart. As was expected, strains of tubercle bacilli resistantto isoniazid have appeared over and above the 4% foundbefore this campaign began, but so far they have notspread widely. The testing of the drug sensitivity of theorganisms isolated from newly discovered cases must bepursued indefinitely to give some warning of an accumula-tion of resistant strains. Subclinical infections due tothese may be the gravest difficulty which this programmemeets.

A similar experimental eradication scheme, involvingdifferent drugs, is in progress in East Africa.4 No-one hasyet cared to forecast how long these projects must con-tinue ; but at the end of ten years it may be safe to say,not that tuberculosis is eradicable, but that the tide hasturned.

RECURRING ULCERS OF THE MOUTH

THE unpleasant disorder of recurring ulceration of themouth is sometimes called aphthous ulcers or canker sores-terms of little value. Many people have these ulcers atsome time or other, but only those who have had frequentrecurrences know how much distress they can cause.

Ulcers appear on the buccal mucosa inside the lips andopposite the molars, on the tongue, and on the soft palateand anterior pillars of the fauces. They are extremelypainful but usually heal within a few days, although insome attacks one or two ulcers take a few weeks to heal,with prolonged pain and scarring, probably because ofsecondary infection.The epidemiology is best studied in general practice

where there are many opportunities to observe the naturalhistory of the condition. Usually the trouble starts in thelate teens or early twenties, and women are more likely tobe affected than men. In a few women the onset may be

delayed until the menopause. In a large group of patientsrecurrences come fairly regularly every two to four months,though in many others attacks are as rare as every fewyears. Ultimately after some twenty or thirty years, theattacks subside, and it is distinctly rare to see this con-dition over the age of 60. Probably therefore, like somepsychosomatic conditions, such as asthma, duodenal ulcer,and migraine, the condition " burns itself out".There are probably many causes. Attacks may be

related to menses, to mental stress, to local trauma, andto certain foods, such as nuts and chocolate. Althoughrecurrent aphthous ulcers have been commonly supposedto be due to a virus, no virus has ever been isolated fromscrapings; and these ulcers run a different clinical coursefrom those other common conditions of the mouth and

lips-recurrent cold sores and herpes simplex.As might be expected, treatment is very unsatisfactory.

The many suggested remedies include hormones formenstrual episodes, and even systemic steroids in severecases, hydrocortisone tablets dissolved in the mouth,antibiotics, and (indefensibly) local radiotherapy. Nothinghas proved to be anywhere near the consistent answer.We draw attention to this situation because we received4. East African/British Medical Research Council. Tubercle, Lond. 1963,

44, 301. See Lancet, Oct. 19, 1963, p. 817.

a letter from a patient who had long been seeking relieffrom recurrent ulcers. Her experience and our researchessuggest that it is best, at present, to say plainly to thepatient that this is a minor illness for which we have noeffective treatment.

NUTRITION EDUCATION

PROTEIN deficiency is the most important nutritionaldisorder in the world today. It affects the health ofhundreds of millions of people in the underdevelopedcountries, and is responsible for a high mortality in pre-school children. Foods rich in protein, especially animalprotein, are expensive, and poverty is an important causeof diets being inadequate in protein. Nevertheless

physicians who work in the rapidly growing big cities incountries in Asia, Africa, and Latin America see severekwashiorkor in children whose parents have incomeswhich allow them to enjoy some of the amenities andminor luxuries of urban life. Many of the mothers havemigrated from the countryside. In their old homes thetraditional way of life, based on peasant agriculture,usually provided a diet at least adequate in protein,except in seasons of scarcity. In the towns these youngpeople have to become accustomed to changed dietaryhabits with many new foods which they have to buy.Further, urban mothers, often owing to the necessity togo out and work, tend to wean their infants early and socut them off from a supply of protein which, even if smallin quantity, is always of high quality. The need foreducation in how to spend money on food is very great inmany parts of the world.

F.A.O. have produced a useful little manual 1 whichdescribes how to run an educational campaign to increaseconsumption of protein. The details are almost entirelyconcerned with fish promotion (it is proper to take a wordfrom the advertising business) in countries in LatinAmerica and North Africa But the general principlescan be applied in other places and to other types ofprotein-rich food. This report is profusely illustratedwith pen-and-ink drawings, many of which are very

funny, and with photographs, some of which are verybeautiful. The author, John Fridthjof, is clearly a man ofimagination. All health educationists would probably liketo see his book, even if they are not concerned with hisspecial problems.

CENTRAL HEALTH SERVICES COUNCIL

IT seems a long time since July 27, 1949, when thisCouncil held its first meeting and " Mr. F. Messer, M.P.,was elected chairman and Prof. Henry Cohen vice-chair-man ". Lord Cohen of Birkenhead, who succeeded toSir Frederich Messer’s post in 1957, can look back onfourteen years of solid, thoughtful, and discerning publicservice with the Council, through which the Ministry ofHealth and the N.H.S. have benefited from professionalopinion on a great number of topics, from the small tothe very large. As chairman of the C.H.S.C. he is suc-ceeded by Sir Howard Collingwood (chairman of theNewcastle Regional Hospital Board), while as chairmanof the Standing Medical Advisory Committee-anappointment he has held since the beginning of theN.H.S.-he is followed by Prof. R. E. Tunbridge. Thevice-chairman of this committee is now Prof. HedleyAtkins.

1. Encouraging the Use of Protein-Rich Foods. Rome: Food and Agri-cultural Organisation. Obtainable from H.M. Stationery Office,P.O. Box 569, London, S.E.1. Pp. 103. 5s.