1108 PROGRESS AGAINST PNEUMOCOCCI

presenting both sides of the picture, for of thetotal of 7 cases described only 3 recovered. Itis notorious and only natural that unexpectedsuccess gains more publicity than expected failure,and the 5 cases with 2 recoveries reported byDr. MAcKEITH and Dr. OPPENHEIMER probablygive a truer picture of what is to be anticipatedfrom this treatment than may be gained fromenthusiastic accounts of single cases. Dr. KENNETHMAY suggests that the failure he reports may beattributable to the pneumococcus becoming resis-tant to the drug ; which would mean that the treat-ment of meningitis complicating pneumonia whichhas already been treated with M. & B. 693 is

likely to be hopeless. There are certainly featuresin some case-records consistent with bacterial

escape from chemical control after several days ofcomparative suppression; but Dr. RAMAN’s case

encourages one to hope that such relapses are notbeyond control, perhaps by massive doses. Whetherbacterial drug-resistance is the true explanation ofthe failures cannot yet be known, but there is

every reason to advise the most vigorous possibletreatment in the first few days with the object ofsterilising the meninges. In view of the incom-

pleteness and variability with which the drug isabsorbed from the alimentary tract the injectionof its more soluble sodium salt might enable theattack to be launched with greater speed andvigour ; but this remains to be seen.We have referred more than once to the mixed

reception M. & B. 693 has had in America ; therehave been elements in it not only of scepticism butof positive indignation at the incompleteness ofthe data that accompanied it across the Atlantic.But the proof of the pudding is in the eating, andthere are further indications that " sulfapyridine,"as it is officially called over there, has not beliedits promise. Science Service reports5 Dr. PERRIN H.LONG as saying that it has " cut the pneumoniadeath-rate at the Johns Hopkins Hospital bytwo-thirds." A. T. WMSON and collaborators 6

have made a careful study of its effect on pneu-monia in children, and their conclusion, wellfounded statistically, is that it shortens the courseof the disease by between three and four days.Another study of pneumonia with striking resultsis reported from Canada by GRAHAM, WARNER,DAUPHINEE and DICKSON.7 It embraces three

groups, each of 50 patients, severally receivingDagenan (M. & B. 693), serum, and no specifictreatment ; the deaths in the three groupsnumbered 3, 6, and 12. Alternate cases of infec-tion with pneumococcus types I, II, V, VII andVIII were given serum, but the drug-treatedgroup includes infections by other types, and tothat extent it is not strictly comparable. On theother hand it included the highest number ofcases with bacteroamia-17 with only 3 deaths-whereas in the serum-treated group there were 7such cases with 4 deaths and in the controls I I

5. Science, April 7, 1939 (suppl. p. 10).6. Wilson, A. T., Spreen, A. H., Cooper, M. L., Stevenson, F. E.,

Cullen, G. E., and Mitchell, A. G., J. Amer. med. Ass.April 15, 1939, p. 1435.

7. Graham, D., Warner, W. P., Dauphinee, J. A., and Dickson,R. C., Canad. med. Ass. J. April, 1939, p. 325.

with 5 deaths. This comparison of chemo- andsero-therapy, to the latter’s disadvantage, is thefirst of its kind ; but if it should seem to threatenthe extinction of serum treatment for pneumonia,be it remembered that once the requirements ofexperimental study are satisfied, there will be noreason, apart from trouble and expense, why thetwo remedies should not be associated.The authors of these two last papers confirm

previous observations that the concentration ofthe drug attained in the blood is very variable.This was also observed by MEAKINS and HANSON 8in a series of 30 cases of pneumonia which weretreated with only 1 death. They suggest thatthese variations may be due to different degrees ofconjugation of the drug, and the same idea is putforward by BRYCE and CLIMENKO,9 who addboth clinical and experimental observations toshow that the extent of conjugation varies withthe basal metabolic rate. All who have studied thesubject seem to agree that optimum dosage hasyet to be defined and that the behaviour of thedrug in the body needs further investigation. Aswe have already pointed out, a method of adminis-tration more certain and rapid in its effect seemsalso to be needed in some cases, and the first twoAmerican authorities quoted here have in fact

given the sodium salt intravenously in order eitherto secure a quicker action or to obviate nausea andvomiting. These are evidently directions in whichthe treatment may be improved and possiblecauses of failure defined.

INFECTIONS OF THE HANDON all sides one sees people with crippling

deformities of the hands following infections simplein their origin ; in some merely rigidity of theterminal joints, in others the loss of a finger orfingers, and in others a stiffening of the whole handrendering it useless for all ordinary occupations.KANAVEL, a pioneer on this subject whose bookhas just reached a seventh (posthumous) edition,"quotes the records of the Industrial Accident Boardof Oklahoma where of 60,600 partial disabilities20 per cent. and of 900 complete disabilities 58 percent. were due to injuries and infections of the hand.It is not stated what proportion of these dis-abilities was caused by infections as distinct frominjuries. The figure seems to vary between 20 and75 per cent. according to the type of work, butdifferentiation is complicated by the fact that

practically every infection starts as an injury,and most injuries become infected. As an illustra-tion of what can be done in the way of prevention,it is worth noting that precautions taken for theremoval of broken baskets and exposed ends ofwire reduced the number of infections from thissource from 75 to 10 in one year. Arrangementsfor the immediate treatment of all injuries by acompetent surgeon and for the early hospitalisation8. Meakins, J. C., and Hanson, F. R., Ibid, p. 333.9. Bryce, D. A., and Climenko, D. R., J. Amer. med. Ass.

March 25, 1939, p. 1182.10. Infections of the Hand. (7th ed.) By Allen B. Kanavel,

M.D., Sc.D., late professor of surgery, NorthwesternMedical School, Chicago. London : Baillière, Tindall andCox. 1939. Pp. 503. 30s.

1109

of cases where infection later develops are

prophylactic measures that should be taken byall responsible for the welfare of workmen.For the proper understanding and treatment

of established infections anatomical study is

essential, and this is the basis of KANAVEL’Sclassic work. He shows how readily the boneof the terminal phalanx may necrose if pressurehas caused thrombosis of the artery of supply,and this is one of the commonest events in pulpinjuries. He explains the route of spread up thefinger and into the palm via the lumbrical canals,and the anatomical location of the potentialspaces in the palm. These spaces are situated

deeply in the hand, behind the long flexor tendonsand in front of the interosseous muscles and theadductor of the thumb. The middle palmar spacelies between the middle metacarpal and the hypo-thenar muscles and is liable to infection from alesion in the three medial fingers, while the thenarspace lies between the middle metacarpal andthe muscles of the thenar eminence, and is liableto infection from a lesion in the index finger orthumb. SPALDING 11 has carried out dissectionsand examined cross-sections of the hand, and hiswork confirms the existence of these two spaces.The septum between them is in his view producedby a special thickening of the fascia along, theradial side of the second lumbrical muscle, whichhe calls the intermediate septum of the hand.It runs from the palmar aponeurosis in front tothe fascia covering the adductor muscle of the

thumb, thus gaining indirect attachment to thethird metacarpal bone. Apart from these twomain spaces there are others between the musclesof.the thenar eminence, and between the musclesof the hypothenar eminence, but these are of lessimportance as sites of secondary infection as theyare definitely separated from the rest of the palmarstructures. BRICKEL,12 in a new work on handand forearm infections, agrees with KANAVELon the main issues, but differs in his division ofthe palmar spaces. He also has made injectionsof opaque material into different parts of the handand fingers, but as the pressure used is not statedthe two sets of experiments may not be comparable.Nor is it certain that injections under pressurewill necessarily follow the same course or belimited by the same structures as inflammatoryexudations. BBiOEBL finds that his injectionsinto the ulnar bursa (the expanded portion of thesheath of the flexor of the little finger) are aptto rupture into the palm, filling the whole palmarconcavity, and to extend as far as the first lumbricalmuscle, on the radial side of the index. The thenar

space of KANAVEL he believes to be nothingmore than a dissection of the fascia from thesurface of the adductor of the thumb, limitedby its attachments. These minor differences ofopinion on anatomy are perhaps not of greatimportance to surgeons, but they serve to remind

11. Spalding, J. E., Guy’s Hosp. Rep. 1938, 88, 432.12. Surgical Treatment of Hand and Forearm Infections. By

A. C. J. Brickel, A.B., M.D., from the departments ofanatomy and surgery, Western Reserve University.London: Henry Kimpton. 1939. Pp. 300. 31s. 6d.

us of the fact that pus can find its way into the

palm, where its early recognition may be of crucialimportance to the individual patient.

Tendon-sheath infections are probably responsiblefor more permanent stiffness than any other classof infection. KANAVBL still advises a long incisionalong the lateral aspect of the digit, withoutstressing the dangers of prolapse and necrosisof the tendon, or of its adherence to the scar

should it survive. It is some years since ISELIN 13

pointed out that excellent drainage can be obtainedin the three middle fingers by opening the sheathfreely at its proximal end in the palm, with shortincisions on each side of the digit opposite theflexion creases, thus preserving the stronger partsof the fibrous sheath, and preventing prolapseof the tendon. In the thumb and little fingerincisions have to be made above the wrist and inthe palm, but long incisions on the digit are betteravoided. IsELiN’s incisions give good functionalresults, and are worthy of more general trial.

Of the other common infections of the hand,those spreading diffusely and rapidly alonglymphatics form an important group. Allauthorities are now agreed that incision is dangerousin this type of infection, but it is sometimes difficultto recognise when it is better to be conservative.The effects of sulphanilamide in reducing the

danger to life have not yet been properly assessed.The responsibility of the practitioner is not endedwhen he has made his incision, or decided thatan incision is not to be made. The restorationof function should be his main concern. Completeimmobilisation should last only a few days, andeven during this time the straight splint should notbe used. Active movements must be started assoon as the acute toxaemia is relieved, and laterphysical and occupational therapy of variouskinds and psychotherapy should be carefullyplanned with the idea of enabling a man to returnfully fit to his previous employment.

13. Iselin, M., Chirurgie de la main, Paris, 1933.

" ... I can only repeat what I said on anotheroccasion-’ I do not believe that as a nation we cannotafford to be healthy.’ At any rate, if it is finance, andfinance only, that stands in the way, then let us be told so,and we can abandon the tedious process of flogging adead horse by continuing to prove self-evident facts, anddevote ourselves to the economic aspects. Most of usare not economists, but we could learn enough not to becrushed by mere shibboleths. For my part I should wantto know whether the existing economic system in thiscountry was for the benefit of the many or the few.... Ishould want to know whether it was really necessarythat there should be such a large disparity between thecost of production of some of the so-called protective foodsand the cost to the purchaser-why, for example, it shouldcost about three times as much to convey a cauliflowerfrom Teddington to a poor woman in Tottenham as it didto produce it. I should want to know whether it wouldnot be possible to make such substances as cod-liver oilavailable for poor people generally at something like theprice at which they can obtain it in hospital. When Iknew all these things I should know whether the approachof the millenium of health was being retarded by vestedinterests, or whether one must continue to sigh for itonly as an impossible ideal."-Sir NORMAL BENNETT,Public Health, May, 1939, p. 231.