Involuntary Self-denial

Involuntary Self-denial

239 THE LANCET LONDON:SATURDAY, FEBRUARY 16, 1946 Involuntary Self-denial THE cries of distress over the reduction of rations in this country are ...

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239

THE LANCET LONDON:SATURDAY, FEBRUARY 16, 1946

Involuntary

Self-denial

THE cries of distress over the reduction of rations in this country are understandable if perhaps a little undignified. After six years of rather boring food most people hoped for improvement during the next few months, and their hopes had a certain amount of official encouragement. After all, the traditional sequel to victory is a banquet and a higher standard of living for the victors. But we should now be old enough to know that long periods of intensive destruction do not increase wealth, and as our world grows smaller it will provide more and more evidence that abundance and scarcity, like peace and war, are " indivisible." An article in these columns a few months ago,l discussing the world shortage of food, suggested that if we did not choose to cut our consumption further for the sake of our European neighbours, circumstances were quite likely to take the choice out of our hands. That is what has now happened, and for some time to come our diet will be poorer through a small reduction in fat, besides being duller if we also lose our dried eggs. On the other hand, rationing of bread is at present no more than a threat, and so long as we can buy it freely there will be no shortage of food in the United Kingdom in the sense known to so many other countries -namely, a shortage of calories. Here anybody who can afford bread and potatoes-and their price is kept low by subsidies-can get as many calories as he wants, and the national daily average consumption will no doubt remain above 2800. Compared with most of the peoples of Europe and Asia we retain, even in this difficult interval between war and peace, our usual privileged position. The immediate problem in Europe is to carry people through to the next harvest-inadequate though this may be. Mr. DEAN ACHESON, the American UnderSecretary of State, estimates that before July more than 28 million Europeans will be reduced to less than 1500 calories a day, and some to less than 1000. The Emergency Economic Committee for Europe reports that over the next few months as many as 100 million will get an average daily total of 1500 or less, while a further 400 million will have 1500-2000. These figures put our own complaints into their proper proportion. It would be wrong, however, to deduce from them that the dreaded Battle of Winter has been lost. On the contrary, thanks not least to the devotion and energy of Americans and British working for the Control Commissions and UNRRA, it should yet be won. The danger war not food shortage, which was inevitable, but famine ; and though there are areas where, for one reason or another, food is and will be very scarce, actual starvation has been almost everywhere averted. Our nearest neighbours, the French, are far from comfortable and suffer from uneven distribution ; but in Marseilles, for example, which has been badly hit, 1.

Lancet, 1945, ii, 565.

the estimated consumption last year was about 2400 calories, and no grave deterioration is probable. The people of Belgium, Holland, and Norway are getting 2300 to 2500 calories, while Denmark has a surplus. UNRRA supplies the Greeks with 1700 calories in Athens, and 1100 in rural areas, to supplement their own fish, fruit, and vegetables, which are unrationed ; Yugoslavia is not so well placed, and in some parts of Bosnia the daily ration is said to contain as little as 1200 calories. Estimates for Poland vary from something over 1500 calories a day to more than 2000, with extra for miners in certain areas at least. In Austria, Vienna is probably as badly off as anywhere, but the January ration there was 2000 calories per head, and the ration for children of up to eighteen months was raised from 1000 to 1600 calories. In the American and British zones of Germany, rations of about 1500 calories for the normal consumer (up to 3000 for miners) are being received in most places, which does not include food (perhaps an average of 200-300 calories) which they may obtain outside the ration scale. Compared with the inhabitants of some of the occupied countries, the Germans are likely to take less harm from a period of. privation -provided it is brief-because during the war they kept up a high level of nutrition at the expense of others. For the countries of south-east Europe we can’ offer no figures, but in Hungary starvation is said to be already widespread. Those who have been most aware of the food situation abroad have been foremost in the recent appeal to the Government not to increase rations here until they could also be increased on the Contineat.22 The PRIME MINISTER refused to give any such undertaking, but the restrictions since announced will go far to remove the discomfort of the scrupulous, for they make it plain that our reserves have really been reduced substantially and that we could not do much more without sacrifices which the public are frankly unwilling to bear. Whether the public could have been brought to another frame of mind is another question : so far there has been no appeal to altruism but merely an appearance of administrative miscalculation. Each change seems to have been made at the last moment because of the pressure of events, and even the excellent 85%-extraction loaf, which should never have been taken off the table, is reintroduced apologetically. If the cupboard is temporarily rather bare, the MINISTER OF FooD should make more of what it does contain. Those of us with atavistic longings for a large steak may feel that we have had our fill of bread (however nutritious) and potatoes : but we should recollect that two-thirds of the population of the world derive 80% of their energy from cereals, and think themselves lucky to get it. The objection to our war-time rations is psychological more than physical : this country was accustomed to an immense choice of food, and does not get the same satisfaction from an immense choice of names for the same food. There are many blessings that we could count if we were in the mood : there is far more fish than formerly ; milk is to be comparatively plentiful this summer ; the orange, so long almost mythical, has become almost commonplace ; the first banana has come, and gone ; we are promised other fruit, fresh, dried, and tinned ;; and eggs have begun to 2. See

Lancet, Feb. 2, 1946, p. 184.

240 come back in their shells just at the moment when the housewife has decided she prefers them dried. The lesson of all this is clear : if the food shortage is to continue, or even grow worse, the authorities, like good cooks, must do all they can to disguise it by variety. In so far as it is irremediable, we should like to know that our self-denial (even if involuntary) is saving lives abroad. Which indeed it is.

Treatment of Pneumococcal Meningitis PNEUMOCOCCAL meningitis is a touchstone for chemotherapy. JEPSON and WHITTY remind us on p. 228 that the case-mortality in pre-sulphon-

days was little short of 100%. Even with sulphonamides and penicillin at our disposal, treatment is not a matter of simple routine, as SMrrx; amide

DUTHIE, and CAIRNS pointed

out in our last issue. None the less they felt able to say on good evidence that the fatality-rate could be reduced to something like 10% if treatment in each case was based on close individual study. Their own results with sulphadiazine and penicillin-5 deaths in 34 fully treated cases-are sufficiently striking to call for general adoption of the methods by which they brought about this therapeutic miracle. An important point is the correct use of sulphon-

amides, preferably sulphadiazine, especially during two phases of the treatment : (1) before penicillin is given, and (2) when penicillin is being withdrawn. Full doses are necessary (initial dose of 4 grammes followed by 2 g. four-hourly) and administration should start as soon as meningitis is suspected, in order to forestall the rapid deterioration which may frustrate all further measures, no matter how energetically these are applied. As early.as possible, diagnostic lumbar puncture is performed and penicillin is injected intrathecally in a dose of 8000-16,000 units (strength : 2000 units per c.cm.). Sulphadiazine is continued, and a second intrathecal injection of penicillin is given twelve hours after the first ; thereafter it is repeated daily for at least 5 days. At the same time intramuscular penicillin is given for 4-5 days to control the primary source of infection and the possible septicaemia. Unless the patient shows signs of intolerance, he should still receive sulphadiazine ; if it has to be withdrawn it should be resumed in reduced dosage (1 g. four-hourly) for a week to cover the withdrawal of intrathecal penicillin. Improvement may be looked for after the first 24-36 hours, which is always an anxious period. This minimum treatment will suffice for about half the cases. In others, difficulties of one kind or another should be expected, recognised, and dealt with according to their nature. The aim is to ensure that enough penicillin reaches all infected areas, and this -may be far from easy. Blockage of the basal cisterns may prevent free circulation ; the lumbar subarachnoid space may be obliterated ; or collections of’pus in the cerebral meninges may be shut’off from the circulating cerebrospinal fluid, particularly in meningitis after head injury. Blockage calls for ventricular and possibly cisternal injections of penicillin, but the complication is a serious one and the best medical and surgical attempts at treatment may fail. Laboratory examination of the fluid from lumbar and ventricular taps will show if penicillin is not circulating freely or is escaping at an abnormal

rate ; and it is

always important to have the fullest information about the bacteriological and cellular picture throughout the course of the illness. JEPSON and WHITTY sought to prevent localised collections of intracranial pus and cisternal blockages by larger initial doses of penicillin (10,000-20,000 units) ; once they gave 50,000 units without harm. SMITH, DUTHIE, and CAIRNS, however, are against large doses of penicillin because of possible harm to the cauda equina and because they doubt their value. In any case, penicillin for intrathecal use must be the purest available, and the solutions must be prepared with the greatest respect for sterility and only with pyrogen-free saline or distilled water; all-glass syringes are preferable to those made of metal and glass. On the whole, it seems likely that the meningeal irritation which sometimes follows intrathecal penicillin is not caused by the penicillin itself but by impurities, and these should not be contributed by It is worth noting that an errors of technique. increased cell-count by itself is not necessarily evidence of impending relapse. In about a third of the cases such relapse may be expected, and it must be treated at once on the same lines as the original infection. When all evidence of meningitis has disappeared and recovery is established, it will be time enough to carry out any surgical measures that may still be required to eliminate the primary source of infection-usually in the ears or nasal sinuses. Often this has been fully dealt with by the parenteral penicillin and sulphadiazine ; if not, it will have been sufficiently controlled to permit of planned surgical treatment at the most suitable moment. It is an important lesson that chemotherapeutic miracles are not wrought with drugs alone. Those who would perform them must practise the best methods known both to the science and art of medicine. possible

Future of Dental

Surgery

WHY the teeth and their related structures are held to be outside the field of medicine has long been a mystery. Diseases of the eye or of the ear, nose, and throat are rightly regarded as belonging to medicine and surgery, and specialisation in these subjects entails the possession of at least a basic medical qualification. That a similar qualification is desirable for dentistry is recognised in the condition that dental surgeons seeking election to the honorary staff of the large teaching hospitals must also be doctors. It was in fact a tragedy that dentistry Yet the was so largely divorced from medicine. final report of the Teviot Committee, though it includes much that is good and encouraging, recommends a further stage of alienation by the setting up of a separate Dental Council so as to make dentistry

self-governing profession. The passing of the Dentists Act in 1921 meant, in effect, that nobody who was not on the dental or medical register could practise any form of dentistry. This has meant that all forms of treatment, from fillings and extractions to the fitting of artificial dentures, have been carried out by the dental surgeon. That the number of dental surgeons is at present quite a

insufficient 1.

to

do

this work is clear from the

Interdepartmental Committee on Dentistry (chairman, Lord Teviot). Final report, Cmd. 6727. H.M. Stationery Office. Is. (see Lancet, Feb. 9, 1946, p. 206.) The interim report was summarised at length in The Lancet, 1944, ii, 701.