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gingival margin and exposure of bone are seen in themouths of many children. From this it is only a short stepto established cancrum oris; but the rapidity of demarca-tion of the gangrenous process is not readily explained.The necrotic area has been described as a cône gangreneux,11in which the base is wider than the extremity: in otherwords, the destruction of mucosa and bone is alwaysgreater than that of the skin. Consequently, when healinghas taken place, trismus almost invariably results fromintraoral scarring, whatever the extent of the externaldeformity.

In the acute stages, prompt treatment with anti-biotics (particularly penicillin) is life-saving; in severalcountries the mortality-rate has been lowered from 75-100% to about 10%.612-14 Reynaud and Diop,"5 how-ever, maintain that antibiotics and supportive treatmentaimed to correct anaemia and malnutrition have no effecton the gangrenous process or the late deformity; unfor-tunately very many children are brought for treatmentonly when gangrene is established. Although, in the past,radical excision of the lesion to prevent further spread hasbeen widely recommended, Tempest is convinced that

early operation is absolutely contraindicated in suchgravely ill children, unless secondary haemorrhage (anunusual complication) is imminent. The separation of thedead tissue and eventual healing can be hastened bysequestrectomy of dead bone, which if retained may leadto persistent suppuration.15The facial mutilation after healing is often hideous,

and saliva dribbles constantly from the defects in thecheek or lips. Plastic operations devised originally for theclosure of defects after ablation of malignant disease inthe same area are readily applicable. Tempest emphasisesthat repair, either at a preliminary stage or as an integralpart of the repair programme, must always include thebest possible correction of the trismus. His illustrationsshow the excellent results which can often be achieved byproperly planned reconstruction.

EXPERIMENTAL ARTHRITIS IN MAN

THE injection of sodium-urate crystals into normal

joints in man and animals induces an acute inflammatoryresponse, with pain, swelling, tenderness, and erythema.Faires and McCarty,16 who were themselves subjects intheir original experiments, found that the joint pain wasso severe that local injections of hydrocortisone and pro-caine failed to control it, and intramuscular pethidine andoral phenylbutazone were necessary to produce relief.

Seegmiller and his colleagues 17 found that injection ofurate crystals into the knees of gouty patients inducedattacks which mimicked spontaneous acute gout and which

usually responded to intravenous colchicine (althoughsome patients required pethidine analgesia for severe pain).

Malawista and Seegmiller 18 and Steele and McCarty 19have investigated the effect of pretreatment with anti-

inflammatory agents on a subsequent injection of 20 mg.11. Reynaud, J., Bel, J., Ly, B. Bull. Soc. méd. Afr. noire Lang. fr. 1961,

6, 416.12. Tupas, A. V., Jongco, A. P. J. Philipp. med. Ass. 1946, 22, 153.13. Phan-Dinh-Tuan. Sem. Hôp. Paris, 1960, 36, 960.14. Phan-Dinh-Tuan. Indian J. Pediat. 1962, 29, 178.15. Reynaud, J., Diop, L. Bull Soc. méd. Afr. noire Lang. fr. 1965, 10, 271.16. Faires, J. S., McCarty, D. J. Lancet, 1962, ii, 682.17. Seegmiller, J. E., Howell, R. R., Malawista, S. E. J. Am. med. Ass. 1962,

180, 469.18. Malawista, S. E., Seegmiller, J. E. Ann. intern. Med. 1965, 62, 648.19. Steele, A. D., McCarty, D. J. Arthritis Rheum. 1966, 9, 430.

of urate crystals. Aspirin, phenylbutazone, colchicine,hydrocortisone, and methyl prednisolone all preventedthe development of the inflammatory response.

In another series of experiments, Steele and McCarty 20have compared the effect of a new drug, indoxole, with aplacebo in a double-blind within-subjects procedure.Indoxole has anti-inflammatory, antipyretic, and analgesiceffects in animals, and Steele and McCarty found that itreduced joint swelling and tenderness in man. Differencesin the final volume of joint-fluid aspirated and knee-skintemperature were not statistically significant. Althoughindoxole has a pronounced analgesic effect, the results donot suggest that it is a highly effective anti-inflammatoryagent in this situation. Aspiration of joint-fluid enablesthe levels of indoxole in the serum and the joint-fluid tobe determined simultaneously, but, unless the mechanismof action of the drug is known, the true significance of itsconcentration within a joint is uncertain.

Reliable procedures for producing and measuringinflammatory changes in man are needed for the studyboth of inflammation and of drugs which may modify it,and it seems that crystal-induced arthritis may provide auseful experimental model. It is not a pleasant procedure,however, and it is not without risk. The search for a moreacceptable inflammatory situation in man must continue.

DR. JOSEPH GARLAND

IN 1948 the circulation of the New England Journal ofMedicine was 24,000: at the end of last year it stood at96,000. There is no mystery behind this immodestfour-times multiplication: for the past nineteen years theJournal has been edited by Dr. Joseph Garland. At theend of June he will hand over to Dr. Franz J. Ingelfinger,who is no stranger: besides holding a chair of medicine atBoston, he has since 1961 been a member of the editorialboard.As Editor, Dr. Garland has attracted much of the

important original work of the day, partly perhaps becauseof his firm grasp of how this should be presented. His

approach is summed up in his own words: " Verbosity is a

fault but so is cryptogrammic abbreviation. Midway liesclear and incisive language, confusing neither by the useof unnecessary words nor by the omission or mutilation ofnecessary ones." 21 His own writing is simple and deft,often conveying in a single sentence what some of the restof us might gasp out in three paragraphs. Of the physi-cian’s " dynamic friends, the manufacturing apothe-caries he once said: " We admire their scientific founda-tions and their genuine philanthropies and appreciatetheir cocktail parties, where our cup runneth over, but westand a little in awe of the sinews that they have ac-quired." 22 His editorials are occasionally stern, often

witty, and always stamped with his individual mark asclearly as if they bore his signature. Elsewhere in the

Journal he has widened the scope and has developed thecorrespondence columns as a medium for exchanginginformation and arguments. Throughout, his work isinformed by a well-stocked mind, and by the quiet kindli-ness that might be expected of a former paediatrician. Dr.Garland’s remarkable success would have been possibleonly for one with his remarkable attributes.

20. Steele, A. D., McCarty, D. J. Ann. rheum. Dis. 1967, 26, 39.21. Garland, J. Int. Rec. Med. 1956, 169, 703.22 Garland, J. New Engl. J. Med. 1957, 257, 1117.