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CEREBRAL ANGIOGRAPHY IN THE DIAGNOSIS OF THE ACUTE STROKE
771
This is
not
quite
accurate
and
is, therefore, possibly
misleading. The sentence should probably read " appreciably lower than in Glasgow and Aberdeen ". In connection with the absence of a similar trend in women, it does not appear that this is actually implied by Pulvertaft.1 He shows, in fact, that so far as total perforations are concerned, this condition is more common in women living in the Glasgow area than in the city of York. The corresponding figure for the city of Aberdeen for the same years is 7-0 per 100,000 of the female population. This is more than twice the Glasgow annual rate and although based on small numbers, since perforation is relatively uncommon amongst women, seems to suggest that there may be a similar trend in women, both for the total perforation-rate and the duodenal perforation-rate. Department of Public Health and Social Medicine,
University
of Aberdeen.
R. DEANS WEIR.
POSTCOITAL EXAMINATION OF SEMEN
SIR,-I am giving you some earlier references 2-5 dealing with the successful treatment of subfertile men, as requested by Mr. Dunn (March 12). Dr. Farris’ book, which he quotes to restate his case, was published in 1950, ten years ago; a good deal of work has been done since then.
H. A. DAVIDSON.
London, W.I.
ANTI-SMOKING CAMPAIGN
SIR,-Mr. Rowntree (March 19) attributes the failure of the Edinburgh campaign to its use of " impersonal and didactic " methods. Although we would not dissent from the view that such methods are not in general the best suited to produce changes in attitudes and behaviour, we doubt whether the use of alternative media would have ensured the success of the campaign. It seems to us that Mr. Rowntree, like many other health educators in this country, attaches so much importance to techniques of presentation that he tends to ignore the psychological implications of the message he seeks to convey and of the behaviour he hopes to change. We are convinced that to change smoking habits on any substantial scale does not depend simply upon making the correct choice between alternative media of communication, but rather upon our first acquiring a much deeper understanding than we possess at present of such questions as why people start to smoke; what factors confirm them in their smoking habits; why some smoke a little and others a lot; what risk " and " probability " play part considerations of in the thinking of people of different levels of education; what emotional reactions are aroused by threats of cancer; and many others, which could be specified. Finally, may we make it clear that we played no part at all in the planning and execution of the campaign ? We were concerned only with assessing the success or failure of the campaign, and our roles were analogous to those of auditors. We believe, incidentally, that to have sought independent and objective evaluation in this way reflects considerable credit on the Edinburgh Public Health "
Department. of Public Health and Social Medicine, University of Edinburgh.
Department
ANN CARTWRIGHT F. M. MARTIN.
1. Pulvertaft, C. N. Brit. J. prev. soc. Med., 1959, 13, 131. 2. Davidson, H. A. Practitioner, 1954, 173, 703. 3. Hanley, H. G. Ann. R. Coll. Surg. Engl. 1955, 17, 159. 4. Hanley, H. G. Proceedings of the 2nd World Congress on Sterility, 1956. 5. Tulloch, W. S. Brit. med. J. 1955 ii, 356.
Fertility and
CEREBRAL ANGIOGRAPHY IN THE DIAGNOSIS OF THE ACUTE STROKE
SIR,-Since its inception in 1927, cerebral angiography expanded enormously, thus marking for Egas Moniz an outstanding and lasting place in the history of medicine. If Dandy baked the bread, Moniz buttered it so thickly that the neuroradiologist was evolved, a vous bonne chance. With the advance of knowledge and the development of more and more complicated techniques in neurohas
chest surgery, and many other branches of medicine, the " one-man-band was replaced by a team. Such a team, a radiologist and two physicians, produced the paper in your issue of March 12. Of their 80 patients submitted to angiography, Dr. Bull and his colleagues demonstrated a specific lesion in 33, but more significantly the lesion was not diagnosable clinically in 17, despite the excellence of the physicians. This work is of unquestionable value. surgery,
"
It is on the " hazards of angiography " that I should like make a few comments. In 1955, in a paper entitled Towards Safer Angiography,l I analysed eight published series of angiograms from the point of view of technique, selection, and, more especially, safety. I found that in 3128 angiograms, there were 22 deaths and 81 complications; of the complications, 23 were permanent and 58 transient. My own series1 and that of Ver Brugghenwere free from mortality or serious complication. A year later, Segelov,3 in his paper, Safe Angiography, recorded a series of 660 angiograms of his own, again without complication, and he reproduced my table. Mainly out of interest, partly from necessity, I took charge of angiography in the Regional Neurosurgical Centre, Liverpool, from 1954. I taught and supervised my trainees, I was free to reject a request for angiography from other clinicians, and I had some excellent anaesthetists. Reviewing the work of the past six years, the growth of this investigation is reflected in the following numbers: to
death (pulmonary embolism); 1 permanent was 1 partial hemiparesis (angiography and ventriculography were performed under the same anaesthetic), and 5 other transient complications. Each patient was examined at least once during the twenty-four hours following angiography. Certainly the stringent method of Bull et al. of assessing morbidity and apportioning it to angiography was not applied in this series. In a case of vascular glioma, the angiography was followed by an immediate biopsy and if this induced bleeding into the tumour; the paralysis that followed was ascribed to the haemorrhage, not to the angiography. It may be that the incidence of morbidity in our material was in fact greater than indicated,
There
yet in none of the 57 cases of internal carotid or middle cerebral thrombosis was there any increase in the clinical deficit, even when angiography was performed bilaterally. The safety of cerebral angiography depends upon several factors: the contrast medium; the personal skill and experience of the angiographer; and my firm personal belief is that a general anaathetic is another important aid to safety. The aneesthetist as a member of the team must understand the problems involved as thoroughly as the clinician and the radiologist. There is no room for amateurism and all the trainees must be supervised. The clinician who insists on angiography regardless of individual circumstances, the radiologist who for long periods spears every structure in the neck, the anaathetist ignorant or mindless of a dangerous drop in blood-pressure are all responsible for mortality. 1. Sedzimir, C. B. J. Neurosurg. 1955, 12, 460. 2. Ver Brugghen, A. Arch. Neurol. Psychiat. 1954, 3. Segelow, J. N. J. Neurosurg. 1956, 13, 567.
71, 518.
772
Dr. Bull and his colleagues investigated patients theoretically representing the greatest potential risks. The fact that they had no mortality and reported only 9 transient complications, despite their strict assessment, gives weight to their conclusion that only " centres with
facilities should continue their endeavours to assess the place of angiography in the management of acute strokes in relation to the methods of treatment available ", to which I should like to add " and only such centres should use angiography in the management of any condition necessitating this investigation ". Walton Hospital,
C. B. SEDZIMIR.
Liverpool.
STAPHYLOCOCCAL INFECTION IN NURSES
SiR,—The article by Dr. Davies (March 19) will stimulate the search for ways of decreasing the time that nursing and ancillary staffs spend off duty on account of
staphylococcal infections. possible method which seems to
minor
A have received less attention than it deserves is the use of a plastic " skin " to be sprayed or painted on to form a protective covering over surface lesions. This would serve the double purpose of protecting the lesions from further infection or injury and acting as a bacterial barrier to the dissemination of organisms from them. Furthermore, it would be technically very simple to incorporate some suitable bactericidal substance in the " skin ". Some investigation has already been done on these lines, notably by Wright/ Leader,2 and Ritelli,3 but it appears that further research into the use of such methods would be of value.
D. E. STEELE
PERTHES’ DISEASE
SIR,-In your issue of March 19 Dr. Cockshott and Dr. Palmer, writing from Nigeria and Rhodesia, disapprove of
Negro child appears to be immune least seems to be only exceptionally affected by it ", which I included in my letter of Feb. 13. The only written reference to the frequency of Perthes’ among Negro children which I know is given in C. W. Goff’s He states that among 110,555 coloured children book.l admitted to the Charity Hospital, Louisiana, New Orleans, from 1941 to 1951, not 1 case of Perthes’ was recorded, and that in the Hospital for Joint Diseases, New York, with an admission-rate of 20%coloured, not a single Perthes’ was ever seen. Only the Tennessee Crippled Children’s Register reported that they had treated 68 white and 6 Negro children affected by this condition. Davies (quoted by Goff), writing from Makerere College Medical School, Kampala, Uganda, reports practically no evidence of Perthes’ among the Negro my statement that " the to
Perthes’,
or
at
population. All this information was further supported in the discussion Latin-American Congress of 1956 in Mexico City of my paper on the blood-supply of the femoral head during growth. Dr. Oswaldo Campos, in charge of a large children’s hospital in Rio de Janeiro, with a large Negro rate of admission, reported that he had hardly ever seen Negro children with Perthes’; and Dr. Harold Boyd from Memphis corroborated these views. I am sure many will welcome my letter if it may have served to stimulate Dr. Cockshott and Dr. Palmer to make a survey of real or true Perthes’ among Negro children in Ibadan, of course excluding not only sickle-cell anaemia but also subluxation, infective coxitis, and enchondral chondrodystrophy. Nuffield Orthopædic Centre, at the
J. TRUETA.
Oxford.
Medical Adviser, Portland Plastics Ltd.
Hythe, Kent.
CORPORAL PUNISHMENT ENVIRONMENTAL STAPHYLOCOCCAL CONTAMINATION
SIR,-I was very interested in the article on staphylococcal contamination by Dr. Foster (March 26). What particularly struck me was the " fallout " of contamination shown in fig. 3. It is very noticeable that one side of the ward is much more heavily contaminated than the other, and I am moved to wonder why: is the ward cleaned by two people, one of whom does floors more efficiently than the other ? Are dressings done by two dressing teams, one more conscientious than the other? Are the curtains or screens on each side of the ward made of similar material, and how efficient is curtain cleansing ? I have always thought that a vacuum duster would be a much useful tool than a floor-washing machine in any hospital; it is deplorable that staff should still be flapping about with dirty fluffy rags, wet or dry, in any surgical ward. Bacteria on the floor must have come from beds or dressings and therefore had to be airborne at some time: the removal of dust by a vacuum cleaner is better than waiting for it to settle on a washable surface, especially as large quantities of it settle anyway on surfaces unlikely to be washed, such as curtains. As a small comment on ward administration, would it not be safer to put all dirty " beds together and so concentrate bacteria in one corner of the ward ? We always did this twenty years ago in my training school-not that we ever expected to have eight " dirty " cases out of thirty in those days, but if we had they would not have been allowed to spread themselves all over the ward as seems to be the case here. One other point-why no bacterial fallout from one of the beds at all ? Had this unfortunate an infection other than Staph. aureu.r, and if not, what is the answer ? more
"
Tooting Bec Hospital, London, S.W.17. 1. 2. 3.
UNA V. BUDGE Principal Tutor.
H. W. S. Lancet, 1944, i, 664. Leader, S. A. Lister J. 1945, 8, 1. Ritelli, D. Gazz. Med. Ital. 1955, 114, 12.
Wright,
accustomed to logical fallacies, and in on this subject; but may I discussions sentimentality, that Dr. article suggest (March 26) reaches an Waycott’s standard in both exceptional respects. To quote only two " of examples petitio principle he speaks of the present agitation for the restoration of corporal punishment ... based, as it is, on fear and ignorance ", and " as our ideas of criminal responsibility alter ". Both statements may be true, but he gives no evidence to support these assertions.
SIR,-We
are
He says there is no proof of the deterrent effect of corporal punishment, and indeed that no proof can be given statistically. May I suggest that an answer is to be found in Pavlov’s work on conditioned reflexes. In quite lowly forms of animal life conditioned inhibition of even powerfully attractive stimuli can be readily established by associating them with pain. One might reasonably expect in man to inhibit anti-social activities by associating them with pain and other unpleasant experiences. Folk wisdom has long since enshrined this in the proverb " A burnt child dreads the fire ". Dr. Waycott asserts that the decline in the number of birchings was explicable only because the courts had found the birch useless as a deterrent; alternative explanations are at least tenable. It may be that this decline was due to growth of sentimentality in magistrates, and to a possibly unwarranted belief in the value of psychological methods of tackling the offender. His description of the technique of corporal punishment, quoted from the Cadogan report, is unpleasant, but this is irrelevant to the merits of the punishment. As a young practitioner I found it unpleasant to give anxsthetics for dental extractions, or for avulsion of a toenail, but as a rational being I recognised the necessity of such procedures. Lastly, some of us reactionaries are not very much interested in his point as to the value or otherwise of corporal punishment in constructive treatment of offenders: we are more selfishly 1.
Legg-Calve-Perthes Syndrome Springfield, 111., 1954.
and Related Osteochondroses of Youth-
This is
not
quite
accurate
and
is, therefore, possibly
misleading. The sentence should probably read " appreciably lower than in Glasgow and Aberdeen ". In connection with the absence of a similar trend in women, it does not appear that this is actually implied by Pulvertaft.1 He shows, in fact, that so far as total perforations are concerned, this condition is more common in women living in the Glasgow area than in the city of York. The corresponding figure for the city of Aberdeen for the same years is 7-0 per 100,000 of the female population. This is more than twice the Glasgow annual rate and although based on small numbers, since perforation is relatively uncommon amongst women, seems to suggest that there may be a similar trend in women, both for the total perforation-rate and the duodenal perforation-rate. Department of Public Health and Social Medicine,
University
of Aberdeen.
R. DEANS WEIR.
POSTCOITAL EXAMINATION OF SEMEN
SIR,-I am giving you some earlier references 2-5 dealing with the successful treatment of subfertile men, as requested by Mr. Dunn (March 12). Dr. Farris’ book, which he quotes to restate his case, was published in 1950, ten years ago; a good deal of work has been done since then.
H. A. DAVIDSON.
London, W.I.
ANTI-SMOKING CAMPAIGN
SIR,-Mr. Rowntree (March 19) attributes the failure of the Edinburgh campaign to its use of " impersonal and didactic " methods. Although we would not dissent from the view that such methods are not in general the best suited to produce changes in attitudes and behaviour, we doubt whether the use of alternative media would have ensured the success of the campaign. It seems to us that Mr. Rowntree, like many other health educators in this country, attaches so much importance to techniques of presentation that he tends to ignore the psychological implications of the message he seeks to convey and of the behaviour he hopes to change. We are convinced that to change smoking habits on any substantial scale does not depend simply upon making the correct choice between alternative media of communication, but rather upon our first acquiring a much deeper understanding than we possess at present of such questions as why people start to smoke; what factors confirm them in their smoking habits; why some smoke a little and others a lot; what risk " and " probability " play part considerations of in the thinking of people of different levels of education; what emotional reactions are aroused by threats of cancer; and many others, which could be specified. Finally, may we make it clear that we played no part at all in the planning and execution of the campaign ? We were concerned only with assessing the success or failure of the campaign, and our roles were analogous to those of auditors. We believe, incidentally, that to have sought independent and objective evaluation in this way reflects considerable credit on the Edinburgh Public Health "
Department. of Public Health and Social Medicine, University of Edinburgh.
Department
ANN CARTWRIGHT F. M. MARTIN.
1. Pulvertaft, C. N. Brit. J. prev. soc. Med., 1959, 13, 131. 2. Davidson, H. A. Practitioner, 1954, 173, 703. 3. Hanley, H. G. Ann. R. Coll. Surg. Engl. 1955, 17, 159. 4. Hanley, H. G. Proceedings of the 2nd World Congress on Sterility, 1956. 5. Tulloch, W. S. Brit. med. J. 1955 ii, 356.
Fertility and
CEREBRAL ANGIOGRAPHY IN THE DIAGNOSIS OF THE ACUTE STROKE
SIR,-Since its inception in 1927, cerebral angiography expanded enormously, thus marking for Egas Moniz an outstanding and lasting place in the history of medicine. If Dandy baked the bread, Moniz buttered it so thickly that the neuroradiologist was evolved, a vous bonne chance. With the advance of knowledge and the development of more and more complicated techniques in neurohas
chest surgery, and many other branches of medicine, the " one-man-band was replaced by a team. Such a team, a radiologist and two physicians, produced the paper in your issue of March 12. Of their 80 patients submitted to angiography, Dr. Bull and his colleagues demonstrated a specific lesion in 33, but more significantly the lesion was not diagnosable clinically in 17, despite the excellence of the physicians. This work is of unquestionable value. surgery,
"
It is on the " hazards of angiography " that I should like make a few comments. In 1955, in a paper entitled Towards Safer Angiography,l I analysed eight published series of angiograms from the point of view of technique, selection, and, more especially, safety. I found that in 3128 angiograms, there were 22 deaths and 81 complications; of the complications, 23 were permanent and 58 transient. My own series1 and that of Ver Brugghenwere free from mortality or serious complication. A year later, Segelov,3 in his paper, Safe Angiography, recorded a series of 660 angiograms of his own, again without complication, and he reproduced my table. Mainly out of interest, partly from necessity, I took charge of angiography in the Regional Neurosurgical Centre, Liverpool, from 1954. I taught and supervised my trainees, I was free to reject a request for angiography from other clinicians, and I had some excellent anaesthetists. Reviewing the work of the past six years, the growth of this investigation is reflected in the following numbers: to
death (pulmonary embolism); 1 permanent was 1 partial hemiparesis (angiography and ventriculography were performed under the same anaesthetic), and 5 other transient complications. Each patient was examined at least once during the twenty-four hours following angiography. Certainly the stringent method of Bull et al. of assessing morbidity and apportioning it to angiography was not applied in this series. In a case of vascular glioma, the angiography was followed by an immediate biopsy and if this induced bleeding into the tumour; the paralysis that followed was ascribed to the haemorrhage, not to the angiography. It may be that the incidence of morbidity in our material was in fact greater than indicated,
There
yet in none of the 57 cases of internal carotid or middle cerebral thrombosis was there any increase in the clinical deficit, even when angiography was performed bilaterally. The safety of cerebral angiography depends upon several factors: the contrast medium; the personal skill and experience of the angiographer; and my firm personal belief is that a general anaathetic is another important aid to safety. The aneesthetist as a member of the team must understand the problems involved as thoroughly as the clinician and the radiologist. There is no room for amateurism and all the trainees must be supervised. The clinician who insists on angiography regardless of individual circumstances, the radiologist who for long periods spears every structure in the neck, the anaathetist ignorant or mindless of a dangerous drop in blood-pressure are all responsible for mortality. 1. Sedzimir, C. B. J. Neurosurg. 1955, 12, 460. 2. Ver Brugghen, A. Arch. Neurol. Psychiat. 1954, 3. Segelow, J. N. J. Neurosurg. 1956, 13, 567.
71, 518.
772
Dr. Bull and his colleagues investigated patients theoretically representing the greatest potential risks. The fact that they had no mortality and reported only 9 transient complications, despite their strict assessment, gives weight to their conclusion that only " centres with
facilities should continue their endeavours to assess the place of angiography in the management of acute strokes in relation to the methods of treatment available ", to which I should like to add " and only such centres should use angiography in the management of any condition necessitating this investigation ". Walton Hospital,
C. B. SEDZIMIR.
Liverpool.
STAPHYLOCOCCAL INFECTION IN NURSES
SiR,—The article by Dr. Davies (March 19) will stimulate the search for ways of decreasing the time that nursing and ancillary staffs spend off duty on account of
staphylococcal infections. possible method which seems to
minor
A have received less attention than it deserves is the use of a plastic " skin " to be sprayed or painted on to form a protective covering over surface lesions. This would serve the double purpose of protecting the lesions from further infection or injury and acting as a bacterial barrier to the dissemination of organisms from them. Furthermore, it would be technically very simple to incorporate some suitable bactericidal substance in the " skin ". Some investigation has already been done on these lines, notably by Wright/ Leader,2 and Ritelli,3 but it appears that further research into the use of such methods would be of value.
D. E. STEELE
PERTHES’ DISEASE
SIR,-In your issue of March 19 Dr. Cockshott and Dr. Palmer, writing from Nigeria and Rhodesia, disapprove of
Negro child appears to be immune least seems to be only exceptionally affected by it ", which I included in my letter of Feb. 13. The only written reference to the frequency of Perthes’ among Negro children which I know is given in C. W. Goff’s He states that among 110,555 coloured children book.l admitted to the Charity Hospital, Louisiana, New Orleans, from 1941 to 1951, not 1 case of Perthes’ was recorded, and that in the Hospital for Joint Diseases, New York, with an admission-rate of 20%coloured, not a single Perthes’ was ever seen. Only the Tennessee Crippled Children’s Register reported that they had treated 68 white and 6 Negro children affected by this condition. Davies (quoted by Goff), writing from Makerere College Medical School, Kampala, Uganda, reports practically no evidence of Perthes’ among the Negro my statement that " the to
Perthes’,
or
at
population. All this information was further supported in the discussion Latin-American Congress of 1956 in Mexico City of my paper on the blood-supply of the femoral head during growth. Dr. Oswaldo Campos, in charge of a large children’s hospital in Rio de Janeiro, with a large Negro rate of admission, reported that he had hardly ever seen Negro children with Perthes’; and Dr. Harold Boyd from Memphis corroborated these views. I am sure many will welcome my letter if it may have served to stimulate Dr. Cockshott and Dr. Palmer to make a survey of real or true Perthes’ among Negro children in Ibadan, of course excluding not only sickle-cell anaemia but also subluxation, infective coxitis, and enchondral chondrodystrophy. Nuffield Orthopædic Centre, at the
J. TRUETA.
Oxford.
Medical Adviser, Portland Plastics Ltd.
Hythe, Kent.
CORPORAL PUNISHMENT ENVIRONMENTAL STAPHYLOCOCCAL CONTAMINATION
SIR,-I was very interested in the article on staphylococcal contamination by Dr. Foster (March 26). What particularly struck me was the " fallout " of contamination shown in fig. 3. It is very noticeable that one side of the ward is much more heavily contaminated than the other, and I am moved to wonder why: is the ward cleaned by two people, one of whom does floors more efficiently than the other ? Are dressings done by two dressing teams, one more conscientious than the other? Are the curtains or screens on each side of the ward made of similar material, and how efficient is curtain cleansing ? I have always thought that a vacuum duster would be a much useful tool than a floor-washing machine in any hospital; it is deplorable that staff should still be flapping about with dirty fluffy rags, wet or dry, in any surgical ward. Bacteria on the floor must have come from beds or dressings and therefore had to be airborne at some time: the removal of dust by a vacuum cleaner is better than waiting for it to settle on a washable surface, especially as large quantities of it settle anyway on surfaces unlikely to be washed, such as curtains. As a small comment on ward administration, would it not be safer to put all dirty " beds together and so concentrate bacteria in one corner of the ward ? We always did this twenty years ago in my training school-not that we ever expected to have eight " dirty " cases out of thirty in those days, but if we had they would not have been allowed to spread themselves all over the ward as seems to be the case here. One other point-why no bacterial fallout from one of the beds at all ? Had this unfortunate an infection other than Staph. aureu.r, and if not, what is the answer ? more
"
Tooting Bec Hospital, London, S.W.17. 1. 2. 3.
UNA V. BUDGE Principal Tutor.
H. W. S. Lancet, 1944, i, 664. Leader, S. A. Lister J. 1945, 8, 1. Ritelli, D. Gazz. Med. Ital. 1955, 114, 12.
Wright,
accustomed to logical fallacies, and in on this subject; but may I discussions sentimentality, that Dr. article suggest (March 26) reaches an Waycott’s standard in both exceptional respects. To quote only two " of examples petitio principle he speaks of the present agitation for the restoration of corporal punishment ... based, as it is, on fear and ignorance ", and " as our ideas of criminal responsibility alter ". Both statements may be true, but he gives no evidence to support these assertions.
SIR,-We
are
He says there is no proof of the deterrent effect of corporal punishment, and indeed that no proof can be given statistically. May I suggest that an answer is to be found in Pavlov’s work on conditioned reflexes. In quite lowly forms of animal life conditioned inhibition of even powerfully attractive stimuli can be readily established by associating them with pain. One might reasonably expect in man to inhibit anti-social activities by associating them with pain and other unpleasant experiences. Folk wisdom has long since enshrined this in the proverb " A burnt child dreads the fire ". Dr. Waycott asserts that the decline in the number of birchings was explicable only because the courts had found the birch useless as a deterrent; alternative explanations are at least tenable. It may be that this decline was due to growth of sentimentality in magistrates, and to a possibly unwarranted belief in the value of psychological methods of tackling the offender. His description of the technique of corporal punishment, quoted from the Cadogan report, is unpleasant, but this is irrelevant to the merits of the punishment. As a young practitioner I found it unpleasant to give anxsthetics for dental extractions, or for avulsion of a toenail, but as a rational being I recognised the necessity of such procedures. Lastly, some of us reactionaries are not very much interested in his point as to the value or otherwise of corporal punishment in constructive treatment of offenders: we are more selfishly 1.
Legg-Calve-Perthes Syndrome Springfield, 111., 1954.
and Related Osteochondroses of Youth-