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700 BROKEN LEGS
272
Finally perhaps we should consider whether the wastage involved in the present method of reprint distribution is not acceptable for the sake of the free interchange of information and ideas and for the contacts, however tenuous they may be, that the reprint helps to foster between doctor and scientist in different parts of the world. Chester Beatty Research Institute, London, S.W.3.
A BRUNNING. B UNNIN DENNS A. DENNIS
700 BROKEN LEGS
SIR,-You
evidently by his facts.
are
more
impressed by Nicoll’s
than How else, when his paper offers no data on internal fixation, can you say, in your annotation last week, "... the results suggest that non-union, residual deformity, and joint contracture are no more common after conservative treatment than after internal fixation " ? As regards non-union, Nicoll’s case seems to rest on his statement, "... it is difficult to imagine that the overall rate of 5% could be significantly reduced by routine internal fixation ". Concerning stiffness and deformity Nicoll himself admits that judgment must be reserved. At Birmingham Accident Hospital, with only a 21/2% non-union rate, we could easily suggest that internal fixation had an advantage; but it would be unwise to jump to conclusions.
theorising
Although we are accustomed to such uncritical thinking elsewhere, it is not worthy of The Lancet. Accident Accident Hospital, H. HICKS. J. H J Birmingham. Birmingham. *** Some readers may suppose from Mr. Hicks’s censure that we made positive assertions based on Nicoll’s paper. In fact, all was tentative: the results suggest..." an indication ...". and " there is Nevertheless, these findings seem well worth discussion.-ED. L. "
...
RECURRENT URINARY INFECTIONS IN GIRLS
SIR, The plea for conservative management of urinary infection in girls is reasonable only if systematic and careful follow-up care is available. Dr. Macaulay’s hypothesis1 that infection may disappear in girls with normal urinary tracts may be valid, but the danger is that this too easily becomes another reason to defer a thorough urological
investigation. Previously unrecognised abnormalities of functional dynamic outlet obstruction with urethral and bladder-neck fibroelastosis are now being recognised with improved techniques of bougiea-botili urethral calibration and voiding cine-cystourethrography. Many of these problems may initially be handled by conservative and minor surgical procedures, such as meatotomy, urethrotomv, or urethral dilatation, reserving open surgical correction for the more stubborn problems. I cannot agree with the statement that the natural history of ureterai reflux is insufficiently known for any"
one to
improve by op-
matters
Macaulay, D. Lancet, 1964, ii,
1319
Fig. 5-Intravenous pyelogram (at 20 minutes) after ileal urinary diversion showing resolving hydronephrosis; sterile urine (December, 1964).
operation; but ureteral reflux is abnormal, leads to renal damage, and should be eliminated. Significant reflux, judged by cystography and ureterovesical calibration, requires ureteral reimplantation, and if properly done before the ureters become
needs
dilated and atonic has
85% chance of success.23
example, figs.
Further evidence of the seriousness of this whole problem found on reviewing thirty-six patients with severe renal failure considered for renal homotransplantation at this hospital in 1964. Ten of these patients had problems of urinary dysfunction with outlet obstruction and reflux. Seven of this latter group (aged 11-30) presented solely with ursemia, the minimal symptoms and signs of the causative urinary-tract dysfunction being unnoticed by patients and doctors alike. 2. Spence, H. M., Leadbetter, W. F., Marshall, V. F., Stewart, C. M., Hutch, J. A. J. Urol. 1961, 85, 119. 3. Leadbetter, G. W., Jr., Leadbetter, W. F. J. Amer. med. Ass. 1961, 175,
a
sterile urine. I agree that not every case
1.
Fig. 4-Voiding cystogram showing ureteral reflux; sterile urine (December, 1964).
too
9ux, despite
1962).
Fig. 3-Intravenous pyelogram (at 20 minutes) showing bilateral hydronephrosis (December, 1964).
eration ". For 1-5 show the natural historv of rapid renal destruction caused by reFig. I-Female, born May, 1958: intravenous pyelogram with meningomyelocele (November,
Fig. 2-Normal voiding cystogram; sterile urine; managed by Crede bladder evacuation 4 times daily (November, 1962).
was
349.
an
Finally perhaps we should consider whether the wastage involved in the present method of reprint distribution is not acceptable for the sake of the free interchange of information and ideas and for the contacts, however tenuous they may be, that the reprint helps to foster between doctor and scientist in different parts of the world. Chester Beatty Research Institute, London, S.W.3.
A BRUNNING. B UNNIN DENNS A. DENNIS
700 BROKEN LEGS
SIR,-You
evidently by his facts.
are
more
impressed by Nicoll’s
than How else, when his paper offers no data on internal fixation, can you say, in your annotation last week, "... the results suggest that non-union, residual deformity, and joint contracture are no more common after conservative treatment than after internal fixation " ? As regards non-union, Nicoll’s case seems to rest on his statement, "... it is difficult to imagine that the overall rate of 5% could be significantly reduced by routine internal fixation ". Concerning stiffness and deformity Nicoll himself admits that judgment must be reserved. At Birmingham Accident Hospital, with only a 21/2% non-union rate, we could easily suggest that internal fixation had an advantage; but it would be unwise to jump to conclusions.
theorising
Although we are accustomed to such uncritical thinking elsewhere, it is not worthy of The Lancet. Accident Accident Hospital, H. HICKS. J. H J Birmingham. Birmingham. *** Some readers may suppose from Mr. Hicks’s censure that we made positive assertions based on Nicoll’s paper. In fact, all was tentative: the results suggest..." an indication ...". and " there is Nevertheless, these findings seem well worth discussion.-ED. L. "
...
RECURRENT URINARY INFECTIONS IN GIRLS
SIR, The plea for conservative management of urinary infection in girls is reasonable only if systematic and careful follow-up care is available. Dr. Macaulay’s hypothesis1 that infection may disappear in girls with normal urinary tracts may be valid, but the danger is that this too easily becomes another reason to defer a thorough urological
investigation. Previously unrecognised abnormalities of functional dynamic outlet obstruction with urethral and bladder-neck fibroelastosis are now being recognised with improved techniques of bougiea-botili urethral calibration and voiding cine-cystourethrography. Many of these problems may initially be handled by conservative and minor surgical procedures, such as meatotomy, urethrotomv, or urethral dilatation, reserving open surgical correction for the more stubborn problems. I cannot agree with the statement that the natural history of ureterai reflux is insufficiently known for any"
one to
improve by op-
matters
Macaulay, D. Lancet, 1964, ii,
1319
Fig. 5-Intravenous pyelogram (at 20 minutes) after ileal urinary diversion showing resolving hydronephrosis; sterile urine (December, 1964).
operation; but ureteral reflux is abnormal, leads to renal damage, and should be eliminated. Significant reflux, judged by cystography and ureterovesical calibration, requires ureteral reimplantation, and if properly done before the ureters become
needs
dilated and atonic has
85% chance of success.23
example, figs.
Further evidence of the seriousness of this whole problem found on reviewing thirty-six patients with severe renal failure considered for renal homotransplantation at this hospital in 1964. Ten of these patients had problems of urinary dysfunction with outlet obstruction and reflux. Seven of this latter group (aged 11-30) presented solely with ursemia, the minimal symptoms and signs of the causative urinary-tract dysfunction being unnoticed by patients and doctors alike. 2. Spence, H. M., Leadbetter, W. F., Marshall, V. F., Stewart, C. M., Hutch, J. A. J. Urol. 1961, 85, 119. 3. Leadbetter, G. W., Jr., Leadbetter, W. F. J. Amer. med. Ass. 1961, 175,
a
sterile urine. I agree that not every case
1.
Fig. 4-Voiding cystogram showing ureteral reflux; sterile urine (December, 1964).
too
9ux, despite
1962).
Fig. 3-Intravenous pyelogram (at 20 minutes) showing bilateral hydronephrosis (December, 1964).
eration ". For 1-5 show the natural historv of rapid renal destruction caused by reFig. I-Female, born May, 1958: intravenous pyelogram with meningomyelocele (November,
Fig. 2-Normal voiding cystogram; sterile urine; managed by Crede bladder evacuation 4 times daily (November, 1962).
was
349.
an