- Email: [email protected]
ACUTE INFECTIONS OF THE FINGERS AND HAND
315
My emphatic reply is no, but I can recall patients with old tuberculous lesions who had no symptoms whose radioexcited major surgical procedures. lIas lie not read my papers on bone tumours ? There I strongly advocate serial radiographic surveys to aid clinical vision without disturbing the sequence of changes by surgical trauma or infection ; but alas, another group as strongly opposes that. Can Dr. Cochrane Shanks (Feb. 2) tell us who advised the Government to purchase foreign films which had little keeping quality and produced such bad radiographs that some of us after trial refused to waste further time using them ?‘ What did happen to those films ? Were they not offered free to hospitals, which would not take them ?’? Were we exporting good British films at that time ? I repeat that the efficient and economical servicing of X-ray units during and for some years after the 1914-18 war by the Office of Works was not characterised by such shameful destruction of efficient units as has followed the issue to hospitals of multiple forms with some such inviting words as : " The following units are available ..." followed by details of highly expensive elaborate equipment by all of four or five manufacturers with invitations to indent for the coming year. Dr. Cochrane Shanks is wrong to say it was always the radiologist who advised the purchase ; he was not always permitted to prevent it. Equipment has been installed contrary to my wishes. I still serve hospitals with equipment 15-20 years old, and can produce radiographs which I am prepared to match against any taken with the aid of " modern " equipment. But such economy does not permit of show ; it is frowned upon by the responsible authorities. Perhaps with the economy which is being forced upon us even Dr. Cochrane Shanks will not be so ready to attack those colleagues who have always been accustomed to practise it. JAMES F. BRAILSFORD. Birmingham.
graphs
FRUIT NEEDED IN SPRUE
treatment of sprue the banana is the but the crops on which we depend have been devastated last year in Jamaica and now in the Cameroons. Next to it should be rated the tinned tomato-juice from Australia, which is never harmed by gales as the top-heavy banana is ; it is to be hoped that this is not one of the tinned fruits whose import is to be
SiR,ňIn the great stand-by ;
prohibited. ,
A PATIENT. WEIL’S DISEASE TREATED WITH PENICILLIN SIR,-In your issue of Dec. 15, Dr. Herbert-Burns and Mr. Flavell report favourably on the action of penicillin in a case of Weil’s disease. Agglutination tests
remained persistently negative during the illness and after recovery, but on clinical evidence the writers suggest that there is no reason to doubt the diagnosis. It is true that an instance has been recordedin which a strain of Leptospira icterohmmorrhagi6v was isolated from a patient who failed to develop antibodies, but experience shows that such a complete absence of agglutinins is very rare. It may be questioned therefore whether there is good justification for quoting a single case, not fully confirmed, as evidence for the value of penicillin, in view of the fact that an analysis of 152 cases of Weil’s disease with jaundice treated by penicillin revealed a case-mortality of 22%2 compared with 23% in pre-penicillin days. Records are too few for an assessment of the therapeutic activity of the newer antibiotics in human leptospirosis ; but in animalsAureomycin ’ and terramycin 3 appear 1. Gamier, M., Reilly, J. C.R. Soc. Biol. Paris, 1917, 80, 101. 2. Broom, J. C. Brit. med. J. 1951, ii, 689. 3. Uhlenhuth, P., Schoenherr, K. E. Z. ImmunForsch. 1951, 108,
289.
efficacious. It would be unfortunate, thereundue complacency regarding the value of should deprive patients of what may turn out
much
more
fore,
if
penicillin to be
more
effective remedies.
Laboratories of Tropical Wellcome Jjaboratories N.BV.L London, N.W.1.
J. C. BROOM. Medicine,
ACUTE INFECTIONS OF THE FINGERS AND HAND
SiR,-In his rational and interesting article of Jan. 26 Mr. Bailey advocates a direct approach to the pulp abscess. During the late war, when lights failed in the blackout, it was occasionally necessary to examine septic fingers by the light of a pocket torch. Transillumination of the infected pulp from the palmar aspect often showed precisely the situation of a small abscess. The reliability of this test has been proved subsequently ; but for satisfactory results a dark-room and a bright beam of light are advisable. M. HARTY. Cambridge.
***The use of transillumination for this purpose was illustrated by Dr. E. P. Samuel in an article in our issue of April 22, 1950.-ED. L. EVOLUTION OF THE TOXIC THYROID GLAND
SiR,-Mr. Levitt (Nov. 24), having arranged his cases of toxic goitre and thyroiditis in an impressively orderly series, maintains that this demonstrates a progression in I time of each individual case through the series. (Dec. 8) admitted the series but denied that this proved the temporal progression, claiming incidentally to know Mr. Levitt at least four alternative explanations. (Jan. 26) asks me to produce them. Here are five, for
good
measure :
1. (Nearest to Mr. Levitt’s hypothesis.) The whole series may be the result of the action of a single abnormal stimulus on thyroids of varying reactivity. The normal response is hyperplasia and clinical hyperthyroidism, but in some older women the same stimulus simply tips the thyroid over at once into a degenerative phase. 2. (The most generally accepted hypothesis.) Toxic goitre and Hashimoto’s disease are two wholly distinct diseases which happen to overlap in some of their clinical and
pathological
manifestations.
3. The same two diseases are distinct, but one pxedisposes to the other so that the two-will be found together more often than can be expected by chance (in the same way that silicosis and tuberculosis blend in the lung not by chance, but are yet not the same disease). 4. The series represents the intermingling of three or four or any number of unrecognised entities : until we have some knowledge of the aetiology of the condition we have none but William of Occam’s authority for assuming that only one or two diseases are involved. Biology gives plenty of examples of distinct pure lines mixing together to produce an apparently homogeneous population with continuous variation. The thyroid is limited in its mode of reaction to injury, but paucity of reactions is no guarantee that the number of types of injury is equally few. We have it on the authority of the bacteriologists that the number of pneumonias is legion :-. without them morbid anatomists and clinicians would be equally hard put to it to say how many there were, and a school of monophysites would undoubtedly arise to prove the essential unity of the whole group. 5. Lymphoid tissue in the human thyroid is a reaction to infection by a universally present thyroxinophilic virus (more abundant in the active gland) which is normally nonvirulent but just occasionally destroys the gland. This is a somewhat fantastic hypothesis ; but there is some evidence that such a condition can be produced in the pancreas of fowls by the virus of infectious lymphomatosis.
I have no intention of defending any of these hypotheses in detail. I am concerned only to show that temporal progression is not the only possible explanation of the tliyroid series. The construction of such series, though often exceedingly profitable, is full of pitfalls. Even a
perfectly
My emphatic reply is no, but I can recall patients with old tuberculous lesions who had no symptoms whose radioexcited major surgical procedures. lIas lie not read my papers on bone tumours ? There I strongly advocate serial radiographic surveys to aid clinical vision without disturbing the sequence of changes by surgical trauma or infection ; but alas, another group as strongly opposes that. Can Dr. Cochrane Shanks (Feb. 2) tell us who advised the Government to purchase foreign films which had little keeping quality and produced such bad radiographs that some of us after trial refused to waste further time using them ?‘ What did happen to those films ? Were they not offered free to hospitals, which would not take them ?’? Were we exporting good British films at that time ? I repeat that the efficient and economical servicing of X-ray units during and for some years after the 1914-18 war by the Office of Works was not characterised by such shameful destruction of efficient units as has followed the issue to hospitals of multiple forms with some such inviting words as : " The following units are available ..." followed by details of highly expensive elaborate equipment by all of four or five manufacturers with invitations to indent for the coming year. Dr. Cochrane Shanks is wrong to say it was always the radiologist who advised the purchase ; he was not always permitted to prevent it. Equipment has been installed contrary to my wishes. I still serve hospitals with equipment 15-20 years old, and can produce radiographs which I am prepared to match against any taken with the aid of " modern " equipment. But such economy does not permit of show ; it is frowned upon by the responsible authorities. Perhaps with the economy which is being forced upon us even Dr. Cochrane Shanks will not be so ready to attack those colleagues who have always been accustomed to practise it. JAMES F. BRAILSFORD. Birmingham.
graphs
FRUIT NEEDED IN SPRUE
treatment of sprue the banana is the but the crops on which we depend have been devastated last year in Jamaica and now in the Cameroons. Next to it should be rated the tinned tomato-juice from Australia, which is never harmed by gales as the top-heavy banana is ; it is to be hoped that this is not one of the tinned fruits whose import is to be
SiR,ňIn the great stand-by ;
prohibited. ,
A PATIENT. WEIL’S DISEASE TREATED WITH PENICILLIN SIR,-In your issue of Dec. 15, Dr. Herbert-Burns and Mr. Flavell report favourably on the action of penicillin in a case of Weil’s disease. Agglutination tests
remained persistently negative during the illness and after recovery, but on clinical evidence the writers suggest that there is no reason to doubt the diagnosis. It is true that an instance has been recordedin which a strain of Leptospira icterohmmorrhagi6v was isolated from a patient who failed to develop antibodies, but experience shows that such a complete absence of agglutinins is very rare. It may be questioned therefore whether there is good justification for quoting a single case, not fully confirmed, as evidence for the value of penicillin, in view of the fact that an analysis of 152 cases of Weil’s disease with jaundice treated by penicillin revealed a case-mortality of 22%2 compared with 23% in pre-penicillin days. Records are too few for an assessment of the therapeutic activity of the newer antibiotics in human leptospirosis ; but in animalsAureomycin ’ and terramycin 3 appear 1. Gamier, M., Reilly, J. C.R. Soc. Biol. Paris, 1917, 80, 101. 2. Broom, J. C. Brit. med. J. 1951, ii, 689. 3. Uhlenhuth, P., Schoenherr, K. E. Z. ImmunForsch. 1951, 108,
289.
efficacious. It would be unfortunate, thereundue complacency regarding the value of should deprive patients of what may turn out
much
more
fore,
if
penicillin to be
more
effective remedies.
Laboratories of Tropical Wellcome Jjaboratories N.BV.L London, N.W.1.
J. C. BROOM. Medicine,
ACUTE INFECTIONS OF THE FINGERS AND HAND
SiR,-In his rational and interesting article of Jan. 26 Mr. Bailey advocates a direct approach to the pulp abscess. During the late war, when lights failed in the blackout, it was occasionally necessary to examine septic fingers by the light of a pocket torch. Transillumination of the infected pulp from the palmar aspect often showed precisely the situation of a small abscess. The reliability of this test has been proved subsequently ; but for satisfactory results a dark-room and a bright beam of light are advisable. M. HARTY. Cambridge.
***The use of transillumination for this purpose was illustrated by Dr. E. P. Samuel in an article in our issue of April 22, 1950.-ED. L. EVOLUTION OF THE TOXIC THYROID GLAND
SiR,-Mr. Levitt (Nov. 24), having arranged his cases of toxic goitre and thyroiditis in an impressively orderly series, maintains that this demonstrates a progression in I time of each individual case through the series. (Dec. 8) admitted the series but denied that this proved the temporal progression, claiming incidentally to know Mr. Levitt at least four alternative explanations. (Jan. 26) asks me to produce them. Here are five, for
good
measure :
1. (Nearest to Mr. Levitt’s hypothesis.) The whole series may be the result of the action of a single abnormal stimulus on thyroids of varying reactivity. The normal response is hyperplasia and clinical hyperthyroidism, but in some older women the same stimulus simply tips the thyroid over at once into a degenerative phase. 2. (The most generally accepted hypothesis.) Toxic goitre and Hashimoto’s disease are two wholly distinct diseases which happen to overlap in some of their clinical and
pathological
manifestations.
3. The same two diseases are distinct, but one pxedisposes to the other so that the two-will be found together more often than can be expected by chance (in the same way that silicosis and tuberculosis blend in the lung not by chance, but are yet not the same disease). 4. The series represents the intermingling of three or four or any number of unrecognised entities : until we have some knowledge of the aetiology of the condition we have none but William of Occam’s authority for assuming that only one or two diseases are involved. Biology gives plenty of examples of distinct pure lines mixing together to produce an apparently homogeneous population with continuous variation. The thyroid is limited in its mode of reaction to injury, but paucity of reactions is no guarantee that the number of types of injury is equally few. We have it on the authority of the bacteriologists that the number of pneumonias is legion :-. without them morbid anatomists and clinicians would be equally hard put to it to say how many there were, and a school of monophysites would undoubtedly arise to prove the essential unity of the whole group. 5. Lymphoid tissue in the human thyroid is a reaction to infection by a universally present thyroxinophilic virus (more abundant in the active gland) which is normally nonvirulent but just occasionally destroys the gland. This is a somewhat fantastic hypothesis ; but there is some evidence that such a condition can be produced in the pancreas of fowls by the virus of infectious lymphomatosis.
I have no intention of defending any of these hypotheses in detail. I am concerned only to show that temporal progression is not the only possible explanation of the tliyroid series. The construction of such series, though often exceedingly profitable, is full of pitfalls. Even a
perfectly