- Email: [email protected]
ADRENAL HYPERPLASIA AND NEOPLASIA
1281
and found the hospital authorities enthusiastic about the value of the plan. With one exception (a London far from country places) the homes were dozen miles of their parent hospitals. All the authorities agreed that the home should be an integral part of the hospital, which supplies stores, food, drugs, and general services. The patients are visited at regular convenient intervals by senior residents and members of the consulting staff. At the homes which are over twelve miles from the parent hospital, the hospital arranges for a general practitioner to be on call in an About half the nursing staff are Stateemergency. registered, and more or less permanent : student nurses take a turn of duty there, and find it stimulating, partly because of the rapid turnover of patients and The because the trained staff have time to teach. patients the same skilled nursing care, and the same medical attention, as they would be getting in hospital, and the home provides it. Pre-students are sometimes allowed to do minor oilices in the home ; and this to be the one place where such young people may safely he allowed to come into contact with patients. (Such homes may therefore prove good training places for nursing cadeta.)No operating-theatre or X-ray or other expensive equipment is needed, for these are all provided at the parent hospital. The patients most suitable for admission are those
hospital, within
a.
partly
with moderately
severe
medical, surgical,
or
gyna’cological
conditions who need 12-15 days in hospital and about the same time in the home. Long-term orthopedic. geriatric, or chronic cases should be sent elsewhere, for they quickly block beds and change the whole spirit and of the home. The hopeful name, the change of scene, and the rapid turnover in population all have a part to play in helping patients to recover quickly, and go back home : at the end of their stay they should not need convalescent care as well. If patients are properly selected, only about 3<)°o of the medical, surgical, and gyn.t-cological beds will be found to he discharging their occupants to the home. A common fear among hospital authorities who have not set up such homes is that the increased turnover in the wards may throw too much extra, work on the nursing staff. In fact there have been no complaints of overwork from ward staff ; and even where the rate of turnover is at its highest the addition of one extra nurse to the ward has been enough to cope with it. Hospitals usually buy country houses to convert into recovery homes. These commonly have good grounds in which patients can refresh themselves, and which will also provide a large part of the vegetables and fruit One such house was converted at a cost of needed. 1800 per bed. and another at a cost of only f470 per bed. The cost of maintaining a patient in a recovery home is less than half the cost of maintaining him in hospital, so the total cost per patient falls. Though hospital waiting-lists are reduced, and turnover increased, the committee could not find any evidence of a recognisable increase in the maintenance costs of a parent hospital as a result of having a recovery home. These findings should reassure hospital authorities longing for a recovery home but fearing to take the plunge ; it should also wake a spirit of adventure in those who have not so far contemplated the possibility.
purpose
NEEDLE BIOPSY OF LUNG
THE
investigation of a case in which radiography has a pulmonary lesion often reaches an impasse, with no clue to the diagnosis from bronchoscopy and bronchography and examination of sputum or bronchial secretions for malignant cells, fungi, and tubercle bacilli. In these circumstances needle biopsy under fluoroscopic control is tempting ; but, because of the dangers of air-embolism, haemorrhage, and the dissemination of shown
infected material or neoplastic tissue, most physicians prefer to transfer the case to the surgeon for exploratory thoracotomy. Dutra and Geraci1 recommend needle biopsy of the lung for a limited class of cases : the clinical evidence should point to an incurable malignant condition, the lesion should be peripheral, and attempts by other methods to clinch the diagnosis should have failed. The area of skin nearest the mass is found by fluoroscopy and marked, and the biopsy is done with a VimSilverman needle. They consider that needle biopsy should not be done if surgical treatment seems feasible a point that is emphasised by one of their cases in which an implant of neoplastic cells in the needle track led to
a
subcutaneous tumour. ADRENAL HYPERPLASIA AND NEOPLASIA
glands either a tumour (usually unihyperplasia (which is bilateral) can produce The abnormality is associated with a large
IN the adrenal
lateral)
or
virilism.22 excretion of 17-ketosteroids in the urine. When congenital it produces macrogenitosomia prsecox in the male and pseudo-hermaphroditism in the female ; there is often also a defect in the regulation of salt metabolism.3 4 If the abnormality arises after the external genitalia have developed in the fourth month of foetal life, then in the female the result is simply virilism, with hirsutism and enlargement of the clitoris. The male still shows macrogenitosomia if the lesion is prepubertal ; since the adrenals are responsible for the abnormal output of hormone, the testes remain infantile, and in this way the disorder can be distinguished from other types of precocious puberty in the male. It is obviously difficult to recognise the abnormality in the male after
puberty. In congenital
cases
but otherwise
tumour-not
hyperplasia is the usual lesion ; necessarily malignant-is more common than hyperplasia, particularly before of steroids secreted puberty. In either case the pattern 6 the adrenal is abnormal.5 et al. have ably Jailer by reviewed the effect of large doses of cortisone on the high output of 17-ketosteroids. From their own wide experience, and from the results reported by others, they show that cases of hyperplasia respond with a fall in a
17-ketosteroids whereas
cases
of tumour do not. Cortisone
usually produces a remission in virilism associated with adrenal hyperplasia, presumably by inhibiting the pituitary ; but tumours of the adrenal seem to be independent of pituitary control and operation is the only treatment. In Cushing’s syndrome the secretion of the normal adrenal hormone is excessive; but there may be an abnormal pattern, and virilism and Cushing’s syndrome can occur together. Although the results were less clearcut than in virilism-the excretion of 17-ketosteroids in Cushing’s syndrome is not necessarily very highJailer et al. found that the " cortisone test " may also be useful in differentiating tumour and hyperplasia of the adrenal in Cushing’s syndrome. A tumour requires For hyperplasia producing a unilateral operation. Cushing’s syndrome bilateral subtotal adrenalectomy may be required if the condition is progressive and disabling ; destruction of the pituitary has also been tried successfully. These are uncommon diseases. Virilism must be distinguished from simple hirsuties, and adrenal virilism 1. Dutra, F. R., Geraci, C. L. J. Amer. med. Ass. 1954, 155, 21. 2. Jailer, J. W. Bull. N.Y. Acad. Med. 1953, 29, 377. 3. Wilkins, L., Fleischmann, W., Howard, J. E. Endocrinology, 1940, 26, 385. 4. Harris, C. F., Scowen, E. F. Arch. Dis. Childh. 1951, 26, 423. 5. Pond, M. H. J. Endocrin. 1954, 10, 202. 6. Bongiovanni, A. M., Eberlein, W. R., Cara, J. J. clin. Endocrin. 1954, 14, 409. 7. Jailer, J. W., Gold, J. J., Wallace, E. Z. Amer. J. Med. 1954, 16, 340.
1282 from that produced by hypothalamic,8 9 pituitary, and gonadal disorders.2 The diagnosis of Cushing’s syndrome requires evidence of adrenal over-activity ; and many women with obesity, hirsuties, hypertension, and diabetes have not got this syndrome. But the few unfortunate patients who have adrenal disorders can often be helped.
TOWARDS CLEAN AIR FoR centuries private citizens and public committees have talked of smoke abatement. The outlook, however, has so steadily darkened that the " six counties overhung with smoke " which William Morris found such difficulty in forgetting, are now indistinguishable from most of their neighbours. The National Smoke Abatement Society (N.S.A.S.) in a memorandum 10 addressed to the Committee on Air Pollution (the Beaver Committee), say that the reason effective action has never been taken is because there has never been an informed determined public demand for it. The London fog disaster of 1952, however, sharply increased interest in air pollution ; and people are readier than they have ever been to attend to its causes and press for remedies. The society believe the subject to be of such importance that smoke prevention should be among the first factors considered when the use of fuels is under discussion ; and that all fuel policies, developments, and propaganda which are not in the interests of smoke prevention (such as propaganda for the overnight use of bituminous slacks on domestic fires) should not be countenanced. No change in legislation would be needed to achieve this-only a change in outlook among those responsible for fuel policies. Many other preventive measures could be applied under the existing laws : coal could be better cleaned, so that it emitted less sulphur dioxide and grit when it was burned ; different types of plant could use appropriate grades of coal for smoke prevention, and the quality supplied could be consistent ; stokers could be better trained ; fuelburning plant could be better maintained and managed, and the rate of modernising plant could be hastened ; both in industry and in the home the use of gas and electricity could be extended ; and the replacement of raw coal with solid smokeless fuel might proceed much faster than it does. Some 37 million tons of smokeless fuel is produced annually in Great Britain, of which only 5 million tons is available for domestic purposes. It has been estimated that-partly by increased production and partly by withdrawals from other markets - 10 million tons could be made available for domestic use by 1957, and 15 million tons by 1962. Meanwhile the society urge that available supplies of smokeless fuels should be sent to areas which will benefit most from their use-such as smokeless zones. Naturally research is needed, not only to develop new processes for the production of smokeless fuel, but on such pollution problems as the removal of sulphur dioxide, grit, and dust from flue gases ; and on the pollution caused by steel and clay industries, coke ovens, cement manufacture, lime-burning, chemical processes, and road-vehicle exhausts. The last is an up-and-coming nuisance which we should do well to scotch in time. Diesel fumes thicken on our roads ; and the plan to exchange London’s 1800 clean and silent trolleybuses for diesel-engine motor-buses has already caused many
protests.ll
Again, proposing
the N.S.A.S. schemes for
think
reducing
that air
local
authorities
pollution get
too
8. Morley, T. P. J. clin. Endocrin. 1954, 14, 1. 9. Bauer, H. G. Ibid, p. 13. 10. To be had from the National Smoke Abatement Society, 30, Grosvenor Place, London, S.W.1. 1954. Pp. 15. 1s. 11. Times, May 6, et. seq.
little encouragement. Initiative of this kind, they say, should be not only approved but stimulated by the Government ; for too many local authorities are still inactive. The law about smoke has remained substantially the same for three-quarters of a century, and is almost entirely of the too-late variety (in the sense that action can only be taken after a nuisance has been caused). The society suggest that new legislation should not only give local authorities better powers for setting up smokeless zones but should enable them to proceed against manufacturers whose chimney emissions exceed prescribed standards. It should also oblige manufacturers who are putting in new fuel-burning plant to have their plans approved beforehand by the local authority. Moreover, all boiler-men and furnace-men should be required to hold a certificate of proficiency ; and local authorities should be obliged to employ only fully qualified smoke inspectors. Finally, the society suggest, the installation in houses or hotels of grates which cannot burn smokeless fuel should be prohibited. The society, in their steady education of the public in this matter, have done good work and done it on a very small budget. They are fully justified in that they deserve a Government grant it, for no agency is better placed for creating the informed public opinion which alone can lift the cloud from us.
suggesting
towards
RECURRENT PANCREATITIS PANCREATITIS is apparently commoner in North America than here. Several accounts of this disease have appeared in the U.S.A. during the last few years 1-3 ; and at the recent meeting in London of the American College of Surgeons Prof. Walter (’. 1IaeKenzie described his extensive experience of it in(’anada.4 According to Phillips,3 it is usually a chronic relapsing disorder in middle-aged alcoholic men. There is a fairly characteristic pattern of attacks of upper abdominal pain, recurring on average three or four times a year, which are often precipitated by alcoholic or dietary indiscretion or by worry or fatigue.2 The attack may be mild, lasting only a few hours, or of the severe acute h:!emorrhagic" type that continues for several days. Vomiting is usual and there may be mild diarrhcea ; pyrexia is seldom pronounced ; loss of weight during the attack may be severe. In uncomplicated cases the patients are free of symptoms between attacks. Eventually fibrosis may lead to cyst formation or to calcification, which may be localised or diffuse. Occasionally severe fibrosis may produce bile-duct obstruction, but this is probably rare. Confirmation of the diagnosis by clinical tests is often difficult. Radiographic evidence of pancreatic calcification, the presence of steatorrhoea, creatorrhoea, or glycosuria, or a raised serum amylase or lipase level are highly significant. But such evidence is to be expected only in severe attacks or when repeated episodes have considerably damaged the gland. In mild attacks and between bouts, investigations often yield negative results. Examination of the duodenal contents after administration of secretin has been recommended, but this test is tedious and difficult and the results are inconstant. With pancreatitis, as with so many diseases, the case-history is often a better guide than a group of tests. The acute episode is best treated conservatively with analgesics (but not morphine) and antibiotics. Atropine or, better,’Probanthine’ is given to decrease gastric and pancreatic secretion, and to relax the ’’
Maimon, S. N., Kirsner, J. B., Palmer, W. L. Arch. intern. Med. 1948, 81, 56. 2. Hersperger, W. G. Sth. Med. J. 1949, 42, 289. 3. Phillips, A. M. Arch. intern. Med. 1954, 93, 337. 4. See Lancet, May 29, 1954, p. 1126. 1.
and found the hospital authorities enthusiastic about the value of the plan. With one exception (a London far from country places) the homes were dozen miles of their parent hospitals. All the authorities agreed that the home should be an integral part of the hospital, which supplies stores, food, drugs, and general services. The patients are visited at regular convenient intervals by senior residents and members of the consulting staff. At the homes which are over twelve miles from the parent hospital, the hospital arranges for a general practitioner to be on call in an About half the nursing staff are Stateemergency. registered, and more or less permanent : student nurses take a turn of duty there, and find it stimulating, partly because of the rapid turnover of patients and The because the trained staff have time to teach. patients the same skilled nursing care, and the same medical attention, as they would be getting in hospital, and the home provides it. Pre-students are sometimes allowed to do minor oilices in the home ; and this to be the one place where such young people may safely he allowed to come into contact with patients. (Such homes may therefore prove good training places for nursing cadeta.)No operating-theatre or X-ray or other expensive equipment is needed, for these are all provided at the parent hospital. The patients most suitable for admission are those
hospital, within
a.
partly
with moderately
severe
medical, surgical,
or
gyna’cological
conditions who need 12-15 days in hospital and about the same time in the home. Long-term orthopedic. geriatric, or chronic cases should be sent elsewhere, for they quickly block beds and change the whole spirit and of the home. The hopeful name, the change of scene, and the rapid turnover in population all have a part to play in helping patients to recover quickly, and go back home : at the end of their stay they should not need convalescent care as well. If patients are properly selected, only about 3<)°o of the medical, surgical, and gyn.t-cological beds will be found to he discharging their occupants to the home. A common fear among hospital authorities who have not set up such homes is that the increased turnover in the wards may throw too much extra, work on the nursing staff. In fact there have been no complaints of overwork from ward staff ; and even where the rate of turnover is at its highest the addition of one extra nurse to the ward has been enough to cope with it. Hospitals usually buy country houses to convert into recovery homes. These commonly have good grounds in which patients can refresh themselves, and which will also provide a large part of the vegetables and fruit One such house was converted at a cost of needed. 1800 per bed. and another at a cost of only f470 per bed. The cost of maintaining a patient in a recovery home is less than half the cost of maintaining him in hospital, so the total cost per patient falls. Though hospital waiting-lists are reduced, and turnover increased, the committee could not find any evidence of a recognisable increase in the maintenance costs of a parent hospital as a result of having a recovery home. These findings should reassure hospital authorities longing for a recovery home but fearing to take the plunge ; it should also wake a spirit of adventure in those who have not so far contemplated the possibility.
purpose
NEEDLE BIOPSY OF LUNG
THE
investigation of a case in which radiography has a pulmonary lesion often reaches an impasse, with no clue to the diagnosis from bronchoscopy and bronchography and examination of sputum or bronchial secretions for malignant cells, fungi, and tubercle bacilli. In these circumstances needle biopsy under fluoroscopic control is tempting ; but, because of the dangers of air-embolism, haemorrhage, and the dissemination of shown
infected material or neoplastic tissue, most physicians prefer to transfer the case to the surgeon for exploratory thoracotomy. Dutra and Geraci1 recommend needle biopsy of the lung for a limited class of cases : the clinical evidence should point to an incurable malignant condition, the lesion should be peripheral, and attempts by other methods to clinch the diagnosis should have failed. The area of skin nearest the mass is found by fluoroscopy and marked, and the biopsy is done with a VimSilverman needle. They consider that needle biopsy should not be done if surgical treatment seems feasible a point that is emphasised by one of their cases in which an implant of neoplastic cells in the needle track led to
a
subcutaneous tumour. ADRENAL HYPERPLASIA AND NEOPLASIA
glands either a tumour (usually unihyperplasia (which is bilateral) can produce The abnormality is associated with a large
IN the adrenal
lateral)
or
virilism.22 excretion of 17-ketosteroids in the urine. When congenital it produces macrogenitosomia prsecox in the male and pseudo-hermaphroditism in the female ; there is often also a defect in the regulation of salt metabolism.3 4 If the abnormality arises after the external genitalia have developed in the fourth month of foetal life, then in the female the result is simply virilism, with hirsutism and enlargement of the clitoris. The male still shows macrogenitosomia if the lesion is prepubertal ; since the adrenals are responsible for the abnormal output of hormone, the testes remain infantile, and in this way the disorder can be distinguished from other types of precocious puberty in the male. It is obviously difficult to recognise the abnormality in the male after
puberty. In congenital
cases
but otherwise
tumour-not
hyperplasia is the usual lesion ; necessarily malignant-is more common than hyperplasia, particularly before of steroids secreted puberty. In either case the pattern 6 the adrenal is abnormal.5 et al. have ably Jailer by reviewed the effect of large doses of cortisone on the high output of 17-ketosteroids. From their own wide experience, and from the results reported by others, they show that cases of hyperplasia respond with a fall in a
17-ketosteroids whereas
cases
of tumour do not. Cortisone
usually produces a remission in virilism associated with adrenal hyperplasia, presumably by inhibiting the pituitary ; but tumours of the adrenal seem to be independent of pituitary control and operation is the only treatment. In Cushing’s syndrome the secretion of the normal adrenal hormone is excessive; but there may be an abnormal pattern, and virilism and Cushing’s syndrome can occur together. Although the results were less clearcut than in virilism-the excretion of 17-ketosteroids in Cushing’s syndrome is not necessarily very highJailer et al. found that the " cortisone test " may also be useful in differentiating tumour and hyperplasia of the adrenal in Cushing’s syndrome. A tumour requires For hyperplasia producing a unilateral operation. Cushing’s syndrome bilateral subtotal adrenalectomy may be required if the condition is progressive and disabling ; destruction of the pituitary has also been tried successfully. These are uncommon diseases. Virilism must be distinguished from simple hirsuties, and adrenal virilism 1. Dutra, F. R., Geraci, C. L. J. Amer. med. Ass. 1954, 155, 21. 2. Jailer, J. W. Bull. N.Y. Acad. Med. 1953, 29, 377. 3. Wilkins, L., Fleischmann, W., Howard, J. E. Endocrinology, 1940, 26, 385. 4. Harris, C. F., Scowen, E. F. Arch. Dis. Childh. 1951, 26, 423. 5. Pond, M. H. J. Endocrin. 1954, 10, 202. 6. Bongiovanni, A. M., Eberlein, W. R., Cara, J. J. clin. Endocrin. 1954, 14, 409. 7. Jailer, J. W., Gold, J. J., Wallace, E. Z. Amer. J. Med. 1954, 16, 340.
1282 from that produced by hypothalamic,8 9 pituitary, and gonadal disorders.2 The diagnosis of Cushing’s syndrome requires evidence of adrenal over-activity ; and many women with obesity, hirsuties, hypertension, and diabetes have not got this syndrome. But the few unfortunate patients who have adrenal disorders can often be helped.
TOWARDS CLEAN AIR FoR centuries private citizens and public committees have talked of smoke abatement. The outlook, however, has so steadily darkened that the " six counties overhung with smoke " which William Morris found such difficulty in forgetting, are now indistinguishable from most of their neighbours. The National Smoke Abatement Society (N.S.A.S.) in a memorandum 10 addressed to the Committee on Air Pollution (the Beaver Committee), say that the reason effective action has never been taken is because there has never been an informed determined public demand for it. The London fog disaster of 1952, however, sharply increased interest in air pollution ; and people are readier than they have ever been to attend to its causes and press for remedies. The society believe the subject to be of such importance that smoke prevention should be among the first factors considered when the use of fuels is under discussion ; and that all fuel policies, developments, and propaganda which are not in the interests of smoke prevention (such as propaganda for the overnight use of bituminous slacks on domestic fires) should not be countenanced. No change in legislation would be needed to achieve this-only a change in outlook among those responsible for fuel policies. Many other preventive measures could be applied under the existing laws : coal could be better cleaned, so that it emitted less sulphur dioxide and grit when it was burned ; different types of plant could use appropriate grades of coal for smoke prevention, and the quality supplied could be consistent ; stokers could be better trained ; fuelburning plant could be better maintained and managed, and the rate of modernising plant could be hastened ; both in industry and in the home the use of gas and electricity could be extended ; and the replacement of raw coal with solid smokeless fuel might proceed much faster than it does. Some 37 million tons of smokeless fuel is produced annually in Great Britain, of which only 5 million tons is available for domestic purposes. It has been estimated that-partly by increased production and partly by withdrawals from other markets - 10 million tons could be made available for domestic use by 1957, and 15 million tons by 1962. Meanwhile the society urge that available supplies of smokeless fuels should be sent to areas which will benefit most from their use-such as smokeless zones. Naturally research is needed, not only to develop new processes for the production of smokeless fuel, but on such pollution problems as the removal of sulphur dioxide, grit, and dust from flue gases ; and on the pollution caused by steel and clay industries, coke ovens, cement manufacture, lime-burning, chemical processes, and road-vehicle exhausts. The last is an up-and-coming nuisance which we should do well to scotch in time. Diesel fumes thicken on our roads ; and the plan to exchange London’s 1800 clean and silent trolleybuses for diesel-engine motor-buses has already caused many
protests.ll
Again, proposing
the N.S.A.S. schemes for
think
reducing
that air
local
authorities
pollution get
too
8. Morley, T. P. J. clin. Endocrin. 1954, 14, 1. 9. Bauer, H. G. Ibid, p. 13. 10. To be had from the National Smoke Abatement Society, 30, Grosvenor Place, London, S.W.1. 1954. Pp. 15. 1s. 11. Times, May 6, et. seq.
little encouragement. Initiative of this kind, they say, should be not only approved but stimulated by the Government ; for too many local authorities are still inactive. The law about smoke has remained substantially the same for three-quarters of a century, and is almost entirely of the too-late variety (in the sense that action can only be taken after a nuisance has been caused). The society suggest that new legislation should not only give local authorities better powers for setting up smokeless zones but should enable them to proceed against manufacturers whose chimney emissions exceed prescribed standards. It should also oblige manufacturers who are putting in new fuel-burning plant to have their plans approved beforehand by the local authority. Moreover, all boiler-men and furnace-men should be required to hold a certificate of proficiency ; and local authorities should be obliged to employ only fully qualified smoke inspectors. Finally, the society suggest, the installation in houses or hotels of grates which cannot burn smokeless fuel should be prohibited. The society, in their steady education of the public in this matter, have done good work and done it on a very small budget. They are fully justified in that they deserve a Government grant it, for no agency is better placed for creating the informed public opinion which alone can lift the cloud from us.
suggesting
towards
RECURRENT PANCREATITIS PANCREATITIS is apparently commoner in North America than here. Several accounts of this disease have appeared in the U.S.A. during the last few years 1-3 ; and at the recent meeting in London of the American College of Surgeons Prof. Walter (’. 1IaeKenzie described his extensive experience of it in(’anada.4 According to Phillips,3 it is usually a chronic relapsing disorder in middle-aged alcoholic men. There is a fairly characteristic pattern of attacks of upper abdominal pain, recurring on average three or four times a year, which are often precipitated by alcoholic or dietary indiscretion or by worry or fatigue.2 The attack may be mild, lasting only a few hours, or of the severe acute h:!emorrhagic" type that continues for several days. Vomiting is usual and there may be mild diarrhcea ; pyrexia is seldom pronounced ; loss of weight during the attack may be severe. In uncomplicated cases the patients are free of symptoms between attacks. Eventually fibrosis may lead to cyst formation or to calcification, which may be localised or diffuse. Occasionally severe fibrosis may produce bile-duct obstruction, but this is probably rare. Confirmation of the diagnosis by clinical tests is often difficult. Radiographic evidence of pancreatic calcification, the presence of steatorrhoea, creatorrhoea, or glycosuria, or a raised serum amylase or lipase level are highly significant. But such evidence is to be expected only in severe attacks or when repeated episodes have considerably damaged the gland. In mild attacks and between bouts, investigations often yield negative results. Examination of the duodenal contents after administration of secretin has been recommended, but this test is tedious and difficult and the results are inconstant. With pancreatitis, as with so many diseases, the case-history is often a better guide than a group of tests. The acute episode is best treated conservatively with analgesics (but not morphine) and antibiotics. Atropine or, better,’Probanthine’ is given to decrease gastric and pancreatic secretion, and to relax the ’’
Maimon, S. N., Kirsner, J. B., Palmer, W. L. Arch. intern. Med. 1948, 81, 56. 2. Hersperger, W. G. Sth. Med. J. 1949, 42, 289. 3. Phillips, A. M. Arch. intern. Med. 1954, 93, 337. 4. See Lancet, May 29, 1954, p. 1126. 1.