AN EASIER ALPHABET

827 In view of the foregoing, encouragement of rapid evacuation of ingested kerosene seems to be desirable, since surely it is easier (particularly with the range of antibiotics now available) to deal with an aspiration pneumonitis or pneumonia, rather titin attempt to deal with the possible absorption of chemical trials, the toxic properties of which are almost unknown. The three positive measures recommended in the article (e.g., ingestion of vegetable oil or ice-cream to dilute the kerosene and diminish the rate of absorption into the blood), I would question because quite possibly diminished rate of absorption might well mean greater perfection of absorption. I would also point out that kerosenes of all three grades are distributed throughout the world in large quantities and I feel that emergency measures to combat intoxication should be very carefully assessed to ensure their ultimate success. Medical Department, Petrochemicals Ltd., Carrington Works, Urmston, Manchester.

B. GEORGE.

CADWALADER AND BEVAN their SiR,-In paper of March 19, Dr. Fourman and his mention what is undoubtedly the first clinical colleagues of description hyperparathyroidism-that of Thomas Cadwalader of Philadelphia, whose account of his " extraordinary case in physic " was published in 1745.

Ralph H. Major1 includes Cadwalader’s essay in his volume Descriptions of Disease (3rd ed., 1945, pp. 299-302), but is presumably in error in interpreting the account as the first description of mollities osseum, or osteomalacia ". Krumbhaarrightly emphasises the historical significance of Cadwalader’s description as the original clinical picture of primary or secondary hyperparathyroidism. Dr. Fourman includes the name of one Bevan, S., in his tist of references; this was Silvanus Bevan, a London apothecary, who, in a letter to the Royal Society in 1743, described a similar clinical condition. At first sight this seems to anticipate

Classical

"

Cadwalader’s account, but in fact the cases were identical. Cadwalader performed the postmortem examination on his "

"

extraordinary case in April, 1742, subsequently informing Bevan of his findings; Bevan thereupon reported them in his letter to the Royal Society. The modem pharmaceutical firm of Allen & Hanburys originated in the apothecary’s shop opened by Silvanus Bevan at Old Plough Court, off Lombard Street, in 1715. In their historical account of this company, D. Chapman-Huston and E. C. Crippsreferred to Bevan’s letter, but they wrongly assumed that Bevan himself

performed

the postmortem

arising from the fact that Bevan’s original letter to the Royal Society contained the phrase " communicated to Silvanus Bevan ", a phrase that was not included in the subsequently published Transactions.

examination, the

error

Thomas Cadwalader and Silvanus Bevan were both members of Welsh Quaker families, many of which were closely knit and interrelated following the religious persecution of their sect in Wales in the latter half of the seventeenth century. Cadwalader probably met Bevan in London when he came to Europe to further his medical education under Cheselden during the years 1728-30. On his return Cadwalader became a Prominent figure in the medical circles of the growing town of Philadelphia, then the largest in the colonies. Among other things he inaugurated anatomical classes and successfully promoted the use of inoculation for smallpox; he also established, in association with Benjamin Franklin, the Philadelphia

Hospital. I contributed

an

account

of the associations between

Cadwalader and Bevan, and of their original descriptions of

hyperparathyroidism, to the Welsh quarterly periodical Y Genhinen in 1955.4 In the same paper I attempted to show 1.

H. Classical Descriptions of Disease; pp. 299-302. Springfield, III., 1945. 2. Science, Medicine, and History; p. 138. Edited by E. Ashworth Underwood. Oxford, 1953. 3. Chapman-Huston, D., Cripps, E. C. Through a City Archway; p. 19.

Major, R.

London, 1954. 4. Y Genhinen, 1955, 5,

86.

that several of the descendants of Welsh Quaker emigrants had made notable contributions to the growth of American medicine, prominent among them Thomas Cadwalader, his young associate John Morgan, and his cousin John Jones.5

G. PENRHYN JONES.

Caernarvon.

LATEX AGGLUTINATION REACTION IN NON-RHEUMATIC DISEASES

SIR,-In the latex

your annotation of March 26 you stated that

(L.T.) and the Rose-Waaler test (D.A.T.) approximately equal in sensitivity, and that the L.T. lacked the specificity of the D.A.T., being positive in a wide variety of unrelated non-rheumatoid conditions. test

were

May I draw your attention to a recent article of mine6 in which I described a series of L.T.s and D.A.T.s in 176 cases of rheumatoid arthritis and non-rheumatoid conditions? In the R.A. group, 89 % of the L.T.S were positive, while the D.A.T.S. was positive in only 74% of the cases. 3 out of 6 cases of disseminated lupus erythematosus gave positive results in the D.A.T. while all 6 cases gave negative results in the L.T.S. Furthermore in 47 cases of non-rheumatic disease, the L.T. was persistently negative, and no false-positive results were seen in the series. Singer and Plotzdescribed a series of L.T.s carried out in tubes, in which 71’3% of rheumatoid-arthritis cases gave positive results. The present series was carried out using latex globulin particles and a simple slide technique, and the probable reason for a higher percentage of positive results (89%) is that the reagents used were superior and more stable. Prince of Wales’s General Hospital,

London,

SIR,-Dr.

N.15.

G. MORGAN.

AN EASIER ALPHABET Pugmire’s article of March 26

was

refreshing

in its

lucidity and reflects a satisfactory tendency to place neuropsychiatry on a scientific basis. However, I feel that the issues involved are more complex than may appear from his discussion. The main reason for designing the " six-bit " alphabet seems to have been a wish to reduce or abolish the redundancy of written English. On the face of it a redundancy of the order of 50% does seem wasteful, since it means that more signal is uttered than is needed to express the Information of the message with complete economy. But all methods of computing the redundancy of language (and there are several) involve an exact and often laborious statistical analysis of the sample, at leisure. That is, the " recipient " of the language in these circumstances has time to function at something like 100% efficiency. In practice, on the other hand, the recipient of spoken or written language is nearly always under the pressure of haste to some extent. It is well known that the risk of error increases with the rate of performance, with many intellectual tasks. In short, it is likely that in normal conversation or reading (as opposed to statistical analysis) the recipient is functioning at less than 100% efficiency and is not extracting from the language all of the Information potentially extractable. It is an accepted principle of communication theory that redundancy serves to protect against errors in transmission; one may therefore regard the redundancy of English as a compromise between " writer’s economy " and " reader’s economy ", and also between the policies of saving time on the one hand and of avoiding loss of Information on the other. By reducing redundancy Dr. Pugmire has developed a highly compact script. If the reader is to extract the same amount of Information from a sentence written in this script as when it is written in the more redundant ordinary script, he will either have to spend more time per symbol or else increase his rate of Information-handling (i.e., " concentrate harder "). Mentally defective or brain-damaged patients probably have less reserve capacity in hand for such tasks, and for them it seems 5. Bull. Hist. Med. 1943, 13, 10; 1948, 22, 543. 6. Ann. rheum. Dis. 1959, 18, 322. 7. Singer, J. M., Plotz. C. M. Amer. J. Med. 1956, 21, 888.

828

doubly likely that redundancy is an important feature of language; " speaker’s economy" and " writer’s economy " must be sacrificed in the interest of the recipient. Who has not had to say the same thing over and over again to a stupid listener, in order to din it in ? A case might, in fact, be made out for designing a language with high redundancy for certain circumstances. It is partly a matter of deciding how much importance to attach to speed and to freedom from error in any given case. Temperamental factors must play a part here, since obsessional subjects will tend to go slow rather than risk a mistake, while others may adopt a more breezy attitude. We must also distinguish between redundancy in the symbolic representation of language (with which Dr. Pugmire is dealing) and in the linguistic representation of thought. It may be that redundancy in the script is only " protective " in cases where the defect lies in the perception and recognition of written symbols, rather than in the comprehension of words. Let us beware of developing too condensed and efficient a language, lest it should become as spare and austere as those of formal logic and algebra. It would be a pity to increase the already large proportion of relatively illiterate people in the population.

University College Hospital Annexe, London, W.1.

H. B. G. THOMAS.

TREATMENT OF BEDSORES

SIR,-I was very interested in Dr. Roberts’ letter of Jan. 30, and, as he has given the formulas of these two creams, I will refer to them as cream i or cream 11. Although we have 245 patients in our hospital, about 30% of whom are bedridden and many incontinent, we have not got many bedsores. We alternate the treatment by using our own " back " ointment, which consists of tinct. benzoin. co. and ol. ricini (28 oz. of each) and paraffin. molle flav., ung. zinci oxidi, and ung. acidi borici (equal parts of each) to 14 lb., or

painting bedsores with gentian-violet,

or

using silicone

cream i or n.

In 6 special cases our ordinary treatment showed no improvement, but in 5 of them the results of cream n were really dramatic and the bedsores healed within seven to ten days. We have used cream i or 11 in about a dozen other bad cases without much improvement, but I would like to mention that most of these patients were suffering from either paralysis agitans or disseminated sclerosis, and naturally their general condition was very weak. It is very difficult to give a decided opinion with only 18 cases, but on the whole our experience is that cream n gave better results. Both

used in the trial were kindly supplied by Messrs. my committee and I wish to thank them very much for their liberal supplies. creams

Ward, Blenkinsop, and

Royal Hospital for Incurables, Donnybrook, Dublin.

ROBERT A. O’MEARA.

PERIORBITAL ŒDEMA AFTER EXERTION

SIR,-Irecently saw a young man, aged 19, who had an interesting history. Since childhood he has occasionally had acute swelling of his eyelids after exercise. This intense oedema sometimes causes almost complete closure of both eyes. This curious complaint prevented him from playing games at school, and has interfered with his activities in the Army. The amount of exercise precipitating an attack is very variable. The condition does not seem to be correlated with excessive facial sweating; and he has noted no seasonal variation. There was no history of allergy. He was recently seen during an attack. Both eyelids were acutely swollen, and in addition he had bilateral chemosis. The latter rapidly disappeared with hydrocortisone drops. Anti-histamines do not prevent attacks. He had moderate acne on both sides of his face, but general examination was otherwise quite normal. Examination of his blood and urine, and X-ray of chest and skull, were normal.

I should be interested to know whether any of your readers have seen this unusual syndrome and can suggest a possible

aetioloe-v. Tidworth,

Hants.

D. P. MULLAN.

ABDOMINAL ANEURYSMS

SIR,-Conceming your annotation1 on this subject, agreed that the question of operation for every abdominal aortic aneurysm has not detectable clinically the facts on which you base your statement been settled, while it is

that " it is hard to substantiate the common belief that any abdominal aneurysm which can be diagnosed should be resected " are not valid. "

(1) You cited the article of Estesand stated, Many died of aneurysmal rupture, but more died of coronary or cerebral thrombosis." This is not true. Estes ascertained the cause of death in 49 of the 64 patients in his series known to be dead and reported that 63-3% of these 49 patients died from rupture of the aneurysm, while the remainder died from other causes. Thus, most of his patients died because of their aneurysms rather than with them. (2) In considering the work of Sheranian and associatede on their experience with aortic homografts, you stated, "At operation only 110 of the 135 aneurysms were resectable," This is not the case. These authors clearly stated that only 10 of these cases were considered inoperable at the time of exploration. They stated further that another 15 cases were excluded from the series because the aneurysm was resected and replaced with a synthetic graft. Thus, you have included these 15 cases as being inoperable when, in fact, these aneurysms were resected and replaced with synthetic prostheses instead of homografts. (3) Since the object of your annotation was to consider whether elective operation for abdominal aortic aneurysm was indicated in all cases, it is not fair to include the 6 cases in the series of Sheranian and coworkers in which emergency operations were performed because the aneurysm had ruptured. The mortality-rate in these 6 cases was 50%. (4) You then say, " if it is assumed that ... in the 25 advanced cases where resection proved impossible at laparotomy the patients were dead" (at the end of three years); here again, we are dealing with 10 inoperable cases, not 25. It is probably invalid to assume, as you have, that all of these patients in whom resection was impossible would be dead at the end of three years. Estes found that 49-2% of patients with untreated abdominal aortic aneurysms survive for three years. Since the patients who have inoperable lesions are essentially untreated patients, there may well be’ only 5 of these patients with non-resectable aneurysms dead at the end of three years, not 25.

We do not dispute the fact that surgical intervention for abdominal aortic aneurysms must be carefully considered, Comparison of patients with surgically treated abdominal aortic aneurysms to a similar group of patients not treated surgically, with both groups being followed for a sufficient period, would be the best way to tell whether surgical intervention is more dangerous than observation. Until such is done, however, your conclusions cannot be validated by your premises. IRWIN J. SCHATZ Mayo Clinic, JOHN L. JUERGENS. Rochester, Minnesota.

*** We are grateful to Dr. Schatz and Dr. Juergens pointing out these lapses. Despite our arithmetical weaknesses, we believe our two main points still hold: (1) it is not known how many aneurysms were turned for

down before Sheranian selected the ones to be operated on; and (2) it is not justifiable to assume that every abdominal aneurysm diagnosed should be resected. As Dr. Schatz and Dr. Juergens emphasise, until it has been 1. 2. 3.

Lancet, 1959, ii, 1018. Estes, J. E. Circulation, 1950, 2, 258. Sheranian, L. O., Edwards, J. E., Kirklin, J. Surg. Gynec. Obstet. 1959, 109, 309.