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CAVERNOUS SINUS THROMBOSIS AND FACIAL INFECTIONS.
ORTHODOXY AND HETERODOXY IN SURGERY.
sweepstakes the position would be different, and it would be my duty to consider the desirability or otherwise, from the point of view of the best interests of the hospital, of the accepting of funds raised by I am, Sir, yours faithfully, this means. St. Bartholomew’s
Hospital, E.C.
1053
generally thought; the results are certainly equal and the physiological to those of gastro-jejunostomy, arrangements are less disturbed by gastro-duodenostomy than by gastro-jejunostomy (what functional value, if any, there is in this it is not easy to determine). The aspersions cast by Mr. Ogilvie on anastomoses
STANMORE.
between the stomach and duodenum are, in my experience, quite unfounded so far as gastro-duoORTHODOXY AND HETERODOXY IN SURGERY. denostomy is concerned. Indeed, I think he is damning an operation which has won for itself quite To the Editor of THE LANCET. an honourable position in the treatment of certain SIR,-In the address on this subject in your issue cases of duodenal ulcer. of April 25th Mr. Ogilvie says : " those operations I am, Sir, yours faithfully, that aim at making an anastomosis between the E. R. FLINT. Leeds, April 30th, 1931. stomach and duodenum are based upon unsound physiology and are unprofitable in practice." Amongst such operations he mentions gastro-duodenostomy INSULIN AND PRESERVATIVE. and duodenectomy-two very different things. Of To the Editor of THE LANCET. the latter I have little first-hand knowledge, but of the former I have had a considerable experience, SIR,-The doubts of Dr. Leyton and Dr. Poulton, and I can assure Mr. Ogilvie, who states that " when as to whether the addition of antiseptic to insulin an anastomosis is made between them (that is, the - solutions would be a benefit, must be shared by the stomach and duodenum) bleeding is troublesome at vast majority of physicians having long practical the time, and leakage is not uncommon afterwards," experience of the use of this substance. I can myself that so far as gastro-duodenostomy is concerned state that I have never come across any sign of illthese statements are entirely contrary to my experi- effect due to the absence of antiseptics in the solutions ence. I never use a clamp on the duodenum and yet which have been in use up to the present time. It bleeding is no more troublesome than it is from the is perhaps doubtful whether the introduction of such jejunum when doing a gastro-jejunostomy, where substances could have any ill-effect, but it seems again I use a clamp only on the stomach. Nor almost certain that no good can thereby be brought have I ever seen a case where leakage has occurred about, and it is also worthy of note that some manufrom the anastomotic line. I think bleeding from facturers, advised by scientific experts of the highest the gastro-duodenal artery might be very trouble- authority, have such strong objection to the suggested some in doing a duodenectomy for a posterior duodenal change that the particular brands of insulin made ulcer ; one has even heard of an injury to the common by them may, in such circumstances, be withdrawn duct in similar circumstances ; if Mr. Ogilvie is from the market. This alone would be most referring to this operation it would be fairer if he regrettable. made a distinction between duodenectomy, which It is to be hoped the Ministry of Health will not for duodenal ulcer I consider a thoroughly bad proceed with the contemplated Bill until an opporoperation, and gastro-duodenostomy, which my tunity has been given to all shades of medical opinion experience leads me to put at least equal to posterior to express views as to the wisdom of the proposed I am, Sir, yours faithfully, gastro-jejunostomy as an operation. I think Mr. measure. T. IZOD BENNETT. Ogilvie would find, on inquiry, that this is the kind of London, W., May 2nd, 1931. . opinion he would receive about gastro-duodenostomy from most surgeons in the first rank-" in those cases where I have performed gastro-duodenostomy CAVERNOUS SINUS THROMBOSIS AND I have been well satisfied with the results ; however, FACIAL INFECTIONS. I usually do posterior gastro-jejunostomy because To the Editor of THE LANCET. the conditions are more often favourable for the In this other of words, operation." performance SiR,-Mr. Scott Brown in your issue of May 2nd the reason why gastro-duodenostomy is not more 960) points out the peril of thrombophlebitis of (p. often performed is neither that the results are inferior the cavernous sinus from seemingly trivial infections nor that the physiology is less sound than that of about the face.- He agrees with observations recorded gastro-jejunostomy as Mr. Ogilvie asserts. by many that infection usually occurs via the facial One of the reasons given for the advocacy of gastro- vein. Surely then the rational procedure is to foreduodenostomy according to Mr. Ogilvie is that the stall spread of infection by this route. This can be food leaving the stomach enters that part of the accomplished by ligating the angular vein. I have small intestine which is most -used to the presence dealt fullywith this preventive operation. Secondly, of an acid medium ; this, he says, is no more than an I wish to reiterate the teaching of Ochsner that to unsupported statement. It is not, however, in my incise or excise a carbuncle of the lip is most danopinion, quite the right way of stating the case. gerous. Local treatment with ample hot moist If he had said that the food enters that part of the of dressings magnesium sulphate preceded by periintestine, into which nature intended it should pass from pheral of whole blood is attended by auto-injections the stomach, more nearly than after gastro-jejunostomy, far better results than excision. Lastly, when he would perhaps agree that mixing of the digestive cavernous sinus thrombosis is established, but the juices and bile with the food has a sounder physio- patient has yet a good hold on life, may I draw logical arrangement than is the case after gastro- attention to Eagleton’s operation described in his " jejunostomy. book, Thrombophlebitis of the Cavernous The real position seems to be this-there is only thoughtful Sinus " (New York, 1926). one good reason why gastro-duodenostomy is not I am, Sir, yours faithfully, more generally done, and that is the anatomical HAMILTON BAILEY. May 2nd, 1931. Harley-street, circumstances are more often unfavourable than 1 otherwise, though in my opinion less often so than is Surgery, Gynecology, and Obstetrics, April, 1928.
I
I
1054
PUST-QPERAT1VM VOMITING.—PANEJ. PRACTTC’E.
ABERRANT MILK SECRETIONS.
To the Editor
of THE
LANCET.
group of workers at the London (R.F.H.) Medical School are anxious to obtain abnormal accretions of human milk for analysis and comparison. Secretions before pregnancy or any other aberrant milk secretions would be welcomed. We should be grateful if any of your readers who may come across such secretions would get into touch with us, in order that we might obtain specimens for analysis. I am, Sir, yours faithfully, SIBYL T. WIDDOWS. London (Royal Free Hospital) School of Medicine for Women (University of London), Hunter-street, Brunswick-square, W.C., May 2nd, 1931.
SiR,—A
POST-OPERATIVE VOMITING.
To the Editor
of THE
LANCET.
SiR,-Dr. Cook’s paper on this subject in your issue of April 18th was both interesting and valuable. The percentage of cases which vomited after gasoxygen, though favourable when compared with ether and other agents, seemed rather higher than One would like to ask then one would expect. " nitrous-oxide " whether the cases classified as and " gas " received ether in addition to reinforce the action of the anaesthetic ? I think it is important to know this, and if Dr. Cook would use your columns to answer this question the value of her paper would be increased. I am, Sir, yours faithfully, Dundee, May 2nd, 1931.
A. H. MACKLIN.
PANEL PRACTICE Pregnancy
.
and Sickness Benefit.
THE National Insurance Gazette continues its useful transcript of the evidence given by Sir Walter Kinnear, controller of national insurance, before the Royal Commission on Unemployment Insurance. In reply to a commissioner he agreed that pregnancy is not in itself sufficient to entitle an insured woman to sickness benefit under the Insurance Acts. Asked whether he would say that this was so in all stages up to the last, Sir Walter replied : " The claims of married women, especially during pregnancy and after childbirth, is one of the problems of the health insurance scheme. The sickness claims ,of married women have risen by over 100 per cent. in the last ten years, and the disablement claims by over 150 per cent. The largest proportionate increase is in the case of married women of 45 years and under, and one of the most difficult questions the societies have to decide is when sickness benefit is properly payable during pregnancy. The society must be satisfied that the statutory condition of incapacity for work is fulfilled in these as in all other cases. A state of pregnancy does not necessarily rise to incapacity. In the case of women in give regular employment as wage earners (for instance, mill hands or factory workers), there is generally unfitness for the ordinary employment for some period before confinement, and if at the same time there is such a degree of bodily disablement as to prevent the woman from undertaking any other kind of work-except possibly household duties of the lightest character—the societies have little
difficulty
in
regarding
the
statutory condition
as
fulfilled, and benefit is paid. Less easy of treatment, however, is the case where the woman, although
admittedly unable to follow her ordinary occupation, is nevertheless capable of performing the ordinary work of her home. Where, in cases of this latter kind, the claim for benefit is submitted a substantial time before the expected date of the confinement, the society would feel considerable hesitation about admitting it-such hesitation being based on the ground that the performance of ordinary household duties may not unreasonably be regarded as an alternative occupation in the case of a married woman. Where, however, the claim is not made until a comparatively late stage, it would be much more likely to receive favourable consideration, inasmuch as societies in general are prepared to recognise the inherent probability of incapacity during the period immediately anterior to confinement." Change of Doctor. In the House of Commons on April 30th Mr. Albery asked the Minister of Health what provision was made for the medical attendance and treatment of an insured person who, at the commencement of a quarter, felt he could not any longer accept medical attendance and treatment from his insurance practitioner, and, when the consent to transfer by that practitioner was refused, was the insured person compelled to pay for his medical attendance and treatment by another doctor during the remainder of the quarter until the transfer was effected by giving one month’s notice to the insurance committee. In reply, Mr. Greenwood said that in these circumstances the insured person would normally be expected to apply for any necessary treatment to the insurance doctor on whose list he remained ; and if he applied for treatment to another doctor any charges for such treatment would not be payable out of insurance funds. But in case of accident or other sudden emergency, application could be made by the insured person to another insurance doctor for treatment at the cost of insurance funds, if the doctor on whose list he remained (or his deputy) were not available. LONDON
HOMOEOPATHIC
HOSPITAL.-When the
Duke of York, the President, visits this hospital on May 20th he will receive the Royal Charter of Incorporation which has been granted to the hospital. The Duchess of York will also attend and receive purses for completion of the debt of 23126 on the extension of the nurses’ home to 107 beds at a cost of .613,839.
RESEARCH FELLOWSHIPS
IN
TUBERCULOSIS.-The
Cross research Fellowships in tuberculosis for 1931-1932 will shortly be awarded by the Medical Research Council, and applications should be lodged with the Council not later than June 6th. The object of these Fellowships is to give special opportunities for study and research to persons " intending to devote themselves to the advancement by teaching or research of curative or preventive treatment of tuberculosis in all or any of its forms." Candidates must be British subjects, and must possess suitable medical, veterinary, or scientific qualifications. The Fellowships will preferably be awarded to those who wish to conduct their studies or inquiries outside Great Britain. They will, as a rule, be awarded for one year, but in special cases may be renewed. The value of the Fellowships will depend upon the standing and qualifications of the candidate, but will not be less than JE300 per annum, with travelling expenses in addition. It may also be possible to award a senior Fellowship of considerably greater value to a specially well-qualified candidate wishing to undertake an intensive study of some particular problem of tuberculosis at a chosen centre of work in another country. Further particulars and forms of application are obtainable from the secretary of the Council, 38, Old Queen-street, London, S.W. 1.
Dorothy Temple
sweepstakes the position would be different, and it would be my duty to consider the desirability or otherwise, from the point of view of the best interests of the hospital, of the accepting of funds raised by I am, Sir, yours faithfully, this means. St. Bartholomew’s
Hospital, E.C.
1053
generally thought; the results are certainly equal and the physiological to those of gastro-jejunostomy, arrangements are less disturbed by gastro-duodenostomy than by gastro-jejunostomy (what functional value, if any, there is in this it is not easy to determine). The aspersions cast by Mr. Ogilvie on anastomoses
STANMORE.
between the stomach and duodenum are, in my experience, quite unfounded so far as gastro-duoORTHODOXY AND HETERODOXY IN SURGERY. denostomy is concerned. Indeed, I think he is damning an operation which has won for itself quite To the Editor of THE LANCET. an honourable position in the treatment of certain SIR,-In the address on this subject in your issue cases of duodenal ulcer. of April 25th Mr. Ogilvie says : " those operations I am, Sir, yours faithfully, that aim at making an anastomosis between the E. R. FLINT. Leeds, April 30th, 1931. stomach and duodenum are based upon unsound physiology and are unprofitable in practice." Amongst such operations he mentions gastro-duodenostomy INSULIN AND PRESERVATIVE. and duodenectomy-two very different things. Of To the Editor of THE LANCET. the latter I have little first-hand knowledge, but of the former I have had a considerable experience, SIR,-The doubts of Dr. Leyton and Dr. Poulton, and I can assure Mr. Ogilvie, who states that " when as to whether the addition of antiseptic to insulin an anastomosis is made between them (that is, the - solutions would be a benefit, must be shared by the stomach and duodenum) bleeding is troublesome at vast majority of physicians having long practical the time, and leakage is not uncommon afterwards," experience of the use of this substance. I can myself that so far as gastro-duodenostomy is concerned state that I have never come across any sign of illthese statements are entirely contrary to my experi- effect due to the absence of antiseptics in the solutions ence. I never use a clamp on the duodenum and yet which have been in use up to the present time. It bleeding is no more troublesome than it is from the is perhaps doubtful whether the introduction of such jejunum when doing a gastro-jejunostomy, where substances could have any ill-effect, but it seems again I use a clamp only on the stomach. Nor almost certain that no good can thereby be brought have I ever seen a case where leakage has occurred about, and it is also worthy of note that some manufrom the anastomotic line. I think bleeding from facturers, advised by scientific experts of the highest the gastro-duodenal artery might be very trouble- authority, have such strong objection to the suggested some in doing a duodenectomy for a posterior duodenal change that the particular brands of insulin made ulcer ; one has even heard of an injury to the common by them may, in such circumstances, be withdrawn duct in similar circumstances ; if Mr. Ogilvie is from the market. This alone would be most referring to this operation it would be fairer if he regrettable. made a distinction between duodenectomy, which It is to be hoped the Ministry of Health will not for duodenal ulcer I consider a thoroughly bad proceed with the contemplated Bill until an opporoperation, and gastro-duodenostomy, which my tunity has been given to all shades of medical opinion experience leads me to put at least equal to posterior to express views as to the wisdom of the proposed I am, Sir, yours faithfully, gastro-jejunostomy as an operation. I think Mr. measure. T. IZOD BENNETT. Ogilvie would find, on inquiry, that this is the kind of London, W., May 2nd, 1931. . opinion he would receive about gastro-duodenostomy from most surgeons in the first rank-" in those cases where I have performed gastro-duodenostomy CAVERNOUS SINUS THROMBOSIS AND I have been well satisfied with the results ; however, FACIAL INFECTIONS. I usually do posterior gastro-jejunostomy because To the Editor of THE LANCET. the conditions are more often favourable for the In this other of words, operation." performance SiR,-Mr. Scott Brown in your issue of May 2nd the reason why gastro-duodenostomy is not more 960) points out the peril of thrombophlebitis of (p. often performed is neither that the results are inferior the cavernous sinus from seemingly trivial infections nor that the physiology is less sound than that of about the face.- He agrees with observations recorded gastro-jejunostomy as Mr. Ogilvie asserts. by many that infection usually occurs via the facial One of the reasons given for the advocacy of gastro- vein. Surely then the rational procedure is to foreduodenostomy according to Mr. Ogilvie is that the stall spread of infection by this route. This can be food leaving the stomach enters that part of the accomplished by ligating the angular vein. I have small intestine which is most -used to the presence dealt fullywith this preventive operation. Secondly, of an acid medium ; this, he says, is no more than an I wish to reiterate the teaching of Ochsner that to unsupported statement. It is not, however, in my incise or excise a carbuncle of the lip is most danopinion, quite the right way of stating the case. gerous. Local treatment with ample hot moist If he had said that the food enters that part of the of dressings magnesium sulphate preceded by periintestine, into which nature intended it should pass from pheral of whole blood is attended by auto-injections the stomach, more nearly than after gastro-jejunostomy, far better results than excision. Lastly, when he would perhaps agree that mixing of the digestive cavernous sinus thrombosis is established, but the juices and bile with the food has a sounder physio- patient has yet a good hold on life, may I draw logical arrangement than is the case after gastro- attention to Eagleton’s operation described in his " jejunostomy. book, Thrombophlebitis of the Cavernous The real position seems to be this-there is only thoughtful Sinus " (New York, 1926). one good reason why gastro-duodenostomy is not I am, Sir, yours faithfully, more generally done, and that is the anatomical HAMILTON BAILEY. May 2nd, 1931. Harley-street, circumstances are more often unfavourable than 1 otherwise, though in my opinion less often so than is Surgery, Gynecology, and Obstetrics, April, 1928.
I
I
1054
PUST-QPERAT1VM VOMITING.—PANEJ. PRACTTC’E.
ABERRANT MILK SECRETIONS.
To the Editor
of THE
LANCET.
group of workers at the London (R.F.H.) Medical School are anxious to obtain abnormal accretions of human milk for analysis and comparison. Secretions before pregnancy or any other aberrant milk secretions would be welcomed. We should be grateful if any of your readers who may come across such secretions would get into touch with us, in order that we might obtain specimens for analysis. I am, Sir, yours faithfully, SIBYL T. WIDDOWS. London (Royal Free Hospital) School of Medicine for Women (University of London), Hunter-street, Brunswick-square, W.C., May 2nd, 1931.
SiR,—A
POST-OPERATIVE VOMITING.
To the Editor
of THE
LANCET.
SiR,-Dr. Cook’s paper on this subject in your issue of April 18th was both interesting and valuable. The percentage of cases which vomited after gasoxygen, though favourable when compared with ether and other agents, seemed rather higher than One would like to ask then one would expect. " nitrous-oxide " whether the cases classified as and " gas " received ether in addition to reinforce the action of the anaesthetic ? I think it is important to know this, and if Dr. Cook would use your columns to answer this question the value of her paper would be increased. I am, Sir, yours faithfully, Dundee, May 2nd, 1931.
A. H. MACKLIN.
PANEL PRACTICE Pregnancy
.
and Sickness Benefit.
THE National Insurance Gazette continues its useful transcript of the evidence given by Sir Walter Kinnear, controller of national insurance, before the Royal Commission on Unemployment Insurance. In reply to a commissioner he agreed that pregnancy is not in itself sufficient to entitle an insured woman to sickness benefit under the Insurance Acts. Asked whether he would say that this was so in all stages up to the last, Sir Walter replied : " The claims of married women, especially during pregnancy and after childbirth, is one of the problems of the health insurance scheme. The sickness claims ,of married women have risen by over 100 per cent. in the last ten years, and the disablement claims by over 150 per cent. The largest proportionate increase is in the case of married women of 45 years and under, and one of the most difficult questions the societies have to decide is when sickness benefit is properly payable during pregnancy. The society must be satisfied that the statutory condition of incapacity for work is fulfilled in these as in all other cases. A state of pregnancy does not necessarily rise to incapacity. In the case of women in give regular employment as wage earners (for instance, mill hands or factory workers), there is generally unfitness for the ordinary employment for some period before confinement, and if at the same time there is such a degree of bodily disablement as to prevent the woman from undertaking any other kind of work-except possibly household duties of the lightest character—the societies have little
difficulty
in
regarding
the
statutory condition
as
fulfilled, and benefit is paid. Less easy of treatment, however, is the case where the woman, although
admittedly unable to follow her ordinary occupation, is nevertheless capable of performing the ordinary work of her home. Where, in cases of this latter kind, the claim for benefit is submitted a substantial time before the expected date of the confinement, the society would feel considerable hesitation about admitting it-such hesitation being based on the ground that the performance of ordinary household duties may not unreasonably be regarded as an alternative occupation in the case of a married woman. Where, however, the claim is not made until a comparatively late stage, it would be much more likely to receive favourable consideration, inasmuch as societies in general are prepared to recognise the inherent probability of incapacity during the period immediately anterior to confinement." Change of Doctor. In the House of Commons on April 30th Mr. Albery asked the Minister of Health what provision was made for the medical attendance and treatment of an insured person who, at the commencement of a quarter, felt he could not any longer accept medical attendance and treatment from his insurance practitioner, and, when the consent to transfer by that practitioner was refused, was the insured person compelled to pay for his medical attendance and treatment by another doctor during the remainder of the quarter until the transfer was effected by giving one month’s notice to the insurance committee. In reply, Mr. Greenwood said that in these circumstances the insured person would normally be expected to apply for any necessary treatment to the insurance doctor on whose list he remained ; and if he applied for treatment to another doctor any charges for such treatment would not be payable out of insurance funds. But in case of accident or other sudden emergency, application could be made by the insured person to another insurance doctor for treatment at the cost of insurance funds, if the doctor on whose list he remained (or his deputy) were not available. LONDON
HOMOEOPATHIC
HOSPITAL.-When the
Duke of York, the President, visits this hospital on May 20th he will receive the Royal Charter of Incorporation which has been granted to the hospital. The Duchess of York will also attend and receive purses for completion of the debt of 23126 on the extension of the nurses’ home to 107 beds at a cost of .613,839.
RESEARCH FELLOWSHIPS
IN
TUBERCULOSIS.-The
Cross research Fellowships in tuberculosis for 1931-1932 will shortly be awarded by the Medical Research Council, and applications should be lodged with the Council not later than June 6th. The object of these Fellowships is to give special opportunities for study and research to persons " intending to devote themselves to the advancement by teaching or research of curative or preventive treatment of tuberculosis in all or any of its forms." Candidates must be British subjects, and must possess suitable medical, veterinary, or scientific qualifications. The Fellowships will preferably be awarded to those who wish to conduct their studies or inquiries outside Great Britain. They will, as a rule, be awarded for one year, but in special cases may be renewed. The value of the Fellowships will depend upon the standing and qualifications of the candidate, but will not be less than JE300 per annum, with travelling expenses in addition. It may also be possible to award a senior Fellowship of considerably greater value to a specially well-qualified candidate wishing to undertake an intensive study of some particular problem of tuberculosis at a chosen centre of work in another country. Further particulars and forms of application are obtainable from the secretary of the Council, 38, Old Queen-street, London, S.W. 1.
Dorothy Temple