- Email: [email protected]
COLORIMETRIC ESTIMATION OF POLYVINYLPYRROLIDONE BY IODINE
197
operation or any line of treatment which ignores this extensive incompetence is not likely to be uniformly successful in healing leg ulcers. Mr. Cockett and Mr. Elgan Jones agree that their follow-up is short, allowing of no definite conclusions about the efficiency of their operation, and I venture to suggest that its basic premise is untenable. The constant finding in phlebograms of ulcerated legs, of a long column of unsupported blood in the deep veins due to an almost total absence of valves, led Bauer and others to investigate the effect of ligature of the popliteal or superficial vein. But as Mr. Goligher has pointed out (Jan. 10), the results of this operation are equivocal. This is not surprising since the column of blood is not a static phenomenon, and a leaking valve will hardly be improved if a complete block is placed across it. The deep veins are the main channels along which blood returns to the heart from the lower limbs, and the swelling which follows the operation is ample witness to the further rise in venous pressure caused by it. Rest and bandaging are even more constantly required than ever. An
more
inescapable conclusion that a reduction pressure (and hence healing of the ulcer) can only be brought about by restoration of the valvular action in the muscle pump. (In animals an attempt has been made to insert acrylic-resin valves, or grafts of a healthy vein with valve.) Such a restoration can be effected by the simple manoeuvre of firm bandaging from toes to knee. Its very simplicity is regarded as suspect by a few, but it does in fact appear to provide a form of valvular action within the deep veins. Originally and consistently advocated by Mr. Dickson Wright/ it is by far the most successful form of treatment yet devised, even in the presence of enormous ulcers. It probably acts in this way : It
in
seems an
venous
The successive turns of the bandage apply a slightly pressure along the leg. Although the surgeon tries to put the bandage on evenly, he never can achieve theoretical equality of pressure throughout, as the faint ridges on the skin indicate when the bandage is removed. This " even " pressure reduces the average calibre of the vein and the slight variations occlude the deep vein at intervals along its length, the average pressure applied being very little greater than the diastolic pressure in that vein. In systole the muscle pump forces blood both up and down the limb through the occluded segments, but mainly upwards, as the resistance is greater distally. In diastole once more, the various points of occlusion due to the turns of bandaging prevent regurgitation downwards of the blood forced upwards during systole.
varying
This valvular action is imperfect but hydrostatically The muscle pump has been repaired most effective. and venous pressure falls. Inevitably the ulcer heals. Hampstead General Hospital, N.W.3.
GERARD KRAFFT.
point they freely communicate, and if the blood by the superficial veins, it can do so by the deep veins, or vice versa ; but when you reach the point above the inner malleolus (where that brown patch of skin so often below that
cannot return
in old
occurs
to be the
me
frequently
persons) it is otherwise, and that appears why ulcers from varicose veins occur
reason
about that
to so
neighbourhood." S. T. ANNING.
Leeds.
COLORIMETRIC ESTIMATION OF POLYVINYLPYRROLIDONE BY IODINE
SIR,-Recent experimental work has enabled
us
to
increase the
sensitivity of the colorimetric method for estimating polyvinylpyrrolidone (F.V.F.) described by Thrower and Campbell.’ The reaction has now been shown to involve free iodine and not the 13- ion as previously stated, and consequently, with solutions of iodine in aqueous potassium iodide, the intensity of colour developed depends on the concentration of free iodine, which is governed by the equilibrium It is not possible to increase the sensitivity by the use of alcoholic solutions of iodine, in which all the iodine is present in an un-ionised form, since ethyl alcohol interferes with the colour reaction. - The behaviour of this coloured complex between iodine and P.V.P. is very similar to that with starch. Thus the colour of the complex is completely discharged by sodium thiosulphate, sodium arsenite, or a strong base. On warming, the colour of the complex disappears but it reappears on cooling. The observations described here were made at 500 m[.L with
a
Unicam SP 500
path length
spectrophotometer
and cells of
optical
1 cm., but similar results have been obtained with
Eel colorimeter (Ilford 603 filter). The optical densities measured against an aqueous solution of identical iodine and potassium-iodide concentrations without any P.v.P. All concentrations referred to below are the actual concentrations in the solution being measured. At constant potassium iodide and iodine concentrations the relationship between optical density and P.V.P. concentration is not a straight line but may approximate to this over a useful range of P.v.P. concentrations at low potassiumiodide and high iodine concentrations. Typical sensitivities in these straight line regions are given in the accompanying table (i, 11,111). In addition the maximum sensitivity obtained under conditions similar to those described by Thrower and Campbellare given (iv).
an
are
VARIATION
OF
SENSITIVITY WITH
COMPOSITION OF
REAGENT
SIR,-I should like to join in congratulating Mr. Cockett and Mr. Elgan Jones on their work on the " ankle blow-out syndrome," which is clearly of fundamental importance both in the aetiology and treatment of certain leg ulcers. The following quotation from John Hilton2 seems an interesting prelude to the careful anatomical investigations of Cockett and Elgan Jones : .
" Why is it that varicose ulcers occur so frequently at the inner and lower part of the leg ? It might be said that they occur because the blood in the veins of the lower extremities has to run up-hill, and gravitation interferes very much with the return of the blood ; the valves get broken down, and the whole pressure is retrograde, if we may so term it, and so these ulcers arise. If that were the sole reason, ulcers should occur by preference on the feet or on the toes, because these are more remote from the general circulation than the ordinary site of ulcers from varicose veins. Hence, I suspect that this cannot be the explanation. The explanation has always-at least for some time past-appeared to me to be this : The superficial and deep veins of the leg freely communicate with each other in the neighbourhood of the ankle-joint. The first two inches above that point is the spot where the greatest stress is laid upon these superficial veins ; 1.
Wright,
A. D.
2. Hilton, J.
A further increase in sensitivity by increasing the iodine concentration is impracticable since the blank absorbs too much light. It is found that, with the most sensitive conditions, a considerable time (1-2 hours) is required for the’ maximum colour to develop, so that it is convenient to sacrifice some sensitivity for greater speed.
These results have suggested the following method, which is about five times more sensitive than that pre-
Lancet, 1931, i, 457.
Ibid, 1861, ii,
245.
1.
Thrower, W. R., Campbell, H. Lancet, 1951, i, 1096.
198 described by Thrower and Campbell : to 10 ml. of the P.v.p. solution, 0.1ml. of a 0-15" iodine solution in 0-1 N potassium iodide is added, and the optical density is measured after 10-15 minutes. The concentration of P.V.P. present is found by using experimentally determined calibration curves. The urine, plasma, or serum must be pretreated, as previously described, before the above measurements are made. An alternative method of removing proteins by acetic acid :I has been found satisfactory.
viously
A fuller account of this method will be Research Laboratories, May & Baker Ltd., Dagenham, Essex. Electro-medical Research Unit, Stoke Maudeville MandeviIIe Hospital, Aylesbury, Bucks.
published
later.
r< H.CAMPBELL. CAMPBELL.
H G. G HUNTER. Cr. HUNTFR.
SUPPORTIVE THERAPY
SiR,-I
was
interested in the Manchester article of
describing an improved type of dextran. Will someone please tell me why this material is dissolved in physiological saline solution ?f Has 6% dextran no osmotic pressure at all ?’? I feel that it is almost impertiJan. 10
nent to remind you, Sir, that the normal serum-chloride level is equivalent to a 0-58% solution of sodium chloride, and that physiological saline contains (usually) 0-9% of sodium chloride, a somewhat unphysiological excess of chloride. Pathological Department, Whipps Cross Hospital, W. W. WALTHER. London, E.11. BOVINE TUBERCULOSIS AND HUMAN TUBERCULOSIS
SiR,-In reply to Mr. Daw (Dec. 27) I should like to say that population variations were taken into account in every county mentioned in the figures given in my letter (Dec. 6). The increase or decrease in the number of notifications is per 100,000 population. Mr. Daw states that " something more than an apparent statistical relationship is required before any such hypothesis can be accepted." In my view, when 10 out of the 11 Scottish counties, with more than 50% of cattle attested, show an increase in human pulmonary tuberculosis, and when 10 out of IScottish counties, with less than 16-5% of cattle attested, show a reduction, the one result is the consequence of the one cause. I gave the figures for the 11 Scottish counties with the highest and lowest proportions of attested cattle. The 10 counties with proportions between those of these two groups would show no significant alteration. Mr. Daw also says " I find Mr. Pitcher’s argument unconvincing." It has long been assumed that bovine tuberculosis increases human tuberculosis. What I have tried to show is that the elimination of bovine tuberculosis does not decrease human infection, but very substantiallv increases it. Turning to the points raised by Dr. Bradshaw (Jan. 10), I applied in every case to the county medical officer of health for notifications of pulmonary and non-pulmonary tuberculosis for the years 1920 (before tuberculin testing of cattle) to 1950 (when the attested-cattle scheme had been in existence for fourteen years, although tuberculin testing of cattle was being practised to a fairly wide extent before 1936, especially in Scotland). I simply took the average for the first five years and compared it with the average for the last five years, taking into account the number of people notified as having pulmonary tuberculosis. In some cases, where figures for the full period were not obtained, the earliest fiveyears were contrasted with the latest five years. The significant feature in Scotland is that until about 1936 all the Scottish counties were showing a reduction in tuberculosis notifications, and this reduction has continued in the counties with relatively few attested 2.
Hunter, G.
Canad. J. Res.
1949, E27, 230.
cattle, whereas the reverse is taking place in counties with 50% or more of attested cattle. Dr. Bradshaw’s suggestion that the final figure for West Lothian should be +119 and Dumbarton +12 is correct, but this alteration merely emphasises my point. In the matter of Glasgow, Dr. Bradshaw points out my error, and I must confess to having confused the Burgh of Glasgow with the Port of Glasgow, Renfrew. The final figures of notifications of pulmonary tuberculosis for the Burgh of Glasgow per 100,000 population should be : 1930-34, 150 ; 1946-50, 248. There has been relatively little alteration in the population ; and the corrected figures further endorse my point. Dr. Bradshaw remarks " there is a fundamental defect in the logic of Mr. Pitcher’s argument " in not considering whether living tubercle bacilli are ingested. My belief is that the milk of a dairy cow infected with tuberculosis (tuberculosis of the udder and hence infection of the milk is an extremely rare condition) contains a substance which I have called " tuberculin " which, when ingested by human beings, increases their resistance to the human bacillus. I am not prepared to say whether this substance is a secretion or excretion or both of the bovine bacillus, but its existence is supported by my figures. I do not believe that pasteurisation would have any effect on the antibody value of this " tuberculin." L. PITCHER. High Wycombe. ,
INTRATHECAL PENICILLIN
SIR,-I have read with interest Dr. Haynes’s letter last week concerning the death of his patient with Waterhouse-Friderichsen syndrome, following the intrathecal injection of penicillin, and also the letter from Dr. Aronson and his colleagues (Dec. 20) concerning the been danger of intrathecal penicillin to which phenol has added. Other cases have lately been described.1 It is with regret that I record the death, some three years ago, of two patients with pyogenic meningitis following the intrathecal injection of 20,000 units of crystalline penicillin to which no preservative had been added. A few hours after the injection, as in Dr. Haynes’s case, convulsions were followed by death. Since then I have not used penicillin intrathecally. Perhaps those with greater experience can tell us the frequency of this complication. I saw no mention of it in the report of the recent discussion on the treatment of non-tuberculous meningitis held at the Royal Society of Medicine. RONALD LASS. Maidstone, Kent. .
CONGENITAL ANOMALIES OF THE BONY THORAX AND LUNGS
SIR,-I have examined miniature fluorographs of 18,570 soldiers, aged 22-28, and I have found the
following
abnormalities of the
bony
thorax :
31 (0.17%) (1) Supernumerary cervical ribs.. Bilateral ........ 7 (0.04%) Unilateral (rt.-sided 18, It.-sided 6) 24(0-13%) 14 (0.07%) (2) Synostosis of ribs...... 12 Between the 1st and 2nd ribs.. Between the 1st, 2nd, and 3rd ribs 1 Between the 8th and 9th ribs .. 1 3 (0-02%) (3) Rudimentary 1st thoracic ribs .. There were thus 48 (0-26%) rib anomalies in all. These figures, although they refer to young men only, agree quite well with those previously published. None of the 31 men with cervical ribs had any symptoms attributable to the condition, though they were all accustomed to strenuous exercise. In 12 cases the radial pulse disappeared when the hand was raised above the head and bent towards the opposite side. Steinerfound 6 cases of tuberculosis among 59 people who had anomalies of the ribs ; but in only 1 of my cases was there 1. Edmunds. V., Proter, R. J. Brit. med. J. 1952, ii, 668; Going, C. H. Ibid, p. 777. 2. Steiner, H. Radiology, 1943, 40, 175.
operation or any line of treatment which ignores this extensive incompetence is not likely to be uniformly successful in healing leg ulcers. Mr. Cockett and Mr. Elgan Jones agree that their follow-up is short, allowing of no definite conclusions about the efficiency of their operation, and I venture to suggest that its basic premise is untenable. The constant finding in phlebograms of ulcerated legs, of a long column of unsupported blood in the deep veins due to an almost total absence of valves, led Bauer and others to investigate the effect of ligature of the popliteal or superficial vein. But as Mr. Goligher has pointed out (Jan. 10), the results of this operation are equivocal. This is not surprising since the column of blood is not a static phenomenon, and a leaking valve will hardly be improved if a complete block is placed across it. The deep veins are the main channels along which blood returns to the heart from the lower limbs, and the swelling which follows the operation is ample witness to the further rise in venous pressure caused by it. Rest and bandaging are even more constantly required than ever. An
more
inescapable conclusion that a reduction pressure (and hence healing of the ulcer) can only be brought about by restoration of the valvular action in the muscle pump. (In animals an attempt has been made to insert acrylic-resin valves, or grafts of a healthy vein with valve.) Such a restoration can be effected by the simple manoeuvre of firm bandaging from toes to knee. Its very simplicity is regarded as suspect by a few, but it does in fact appear to provide a form of valvular action within the deep veins. Originally and consistently advocated by Mr. Dickson Wright/ it is by far the most successful form of treatment yet devised, even in the presence of enormous ulcers. It probably acts in this way : It
in
seems an
venous
The successive turns of the bandage apply a slightly pressure along the leg. Although the surgeon tries to put the bandage on evenly, he never can achieve theoretical equality of pressure throughout, as the faint ridges on the skin indicate when the bandage is removed. This " even " pressure reduces the average calibre of the vein and the slight variations occlude the deep vein at intervals along its length, the average pressure applied being very little greater than the diastolic pressure in that vein. In systole the muscle pump forces blood both up and down the limb through the occluded segments, but mainly upwards, as the resistance is greater distally. In diastole once more, the various points of occlusion due to the turns of bandaging prevent regurgitation downwards of the blood forced upwards during systole.
varying
This valvular action is imperfect but hydrostatically The muscle pump has been repaired most effective. and venous pressure falls. Inevitably the ulcer heals. Hampstead General Hospital, N.W.3.
GERARD KRAFFT.
point they freely communicate, and if the blood by the superficial veins, it can do so by the deep veins, or vice versa ; but when you reach the point above the inner malleolus (where that brown patch of skin so often below that
cannot return
in old
occurs
to be the
me
frequently
persons) it is otherwise, and that appears why ulcers from varicose veins occur
reason
about that
to so
neighbourhood." S. T. ANNING.
Leeds.
COLORIMETRIC ESTIMATION OF POLYVINYLPYRROLIDONE BY IODINE
SIR,-Recent experimental work has enabled
us
to
increase the
sensitivity of the colorimetric method for estimating polyvinylpyrrolidone (F.V.F.) described by Thrower and Campbell.’ The reaction has now been shown to involve free iodine and not the 13- ion as previously stated, and consequently, with solutions of iodine in aqueous potassium iodide, the intensity of colour developed depends on the concentration of free iodine, which is governed by the equilibrium It is not possible to increase the sensitivity by the use of alcoholic solutions of iodine, in which all the iodine is present in an un-ionised form, since ethyl alcohol interferes with the colour reaction. - The behaviour of this coloured complex between iodine and P.V.P. is very similar to that with starch. Thus the colour of the complex is completely discharged by sodium thiosulphate, sodium arsenite, or a strong base. On warming, the colour of the complex disappears but it reappears on cooling. The observations described here were made at 500 m[.L with
a
Unicam SP 500
path length
spectrophotometer
and cells of
optical
1 cm., but similar results have been obtained with
Eel colorimeter (Ilford 603 filter). The optical densities measured against an aqueous solution of identical iodine and potassium-iodide concentrations without any P.v.P. All concentrations referred to below are the actual concentrations in the solution being measured. At constant potassium iodide and iodine concentrations the relationship between optical density and P.V.P. concentration is not a straight line but may approximate to this over a useful range of P.v.P. concentrations at low potassiumiodide and high iodine concentrations. Typical sensitivities in these straight line regions are given in the accompanying table (i, 11,111). In addition the maximum sensitivity obtained under conditions similar to those described by Thrower and Campbellare given (iv).
an
are
VARIATION
OF
SENSITIVITY WITH
COMPOSITION OF
REAGENT
SIR,-I should like to join in congratulating Mr. Cockett and Mr. Elgan Jones on their work on the " ankle blow-out syndrome," which is clearly of fundamental importance both in the aetiology and treatment of certain leg ulcers. The following quotation from John Hilton2 seems an interesting prelude to the careful anatomical investigations of Cockett and Elgan Jones : .
" Why is it that varicose ulcers occur so frequently at the inner and lower part of the leg ? It might be said that they occur because the blood in the veins of the lower extremities has to run up-hill, and gravitation interferes very much with the return of the blood ; the valves get broken down, and the whole pressure is retrograde, if we may so term it, and so these ulcers arise. If that were the sole reason, ulcers should occur by preference on the feet or on the toes, because these are more remote from the general circulation than the ordinary site of ulcers from varicose veins. Hence, I suspect that this cannot be the explanation. The explanation has always-at least for some time past-appeared to me to be this : The superficial and deep veins of the leg freely communicate with each other in the neighbourhood of the ankle-joint. The first two inches above that point is the spot where the greatest stress is laid upon these superficial veins ; 1.
Wright,
A. D.
2. Hilton, J.
A further increase in sensitivity by increasing the iodine concentration is impracticable since the blank absorbs too much light. It is found that, with the most sensitive conditions, a considerable time (1-2 hours) is required for the’ maximum colour to develop, so that it is convenient to sacrifice some sensitivity for greater speed.
These results have suggested the following method, which is about five times more sensitive than that pre-
Lancet, 1931, i, 457.
Ibid, 1861, ii,
245.
1.
Thrower, W. R., Campbell, H. Lancet, 1951, i, 1096.
198 described by Thrower and Campbell : to 10 ml. of the P.v.p. solution, 0.1ml. of a 0-15" iodine solution in 0-1 N potassium iodide is added, and the optical density is measured after 10-15 minutes. The concentration of P.V.P. present is found by using experimentally determined calibration curves. The urine, plasma, or serum must be pretreated, as previously described, before the above measurements are made. An alternative method of removing proteins by acetic acid :I has been found satisfactory.
viously
A fuller account of this method will be Research Laboratories, May & Baker Ltd., Dagenham, Essex. Electro-medical Research Unit, Stoke Maudeville MandeviIIe Hospital, Aylesbury, Bucks.
published
later.
r< H.CAMPBELL. CAMPBELL.
H G. G HUNTER. Cr. HUNTFR.
SUPPORTIVE THERAPY
SiR,-I
was
interested in the Manchester article of
describing an improved type of dextran. Will someone please tell me why this material is dissolved in physiological saline solution ?f Has 6% dextran no osmotic pressure at all ?’? I feel that it is almost impertiJan. 10
nent to remind you, Sir, that the normal serum-chloride level is equivalent to a 0-58% solution of sodium chloride, and that physiological saline contains (usually) 0-9% of sodium chloride, a somewhat unphysiological excess of chloride. Pathological Department, Whipps Cross Hospital, W. W. WALTHER. London, E.11. BOVINE TUBERCULOSIS AND HUMAN TUBERCULOSIS
SiR,-In reply to Mr. Daw (Dec. 27) I should like to say that population variations were taken into account in every county mentioned in the figures given in my letter (Dec. 6). The increase or decrease in the number of notifications is per 100,000 population. Mr. Daw states that " something more than an apparent statistical relationship is required before any such hypothesis can be accepted." In my view, when 10 out of the 11 Scottish counties, with more than 50% of cattle attested, show an increase in human pulmonary tuberculosis, and when 10 out of IScottish counties, with less than 16-5% of cattle attested, show a reduction, the one result is the consequence of the one cause. I gave the figures for the 11 Scottish counties with the highest and lowest proportions of attested cattle. The 10 counties with proportions between those of these two groups would show no significant alteration. Mr. Daw also says " I find Mr. Pitcher’s argument unconvincing." It has long been assumed that bovine tuberculosis increases human tuberculosis. What I have tried to show is that the elimination of bovine tuberculosis does not decrease human infection, but very substantiallv increases it. Turning to the points raised by Dr. Bradshaw (Jan. 10), I applied in every case to the county medical officer of health for notifications of pulmonary and non-pulmonary tuberculosis for the years 1920 (before tuberculin testing of cattle) to 1950 (when the attested-cattle scheme had been in existence for fourteen years, although tuberculin testing of cattle was being practised to a fairly wide extent before 1936, especially in Scotland). I simply took the average for the first five years and compared it with the average for the last five years, taking into account the number of people notified as having pulmonary tuberculosis. In some cases, where figures for the full period were not obtained, the earliest fiveyears were contrasted with the latest five years. The significant feature in Scotland is that until about 1936 all the Scottish counties were showing a reduction in tuberculosis notifications, and this reduction has continued in the counties with relatively few attested 2.
Hunter, G.
Canad. J. Res.
1949, E27, 230.
cattle, whereas the reverse is taking place in counties with 50% or more of attested cattle. Dr. Bradshaw’s suggestion that the final figure for West Lothian should be +119 and Dumbarton +12 is correct, but this alteration merely emphasises my point. In the matter of Glasgow, Dr. Bradshaw points out my error, and I must confess to having confused the Burgh of Glasgow with the Port of Glasgow, Renfrew. The final figures of notifications of pulmonary tuberculosis for the Burgh of Glasgow per 100,000 population should be : 1930-34, 150 ; 1946-50, 248. There has been relatively little alteration in the population ; and the corrected figures further endorse my point. Dr. Bradshaw remarks " there is a fundamental defect in the logic of Mr. Pitcher’s argument " in not considering whether living tubercle bacilli are ingested. My belief is that the milk of a dairy cow infected with tuberculosis (tuberculosis of the udder and hence infection of the milk is an extremely rare condition) contains a substance which I have called " tuberculin " which, when ingested by human beings, increases their resistance to the human bacillus. I am not prepared to say whether this substance is a secretion or excretion or both of the bovine bacillus, but its existence is supported by my figures. I do not believe that pasteurisation would have any effect on the antibody value of this " tuberculin." L. PITCHER. High Wycombe. ,
INTRATHECAL PENICILLIN
SIR,-I have read with interest Dr. Haynes’s letter last week concerning the death of his patient with Waterhouse-Friderichsen syndrome, following the intrathecal injection of penicillin, and also the letter from Dr. Aronson and his colleagues (Dec. 20) concerning the been danger of intrathecal penicillin to which phenol has added. Other cases have lately been described.1 It is with regret that I record the death, some three years ago, of two patients with pyogenic meningitis following the intrathecal injection of 20,000 units of crystalline penicillin to which no preservative had been added. A few hours after the injection, as in Dr. Haynes’s case, convulsions were followed by death. Since then I have not used penicillin intrathecally. Perhaps those with greater experience can tell us the frequency of this complication. I saw no mention of it in the report of the recent discussion on the treatment of non-tuberculous meningitis held at the Royal Society of Medicine. RONALD LASS. Maidstone, Kent. .
CONGENITAL ANOMALIES OF THE BONY THORAX AND LUNGS
SIR,-I have examined miniature fluorographs of 18,570 soldiers, aged 22-28, and I have found the
following
abnormalities of the
bony
thorax :
31 (0.17%) (1) Supernumerary cervical ribs.. Bilateral ........ 7 (0.04%) Unilateral (rt.-sided 18, It.-sided 6) 24(0-13%) 14 (0.07%) (2) Synostosis of ribs...... 12 Between the 1st and 2nd ribs.. Between the 1st, 2nd, and 3rd ribs 1 Between the 8th and 9th ribs .. 1 3 (0-02%) (3) Rudimentary 1st thoracic ribs .. There were thus 48 (0-26%) rib anomalies in all. These figures, although they refer to young men only, agree quite well with those previously published. None of the 31 men with cervical ribs had any symptoms attributable to the condition, though they were all accustomed to strenuous exercise. In 12 cases the radial pulse disappeared when the hand was raised above the head and bent towards the opposite side. Steinerfound 6 cases of tuberculosis among 59 people who had anomalies of the ribs ; but in only 1 of my cases was there 1. Edmunds. V., Proter, R. J. Brit. med. J. 1952, ii, 668; Going, C. H. Ibid, p. 777. 2. Steiner, H. Radiology, 1943, 40, 175.