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EARLY AMPUTATION FOR SEVERE INJURY
1441
CORRESPONDENCE PRONTOSIL IN STREPTOCOCCAL INFECTIONS To the Editor of THE LANCET
SiR,-In view of the promising results reported in THE LANCET of June 6th it is very desirable to complete our clinical trial of Prontosil treatment in
streptococcus-infected cases as quickly as possible ; and subsequently-if laboratory tests seem to warrant it-to undertake a similar thorough trial with the related substance p-aminobenzenesulphonamide in a similar large group of puerperal fever cases, in order that the experience gained with both agents may become generally available without delay. To this end we would ask for the cooperation of private doctors, hospitals, and public health authorities in sending to us puerperal fever cases which are known to be, or likely to be, infected by haemolytic streptococci. Needless to say we do not want oldstanding cases of parametritis, white leg, &c., nor do we suggest the removal of moribund cases to hospital. Acute early cases seem likely to benefit most by the treatment. To secure admission it is only necessary to communicate with the resident medical officer by telephone (Riverside 6081/2), giving a few particulars of the case. I am, Sir, yours faithfully, LEONARD COLEBROOK. Bernhard Baron Memorial Research Laboratories, Queen Charlotte’s Hospital, W., June 12th. EARLY AMPUTATION FOR SEVERE INJURY
To the Editor
of THE LANCET an annotation under this reference to SiR,—With in issue of heading your May 30th (p. 1249), it was at a meeting attended by many members of the R.A.M.C. that Prof. A. K. Henry, head of the surgical unit at the Egyptian Faculty of Medicine, Cairo (Kasr-el-Ainy Hospital), formulated his preliminary ideas and results. Unfortunately, owing to a crowded programme, there was no time to prolong the discussion or emphasise the revolution these ideas should cause in the practice of advanced dressing stations, field ambulances, and first-line casualty clearing stations. Abdulsamie’s paper gives a very clear description of the ideal treatment and I maintain that the case for " immediate " amputation is proved. Your call for further observations is certainly well timed, and I hope that officers of the fighting services will be able to give their views and opinions. At the commencement of the last war I was with the French VIIIth Army and I was greatly hampered by the official attitude that an amputated patient was an expense to the State. I am happy to remember that with the British forces no consideration of future pensions was allowed to interfere with our practice ; but with the vastly accelerated means of transport in late years I am afraid there may be a danger of trusting to rapid evacuation of severely wounded instead of immediate attention, that is amputation," to the severe crushes in the first-line units. I am, Sir, yours faithfully, H. STIVEN, "
Retd. Lieut.-Col., R.A.M.C. Demerdache Hospital, Cairo, June 9th.
THE PHANTASY OF MURDER
LANCET SIR,-I understand that the murderer of a woman in a Clapham flat has had his appeal dismissed and as this matter is no longer sub judice it is permissible to draw attention to a fact that has long been To the Editor
of THE
neglected. This
man made a confession of having committed another murder three years ago, but was acquitted. This acting a phantasy of murder indicates the future murderer but it is treated by the judicial authorities with off-handedness. This is by no means the first case in which a murderer has made a false confession and has had it disregarded by the police but has proceeded to commit a real murder. Some years ago a young man confessed to the police in Dartford that he had killed a boy. His confession was found to be false and he was discharged and told not to be so foolish. A few days later he took a knife and with it killed a girl on Dartford Heath. I have recently pointed out that this false confession of murder is an early symptom of schizophrenia (Clin. Jour., May, 1936), but there is little opportunity to confirm this belief. I would suggest, however, that the matter is proved sufficiently for all persons making false confessions of murder to be recommended by the judicial authorities for medical examination by a trained psychiatrist. If this is done some unfortunates may avoid being murdered and some schizophrenics avoid hanging. I am, Sir, yours faithfully, CLIFFORD ALLEN. Harley-street, W., June 16th.
AVITAMINOSES
To the Editor of THE LANCET SiR,-In a recent paper1 Loewenthal, working iDUganda on cases of vitamin-A deficiency, summarises. the signs and symptoms which have so far been ascribed to this deficiency, and divides them into those which he accepts and those of which he is doubtful, as follows :ACCEPTED
Eye MM?M/&eoM.s.—Xerophthahnia ; ; keratomalacia ;night-blindness. Skin manifestations.-Harsh dryness of the skin, with tendency to papular eruption. Nails lose lustre and. become striated and brittle. DOUBTFUL
1. "Neuritis." 2. " Sore mouth " ; perleche. 3. " Itchy " scrotum. 4. Diarrhoea and dysentery.
5. General infections. 6. Cutaneous sepsis. 7. Changes in the hair.
With regard to the first three of the "doubtful"’ group, a paper by Pallister and myself2 proves fairlyconclusively, if not absolutely, that they are due to a deficiency of the P-P (pellagra-preventive) factor ;, it is significant that Loewenthal states that it is now generally believed that perleche is due partially to an attack by fungus on the mouth, while Pallister and I found similar evidence of fungus attacking. the scrotal skin in some of our cases and that a. fungicide such as Whitfield’s ointment was of value in treatment. Fungus in these cases seems to me to play a similar part to that of sun exposure in pellagra, having an excessive effect on the skin of those people who have deficiency of the P-P factor in their food. The diarrhcea and dysentery so longassociated with pellagra may well be, as far as my experience of a few cases of characteristic pellagra in Malaya goes, causative factors in producingpellagra rather than effects of pellagra. If these arguments can be confirmed, then pellagra throughout. the world may be finally accepted as due to deficiency 1 Loewenthal, L. J. A. : Ann. Trop. Med., 1935, xxix., 467. 2 Landor, J. V., and Pallister, R. A. : Trans. Roy. Soc. Trop. Med. and Hyg., 1935, xxix., 121.
CORRESPONDENCE PRONTOSIL IN STREPTOCOCCAL INFECTIONS To the Editor of THE LANCET
SiR,-In view of the promising results reported in THE LANCET of June 6th it is very desirable to complete our clinical trial of Prontosil treatment in
streptococcus-infected cases as quickly as possible ; and subsequently-if laboratory tests seem to warrant it-to undertake a similar thorough trial with the related substance p-aminobenzenesulphonamide in a similar large group of puerperal fever cases, in order that the experience gained with both agents may become generally available without delay. To this end we would ask for the cooperation of private doctors, hospitals, and public health authorities in sending to us puerperal fever cases which are known to be, or likely to be, infected by haemolytic streptococci. Needless to say we do not want oldstanding cases of parametritis, white leg, &c., nor do we suggest the removal of moribund cases to hospital. Acute early cases seem likely to benefit most by the treatment. To secure admission it is only necessary to communicate with the resident medical officer by telephone (Riverside 6081/2), giving a few particulars of the case. I am, Sir, yours faithfully, LEONARD COLEBROOK. Bernhard Baron Memorial Research Laboratories, Queen Charlotte’s Hospital, W., June 12th. EARLY AMPUTATION FOR SEVERE INJURY
To the Editor
of THE LANCET an annotation under this reference to SiR,—With in issue of heading your May 30th (p. 1249), it was at a meeting attended by many members of the R.A.M.C. that Prof. A. K. Henry, head of the surgical unit at the Egyptian Faculty of Medicine, Cairo (Kasr-el-Ainy Hospital), formulated his preliminary ideas and results. Unfortunately, owing to a crowded programme, there was no time to prolong the discussion or emphasise the revolution these ideas should cause in the practice of advanced dressing stations, field ambulances, and first-line casualty clearing stations. Abdulsamie’s paper gives a very clear description of the ideal treatment and I maintain that the case for " immediate " amputation is proved. Your call for further observations is certainly well timed, and I hope that officers of the fighting services will be able to give their views and opinions. At the commencement of the last war I was with the French VIIIth Army and I was greatly hampered by the official attitude that an amputated patient was an expense to the State. I am happy to remember that with the British forces no consideration of future pensions was allowed to interfere with our practice ; but with the vastly accelerated means of transport in late years I am afraid there may be a danger of trusting to rapid evacuation of severely wounded instead of immediate attention, that is amputation," to the severe crushes in the first-line units. I am, Sir, yours faithfully, H. STIVEN, "
Retd. Lieut.-Col., R.A.M.C. Demerdache Hospital, Cairo, June 9th.
THE PHANTASY OF MURDER
LANCET SIR,-I understand that the murderer of a woman in a Clapham flat has had his appeal dismissed and as this matter is no longer sub judice it is permissible to draw attention to a fact that has long been To the Editor
of THE
neglected. This
man made a confession of having committed another murder three years ago, but was acquitted. This acting a phantasy of murder indicates the future murderer but it is treated by the judicial authorities with off-handedness. This is by no means the first case in which a murderer has made a false confession and has had it disregarded by the police but has proceeded to commit a real murder. Some years ago a young man confessed to the police in Dartford that he had killed a boy. His confession was found to be false and he was discharged and told not to be so foolish. A few days later he took a knife and with it killed a girl on Dartford Heath. I have recently pointed out that this false confession of murder is an early symptom of schizophrenia (Clin. Jour., May, 1936), but there is little opportunity to confirm this belief. I would suggest, however, that the matter is proved sufficiently for all persons making false confessions of murder to be recommended by the judicial authorities for medical examination by a trained psychiatrist. If this is done some unfortunates may avoid being murdered and some schizophrenics avoid hanging. I am, Sir, yours faithfully, CLIFFORD ALLEN. Harley-street, W., June 16th.
AVITAMINOSES
To the Editor of THE LANCET SiR,-In a recent paper1 Loewenthal, working iDUganda on cases of vitamin-A deficiency, summarises. the signs and symptoms which have so far been ascribed to this deficiency, and divides them into those which he accepts and those of which he is doubtful, as follows :ACCEPTED
Eye MM?M/&eoM.s.—Xerophthahnia ; ; keratomalacia ;night-blindness. Skin manifestations.-Harsh dryness of the skin, with tendency to papular eruption. Nails lose lustre and. become striated and brittle. DOUBTFUL
1. "Neuritis." 2. " Sore mouth " ; perleche. 3. " Itchy " scrotum. 4. Diarrhoea and dysentery.
5. General infections. 6. Cutaneous sepsis. 7. Changes in the hair.
With regard to the first three of the "doubtful"’ group, a paper by Pallister and myself2 proves fairlyconclusively, if not absolutely, that they are due to a deficiency of the P-P (pellagra-preventive) factor ;, it is significant that Loewenthal states that it is now generally believed that perleche is due partially to an attack by fungus on the mouth, while Pallister and I found similar evidence of fungus attacking. the scrotal skin in some of our cases and that a. fungicide such as Whitfield’s ointment was of value in treatment. Fungus in these cases seems to me to play a similar part to that of sun exposure in pellagra, having an excessive effect on the skin of those people who have deficiency of the P-P factor in their food. The diarrhcea and dysentery so longassociated with pellagra may well be, as far as my experience of a few cases of characteristic pellagra in Malaya goes, causative factors in producingpellagra rather than effects of pellagra. If these arguments can be confirmed, then pellagra throughout. the world may be finally accepted as due to deficiency 1 Loewenthal, L. J. A. : Ann. Trop. Med., 1935, xxix., 467. 2 Landor, J. V., and Pallister, R. A. : Trans. Roy. Soc. Trop. Med. and Hyg., 1935, xxix., 121.