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FEMORAL THROMBOSIS
1471 counterblast should cover the same ground original, and should employ methods of investigation which are at least as thorough. I ask permission to put before your readers a comparison of the plan of the two pieces of work :- That of Graves and Pickworth comprises a careful record of a thousand cases of mental disorder investigated and treated by rhinological means over a period of five years. Their publication includes a record of the duration of the naso-pharyngeal sepsis, and the bacteriology of washings from the sinuses, with minute descriptions (averaging 2 pages each) of 33 illustrative cases and many photographs. It comprises post-mortem examination of 317 cases, examined macroscopically and microscopically ; and this monumental investigation includes 2 pages of bibliography and references. The Edinburgh report, upon the other hand, is a relatively dilettante affair. The omission of postmortem and bacteriological examination has resulted in a most gratifying diminution in labour, so that the whole report covers only 13 pages, and gives some 13 references. The survey purports to give the nasal findings in 818 cases, but the rhinological methods employed simply do not compare in thoroughness with those used in Birmingham; and the only criteria of sinusitis admitted were apparently "the presence of pus in the nose or nasopharynx, or relative opacity to transillumination of one or more
Also,
as
a
the
of the air cavities." The idea that the diagnosis of chronic sinusitis depends upon the presence of pus dies hard ; and it does not explain the very common case in which over a period of years there are attacks of undeniable sinusitis, gradually increasing in severity and duration. Because there is no pus between attacks, are we to say that the chronic sinusitis does not exist during these intervals Surely not. A flare-up, complete with pus, can be precipitated by a vaccine ; and the presence of a haemolytic streptococcus in the subepithelial tissues can usually be demonstrated by the incubation of a piece of mucosa collected from an area on, say, the middle turbinate, previously sterilised. With regard to treatment, I submit that the Edinburgh report is unintentionally but profoundly misleading. The chronic sinusitis which is associated with mental disorder is, from the published literature and also in my limited experience, of the most widespread and well-entrenched type. Mr. Brownlie Smith’s radical operations upon the antra were logically conceived, and achieved the removal of the diseased tissue-the antral linings. But (except in infections of dental origin) is it the rule to find that the antra alone are involved Our out-patient departments are thronged with patients upon whom antral operations have been skilfully performed, but whose ethmoids and sphenoids have grown steadily worse since their operations ; and it is this unaccountable but prevalent assumption that chronic sinusitis is restricted to the antra that has given rise to the derisive saying " Once a sinus operation, always a sinus operation." An abdominal surgeon who removed half an infected appendix would expect the remaining half to show resentment in no uncertain way at its omission from the scope of the operation, and it is surprising that rhinologists should ever have expected that septic foci in the sinuses should behave differently. Modern rhinological opinion in America, Austria, Australia, and the United Kingdom, while tending more and more to limit surgical intervention, demands that an operation shall include in its scope the whole area involved in the infection. The operations which constituted the treatment of the sinusitis
in the
work were not conceived in this In all seriousness, could any rhinologist quote " removal of polypi " as a considered attempt to remove all the sinus disease of which the polypi are a result ? Again, is " inflammatory condition of the middle turbinal " a recognised diagnosis, or is removal of the turbinal really suggested as a removal of all the disease ? The entire absence of post-mortem examination in this investigation invalidates it considerably (or else the time spent in such examinations in other departments of medicine is to be deplored). While the omission of bacteriological examination, in 1938, reminds me of the story of a very senior consultant before the war who, when twitted with his disregard of microscopical evidence, said, " God gave me these two eyes ; and anything I can’t see with their help wasn’t meant for me to look at ! " I cannot pose as an unprejudiced observer, for I have made the pilgrimage to Birmingham. My own observations have in their small way caused me fervently to range myself upon the side of Graves and Pickworth ; and until work of equal weight is thrown into the balance upon the opposite side, there I shall stay.-I am, Sir, yours faithfully, BEDFORD RUSSELL. London, June 15th.
Edinburgh
spirit.
THE FIRST APPENDICECTOMY To the Editor of THE LANCET
SIR,—Prof. A. W. Sheen asks in your issue of June Ilth whether it is true that Charters Symonds performed the first appendicectomy en froid in this country. It is true not only for this country, but, according to Howard Kelly, for all countries. Charters Symonds and his medical colleague, Mahomed, had become interested in the post-mortem lesions of appendicitis, which had been closely studied at Guy’s ever since Bright and Addison gave their classical description of the disease in their " Elements of the Practice of Medicine," published in 1839. After much thought and discussion Symonds performed the first " interval " operation for appendicitis at Guy’s Hospital on August 24th, 1883. He made a lateral incision without opening the periIn a paper published two years later, toneum. after Mahomed’s untimely death, he wrote, shortly " I believe I am correct in saying that this is the first case in which a concretion or calculus has been removed from the appendix without at the same time opening an abscess, and the credit of whatever value rests in the procedure must be given to my lamented colleague Dr. Mahomed, at whose suggestion the operation was undertaken, and who advocated the inguinal incision in opposition to that along the linea semilunaris proposed by myself." Cases of appendicitis at that time were admitted under the care of the physicians, and it was some years before Symonds could find any other of his medical colleagues willing to give him an opportunity of repeating the I am, Sir, yours faithfully, operation. ARTHUR F. HURST. Guy’s Hospital, June 16th. FEMORAL THROMBOSIS
To the Editor of THE LANCET SIR,—In your issue of June llth Dr. W. N. Leak asks about the age-incidence of the cases of femoral thrombosis recorded in my article of May 28th. In the cases recorded, the age-incidence at the time of onset of the thrombosis varied from 13 to 63. Eleven of the patients were under 20 at the time of the thrombosis, and three were under 18 (viz., 13, 16, and 17). In the first two of these three the thrombosis
1472
complication of typhoid or paratyphoid, and in the third case the condition was a white leg. As a whole, femoral thrombosis is relatively infrequent during the growth period of life and is almost unknown in children. This immunity in early life is particularly marked in the case of post-operative thrombosis and this complication with pulmonary emboli is extremely rare in childhood. Personally I do not remember ever having seen a clear-cut case of deep femoral thrombosis in a young child. At the same time it may be true that recovery is likely to be more complete in younger patients. With regard to the first case quoted by Dr. Leak, of the baby of 7 months with pyæmia and abscesses following acute osteomyelitis, I am afraid that in the presence of such extensive acute septic complications it would be difficult to regard this as a clear-cut case of femoral thrombosis. Writing of his second case, of severe white leg treated with Contramine (B.D.H.), Dr. Leak himself admits that the limb still shows slight swelling at the end of the day and a tendency to develop painful ulcers after slight was a
injuries. My object
in recording these 85 cases of femoral thrombosis was to discuss the bearings of the ultimate or remote clinical picture upon the possible aetiological factors. In the series recorded it was certainly true that in no patient did the limb return entirely to normal. I was, however, careful to point out that in the absence of complications many patients show a tendency towards recovery. I have no personal experience of the treatment of femoral thrombosis either by means of contramine or by injections of vitamins A and D ; but on the evidence put forward by Dr. Leak I cannot alter my opinion as to the permanence of some degree of circulatory impairment after femoral thrombosis, no matter how great the recovery from the acute phase. I am, Sir, yours faithfully, REGINALD T. PAYNE. Harley-street, W., June 18th.
SUBCUTANEOUS EMPHYSEMA IN ASTHMA To the Editor of THE LANCET SIR,—I read with interest the article on sub. cutaneous emphysema and pneumothorax in bronchial asthma, written by R. W. Elliott, house physician at the Royal Infirmary, Sheffield, and published in He states that he was your issue of May 14th. unable to find reports of more than four cases of subcutaneous emphysema complicating asthma, and I would therefore like to refer him to an article in the American Journal of Medical Sciences for May, 1938, in which Drs. L. Rosenberg and J. Rosenberg, after reporting their own case, add seventeen previously published. Apparently this condition is not too rare a complication of bronchial asthma. I was called in consultation to see a patient of Dr. C. W. Kenney at the Syracuse Memorial Hospital, a woman
21 years of age
who
was
seven
months
pregnant, who had had moderately severe hay-fever all summer. Recently she had developed a persistent cough, and on the night before admittance to the hospital she had an unusually hard coughing spell, followed by dyspnoea. In her past history the fact was elicited that she had had operation for quinsy
of the throat on two occasions. Examination showed a rather extensive subcutaneous emphysema extending up both sides of the neck and over the chest. X rays did not reveal any pneumothorax. It was thought in this particular case that a fracture of the hyoid bone might be the source of entry of the air into the subcutaneous tissues ; or the previous quinsy operations might have caused some weakness in the wall of the pharynx
a further source of the adventitious air ; but X ray of the body or cornu of the hyoid bone was negative and there was no tear demonstrable in the pharynx adjacent to the tonsillar tissue.
as
This
case
has not been reported before. I am, Sir, yours faithfully, HENRY H. HAFT.
Medical Arts Building, Syracuse, N.Y., June 8th.
THE TRIAL LABOUR—AND AFTER
To the Editor
of
THE LANCET
am very interested in your leading article this subject. I have never been an advocate of trial labour for several reasons : first, it has always appeared to me to be rather a misleading term, and I have never been quite sure what its advocates mean by it. One idea seems to be that a trial labour is one conducted with all possible asepsis and antisepsis so that, should it become necessary, a Cæsarean section can be performed without undue risk ; but, surely, every labour should be conducted with all possible antiseptic and aseptic care, so every labour is a trial
SIR,—I
on
labour. Another view
to be that decide if
should not is present, or likely to become present in two or three weeks, but just wait and see if it is present when labour fails to progress. Surely this is a retrograde step? We should endeavour to make up our minds when the foetus has reached the optimum size, and, if labour does not ensue, induction of premature labour is more scientific. Admittedly, human error will come into some cases, but the more we strive to form correct judgment the fewer will be the errors., Your article rightly stresses the importance of doing everything in our power to avoid a stillbirth at the first pregnancy, and I strongly agree with all that is said of the effect of frustration of the maternal urge. The loss of a first baby is so serious that I have always opposed the dictum " never a Cæsarean section with the first baby." The notes of the case quoted hardly seem to me to come within the category of trial labour at all. The first pregnancy was a breech presentation, diagnosed during pregnancy, and external version was apparently successfully performed and presumably, as not infrequently happens, the foetus reverted to breech, which fact apparently was not noticed until labour had commenced. The child when born weighed 9 lb., and I do not consider that a foetus of this weight, presenting by the breech, at a first labour, can be classified as a trial labour. The patient’s second pregnancy certainly afforded every suggestion for consideration of a Caesarean section in the interests of the child. One could hardly call it a trial labour even if it had been left, and in my opinion a Cæsarean section was completely justified. Finally, I fail to see why the mother was " faced with the probability of further operations for the birth of any future children." If there is good union of the uterine wall there is no reason at all why subsequent labours should not be normal labours, provided a vertex presentation is present and there is make any
no
seems
attempt
to
one
disproportion
disproportion. I am,
Sir,
yours
faithfully, LOUIS CARNAC RIVETT.
Harley-street, W., June 21st.
Also,
as
a
the
of the air cavities." The idea that the diagnosis of chronic sinusitis depends upon the presence of pus dies hard ; and it does not explain the very common case in which over a period of years there are attacks of undeniable sinusitis, gradually increasing in severity and duration. Because there is no pus between attacks, are we to say that the chronic sinusitis does not exist during these intervals Surely not. A flare-up, complete with pus, can be precipitated by a vaccine ; and the presence of a haemolytic streptococcus in the subepithelial tissues can usually be demonstrated by the incubation of a piece of mucosa collected from an area on, say, the middle turbinate, previously sterilised. With regard to treatment, I submit that the Edinburgh report is unintentionally but profoundly misleading. The chronic sinusitis which is associated with mental disorder is, from the published literature and also in my limited experience, of the most widespread and well-entrenched type. Mr. Brownlie Smith’s radical operations upon the antra were logically conceived, and achieved the removal of the diseased tissue-the antral linings. But (except in infections of dental origin) is it the rule to find that the antra alone are involved Our out-patient departments are thronged with patients upon whom antral operations have been skilfully performed, but whose ethmoids and sphenoids have grown steadily worse since their operations ; and it is this unaccountable but prevalent assumption that chronic sinusitis is restricted to the antra that has given rise to the derisive saying " Once a sinus operation, always a sinus operation." An abdominal surgeon who removed half an infected appendix would expect the remaining half to show resentment in no uncertain way at its omission from the scope of the operation, and it is surprising that rhinologists should ever have expected that septic foci in the sinuses should behave differently. Modern rhinological opinion in America, Austria, Australia, and the United Kingdom, while tending more and more to limit surgical intervention, demands that an operation shall include in its scope the whole area involved in the infection. The operations which constituted the treatment of the sinusitis
in the
work were not conceived in this In all seriousness, could any rhinologist quote " removal of polypi " as a considered attempt to remove all the sinus disease of which the polypi are a result ? Again, is " inflammatory condition of the middle turbinal " a recognised diagnosis, or is removal of the turbinal really suggested as a removal of all the disease ? The entire absence of post-mortem examination in this investigation invalidates it considerably (or else the time spent in such examinations in other departments of medicine is to be deplored). While the omission of bacteriological examination, in 1938, reminds me of the story of a very senior consultant before the war who, when twitted with his disregard of microscopical evidence, said, " God gave me these two eyes ; and anything I can’t see with their help wasn’t meant for me to look at ! " I cannot pose as an unprejudiced observer, for I have made the pilgrimage to Birmingham. My own observations have in their small way caused me fervently to range myself upon the side of Graves and Pickworth ; and until work of equal weight is thrown into the balance upon the opposite side, there I shall stay.-I am, Sir, yours faithfully, BEDFORD RUSSELL. London, June 15th.
Edinburgh
spirit.
THE FIRST APPENDICECTOMY To the Editor of THE LANCET
SIR,—Prof. A. W. Sheen asks in your issue of June Ilth whether it is true that Charters Symonds performed the first appendicectomy en froid in this country. It is true not only for this country, but, according to Howard Kelly, for all countries. Charters Symonds and his medical colleague, Mahomed, had become interested in the post-mortem lesions of appendicitis, which had been closely studied at Guy’s ever since Bright and Addison gave their classical description of the disease in their " Elements of the Practice of Medicine," published in 1839. After much thought and discussion Symonds performed the first " interval " operation for appendicitis at Guy’s Hospital on August 24th, 1883. He made a lateral incision without opening the periIn a paper published two years later, toneum. after Mahomed’s untimely death, he wrote, shortly " I believe I am correct in saying that this is the first case in which a concretion or calculus has been removed from the appendix without at the same time opening an abscess, and the credit of whatever value rests in the procedure must be given to my lamented colleague Dr. Mahomed, at whose suggestion the operation was undertaken, and who advocated the inguinal incision in opposition to that along the linea semilunaris proposed by myself." Cases of appendicitis at that time were admitted under the care of the physicians, and it was some years before Symonds could find any other of his medical colleagues willing to give him an opportunity of repeating the I am, Sir, yours faithfully, operation. ARTHUR F. HURST. Guy’s Hospital, June 16th. FEMORAL THROMBOSIS
To the Editor of THE LANCET SIR,—In your issue of June llth Dr. W. N. Leak asks about the age-incidence of the cases of femoral thrombosis recorded in my article of May 28th. In the cases recorded, the age-incidence at the time of onset of the thrombosis varied from 13 to 63. Eleven of the patients were under 20 at the time of the thrombosis, and three were under 18 (viz., 13, 16, and 17). In the first two of these three the thrombosis
1472
complication of typhoid or paratyphoid, and in the third case the condition was a white leg. As a whole, femoral thrombosis is relatively infrequent during the growth period of life and is almost unknown in children. This immunity in early life is particularly marked in the case of post-operative thrombosis and this complication with pulmonary emboli is extremely rare in childhood. Personally I do not remember ever having seen a clear-cut case of deep femoral thrombosis in a young child. At the same time it may be true that recovery is likely to be more complete in younger patients. With regard to the first case quoted by Dr. Leak, of the baby of 7 months with pyæmia and abscesses following acute osteomyelitis, I am afraid that in the presence of such extensive acute septic complications it would be difficult to regard this as a clear-cut case of femoral thrombosis. Writing of his second case, of severe white leg treated with Contramine (B.D.H.), Dr. Leak himself admits that the limb still shows slight swelling at the end of the day and a tendency to develop painful ulcers after slight was a
injuries. My object
in recording these 85 cases of femoral thrombosis was to discuss the bearings of the ultimate or remote clinical picture upon the possible aetiological factors. In the series recorded it was certainly true that in no patient did the limb return entirely to normal. I was, however, careful to point out that in the absence of complications many patients show a tendency towards recovery. I have no personal experience of the treatment of femoral thrombosis either by means of contramine or by injections of vitamins A and D ; but on the evidence put forward by Dr. Leak I cannot alter my opinion as to the permanence of some degree of circulatory impairment after femoral thrombosis, no matter how great the recovery from the acute phase. I am, Sir, yours faithfully, REGINALD T. PAYNE. Harley-street, W., June 18th.
SUBCUTANEOUS EMPHYSEMA IN ASTHMA To the Editor of THE LANCET SIR,—I read with interest the article on sub. cutaneous emphysema and pneumothorax in bronchial asthma, written by R. W. Elliott, house physician at the Royal Infirmary, Sheffield, and published in He states that he was your issue of May 14th. unable to find reports of more than four cases of subcutaneous emphysema complicating asthma, and I would therefore like to refer him to an article in the American Journal of Medical Sciences for May, 1938, in which Drs. L. Rosenberg and J. Rosenberg, after reporting their own case, add seventeen previously published. Apparently this condition is not too rare a complication of bronchial asthma. I was called in consultation to see a patient of Dr. C. W. Kenney at the Syracuse Memorial Hospital, a woman
21 years of age
who
was
seven
months
pregnant, who had had moderately severe hay-fever all summer. Recently she had developed a persistent cough, and on the night before admittance to the hospital she had an unusually hard coughing spell, followed by dyspnoea. In her past history the fact was elicited that she had had operation for quinsy
of the throat on two occasions. Examination showed a rather extensive subcutaneous emphysema extending up both sides of the neck and over the chest. X rays did not reveal any pneumothorax. It was thought in this particular case that a fracture of the hyoid bone might be the source of entry of the air into the subcutaneous tissues ; or the previous quinsy operations might have caused some weakness in the wall of the pharynx
a further source of the adventitious air ; but X ray of the body or cornu of the hyoid bone was negative and there was no tear demonstrable in the pharynx adjacent to the tonsillar tissue.
as
This
case
has not been reported before. I am, Sir, yours faithfully, HENRY H. HAFT.
Medical Arts Building, Syracuse, N.Y., June 8th.
THE TRIAL LABOUR—AND AFTER
To the Editor
of
THE LANCET
am very interested in your leading article this subject. I have never been an advocate of trial labour for several reasons : first, it has always appeared to me to be rather a misleading term, and I have never been quite sure what its advocates mean by it. One idea seems to be that a trial labour is one conducted with all possible asepsis and antisepsis so that, should it become necessary, a Cæsarean section can be performed without undue risk ; but, surely, every labour should be conducted with all possible antiseptic and aseptic care, so every labour is a trial
SIR,—I
on
labour. Another view
to be that decide if
should not is present, or likely to become present in two or three weeks, but just wait and see if it is present when labour fails to progress. Surely this is a retrograde step? We should endeavour to make up our minds when the foetus has reached the optimum size, and, if labour does not ensue, induction of premature labour is more scientific. Admittedly, human error will come into some cases, but the more we strive to form correct judgment the fewer will be the errors., Your article rightly stresses the importance of doing everything in our power to avoid a stillbirth at the first pregnancy, and I strongly agree with all that is said of the effect of frustration of the maternal urge. The loss of a first baby is so serious that I have always opposed the dictum " never a Cæsarean section with the first baby." The notes of the case quoted hardly seem to me to come within the category of trial labour at all. The first pregnancy was a breech presentation, diagnosed during pregnancy, and external version was apparently successfully performed and presumably, as not infrequently happens, the foetus reverted to breech, which fact apparently was not noticed until labour had commenced. The child when born weighed 9 lb., and I do not consider that a foetus of this weight, presenting by the breech, at a first labour, can be classified as a trial labour. The patient’s second pregnancy certainly afforded every suggestion for consideration of a Caesarean section in the interests of the child. One could hardly call it a trial labour even if it had been left, and in my opinion a Cæsarean section was completely justified. Finally, I fail to see why the mother was " faced with the probability of further operations for the birth of any future children." If there is good union of the uterine wall there is no reason at all why subsequent labours should not be normal labours, provided a vertex presentation is present and there is make any
no
seems
attempt
to
one
disproportion
disproportion. I am,
Sir,
yours
faithfully, LOUIS CARNAC RIVETT.
Harley-street, W., June 21st.