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FLEXION SPASMS AND CONTRACTURES IN SPINAL-CORD DISEASE
913 the use of potent " drugs "); (2) efficiency of action; (3) simplicity of use; (4) low cost; (5) that the rationale should be capable of convincing translation into a simple story which the patient can appreciate-this I consider most necessary in gaining the patient’s full cooperation. Certain of the hydrophilic colloid group fulfil these criteria admirably and are capable of preparation at low cost in hospital pharmacies. However weight reduction methods are " modish " creatures. treatments " 4 all In 1912 there were at least 24 proprietory of which have fallen by the wayside. Today a dozen or so methods come to mind including 3 or 4 potent drugs, and in the out
"
future
we
shall
no
doubt
meet new
variations of method.
with breast cancer registered between 1930 and 1939 inclusive. Also shown is the percentage of cases placed in clinical stages I and 11 each year. The graph of survival-rate is closely paralleled by that of the clinical staging, and this figure is analogous to that shown in Mr. Bond and Dr. Waterhouse’s letter. The age-distribution of the patients is also relevant in the comparison of different series, yet you make no mention of this point. Even in the absence of this information about the Mayo Clinic series, it would seem that the figures do no more than support the maxim that the apparently good results are mainly, if not wholly, the results of selection.
REGINALD S. MURLEY.
J. N. BADHAM. USE AND TOXICITY OF SULPHONAMIDES SIR,-It is good that Dr. Arneil (April 19) has sounded what I hope will be the death knell of that dangerous
drug, sulphamerazine. It is good, too, that in your annotation you emphasise the value and safety of sulphadimidine. Alas though, too many doctors only know of this drug as ’ Sulphamezathine’ which, to the ear, sounds little different from sulphamerazine. I have often found it necessary, when recommending the use of sulphadimidine, to add the proprietary name by way of explanation. Cannot the manufacturers suggest a way of avoiding this confusion ? Greater prominence of the official B.P. name on their labels would help. BERNARD M. LAURANCE. TREATMENT OF
BREAST
CANCER
SIR,-Mr. Bond and Dr. Waterhouse (Feb. 22) and Dr. George Crile, Jr. (April 5) are correct in implying that " the strong challenge from the Mayo Clinic " is indeed no challenge at all, except perhaps to those folk who seem unable to assess the proper significance of published figures. Your editorial certainly presents the Mayo Clinic figures in somewhat tendentious fashion, and though you find it difficult to compare " figures from the Mayo Clinic and those from Edinburgh " one is glad to see that your correspondents do not experience the same difficulty. The close correlation between survival-rate and the stage of the disease is well brought out in the accompanying figure from a series of 1044 cases seen at St. Bartholomew’s Hospital.5 The figure shows the crude five-year survival-rate for patients 4. More Secret Remedies. British Medical Association, London, 1912. 5. Williams, I. G., Murley, R. S., Curwen, M. P. Brit. med. J. 1953, ii, 787.
1044 cases of breast cancer. Continuous line-5-year-survival rate in all cases registered. Broken line-percentage of cases in clinical stagesI and II.
NEW METHOD OF PHENOBARBITONE ADMINISTRATION SIR,-Although my experience here is limited to "
one
"
hystero-epileptic patient, and a period of four weeks, Dr. Pearson’s (April 19, p. 853) critical comments on Dr. O’Connor’s innovation (March 22, p. 609) prompt me to say that this patient (who over the last two years proved impervious to any form of therapy) has changed beyond recognition since being put on phenobarbitone’Spansules.’ Wyke House Hospital, Isleworth, Middlesex.
H. PULLAR-STRECKER.
FLEXION SPASMS AND CONTRACTURES IN SPINAL-CORD DISEASE SIR,-My interest in the paper by Mr. Platt, Dr. Ritchie
Russell, and Dr. Willison (April 12) prompts me to make the following comments on some of their statements. It is indeed gratifying that clinicians are becoming more and more aware pf the various intrinsic and extrinsic factors that influence spasticity in patients suffering from spinal-cord afflictions, and, in this connection, the beneficial effect of utilising postural reflexes in the counteraction of flexor spasms, as postulated by previous workers, is confirmed by the authors. On the other hand, their sweeping statement that, in cases of spinal-cord disease causing severe paraplegia, a day or two in bed may lead to permanent loss of all capacity to be other than chair-ridden or even bed-fast is, to say the least, exaggerated, if not altogether misleading. Furthermore, I was to read the authors’ criticism of anterior rhizotomy of lumbar and sacral roots for relieving spasticity by claiming that it produces such wasting of gluteal muscles that sitting becomes uncomfortable. This view will hardly be acceptable to neurosurgeons who have had experience with this method, nor is it in accordance with the vast experience gained on patients with conus/cauda-equina lesions or residual paralysis following poliomyelitis. If anterior rhizotomy is contemplated in patients where severe and intractable spasms and contractures of the hip flexors and adductors are predominant, complete atrophy of the gluteal muscles can be avoided by sparing L4 or L5 roots. Judging from the immediate postoperative condition of their third case, following their technique of combined bilateral obturator resection and iliopsoas resection in one session, it is obvious that their procedure is no less formidable and hazardous to the patient than anterior rhizotomy, and anyone contemplating this type of operation would be well advised to carry it out in stages.
surprised
The authors, in the techniques of physical therapy described, have very closely followed the principles and details of treatment introduced and practised during the last 14 years in the National Spinal Injuries Centre, Stoke Mandeville, and have freely used its resources. In their description of their first case, whom I had the opportunity to see myself in consultation, I missed any reference to the remarkable beneficial effects of hydrotherapy in our swimming-pool-not only as an overall training effect but, indeed, in this particular case, as a most efficient method of relieving spasticity. Moreover, this patient is photo-
914
graphed in a walking-chair which I designed a few years ago specifically for exercises for paraplegics with complete or incomplete lesions. I assume that the authors did not realise that this design had not been published (it will be described in detail elsewhere), as they would otherwise no
doubt have made due reference.
National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, Bucks.
with shigellx and salmonellx. that the interpretation of the presence in fasces of an enteric virus, which may be as widely distributed as Esch. coli, would present almost the same problems as exist with the serotypes of Esch. coli in question, which have been associated consistently with the disease (if I may call it so) at least since the 1920s.6e Finally, for a comprehensive account of the aetiology I would refer Dr. Librach to the Royal College of Physicians of Edinburgh Publication no. 5.7 City Hospital, Greenbank Drive, G. SANGSTER. Edinburgh, 10.
way It
as
seems to me "
LUDWIG GUTTMANN.
** This letter has been shown
to Mr. Platt and his who write: We are sorry that Dr. Guttman is so critical of our methods of treating flexion spasms and contractures. Our approach to the problem differs in several respects from those which he has developed so successfully for cases of traumatic paraplegia, but we think he will find that the method now described proves to have some important advantages. We were unaware that the walking-chair used to support the patient for the photograph had anv special features."-ED. L. "
colleagues,
regard to transmission, the agents in intestinal infections (including viruses) enter the bowel usually by mouth, at which they may arrive in many ways, and there seems to be no reason to doubt that infection with Esch. coli is acquired in the same
With
SIR GEORGE SAVAGE AND THE SANDS OF TIME
POSTOPERATIVE HYPOTENSION
SIR,-As
in Grosvenor Street. Savage contributed many interesting articles, written for the students, to the Guy’s Hospital Gazette, which I eagerly read, as my father continued to be a subscriber to the Gazette until his death. One of the articles that fascinated me was entitled The Sands of Time, and I think it ought not to be forgotten. It described some of the mental troubles of old people, and fancifully compared the mind of an old person to the sands on a desert, blown about by the wind. A storm would blow away the top layer of sand and expose an underlying layer, which might be taken to correspond to a fanciful memory of remorse for having once stolen a sixpenny piece as a boy. A fresh storm might expose another layer, which unfortunately corresponded to the memory of having once told his father a falsehood. At last fresh winds might arise and cause a new layer to be reached, which fortunately corresponded to one of the happiest memories of his life.
(March 15), postoperative hypo-
position. In 176
copy of his bust that used to stand in the hall of his house
you say
tension is relatively common; and it is seen particularly in patients returned to the horizontal from the lithotomy of major vaginal surgery, a significant degree of found in 101 (5700).8 Of a series of 75 cases of anaathesia for perurethral prostatectomy, which I hope to publish later, in 36 (48",,) the systolic pressure fell to below 100 mm. Hg, or to a level more than 50 mm. Hg below the preoperative level, when the legs were lowered. As you also say, routine recording of the blood-pressure after operations is not common practice. Quite a number of the above patients had none of the recognised signs of hypotension. Indeed, they had an easily palpable pulse at a rate within normal limits: they were dry, warm, and of good colour; and they were conscious and cooperative. cases
hypotension
SIR,-I saw a good deal of Sir George Savage (18421921), as my father was virtually an old Guy’s man and a personal friend of Addison, who presented him with a
"
The
by
was
dangers that beset these patients
Both patients, on return to the ward, appeared so well to the that they were propped up to encourage drinking. Both quickly became unconscious, had a further fall in bloodpressure, and soon showed signs of shock. Fortunately, laying the patients flat and applying restorative measures resulted in obvious improvement.
nurse
Until recovery-rooms with trained staff are as standard in the theatre equipment as operating-tables and anxsthetic machines, such incidents are certain to recur. Meanwhile it is of vital importance that postoperative hypotension should be recognised and that doctors and nurses should be aware of its inherent dangers. WOOLFRED SNIPER.
F. PARKES WEBER.
PILONIDAL SINUS OF THE UMBILICUS
INFANTILE GASTROENTERITIS
SiR.-The
answers to
many of Dr. Librach’s
questions
(April 5) relating to fundamental work on infantile intestinal flora are to be found in various articles 15 as well as textbooks of pxdiatrics and bacteriology. Dr. Librach is
no
doubt
aware
may be illustrated
two cases.
that many commensals
(including Escherichia coli) are pathogenic outside their normal habitat, and that some are potentially so in their own systemse.g., pneumococci and staphylococci in the respiratory tract. In this example there is a further similarity to Esch. coli gastroenteritis in so far as certain types (or strains) of these organisms are involved more than others in the production of pneumonia. In all infections the host plays an important role. In the case of gastroenteritis, favourable living conditions in the small bowel for Esch. coli are provided by the diet of cow’s milk (the carbohydrate/protein ratio amongst other factors). 1. Davison, W. C. Amer. J. Dis. Child. 1925, 19, 743. 2. Gertsley, J. R., Howell, K. M., Nagel, B. R. ibid. 1932, 43, 555. 3. Hall, I. C., O’Toole, B. ibid. 1935, 49, 390. 4. Blacklock, J. W. S., Guthrie, K. J., Macpherson, I. J. Path. Bact. 1937, 44, 721. 5. Crowley, H., Downie, H. W., Fulton, F., Wilson, G. S. Lancet, 1941, ii, 590.
to the article by Dr. Sadeghiand Mr. Rains Nejad (March 15), it may be of interest a to report similar case.
SIR,-With reference
A hirsute Italian man aged 34 came to see me recently complaining of a sore navel. Examination revealed a similar picture to the illustration shown; a bundle of downward pointing hairs with roots orientated inwards, protruding from the umbilicus, in which there was some moist intertrigo. The umbilicus was held open with forceps and the bundle was withdrawn. Most of the hairs were free, but the root ends of a few were embedded in a small mass of granulation tissue lying at the bottom of the pit. The granulations were touched with silver nitrate and the soreness subsequently subsided. I referred him to Mr. Gordon Bohn who found a few more loose hairs at the bottom of the umbilicus and agreed that no further treatment seemed necessarv.
P. M. R. HEMPHILL. Sonning Common, nr. Reading. 6. Adam, A. Jb. Kinderheilk. 1927, 116, 8. 7. Smith, J. Royal College of Physicians of Edinburgh Publications, no. 1955; see Lancet, 1955, ii, 1182. 8. Canad. Anœsth. Soc. J. 1956, 3, 216.
5.
"
future
we
shall
no
doubt
meet new
variations of method.
with breast cancer registered between 1930 and 1939 inclusive. Also shown is the percentage of cases placed in clinical stages I and 11 each year. The graph of survival-rate is closely paralleled by that of the clinical staging, and this figure is analogous to that shown in Mr. Bond and Dr. Waterhouse’s letter. The age-distribution of the patients is also relevant in the comparison of different series, yet you make no mention of this point. Even in the absence of this information about the Mayo Clinic series, it would seem that the figures do no more than support the maxim that the apparently good results are mainly, if not wholly, the results of selection.
REGINALD S. MURLEY.
J. N. BADHAM. USE AND TOXICITY OF SULPHONAMIDES SIR,-It is good that Dr. Arneil (April 19) has sounded what I hope will be the death knell of that dangerous
drug, sulphamerazine. It is good, too, that in your annotation you emphasise the value and safety of sulphadimidine. Alas though, too many doctors only know of this drug as ’ Sulphamezathine’ which, to the ear, sounds little different from sulphamerazine. I have often found it necessary, when recommending the use of sulphadimidine, to add the proprietary name by way of explanation. Cannot the manufacturers suggest a way of avoiding this confusion ? Greater prominence of the official B.P. name on their labels would help. BERNARD M. LAURANCE. TREATMENT OF
BREAST
CANCER
SIR,-Mr. Bond and Dr. Waterhouse (Feb. 22) and Dr. George Crile, Jr. (April 5) are correct in implying that " the strong challenge from the Mayo Clinic " is indeed no challenge at all, except perhaps to those folk who seem unable to assess the proper significance of published figures. Your editorial certainly presents the Mayo Clinic figures in somewhat tendentious fashion, and though you find it difficult to compare " figures from the Mayo Clinic and those from Edinburgh " one is glad to see that your correspondents do not experience the same difficulty. The close correlation between survival-rate and the stage of the disease is well brought out in the accompanying figure from a series of 1044 cases seen at St. Bartholomew’s Hospital.5 The figure shows the crude five-year survival-rate for patients 4. More Secret Remedies. British Medical Association, London, 1912. 5. Williams, I. G., Murley, R. S., Curwen, M. P. Brit. med. J. 1953, ii, 787.
1044 cases of breast cancer. Continuous line-5-year-survival rate in all cases registered. Broken line-percentage of cases in clinical stagesI and II.
NEW METHOD OF PHENOBARBITONE ADMINISTRATION SIR,-Although my experience here is limited to "
one
"
hystero-epileptic patient, and a period of four weeks, Dr. Pearson’s (April 19, p. 853) critical comments on Dr. O’Connor’s innovation (March 22, p. 609) prompt me to say that this patient (who over the last two years proved impervious to any form of therapy) has changed beyond recognition since being put on phenobarbitone’Spansules.’ Wyke House Hospital, Isleworth, Middlesex.
H. PULLAR-STRECKER.
FLEXION SPASMS AND CONTRACTURES IN SPINAL-CORD DISEASE SIR,-My interest in the paper by Mr. Platt, Dr. Ritchie
Russell, and Dr. Willison (April 12) prompts me to make the following comments on some of their statements. It is indeed gratifying that clinicians are becoming more and more aware pf the various intrinsic and extrinsic factors that influence spasticity in patients suffering from spinal-cord afflictions, and, in this connection, the beneficial effect of utilising postural reflexes in the counteraction of flexor spasms, as postulated by previous workers, is confirmed by the authors. On the other hand, their sweeping statement that, in cases of spinal-cord disease causing severe paraplegia, a day or two in bed may lead to permanent loss of all capacity to be other than chair-ridden or even bed-fast is, to say the least, exaggerated, if not altogether misleading. Furthermore, I was to read the authors’ criticism of anterior rhizotomy of lumbar and sacral roots for relieving spasticity by claiming that it produces such wasting of gluteal muscles that sitting becomes uncomfortable. This view will hardly be acceptable to neurosurgeons who have had experience with this method, nor is it in accordance with the vast experience gained on patients with conus/cauda-equina lesions or residual paralysis following poliomyelitis. If anterior rhizotomy is contemplated in patients where severe and intractable spasms and contractures of the hip flexors and adductors are predominant, complete atrophy of the gluteal muscles can be avoided by sparing L4 or L5 roots. Judging from the immediate postoperative condition of their third case, following their technique of combined bilateral obturator resection and iliopsoas resection in one session, it is obvious that their procedure is no less formidable and hazardous to the patient than anterior rhizotomy, and anyone contemplating this type of operation would be well advised to carry it out in stages.
surprised
The authors, in the techniques of physical therapy described, have very closely followed the principles and details of treatment introduced and practised during the last 14 years in the National Spinal Injuries Centre, Stoke Mandeville, and have freely used its resources. In their description of their first case, whom I had the opportunity to see myself in consultation, I missed any reference to the remarkable beneficial effects of hydrotherapy in our swimming-pool-not only as an overall training effect but, indeed, in this particular case, as a most efficient method of relieving spasticity. Moreover, this patient is photo-
914
graphed in a walking-chair which I designed a few years ago specifically for exercises for paraplegics with complete or incomplete lesions. I assume that the authors did not realise that this design had not been published (it will be described in detail elsewhere), as they would otherwise no
doubt have made due reference.
National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, Bucks.
with shigellx and salmonellx. that the interpretation of the presence in fasces of an enteric virus, which may be as widely distributed as Esch. coli, would present almost the same problems as exist with the serotypes of Esch. coli in question, which have been associated consistently with the disease (if I may call it so) at least since the 1920s.6e Finally, for a comprehensive account of the aetiology I would refer Dr. Librach to the Royal College of Physicians of Edinburgh Publication no. 5.7 City Hospital, Greenbank Drive, G. SANGSTER. Edinburgh, 10.
way It
as
seems to me "
LUDWIG GUTTMANN.
** This letter has been shown
to Mr. Platt and his who write: We are sorry that Dr. Guttman is so critical of our methods of treating flexion spasms and contractures. Our approach to the problem differs in several respects from those which he has developed so successfully for cases of traumatic paraplegia, but we think he will find that the method now described proves to have some important advantages. We were unaware that the walking-chair used to support the patient for the photograph had anv special features."-ED. L. "
colleagues,
regard to transmission, the agents in intestinal infections (including viruses) enter the bowel usually by mouth, at which they may arrive in many ways, and there seems to be no reason to doubt that infection with Esch. coli is acquired in the same
With
SIR GEORGE SAVAGE AND THE SANDS OF TIME
POSTOPERATIVE HYPOTENSION
SIR,-As
in Grosvenor Street. Savage contributed many interesting articles, written for the students, to the Guy’s Hospital Gazette, which I eagerly read, as my father continued to be a subscriber to the Gazette until his death. One of the articles that fascinated me was entitled The Sands of Time, and I think it ought not to be forgotten. It described some of the mental troubles of old people, and fancifully compared the mind of an old person to the sands on a desert, blown about by the wind. A storm would blow away the top layer of sand and expose an underlying layer, which might be taken to correspond to a fanciful memory of remorse for having once stolen a sixpenny piece as a boy. A fresh storm might expose another layer, which unfortunately corresponded to the memory of having once told his father a falsehood. At last fresh winds might arise and cause a new layer to be reached, which fortunately corresponded to one of the happiest memories of his life.
(March 15), postoperative hypo-
position. In 176
copy of his bust that used to stand in the hall of his house
you say
tension is relatively common; and it is seen particularly in patients returned to the horizontal from the lithotomy of major vaginal surgery, a significant degree of found in 101 (5700).8 Of a series of 75 cases of anaathesia for perurethral prostatectomy, which I hope to publish later, in 36 (48",,) the systolic pressure fell to below 100 mm. Hg, or to a level more than 50 mm. Hg below the preoperative level, when the legs were lowered. As you also say, routine recording of the blood-pressure after operations is not common practice. Quite a number of the above patients had none of the recognised signs of hypotension. Indeed, they had an easily palpable pulse at a rate within normal limits: they were dry, warm, and of good colour; and they were conscious and cooperative. cases
hypotension
SIR,-I saw a good deal of Sir George Savage (18421921), as my father was virtually an old Guy’s man and a personal friend of Addison, who presented him with a
"
The
by
was
dangers that beset these patients
Both patients, on return to the ward, appeared so well to the that they were propped up to encourage drinking. Both quickly became unconscious, had a further fall in bloodpressure, and soon showed signs of shock. Fortunately, laying the patients flat and applying restorative measures resulted in obvious improvement.
nurse
Until recovery-rooms with trained staff are as standard in the theatre equipment as operating-tables and anxsthetic machines, such incidents are certain to recur. Meanwhile it is of vital importance that postoperative hypotension should be recognised and that doctors and nurses should be aware of its inherent dangers. WOOLFRED SNIPER.
F. PARKES WEBER.
PILONIDAL SINUS OF THE UMBILICUS
INFANTILE GASTROENTERITIS
SiR.-The
answers to
many of Dr. Librach’s
questions
(April 5) relating to fundamental work on infantile intestinal flora are to be found in various articles 15 as well as textbooks of pxdiatrics and bacteriology. Dr. Librach is
no
doubt
aware
may be illustrated
two cases.
that many commensals
(including Escherichia coli) are pathogenic outside their normal habitat, and that some are potentially so in their own systemse.g., pneumococci and staphylococci in the respiratory tract. In this example there is a further similarity to Esch. coli gastroenteritis in so far as certain types (or strains) of these organisms are involved more than others in the production of pneumonia. In all infections the host plays an important role. In the case of gastroenteritis, favourable living conditions in the small bowel for Esch. coli are provided by the diet of cow’s milk (the carbohydrate/protein ratio amongst other factors). 1. Davison, W. C. Amer. J. Dis. Child. 1925, 19, 743. 2. Gertsley, J. R., Howell, K. M., Nagel, B. R. ibid. 1932, 43, 555. 3. Hall, I. C., O’Toole, B. ibid. 1935, 49, 390. 4. Blacklock, J. W. S., Guthrie, K. J., Macpherson, I. J. Path. Bact. 1937, 44, 721. 5. Crowley, H., Downie, H. W., Fulton, F., Wilson, G. S. Lancet, 1941, ii, 590.
to the article by Dr. Sadeghiand Mr. Rains Nejad (March 15), it may be of interest a to report similar case.
SIR,-With reference
A hirsute Italian man aged 34 came to see me recently complaining of a sore navel. Examination revealed a similar picture to the illustration shown; a bundle of downward pointing hairs with roots orientated inwards, protruding from the umbilicus, in which there was some moist intertrigo. The umbilicus was held open with forceps and the bundle was withdrawn. Most of the hairs were free, but the root ends of a few were embedded in a small mass of granulation tissue lying at the bottom of the pit. The granulations were touched with silver nitrate and the soreness subsequently subsided. I referred him to Mr. Gordon Bohn who found a few more loose hairs at the bottom of the umbilicus and agreed that no further treatment seemed necessarv.
P. M. R. HEMPHILL. Sonning Common, nr. Reading. 6. Adam, A. Jb. Kinderheilk. 1927, 116, 8. 7. Smith, J. Royal College of Physicians of Edinburgh Publications, no. 1955; see Lancet, 1955, ii, 1182. 8. Canad. Anœsth. Soc. J. 1956, 3, 216.
5.