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INTUSSUSCEPTION
1006 in branches of our profession so naturally know more than those of us who have wasted so many years learning that which they have acquired so easily. I am, Sir, yours faithfully, Harley Street, W.1, April 22.
CLIFFORD ALLEN.
* * The- question whether mental treatment should be practised solely by doctors was debated by the National Council for Mental Hygiene last January when we commented in a leading article (Jan. 21, p. 154) on the differences of opinion within the medical profession. The report of the B.M.A. council, to which Dr. Allen refers, may be read in last week’s supplement (p. 206) to the British Medical Journal. This report concludes with two recommendations : Recommendation A : That the Representative Body approve the following principles :1. No lay psychotherapist should undertake treatment unless : (i) The patient has been recommended to him by a registered medical practitioner, or has had his case investigated by such a practitioner at the request of the lay psychotherapist. (ii) The lay psychotherapist has undergone a prescribed and approved course of training. 2. No medical practitioner should recommend a patient to a lay psychotherapist unless : (i) The medical practitioner is himself a specialist in psychological medicine or has referred the case to such a specialist. (ii) The medical practitioner has satisfied himself that the lay psychotherapist has undergone a prescribed and approved course
of training. 3. Where treatment is undertaken by a medical practitioner and a lay psychotherapist in cooperation, the responsibility for the case should lie with the medical practitioner and there should be consultation from time to time between the medical practitioner and the lay psycho-
therapist. Recorrvrnendation B:
: That the Representative Body opinion that lay psychotherapists should undergo a special training of at least two years’ duration on the basis of a curriculum to be agreed upon by the responsible bodies; and that the Association take the initiative in putting machinery in motion for the establishment of approved courses of training.
express the
INTUSSUSCEPTION was much interested in Mr. Ian Fraser’s of a case of recurrent intussusception, published in your issue of April 15, and in Mr. Frank Forty’s letter the following week. With regard to the lymph-glands my experience supports Mr. Forty’s view that the enlargement which is such a constant feature of these cases is the result of an acute enteritis. I agree with him that caseation is not seen ; nor are other signs of intraabdominal tuberculosis except the presence of free fluid. Although I have never removed a gland for section I have frequently removed the appendix where the general condition seemed to warrant the additional procedure. On the surface the appendix often appears injected and on section it has invariably shown intense lymphoid hyperplasia, the mucosa being swollen and having a mammillated appearance and the colour being a deep reddish-brown. Microscopical examination shows submucous lymphoid hyperplasia with round-celled infiltration of the other coats, especially the subserous region. The following recent case is of interest :A boy aged 2 was admitted to Hampstead General Hospital on April 12 with ? acute intussusception. There was a history of tuberculosis on the mother’s side. One other child, aged 4, was quite well. Fulltime healthy baby. Breast-fed for 2 months then fed on Nestle’s milk (condensed) until 9 months old. At this time there was a slight attack of diarrhoea ;
SiR,—I
account
otherwise the child had been quite well until the day before admission when he had a fall whilst playing with another child who fell onto him. Immediately afterwards he complained of acute pain right across the abdomen (? colic). About one hour afterwards he vomited copiously, and the pains continued until bedtime. The child slept well all night, and seemed better early in the morning, but he still had spasms of pain. After admission he slept for an hour and did not appear to be in pain. On waking however he had an acute attack of pain and then passed a small amount of bloodstained mucus without faecal matter. He screamed a great deal after this but there was no further vomiting. On examination the child looked ill. Temperature 994° F., pulse-rate 125, respirations 24. An indefinite mass was palpable on a level with and slightly above and to the right of the umbilicus. The right iliac fossa felt empty. No tumour was palpable on rectal examination, but blood and mucus were present on the finger. Bile The urine contained acetone. was absent. A diagnosis of intussusception was made and operation performed the same evening. The abdomen was
opened through
a
right paramedian incision.
found to be due to an enormous enlargement of the ileocsecal lymphatic glands, the caecum being partly undescended. There was no sign of an intussusception nor was there any evidence that it had been present and had reduced itself spontaneously. There was no induration of the caecal wall and apart from some free fluid there was no definite evidence of tuberculosis. The appendix appeared injected and was removed and the abdomen closed without drainage. Macroscopically the appendix showed the typical appearance of lymphoid hyperplasia. The section was examined by Dr. Rickword Lane, who reported as follows : " The appendix shows marked lymphoid hyperplasia and in one or two places areas suggestive of early tuberculous foci in the germ centres. There is marked chronic inflammatory lymphocytic reaction in the subserous coat but no specific tuberculous reaction. No tubercle bacilli could be found in Ziehl-Neelsen preparations." The child appeared fairly comfortable through the night, but vomited green fluid twice the following morning, after which there was no further vomiting. Thirty-six hours after operation he passed a small motion of normal consistency with a small amount of blood. No further attacks of pain occurred and three days later he was taking an ordinary diet and the stools were normal. The
mass
was
In this case, even in the absence of a palpable mass, the sudden onset and absence of bile and fsecal matter were against a diagnosis of acute enterocolitis. The presence of a palpable mass of glands greatly
increased the difficulty. There remains the possibility of spontaneous reduction of an intussusception. I am, Sir, yours faithfully, CAMERON MACLEOD. Harley Street, W.1, April 24. STERILISATION OF DRESSINGS
SiR,-The suggestion regarding the sterilisation of operation drums which was made some years ago by K. Black (Brit. med. J. 1935, 1, 157) is not often mentioned in the literature. He advocated packing into the bundle of dressings a number of small bars of fusible metal alloy, to melt at serial temperaturese.g., 100° C., 110°, 120°, 130°, and so on, as desired. The bars of fusible alloy can be easily and cheaply compounded in any hospital workshop, and stamped with their melting temperature. But of course their employment in this way does not distinguish between dry and moist heat. I am, Sir, yours faithfully, E. G. T. LIDDELL. Trinity College, Oxford, April 22.
CLIFFORD ALLEN.
* * The- question whether mental treatment should be practised solely by doctors was debated by the National Council for Mental Hygiene last January when we commented in a leading article (Jan. 21, p. 154) on the differences of opinion within the medical profession. The report of the B.M.A. council, to which Dr. Allen refers, may be read in last week’s supplement (p. 206) to the British Medical Journal. This report concludes with two recommendations : Recommendation A : That the Representative Body approve the following principles :1. No lay psychotherapist should undertake treatment unless : (i) The patient has been recommended to him by a registered medical practitioner, or has had his case investigated by such a practitioner at the request of the lay psychotherapist. (ii) The lay psychotherapist has undergone a prescribed and approved course of training. 2. No medical practitioner should recommend a patient to a lay psychotherapist unless : (i) The medical practitioner is himself a specialist in psychological medicine or has referred the case to such a specialist. (ii) The medical practitioner has satisfied himself that the lay psychotherapist has undergone a prescribed and approved course
of training. 3. Where treatment is undertaken by a medical practitioner and a lay psychotherapist in cooperation, the responsibility for the case should lie with the medical practitioner and there should be consultation from time to time between the medical practitioner and the lay psycho-
therapist. Recorrvrnendation B:
: That the Representative Body opinion that lay psychotherapists should undergo a special training of at least two years’ duration on the basis of a curriculum to be agreed upon by the responsible bodies; and that the Association take the initiative in putting machinery in motion for the establishment of approved courses of training.
express the
INTUSSUSCEPTION was much interested in Mr. Ian Fraser’s of a case of recurrent intussusception, published in your issue of April 15, and in Mr. Frank Forty’s letter the following week. With regard to the lymph-glands my experience supports Mr. Forty’s view that the enlargement which is such a constant feature of these cases is the result of an acute enteritis. I agree with him that caseation is not seen ; nor are other signs of intraabdominal tuberculosis except the presence of free fluid. Although I have never removed a gland for section I have frequently removed the appendix where the general condition seemed to warrant the additional procedure. On the surface the appendix often appears injected and on section it has invariably shown intense lymphoid hyperplasia, the mucosa being swollen and having a mammillated appearance and the colour being a deep reddish-brown. Microscopical examination shows submucous lymphoid hyperplasia with round-celled infiltration of the other coats, especially the subserous region. The following recent case is of interest :A boy aged 2 was admitted to Hampstead General Hospital on April 12 with ? acute intussusception. There was a history of tuberculosis on the mother’s side. One other child, aged 4, was quite well. Fulltime healthy baby. Breast-fed for 2 months then fed on Nestle’s milk (condensed) until 9 months old. At this time there was a slight attack of diarrhoea ;
SiR,—I
account
otherwise the child had been quite well until the day before admission when he had a fall whilst playing with another child who fell onto him. Immediately afterwards he complained of acute pain right across the abdomen (? colic). About one hour afterwards he vomited copiously, and the pains continued until bedtime. The child slept well all night, and seemed better early in the morning, but he still had spasms of pain. After admission he slept for an hour and did not appear to be in pain. On waking however he had an acute attack of pain and then passed a small amount of bloodstained mucus without faecal matter. He screamed a great deal after this but there was no further vomiting. On examination the child looked ill. Temperature 994° F., pulse-rate 125, respirations 24. An indefinite mass was palpable on a level with and slightly above and to the right of the umbilicus. The right iliac fossa felt empty. No tumour was palpable on rectal examination, but blood and mucus were present on the finger. Bile The urine contained acetone. was absent. A diagnosis of intussusception was made and operation performed the same evening. The abdomen was
opened through
a
right paramedian incision.
found to be due to an enormous enlargement of the ileocsecal lymphatic glands, the caecum being partly undescended. There was no sign of an intussusception nor was there any evidence that it had been present and had reduced itself spontaneously. There was no induration of the caecal wall and apart from some free fluid there was no definite evidence of tuberculosis. The appendix appeared injected and was removed and the abdomen closed without drainage. Macroscopically the appendix showed the typical appearance of lymphoid hyperplasia. The section was examined by Dr. Rickword Lane, who reported as follows : " The appendix shows marked lymphoid hyperplasia and in one or two places areas suggestive of early tuberculous foci in the germ centres. There is marked chronic inflammatory lymphocytic reaction in the subserous coat but no specific tuberculous reaction. No tubercle bacilli could be found in Ziehl-Neelsen preparations." The child appeared fairly comfortable through the night, but vomited green fluid twice the following morning, after which there was no further vomiting. Thirty-six hours after operation he passed a small motion of normal consistency with a small amount of blood. No further attacks of pain occurred and three days later he was taking an ordinary diet and the stools were normal. The
mass
was
In this case, even in the absence of a palpable mass, the sudden onset and absence of bile and fsecal matter were against a diagnosis of acute enterocolitis. The presence of a palpable mass of glands greatly
increased the difficulty. There remains the possibility of spontaneous reduction of an intussusception. I am, Sir, yours faithfully, CAMERON MACLEOD. Harley Street, W.1, April 24. STERILISATION OF DRESSINGS
SiR,-The suggestion regarding the sterilisation of operation drums which was made some years ago by K. Black (Brit. med. J. 1935, 1, 157) is not often mentioned in the literature. He advocated packing into the bundle of dressings a number of small bars of fusible metal alloy, to melt at serial temperaturese.g., 100° C., 110°, 120°, 130°, and so on, as desired. The bars of fusible alloy can be easily and cheaply compounded in any hospital workshop, and stamped with their melting temperature. But of course their employment in this way does not distinguish between dry and moist heat. I am, Sir, yours faithfully, E. G. T. LIDDELL. Trinity College, Oxford, April 22.