LORD LISTER ON NERVE REPAIR

833

,

attend his OP’s on Thursday. Next day I received this .letter : " Sir. I wish you had a put me a note in so that I could have seen a Dr. on a Friday so I was trying to do the Eye Infirmary as well, I have to kill two birds with one stone or try too to try and save expences, being market day any one might be able to get a bit of company to go up with the Fridays Dr. You have not to be there so early, don’t you think it will be best. Can I get a reccomend from the hospital aid for the Eye Infirmary. I have not ask them for any yet. No doubt you will think I am and old fidget the . Eye Dr. ask Dr. Gordon to examine me as I was under Dr. Gordon my first trip to the hospital. I had 2 months out door treatment and three months with my own Dr. before I started with the hospital that was for my throat I had medical treatment, I was 17 years old then Dr. Gordon was medical are- you putting me under a medical I feel if I could get something for the kidneys I should get rid of these itchy spots they nearly drive one dotty when they itch so, it must be in the blood, because I have not always had them. I am unable to put in an envelope as cannot get them here but have put in a stamp from your’s truly, Mrs. Jones. Dr. Gordon examine me shortly after I had my operation in 1928, about 1929 or 1930 Dr. Gordon he examine me. I know it is treatment l’ require with taking barley water it as relieved it before I started taking barley water I did not know how to walk up as far as the farm that is the farthest I have been for 2 months. I hope you will put. me under a good medical one that does not speak sharp or else I shall be done for all of a shake all day after. I hope you will forgive me for being so much trouble." Who wouldn’t ? * * *

Time for contemplation has always been a characteristic of the East, and not without reason I have been pondering our sense of smell. It would be interesting to know with how many types of olfactory end-organs we are endowed and how quickly one type can accommodate itself to distinguish a new odour. It may be that there is one for each available smell, some lying latent but vigilant to seize on their respective stimulants and wax fat under their fertilising influence. Or the 4 ’ smell-buds " may be versatile, each able to appreciate a variety of odours. The newcomer to the East will favour the latter theory, for rough smells jostle ’one

Letters to the Editor LORD LISTER

ON

NERVE REPAIR

SIR,—In survey of the progress of repair of nerves by’ F. K. Sanders from the Department of Zoology and ComparativeAnatomy, Oxford (Brain, 1942, 65, 281), it is stated that Assaky in 1886 was the an

important

first in experimental work upon animals to attempt to bridge a gap in a nerve by means of a framework of catgut, designed to act as a scaffolding for the downgrowth of the new axons. On turning to this paper (Arch. gén. Méd. 1886, 2, 529 I find that it was published in the November number of that year. The copy which I consulted was marked as received by the librarian of the Royal Medical and Chirurgical Society on Nov. 6, 1886. The letter, which is appended, from Lord Lister to my father, the late Sir Hector Cameron, of Glasgow, is dated four days earlier, Nov. 2, 1886. 12, Park Crescent, Portland Place,

My

dear

2 Nov.

Cameron,

!

/86.

———

brought his son to see me today. From the history of slow growth and the perfect freedom of the skin with absence of glandular, enlargement we may fairly hope that the tumour is non-malignant. From its situation and from the fact that handling it causes pain in the sole of the foot and has done so from the first when it was quite small, Mr.

I fear it is a neuroma of the sciatic nerve. If this is the case, and the nerveis involved throughout its thickness for the full length of the tumour, I should greatly fear that amputation would be preferable to leaving the limb as a powerless encumbrance. If, what I fear can hardly be hoped, the nerve should be found to be merely expanded over the growth, or even if the neuroma were limited to one side of the nerve, it might be possible to dissect off the nerve and leave it. What makes me fear that this would hardly be practicable is that pressure on parts of the tumour at a considerable distance from each other in a lateral direction causes pain in the foot. Supposing that the nerve should be implicated in only a short extent of its ’length, say a couple of inches, it would, I think, be worth while to try whether regeneration of nerve-fibres might be brought about by connecting the ends of the nerve by means of several very fine catgut stitches applied with a sewing needle so as to form a channel along which new nerve-tissue might develope itself, see diagram.

another in a determination ’to overpower him before defensive preparations are complete. After a time however he will, I think, find his opinions veering towards the former. He will, gradually notice that he can isolate different elements in what was previously merely one mighty stench. His smell-buds, tenderly nurtured in the super-sanitation of -the West, begin to show, through constant exposure, a selectivity and ability to discern without effort whether there really is something the matter with the deep trench latrine, or whether it is only a relic of yesterday’s visit from the 4 locals. Whichever theory is correct, smell-buds serving in these parts are earning their keep and will have some fine tales to tell after the war. ("I remember when I was in Bagdad, my dear...") I enclose a hank of catgut’ which you would find very There are smells here for every taste, to titivate every suitable for the purpose. It is prepared with tannic acid reflex. Smells violent and smells delicate’ (few of these and holds perfectly as a knot, and has considerable strength though). Smells subtle and smells blatant in their very supple when moistened, and is not absorbed effrontery. Smells to send one’s olfactory apparatus although for several It is convenient to wind it upon a cotton reeling. Smells suggestive of a permanent uncinate fit. reel; and days. this is put into a bowl of 1 to 2000 Corrosive Dust and sweat, pungency and fragrance intermingle to give that quality without which East would not be . Sublimate solution a little before the operation commences, to make sure that it is perfectly aseptic. As I write I cannot East. Again, in the cool of the evening when the red help feeling that we are on somewhat new ground, and that and golden sun is setting behind the palm trees and one’s it is somewhat difficult to draw the line as to the length of thoughts turn westwards, nostalgic buds bring memories nerve removed which would make such a proceeding hope of English meadows and English country lanes, of Spring less. I would relax the nerveby bending the knee to a mornings and Autumn evenings in a pleasant land. certain extent and keeping it bent by a bandage connecting Yes, our smell-buds are working to capacity and hoping pelvis and foot. I would put some threads through and that on their return they will not be confronted with through the thickness of the nerve and others through too strong an odour of officialdom in their owners’ parts of the circumference. profession, disturbing whiffs of which are already correspondingamputation should prove necessary, I do not Supposing threatening to overtax their reserves. think it would be needful to amputate very high up in the thigh. Or rather perhaps I should say, that I should hope Surgeon Rear-Admiral G. Gordon-Taylor, lTr. H. S. to be able to dissect out the tumour and amputate near the knee. I told the father and also the boy that I thought it Souttar, Prof. R. V. Christie, Sir John Stopford, FRS, and Sir James Walton havebeen appointed to the Home Secrea case which ought to be operated upon, but that I felt it tary’s advisory committee on the administration of the impossible to say, till the operation revealed the true state of matters, whether amputation would be necessary or not. Cruelty to Animals Act 1876. m

channel along which new lissne

myht debclohe dself, see

di

nuve cetfut theres muve

Jenclore a

hank of catyul which

,

you monld find may sintable for the

r

834 There is one thing to be said, that an endeavour to save the limb even though a large amount of nerve were removed, would do no harm beyond delaying an amputation which might ultimately prove needful. Yours ever affectely,

of the intravenous route in any is due to the saving of time, and suggest that it is to the more frequent use of this route, rather than the amount of antitoxin given by it, that the improved results claimed by the heavy-dose school are due. Once a, reasonable amount of antitoxin is in circulation we JOSEPH LISTER. may stand by, not with " complacence "’but with the I do not know how far Lord Lister’s suggestion ] that further toxaemia is prevented and that knowledge original or how much it owed to an acquaintance with1the outcome is decided by the amount of toxin already the experimental work which had just been concluded jfixed in the tissues. Spread of membrane within 24 in Assaky’s laboratory in the University of Paris. His ] of a reasonable dose is not, in itself, an indication hours words " As I write I cannot help feeling that we are jfor further antitoxin. on somewhat new ground " seem to suggest that he is It is certainly true that there is considerable variation recommending a new and original procedure, and I in severity in different localities and also in the same feel that if by some means he had knowledge of Assaky’s ]locality at different times. Our faucial diphtheria casework before publication he would not have failed to jfatality rate here has varied from 3-6% in 1935 to 13-9% make some reference to it. It is possible that otherin 1936 and 1-8% in 1943. During this period the dosage surgeons at an even earlier date may have made similar and administration of antitoxin was always that inattempts, on the human subject, to deal with thedicated above. Epidemiological variations like these difficulty of wide separation between the ends of the indicate how difficult it is to make a valid comparison divided’nerve. If so I have not been able to find-the between diphtheria in different localities, or to assess the reference and meanwhile this letter of Lord Lister’s, relative value of two methods of treatment. But we so admirable in its completeness and in its clarity, not are satisfied that we give sufficient antitoxin and have to speak of its beautiful handwriting, that it mightevidence that the causes of both the abnormally high serve as a model to consultants of the present day, and the abnormally low case-fatality rates lie elsewhere. in as in so much else. claim for him a this may priority H. MASON LEETE. If the idea came to him from the experimental work NIGEL W. ROBERTS. Hull City Hospital, Cottingham. of others, it is but another illustration of the quickness with which he was wont to see what may be called the PSYCHIATRIST OR MEDICAL OFFICER ? connotation of research. As Clifford Allbutt happily concern has been expressed " SIR,-Some put it, Though Lister saw the vast importance of the because, under the new scales recently of pay for mental nurses, discoveries of Pasteur, he saw it because he was watching matrons and inspectors are receiving more than assistant on the heights ; and he was watching there alone." medical officers. I need hardly say that this concern I do not know whether the operation was performed does not emanate from the matrons and inspectors. as suggested, or whether the suggestion in this case May I suggest that the anomalies in the present position proved impracticable. I am much indebted to Mr. arise from the fact that the title " assistant medical Bishop of the library of the Royal Society of Medicine officer," with all that it implies, is as out of date as the for help in my search for references. " lunatic asylum." It is indissolubly associated with the London, H. CHARLES CAMERON. custodial atmosphere of the Victorian mental institution. If the psychiatrist is to make the fullest use of his TREATMENT OF DIPHTHERIA special approach to medicine-if indeed he is to mairtain SiR,-In your issue of Dec. 9, Dr. Johnstone and Dr. a balanced understanding of his specialty-he must be Fluker find fault with the recommendations made in your released in part at least from his mental hospital duties leading article of Nov. 11regarding dosage of diphtheria and must adopt the general hospital or health centre as antitoxin. They stir the ashes of an old controversy. his headquarters. He will thus be able to contribute to We consider the-amounts suggested in your article to the solution of the myriad psychiatric problems which be not only adequate but ampler and certainly more arise in general medicine and other special branches. nearly related to the true needs of the patient than the He will rub shoulders with his colleagues who are hundreds of thousands of units that some clinicians see primarily interested in the maintenance of the physical fit to squander. Antitoxin will counteract toxaemia ; aspects of health, to his and their mutual advantage. The AMO with suitable experience and qualifications beyond this it does nothing. Over 20 years ago W. H. Park pointed out that 50,000-antitoxic units far exceeded will thus be in effect a specialist in psychiatry and will a neutralising dose for the greatest amount of toxin that be entitled to claim a salary commensurate with his could possibly be elaborated in the severest case. status, like other specialists. The cost of these changes E. W. Goodall wrote (1928) " any amount over 30,000 would be small. The gain to the patient and. to psyunits ... is wasted." In our view these statements, chiatry would be considerable. and others to the same effect, are no less true today than BRIAN H. KIRMAN. St. Mary Cray, Kent. when first made. It should be remembered that even SMALLPOX AMONG THE VACCINATED a single unit of antitoxin is not a trifling amount, and that a dose of 50,000 units possesses a vast neutralising SIR,—In your leader of Nov. 25 you say that *’lymph should be used within a week of’manufacture,’ power. It will indeed protect no less than 1200 tons of guineapig tissue against a minimal lethal dose of diph- but if properly refrigerated can be kept for a fortnight." theria toxin, and therefore should give a very wide To avoid misunderstanding, will you permit me to margin of protection to some 100 lb. of human tissue. amplify this statement ? The provisions regarding The dosage scale used in the Kingston-upon-Hull storage before issue and the period after issue within City Hospital is : prophylactic, 500 units ; tonsillar which it must be used are fully detailed in the Thera’diphtheria, 4000-8000 units ; nasopharyngeal (Ist-grade peutic Substances Regulations No. 370, 1944, Part 1 (B)_ severity), 8000 units intramuscularly followed an hour paragraphs 6 (1) and 6 (2) of the second schedule. In later by 8000 units intravenously ; nasopharyngeal (very effect they state that the date of manufacture is the date severe), 20,000 units intramuscularly plus 20,000 units on which the vaccine lymph is removed for issue from intravenously. Severe cases in this district have been cold storage, after having been kept continuously at a of the most toxic and malignant variety ; nevertheless temperature below 0° C since the date of filling into conwe have never felt that a patient died for want of antitainers for issue, and if the lymph is kept below 0° C the toxin, though some havedied from delay in getting it. potency can be assured for at least six months. In Conversely, several cases showing purpuric haemorrhages practice we keep the temperature of our cold-storage into the skin and gallop cardiac rhythm-signs usually The lymph, after issue room round - 10° C (14° F). regarded as heralds of a fatal issue-have received no from cold storage, must be used by the recipient within more than 40,000 units and recovered. Had we used a week of manufacture, it being understood that he 200,000 units (or a million!) it is probable that we keeps it at room temperature in a cool dark place. should have attributed such remarkable recoveries to Provided that he has a domestic refrigerator working the large amount of antitoxin used. between 0’C and — 10C (32°to 50° F) and keeps it You rightly emphasise that the time of the adminiscontinuously there, he can use it up to 14 days from tration of antitoxin, relative to the onset of the disease, date of manufacture. is vastly more important than the dose. We believe W. D. H. STEVENSON. London, NW9. that the

advantage

severe case

-’

was

’

Wl.,

‘