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LOUSY CLOTHING
760
though I am of the opinion that it plays a minor role as compared with external restraint. Furthermore, it is questionable if the figures quoted by them (1’2 per cent. of fractures generally as against my 1-25 per cent. and their own of 2-07 per cent.) detracts from my argument. In practically all reports of fractures in series of cases that I have read the ages of the patients treated is considerably less than the ages of those I have treated, indeed it is uncommon to read of patients over fifty years. Since this is so and if age is a factor of importance in the production of fractures, I should have had a much higher incidence of fractures than I actually did have. Also, I stated that most probably the fracture in the lady of fifty-nine ’was due to restraint unwittingly applied. These two points, instead of detracting from my argument, would seem to add considerably to it. What appears to be a further support for my argument is forthcoming in the figures quoted by Drs. themselves (who admit to Wyllie and Mayer-Gross albeit gentle restraint) where in a using restraint, numerically comparable number of cases (although some of mine were more elderly) their figure for fractures is higher than mine in 25 cases over the age of fifty. Lastly, I would like to point out how their surmise that " The infrequent occurrence of fractures in epileptics is probably due to the fact that in most cases their bones have been habituated to the strain of fits from youth " is quite inadequate to explain the rarity of fractures in cases of idiopathic epilepsy beginning late in life or in epileptiform attacks (other than those produced by cardiazol) occurring from other causes in the middle-aged or elderly.
I am,
Sir,
faithfully,
yours
RANKINE GOOD.
Glasgow Royal Mental Hospital.
LOUSY CLOTHING
SIR,-Recently Professor Buxtondescribed apparatus for determining the critical lethal temperature for lice. He found 53’50 C. for five minutes, 52’00 C. for ten minutes, and 50,00 C. for thirty minutes lethal for eggs. In the case of adult lice he found 51.50 C. for five minutes, 49,50 C. for ten to thirty minutes, and 46’00 C. for forty-five minutes to one hour lethal for both sexes and for immature specimens. A paper he read to the Royal Society of Tropical Medicine and Hygiene2 stimulated a discussion in which Colonel W. Byam remarked about the infectivity of louse faeces in garments and blankets. The War Office trench-fever investigation committee showedthat the infectivity of the louse’s excreta is very high; 0-1 mg. has sufficed to give the disease when inoculated into man. The virulence of the excreta is destroyed by dry heat at 100° C. in twenty minutes and by moist heat at 60° C. in twenty minutes.4 The virus of trench fever seems to be more resistant than that of typhus where the excreta of lice dried in air lose their virulence in a few days.5 It is a fact, however, that fatalities among research workers who handle the excreta of lice infected with the virus of typhus havebeen regrettably frequent in the past, before protective vaccination with the preparation of Weigl became possible. In my
intelligent
own man
experience,
investigator, a very danger of infection and
an
who knew the
1. Buxton, P. A., Brit. med. J., March 2, 1940, p. 341. 2. Trans. R. Soc. trop. Med. Hyg. January, 1940, p. 365. 3. See Trench Fever, by W. Byam, London, 1919. 4. Topley, W. W. C. and Wilson, G. S. Principles of Bacteriology and Immunity, London, 2nd ed., p. 1463. 5. Nicolle, Blanc and Conseil, C.R. Soc. Biol. Paris, 1914, 159,
661.
took full precautions against lice, developed typhus after taking samples of venous blood from five cases who were confined in a small room lacking in ventilation and under extreme conditions of dirt and destitution. The investigator wore protective clothing, which he removed immediately he ’left the sick-room and placed in a canvas bag for disinfestation. Within an hour lie had removed all his other clothing and sent it to the disinfestor, had a bath in dilute lysol and searched his body for lice. After the bath he put It was ultimately concluded that on fresh clothing. this man acquired his infection by inhaling louse faeces released into the air of the room from stirred-up dirty bedding and clothing. At the time there was only the one focus of the disease, and he had no further contact with cases or infective material either before or after the occasion on which he collected the blood samples. In his case the incubation period was thirteen days. It seems worth considering whether disinfection as well as disinfestation may not be required in the treatment of lousy clothing in areas where trench fever or typhus are endemic. I am, Sir, yours faithfully,
FRANK MARSH. Pathological Laboratory, c/o Anglo-Iranian Oil Co., Ltd., Abadan, Iran. PEPTIC ULCER IN THE SERVICES
SiR,—The contributors to this discussion ought to set out the evidence that young subjects of peptic ulcer will never be able to resist the rigours of Service
cooking. This pessimistic assumption is contrary to the experience of many patients who had a complete remission of symptoms during their war-time service in 1914—18, contrary to German teaching, though admittedly their cooking can’t be compared with ours, and contrary to modern ideas on the aetiology of ulcer. Leaving mass destruction of the stomach out of consideration-the Nordic theory that stomachs should be altered to fit the diet instead of the other way round thoroughly tested on the Continent in the decade after the last war and didn’t work-we are advised to turn these patients out of the Forces and send them back to the war-time mental strain of civilian life. If we do so we probably condemn the majority to a lifetime of physical and mental inferiority, as well as depriving the country of the full benefit of men who are possibly more conscientious and intelligent than the average. Even if all our prolific gastroenterological thinkers gave this advice, I should still feel disinclined to accept the opinion of a weak and badly organised branch of British medicine, which year after year grinds out the same old ideas, based on the same fallacy of the selected sample of patients who come to surgery or post-mortem and the same misunderstanding of the radiology and physiology of the gut. As some of our grandfathers and even greatgrandfathers knew, there are two entirely different points to be considered in the treatment of peptic ulcer. The first is: What is the difficulty in the life of the patient which causes the breakdown in gut function7 This is no place to argue the pathological chain of events in detail, and of course it varies to some exent from patient to patient, but I believe the commonest answer to this question is that the modern concentrated starchy diet is especially difficult for intestines reflexly irritated by worry and strain, and that this difficulty is exaggerated by sedentary life and vices like aperients, oversmoking and the like. The second point is: How much organic damage has already been done?7 In practice we start with a bland
was
though I am of the opinion that it plays a minor role as compared with external restraint. Furthermore, it is questionable if the figures quoted by them (1’2 per cent. of fractures generally as against my 1-25 per cent. and their own of 2-07 per cent.) detracts from my argument. In practically all reports of fractures in series of cases that I have read the ages of the patients treated is considerably less than the ages of those I have treated, indeed it is uncommon to read of patients over fifty years. Since this is so and if age is a factor of importance in the production of fractures, I should have had a much higher incidence of fractures than I actually did have. Also, I stated that most probably the fracture in the lady of fifty-nine ’was due to restraint unwittingly applied. These two points, instead of detracting from my argument, would seem to add considerably to it. What appears to be a further support for my argument is forthcoming in the figures quoted by Drs. themselves (who admit to Wyllie and Mayer-Gross albeit gentle restraint) where in a using restraint, numerically comparable number of cases (although some of mine were more elderly) their figure for fractures is higher than mine in 25 cases over the age of fifty. Lastly, I would like to point out how their surmise that " The infrequent occurrence of fractures in epileptics is probably due to the fact that in most cases their bones have been habituated to the strain of fits from youth " is quite inadequate to explain the rarity of fractures in cases of idiopathic epilepsy beginning late in life or in epileptiform attacks (other than those produced by cardiazol) occurring from other causes in the middle-aged or elderly.
I am,
Sir,
faithfully,
yours
RANKINE GOOD.
Glasgow Royal Mental Hospital.
LOUSY CLOTHING
SIR,-Recently Professor Buxtondescribed apparatus for determining the critical lethal temperature for lice. He found 53’50 C. for five minutes, 52’00 C. for ten minutes, and 50,00 C. for thirty minutes lethal for eggs. In the case of adult lice he found 51.50 C. for five minutes, 49,50 C. for ten to thirty minutes, and 46’00 C. for forty-five minutes to one hour lethal for both sexes and for immature specimens. A paper he read to the Royal Society of Tropical Medicine and Hygiene2 stimulated a discussion in which Colonel W. Byam remarked about the infectivity of louse faeces in garments and blankets. The War Office trench-fever investigation committee showedthat the infectivity of the louse’s excreta is very high; 0-1 mg. has sufficed to give the disease when inoculated into man. The virulence of the excreta is destroyed by dry heat at 100° C. in twenty minutes and by moist heat at 60° C. in twenty minutes.4 The virus of trench fever seems to be more resistant than that of typhus where the excreta of lice dried in air lose their virulence in a few days.5 It is a fact, however, that fatalities among research workers who handle the excreta of lice infected with the virus of typhus havebeen regrettably frequent in the past, before protective vaccination with the preparation of Weigl became possible. In my
intelligent
own man
experience,
investigator, a very danger of infection and
an
who knew the
1. Buxton, P. A., Brit. med. J., March 2, 1940, p. 341. 2. Trans. R. Soc. trop. Med. Hyg. January, 1940, p. 365. 3. See Trench Fever, by W. Byam, London, 1919. 4. Topley, W. W. C. and Wilson, G. S. Principles of Bacteriology and Immunity, London, 2nd ed., p. 1463. 5. Nicolle, Blanc and Conseil, C.R. Soc. Biol. Paris, 1914, 159,
661.
took full precautions against lice, developed typhus after taking samples of venous blood from five cases who were confined in a small room lacking in ventilation and under extreme conditions of dirt and destitution. The investigator wore protective clothing, which he removed immediately he ’left the sick-room and placed in a canvas bag for disinfestation. Within an hour lie had removed all his other clothing and sent it to the disinfestor, had a bath in dilute lysol and searched his body for lice. After the bath he put It was ultimately concluded that on fresh clothing. this man acquired his infection by inhaling louse faeces released into the air of the room from stirred-up dirty bedding and clothing. At the time there was only the one focus of the disease, and he had no further contact with cases or infective material either before or after the occasion on which he collected the blood samples. In his case the incubation period was thirteen days. It seems worth considering whether disinfection as well as disinfestation may not be required in the treatment of lousy clothing in areas where trench fever or typhus are endemic. I am, Sir, yours faithfully,
FRANK MARSH. Pathological Laboratory, c/o Anglo-Iranian Oil Co., Ltd., Abadan, Iran. PEPTIC ULCER IN THE SERVICES
SiR,—The contributors to this discussion ought to set out the evidence that young subjects of peptic ulcer will never be able to resist the rigours of Service
cooking. This pessimistic assumption is contrary to the experience of many patients who had a complete remission of symptoms during their war-time service in 1914—18, contrary to German teaching, though admittedly their cooking can’t be compared with ours, and contrary to modern ideas on the aetiology of ulcer. Leaving mass destruction of the stomach out of consideration-the Nordic theory that stomachs should be altered to fit the diet instead of the other way round thoroughly tested on the Continent in the decade after the last war and didn’t work-we are advised to turn these patients out of the Forces and send them back to the war-time mental strain of civilian life. If we do so we probably condemn the majority to a lifetime of physical and mental inferiority, as well as depriving the country of the full benefit of men who are possibly more conscientious and intelligent than the average. Even if all our prolific gastroenterological thinkers gave this advice, I should still feel disinclined to accept the opinion of a weak and badly organised branch of British medicine, which year after year grinds out the same old ideas, based on the same fallacy of the selected sample of patients who come to surgery or post-mortem and the same misunderstanding of the radiology and physiology of the gut. As some of our grandfathers and even greatgrandfathers knew, there are two entirely different points to be considered in the treatment of peptic ulcer. The first is: What is the difficulty in the life of the patient which causes the breakdown in gut function7 This is no place to argue the pathological chain of events in detail, and of course it varies to some exent from patient to patient, but I believe the commonest answer to this question is that the modern concentrated starchy diet is especially difficult for intestines reflexly irritated by worry and strain, and that this difficulty is exaggerated by sedentary life and vices like aperients, oversmoking and the like. The second point is: How much organic damage has already been done?7 In practice we start with a bland
was