MANIPULATION AND CERVICAL SPONDYLITIS

355 Tuberculin

positivity

or

negativity in an Irish migrant,

however, is not the final determinant or

she

will later develop tuberculous

as

to whether he

disease.

If we may again quote Wallgren 10 : " Natural resistance is of greater importance for the subsequent course of tuberculous infection than acquired specific immunity." We stated that the probability is that many migrants have a low level of natural resistance because " Ireland did not experience the peak of its epidemic wave of tuberculosis until much later than England." Dr. James thinks that here we go ’’seriously astray" and finds our argument " difficult to follow." But we produced-we believe-sufficient evidence that the Irish immigrant broke down with tuberculosis more frequently than the native English city dweller. This, we think, is the crux of the matter-"the level of resistance of a community is proportional to the amount of tuberculosis it has experienced." In other words, the breakdown-rate is fundamentally dependent on the level of natural resistance ; and this is determined, not by race, but by the tuberculous experience of previous generations. So far as rural Ireland is concerned this experience is considerably less than that of London or other cities ; hence there are likely to be more susceptibles amongst the rural Irish. If such susceptibles are infected before they leave Ireland they are, because of low inherited resistance, likely to break down more commonly than their city contemporaries who are more inured to the disease ; this breakdown is liable to occur, however, irrespective of the locality where infection is acquired. Although the available evidence regarding the high level of tuberculin-negativity in rural Ireland suggests that infection after emigration must be the more frequent, the possibility of individual breakdown with disease in either instance is equally high. We adhere, nevertheless, to the suggestion put forward in our article-that B.C.G. vaccination of tuberculin-negative Irish immigrants with provision of a follow-up scheme in Britain should be seriously considered. We would add that this follow-up scheme should also include the tuberculin-positive Irish immigrant; for this group also contains susceptibles.

Dr. James raises other

points.

Progressive primary tuberculosis in adults may be extremely uncommon in Northern Ireland, but in England there is evidence to indicate its prevalence ; resection specimens give abundant proof. 11 12 Pleural effusions do occur in persons who have been tuberculin-positive for many years, but only too frequently are they the sequelse of primary infections in adolescents and young adults ; superinfection remains an unknown quantity ; and regarding the lack of evidence from the Dominions and U.S.A. of a high incidence of disease in immigrants from rural Ireland, we suggest that this may not have been sought; in any event the numbers are much smaller. Clare Hall Hospital, South Mimms, Barnet.

SiB,ŁThere have

EVELYN V. HESS NORMAN MACDONALD.

VICARIOUS APPETITE is a small group of English words which

meaning for ordinary people and another quite meaning, with no support from etymology or dictionaries, for doctors only. Examples are confabulate (talk together, not invent a story) and homonymous (having the same name, not having the same boundaries). This group ought to be diminished, and it is a pity that Dr. Muir, in his instructive and entertaining letter of Feb. 5, should seek to enlarge it by the addition one

different

of the word vicarious. When I read the heading "vicarious appetite " I took it to refer to someone who felt hungry on behalf of someone else, and read on in hope of learning how such a thing could happen. That, I submit, is the only way in which any ordinary person could take the phrase. It cannot mean an appetite for unnourishing substances instead of food, and still less an appetite for one food to the exclusion of others. This new usage, if it were accepted, would be the more Acta. tuberc. scand. 1954, 28, 155. 11. Pagel, W., Simmonds, F. A. H., Macdonald, N. Tuberculosis. London, 1953 ; p. 170. 12. Pagel, W., Nassau, E. Tubercle, 1951, 32, 120. 10. Wallgren, A.

Pulmonary

confusing because in our medical vocabulary we already have an example of correct usage, namely vicarious menstruation (the performance of the function of menstruation by structures other than the uterus). What is wrong with " perverted appetite " Q JOHN PENMAN. London, S.W.20. SIR,-Why vicarious (in Dr. Muir’s letter last week) ? The patient is not satisfied by someone else eating the food. Why not capricious ? Or eclectic? MCGREGOR. DONALD McGREGOR. Bonar Bridge, Sutherland. VENEREOLOGY AND DERMATOLOGY

SIR,—Administrative convenience

has prevailed and in East Kent to a are in venereology. It was not the fault of the successful candidate that this was made a dual appointment and we wish him well in his difficult task. In the interests of the registrars working in our two departments it is most important for us to know whether this policy has come to stay. If so, we must start to train our registrars both in dermatology and in venereology no matter to which department they have been appointed. It is only in this way that they can become eligible for any future dual appointments. They will have to face a difficult future in which they must try to become as efficient’ as their full-time colleagues in both of these very different specialties. AMBROSE KING BRIAN RUSSELL. The London Hospital, E.1.

dermatologist has been appointed post in which several of the sessions a

-

MANIPULATION AND CERVICAL SPONDYLITIS SiR,-In all the recent communications in your columns on the subject of cervical spondylitis, it has been stated that treatment by manipulation is contra-indicated. In common with most of my orthopaedic colleagues I treat a large number of these cases by manipulation, and have been doing so for the last twenty years with increasing frequency owing to the favourable results obtained. Often they are repeat manipulations performed at the demand of the patient, and I do not remember any case in which there was evidence that structural damage had been caused. I believe this unfortunate conflict of opinion is due to two factors. First, the neurologist tends to see these cases in their early stages when the disc is softened and pulpy" and liable to prolapse, causing pressure on cord or nerve-roots, whereas the orthopaedic surgeon sees the late cases when the tissues of the disc have been largely absorbed and a secondary traumatic arthritis has developed with associated symptoms of root irritation. In the early cases manipulation is nearly always inadvisable and could cause serious damage, whereas in the late cases there is no disc tissue capable of prolapsing and the procedure is safe and often dramatically effective. Secondly, the neurologist will naturally see the bad results of inadvisable or inexpert manipulation but not the good results, since they do not require his services. To the orthopaedic surgeon manipulation does not mean a forcible wrenching but gentle and precisely gauged movements performed under manual traction and with the muscles completely relaxed, which is best achieved by the rapid administration of a small dose of intravenous thiopentone. It should be carried out with the greatest caution in early cases, especially when neurological signs of root or cord pressure are present, and when the disc spaces are not markedly narrowed. Even then it should only be done if an adequate period of rest has been ineffective and operation is being "

contemplated. It is safe in late cases when the joint spaces are narrowed and arthritic changes have developed, when there is little actual stiffness, no neurological signs, and

356

guarding muscle spasm. There are thus two para. doxes : the more advanced the radiological changes the safer does manipulation become; and the less the stiffness the greater the likelihood of benefit accruing. Those who say that manipulation has no place in the treatment of cervical spondylitis should bear in mind that if manipulation is denied to them under expert guidance, patients will inevitably seek help from the unqualified practitioners, for they know that manipulation can help. They do not know that it can also be disastrous.

no

Guy’s Hospital, London, S.E.1.

T. T. STAMM. INFLUENZA

very interested in your topical discussion as seen in general practice this winter. In support of the general trends which you have noted I would like to add the experiences of my own practice of approximately 5000 patients in Southeast London.

SIR,—I

last week

was on

influenza

Whereas the North and the West had their epidemics in November and December, we in this area are only just recovering from our share which began in early January and reached its peak in the third week of that month. It must be said at the outset that the figures I have collected are based solely on clinical findings-i.e., sudden onset, variable fever, generalised aches and pains, painful eyes, and symptoms referred to the respiratory tract. As you point out in your leader last week, the differential diagnosis of upper respiratory tract infections, including influenza, is in a state of flux and chaos and it is often clinically impossible to distinguish between the common cold, febrile catarrh (or A.R.D.), and influenza. My figures may therefore be liable to give too high an incidence by inadvertently including some of the other common viral infections of the upper respiratory tract. Another factor which may give a wrong picture of the total incidence is that not all patients suffering from this condition consulted me for their symptoms, and some cases may have been missed, tending to counterbalance the first possible error. Moreover, we are all aware of the fact that serological tests now exist for the diagnosis of influenza, but unfortunately during an epidemic there is little time to carry these out. It is known however that in the past two months, during the course of an investigation into acute chests in general practice, some cases of influenza B, proven serologically, were seen in this area, so it is known that the virus has been active. One last point about the diagnosis of influenza : it should only be made during an epidemic, and when applied to sporadic cases the label is usually incorrect. Between the end of December and early February 150 cases of influenza were diagnosed in my practice. The age-distribution is shown in the accompanying table. The sex-distribution was equal. As in the Gloucestershire practice you quote, the maximal incidence was in children below 10. This AGE-DISTRIBUTION OF INFLUENZA CASES

COMPLICATIONS

I have found unusual, for in the two previous influenza-A in 1950 and 1953 there were few cases in children, the greatest number of cases being in young and middle-aged adults. Clinically this epidemic has been on a lesser scale than those two already mentioned. The acute stage lasted as a rule from two to four days with a relatively low incidence of

epidemics

"

post-influenzal debility." It

was

rather difficult to be certain whether the chest

complications were directly attributable to the influenza, but during this same period there occurred 15 acute.chests which were probably related to the epidemic. This gives a 10% incidence of chest complications. It is of some interest to compare this, and the types of complication, with those in the two previous epidemics (see table). These are of course small numbers, and definite "

"

conclusions should not be drawn too readily; but the figures are in many respects remarkably similar, showing a fairly constant proportion of complications and some. what similar clinical types. This suggests that, contrary to the common belief that influenza B is a milder illness than type A, the incidence of chest complications is much the same in the two types. This viewpoint is also

shared

by Professor Stuart-Harris.l JOHN FRY, FRY.

Beckenham, Kent.

TOTAL GASTRECTOMY

SIR,—Your leading article of Jan. 29 is in conflict with experience. In your words, a patient " may not

our

become a frank invalid " after total gastrectomy but " he will no longer be the man he was " ; there is an implication that the operation should be more or less reserved for malignant disease ; and finally it is suggested that cesophagoduodenostomy is the anastomosis of

choice.

Surely this is the worst of choices. Admittedly satisfied patients write letters and it is the dissatisfied ones who haunt us ; but

even

after this operation cases

if

we

seems

allow for this, to be the

some

discomfort

rule, and in the worst

tryptic

oesophagitis may make

a

patient almost suicidal. He refuses to go to bed and tries to sleep sitting upright. Anas. tomosis of the

oesophagus a loop of jejunum, with to

or without entero -anasto.

mosis, gives no better result. The modern operation is a Roux-Y with the loop carrying the duode. nal secretions inserted at least 18 in. below the cesophagojejunal anastomosis. The side loop drains into the intestine below the mesocolon where it is unlikely to be kinked by adhesions. Serious trouble from reflux is rare ; when it does occur, it suggests that the valvular segment is too short. Further experience may reverse our judgment, but so far there has been less difficulty with nutrition after this operation than after many subtotal gastrectomies. The accompanying weight chart belongs to a patient who had recurrent ulcers after a gastroenterostomy ; a partial gastrectomy (A), a subtotal (B), and a vagotomy (c) 1.

Stuart-Harris, C. H. Brit. med.

J. Feb. 5,

1955, p. 348.