MITCHELL-NELSON TEXTBOOK OF PEDIATRICS

880 literature regarding the effects of hyperthyroidism on human and animal tuberculosis,56 It is an old clinical observation that hyperthyroidism seems to have an inhibitory influence on tuberculosis, and that hyperthyroidism has many features in common with adrenal insufficiency. It has recently been shown5 that 30 ug. of thyroxine bi-weekly (one tenth of the dosage of Long and Miles) produces an increase, and thyroidectomy a decrease, in the survival-time of the guineapig with tuberculosis. The effects of thyroidectomy or larger doses of thiouracil would therefore be of interest, as it is likely that sensitivity would be increased. It might be possible to determine whether the cortex had been exhausted or not, as a result of excess thyroxine, by the administration of a minimal dose of A.C.T.H. and the observation of its effects on sensitivity. A large dose might mask the exhaustion unless it was absolute, which seems unlikely. The dosage administered by Long and Miles was, according to the data, 600 times that which would give unequivocal evidence of adrenal stimulation in the test rat. The old theory that the thyroid and the adrenal are in opposition is not in accord with recent evidence,7 which is more in favour of a partnership between these glands in the metabolic processes, except when the balance is grossly disturbed, as in hyperthyroidism. The hypertrophy of the cortex followed by exhaustion produced by thyroxine, and the involution following thiouracil or thyroidectomy, would seem most readily explained by the concept of increased tissue utilisation of hormones.8 Thus, excess thyroxine, by increasing the rate of metabolism, increases the utilisation of the sugar hormones, and brings about their increased secretion to meet the demand, while the lack of thyroxine brings about decreased need for these hormones and involution of the cortex. This theory seems most logical, as there can be no doubt that it is for the purpose of supplying hormones to the tissues that the endocrine glands exist at all. The influence of the target tissues cannot therefore be ignored, as is so commonly done. The report by Long and Miles can no more be regarded as indicative of any influence of the thyroid on hypersensitivity than this analysis can be taken as ruling out the possibility. H. MORROW BROWN. Edinburgh.

Since routine chest radiography is being made available

large groups of the population, we would plead that priority be given to expectant mothers. Dr. Turner, for

has shown that one of the " is during the first four months of -pregnancy. It is the practice in this hospital for every expectant mother to have a chest X-ray examination as If the mechanists soon after her first visit as possible. have their way, then every primigravida will have a radiological examination of her pelvis. We feel there is just as strong a case for routine X-ray examination of the chest. In view of the discussion in the medical and lay press on the allocation of beds ton tuberculosis, we should like to point out that at this hospital a number of antenatal beds are reserved for tuberculous mothers. ANDREW MORLAND University College Hospital, W. C. W. NIXON. London, W.C.1. in his article of "

April 15,

danger periods

’

MITCHELL-NELSON TEXTBOOK OF PEDIATRICS SIR,—Your review of the excellent Mitchell and Nelson Textbook of Pediatrics (April 22, p. 766) is hardly fair in its criticism of the book. You say : " It is a little startling to find emotional growth and development discussed in less than a page." There is a 14-page section entitled Mental and Emotional Development, quite apart from the chapter on Psychological Disorders, in which mental and emotional development are inevitably discussed. I agree that the sections on emotional development and behaviour problems are inadequte, as in other textbooks of paediatrics, but your statement is misleading. R. S. ILLINGWORTH Professor of Child Health. *

** Our comment was perhaps too emphatic. Though the passages headed Emotional Development occupy less than a page, a good deal is said on this subject in the rest of this section and in other parts of the book.-ED. L. LOOP TRANSPLANTATION OF URETERS a modified technique for transplantation of the ureters into the colon which has. certain outstanding advantages over the more commonly practised methods. A brief account of it may be of

SIR,—I have been using

interest, since I

am

not

aware

that it has been described

before. PREGNANCY AND PULMONARY TUBERCULOSIS

SIR,—Dr. Stewart and Dr. Simmonds mentioned in their letter last week the importance of X-ray observation of pregnant women. Jacobs,9 at Paddington Hospital, was one of the first in this country to undertake a screen examination of the chest of all women attending an antenatal department. From January, 1943, to April, 1946, a total of 4430 women were screened. He found 27 cases (0-61%) of active pulmonary tuberculosis requiring immediate admission. There were 11 cases (0-25%) possibly active, and 30 (0-67%) probably inactive. Thus the total cases of tuberculosis were 68 (1-53%). From January, 1946, to August, 1949, at University College Hospital 3581 expectant mothers had an X-ray examination of the chest. Among these pulmonary tuberculosis was discovered in 28 cases (0-74%)-13 active and 15 inactive. All these women had had the usual chest examination by a medical officer in the antenatal clinic. In only one were any abnormal signs discovered by ordinary physical examination. -

Izzo, R. A., Cicardo, V. H. Amer. Rev. Tuberc. 1947, 56, 52. 6. Rich, A. R. The Pathogenesis of Tuberculosis. Springfield,

5.

1944. 7. Reiss, R. S., Forsham, P. H., Thorn, G. W. J. clin. Endocrinol. 1949, 9, 659. 8. Sayers, G., Sayers, M. A. Rec. Progr. Hormone Res. 1948, 2, 81. 9. Jacobs, A. L. J. Obstet. Gynœc. 1946, 53, 369.

The abdomen is opened through a left paramedian incision and the bowels are packed off. Separate incisions are made through the posterior peritoneum over each ureter, and both Each ureter is divided are mobilised up to the bladder. just above a long curved clamp such as Moynihan’s gallbladder forceps, and the distal stumps are ligatured. No traumatising instrument is placed on the proximal ends, which are each wrapped in a swab. A fine silk suture is inserted through the end of the right ureter and the silk is left long. With the left index finger as a guide, a long curved artery forceps is gently tunnelled through behind the mesosigmoid from the left incision in the posterior peritoneum to the right. The silk attached to the right ureter is picked up and drawn through to the left side of the mesosigmoid with the right ureter. The end of each ureter is cut obliquely, and the pointed extremities are then conjoined by two fine silk ‘

sutures.

A ureteric

loop has now been formed by the left ureter downwards and inwards and the right ureter curving upwards and outwards. The ureteric loop is laid alongside the sigmoid colon so that it lies in the position of maximum ease. With the proposed anastomosis in view, a little adjustment enables the optimum site to be marked by two stay sutures on either side of the bowel wall. The segment of the colon is picked up by four Babcock’s forceps to facilitate making a longitudinal incision about 13/4 in. long through the seromuscular coats of the bowel over one of the tæniæ. A very small opening is made in the protruding mucosa at the level of the marking sutures, which should also be the mid-point of the incision. The loop is now placed in the gutter thus formed so that the oblique openings of the

passing