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PERFORATION OF COLON AFTER BARIUM ENEMA
96 reacted indifferently to cortisone,- but 1 reacted extremely well. The 4 patients who temporarily improved with butazolidine also improved rapidly with cortisone. G. D. KERSLEY D. WATSON Royal National Hospital for J. BREMNER Rheumatic Diseases, J. B. MILLARD. Bath. PERFORATION OF COLON AFTER BARIUM ENEMA two SIR,—The interesting case-reports of accidental injection of barium sulphate into the peritoneal cavity 12 .stimulate me to offer a further case-report. A man, aged 62, was admitted to the West London Hospital on Oct. 25, 1952, with complete intestinal obstruction. The pattern of the distension suggested colonic obstruction with a possibility of volvulus of the sigmoid colon. I therefore did a sigmoidoscopic examination, using the standard Yeoman instrument with the patient in the knee-chest position. No resistance was encountered, nor did he complain of more than mild discomfort. No lesion was seen up to 8 in., and the instrument was removed. In order to locate the site of obstruction, radiography with a barium enema was arranged. No sooner had a few ounces of the fluid been run into the rectum than the patient became pale, and sweated and complained of abdominal pain. The examination was therefore stopped, no radiographs having been taken. Laparotomy was performed the same evening. On opening the peritoneum it was found that it contained a considerable quantity of milky fluid, and that all the intestines, mesentery, and omentum were sugared with barium. A ring carcinoma of the splenic flexure was found to be the cause of the obstruction, and the site of the perforation was a linear tear 1 in. long on the antimesenteric border of the sigmoid colon, far below the growth, and about opposite the promontory of the sacrum. The perforation was sutured and a Senn-Kader cæcostomy performed. The patient’s recovery was complicated by peritonitis and a very irregular pulse ; but he stood very well a resection and end-to-end anastomosis of the splenic flexure three weeks later, and has made a good recovery.
This case General Infirmary, Leeds.
closely
resembles
one
reported by
Isaacs.3
A. V. POLLOCK.
LIGATION OF THE POPLITEAL VEIN FOR THE GRAVITATIONAL SYNDROME SIR,—Despite the somewhat guarded wording of the conclusions and summary to his paper last week, Mr. Moore has none the less conveyed the impression that ligation of the popliteal vein is a procedure of some value in the treatment of gravitational leg ulcers. I would suggest that the facts recorded in his paper warrant no such conclusion. He admits that in his experience popliteal vein interruption alone has generally not caused leg ulcers to heal.. He has therefore combined ligation with a period of bed rest and skin grafting and thereby completely confused the therapeutic issue. It is of course well known that leg ulcers, whatever their cause, can almost invariably be induced to heal by strict bed rest and grafting alone without any interference with the veins. The only way, therefore, in which the benefits of popliteal vein ligation might be revealed in Mr. Moore’s cases submitted to this combined treatment would be by a significantly lower incidence of recurrence of ulceration after discharge from hospital. We are told that 7 of his Ipatients showed no signs of recurrence for periods from 9 months to 3 years. I do not consider that these results are very different from what might be obtained after bed rest and grafting alone, especially if the patients were careful to support the leg by an elastic stocking or bandage as apparently did most of Mr. lioore’s cases. My own experience of interruption of the deep venous system for leg ulceration due to old thrombosis or 1. Serjeant. J. C. B., Raymond, J. A. Lancet, 1952, ii, 1245. 2. de Fonseka, C. P. Ibid, p. 1246. 3. Isaacs, I. J. Amer. med. Ass. 1952, 150, 645 ; case 2.
apparent valvular incompetence of the deep leg veins has been confined to superficial femoral vein ligation; but the principle of this operation and that of ligation of the popliteal vein is the same, and the results should presumably also be similar. I have now done 26 of these operations ; and, so that these patients might be kept up and about, the ligation was done in the outpatient department, or was followed by at most 36-48 hours of hospitalisation. Subsequently the patients attended the varicose vein clinic for local treatment with Unna’s paste or elastic adhesive bandage. It was thus possible to compare their progress with that of other similar cases treated only by bandaging. There were variationsusually quite unpredictable-in the rate of healing of individual ulcers in both groups, but it could not be claimed that in general the surgically treated group healed any more rapidly than the other ; the usual time taken for .complete healing was 9-10 months. 2 cases were particularly instructive, because they had ulcers on both legs and superficial femoral vein ligation was practised on one side only in each case, the opposite side serving as a control. There was no obvious differ. ence in the rate of healing in the two legs in either case.
These experiences have led me to abandon interruption of the deep venous system in the treatment of leg ulcers. St. Mary’s Hospital, J. C. GOLIGHER. London, W.2.
REPRESENTATION OF WHOLE-TIME SPECIALISTS
SIR,—On Dec. 19 a deputation of representatives of the Association of Whole-time Salaried Specialists met the staff side of Committee B of the Medical Whitley Council ; and at that meeting matters affecting whole-time officers in the National Health Service, including the question of their representation on the staff side of Committee B, were discussed.l In view of the well-known dissatisfaction in the minds of whole-time officers regarding the disparities which have existed and still exist in their terms and conditions of service, as has been emphasised recently by much correspondence in your columns. I should like to give a brief resume of the points which were put forward by our deputation to the staff side of Whitley Committee B on behalf of whole-time consultants. The following are the particular matters to which we referred : 1. The difference in remuneration between the two classes of consultants (whole-time and part-time) is 1½ sessionsor, expressed in cash on the basis of the top grade of salary. £ 375 per annum. 2. To offset this difference of £ 375 per annum, the part-time consultant has the following : (a) Private practice. (b) Payment for domiciliary visiting up to ot840 per annum. (c) The right to claim mileage allowance from his home or -
consulting-room. The ability to claim,
without difficulty, income-tax relief for many items for which the whole-time consultant cannot claim, such as subscriptions’ to learned societies, purchase of medical books and periodicals, expenses of attendance at congresses and clinical ; meetings, and car and telephone expenses. 3. The importance of car allowances for whole-time consultants was stressed. It was pointed out that a car is ; essential as all whole-time consultants must be quickly available for emergency calls and domiciliary visits if agreed The same applies to telephone _ rentals. to be undertaken. ‘ At the request of the staff side, -concrete instances were given ;‘ of the unsatisfactory mileage arrangements and the anomalies that arise out of them. 4. It was pointed out that the Spens Report on Consultants (para. 17, 6) in our view recommended- that all specialists ; should be on an equal basis ill regard to -payment for domiciliary visits, and we-asked-.for reconsideration of the interpretation of this paragraph,
(d)
’
!
--
.
1. Brit.
med. J.
,
1952, ii, suppl.
p. 234.
This case General Infirmary, Leeds.
closely
resembles
one
reported by
Isaacs.3
A. V. POLLOCK.
LIGATION OF THE POPLITEAL VEIN FOR THE GRAVITATIONAL SYNDROME SIR,—Despite the somewhat guarded wording of the conclusions and summary to his paper last week, Mr. Moore has none the less conveyed the impression that ligation of the popliteal vein is a procedure of some value in the treatment of gravitational leg ulcers. I would suggest that the facts recorded in his paper warrant no such conclusion. He admits that in his experience popliteal vein interruption alone has generally not caused leg ulcers to heal.. He has therefore combined ligation with a period of bed rest and skin grafting and thereby completely confused the therapeutic issue. It is of course well known that leg ulcers, whatever their cause, can almost invariably be induced to heal by strict bed rest and grafting alone without any interference with the veins. The only way, therefore, in which the benefits of popliteal vein ligation might be revealed in Mr. Moore’s cases submitted to this combined treatment would be by a significantly lower incidence of recurrence of ulceration after discharge from hospital. We are told that 7 of his Ipatients showed no signs of recurrence for periods from 9 months to 3 years. I do not consider that these results are very different from what might be obtained after bed rest and grafting alone, especially if the patients were careful to support the leg by an elastic stocking or bandage as apparently did most of Mr. lioore’s cases. My own experience of interruption of the deep venous system for leg ulceration due to old thrombosis or 1. Serjeant. J. C. B., Raymond, J. A. Lancet, 1952, ii, 1245. 2. de Fonseka, C. P. Ibid, p. 1246. 3. Isaacs, I. J. Amer. med. Ass. 1952, 150, 645 ; case 2.
apparent valvular incompetence of the deep leg veins has been confined to superficial femoral vein ligation; but the principle of this operation and that of ligation of the popliteal vein is the same, and the results should presumably also be similar. I have now done 26 of these operations ; and, so that these patients might be kept up and about, the ligation was done in the outpatient department, or was followed by at most 36-48 hours of hospitalisation. Subsequently the patients attended the varicose vein clinic for local treatment with Unna’s paste or elastic adhesive bandage. It was thus possible to compare their progress with that of other similar cases treated only by bandaging. There were variationsusually quite unpredictable-in the rate of healing of individual ulcers in both groups, but it could not be claimed that in general the surgically treated group healed any more rapidly than the other ; the usual time taken for .complete healing was 9-10 months. 2 cases were particularly instructive, because they had ulcers on both legs and superficial femoral vein ligation was practised on one side only in each case, the opposite side serving as a control. There was no obvious differ. ence in the rate of healing in the two legs in either case.
These experiences have led me to abandon interruption of the deep venous system in the treatment of leg ulcers. St. Mary’s Hospital, J. C. GOLIGHER. London, W.2.
REPRESENTATION OF WHOLE-TIME SPECIALISTS
SIR,—On Dec. 19 a deputation of representatives of the Association of Whole-time Salaried Specialists met the staff side of Committee B of the Medical Whitley Council ; and at that meeting matters affecting whole-time officers in the National Health Service, including the question of their representation on the staff side of Committee B, were discussed.l In view of the well-known dissatisfaction in the minds of whole-time officers regarding the disparities which have existed and still exist in their terms and conditions of service, as has been emphasised recently by much correspondence in your columns. I should like to give a brief resume of the points which were put forward by our deputation to the staff side of Whitley Committee B on behalf of whole-time consultants. The following are the particular matters to which we referred : 1. The difference in remuneration between the two classes of consultants (whole-time and part-time) is 1½ sessionsor, expressed in cash on the basis of the top grade of salary. £ 375 per annum. 2. To offset this difference of £ 375 per annum, the part-time consultant has the following : (a) Private practice. (b) Payment for domiciliary visiting up to ot840 per annum. (c) The right to claim mileage allowance from his home or -
consulting-room. The ability to claim,
without difficulty, income-tax relief for many items for which the whole-time consultant cannot claim, such as subscriptions’ to learned societies, purchase of medical books and periodicals, expenses of attendance at congresses and clinical ; meetings, and car and telephone expenses. 3. The importance of car allowances for whole-time consultants was stressed. It was pointed out that a car is ; essential as all whole-time consultants must be quickly available for emergency calls and domiciliary visits if agreed The same applies to telephone _ rentals. to be undertaken. ‘ At the request of the staff side, -concrete instances were given ;‘ of the unsatisfactory mileage arrangements and the anomalies that arise out of them. 4. It was pointed out that the Spens Report on Consultants (para. 17, 6) in our view recommended- that all specialists ; should be on an equal basis ill regard to -payment for domiciliary visits, and we-asked-.for reconsideration of the interpretation of this paragraph,
(d)
’
!
--
.
1. Brit.
med. J.
,
1952, ii, suppl.
p. 234.