POSTURE

237 stools.

Many possible contributory

causes

have been

considered, such as deficiency of intrinsic or extrinsic factor, inability to absorb iron, and other nutritional defects. But the gastric juice is usually normal, with adequate intrinsic factor, and in most cases no deficiency of diet can be demonstrated. The work of Cameron, Watson, and Witts 3 in Oxford may throw some light on the aetiology of this type of ansemia, for they produce new evidence in support of an old, rather disfavoured theory. In investigating the anæmia which often accompanies intestinal stricture they produced a macrocytic anaemia by forming blind loops of intestine in rats, the essential feature being stagnation of intestinal contents. They suggest that the anæmia is produced by.toxins or cranged bacterial flora in the blind loop which destroy or otherwise use up the hsemopoietic factors. Is it not possible that some such mechanism contributes to the anemia of diaphragmatic hernia ??, I would suggest, Sir, that, your explanation of the cause is over-simplified, and that, although in many cases haemorrhage may be the main factor, deficient intake, failure of absorption, and stagnation of visceral contents may also play a part. R. G. MITCHELL. Royal Hospital for Sick Children, Edinburgh.

SIGNIFICANCE OF THE DISCOVERY OF THE EFFECTS OF CORTISONE

SIR,—I

am

fascinated

by

the

refreshing

article

4

and correspondence 56 on disease processes. I should regret the passing of " focal sepsis " and I should am prepared to put in a good word for it. not be sorry if the " general adaptation syndrome were stillborn, for that would excuse many, including myself, from the unequal task of mastering it. But if there is a possibility of interring the " psychosomatic hypothesis," I am really roused, and willingly lend a

hand. I am tempted into this tricky correspondence by Dr. G. R. Venning’s 6 confident reference to the " widely accepted correlation between personality types and the occurrence of particular diseases, of which perhaps the best examples are ulcerative colitis, migraine, hypertension, and peptic ulcer." Three of these conditions I have treated surgically for many years. From the fourth (number two on the list) I am myself a sufferer-mildly and occasionally but unmistakably, with all the classical symptoms. In my opinion the " personality type " in these maladies is inconstant, unless we confuse personality with the mental attitude created by the illness. Relieved of their troubles by successful surgery, patients from groups one, three, and four, are no different from their fellows and are indistinguishable apart ! Yet these are " perhaps the best examples." If any there be who doubt this statement, I would suggest a psychological study of sufficient numbers of such patients at a suitable interval after the successful completion of their treatment. CHARLES WELLS University of Liverpool.

Professor of

Surgery.

SIR,—There is one matter that should be mentioned if Professor Pickering’s dismissal of psychosomatic medicine is to be seen in its proper perspective. The late Professor Choyce used to speak of the waters of Lethe that flowed between the anatomy and physiology departments and the medical schools. Of only one branch of medicine is this still true, and that is the 3. Cameron, D. G., Watson, G. M., Witts, L. J. Blood, 1949, 4, 803. 4. Pickering, G. W. Lancet, July 15, 1950, p. 81. 5. Meiklejohn, A. P. Ibid, July 22, p. 154. Leys, D. Ibid,

July 29, p. 194. 6. Venning, G. R.

Bourne, A. Ibid, p. 194. Ibid, July 22, p. 154.

relation of the emotions to bodily health. There is a and honourable tradition of physiological study, which academic medicine in this country has refused to carry on, either directly or by providing facilities for others. The psychiatrists have their own word for this, but it does seem remarkable that the natural curiosity of medical scientists, to put it no higher, has led to so little exploration of this field. Academic medicine may be entitled to dismiss psychosomatics for lack of evidence. In fairness it should at the same time recognise its own responsibility for the deficiency.

long

J. N. MORRIS.

Willesden.

REGISTRAR APPOINTMENTS

SIR,—Dr. Stewart, in his letter of July 15, has put in for

a

appointments at registrar level for oversea postgraduates ; I want to commend his suggestion most strongly to hospital staff committees. It would seem that the registrar is indeed a necessity to our hospital system under present establishments. A registrar is a postgraduate with a knowledge of his subject and bent on acquiring breadth and depth of experience. Not only from the Dominions but throughout Western Europe (and especially in Scandinavia) there are many such who are eager to work for a period in British hospitals ; on mv tour in Denmark this year I was asked many times how such an appointment could be arranged. I did arrange one junior appointment last

plea

more

deal of trouble it higher authority or the General Medical Council (at that level the scheme worked very smoothly) but from senior hospital staff. However, the appointment was a great success ; but many are turned awav rebuffed or with a cold invitation to visit the hospitals as an observer, and so turn their eyes only to the United States, making both themselves and us the poorer. If Britain is to retain her proud position in the future as a centre for world medicine, at the same time enriching her own thought with the stimulus of fresh minds, and make her full contribution to international understanding, Dr. Stewart’s suggestion has much to commend it, and if put into practice could result in nothing but good. PHYLLIS M. EDWARDS. London, W.4.

year for

a

Danish anæsthetist, and

a

cost me-not from

POSTURE

SIR,—I read with interest the letter of July 15 from Dr. Gellner, on the influence during childhood of the heel of the shoe and the tilt of the head. None will dispute the desirability of a good posture, and it is easy to appreciate that the method of walking with a book on the head is effective. In order to rectify some foot disturbances I have taught many children the following simple manner of walking to obtain a good

poise. The

and head are all placed wall with the hands elevated high above the head. The child is then taught to stretch the hands higher still, which will normally be about another inch. This can only be done with the body fully upright, its curves straightened out, and with an adequate tightening of the abdominal muscles. While the body is thus tense the arms are dropped, and the shoulders relaxed ; and the child is instructed to walk without stiffness, looking towards a point on a level with the eyes. This exercise does undoubtedly give a good carriage, and checks certain foot disturbances without the necessity of using a book.

against

heels, buttocks, shoulders, a

The subject of posture is however, more complex than it at first appears. We assume that the headerect position, being graceful, is the natural one. But in walking the natural tendency is for the trunk to precede the feet. We do not walk by placing the leg

238 first in front of the body, although this is the acquired method of the mannequin. The first thing we do in walking is to incline the body forward from the ankle-

interesting to notice a line of guardsmen, posture is beyond reproach. At the command quick march" the whole line will be noticed to lean forward as a preliminary to the first step. Is it not possible, therefore, that the slight pitching forward of the head is a natural anticipation of the manoeuvre, and that the erect head is a state acquired either by specific exercises or the carrying of a weight upon the joint.

Obituary IVOR ISAAC PRICE

It is

whose

M.B.

LOND., F.R.C.S.

"

head ? It does appear obvious that there is need to avoid obstacles immediately in front of us, and that looking straight ahead may not always be satisfactory. A child would naturally look downwards, particularly in the tottering stage. The suggestion that the slight heel would necessarily tilt the body forward in a child cannot be accepted. The body does not bend forward any the more because we walk downhill ; if anything the tendency is to throw the bodyweight backwards to compensate for the incline. The range of action of the ankle-joint is indeed sufficient to compensate for sloping surfaces. In the average adult flexible foot a considerable range is possible without tilting the body forward, and a child has an even greater range. The toddler’s slight heel can therefore have no influence on the positioning of the head. Civilisation may be responsible for many disorders, but it is doubtful whether the toddler’s small heel can be rightly blamed for bad posture. H. E. WALKER. London Foot Hospital, W’.1. EXCRETION

OF

POTASSIUM AFTER GASTRECTOMY

PARTIAL

SIR,—In your issue of July 22, Mr. Wilkinson and his

colleagues comment on the excessive excretion of potassium that may occur soon after operation. It is tempting to suggest that this sudden loss of potassium is, like the more gradual loss of nitrogen, a result of the increased excretion of adrenal hormone after injury.’ The loss of potassium does not seem to depend on the development of an inflammatory reaction, for it may take place with other types of injury. Albright2 observed a transient rise in potassium excretion together with a rise in 17-ketosteroid excretion in a patient who, while on a metabolic balance study, received too rapid an intravenous infusion. The phenomenon has been observed after exposure. It has recently been described in dogs allowed to go into diabetic coma.3 It may be reproduced by stimulating the adrenal cortex with adrenocorticotropic hormone (A.C.T.H.)4 or by giving Compound F-an adrenal steroid with " sugar hormone " activity. In these experiments the increase in excretion of potassium occurs without a rise in the serum level; so the effect of the hormone must be on the kidney. The kidney does not conserve potassium and may even actively excrete it; so a deficiency can easily arise.6 It is not, however, easily demonstrated, since serum levels may not fall. The liberation of adrenal hormone would also explain the sodium retention observed after operation, since sodium is retained when A.C.T.H. is given. Nuffield Department of Clinical PAUL FOURMAN. Medicine, University of Oxford.

1.

2.

3.

4. 5. 6.

Talbot, N. B., Albright, F., Saltzmann, A. H., Zygmuntowicz, A., Wixom, R. J. clin. Endocrinol. 1947, 7, 331. Albright, F., Reifenstein, E. C., Forbes, A. P. Conference on Metabolic Aspects of Convalescence: 11th meeting. New York, 1945 ; p. 45. McArthur, J. W., Harting, D., Smart, G. A., Talbot, N. B. J. clin. Invest. 1950, 29, 832. Bartter, F. C., Fourman, P., Forbes, A. P., Jeffries, W. M., Albright, F. Transactions of 1st Conference on Metabolic Interrelations. New York, 1949; p. 137. Fourman, P. Canadian Physiological Society : proceedings of 13th annual meeting, 1949. Tarail, R., Elkinton, J. R. J. clin. Invest. 1949, 28, 99.

Mr. Ivor Price who died on July 24, at the age of 46, was born in London and educated at Daventry Founda. tion School. He entered King’s College Hospital Medical School in 1920, where he had a distinguished academic career as an undergraduate, winning a number of prizes. In 1925 he qualified and in the following year he took the M.B. Lond. He held the resident posts at King’s and the appointments of resident medical officer at Queen Mary’s Hospital to the East End, and medical superintendent at the Seaman’s Hospital, Tilbury, before taking his F.R.c.s. in 1928. The previous year he had entered the London County Council hospital service, and he was on the staff of Bethnal Green Hospital a,nd St. Andrew’s Hospital, Bow, till in 1938 he was appointed deputy medical superintendent and senior surgeon to St. Mary Islington Hospital. In 1948 he became consultant surgeon to the newly formed Whittington Hospital, an appointment which he held to the time of his death. T. St.M. N. writes : " One could not wish for a better colleague than Price. He accepted a case for surgery with the greatest care, but he never turned away from an operation which might be of benefit to the patient, however great the surgical risk. Having taken over a patient, he treated him first as an individual, and then as a surgical problem, sparing neither time nor effort on his behalf. In his resident position he saw and treated most of the surgical emergencies in a large general hospital, and rapidly acquired tremendous practical experience. He soon began to specialise in gastroenterology, and he swiftly acquired a high and steadily increasing reputation in this specialty among his colleagues in North London. An academic as well as a practical surgeon, he was always alive to what was new and progressive in surgical trends. He was a good teacher, and many of his postgraduate students owed much of their success to his friendly assistance. From his juniors he expected the high standard which he set himself, demanding the same keenness, thoroughness, and self-sacrifice ; but he was generous with his praise for the good diagnosis, the useful suggestion, the successful surgical performance. Sociable and amusing, he was a great raconteur of amusing incidents, often at his own expense. He was interested in the hospital as a whole, and many of the staff in all grades regarded him as their friend. His work was his primary interest, and he could never accept the advice of his doctors to slow down and retire when the first symptoms of his illness showed themselves. Indeed he had lately taken charge of the surgical side of a large gastro-enterological unit, where he was working to within a few hours of his death." Mr. Price leaves a widow and a son aged five. ‘

"

GEOFFREY MICHAEL FULTON BARNETT M.B. N.Z., F.R,.C.S., F.R.A.C.S. Dr. G. M. F. Barnett, who died at the age of 58 years on July 13, while driving his car in Dunedin, was assistant surgeon to Dunedin Hospital and lecturer in clinical surgery in Otago University. The eldest son of the late Sir Louis Barnett, formerly professor of surgery in Otago University, he was born in Dunedin and educated at Christ’s College and Otago University. While still a student he served in Gallipoli during the 1914-18 war. After graduating at Otago in 1920, he came to London and he held the post of resident medical officer at Middlesex Hospital while taking his F.R.C.s. He returned in 1925 to Dunedin where he practised up to the time of his death. For many years he served as a member of the War Pensions Appeal Board. A friend adds : " Of a quiet disposition, Barnett was beloved by a wide circle of professional colleagues, and by his patients. A rugby footballer in his youth, he later was a keen golfer

and bowler." His wife, two sons, and three A third son was killed in the late

daughters survive him. war.

‘