- Email: [email protected]
RECURRENT URINARY INFECTIONS IN GIRLS
384
people have found this very difficult. She avoids this by assuming that the Industrial Injuries Act suggests that compensation should be given for all types of pulmonary disability. This I find inexcusable. I do not wish to give the impression that I consider the Industrial Injuries Act ideal: far from it, but I do want to say that I think the Medical Panels do an impossible job reasonably well. The fault is mainly with the Act and not with the Panels. Rhoose, near Barry, A. L. COCHRANE. Glamorgan.
SiR,—The article by Dr. Catterall and Mr. Hunter demonstrates some of the problems of diagnosis and assessment of disability in pneumoconiosis of coalworkers which have been evident for many years. There have been a number of careful investigations into lung function, such as that by Gilson and Hugh-Jones.1 Dr. Catterall and Mr. Hunter make no reference to the statutory framework within which the pneumoconiosis boards have to wotk. This defines pneumoconiosis in terms of radiology and histology, and it is in these terms that a diagnosis to satisfy legal requirements must be made. Contrary to the impression given in the article, bronchitis and emphysema are not compensable. The diagnostic value of pulmonary-function tests is limited by the fact that disease diagnosed in this way is not the prescribed disease " and cannot attract compensation. The authors give no observations which would enhance the diagnostic value of pulmonary-function tests; indeed, their division of the functional state of their subjects into four groups, not one of which contains either all or none of the cases of radiological pneumoconiosis, clearly demonstrates the limitations of these tests. Furthermore, it is certain that respiratory disability in coalminers may be due to other causes, some of which are unrelated to their work. For this reason it is regrettable that no reference is made to the miners’ smoking histories. "
Since there are no specific functional changes in pneumoconiosis of coalworkers, tests of function cannot be used to assess the proportion of disability which is attributable to this disease; therefore we cannot agree that referring to a respiratory-function laboratory coalminers who wish to apply for compensation would, by itself, help either the applicant or the medical board. R. I. MCCALLUM McCALLUM Nuffield Department of Industrial Health, Xuitietd T L. L cATtjADTG. G LEATHART. The University, Xewcastte Newcastle upon Tyne, 1. 1. G.
compensation. This is a conclusion which has inevitably engendered a great deal of heat. The diagnosis and assessment of disability in pneumoconiosis is admittedly very difficult, and the Pneumoconiosis Panels, within the somewhat rigid administrative and legal framework in which they have to work, are doing a very good job indeed. I know many of them well, and have worked closely with them on numerous occasions in connection with difficult cases; they most
themselves would be the first to admit that mistakes can be made. They are, however, in a unique position as regards compensation cases in that their diagnoses and assessments of disability, apart from death claims, are not subject to appeal. Dr. Catterall and Mr. Hunter, by using much more thorough lung-function tests than are at the disposal of the Panels for assessment of disability, have shown what might happen if an appeal system similar to that in France were to be adopted in this country. There, appeal boards, called Colleges de Trois Médecins, have been set up in the main industrial centres. Claimants who appeal are admitted to hospital for a week to undergo intensive examinations, including a full range of pulmonary-function tests. I have been privileged to sit at one of the Collèges and assist in the assessment and diagnosis of cases. I came away with the strong impression that justice was not only done in each case but was manifestly seen to be done. If some such system were to be adopted here, much of the criticisms of the findings of the Pneumoconiosis Panels, and of the sense of injustice of individual claimants, would probably disappear. For all these reasons I regard the paper by Dr. Catterall and Mr. Hunter as a valuable contribution to the study of, and to the diagnosis and assessment of disability in, the
pneumoconioses. No doubt Dr. Catterall will reply to the criticisms put forward by Dr. Gilson and Mr. Oldham, but it seems to me that the discrepancies which they note in tables I and II could have represented the findings on two different occasions. As for case 32, the massive shadow looks like cancer, and the category 3n applies only to the dust changes. Incidentally the X-ray picture illustrated in fig. 4 (case 31) is reminiscent of asbestosis.
Finally, I should have expected that Dr. Gilson, himself distinguished pulmonary physiologist, would have welcomed the application of full lung-function studies to the assessment of disability in pneumoconiosis. a
A. I. G. MCLAUGHLIN. RECURRENT URINARY INFECTIONS IN GIRLS
SIR,-The severity of the attacks by Dr. Fletcher (Jan. 30), and by Dr. Gilson and Mr. Oldham (Feb. 6) on the article by Dr. Catterall and Mr. Hunter (Jan. 16) is probably a measure of its importance. These correspondents chide you for publishing the article because they do not agree with its findings. Is there to be no free discussion on the various problems in pneumoconiosis unless all the participants conform to the views and thought-patterns of the establishment ? Are all poachers on the sacred preserves to be shot down ? Of course the article can be criticised;
most articles can be. But Dr. Catterall and Mr. Hunter, in my opinion, have been criticised for the wrong reasons. They did not set out to produce an epidemiological or statistical study. What they have done is to carry out careful clinical, radiographic, and lung-function studies on 35 coalminers who had been exposed for many years to the inhalation of coal-dust and had become disabled from occupational factors, either alone or combined with other factors in their total environment. I take it that the subjects included all those miners who came to their hospital at Leeds. Having examined their cases thoroughly, they compared their findings with those of the Pneumoconiosis Panels. They concluded that the compensation awarded by the Panels bore little relation to di&abiHty. and that the miners with least disability received the 1. Gilson,
J C , Hugh-Jones, P. Spec. Rep. Ser. med. Res. Coun, Lond. 290
1955. no
SIR,-May I reply briefly to the letters from Mr. Innes Williams (Jan. 9) and Dr. Markland (Jan. 30) about my paper on this topic. Both letters raise the same point-the importance of ureteral reflux in determining the fate of patients with urinary infections. I stand by my original statement about the possible occurrence of this condition in normal persons, though it has been questioned, in view of the following quotation from one of the After reviewing 16 reports sources to which I referred. Kleeman et al.say: " These findings suggest that vesicoureteral reflux occurs in a variable number of normal individuals." Both your correspondents question my assertion that the natural history of ureteral reflux is uncertain. Mr. Innes Williams, however, writes that minor degrees of reflux are often transient, and that " even more severe forms may cease spontaneously". This is precisely my point-that some patients with reflux recover from it, but that the factors involved are largely unknown. As for Dr. Markland’s contention that " significant reflux requires ureteral reimplantation ": I must insist that this is a personal opinion and not an established principle. Stewart2 writes: Until [the] mechanism of reflux is better understood, and until one can predict more reliably the outcome of an operative procedure, so-called ’vesicoureteroplasty ’ should be held in abeyance." ...
"
1. Kleeman, C. R., Hewitt, W. L., Guze, L. B. Medicine, 1960, 39, 3. 2. Panel on Ureteral Reflux in Children. J. Urol. 1961, 85, 119.
385
The panel discussion at which Stewart was speaking is worth studying by anyone interested in the subject. Four eminent urologists considered ureteral reflux at great length and expressed opinions so divergent that one can only conclude that in this field dogmatic statements are
unwarranted. Duchess of York
Hospital for Babies,
Manchester,
19.
DUNCAN MACAULAY.
700 BROKEN LEGS
SIR,-Your annotation (Jan. 23) rightly draws attention Nicoll’s recent review, and will, I hope, stimulate discussion. It might even lead to an exchange of results so that we could finally decide whether broken legs are becoming more difficult to mend or whether we are just making it seem so. Unfortunately so many of us are beguiled by the apparent advantages of internal fixation that we tend to regard all things
to
internal
as secure.
It certainly would be difficult to find 674 fractured legs treated conservatively in any hospital region here, and I cannot recall a publication in the last few years aimed at providing a fair comparison between external and internal fixation. South African orthopaedic surgeons should be congratulated on having a two-thirds majority despite the fact that many are post-war trained, either in Great Britain or the United States; at the height of the fixation fever. Because of the lack of precise and unbiased evaluation, a " belt-and-braces mentality persists. We plate the tibia and plaster the leg; we nail the femoral shaft and add the stresses of a walking caliper. We watch the printed shadows, and shy from eye and touch. But what the eye cannot see the X-ray should "
not
grieve over.
" Let it knit " is not a bad thing to write on all full-leg plasters where the skin is intact. So often, too, is union frustrated by frequent plaster changes and inexpert handling by radiographers and others, that it might not be out of place to add: Not to be opened before Christmas. JOCELYN HILL. Leicester. SOCIAL MEDICINE
SIR,-Professor Paul’s letter1 ends by inviting " criticism from anyone who happens to be interested in this subject, and particularly from those who knew Professor Ryle ... " . As his ward-clerk, later as his registrar, and thereafter as a frequent visitor to his home, I should like to add these comments. Like Paul, who is a clinician primarily, Ryle always had the broadest outlook on medicine. At Guy’s Hospital he noted that rheumatic fever was much commoner in people who came from houses near the river, and said that this was not necessarily because of the nearness of the river but because of poor social circumstances and especially the conditions accompanying working-class life in large cities."2 His first practical experience of clinical epidemiology probably dates from his work on leptospirosis icterohaemorrhagica and ’typhoid in the 1914-18 war. He never lost his interest in ordinary epidemiology, and the chapter on The Social Pathology of Rheumatic Fever " in his Natural History of Disease 2 demonstrates his evolution which culminated in his chair of social medicine. The phrase " social medicine " is bedevilled by its political implications as Dr. Parnell has said (Jan. 23). " Social pathology" seems to me a worse term than " social medicine " because nobody should think of health in terms of pathology alone, although pathology is a very good servant, and population pathology " and " environmental medicine will probably never be adopted as substitutes. In England epidemi"
"
"
ology
now seems to
Paul infers, and 1. 2.
Paul, J. Ryle, J.
take
possibly
a
much wider view than Professor orthodox epidemiologists do not
R. Lancet, 1964, ii, 1392. A. The Natural History of Disease.
London, 1948.
approve. For
example,
the
recently published Epidemiology.
Research and Teaching (by Prof. J. Pemberton. London, 1962), deals with a few infectious diseases, but devotes much space to the epidemiology of cancer, arterial
Reports
on
blood-pressure, and neurological disease, and to some recent developments in the teaching of social medicine. All this would have interested John Ryle, who I am sure would have favoured the term " social medicine ". He had much of the spirit of John Wesley, and could " certainly have said with him, I look upon all the world as my parish ". Without widespread harmony among all who wish for a healthy world, and without a catholic approach, medicine will not advance as John Ryle wished. R. E. SMITH. IRREVERSIBLE SHOCK to
SiR,ŁIn your very interesting editorial (Jan. 30) you refer reduced " venous return and cardiac output " as though
the second resulted from the first instead of vice versa, and as though both were a logical consequence of diminished blood-volume. May I show by an analogy why this is not so ? If the inlet and output pipes of a simple mechanical pump are in a ring circuit via a bladder full of fluid, it is surely obvious that circulation of fluid by the pump neither affects nor is affected by the state of inflation or deflation of the bladder. In the same way hxmorrhage and transfusion deflate or inflate the vascular system. The idea that either must have " any direct effect on venous return " is without foundation. Surely the mechanism which is affected is not venous return but venous pressure. This may indeed change cardiac output. You quote Cerletti et al. as having shown that a certain drug " sharply decreased the limb volume of cats, probably by venoconstriction, and it increased venous return and cardiac output ". If this means that venous return increased because of the emptying of blood from the limb I would point out that vasoconstriction can only shift blood from one part of the vascular system to another (or out of it altogether). It cannot, except momentarily and to a proportionally minute extent, alter venous return. However, it can and often does raise venous pressure, and this in turn may alter cardiac output and therefore venous return. It is only altered cardiac output which can make any sustained difference to venous return. Venous pressure, on the other hand, is created by, maintained by, and constantly under the influence of vascular compression. Surely the time has come to make less use of the unhelpful and mathematically vague concept of venous return, which, as commonly thought of, seems to envisage the heart as filling like a bath from a tap. Venous pressure is a much more realistic as well as measurable entity without which the heart could not possibly function. To omit mention of this important variable in an editorial on shock in 1965 is anachronistic to say the least.
joined
"
May I suggest, too, that " vasoconstriction should give way to vasocompression except when it is meant to imply alteration of calibre. H. DAINTREE JOHNSON. London, W.1. "
"
SIR,-The last paragraph of your excellent leader refers specifically to the subject of induced tolerance shock. But it is remarkable to find no reference the work of Ungar/ whose observations are highly relevant to this subject. His paper should be read in full. In it he showed that trauma of just sublethal severity protects against future severe trauma, that this protection is considerable, and that it is serum-transmissible from one animal to another and from rabbits to guineapigs. He also showed that large doses of ascorbic acid gave a protection which was as effective as previous trauma in preventing a lethal outcome.
to
to
1.
Ungar, G. Lancet, 1943, i,
421.
people have found this very difficult. She avoids this by assuming that the Industrial Injuries Act suggests that compensation should be given for all types of pulmonary disability. This I find inexcusable. I do not wish to give the impression that I consider the Industrial Injuries Act ideal: far from it, but I do want to say that I think the Medical Panels do an impossible job reasonably well. The fault is mainly with the Act and not with the Panels. Rhoose, near Barry, A. L. COCHRANE. Glamorgan.
SiR,—The article by Dr. Catterall and Mr. Hunter demonstrates some of the problems of diagnosis and assessment of disability in pneumoconiosis of coalworkers which have been evident for many years. There have been a number of careful investigations into lung function, such as that by Gilson and Hugh-Jones.1 Dr. Catterall and Mr. Hunter make no reference to the statutory framework within which the pneumoconiosis boards have to wotk. This defines pneumoconiosis in terms of radiology and histology, and it is in these terms that a diagnosis to satisfy legal requirements must be made. Contrary to the impression given in the article, bronchitis and emphysema are not compensable. The diagnostic value of pulmonary-function tests is limited by the fact that disease diagnosed in this way is not the prescribed disease " and cannot attract compensation. The authors give no observations which would enhance the diagnostic value of pulmonary-function tests; indeed, their division of the functional state of their subjects into four groups, not one of which contains either all or none of the cases of radiological pneumoconiosis, clearly demonstrates the limitations of these tests. Furthermore, it is certain that respiratory disability in coalminers may be due to other causes, some of which are unrelated to their work. For this reason it is regrettable that no reference is made to the miners’ smoking histories. "
Since there are no specific functional changes in pneumoconiosis of coalworkers, tests of function cannot be used to assess the proportion of disability which is attributable to this disease; therefore we cannot agree that referring to a respiratory-function laboratory coalminers who wish to apply for compensation would, by itself, help either the applicant or the medical board. R. I. MCCALLUM McCALLUM Nuffield Department of Industrial Health, Xuitietd T L. L cATtjADTG. G LEATHART. The University, Xewcastte Newcastle upon Tyne, 1. 1. G.
compensation. This is a conclusion which has inevitably engendered a great deal of heat. The diagnosis and assessment of disability in pneumoconiosis is admittedly very difficult, and the Pneumoconiosis Panels, within the somewhat rigid administrative and legal framework in which they have to work, are doing a very good job indeed. I know many of them well, and have worked closely with them on numerous occasions in connection with difficult cases; they most
themselves would be the first to admit that mistakes can be made. They are, however, in a unique position as regards compensation cases in that their diagnoses and assessments of disability, apart from death claims, are not subject to appeal. Dr. Catterall and Mr. Hunter, by using much more thorough lung-function tests than are at the disposal of the Panels for assessment of disability, have shown what might happen if an appeal system similar to that in France were to be adopted in this country. There, appeal boards, called Colleges de Trois Médecins, have been set up in the main industrial centres. Claimants who appeal are admitted to hospital for a week to undergo intensive examinations, including a full range of pulmonary-function tests. I have been privileged to sit at one of the Collèges and assist in the assessment and diagnosis of cases. I came away with the strong impression that justice was not only done in each case but was manifestly seen to be done. If some such system were to be adopted here, much of the criticisms of the findings of the Pneumoconiosis Panels, and of the sense of injustice of individual claimants, would probably disappear. For all these reasons I regard the paper by Dr. Catterall and Mr. Hunter as a valuable contribution to the study of, and to the diagnosis and assessment of disability in, the
pneumoconioses. No doubt Dr. Catterall will reply to the criticisms put forward by Dr. Gilson and Mr. Oldham, but it seems to me that the discrepancies which they note in tables I and II could have represented the findings on two different occasions. As for case 32, the massive shadow looks like cancer, and the category 3n applies only to the dust changes. Incidentally the X-ray picture illustrated in fig. 4 (case 31) is reminiscent of asbestosis.
Finally, I should have expected that Dr. Gilson, himself distinguished pulmonary physiologist, would have welcomed the application of full lung-function studies to the assessment of disability in pneumoconiosis. a
A. I. G. MCLAUGHLIN. RECURRENT URINARY INFECTIONS IN GIRLS
SIR,-The severity of the attacks by Dr. Fletcher (Jan. 30), and by Dr. Gilson and Mr. Oldham (Feb. 6) on the article by Dr. Catterall and Mr. Hunter (Jan. 16) is probably a measure of its importance. These correspondents chide you for publishing the article because they do not agree with its findings. Is there to be no free discussion on the various problems in pneumoconiosis unless all the participants conform to the views and thought-patterns of the establishment ? Are all poachers on the sacred preserves to be shot down ? Of course the article can be criticised;
most articles can be. But Dr. Catterall and Mr. Hunter, in my opinion, have been criticised for the wrong reasons. They did not set out to produce an epidemiological or statistical study. What they have done is to carry out careful clinical, radiographic, and lung-function studies on 35 coalminers who had been exposed for many years to the inhalation of coal-dust and had become disabled from occupational factors, either alone or combined with other factors in their total environment. I take it that the subjects included all those miners who came to their hospital at Leeds. Having examined their cases thoroughly, they compared their findings with those of the Pneumoconiosis Panels. They concluded that the compensation awarded by the Panels bore little relation to di&abiHty. and that the miners with least disability received the 1. Gilson,
J C , Hugh-Jones, P. Spec. Rep. Ser. med. Res. Coun, Lond. 290
1955. no
SIR,-May I reply briefly to the letters from Mr. Innes Williams (Jan. 9) and Dr. Markland (Jan. 30) about my paper on this topic. Both letters raise the same point-the importance of ureteral reflux in determining the fate of patients with urinary infections. I stand by my original statement about the possible occurrence of this condition in normal persons, though it has been questioned, in view of the following quotation from one of the After reviewing 16 reports sources to which I referred. Kleeman et al.say: " These findings suggest that vesicoureteral reflux occurs in a variable number of normal individuals." Both your correspondents question my assertion that the natural history of ureteral reflux is uncertain. Mr. Innes Williams, however, writes that minor degrees of reflux are often transient, and that " even more severe forms may cease spontaneously". This is precisely my point-that some patients with reflux recover from it, but that the factors involved are largely unknown. As for Dr. Markland’s contention that " significant reflux requires ureteral reimplantation ": I must insist that this is a personal opinion and not an established principle. Stewart2 writes: Until [the] mechanism of reflux is better understood, and until one can predict more reliably the outcome of an operative procedure, so-called ’vesicoureteroplasty ’ should be held in abeyance." ...
"
1. Kleeman, C. R., Hewitt, W. L., Guze, L. B. Medicine, 1960, 39, 3. 2. Panel on Ureteral Reflux in Children. J. Urol. 1961, 85, 119.
385
The panel discussion at which Stewart was speaking is worth studying by anyone interested in the subject. Four eminent urologists considered ureteral reflux at great length and expressed opinions so divergent that one can only conclude that in this field dogmatic statements are
unwarranted. Duchess of York
Hospital for Babies,
Manchester,
19.
DUNCAN MACAULAY.
700 BROKEN LEGS
SIR,-Your annotation (Jan. 23) rightly draws attention Nicoll’s recent review, and will, I hope, stimulate discussion. It might even lead to an exchange of results so that we could finally decide whether broken legs are becoming more difficult to mend or whether we are just making it seem so. Unfortunately so many of us are beguiled by the apparent advantages of internal fixation that we tend to regard all things
to
internal
as secure.
It certainly would be difficult to find 674 fractured legs treated conservatively in any hospital region here, and I cannot recall a publication in the last few years aimed at providing a fair comparison between external and internal fixation. South African orthopaedic surgeons should be congratulated on having a two-thirds majority despite the fact that many are post-war trained, either in Great Britain or the United States; at the height of the fixation fever. Because of the lack of precise and unbiased evaluation, a " belt-and-braces mentality persists. We plate the tibia and plaster the leg; we nail the femoral shaft and add the stresses of a walking caliper. We watch the printed shadows, and shy from eye and touch. But what the eye cannot see the X-ray should "
not
grieve over.
" Let it knit " is not a bad thing to write on all full-leg plasters where the skin is intact. So often, too, is union frustrated by frequent plaster changes and inexpert handling by radiographers and others, that it might not be out of place to add: Not to be opened before Christmas. JOCELYN HILL. Leicester. SOCIAL MEDICINE
SIR,-Professor Paul’s letter1 ends by inviting " criticism from anyone who happens to be interested in this subject, and particularly from those who knew Professor Ryle ... " . As his ward-clerk, later as his registrar, and thereafter as a frequent visitor to his home, I should like to add these comments. Like Paul, who is a clinician primarily, Ryle always had the broadest outlook on medicine. At Guy’s Hospital he noted that rheumatic fever was much commoner in people who came from houses near the river, and said that this was not necessarily because of the nearness of the river but because of poor social circumstances and especially the conditions accompanying working-class life in large cities."2 His first practical experience of clinical epidemiology probably dates from his work on leptospirosis icterohaemorrhagica and ’typhoid in the 1914-18 war. He never lost his interest in ordinary epidemiology, and the chapter on The Social Pathology of Rheumatic Fever " in his Natural History of Disease 2 demonstrates his evolution which culminated in his chair of social medicine. The phrase " social medicine " is bedevilled by its political implications as Dr. Parnell has said (Jan. 23). " Social pathology" seems to me a worse term than " social medicine " because nobody should think of health in terms of pathology alone, although pathology is a very good servant, and population pathology " and " environmental medicine will probably never be adopted as substitutes. In England epidemi"
"
"
ology
now seems to
Paul infers, and 1. 2.
Paul, J. Ryle, J.
take
possibly
a
much wider view than Professor orthodox epidemiologists do not
R. Lancet, 1964, ii, 1392. A. The Natural History of Disease.
London, 1948.
approve. For
example,
the
recently published Epidemiology.
Research and Teaching (by Prof. J. Pemberton. London, 1962), deals with a few infectious diseases, but devotes much space to the epidemiology of cancer, arterial
Reports
on
blood-pressure, and neurological disease, and to some recent developments in the teaching of social medicine. All this would have interested John Ryle, who I am sure would have favoured the term " social medicine ". He had much of the spirit of John Wesley, and could " certainly have said with him, I look upon all the world as my parish ". Without widespread harmony among all who wish for a healthy world, and without a catholic approach, medicine will not advance as John Ryle wished. R. E. SMITH. IRREVERSIBLE SHOCK to
SiR,ŁIn your very interesting editorial (Jan. 30) you refer reduced " venous return and cardiac output " as though
the second resulted from the first instead of vice versa, and as though both were a logical consequence of diminished blood-volume. May I show by an analogy why this is not so ? If the inlet and output pipes of a simple mechanical pump are in a ring circuit via a bladder full of fluid, it is surely obvious that circulation of fluid by the pump neither affects nor is affected by the state of inflation or deflation of the bladder. In the same way hxmorrhage and transfusion deflate or inflate the vascular system. The idea that either must have " any direct effect on venous return " is without foundation. Surely the mechanism which is affected is not venous return but venous pressure. This may indeed change cardiac output. You quote Cerletti et al. as having shown that a certain drug " sharply decreased the limb volume of cats, probably by venoconstriction, and it increased venous return and cardiac output ". If this means that venous return increased because of the emptying of blood from the limb I would point out that vasoconstriction can only shift blood from one part of the vascular system to another (or out of it altogether). It cannot, except momentarily and to a proportionally minute extent, alter venous return. However, it can and often does raise venous pressure, and this in turn may alter cardiac output and therefore venous return. It is only altered cardiac output which can make any sustained difference to venous return. Venous pressure, on the other hand, is created by, maintained by, and constantly under the influence of vascular compression. Surely the time has come to make less use of the unhelpful and mathematically vague concept of venous return, which, as commonly thought of, seems to envisage the heart as filling like a bath from a tap. Venous pressure is a much more realistic as well as measurable entity without which the heart could not possibly function. To omit mention of this important variable in an editorial on shock in 1965 is anachronistic to say the least.
joined
"
May I suggest, too, that " vasoconstriction should give way to vasocompression except when it is meant to imply alteration of calibre. H. DAINTREE JOHNSON. London, W.1. "
"
SIR,-The last paragraph of your excellent leader refers specifically to the subject of induced tolerance shock. But it is remarkable to find no reference the work of Ungar/ whose observations are highly relevant to this subject. His paper should be read in full. In it he showed that trauma of just sublethal severity protects against future severe trauma, that this protection is considerable, and that it is serum-transmissible from one animal to another and from rabbits to guineapigs. He also showed that large doses of ascorbic acid gave a protection which was as effective as previous trauma in preventing a lethal outcome.
to
to
1.
Ungar, G. Lancet, 1943, i,
421.