- Email: [email protected]
REFLECTIONS ON MEDICAL TRAVEL
490
Unfortunately many local authorities give either only partial treatment or none at all to their sludge, and I do not think that this type should be confused with that receiving full extensive treatment. G. E. TUCKER. ADRENALINE
FOR
VOMITING
OF
PREGNANCY
SIR,-A recent letter from Dr. Eccles (Aug. 3) drew attention to a " forgotten " treatment of vomiting of pregnancy by the oral administration of adrenaline. Such a treatment would not appear to fit in with the currently accepted views of the hormonal causation of vomiting of pregnancy. Nevertheless we have had, over the past two years, a considerable number of letters from medical men reporting their observations thatBovril’ is very effective in the treatment of this disorder. As our research department is carrying out new investigations into the chemical composition and physiological effects of Bovril, we would welcome any information from your readers relevant to this subject. We already know from our chemical investigations that this product derived from animal muscle contains a very large number of substances of physiological interest.’What is not known is the physiological effects of many of these compounds if given by mouth. It is possible that a collection of clinical impressions might point the way to opening up this field. Bovril Research Laboratories, London, E.C.1.
A. E. BENDER.
ÆTIOLOGY OF PRE-ECLAMPSIA SIR,—Since my letter of June 1, Caldeyro-Barcia
et a
have recorded a much larger series of severe cases of hydramnios than we have been able to study here, some of their patients the intra-uterine pressure was raised above normal, and they were able to reduce the pressure by withdrawing up to 5 litres of fluid. On patients were not so distended, and this may account for our differing pressure measurements, to which Mr. Sophiao draws attention in his letter of July 13. The question of hydramnios does not, I think, affect the main argument concerning the role of myometria) activity in pre-eclampsia" University College Hospital, C. N. SMYTH. London. RECURRENT APHTHOUS STOMATITIS
SiR,-Your annotation of Aug.
10
interested mE
considerably. Being myself in dental practice, a large number of patients with aphthous ulcers come my way. Unfm. tunately, small lesions of the oral mucosa, differingiu pathology, often simulate each other, with the result that the terminology tends to be confusing. However, the prevalence of the condition and the periodicity as described by Sircus et al. make it seem likely that this is the aphthous ulceration seen so frequently in the dental surgery. For the past six or seven years I have been prescribing oral anti-histamine for the condition, and so far as I remember no case has failed to respond. The dis. comfort disappears in 24-36 hours, though the ulcers may take 4 to 5 days to heal completely. This compares with an average of 10 days in untreated cases. Ambodryl (25 mg. b.d.) has proved most successful because of it, lack of soporific effect. Perhaps the cure suggests the cause ;it may at least point the way for further investigation. JOHN G. OWEN. an
TREATMENT OF HIRSCHSPRUNG’S DISEASE
SIR,—Mr. Cooling (Aug. 3) seems unjust in his criticism of Mr. O’Donnell’s letter of July 20. Mr. O’Donnell did not " condemn State’s operation out of hand." He gave his reasons for preferring the Swenson procedure, for which large-scale and careful follow-up studies are available, and suggested that the proponents of State’s operation should match them with a similarly critical review. It is true that Mr. Wyllie 2 made the point that dissection on the muscular wall of the rectum is timeconsuming in the absence of a ready plane of cleavage. Nevertheless, patient dissection is all that is required to achieve the mobilisation. The position can be quite different in the secondary operation when the fixation of the rectum to the surrounding tissues is much firmer and can become hazardous instead of merely tedious. But Mr. Wyllie 2 has undoubtedly produced the important reason for considering as potentially dangerous Mr. Cooling’s advice to try State’s operation first. It is that Hirschsprung’s disease may kill the patient. The question is not one of growing up constipated or not " but of growing up at all. Mr. Cooling is probably hitting the nail on the head when he suggests that the children’s hospitals get the early severe case and the rectal hospitals the case in which the patient has survived to adult life. Nor do I feel that Mr. Wyllie is required to explain why the results of this (Swenson) operation are not as good as one would hope for on theoretical grounds." On the pathological basis of an aganglionic segment the Swenson procedure is a rational way of relieving the condition. But the question remained-how well could continence be maintained after such a radical removal of the distal rectum ? I would have thought that the surprising thing was how well these children manage without this specialised piece of bowel, for most of the troubles referred to were temporary and minor ones. Certainly in my experience the parents (and children too when old enough) have thought them trivial in comparison to the miserv of Hirschsprung’s disease. H. H. NIXON. "
"
can
REFLECTIONS ON MEDICAL TRAVEL
SIR,—I have read with interest Professor L. J. Witts’s on his recent visit to the Far East and the Antipodes. No less does the call " Come over into Macedonia and help us " come from those of us who work in medical missions in Africa. In a recent issue of the Nursing Tinvcs there is an account of a nursing sister in Tanganyika doing a csesarean section for lack of a doctor. Here in a far less remote part our need is no less desperate.
two articles
The work is among a primitive and backward people. 11’/ have 110 inpatients and an average of 30 outpatients daily: The general administration, dispensing, radiography, nurses lectures, emergency operations, and calls out to the district are all dealt with by one doctor. A large amount of work is left undone for lack of an assistant. This tale can be repeated by many Anglican missions in Africa. Time and time again we read of or hear from our colleague’ of the difficulties of practice in the United Kingdom today, Where then is that spirit of service and of adventure, the enthusiasm for use of initiative, the real love of one’s fellow men ? There is joy in practising one’s profession where there is BC question of overcrowding, where there is a real need for such help as one can give. There is the deeper joy of obedienceto Our Lord’s command to heal the sick and there is also the joy of working side by side with the Church. On a pro fessional level the work is extremely varied and full of interest
Are the young doctors of today so concerned with the security that the Welfare State offers them ? History shows us that there is little if any security in this world. Is there no-one? Come over into Macedonia—into Caldeyro-Barcia, C., Pose, S. V., Alvarez, H. Gynec. 1957, 73, 1238. 2. Witts, L. J. Lancet, 1957, i, 1291, 1343. 1.
1. Biochem J. (in the press). 2. Wyllie, G. G. Lancet, 1957, i, 1143
2
Amer. J.
Obstet.
I
491
Africa-and help us, for our need is very great and time is getting short. Information would gladly be given by any of
the
the missionarv societies of the Church. All Saints Mission Hospital, PAULINE C. MARSHALL. Transkei, Cape Province. THE NEWBORN INFANT’S OXYGEN-SUPPLY
SIR,—While the Rappaport 1-Jäykkä 2 principle of
in the neonate seems to be sound, how it can be applied to hyaline-membrane disease, and I am in agreement with Dr. Brown’s criticisms (July 13, Aug. 3) of Dr. Bonham Carter’s views3 on the genesis of this syndrome. Indeed, the congestion of the lungs is so great in this condition that a substantial component of the membrane is formed by lysed red bloodcells-as I have already demonstrated 4-7-which, incidentally, would seem to establish beyond doubt (and more definitely than Gitlin and Craig 8 have done) that the membrane is an exudate from the pulmonary
When there is only one record of a past event, as in this Bible story, there is scientifically no justification for picking out the bits of the record that suit our particular This lesson needs to be learned by medical thesis. professors, and by some theological professors. Perhaps they would be well advised to interpret this particular storv as a warning on the fate of all Philistines. F. L. CLARK.
pulmonary expansion I fail to
see
capillaries. Dr. Bonham Carter’s hypotheses fail to embrace the known effects of high oxygen tensions, diabetes, or hormones in promoting the development of hyaline membranes, and it is not at all clear to me how vena-caval pressures can be accurately or even speculatively related to pulmonary capillary pressures.9 Lastly, I must agree with Dr. Bonham Carter and Dr. Gunther 10 when they say that they are not clear that hyaline-membrane disease and all of the pulmonary syndrome are the same thing. If that is the case, why coin new names before we understand what the basic mechanisms are’? General Hospital. Sudbury, Ontario, Canada.
MATTHEW J. G. LYNCH.
A NEW DISEASE ?
SIR,—Like Dr. Roberts (Aug. 24)
I
was
taught
as
a
medical student that syphilis was described in the Old Testament. But the evidence adduced to me was Proverbs (XII, 4) where a virtuous woman is described as a crown to her husband, but she that rnaketh ashamed is as rottenness in his bones, or as some translations have it as pus in his bones. The description is no doubt meant figuratively ; but it was suggested that it must refer to gummata and not tuberculosis (which would not be common as a chronic condition allowing a man still to pursue his male habits). C. O. S. BLYTII BROOKE. -
"
SIR,—Surely, the phrase, Till a dart strike through his liver" (Proverbs, VII, 23) immediately suggests the lightning pains of taboparesis to a medical reader-a thorough case-history having been given by the Bible in the earlier part of the same chapter. AYLMER J. CROMPTON.
SIR,—Although the late Prof. Haswell Wilson may have talked to his students with his tongue in his cheek about the remote possibility of Samson being a syphilitic, the fact that Dr. Roberts has put it on record (Aug. 24) justifies a challenge of the facts quoted. The Bible nowhere suggests that Samson announced that, he could demolish the temple unaided." Judges (xvi, 30) states that he did it, thus bringing down not only the pillars of the temple but also two pillars (asthenia and general paralysis of the insane) of this strange hypothesis. "
1. Rappaport, T. Lancet, July 20, 1957, p. 148. 2. Jaykka, S. Acta pœdiat., Stockh. 1957, 46, suppl. 112. 3. Bonham Carter, R. E. Lancet, 1957, i, 1292. 4. Lynch, M. J. G., Mellor, L. D. Ibid, 1955, i, 1002. 5. Lynch, M. J. G., Mellor, L. D. J. Pediat. 1955, 47, 275. 6. Lynch, M. J. G. Ibid, 1956, 48, 165. 7. Lynch, M. J. G., Mellor, L. D., Badgery, A. R. Ibid, p. 602. 8. Gitlin, D., Craig, J. M. Pediatrics, 1956, 17, 64. 9. Bonham Carter, R. E., Bound, J. P., Smellie, J. Lancet, 1956,
ii, 1320. 10. Bonham Carter, R.
E., Gunther, M.
Ibid, July 6, 1957, p. 45.
TRANSMISSION OF YAWS
SIR,—In the letter from the Widdicombe File (Aug. 10, p. 285) Harry Hawke asks why yaws is still confined to the tropics. But within the tropics it was rapidly disunder urbanised conditions long before the Bismuth and arsenic were introduction of penicillin. useful and were widely used. The following are the conditions which favour the transmission of yaws :
appearing
(1) A warm damp climate. (2) Little or no clothing-therefore skin exposed abrasions,
to
flies, and
to
to infections.
(3) Infrequent or irregular bathing. (4) Minor trauma neglected. (5) Floors and compound persistently
infected by discharge from lesions of feet, &c., from those who have yaws. (6) Overcrowded sleeping conditions. (7) Lack of treatment, so that each case remains infective for a long time.
Reversal of any of these factors will diminish the spread of yaws. CICELY D. WILLIAMS. EFFECT OF ANTIBIOTICS ON PURULENT SPUTUM
SIR,—We are grateful for the helpful comments made by Dr. May and Dr. Oswald (Aug. 17) on our article of Aug. 3. We should, however, like to say that ours was intended primarily as a clinical paper, and the work was not undertaken as a bacteriological research project. We were aware of the value of multiple sputum exanunations in determining the true bacterial flora in chronic bronchitis and bronchiectasis, but we were anxious to adopt a procedure which was likely to represent normal practice in the average hospital. In this respect we believe routine " practice means a single pre-treatment specimen. It should be mentioned that, though only a single specimen of sputum was used in our series, the specimen was examined very thoroughly. It was treated with pancreatin, films were examined, and two culture-plates (blood-agar and heated blood-agar) were used for each examination. With regard to our isolation-rate, we should point out that our figures refer to predominant growths, and the actual isolation-rate of the significant pathogens would have been considerably higher if " the mere presence " of the organisms had been recorded. Dr. May and his co-workers have well established the importance of Htemophilus influenzœ and the pneumo"
coccus in chronic bronchitis and bronchiectasis, and this is now generally accepted. Dr. May and Dr. Oswald say that at their bronchitis clinic they now seldom examine the sputum bacteriologically, routine or otherwise, and that treatment is based on the assumption that both organisms are present. On this basis there would seem to be no place for penicillin alone as primary treatment, but our results with this drug, at least in chronic bronchitis, suggest otherwise. They mention a case where one specimen of sputum showed no H. influenzœ but a second did, and the patient’s response " was completely in accord with the to chemotherapy supposition that H. influenzce was the pathogen." We are sure they would agree that in our 11 cases where H. influenzœ was cultured as a predominant organism the same supposition would apply. Penicillin, in one should have been or two mega units daily dosage, ineffective in these cases, as " neither would suppress H. influenzœ" yet 6 of these 11 cases resnonded to "
"
Unfortunately many local authorities give either only partial treatment or none at all to their sludge, and I do not think that this type should be confused with that receiving full extensive treatment. G. E. TUCKER. ADRENALINE
FOR
VOMITING
OF
PREGNANCY
SIR,-A recent letter from Dr. Eccles (Aug. 3) drew attention to a " forgotten " treatment of vomiting of pregnancy by the oral administration of adrenaline. Such a treatment would not appear to fit in with the currently accepted views of the hormonal causation of vomiting of pregnancy. Nevertheless we have had, over the past two years, a considerable number of letters from medical men reporting their observations thatBovril’ is very effective in the treatment of this disorder. As our research department is carrying out new investigations into the chemical composition and physiological effects of Bovril, we would welcome any information from your readers relevant to this subject. We already know from our chemical investigations that this product derived from animal muscle contains a very large number of substances of physiological interest.’What is not known is the physiological effects of many of these compounds if given by mouth. It is possible that a collection of clinical impressions might point the way to opening up this field. Bovril Research Laboratories, London, E.C.1.
A. E. BENDER.
ÆTIOLOGY OF PRE-ECLAMPSIA SIR,—Since my letter of June 1, Caldeyro-Barcia
et a
have recorded a much larger series of severe cases of hydramnios than we have been able to study here, some of their patients the intra-uterine pressure was raised above normal, and they were able to reduce the pressure by withdrawing up to 5 litres of fluid. On patients were not so distended, and this may account for our differing pressure measurements, to which Mr. Sophiao draws attention in his letter of July 13. The question of hydramnios does not, I think, affect the main argument concerning the role of myometria) activity in pre-eclampsia" University College Hospital, C. N. SMYTH. London. RECURRENT APHTHOUS STOMATITIS
SiR,-Your annotation of Aug.
10
interested mE
considerably. Being myself in dental practice, a large number of patients with aphthous ulcers come my way. Unfm. tunately, small lesions of the oral mucosa, differingiu pathology, often simulate each other, with the result that the terminology tends to be confusing. However, the prevalence of the condition and the periodicity as described by Sircus et al. make it seem likely that this is the aphthous ulceration seen so frequently in the dental surgery. For the past six or seven years I have been prescribing oral anti-histamine for the condition, and so far as I remember no case has failed to respond. The dis. comfort disappears in 24-36 hours, though the ulcers may take 4 to 5 days to heal completely. This compares with an average of 10 days in untreated cases. Ambodryl (25 mg. b.d.) has proved most successful because of it, lack of soporific effect. Perhaps the cure suggests the cause ;it may at least point the way for further investigation. JOHN G. OWEN. an
TREATMENT OF HIRSCHSPRUNG’S DISEASE
SIR,—Mr. Cooling (Aug. 3) seems unjust in his criticism of Mr. O’Donnell’s letter of July 20. Mr. O’Donnell did not " condemn State’s operation out of hand." He gave his reasons for preferring the Swenson procedure, for which large-scale and careful follow-up studies are available, and suggested that the proponents of State’s operation should match them with a similarly critical review. It is true that Mr. Wyllie 2 made the point that dissection on the muscular wall of the rectum is timeconsuming in the absence of a ready plane of cleavage. Nevertheless, patient dissection is all that is required to achieve the mobilisation. The position can be quite different in the secondary operation when the fixation of the rectum to the surrounding tissues is much firmer and can become hazardous instead of merely tedious. But Mr. Wyllie 2 has undoubtedly produced the important reason for considering as potentially dangerous Mr. Cooling’s advice to try State’s operation first. It is that Hirschsprung’s disease may kill the patient. The question is not one of growing up constipated or not " but of growing up at all. Mr. Cooling is probably hitting the nail on the head when he suggests that the children’s hospitals get the early severe case and the rectal hospitals the case in which the patient has survived to adult life. Nor do I feel that Mr. Wyllie is required to explain why the results of this (Swenson) operation are not as good as one would hope for on theoretical grounds." On the pathological basis of an aganglionic segment the Swenson procedure is a rational way of relieving the condition. But the question remained-how well could continence be maintained after such a radical removal of the distal rectum ? I would have thought that the surprising thing was how well these children manage without this specialised piece of bowel, for most of the troubles referred to were temporary and minor ones. Certainly in my experience the parents (and children too when old enough) have thought them trivial in comparison to the miserv of Hirschsprung’s disease. H. H. NIXON. "
"
can
REFLECTIONS ON MEDICAL TRAVEL
SIR,—I have read with interest Professor L. J. Witts’s on his recent visit to the Far East and the Antipodes. No less does the call " Come over into Macedonia and help us " come from those of us who work in medical missions in Africa. In a recent issue of the Nursing Tinvcs there is an account of a nursing sister in Tanganyika doing a csesarean section for lack of a doctor. Here in a far less remote part our need is no less desperate.
two articles
The work is among a primitive and backward people. 11’/ have 110 inpatients and an average of 30 outpatients daily: The general administration, dispensing, radiography, nurses lectures, emergency operations, and calls out to the district are all dealt with by one doctor. A large amount of work is left undone for lack of an assistant. This tale can be repeated by many Anglican missions in Africa. Time and time again we read of or hear from our colleague’ of the difficulties of practice in the United Kingdom today, Where then is that spirit of service and of adventure, the enthusiasm for use of initiative, the real love of one’s fellow men ? There is joy in practising one’s profession where there is BC question of overcrowding, where there is a real need for such help as one can give. There is the deeper joy of obedienceto Our Lord’s command to heal the sick and there is also the joy of working side by side with the Church. On a pro fessional level the work is extremely varied and full of interest
Are the young doctors of today so concerned with the security that the Welfare State offers them ? History shows us that there is little if any security in this world. Is there no-one? Come over into Macedonia—into Caldeyro-Barcia, C., Pose, S. V., Alvarez, H. Gynec. 1957, 73, 1238. 2. Witts, L. J. Lancet, 1957, i, 1291, 1343. 1.
1. Biochem J. (in the press). 2. Wyllie, G. G. Lancet, 1957, i, 1143
2
Amer. J.
Obstet.
I
491
Africa-and help us, for our need is very great and time is getting short. Information would gladly be given by any of
the
the missionarv societies of the Church. All Saints Mission Hospital, PAULINE C. MARSHALL. Transkei, Cape Province. THE NEWBORN INFANT’S OXYGEN-SUPPLY
SIR,—While the Rappaport 1-Jäykkä 2 principle of
in the neonate seems to be sound, how it can be applied to hyaline-membrane disease, and I am in agreement with Dr. Brown’s criticisms (July 13, Aug. 3) of Dr. Bonham Carter’s views3 on the genesis of this syndrome. Indeed, the congestion of the lungs is so great in this condition that a substantial component of the membrane is formed by lysed red bloodcells-as I have already demonstrated 4-7-which, incidentally, would seem to establish beyond doubt (and more definitely than Gitlin and Craig 8 have done) that the membrane is an exudate from the pulmonary
When there is only one record of a past event, as in this Bible story, there is scientifically no justification for picking out the bits of the record that suit our particular This lesson needs to be learned by medical thesis. professors, and by some theological professors. Perhaps they would be well advised to interpret this particular storv as a warning on the fate of all Philistines. F. L. CLARK.
pulmonary expansion I fail to
see
capillaries. Dr. Bonham Carter’s hypotheses fail to embrace the known effects of high oxygen tensions, diabetes, or hormones in promoting the development of hyaline membranes, and it is not at all clear to me how vena-caval pressures can be accurately or even speculatively related to pulmonary capillary pressures.9 Lastly, I must agree with Dr. Bonham Carter and Dr. Gunther 10 when they say that they are not clear that hyaline-membrane disease and all of the pulmonary syndrome are the same thing. If that is the case, why coin new names before we understand what the basic mechanisms are’? General Hospital. Sudbury, Ontario, Canada.
MATTHEW J. G. LYNCH.
A NEW DISEASE ?
SIR,—Like Dr. Roberts (Aug. 24)
I
was
taught
as
a
medical student that syphilis was described in the Old Testament. But the evidence adduced to me was Proverbs (XII, 4) where a virtuous woman is described as a crown to her husband, but she that rnaketh ashamed is as rottenness in his bones, or as some translations have it as pus in his bones. The description is no doubt meant figuratively ; but it was suggested that it must refer to gummata and not tuberculosis (which would not be common as a chronic condition allowing a man still to pursue his male habits). C. O. S. BLYTII BROOKE. -
"
SIR,—Surely, the phrase, Till a dart strike through his liver" (Proverbs, VII, 23) immediately suggests the lightning pains of taboparesis to a medical reader-a thorough case-history having been given by the Bible in the earlier part of the same chapter. AYLMER J. CROMPTON.
SIR,—Although the late Prof. Haswell Wilson may have talked to his students with his tongue in his cheek about the remote possibility of Samson being a syphilitic, the fact that Dr. Roberts has put it on record (Aug. 24) justifies a challenge of the facts quoted. The Bible nowhere suggests that Samson announced that, he could demolish the temple unaided." Judges (xvi, 30) states that he did it, thus bringing down not only the pillars of the temple but also two pillars (asthenia and general paralysis of the insane) of this strange hypothesis. "
1. Rappaport, T. Lancet, July 20, 1957, p. 148. 2. Jaykka, S. Acta pœdiat., Stockh. 1957, 46, suppl. 112. 3. Bonham Carter, R. E. Lancet, 1957, i, 1292. 4. Lynch, M. J. G., Mellor, L. D. Ibid, 1955, i, 1002. 5. Lynch, M. J. G., Mellor, L. D. J. Pediat. 1955, 47, 275. 6. Lynch, M. J. G. Ibid, 1956, 48, 165. 7. Lynch, M. J. G., Mellor, L. D., Badgery, A. R. Ibid, p. 602. 8. Gitlin, D., Craig, J. M. Pediatrics, 1956, 17, 64. 9. Bonham Carter, R. E., Bound, J. P., Smellie, J. Lancet, 1956,
ii, 1320. 10. Bonham Carter, R.
E., Gunther, M.
Ibid, July 6, 1957, p. 45.
TRANSMISSION OF YAWS
SIR,—In the letter from the Widdicombe File (Aug. 10, p. 285) Harry Hawke asks why yaws is still confined to the tropics. But within the tropics it was rapidly disunder urbanised conditions long before the Bismuth and arsenic were introduction of penicillin. useful and were widely used. The following are the conditions which favour the transmission of yaws :
appearing
(1) A warm damp climate. (2) Little or no clothing-therefore skin exposed abrasions,
to
flies, and
to
to infections.
(3) Infrequent or irregular bathing. (4) Minor trauma neglected. (5) Floors and compound persistently
infected by discharge from lesions of feet, &c., from those who have yaws. (6) Overcrowded sleeping conditions. (7) Lack of treatment, so that each case remains infective for a long time.
Reversal of any of these factors will diminish the spread of yaws. CICELY D. WILLIAMS. EFFECT OF ANTIBIOTICS ON PURULENT SPUTUM
SIR,—We are grateful for the helpful comments made by Dr. May and Dr. Oswald (Aug. 17) on our article of Aug. 3. We should, however, like to say that ours was intended primarily as a clinical paper, and the work was not undertaken as a bacteriological research project. We were aware of the value of multiple sputum exanunations in determining the true bacterial flora in chronic bronchitis and bronchiectasis, but we were anxious to adopt a procedure which was likely to represent normal practice in the average hospital. In this respect we believe routine " practice means a single pre-treatment specimen. It should be mentioned that, though only a single specimen of sputum was used in our series, the specimen was examined very thoroughly. It was treated with pancreatin, films were examined, and two culture-plates (blood-agar and heated blood-agar) were used for each examination. With regard to our isolation-rate, we should point out that our figures refer to predominant growths, and the actual isolation-rate of the significant pathogens would have been considerably higher if " the mere presence " of the organisms had been recorded. Dr. May and his co-workers have well established the importance of Htemophilus influenzœ and the pneumo"
coccus in chronic bronchitis and bronchiectasis, and this is now generally accepted. Dr. May and Dr. Oswald say that at their bronchitis clinic they now seldom examine the sputum bacteriologically, routine or otherwise, and that treatment is based on the assumption that both organisms are present. On this basis there would seem to be no place for penicillin alone as primary treatment, but our results with this drug, at least in chronic bronchitis, suggest otherwise. They mention a case where one specimen of sputum showed no H. influenzœ but a second did, and the patient’s response " was completely in accord with the to chemotherapy supposition that H. influenzce was the pathogen." We are sure they would agree that in our 11 cases where H. influenzœ was cultured as a predominant organism the same supposition would apply. Penicillin, in one should have been or two mega units daily dosage, ineffective in these cases, as " neither would suppress H. influenzœ" yet 6 of these 11 cases resnonded to "
"