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RETROPUBIC PROSTATECTOMY
799 incubation when they have been subjected to P.A.S. concentrations higher than 0-015 mg. per 100 ml. so that the characteristic myceliform forms never arise. I have interpreted this phenomenon as a sign that there is an initial growth which ceases after some days owing to the bacteriostatic effect of P.A.S. The greater the growth-rate of the bacilli, the greater will be the initial growthbefore P.A.s. has time to exert its inhibiting effect. The fact that P.A.S. does not immediately affect the growth with Pryce’s slide-culture method agrees with the findings of Lehmann,3 who seldom obtained more than 90-95% inhibition in experiments with Sauton cultures despite high P.A.S. concentrations. So far I have not observed any consistent resistance to P.A.S. in my experiments with numerous samples from patients treated with this substance. In no case was there any growth in a concentration of 1-5 mg. P.A.S. per 100 ml., and consequently, since in ordinary P.A.S. therapy the blood concentration usually lies between 2 and 6 mg. per 100 ml., resistance of clinical importance has not been observed. OLOF SIEVERS. Bacteriological Laboratory, Sahlgren’s Hospital, Gothenburg, Sweden.
Should he have an operation ? It is in this type of case that I believe the residual-urine test to be of great value. Surely a prostate which prevents the bladder from emptying must be more dangerous than one which is less obstructive. I have been aware for a long time that a prostate might affect the upper urinary tract without producing residual urine, but have found little evidence of this in my own practice. I think that such cases must be exceptional and need not affect our general indications for operation. T. L. CHAPMAN. Glasgow.
prolonged
RISK FROM ASPIRIN PREPARATION
SiR,--In recent years an aspirin preparation has been introduced to the English market from across the Atlantic of which the novelty is that it can be eaten like a sweet." Have the makers carefully considered how easy it would be for an infant exploring the cupboards to eat these tablets " just like sweets " ? Who has not rescued his own children just in time from such a happening ? A warning on the package, and the wrapping of all tablets of this type in transparent paper of a distinctive colour never used for sweets, might help to "
e
counter the risk. Newcastle-on-Tyne.
A. FORSTER.
RETROPUBIC PROSTATECTOMY
surprised that Mr. Millin and Mr. Macalister (April 23) do not always advise operation for SiR,-I am not
with minimal symptoms. I am surprised indeed that they describe this view as "commonplace knowledge." Examination of the appropriate chapters of 8 standard textbooks of general surgery showed that 5 make no mention of expectant treatment, describe the condition as progressive, and give the impression that - the prostate which is enlarged should be removed if the patient’s condition is good enough. This is a matter of great importance and one which cannot be put aside lightly. An enormous proportion of men over fifty-five have some enlargement of the-
prostatic enlargement very
prostate, and of these a considerable number have mild urinary symptoms which continue to the end of their lives without any effect on their health. These symptoms often regarded as a natural result of age, and in the past such patients did not seek medical advice. I believe that this is the reason why so many writers describe as exceptional the non-progressive case of prostatic enlargement. With spreading knowledge, more and more patients with mild symptoms now consult surgeons. This is much to be encouraged and gives hope that a larger number of progressive cases will be treated at an earlier stage. It would be wrong if all of these mild cases were treated by operation, and I think that the article of March 5 by Mr. Millin and his colleagues might be interpreted as encouragement to do so. This impression could be corrected from Mr. Millin’s writings elsewhere, but there are many surgeons who remove prostates but who do not study the specialist literature of urology. My experience of the expectant treatment of prostatic cases has justified fully the continued use of the residualurine test, though my dependence on it has been exaggerated by your correspondents. No surgeon would refuse to help a distressed patient because his case did not ful.1 precise criteria. A more difficult decision must be made when a patient seeks advice about symptoms which are merely a minor inconvenience. Such a patient is concerned, not about the present, but about the future. He is fit ; his prostate is enlarged. are
’
THE MEDICAL ILLUSTRATOR
SiB,—I protest against education throughterror. as depicted in fig. 2 of the article by the senior medical illustrator of Guy’s Hospital in your issue of April 23.
.
This is wrong whether the education be general, health, or medical. It belongs to the time of Hieronymus Bosch and later of Heilige Breughel with. their representations of what may happen to us in Hell. It is not absent from the woodcuts of Albrecht Durer, who was contemporary with the former. It savours of nursemaid discipline with the frightening of her charges first with Boney, then with Bogy, and finally with a Bobby. All this is now a thing of the past. Rule by frightening the instructed is not in the spirit of our time and never was of England. Our artists have never used their powers to compel us to the will of those that would rule us ; nor will the illustrator to Guy’s find any evidence of it in the work of her predecessor, Joseph Towne, although he could depict emotion when he needed it, as may be seen in the first of the three wax models of the huge aortic aneurysm in which there is a depiction of agonising pain with the " drawn expression " of tense, halfcontracted muscles of the whole face that vies with any other example of the sculptor’s art. This wrong use of her art is of the greater moment because the illustrator to Guy’s has a great power of representing emotion in a few lines. Witness this picture with the variation in each of the four ages, although we may doubt whether the infant has yet an intelligence that will appreciate the meaning of death or its symbolism in a clothed skeleton. Give it a human femur and it will find it as excellent a drumstick as that of a Moa if there is a dustbin lid lying about ready for it to beat. Fig. i is in the right spirit. There is no doubt that that child has whoopers," and the calmness of the little nurse-mother is just what is needed under the circumstances. This is so truly England that the original might even be purchased by the Chantrey trustees, leaving the weeping Widow of the Cross-Roads, with its French influence, which public opinion compelled the Ministry of Transport to withdraw, to those of the Tate. Education by terror is a part of a trend that is but too evident today. Some years ago I gave a clinical lecture on Appointment with Fear, dealing with signatures for anaesthetics, for refusal to accept a doctor’s advice, and for leaving hospital, all of which I used to forbid I am glad therefore that my house-surgeon ever to use. it is one working at my own hospital that has enabled 111e to raise this point. To do so with reference to any other might savour of bad form. It was the late Dr. E. W. Goodall that first put this conception of criticism, without condemnation, into my head. He used to show to his D.P.H. class plans of the medical wards in Hunt’s house at Guy’s, with their four rows of beds between the crossventilation of the windows, as an example of* how not to build a hospital. He told me that he was glad they he would have some came from his own hospital ; diffidence in speaking about them with the emphasis, that was a part of his nature, had they been at any other. And so here. The last paragraph of this paper shows that it is a matter of Guy’s not of its senior illustrator. In the first It is a question of the Code of the Herd. instance of the little Herd of Guy’s ; but I much suspect, also of that larger Herd, of which this is but a small part, and which involves all the teaching schools at least in "
London.
Fifty years ago the direction of the code of the herd at a teaching hospital was in the hands of the individual members of the staff. This began to-change when the members increased to such an extent that no man had
Should he have an operation ? It is in this type of case that I believe the residual-urine test to be of great value. Surely a prostate which prevents the bladder from emptying must be more dangerous than one which is less obstructive. I have been aware for a long time that a prostate might affect the upper urinary tract without producing residual urine, but have found little evidence of this in my own practice. I think that such cases must be exceptional and need not affect our general indications for operation. T. L. CHAPMAN. Glasgow.
prolonged
RISK FROM ASPIRIN PREPARATION
SiR,--In recent years an aspirin preparation has been introduced to the English market from across the Atlantic of which the novelty is that it can be eaten like a sweet." Have the makers carefully considered how easy it would be for an infant exploring the cupboards to eat these tablets " just like sweets " ? Who has not rescued his own children just in time from such a happening ? A warning on the package, and the wrapping of all tablets of this type in transparent paper of a distinctive colour never used for sweets, might help to "
e
counter the risk. Newcastle-on-Tyne.
A. FORSTER.
RETROPUBIC PROSTATECTOMY
surprised that Mr. Millin and Mr. Macalister (April 23) do not always advise operation for SiR,-I am not
with minimal symptoms. I am surprised indeed that they describe this view as "commonplace knowledge." Examination of the appropriate chapters of 8 standard textbooks of general surgery showed that 5 make no mention of expectant treatment, describe the condition as progressive, and give the impression that - the prostate which is enlarged should be removed if the patient’s condition is good enough. This is a matter of great importance and one which cannot be put aside lightly. An enormous proportion of men over fifty-five have some enlargement of the-
prostatic enlargement very
prostate, and of these a considerable number have mild urinary symptoms which continue to the end of their lives without any effect on their health. These symptoms often regarded as a natural result of age, and in the past such patients did not seek medical advice. I believe that this is the reason why so many writers describe as exceptional the non-progressive case of prostatic enlargement. With spreading knowledge, more and more patients with mild symptoms now consult surgeons. This is much to be encouraged and gives hope that a larger number of progressive cases will be treated at an earlier stage. It would be wrong if all of these mild cases were treated by operation, and I think that the article of March 5 by Mr. Millin and his colleagues might be interpreted as encouragement to do so. This impression could be corrected from Mr. Millin’s writings elsewhere, but there are many surgeons who remove prostates but who do not study the specialist literature of urology. My experience of the expectant treatment of prostatic cases has justified fully the continued use of the residualurine test, though my dependence on it has been exaggerated by your correspondents. No surgeon would refuse to help a distressed patient because his case did not ful.1 precise criteria. A more difficult decision must be made when a patient seeks advice about symptoms which are merely a minor inconvenience. Such a patient is concerned, not about the present, but about the future. He is fit ; his prostate is enlarged. are
’
THE MEDICAL ILLUSTRATOR
SiB,—I protest against education throughterror. as depicted in fig. 2 of the article by the senior medical illustrator of Guy’s Hospital in your issue of April 23.
.
This is wrong whether the education be general, health, or medical. It belongs to the time of Hieronymus Bosch and later of Heilige Breughel with. their representations of what may happen to us in Hell. It is not absent from the woodcuts of Albrecht Durer, who was contemporary with the former. It savours of nursemaid discipline with the frightening of her charges first with Boney, then with Bogy, and finally with a Bobby. All this is now a thing of the past. Rule by frightening the instructed is not in the spirit of our time and never was of England. Our artists have never used their powers to compel us to the will of those that would rule us ; nor will the illustrator to Guy’s find any evidence of it in the work of her predecessor, Joseph Towne, although he could depict emotion when he needed it, as may be seen in the first of the three wax models of the huge aortic aneurysm in which there is a depiction of agonising pain with the " drawn expression " of tense, halfcontracted muscles of the whole face that vies with any other example of the sculptor’s art. This wrong use of her art is of the greater moment because the illustrator to Guy’s has a great power of representing emotion in a few lines. Witness this picture with the variation in each of the four ages, although we may doubt whether the infant has yet an intelligence that will appreciate the meaning of death or its symbolism in a clothed skeleton. Give it a human femur and it will find it as excellent a drumstick as that of a Moa if there is a dustbin lid lying about ready for it to beat. Fig. i is in the right spirit. There is no doubt that that child has whoopers," and the calmness of the little nurse-mother is just what is needed under the circumstances. This is so truly England that the original might even be purchased by the Chantrey trustees, leaving the weeping Widow of the Cross-Roads, with its French influence, which public opinion compelled the Ministry of Transport to withdraw, to those of the Tate. Education by terror is a part of a trend that is but too evident today. Some years ago I gave a clinical lecture on Appointment with Fear, dealing with signatures for anaesthetics, for refusal to accept a doctor’s advice, and for leaving hospital, all of which I used to forbid I am glad therefore that my house-surgeon ever to use. it is one working at my own hospital that has enabled 111e to raise this point. To do so with reference to any other might savour of bad form. It was the late Dr. E. W. Goodall that first put this conception of criticism, without condemnation, into my head. He used to show to his D.P.H. class plans of the medical wards in Hunt’s house at Guy’s, with their four rows of beds between the crossventilation of the windows, as an example of* how not to build a hospital. He told me that he was glad they he would have some came from his own hospital ; diffidence in speaking about them with the emphasis, that was a part of his nature, had they been at any other. And so here. The last paragraph of this paper shows that it is a matter of Guy’s not of its senior illustrator. In the first It is a question of the Code of the Herd. instance of the little Herd of Guy’s ; but I much suspect, also of that larger Herd, of which this is but a small part, and which involves all the teaching schools at least in "
London.
Fifty years ago the direction of the code of the herd at a teaching hospital was in the hands of the individual members of the staff. This began to-change when the members increased to such an extent that no man had