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ŒSOPHAGEAL HIATUS HERNIA
339 ŒSOPHAGEAL HIATUS HERNIA SIR,—In reading your leading article of Aug. 2 I was interested in the close parallel between the probable mechanism whereby reflux from the stomach is prevented (Allison1) and that which prevents dribbling of urine in
the female (Jeffcoate 2). As I understand it, reflux from the stomach may occur when the cesophageal hiatus in the diaphragm is relaxed, allowing the angle between the oesophagus and the upper surface of the cardiac end of the stomach to Jeffcoate has shown that stressbe straightened out. incontinence of urine in the female occurs when the angle between the base of the bladder and the urethra is straightened out. The parallel to Allison’s " parahiatal hernia" is cystocele. Each of these may occur without incompetence of the retaining mechanism. Each may be associated with incompetence when the retaining angle is lost. A. AMBERY SMITH. University of Leeds. ,
REASON AND UNREASON IN PSYCHOLOGICAL MEDICINE
SIR,—It seems likely that Dr. Dillon (Aug. 2) missed the main point that I tried (perhaps unsuccessfully) to make in my first Croonian lecture. My argument was that, if in the human sciences one’s approach to causality is limited to the establishment of efficient or final causes, one is apt to be bogged down in a false metaphysic. I cannot however go the whole way with Dr. Dillon and admit that natural science can altogether dispense with the notion of " dependable sequences " and remain scientific. E. B. STRAUSS. London, W.I. FEEDING DISORDERS IN INFANTS
SIR,—I hesitate to comment upon Miss Morrison’s letter in your issue of Aug. 9, because Professor Vining manifestly needs no support from me ; but the assertion that the cause of digestive disorder in infants is practically always a wrongly balanced mixture " and seldom due merely to underfeeding or overfeeding " cannot be allowed to pass unchallenged. It is somewhat disturbing to read the advice given on occasion in the infant-management columns of the lay press. Infants with such symptoms as fretfulness," "
"colic,"
"
never seems
satisfied," constipation, vomiting,
and failure to thrive, are said to be dyspepsia, wind, and even overfeeding.
suffering
from
I remember one case in particular of an infant with these which had been given a weaker feed by its mother with no success. The comment and advice given was : " How right you were Mother, to weaken the feed, even so it should be weaker still." A specially balanced formula was sent under separate cover.
symptoms
Now there is absolutely no mystery about most of these infants; they are simply underfed, some of them grossly underfed. Anyone offering more feed can prove this. Underfeeding is one of the commonest faults of infant management, as Professor Vining, Professor Illingworth, and Dr. Charlotte Naish have repeatedly averred. One reason for its frequency may be that mothers tend to read not THE LANCET but Nurse Blank’s column in their weekly journal. Such publications have a considerable responsibility to their readers, and because of this I suggest that their watchword should be simplicity rather than complexity. Cow’s milk is so similar to breast-milk that some simple modification only is necessary. The suggestion that ingredients " should be balanced " merely baffles "
"
1. Allison, P. R. Sury. Gynec. Obstet. 1951, 92, 419. 2. Jeffcoate, T. N. A. Address to the 13th British Congress of Obstetrics and Gynæcology, 1952 ; see Lancet, July 26, 1952,
p. 189.
harassed mother, causing her to ignore the often obvious symptoms of hunger in her baby. There seems to be a belief that the mere male, by virtue of his sex, cannot understand these problems. Prof. Alan Broun does not subscribe to this view ; he describes in his Ingleby lectures of 1948 the father of a " young child supposedly suffering from " tummy-ache rending the night air with its cries ; the ignorant and ignored male observes, " If that were a puppy I’d say he was hungrv and feed it." B. S. B. WOOD. Birmingham. a
LIVER EXTRACT FOR HERPETIC PAIN
SIR,—Dr. Christopher Howard’s letter in your issue Aug. 2 prompts me to write in support of his findings. My own experience has been that liver extract, apart
of
from the relief of herpetic pain, can have a most beneficial effect on the whole course of herpes zoster. The response varies from one case to another, but I have yet to meet a case which has failed to respond in some degree provided injections are started as early as possible and repeated if necessary. At best, the results can be little short of dramatic, and it was a case of this nature that drew my attention to an interesting side-effect. A middle-aged woman came to see me in the autumn; with an early typical herpes of the left loin. I gave her 2 ml. ’Anahaemin’ which resulted in rapid relief of symptoms and disappearance of the local lesions. About a year later she asked me if the injection could have been responsible for her freedom from chilblains throughout the winter ; she was normally a " martyr " to these, and had not enjoyed such comfort for years. A further trial injection seemed justified, and the result was again satisfactory.
I have since used liver extract for a number of chilblain cases. Again the response varies from one patient to another. Injections may have to be repeated in the more obstinate cases, but I have found no other form of therapy so rapid in its effect, the relief of irritation often becoming apparent in a matter of hours, and the healing of broken chilblains being much expedited. J. H. MOYNIHAN. Ashwell, Herts. SYRINGE-TRANSMITTED TUBERCULOSIS SIR,—I think that one point in this subject, discussed in your annotation of July 5, has not yet received sufficient attention. Most people seem to agree that the tubercle bacilli enter from without and that they are carried by infected needles or syringes. The fact that these abscesses have become more common since the introduction of penicillin is partly explained by the use of the small rubber-capped bottle for penicillin. The cap is pierced with the needle when withdrawing the solution ; and, as these bottles may be used for multiple injections, once the contents are infected an abscess may follow each subsequent injection. The of that this kind bottle and rubber is, however, point cap is nothing new-insulin has been kept in this way for years. Admittedly the number of penicillin injections of abscesses given to children (in whom the have developed) is larger than the number of insulin injections, but I cannot find a single report of a tuberculous abscess after an insulin injection. And diabetics are certainly not resistant to tuberculosis ! The use of the bottle instead of the ampoule does not explain everything. I think the basic point is this : the needles and syringes that carry tubercle bacilli are usually loaded with other germs as well, mainly grampositive cocci, which are sensitive to penicillin. Inside the bottle the antibiotic exerts some sort of bacterial selection, and only the tubercle bacilli survive. When the solution is injected a tuberculous abscess ensues. When insulin or some substance other than an antibiotic is injected, a trivial pyogenic abscess occurs. Novara Civil Hospital, EDGARDO RUCCI. Italy.
majority
the female (Jeffcoate 2). As I understand it, reflux from the stomach may occur when the cesophageal hiatus in the diaphragm is relaxed, allowing the angle between the oesophagus and the upper surface of the cardiac end of the stomach to Jeffcoate has shown that stressbe straightened out. incontinence of urine in the female occurs when the angle between the base of the bladder and the urethra is straightened out. The parallel to Allison’s " parahiatal hernia" is cystocele. Each of these may occur without incompetence of the retaining mechanism. Each may be associated with incompetence when the retaining angle is lost. A. AMBERY SMITH. University of Leeds. ,
REASON AND UNREASON IN PSYCHOLOGICAL MEDICINE
SIR,—It seems likely that Dr. Dillon (Aug. 2) missed the main point that I tried (perhaps unsuccessfully) to make in my first Croonian lecture. My argument was that, if in the human sciences one’s approach to causality is limited to the establishment of efficient or final causes, one is apt to be bogged down in a false metaphysic. I cannot however go the whole way with Dr. Dillon and admit that natural science can altogether dispense with the notion of " dependable sequences " and remain scientific. E. B. STRAUSS. London, W.I. FEEDING DISORDERS IN INFANTS
SIR,—I hesitate to comment upon Miss Morrison’s letter in your issue of Aug. 9, because Professor Vining manifestly needs no support from me ; but the assertion that the cause of digestive disorder in infants is practically always a wrongly balanced mixture " and seldom due merely to underfeeding or overfeeding " cannot be allowed to pass unchallenged. It is somewhat disturbing to read the advice given on occasion in the infant-management columns of the lay press. Infants with such symptoms as fretfulness," "
"colic,"
"
never seems
satisfied," constipation, vomiting,
and failure to thrive, are said to be dyspepsia, wind, and even overfeeding.
suffering
from
I remember one case in particular of an infant with these which had been given a weaker feed by its mother with no success. The comment and advice given was : " How right you were Mother, to weaken the feed, even so it should be weaker still." A specially balanced formula was sent under separate cover.
symptoms
Now there is absolutely no mystery about most of these infants; they are simply underfed, some of them grossly underfed. Anyone offering more feed can prove this. Underfeeding is one of the commonest faults of infant management, as Professor Vining, Professor Illingworth, and Dr. Charlotte Naish have repeatedly averred. One reason for its frequency may be that mothers tend to read not THE LANCET but Nurse Blank’s column in their weekly journal. Such publications have a considerable responsibility to their readers, and because of this I suggest that their watchword should be simplicity rather than complexity. Cow’s milk is so similar to breast-milk that some simple modification only is necessary. The suggestion that ingredients " should be balanced " merely baffles "
"
1. Allison, P. R. Sury. Gynec. Obstet. 1951, 92, 419. 2. Jeffcoate, T. N. A. Address to the 13th British Congress of Obstetrics and Gynæcology, 1952 ; see Lancet, July 26, 1952,
p. 189.
harassed mother, causing her to ignore the often obvious symptoms of hunger in her baby. There seems to be a belief that the mere male, by virtue of his sex, cannot understand these problems. Prof. Alan Broun does not subscribe to this view ; he describes in his Ingleby lectures of 1948 the father of a " young child supposedly suffering from " tummy-ache rending the night air with its cries ; the ignorant and ignored male observes, " If that were a puppy I’d say he was hungrv and feed it." B. S. B. WOOD. Birmingham. a
LIVER EXTRACT FOR HERPETIC PAIN
SIR,—Dr. Christopher Howard’s letter in your issue Aug. 2 prompts me to write in support of his findings. My own experience has been that liver extract, apart
of
from the relief of herpetic pain, can have a most beneficial effect on the whole course of herpes zoster. The response varies from one case to another, but I have yet to meet a case which has failed to respond in some degree provided injections are started as early as possible and repeated if necessary. At best, the results can be little short of dramatic, and it was a case of this nature that drew my attention to an interesting side-effect. A middle-aged woman came to see me in the autumn; with an early typical herpes of the left loin. I gave her 2 ml. ’Anahaemin’ which resulted in rapid relief of symptoms and disappearance of the local lesions. About a year later she asked me if the injection could have been responsible for her freedom from chilblains throughout the winter ; she was normally a " martyr " to these, and had not enjoyed such comfort for years. A further trial injection seemed justified, and the result was again satisfactory.
I have since used liver extract for a number of chilblain cases. Again the response varies from one patient to another. Injections may have to be repeated in the more obstinate cases, but I have found no other form of therapy so rapid in its effect, the relief of irritation often becoming apparent in a matter of hours, and the healing of broken chilblains being much expedited. J. H. MOYNIHAN. Ashwell, Herts. SYRINGE-TRANSMITTED TUBERCULOSIS SIR,—I think that one point in this subject, discussed in your annotation of July 5, has not yet received sufficient attention. Most people seem to agree that the tubercle bacilli enter from without and that they are carried by infected needles or syringes. The fact that these abscesses have become more common since the introduction of penicillin is partly explained by the use of the small rubber-capped bottle for penicillin. The cap is pierced with the needle when withdrawing the solution ; and, as these bottles may be used for multiple injections, once the contents are infected an abscess may follow each subsequent injection. The of that this kind bottle and rubber is, however, point cap is nothing new-insulin has been kept in this way for years. Admittedly the number of penicillin injections of abscesses given to children (in whom the have developed) is larger than the number of insulin injections, but I cannot find a single report of a tuberculous abscess after an insulin injection. And diabetics are certainly not resistant to tuberculosis ! The use of the bottle instead of the ampoule does not explain everything. I think the basic point is this : the needles and syringes that carry tubercle bacilli are usually loaded with other germs as well, mainly grampositive cocci, which are sensitive to penicillin. Inside the bottle the antibiotic exerts some sort of bacterial selection, and only the tubercle bacilli survive. When the solution is injected a tuberculous abscess ensues. When insulin or some substance other than an antibiotic is injected, a trivial pyogenic abscess occurs. Novara Civil Hospital, EDGARDO RUCCI. Italy.
majority