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THE ATTACK ON THE SLUMS
1235
CORRESPONDENCE THE ATTACK ON THE SLUMS
To the.Editor of THE LANCET SIR,-May I congratulate you on the leading article in your issue of Nov. llth. In respect of the reference to my own calculations, recently published - jn the Architects’ Journal, and Sir Ernest Simon’s estimates in the " anti-slum campaign," I do not really think that the figures which you quote are comparable. It is therefore impossible to say that his err on the high side or mine err on the low. His figure of 4,000,000 is a rather vast one certainly, - and I for one should not be prepared to estimate that there were in this country such a large number of unsatisfactory houses-this for reasons which I have
stated elsewhere. But Sir Ernest Simon’s immediate programme is to supply each family with a separate dwelling, for which need he gives a figure. My figure of 1,400,000 relates to housing needs at the
present time, taking account both of overcrowding -and unfit houses. I would agree that my estimate is in fact probably on the low side, but, being in no sense comparable with Sir Ernest Simon’s, the considerations of which you take account in your article are really not applicable. Again, you adjudge as too low my estimate that housing conditions in the areas not dealt with in my -survey are half as bad as in the towns which were included. The report of Dr. Mackintosh on the health of Northamptonshire can hardly be said to prove that this is an under-estimate, as Northampton:shire is not a very large part of Great Britain. I am, Sir, yours faithfully, PHILIP H. MASSEY, B.Sc. Mecklenburgh-street, W.C., Nov. 16th, 1933. -
DIVERTICULA OF THE SMALL INTESTINE
To the Editor
of THE LANCET SiR,—A considerable experience of diverticula of the alimentary tract and of the associated literature has interested me in this subject during the past few
Your annotation of Nov. llth raises some interesting points. If those diverticula which are obviously secondary to traction, ulceration, or cicatri. sation are excluded a large group is left which may be conveniently termed idiopathic-a word which in this instance will probably come to mean congenital. Single examples of the duodenal variety have not been recorded more frequently than multiple. The pancreas is developed from three duodenal buds-two ventral and one dorsal. Two of these buds persist as the ducts of Santorini and Wirsung, the third disappears; it is probable that occasional persistence of this or even of accessory buds, accounts for the solitary duodenal diverticulum which is usually perivaterian in situation. Certainly the case described by D. P. D. Wilkie (Edin. Med. Jour., 1913, ii., 219), in which the pancreatic tissue was found in the fundus, is explicable in this way. Solitary diverticula containing pancreatic tissue, found in association with the first few inches of the jejunum, may originate in the same manner. All other solitary diverticula of the small intestine, jejunal or ileal, represent persistence of the enteric portion of the vitelline duct, associated with the name of Johann Meckel. In addition to the mechanical and inflammatory disturbances which may arise in sacs of this type, pathological changes are also years.
liable to
occur
in connexion
with heterotopic deposits
of pancreatic or gastric epithelium. In my Hunterian lecture (1933) I recorded also a series of neoplasms originating in these diverticula. Similarly it is probable that multiple diverticula, which are never encountered in connexion with the ileum alone, but invariably with the jejunum or
duodenum, are congenital; they probably represent persistence of the duodenal ceeca of fishes, and the diverticula of the duodenal and jejunal portions of the intestinal tract in pig and human embryos, described by Lewis and Thyng (Amer. Jour. Anat., 1908, vii., 505). J. R. Ryder (Vet. Record, 1930, x., 707) records the comparative frequency with which multiple diverticula of the small bowel are found in pit ponies of Icelandic stock. Some of the multiple diverticula of my own series had walls as muscular as those of the parent bowel, and none was complicated by sclerosis of the mesenteric vessels. Cases have occurred of general diverticulosis of the hollow viscera. Such are the facts which lead me to believe in the congenital origin of these diverticula. The value of forcible distension experiments is dubious because it is unlikely that any comparable increase of the pressure within the bowel occurs under natural circumstances. The pouches rarely, if ever, occur in relation to organic obstructions, and diverticulosis associated with duodenal ileus is unknown. There is one great difficulty to overcome before an explanation which assumes herniation of a previously intact bowel wall is accepted-namely, the fact that the antimesenteric border of the bowel is subjected to much more stress than the mesenteric, yet these diverticula occur on the latter. It may be argued that the vascular openings are in the mesenteric borders, but it does not seem reasonable to believe that nature would leave these places vulnerable; otherwise diverticulosis would be more common. In my cases the pouches were in the peritoneal windows-i.e., between the vascular openings. I am, Sir, yours faithfully, GEORGE A. MASON. Newcastle-upon-Tyne, Nov. 15th, 1933. ACHOLURIC JAUNDICE
To the Editor of THE LANCET SIR,-Dr. A. P. Thomson describes in your last issue (p. 1139) a case of acholuric jaundice with neither increased fragility of the red cells nor any evidence of a familial incidence. Although some cases are recorded in which this condition is apparently acquired, and others in which the fragility of the red cells is normal, yet when both these cardinal signs are absent it is surely better to describe such a case as an example of hsemolytic anaemia, and leave it at that. Moreover, Dr. Thomson’s case is unusual in other respects. The considerable leucopenia and the low reticulocyte counts, the normal Price-Jones curve (made, it is true, a few months after splenectomy), the persistence of the pre-operative degree of ansemia, and of the positive indirect van den Bergh reaction a year after splenectomy—while they do not individually exclude the diagnosis, yet in sum they throw doubt on it. These findings suggest an intermediate condition between splenic anoemia-the original diagnosis-and haemolytic anaemia; there is evidence of both depressed blood formation (leucopenia and absence of reticulocytosis) and of excessive haemolysis. Whatever the exact diagnosis may be, this letter is
CORRESPONDENCE THE ATTACK ON THE SLUMS
To the.Editor of THE LANCET SIR,-May I congratulate you on the leading article in your issue of Nov. llth. In respect of the reference to my own calculations, recently published - jn the Architects’ Journal, and Sir Ernest Simon’s estimates in the " anti-slum campaign," I do not really think that the figures which you quote are comparable. It is therefore impossible to say that his err on the high side or mine err on the low. His figure of 4,000,000 is a rather vast one certainly, - and I for one should not be prepared to estimate that there were in this country such a large number of unsatisfactory houses-this for reasons which I have
stated elsewhere. But Sir Ernest Simon’s immediate programme is to supply each family with a separate dwelling, for which need he gives a figure. My figure of 1,400,000 relates to housing needs at the
present time, taking account both of overcrowding -and unfit houses. I would agree that my estimate is in fact probably on the low side, but, being in no sense comparable with Sir Ernest Simon’s, the considerations of which you take account in your article are really not applicable. Again, you adjudge as too low my estimate that housing conditions in the areas not dealt with in my -survey are half as bad as in the towns which were included. The report of Dr. Mackintosh on the health of Northamptonshire can hardly be said to prove that this is an under-estimate, as Northampton:shire is not a very large part of Great Britain. I am, Sir, yours faithfully, PHILIP H. MASSEY, B.Sc. Mecklenburgh-street, W.C., Nov. 16th, 1933. -
DIVERTICULA OF THE SMALL INTESTINE
To the Editor
of THE LANCET SiR,—A considerable experience of diverticula of the alimentary tract and of the associated literature has interested me in this subject during the past few
Your annotation of Nov. llth raises some interesting points. If those diverticula which are obviously secondary to traction, ulceration, or cicatri. sation are excluded a large group is left which may be conveniently termed idiopathic-a word which in this instance will probably come to mean congenital. Single examples of the duodenal variety have not been recorded more frequently than multiple. The pancreas is developed from three duodenal buds-two ventral and one dorsal. Two of these buds persist as the ducts of Santorini and Wirsung, the third disappears; it is probable that occasional persistence of this or even of accessory buds, accounts for the solitary duodenal diverticulum which is usually perivaterian in situation. Certainly the case described by D. P. D. Wilkie (Edin. Med. Jour., 1913, ii., 219), in which the pancreatic tissue was found in the fundus, is explicable in this way. Solitary diverticula containing pancreatic tissue, found in association with the first few inches of the jejunum, may originate in the same manner. All other solitary diverticula of the small intestine, jejunal or ileal, represent persistence of the enteric portion of the vitelline duct, associated with the name of Johann Meckel. In addition to the mechanical and inflammatory disturbances which may arise in sacs of this type, pathological changes are also years.
liable to
occur
in connexion
with heterotopic deposits
of pancreatic or gastric epithelium. In my Hunterian lecture (1933) I recorded also a series of neoplasms originating in these diverticula. Similarly it is probable that multiple diverticula, which are never encountered in connexion with the ileum alone, but invariably with the jejunum or
duodenum, are congenital; they probably represent persistence of the duodenal ceeca of fishes, and the diverticula of the duodenal and jejunal portions of the intestinal tract in pig and human embryos, described by Lewis and Thyng (Amer. Jour. Anat., 1908, vii., 505). J. R. Ryder (Vet. Record, 1930, x., 707) records the comparative frequency with which multiple diverticula of the small bowel are found in pit ponies of Icelandic stock. Some of the multiple diverticula of my own series had walls as muscular as those of the parent bowel, and none was complicated by sclerosis of the mesenteric vessels. Cases have occurred of general diverticulosis of the hollow viscera. Such are the facts which lead me to believe in the congenital origin of these diverticula. The value of forcible distension experiments is dubious because it is unlikely that any comparable increase of the pressure within the bowel occurs under natural circumstances. The pouches rarely, if ever, occur in relation to organic obstructions, and diverticulosis associated with duodenal ileus is unknown. There is one great difficulty to overcome before an explanation which assumes herniation of a previously intact bowel wall is accepted-namely, the fact that the antimesenteric border of the bowel is subjected to much more stress than the mesenteric, yet these diverticula occur on the latter. It may be argued that the vascular openings are in the mesenteric borders, but it does not seem reasonable to believe that nature would leave these places vulnerable; otherwise diverticulosis would be more common. In my cases the pouches were in the peritoneal windows-i.e., between the vascular openings. I am, Sir, yours faithfully, GEORGE A. MASON. Newcastle-upon-Tyne, Nov. 15th, 1933. ACHOLURIC JAUNDICE
To the Editor of THE LANCET SIR,-Dr. A. P. Thomson describes in your last issue (p. 1139) a case of acholuric jaundice with neither increased fragility of the red cells nor any evidence of a familial incidence. Although some cases are recorded in which this condition is apparently acquired, and others in which the fragility of the red cells is normal, yet when both these cardinal signs are absent it is surely better to describe such a case as an example of hsemolytic anaemia, and leave it at that. Moreover, Dr. Thomson’s case is unusual in other respects. The considerable leucopenia and the low reticulocyte counts, the normal Price-Jones curve (made, it is true, a few months after splenectomy), the persistence of the pre-operative degree of ansemia, and of the positive indirect van den Bergh reaction a year after splenectomy—while they do not individually exclude the diagnosis, yet in sum they throw doubt on it. These findings suggest an intermediate condition between splenic anoemia-the original diagnosis-and haemolytic anaemia; there is evidence of both depressed blood formation (leucopenia and absence of reticulocytosis) and of excessive haemolysis. Whatever the exact diagnosis may be, this letter is