THE FULL USE OF ARTIFICIAL LIMBS.

614 visceral muscle, the second to conditions affecting crutches or pegs, some to this day because they cannot investments and mesenteries of organs and subserosae drag 8 lb. along with a short stump. Quoting from one of their containing serous sacs. Unless spasm occur in of the ex-Service societies, a number in the streets like the muscular tunic, or unless outlying structures are a bit of sympathy and prefer not to wear a limb, but I involved in the visceral lesion, visceral disease of grave believe firmly that if it was once brought home to import may remain undiscovered. Viscera themselves them that they could quite simply return to are innervated from segmentary centres of the cord, nearly all their pre-war activity they would often far distant from sources whence their invest- never ask for sympathy. It has been my privilege ments derive their central neuronic supply, conse- lately to help out of my experience a case that quently viscero-sensory impressions from an affected had not walked more than half a mile for ten years. organ are felt in one zonal region, while viscero- A light limb was obtained, a short course of training sensory impressions, from investments of the same undergone, and to quote the patient, "What it means to find that one can walk normally, to get to the shops, organ, are manifested at another place. For instance, viscero-sensory impressions from and carry out household duties, and, above all, to have use of both hands, because no stick or crutch is muscular tunics of stomach and duodenum follow the track laid down by great splanchnic strands, and their necessary, is beyond words." The surgeons in charge deflections on the spinal system are manifested as of limb hospitals have no time, naturally, but if the referred pain and algesia at points of outcrop and at need of training were once established there could be terminals of upper intercostal nerves, as witness so- no better way of finding employment for some of our called hepar or shoulder liver pain, described with disabled men than in making them efficient and in much accuracy by John Hilton in his lectures upon establishing them in the limb centres as trainers of all " Rest and Pain." Whereas when gastric or duodenal those who need it. I am, Sir, yours faithfully, ulcerations invade investments of these organs or GEORGE A. PONSONBY. encroach upon their peritoneal coverings viscerosensory impressions are felt in epigastric or in hypochondriac regions. I give only a single example, but it is sufficiently THE LABELLING OF THYROID TABLETS. illustrative to explain differences which too frequently To the Editor of THE LANCET. divide authoritative opinion upon the reliability of new read with great interest Dr. A. E. have methods of clinical research in the differential diagnosis SIR,-We Carver’s letter in your issue of March 12th, and we of visceral disease. desire to say that we agree with every word of it. In I am. Sir. vonrs faithfnllv. the early days of thyroid medication our own practice H. WALTER VERDON, F.R.C.S. in the matter of labelling thyroid gland tablets was based on the content of desiccated thyroid-i.e., a tablet containing 1 gr. of desiccated thyroid was labelled THE FULL USE OF ARTIFICIAL LIMBS. " 1 grain," with the statement that this was equivalent To the Editor of THE LANCET. to 5 gr. of the fresh gland. Later we found that there SIR,-Your annotation of March 5th referring to Dr. was much misunderstanding as to the dosage and M. Duckrell’s letter is of the greatest interest to nomenclature of thyroid, and on making inquiries of a those who have lost limbs, and holds out hope number of prescribers as to what they meant when that medical opinion is awakening to the fact they wrote " Tab. thyroid 1 grain " we found that, that muscle training and education of the senses without exception, every doctor consulted by us meant are all-important and indeed imperative to those 1 gr. of the fresh thyroid, or 1/5 gr. of the desiccated who have lost limbs before they can return to a gland. In view of the importance attached to dosage of normal existence. My personal experience is a thigh a potent drug like thyroid, it was felt that if any doubt existed as to the doctor’s intention it was safer to err amputation, of which I believe there are thousands. on the side of giving too small, rather than too large, The limb-makers are perfectly frank, and there is no and our disguise that as regards war cases the aim and object a dose, and, hence, our practice was reversed of the authorities was to clear the limb hospitals and to labels altered accordingly. The labels now read thus: send home the men as soon as possible with the best "Compressed Tablets Thyroids. Each tablet represents limb available at the time ; and of all the mechanical 1 grain of fresh thyroid gland equal to 1/5 grain of siccum B.P.," and medical men who see appliances Invented the central knee-control with Thyroideum harness over the shoulders was the simplest to avoid our labels, or who read our literature, can be under no the use of muscles, wasted by weeks in bed, and illusion as to the actual thyroid content of any tablet. Our experience suggests that writers, and possibly to give a certain amount of confidence to men who had got to regain their balance. Speaking from teachers, fail to make clear the distinction between and dried thyroids. It would undoubtedly be personal experience since 1916, and quoting from an fresh better were one rule universally adopted, but in view of I know 20 that a of over mechanical years, experience knee worked from the shoulder is entirely unnecessary, the fact that some generations of medical men think in and that with a light, well-fitting limb the stump and terms of the fresh gland only. it will be difficult to the stump muscles can develop an easy natural walk induce them to alter their practice, and the question for with perfect balance, and that the benefit to the manufacturers is how best to carry out the intentions general health of the patient is tremendous. Freedom of the prescriber. It has also to be borne in mind that from harness over the chest and shoulders, freedom the Pharmacopoeia designation is "thyroideum siecum," from mechanical aid is something, but the very fact and where a prescriber writes "thyroid" only, no one that the muscles must be developed normally and can say that it is wrong to give the fresh thyroid. when a prescriber writes " thyroid extract" brought into daily use means much more. The system Obviously, a tablet the B.P. substance should be representing of training you mention varies with each case, and where one man whose stump muscles had been trained dispensed.-We are, Sir, yours faithfully, PARKE, DAVIS AND CO. during the period his limb was being made was perfectly ready to go home three days after his limb was fitted, another who had acquired bad habits and a flexed AS OTHERS SEE US. stump required several weeks of careful supervision, To the Editor of THE LANCET. though many of the exercises can be carried out at l, home. An occasional case may require only eight or SIR,-The letter from my old and long lost-sight-of nine days, some two or three weeks, while a few may friend, Dr. Wilson Parry, shows a misunderstanding of require as much as three months. The greater number the point which my previous contribution was intended of men whom I have met have received little or no to make. I certainly have no personal reason to comof the lack of " worship " among the town wageinstruction, and that is why they rise up on the good toe and sling the artificial limb along anyhow, rising earners ; rather the reverse. But what disturbs me is and sinking with each step. Many of them are on by the bulk of working people with whom I come

the

plain that,