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THYROID AND COLD SENSITIVITY
347
It seems particularly important in the present state of our knowledge that cases should be recorded where the mother has rubella early in pregnancy and the child is born without any malformations. Galton Laboratory, University College, JULIA BELL. London.
cation.)
Specimens
AMYLOID MACROGLOSSIA
SIR,—Dr. M. D. Baber’s
case
interest and helps to show that
ago.
When an example was described by Weber, Cade, Stott, and Pulvertaft in 1937macroglossia due to amyloidosis was unknown in Britain, though cases had
published in America. Since then besides the two recorded by Barnard, Smith, and Woodhouse2 quite a number of cases of primary amyloidosis-with or without been
macroglossia-have been brought forward and others have remained unpublished. Personally I have seen two typical examples of the Lubarsch-Pick syndrome shortly before the commencement of the war, and I hope they will be described by the doctors through whose kindness I was able to examine them. I suspect that some cases recorded in medical literature-even during the last ten years-have not been recognised as examples of the Lubarsch-Pick syndrome. For instance, I recently came across the account of a case demonstrated
by
Dr. G. H. Belote3 as
one
of
"tertiary
syphilis with amyloid deposits in the eyelids, lips, tongue, pharynx and larynx " in a man, aged 56, complaining of sore tongue. Ten years previously the tongue had shown "some thickening, but no ulceration." When this case was demonstrated there were waxy flesh-coloured papules on eyelids and lips ; and there was thickening of the tongue, of the alveolar regions, of the tonsillar region, of the pharynx, and of the larynx. The serological reaction for syphilis was negative, and a biopsy showed amyloid material.
Surely, that syndrome. I
was
an
example of the Lubarsch-Pick
do not know if it
was
sections
of these
two
cases
were
meeting of the Association of Clinical Pathologists in January, 1946. Where the amyloid deposit is slight, it is in sheaths a
of smaller blood-vessels and in interstitial fasciae. The three cases which have now been seen in this department suggest that atypical systemic amyloidosis is a disease sui generis, which may affect any tissue in the body. F. B. SMITH Department of Pathology, R. T. COOKE. Royal Infirmary; Preston.
PREVENTION OF EPIDEMIC NEONATAL DIARRHŒA SiR.,-In his article of Jan. 11 Mr. Stern suggests that " infection may be spread by the heavy and increasing contamination of the film which forms in feeding-bottles in constant use." Is it not time that the narrow-necked bottle was discarded altogether and theHygeia’ type of wide-necked, straight-sided bottle, with large rubber teat, substituted ? I believe these bottles are widely used in Canada and the U.S.A., and feel sure they could be produced in England too. The hygeia bottle is readily cleaned with hot water, to which washing soda has been added, and a stiff brush; and all parts of the bottle are easily accessible to the brush, which is patently not so with the narrow-necked bottle. The formation of film is thus easily prevented, and the bottles must of course be boiled for each feed. With regard to the suggestion that sterilisation by’ boiling destroys rubber teats, I havebeen using the It same teat for my own baby for over 4 months now. has been boiled daily for at least 5 minutes and shows and this is not an isolatedno sign of perishing yet;
experience. Johannesburg, South Africa.
ELIZABETH LUND.
described later at
RECRUITMENT OF STUDENT NURSES
greater length. F. PARKES WEBER.
London, W.1.
and
demonstrated at
(Feb. 8) is of great cases of primary amyloidosis, notably those accompanied by obvious macroglossia (the Lubarsch-Pick syndrome), are not of such extreme rarity as was supposed until ten years
-
The spleen contained many giant-cells of foreign-body type, presumably a reaction to amyloid which almost replaced the The gastrocnemius also showed a whole bulk of the organ. striking myositis. (The notes of more than one case previouslv recorded mention pains in the legs comparable with claudi-
SIR,—Dr. Margaret Baber’s report of another case of amyloid macroglossia (Feb. 8) prompts a, brief note of two further cases of atypical amyloidosis, both men, one with macroglossia.
SIR,—Speaking from personal experience, based on entry of a daughter into general nursing training, I strongly support the need for revision of the pay of student nurses along the lines suggested by your correspondent of Feb. 8. The position is worsened by the fact
the
that the Commissioners of Inland Revenue have decided that no allowance is given for any child who earns-more than £50 per annum (except for scholarships). This at home in decision at once excludes any tax relief for parents heart-failure. He came to necropsy because he had received a full military pension for rheumatoid arthritis since the war paying higher rates of tax who have been public-spirited of 1914-18. The notes are summarised : widespread rheuma- enough either to agree to, or to stimulate, the entry of their daughters into nursing. toid deformities of all limb joints ; wasting ; gross generalised It is obvious, of course, that if the pay of student nurses œdema; pallor and puffiness of the face, with thick lips ; tongue enlarged to fill the mouth ; sterile pus in one knee- is increased similar increases must be granted to all the joint ; heart 420 g. ; microscopically, much amyloid in the more senior grades. Increases beyond those proposed tongue, heart, kidneys, spleen, and adrenal glands. (One in the Rushcliffe scales are needed, in my opinion, if conditions in the nursing profession are to compete withof the cases reported by Edwards4 bad rheumatoid arthritis.) those of industry and commerce. CASE 2.-A boiler fireman, aged 61, was admitted to A. T. W. POWELL. Public Health Department, Walthamstow. hospital in August, 1945, with congestive heart-failure after 18 months of ill health ; he had dyspnoea, retrosternal pain on exertion, aching legs on exertion, giddiness, insomnia, and THYROID AND COLD SENSITIVITY swollen ankles. The blood-pressure was 60/35 mm. Hg in SIR,-Dr. S. L. Simpson makes the interesting suggeshospital, and the haemoglobin 77%. The condition was tion (March 8) that thyroid should be given to healthy diagnosed as myocardial fibrosis. Necropsy four hours after volunteers in order to investigate its capacity to increase death on thethird day in hospital showed oedema of legs, A word of resistance to cold and induce well-being. moderate ascites, and bilateral hydrothorax ; large thickis needed, however, should such an experiment warning walled heart (580 g.), pale, of rubbery consistence, and with be undertaken. many subepicardial petechise ; spleen (340 g.) of a striking red S. W. Patterson has warned that thyroid may cause colour, firm and friable, resembling a cake of wax ; no addiction. It acts as a tonic by increasing energy, macroglossia. Microscopically, amyloid was present in very improving the appetite, and enhancing mental alertness ; large amount in heart, spleen, kidneys, and adrenals ; in and neurotics are apt to take to it. The widespread rather less amount in liver, pharynx, tongue, gastrocnemius, administration of thyroid to otherwise healthy obese pancreas, meninges, a meningioma, diaphragm, prostate, patients and to those with assumed " slight glandular thyroid, and lung ; and none was found in biceps and skin. underfunction " has created quite a few cases of moderate addiction. Happily, the metabolic effects are often not 1. Quart. J. Med. 1937, 6, 181. too harmful, possibly because the present diet is poor in 2. J. Path. Bact. 1938, 47, 311.
aged 59, bedridden for two years, died October, 1945, in a manner suggesting congestive
C4.SE 1.—A
man,
3. Arch. Derm. Syph., N.Y. 1937, 35, 540. 4. Edwards, J. L. J. Path. Bact. 1945, 57, 283.
1. Brit. med. J.
1934, ii, 6.
348 and perhaps also because of the formation of antihormones. I saw such a patient quite recently who had taken 15 grains of thyroid daily for eighteen months .and had remained well, except for a tachycardia of’106120. It took more than six months to reduce the dose to 1½—2 grains dailv. V. C. MEDVEI. London. S.W.3. STAMMERING SIR,—Speech therapists should be indebted to Dr. Chrysanthis (Feb. 15) for his data on the incidence of stammering in the Greek elementary schools of Nicosia, Cyprus. A number of factors mentioned in this con-
proteins,
v
nexion—such as anthropological peculiarities, intelligence, handedness, and sex-are still so controversial that they cannot be discussed briefly. I must, however, challenge
the statement that " according to many investigators, stammering is unknown among the Chinese, whose language consists of monosyllables." This opinion can be traced back to Colombat d’Isères ,(Trait,- de tous les vices de la parole et en particulier du Begaiement, Paris, 1840). He mentions that a boy born of a Chinese mother and a French father was able to speak Chinese perfectly but stammered when speaking French. With reference to Colombat’s opinion, James Hunt, in his book on stammering (London, 1865), explicitly says that " the assertion which has been made on various occasions, on very slender grounds, that there are no stutterers in China is refuted by the fact that the Chinese language possesses a term for impediments of speech." Kussmaul (Pathologie der Sprache, 1877) again gives it out to be an established fact that there are no stammerers in China. He attributes stammering to a lesion of a hypothetical centre of syllable coordination, and it is therefore probable that he adduced Colombat’s statement concerning the absence of stammering in people speaking a monosyllabic language in support of his theory. Kussmaul was a great expert on the pathology of speech, and it is therefore not surprising that, on his authority, other authors took the statement for granted. Chinese physicians whom Gutzmann (Sprachheilkunde, 1912) asked about the truth of Colombat’s statement were greatly astonished and declared that stammering was just as common in China as in Europe. They also informed him that the Chinese term was kchi-ko. For the sake of historical accuracy I should be grateful if you would publish these lines, particularly as the erroneous statement ,has since then been quoted in the
dailv
Dress.
LEOPOLD STEIN.
Tavistock Clinic, London, W.1.
BENIGN
LYMPHOCYTIC MENINGITIS AND GLANDULAR FEVER
interested in Sir Henry Tidy’s article of Dec. 7, particularly because by chance I recently discovered another study of this relationship from America. Coogan and colleaguesconcluded that " a suggestion is contained here that at least some cases of lymphocytic meningitis are really cases of infectious mononucleosis with meningismus." They quote Huber,2 who reported 3 cases of glandular fever exhibiting meningismus, 2 of which showed a lymphocytosis in the spinal fluid.
SIR,—I
of those who have been unfortunate enough to be given a low fistula. The use of the suprapubic catheter is to provide adequate drainage during the period before the development of automatic bladder activity or the return of voluntary micturition, while at the same time preventing serious or ascending infection. In my experience it does this more safely and certainly than the urethral catheter, even with tidal drainage. E. W. RICHES. London, W.I. THE PERIODICALS SIR,—The suspension of the periodicals, and the manner in which it was effected, raise considerations whose importance has not, I submit, been fully appreciated. Two explanations of the suspension, conflicting with one another and with the facts, were given in the two Houses of Parliament, but in both Houses all pretence of any statutory sanction was immediately abandoned. On Feb. 25 in the Commons, the Prime Minister, challenged at question time for the statutory authority upon which suspension had been made, declared, twice over, that it was " done by agreement " between the Periodical Proprietors Association (P.P.A.) and the Government. Lord Chorley, replying for the Government in the Lords
(Feb. 27), repudiated the " agreement " argument. "Suspension of publication was secured," he said, " by an instruction issued after consultation with bodies representing major interests in the newspaper and periodical press." Speaking with all the authority of a professor of law in the University of London, he declared categorically that " instruction is the word which I think most accurately describes " the procedure adopted.
The ascertained facts are that Mr. Shinwell had issued the " instruction " three days before any consultation with the P.P.A. was attempted. The " instruction" had, and was intended to have, all the appearance of an imperial rescript. The P.P.A. taking that view of it, and confronted with an accomplished fact, had no alternative but to " agree." E. GRAHAM-LITTLE. House of Commons.
* * * Like the Economist, we felt that some latitude of authority should be conceded to His Majesty’s Government, if they are acting in good faith in an undoubted" national emergency," but we trust that " instructions of this kind will never be issued again. The P.P.A. agreed with the Ministry that, in order to equalise sacrifices, duplicated issues should not be published; and our membership of the P.P.A. therefore prevented production of the token issues by which we had hoped to maintain continuity of publication.-ED. L. WELFARE OF DEAF CHILDREN
was
C.R.S., Brancepeth, Co. Durham.
R. N. JOHNSTON.
TRAUMATIC PARAPLEGIA SIR,—In your account of the recent discussion on traumatic paraplegia at the Royal Society of Medicine (Jan. 4, p. 23) you misquote my instructions for the It should be introduction of a suprapubic catheter. inserted at the highest point of bladder dullness, or midway between the umbilicus and the symphysis-whichever is the lower. There is no advantage, and some possible danger, in a tube put in higher than the mid-
point. Your leading article of Feb. 15 (p. 258) seems to infer that I advocate permanent suprapubic drainage for these This is far from being the case, and I have pointed cases. out that one of the advantages of the small high suprapubic fistula is the readiness with which it closes when the tube is removed. The majority of our cases at Stoke Mandeville have their bladders closed, and much of my time there is spent in closing surgically the bladders 1. Coogan, T. J.,
Martinson, D. L., Mathews,
1945, 87, 296.
W. H.
2. Huber, W. Schweiz. med. Wschr. 1938, 68, 892.
Illinois med. J.
SIR,—My attention has been drawn to the letter of Miss Edwardes, secretary of the Deaf Children’s Society,
in your issue of Dec. 21 (p. 923). There is much to be commended in this letter but it raises some points which call for a reply. Deaf children have suffered too -long from lack of proper facilities and from the fact that their parents have been given incomplete or inaccurate advice. There is not sufficient accommodation at the moment for all deaf children to be admitted to schools immediately their affliction is diagnosed, but it is essential that practitioners, and the parents of deaf children, should be made aware of the best and only satisfactory method of providing for their education. Your correspondent says that the young deaf child need not be instructed by a fully qualified teacher. But the whole foundation of the deaf child’s education and his whole outlook on life depend on the training in his early years. Only the qualified teacher can meet the needs of the young deaf child. It is to be hoped that the efforts of parents and such societies as that represented by your correspondent will be directed to ensuring increased facilities for young deaf children under fully qualified teachers. A further point is the advisability of young deaf children attending a residential sehool. There are comparatively few deaf children whose homes are so situated that it is convenient or suitable for them to attend day schools even when they have reached normal schoo Even in the large age let alone nursery-school age. cities the travelling involved would often be much more a young child could be expected to undertake, and ,
’
than
It seems particularly important in the present state of our knowledge that cases should be recorded where the mother has rubella early in pregnancy and the child is born without any malformations. Galton Laboratory, University College, JULIA BELL. London.
cation.)
Specimens
AMYLOID MACROGLOSSIA
SIR,—Dr. M. D. Baber’s
case
interest and helps to show that
ago.
When an example was described by Weber, Cade, Stott, and Pulvertaft in 1937macroglossia due to amyloidosis was unknown in Britain, though cases had
published in America. Since then besides the two recorded by Barnard, Smith, and Woodhouse2 quite a number of cases of primary amyloidosis-with or without been
macroglossia-have been brought forward and others have remained unpublished. Personally I have seen two typical examples of the Lubarsch-Pick syndrome shortly before the commencement of the war, and I hope they will be described by the doctors through whose kindness I was able to examine them. I suspect that some cases recorded in medical literature-even during the last ten years-have not been recognised as examples of the Lubarsch-Pick syndrome. For instance, I recently came across the account of a case demonstrated
by
Dr. G. H. Belote3 as
one
of
"tertiary
syphilis with amyloid deposits in the eyelids, lips, tongue, pharynx and larynx " in a man, aged 56, complaining of sore tongue. Ten years previously the tongue had shown "some thickening, but no ulceration." When this case was demonstrated there were waxy flesh-coloured papules on eyelids and lips ; and there was thickening of the tongue, of the alveolar regions, of the tonsillar region, of the pharynx, and of the larynx. The serological reaction for syphilis was negative, and a biopsy showed amyloid material.
Surely, that syndrome. I
was
an
example of the Lubarsch-Pick
do not know if it
was
sections
of these
two
cases
were
meeting of the Association of Clinical Pathologists in January, 1946. Where the amyloid deposit is slight, it is in sheaths a
of smaller blood-vessels and in interstitial fasciae. The three cases which have now been seen in this department suggest that atypical systemic amyloidosis is a disease sui generis, which may affect any tissue in the body. F. B. SMITH Department of Pathology, R. T. COOKE. Royal Infirmary; Preston.
PREVENTION OF EPIDEMIC NEONATAL DIARRHŒA SiR.,-In his article of Jan. 11 Mr. Stern suggests that " infection may be spread by the heavy and increasing contamination of the film which forms in feeding-bottles in constant use." Is it not time that the narrow-necked bottle was discarded altogether and theHygeia’ type of wide-necked, straight-sided bottle, with large rubber teat, substituted ? I believe these bottles are widely used in Canada and the U.S.A., and feel sure they could be produced in England too. The hygeia bottle is readily cleaned with hot water, to which washing soda has been added, and a stiff brush; and all parts of the bottle are easily accessible to the brush, which is patently not so with the narrow-necked bottle. The formation of film is thus easily prevented, and the bottles must of course be boiled for each feed. With regard to the suggestion that sterilisation by’ boiling destroys rubber teats, I havebeen using the It same teat for my own baby for over 4 months now. has been boiled daily for at least 5 minutes and shows and this is not an isolatedno sign of perishing yet;
experience. Johannesburg, South Africa.
ELIZABETH LUND.
described later at
RECRUITMENT OF STUDENT NURSES
greater length. F. PARKES WEBER.
London, W.1.
and
demonstrated at
(Feb. 8) is of great cases of primary amyloidosis, notably those accompanied by obvious macroglossia (the Lubarsch-Pick syndrome), are not of such extreme rarity as was supposed until ten years
-
The spleen contained many giant-cells of foreign-body type, presumably a reaction to amyloid which almost replaced the The gastrocnemius also showed a whole bulk of the organ. striking myositis. (The notes of more than one case previouslv recorded mention pains in the legs comparable with claudi-
SIR,—Dr. Margaret Baber’s report of another case of amyloid macroglossia (Feb. 8) prompts a, brief note of two further cases of atypical amyloidosis, both men, one with macroglossia.
SIR,—Speaking from personal experience, based on entry of a daughter into general nursing training, I strongly support the need for revision of the pay of student nurses along the lines suggested by your correspondent of Feb. 8. The position is worsened by the fact
the
that the Commissioners of Inland Revenue have decided that no allowance is given for any child who earns-more than £50 per annum (except for scholarships). This at home in decision at once excludes any tax relief for parents heart-failure. He came to necropsy because he had received a full military pension for rheumatoid arthritis since the war paying higher rates of tax who have been public-spirited of 1914-18. The notes are summarised : widespread rheuma- enough either to agree to, or to stimulate, the entry of their daughters into nursing. toid deformities of all limb joints ; wasting ; gross generalised It is obvious, of course, that if the pay of student nurses œdema; pallor and puffiness of the face, with thick lips ; tongue enlarged to fill the mouth ; sterile pus in one knee- is increased similar increases must be granted to all the joint ; heart 420 g. ; microscopically, much amyloid in the more senior grades. Increases beyond those proposed tongue, heart, kidneys, spleen, and adrenal glands. (One in the Rushcliffe scales are needed, in my opinion, if conditions in the nursing profession are to compete withof the cases reported by Edwards4 bad rheumatoid arthritis.) those of industry and commerce. CASE 2.-A boiler fireman, aged 61, was admitted to A. T. W. POWELL. Public Health Department, Walthamstow. hospital in August, 1945, with congestive heart-failure after 18 months of ill health ; he had dyspnoea, retrosternal pain on exertion, aching legs on exertion, giddiness, insomnia, and THYROID AND COLD SENSITIVITY swollen ankles. The blood-pressure was 60/35 mm. Hg in SIR,-Dr. S. L. Simpson makes the interesting suggeshospital, and the haemoglobin 77%. The condition was tion (March 8) that thyroid should be given to healthy diagnosed as myocardial fibrosis. Necropsy four hours after volunteers in order to investigate its capacity to increase death on thethird day in hospital showed oedema of legs, A word of resistance to cold and induce well-being. moderate ascites, and bilateral hydrothorax ; large thickis needed, however, should such an experiment warning walled heart (580 g.), pale, of rubbery consistence, and with be undertaken. many subepicardial petechise ; spleen (340 g.) of a striking red S. W. Patterson has warned that thyroid may cause colour, firm and friable, resembling a cake of wax ; no addiction. It acts as a tonic by increasing energy, macroglossia. Microscopically, amyloid was present in very improving the appetite, and enhancing mental alertness ; large amount in heart, spleen, kidneys, and adrenals ; in and neurotics are apt to take to it. The widespread rather less amount in liver, pharynx, tongue, gastrocnemius, administration of thyroid to otherwise healthy obese pancreas, meninges, a meningioma, diaphragm, prostate, patients and to those with assumed " slight glandular thyroid, and lung ; and none was found in biceps and skin. underfunction " has created quite a few cases of moderate addiction. Happily, the metabolic effects are often not 1. Quart. J. Med. 1937, 6, 181. too harmful, possibly because the present diet is poor in 2. J. Path. Bact. 1938, 47, 311.
aged 59, bedridden for two years, died October, 1945, in a manner suggesting congestive
C4.SE 1.—A
man,
3. Arch. Derm. Syph., N.Y. 1937, 35, 540. 4. Edwards, J. L. J. Path. Bact. 1945, 57, 283.
1. Brit. med. J.
1934, ii, 6.
348 and perhaps also because of the formation of antihormones. I saw such a patient quite recently who had taken 15 grains of thyroid daily for eighteen months .and had remained well, except for a tachycardia of’106120. It took more than six months to reduce the dose to 1½—2 grains dailv. V. C. MEDVEI. London. S.W.3. STAMMERING SIR,—Speech therapists should be indebted to Dr. Chrysanthis (Feb. 15) for his data on the incidence of stammering in the Greek elementary schools of Nicosia, Cyprus. A number of factors mentioned in this con-
proteins,
v
nexion—such as anthropological peculiarities, intelligence, handedness, and sex-are still so controversial that they cannot be discussed briefly. I must, however, challenge
the statement that " according to many investigators, stammering is unknown among the Chinese, whose language consists of monosyllables." This opinion can be traced back to Colombat d’Isères ,(Trait,- de tous les vices de la parole et en particulier du Begaiement, Paris, 1840). He mentions that a boy born of a Chinese mother and a French father was able to speak Chinese perfectly but stammered when speaking French. With reference to Colombat’s opinion, James Hunt, in his book on stammering (London, 1865), explicitly says that " the assertion which has been made on various occasions, on very slender grounds, that there are no stutterers in China is refuted by the fact that the Chinese language possesses a term for impediments of speech." Kussmaul (Pathologie der Sprache, 1877) again gives it out to be an established fact that there are no stammerers in China. He attributes stammering to a lesion of a hypothetical centre of syllable coordination, and it is therefore probable that he adduced Colombat’s statement concerning the absence of stammering in people speaking a monosyllabic language in support of his theory. Kussmaul was a great expert on the pathology of speech, and it is therefore not surprising that, on his authority, other authors took the statement for granted. Chinese physicians whom Gutzmann (Sprachheilkunde, 1912) asked about the truth of Colombat’s statement were greatly astonished and declared that stammering was just as common in China as in Europe. They also informed him that the Chinese term was kchi-ko. For the sake of historical accuracy I should be grateful if you would publish these lines, particularly as the erroneous statement ,has since then been quoted in the
dailv
Dress.
LEOPOLD STEIN.
Tavistock Clinic, London, W.1.
BENIGN
LYMPHOCYTIC MENINGITIS AND GLANDULAR FEVER
interested in Sir Henry Tidy’s article of Dec. 7, particularly because by chance I recently discovered another study of this relationship from America. Coogan and colleaguesconcluded that " a suggestion is contained here that at least some cases of lymphocytic meningitis are really cases of infectious mononucleosis with meningismus." They quote Huber,2 who reported 3 cases of glandular fever exhibiting meningismus, 2 of which showed a lymphocytosis in the spinal fluid.
SIR,—I
of those who have been unfortunate enough to be given a low fistula. The use of the suprapubic catheter is to provide adequate drainage during the period before the development of automatic bladder activity or the return of voluntary micturition, while at the same time preventing serious or ascending infection. In my experience it does this more safely and certainly than the urethral catheter, even with tidal drainage. E. W. RICHES. London, W.I. THE PERIODICALS SIR,—The suspension of the periodicals, and the manner in which it was effected, raise considerations whose importance has not, I submit, been fully appreciated. Two explanations of the suspension, conflicting with one another and with the facts, were given in the two Houses of Parliament, but in both Houses all pretence of any statutory sanction was immediately abandoned. On Feb. 25 in the Commons, the Prime Minister, challenged at question time for the statutory authority upon which suspension had been made, declared, twice over, that it was " done by agreement " between the Periodical Proprietors Association (P.P.A.) and the Government. Lord Chorley, replying for the Government in the Lords
(Feb. 27), repudiated the " agreement " argument. "Suspension of publication was secured," he said, " by an instruction issued after consultation with bodies representing major interests in the newspaper and periodical press." Speaking with all the authority of a professor of law in the University of London, he declared categorically that " instruction is the word which I think most accurately describes " the procedure adopted.
The ascertained facts are that Mr. Shinwell had issued the " instruction " three days before any consultation with the P.P.A. was attempted. The " instruction" had, and was intended to have, all the appearance of an imperial rescript. The P.P.A. taking that view of it, and confronted with an accomplished fact, had no alternative but to " agree." E. GRAHAM-LITTLE. House of Commons.
* * * Like the Economist, we felt that some latitude of authority should be conceded to His Majesty’s Government, if they are acting in good faith in an undoubted" national emergency," but we trust that " instructions of this kind will never be issued again. The P.P.A. agreed with the Ministry that, in order to equalise sacrifices, duplicated issues should not be published; and our membership of the P.P.A. therefore prevented production of the token issues by which we had hoped to maintain continuity of publication.-ED. L. WELFARE OF DEAF CHILDREN
was
C.R.S., Brancepeth, Co. Durham.
R. N. JOHNSTON.
TRAUMATIC PARAPLEGIA SIR,—In your account of the recent discussion on traumatic paraplegia at the Royal Society of Medicine (Jan. 4, p. 23) you misquote my instructions for the It should be introduction of a suprapubic catheter. inserted at the highest point of bladder dullness, or midway between the umbilicus and the symphysis-whichever is the lower. There is no advantage, and some possible danger, in a tube put in higher than the mid-
point. Your leading article of Feb. 15 (p. 258) seems to infer that I advocate permanent suprapubic drainage for these This is far from being the case, and I have pointed cases. out that one of the advantages of the small high suprapubic fistula is the readiness with which it closes when the tube is removed. The majority of our cases at Stoke Mandeville have their bladders closed, and much of my time there is spent in closing surgically the bladders 1. Coogan, T. J.,
Martinson, D. L., Mathews,
1945, 87, 296.
W. H.
2. Huber, W. Schweiz. med. Wschr. 1938, 68, 892.
Illinois med. J.
SIR,—My attention has been drawn to the letter of Miss Edwardes, secretary of the Deaf Children’s Society,
in your issue of Dec. 21 (p. 923). There is much to be commended in this letter but it raises some points which call for a reply. Deaf children have suffered too -long from lack of proper facilities and from the fact that their parents have been given incomplete or inaccurate advice. There is not sufficient accommodation at the moment for all deaf children to be admitted to schools immediately their affliction is diagnosed, but it is essential that practitioners, and the parents of deaf children, should be made aware of the best and only satisfactory method of providing for their education. Your correspondent says that the young deaf child need not be instructed by a fully qualified teacher. But the whole foundation of the deaf child’s education and his whole outlook on life depend on the training in his early years. Only the qualified teacher can meet the needs of the young deaf child. It is to be hoped that the efforts of parents and such societies as that represented by your correspondent will be directed to ensuring increased facilities for young deaf children under fully qualified teachers. A further point is the advisability of young deaf children attending a residential sehool. There are comparatively few deaf children whose homes are so situated that it is convenient or suitable for them to attend day schools even when they have reached normal schoo Even in the large age let alone nursery-school age. cities the travelling involved would often be much more a young child could be expected to undertake, and ,
’
than