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ÆTIOLOGY OF MONGOLISM
871 AORTIC EMBOLECTOMY SiR,-Mr. Ian Gordon’s article of Oct. 9 will be of interest to every general surgeon ; for, in view of the " rarity and urgency of riding " embolus, a surgeon faced with this operation is likely to find himself doing it for the first time and will have to rely on what he has read as a guide to his technique. Having had this experience myself over five years ag01 (the patient is still alive and well), I should like to make the following observations : -
(1)
The
probably
transperitoneal approach
is the most direct and
easiest.
round the aorta and common iliac arteries and efficient. They can be tied in a half-hitch over a rubber tube and controlled by the assistant. (3) The incision should be made in the aorta itself if a healthy site can be found. Suturing of this is no more difficult than suturing a common iliac artery, and the latter carries the grave risk of narrowing and thrombosis, as Mr. Gordon mentions. (4) The aorta should be incised with the iliac tapes loose. Clot will not be lost down the limbs, since the blood-flow (which is small with the aorta controlled) will come upwards from the isch2amic area.
in convalescence : the other nipple and had always been so. Another point of interest was that a fibroadenoma had been removed from the excised breast twenty years before.
The
was
patient depressed
It is anatomically improbable that the penetrating hair arose in a follicle associated with sebaceous glands and not revealed in the sections. It would seem, therefore, that penetration by hair is a hazard of congenital retraction " of the nipple. Perhaps others may have experience of this complication. "
King Edward Memorial Hospital, London, W.13.
(2) Tapes passed
are
simple
’
If the iliac tapes are tightened first there is a risk of shearing off " tails " of clot below them, with subsequent difficulty in extraction, or even failure to relieve the block in a main artery. The function of the iliac tapes is to give a completely dry field for suturing the aorta, and to prevent clot being swept downwards when the aorta is momentarily released to prove its patency. E. E. T. TAYLOR. Northampton. TUBERCULOUS MENINGITIS SIR,-You are at pains in your leader last week to point out that for diagnosis and treatment this disease is an emergency, and that " any insidious illness with headache and drowsiness or irritability may be due to Rather surprisingly you do not early meningitis." mention that the disease is almost 100% preventable, and that the time has comeŇhas long come-to start a national campaign for the B.c.G. vaccination and subsequent follow-up of all infants. E. H. R. SMITHARD. London, S.E.6.
PENETRATION OF HAIR INTO BREAST SIR,-The recent correspondence on the penetration of hairs into the foot prompts me to record the penetration of a hair into another unusual site-into the breast via " retracted " nipple. This event led to a a congenitally chronic induration in the breast and its eventual removal by radical surgery. Radical mastectomy was performed in a married woman of 47 for a hard mass in the right breast with retraction and elevation of the nipple. When the breast was sectioned for pathological examination, a chronic abscess cavity was found and the rest of the breast tissue was much tougher in consistency than normal. Microscopical sections showed abscess formation, fat necrosis, and diffuse periductal mastitis ; there were also fibroadenosis and two small hyalinised fibroadenomas. No carcinoma was found in eight blocks of tissue. The whole of the depressed nipple was taken for section, because at this time nipples were being sectioned routinely to discover if congenital " retraction " had any distinct microscopic features. This nipple had a hair lying in a small abscess cavity just beneath the zone of unstriped muscle. Serial sections revealed that the hair was lying in a duct, the epithelium of which had been destroyed by inflammation ; it was traced to a ragged termination, just outside the surface opening of the duct. The nipple area showed the superabundant sebaceous glands which seem to be a feature of congenital retraction," though here the retraction was almost certainly increased by fibrosis consequent upon "
inflammation.
1. Brit. J. Surg.
1951, 39, 280.
was seen
W. S. KILLPACK.
ÆTIOLOGY OF MONGOLISM
SiR,-Professor Penrose, in his paper of Sept. 11, notes that mongolism occurs " in African, Indian, Chinese, and Japanese populations, though the incidence appears particularly high among Europeans." During the past eight years I have seen cases of this condition in children of the following nationalities :
Egyptian, Pakistani, Indian, Thai, Indonesian, HongKong Chinese, as well as in Europeans, North Americans, and Jamaicans. Perhaps of more interest is the fact that no children with this form of mental deficiency were seen during a period of several years’ psediatric experience in Nigeria, working among an almost unmixed African population. By contrast, mongolism, while not as frequent as in Europe, is not uncommon amongst mainly Negro children in the much more intermixed populations of Jamaica In a recent paper I have and the Southern States. suggested that this may indicate that whatever factor is responsible may be acquired from non-African-that is Caucasian and Asian_sources.1 In any case, further scientifically conducted surveys of the racial incidence of this condition might produce further clues to its
aetiology. All-India Institute of Hygiene and Public Health, Calcutta.
D. B. JELLIFFE.
LIABILITY FOR ACTS OF DEPUTY
Si[R,-In my opinion Dr. Eimerl is absolutely right, in his letters of Sept. 25 and Oct. 16, in pointing out that on the reported facts the recommendation of the Devon and Exeter Executive Councilis ridiculous. It is reported that the patient’s messengers were told that the doctor’s partner was deputising for him at the time advice was sought. What more can a G.P. do than arrange for another G.P. to stand in for him (on a reciprocal basis probably) when he is not available for a reasonable cause to attend patients on his list ? Indeed this is recognised in para. 8 (9) of the Terms of ServiceS which states : " In the case of two or more practitioners practising in partnership or as a principal and assistant, treatment may at any time be given by a partner or assistant of the practitioner in whose list the patient is included, instead of by the practitioner in person, if reasonable steps are taken to secure continuity of treatment." The real trouble is that para. 8 (8) of the Terms of Service, which are binding on an N.H.S. principal, makes him " responsible for all acts and omissions of any practitioner acting as his deputy or assistant in relation to his obligations under these terms of service." The medical protection societies, in conjunction with the General Medical Services Committee, are pressing the Minister of Health for an amendment of this unfair and illogical rule to provide that a principal who has made reasonable deputising arrangements with another principal (who is on the list of an executive council and therefore can be penalised if found to be in breach of the 1. Jelliffe, D. B. W. Ind. med. J. (in the press). 2. Manchester Guardian, Aug. 19, 1954 ; see Lancet, Sept. 11, 1954, p.549. 3. N.H.S. (General Medical and Pharmaceutical Services) Regulations, 1954, First Schedule. s.l. 1954, no. 669.
(1)
The
probably
transperitoneal approach
is the most direct and
easiest.
round the aorta and common iliac arteries and efficient. They can be tied in a half-hitch over a rubber tube and controlled by the assistant. (3) The incision should be made in the aorta itself if a healthy site can be found. Suturing of this is no more difficult than suturing a common iliac artery, and the latter carries the grave risk of narrowing and thrombosis, as Mr. Gordon mentions. (4) The aorta should be incised with the iliac tapes loose. Clot will not be lost down the limbs, since the blood-flow (which is small with the aorta controlled) will come upwards from the isch2amic area.
in convalescence : the other nipple and had always been so. Another point of interest was that a fibroadenoma had been removed from the excised breast twenty years before.
The
was
patient depressed
It is anatomically improbable that the penetrating hair arose in a follicle associated with sebaceous glands and not revealed in the sections. It would seem, therefore, that penetration by hair is a hazard of congenital retraction " of the nipple. Perhaps others may have experience of this complication. "
King Edward Memorial Hospital, London, W.13.
(2) Tapes passed
are
simple
’
If the iliac tapes are tightened first there is a risk of shearing off " tails " of clot below them, with subsequent difficulty in extraction, or even failure to relieve the block in a main artery. The function of the iliac tapes is to give a completely dry field for suturing the aorta, and to prevent clot being swept downwards when the aorta is momentarily released to prove its patency. E. E. T. TAYLOR. Northampton. TUBERCULOUS MENINGITIS SIR,-You are at pains in your leader last week to point out that for diagnosis and treatment this disease is an emergency, and that " any insidious illness with headache and drowsiness or irritability may be due to Rather surprisingly you do not early meningitis." mention that the disease is almost 100% preventable, and that the time has comeŇhas long come-to start a national campaign for the B.c.G. vaccination and subsequent follow-up of all infants. E. H. R. SMITHARD. London, S.E.6.
PENETRATION OF HAIR INTO BREAST SIR,-The recent correspondence on the penetration of hairs into the foot prompts me to record the penetration of a hair into another unusual site-into the breast via " retracted " nipple. This event led to a a congenitally chronic induration in the breast and its eventual removal by radical surgery. Radical mastectomy was performed in a married woman of 47 for a hard mass in the right breast with retraction and elevation of the nipple. When the breast was sectioned for pathological examination, a chronic abscess cavity was found and the rest of the breast tissue was much tougher in consistency than normal. Microscopical sections showed abscess formation, fat necrosis, and diffuse periductal mastitis ; there were also fibroadenosis and two small hyalinised fibroadenomas. No carcinoma was found in eight blocks of tissue. The whole of the depressed nipple was taken for section, because at this time nipples were being sectioned routinely to discover if congenital " retraction " had any distinct microscopic features. This nipple had a hair lying in a small abscess cavity just beneath the zone of unstriped muscle. Serial sections revealed that the hair was lying in a duct, the epithelium of which had been destroyed by inflammation ; it was traced to a ragged termination, just outside the surface opening of the duct. The nipple area showed the superabundant sebaceous glands which seem to be a feature of congenital retraction," though here the retraction was almost certainly increased by fibrosis consequent upon "
inflammation.
1. Brit. J. Surg.
1951, 39, 280.
was seen
W. S. KILLPACK.
ÆTIOLOGY OF MONGOLISM
SiR,-Professor Penrose, in his paper of Sept. 11, notes that mongolism occurs " in African, Indian, Chinese, and Japanese populations, though the incidence appears particularly high among Europeans." During the past eight years I have seen cases of this condition in children of the following nationalities :
Egyptian, Pakistani, Indian, Thai, Indonesian, HongKong Chinese, as well as in Europeans, North Americans, and Jamaicans. Perhaps of more interest is the fact that no children with this form of mental deficiency were seen during a period of several years’ psediatric experience in Nigeria, working among an almost unmixed African population. By contrast, mongolism, while not as frequent as in Europe, is not uncommon amongst mainly Negro children in the much more intermixed populations of Jamaica In a recent paper I have and the Southern States. suggested that this may indicate that whatever factor is responsible may be acquired from non-African-that is Caucasian and Asian_sources.1 In any case, further scientifically conducted surveys of the racial incidence of this condition might produce further clues to its
aetiology. All-India Institute of Hygiene and Public Health, Calcutta.
D. B. JELLIFFE.
LIABILITY FOR ACTS OF DEPUTY
Si[R,-In my opinion Dr. Eimerl is absolutely right, in his letters of Sept. 25 and Oct. 16, in pointing out that on the reported facts the recommendation of the Devon and Exeter Executive Councilis ridiculous. It is reported that the patient’s messengers were told that the doctor’s partner was deputising for him at the time advice was sought. What more can a G.P. do than arrange for another G.P. to stand in for him (on a reciprocal basis probably) when he is not available for a reasonable cause to attend patients on his list ? Indeed this is recognised in para. 8 (9) of the Terms of ServiceS which states : " In the case of two or more practitioners practising in partnership or as a principal and assistant, treatment may at any time be given by a partner or assistant of the practitioner in whose list the patient is included, instead of by the practitioner in person, if reasonable steps are taken to secure continuity of treatment." The real trouble is that para. 8 (8) of the Terms of Service, which are binding on an N.H.S. principal, makes him " responsible for all acts and omissions of any practitioner acting as his deputy or assistant in relation to his obligations under these terms of service." The medical protection societies, in conjunction with the General Medical Services Committee, are pressing the Minister of Health for an amendment of this unfair and illogical rule to provide that a principal who has made reasonable deputising arrangements with another principal (who is on the list of an executive council and therefore can be penalised if found to be in breach of the 1. Jelliffe, D. B. W. Ind. med. J. (in the press). 2. Manchester Guardian, Aug. 19, 1954 ; see Lancet, Sept. 11, 1954, p.549. 3. N.H.S. (General Medical and Pharmaceutical Services) Regulations, 1954, First Schedule. s.l. 1954, no. 669.