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TUBERCULIN TESTS
252 civilian hospital practice in many parts of the country, the methods of therapy employed by these ex-soldiers will be found to be in advance of the routine practice in vogue in many areas. For these and other reasons your reference to the creation of a pool containing those whose careers will be determined by the new health service is welcome, particularly to one who has tried in several ways to impress the need for this or some similar scheme on the highest authorities. Possibly it will not be feasible until Parliament has considered whether or not a National Health Service is to be established ; but an immediate statement that such a pool will at once be formed if Parliament assents to the proposals would enable many men, who are at present undecided, to make their plans
that the European personnel of the West African Command represents a highly mepacrinised population. The incidence of other skin diseases which might be confused with lichen planus shows no conceivably increase after suppressive treatment was changed from quinine to mepacrine ; and certainly since 1944, when confidential information about a possible association of lichen planus with mepacrine was first received, such confusion can be ruled out. From the experience in this Command it would not be easy to claim any relationship between the incidence of lichen planus and the administration of mepacrine. -
G. M. FINDLAY Brigadier ; Consulting Physician
in Tropical Medicine, West Africa Command.
accordingly.
R. M. B. MACKENNA.
Liverpool.
TUBERCULIN TESTS SiR,-Dr. Deane’s method of abrading the skin with sandpaper before applying tuberculin jelly (Feb. 2, p. 162) seems to offer a useful way of increasing the sensitivity of this test. It will be interesting to see if complete correlation with the Mantoux (1 :1000) test is borne out in a large series of tests. I have recently been experimenting on similar lines by using single or multiple needle pricks through the superficial layers of the skin (as in one of the methods of vaccination) to try to increase the absorption of tuberculin. Most of the experiments were done, not with jelly, but with a drop of undiluted Old Tuberculin placed on the skin, the pricks being made through it. An intradermal test, however, using the same batch of tuberculin diluted 1 : 1000, proved the more reliable of the two methods. Incidentally, undiluted Old Tuberculin has excellent keeping qualities and is much cheaper to use than tuberculin jelly. The need for a reliable and easily applied tuberculin skin-test for children might be met if some substance were found which, when used for cleansing the skin before testing, also increased its permeability to tuberculin. HUGH CLIMIE.
Kirkcaldy.
MEPACRINE AND LICHEN PLANUS SiR,-In view of the suggestion that long-continued administration of mepacrine may be associated with an increased incidence of lichen planus,the records of the West African Command may be of interest. The table shows the number of cases of lichen planus admitted to military hospitals in the four West African Colonies from 1941 to 1945, together with the incidence per 1000 strength.
African troops were never on suppressive mepacrine. European troops began taking mepacrine as a suppressive
on March 15, 1943, and have continued ever since. Before March, 1943, the mepacrine was only employed as part of the routine treatment of malarial attacks, the usual course being not more than 0-3 g. daily for 7 days. After March, 1943, mepacrine came to be used almost exclusively for treatment as well as for suppression ; quinine was administered only in cerebral cases and where there was hyperpyrexia or continued vomiting due to mepacrine. The usual period on mepacrine as a suppressive was 18 months, but many persons have taken it for from 2 to 3 years. It may therefore be claimed
1. See
Lancet, 1945, ii, 711.
DESIGN OF RAILWAY CARRIAGES
SIR,-I fully agree with all your peripatetic correspondent writes (.Tan. 19) about the advantages of the American over the English type of railway coach, and I have adopted his company. May I
suggestion and written
to my railway make one to him and other travelling colleagues ? It is that they should expostulate, in other words make a polite remonstrance, with passengers who cough unguardedly ! In my experience this is never resented and always respected. On two recent occasions persistent coughs were stopped for 1 and 3 hours respectively-that was to the end of the journeys. I once heard a cleric start his sermon in a crowded cathedral with an appeal for no coughing ; it was most effective. The Ministry of Health should add "Stop that cough ! It may not be necessary" to its exhortations and send them to church and chapel, concert-hall and cinema. A. R. NELIGAN. Droitwich. now
PROSTATECTOMY
Sm,-Like Mr. Newell, my first impressions of a limited experience of retropubic prostatectomy have been very favourable, and what is, I think, most surprising is the excellent exposure of the interior of the cavity after the prostate has been removed. However, my reason for writing is to point but how -
easy it is, when doing this operation, to pick up, ligate, and divide the vas as it runs up the lateral wall of the pelvis to the internal ring. This is done after the prostatic capsule has been sutured, before closing the linea alba, and obviates the separate incision required when the vas is divided at the usual site in the spermatic cord. Wolverhampton.
R. MILNES WALKER.
SiR,-In your account (Feb. 9, p. 199) of the meeting of the urological section of the Royal Society of Medicine " on Jan. 31, you state that I had had 1 death in a case it had where been impossible to return the catheter into the bladder after it had slipped out." This is an inaccurate report of what I said, and the mention of the incident separated from the context of my remarks may give the impression that the occurrence was used by me in adverse criticism of the operation. The death referred to followed my 8th operation, under the following circumstances. The patient suffered from an old-standing cardiac dilatation and aortic disease. The operation was finished in 35 minutes and the patient’s condition at its completion was considered to be eminently satisfactory. On proceeding to place the retention stitch through the catheter the latter was found to have slipped out. Great difficulty was experienced in replacing a catheter into the bladder but this was finally accomplished. The urethral manipulations, however, were followed by symptoms of severe shock. There was no response to plasma infusion and other supportive treatment, and death from cardiac failure took place 7 hours after operation. This is the sole fatality in the 23 retropubic prostatectomies which I have ‘
performed.
I take this opportunity of paying tribute to Mr. Terence Millin, to whose brilliant ingenuity we owe this new method of approach to the prostate. I believe his claim to have devised an operation that is better than the old ones is fully justified. ARTHUR JACOBS. Glasgow.
that the European personnel of the West African Command represents a highly mepacrinised population. The incidence of other skin diseases which might be confused with lichen planus shows no conceivably increase after suppressive treatment was changed from quinine to mepacrine ; and certainly since 1944, when confidential information about a possible association of lichen planus with mepacrine was first received, such confusion can be ruled out. From the experience in this Command it would not be easy to claim any relationship between the incidence of lichen planus and the administration of mepacrine. -
G. M. FINDLAY Brigadier ; Consulting Physician
in Tropical Medicine, West Africa Command.
accordingly.
R. M. B. MACKENNA.
Liverpool.
TUBERCULIN TESTS SiR,-Dr. Deane’s method of abrading the skin with sandpaper before applying tuberculin jelly (Feb. 2, p. 162) seems to offer a useful way of increasing the sensitivity of this test. It will be interesting to see if complete correlation with the Mantoux (1 :1000) test is borne out in a large series of tests. I have recently been experimenting on similar lines by using single or multiple needle pricks through the superficial layers of the skin (as in one of the methods of vaccination) to try to increase the absorption of tuberculin. Most of the experiments were done, not with jelly, but with a drop of undiluted Old Tuberculin placed on the skin, the pricks being made through it. An intradermal test, however, using the same batch of tuberculin diluted 1 : 1000, proved the more reliable of the two methods. Incidentally, undiluted Old Tuberculin has excellent keeping qualities and is much cheaper to use than tuberculin jelly. The need for a reliable and easily applied tuberculin skin-test for children might be met if some substance were found which, when used for cleansing the skin before testing, also increased its permeability to tuberculin. HUGH CLIMIE.
Kirkcaldy.
MEPACRINE AND LICHEN PLANUS SiR,-In view of the suggestion that long-continued administration of mepacrine may be associated with an increased incidence of lichen planus,the records of the West African Command may be of interest. The table shows the number of cases of lichen planus admitted to military hospitals in the four West African Colonies from 1941 to 1945, together with the incidence per 1000 strength.
African troops were never on suppressive mepacrine. European troops began taking mepacrine as a suppressive
on March 15, 1943, and have continued ever since. Before March, 1943, the mepacrine was only employed as part of the routine treatment of malarial attacks, the usual course being not more than 0-3 g. daily for 7 days. After March, 1943, mepacrine came to be used almost exclusively for treatment as well as for suppression ; quinine was administered only in cerebral cases and where there was hyperpyrexia or continued vomiting due to mepacrine. The usual period on mepacrine as a suppressive was 18 months, but many persons have taken it for from 2 to 3 years. It may therefore be claimed
1. See
Lancet, 1945, ii, 711.
DESIGN OF RAILWAY CARRIAGES
SIR,-I fully agree with all your peripatetic correspondent writes (.Tan. 19) about the advantages of the American over the English type of railway coach, and I have adopted his company. May I
suggestion and written
to my railway make one to him and other travelling colleagues ? It is that they should expostulate, in other words make a polite remonstrance, with passengers who cough unguardedly ! In my experience this is never resented and always respected. On two recent occasions persistent coughs were stopped for 1 and 3 hours respectively-that was to the end of the journeys. I once heard a cleric start his sermon in a crowded cathedral with an appeal for no coughing ; it was most effective. The Ministry of Health should add "Stop that cough ! It may not be necessary" to its exhortations and send them to church and chapel, concert-hall and cinema. A. R. NELIGAN. Droitwich. now
PROSTATECTOMY
Sm,-Like Mr. Newell, my first impressions of a limited experience of retropubic prostatectomy have been very favourable, and what is, I think, most surprising is the excellent exposure of the interior of the cavity after the prostate has been removed. However, my reason for writing is to point but how -
easy it is, when doing this operation, to pick up, ligate, and divide the vas as it runs up the lateral wall of the pelvis to the internal ring. This is done after the prostatic capsule has been sutured, before closing the linea alba, and obviates the separate incision required when the vas is divided at the usual site in the spermatic cord. Wolverhampton.
R. MILNES WALKER.
SiR,-In your account (Feb. 9, p. 199) of the meeting of the urological section of the Royal Society of Medicine " on Jan. 31, you state that I had had 1 death in a case it had where been impossible to return the catheter into the bladder after it had slipped out." This is an inaccurate report of what I said, and the mention of the incident separated from the context of my remarks may give the impression that the occurrence was used by me in adverse criticism of the operation. The death referred to followed my 8th operation, under the following circumstances. The patient suffered from an old-standing cardiac dilatation and aortic disease. The operation was finished in 35 minutes and the patient’s condition at its completion was considered to be eminently satisfactory. On proceeding to place the retention stitch through the catheter the latter was found to have slipped out. Great difficulty was experienced in replacing a catheter into the bladder but this was finally accomplished. The urethral manipulations, however, were followed by symptoms of severe shock. There was no response to plasma infusion and other supportive treatment, and death from cardiac failure took place 7 hours after operation. This is the sole fatality in the 23 retropubic prostatectomies which I have ‘
performed.
I take this opportunity of paying tribute to Mr. Terence Millin, to whose brilliant ingenuity we owe this new method of approach to the prostate. I believe his claim to have devised an operation that is better than the old ones is fully justified. ARTHUR JACOBS. Glasgow.