- Email: [email protected]
TUBERCULOSIS FOLLOWING INJECTION
617 and woman-for instance, work, food, housing, and clothes. It was not that these were provided, but that the individual need not worry about their provision, which enhanced the sense of security. With the end of the war, morale inevitably worsened. The sudden disappearance of the overriding communal motive, together with the natural relaxation after a period of tension, would have sufficed to make a disruptive. social picture even without the loss of the sense of security resulting from material shortages, the return of forgotten husbands to homes " otherwise occupied," the unconscious guilt of those who left their families, and the less unconscious (even if still unjustified) guilt of those who stayed at home. To restore morale we have to restore both the sense of purpose and the sense of security. It might be possible to maintain morale, as the Russians seemed to be doing, by inventing new fears of war which would bind the people together against a common, even if so far a hypothetical, enemy ; but to do this would require a further denial of democratic government which our people would fortunately not tolerate. It would in any event only delay the realisation of the individual’s, as opposed to the State’s, insecurity. To return to the problem of health. The sense of security is to a much larger extent than is generally’ realised dependent on interpersonal contact between members of a community, and to a much smaller extent on the physical conditions of security. We may therefore aim at increasing social contact between people. There is ready to hand an adequate motive for health-giving activity in a war-weary country : recreation. A blueprint for action along these lines is, I think, to be found in the accounts of that admirable social experiment, the Pioneer Health Centre at Peckham. By laying emphasis on recreation, a, motive is provided which is universally acceptable and which is persistent. By providing a focus for interpersonal exchange and communal integration, and by having the centre run under the guidance of properly trained biologists, every opportunity is given for the development of the sense of security. Morale is improved and a rich soil prepared for the seeds of health education. Dr. Kennedy speaks of the need for more recreational facilities and for more biologists. It is important to emphasise that these two must be closely linked. " Biology is the science of life ; and inasmuch as recreation " is a subject for science, it is the biologist’s responsibility. In conclusion, we may remind ourselves that medical education-at least up to 1939-used a’ fragmentary rather than a holistic approach ; and that our profession is primarily oriented toward the relief of illness, secondarily toward the maintenance of health, and only thirdly toward the enhancement of positive health. In the nature of medical work, as at present taught and organised, we see more and think more about disease than about health. A great deal of hard thinking and versatility will be required by our profession if we are to make a real contribution to this problem. JAMES R. MATHERS. Na,rborough, Leicestershire. ’
PILONIDAL SINUS SIR,—Mr. Patey and Professor Scarff (Oct. 5, p. 484) make two questionable assertions. (1) They say there is a world of difference between sacrococcygeal cysts and tumours of undoubted developmental origin and pilonidal sinus. They claim that the pilonidal sinus is higher in the natal cleft, but those of us whose lot it is to see a disproportionate number of children’s posteriors have seen many more than the 16 cysts and tumours of developmental origin which Raven collected in London museums. It is true that some of these are very near the anus but most are high up and all grades are seen from the massive dermoid to the short sinus and dimple. (2) They stress the importance of hair in the aetiology. Surely this very fact emphasises the developmental origin of the pilonidal sinus. The body hair does not grow until stimulated by puberty hormone levels, and it is the young adult in whom the symptoms first develop most commonly. It is difficult to believe that the tough tissues of the sacrococcygeal region can be pierced by a human hair which has been sat on. ,
One of the reasons for so many failures in treatment the war has been that the advent of powerful chemical bacteriostats has tempted the surgeon to " try his luck " and close primarily the gaping -chasm of his wise and wide excision. Healing of the bottom from the bottom must still remain a fundamental rite.
during
D. F. ELLISON NASH.
London.
TUBERCULOSIS FOLLOWING INJECTION
SIR,-Several interesting points
emerge from Mr. Ebrill
and Dr. Elek’s account of a tuberculous abscess arising at the site of a previous intramuscular injection of penicillin (Sept. 14, p. 379). Although the authors do
the term, it is clear that they regard the abscess example of primary tuberculosis (i.e., arising in a previously uninfected individual, who would have been tuberculin-negative had he been tested before One cannot, of course, be the penicillin injection). dogmatic, but the clinical details given are far more suggestive of a post-primary tuberculous abscess (i.e., arising in a previously infected allergic individual, whose Mantoux reaction would have been positive previously had it been tested). Such a post-primary abscess could, of course, havearisen as a result of introducing virulent tubercle bacilli during the penicillin injection, but this is extremely unlikely. Bacilli accidentally inoculated into tuberculo-allergic individuals in this way are usually effectively dealt with by the body’s defence mechanism, as was first shown many years ago by Koch when he described what is now known as the Koch phenomenon. The most likely explanation is, I think, the one which Ebrill and Elek dismiss as a practical impossibilitynamely, that the abscess arose as a blood-borne infection. Such disseminated tuberculous abscesses are by no means rare in sanatorium practice, particularly in the so-called haematogenous type of disease, and in the case not as
use
an
described the haematoma appears to have’ acted as a locus minoris resistantiœ. The fact that clinical and radiological examination has revealed no other tuberculous focus is, of course, inconclusive ; it is quite common not to find a primary tuberculous focus in persons undergoing Mantoux-conversion while under observation (e.g., in sanatorium staff). In such cases the site of infection may be in the alimentary tract. Two clinical details would have been helpful. Firstly, no mention is made of the presence or absence of inguinal adenitis. With a large primary tuberculous abscess of the thigh, caseous adenitis of the regional lymph-nodes would almost certainly have occurred, while " drainage glands of a post-primary abscess, if examined by biopsy, could have been distinguished histologically by the relative absence of caseation. Secondly, no mention is made of the type of bacillus recovered from the pus. The finding of bovine bacilli would have been a pointer, admittedly a weak one, to the presence of a bovine
°
‘
" °
alimentary infection. It might be of interest to note that by a curious coincidence two patients and a possible third have been admitted to this hospital during the last month, each with lupus verrucosus of the hand following an injury involving a breach of skin surface. It is tempting to picture the very natural reaction of sucking the injured member (and both patients have active pulmonary lesions), but it is far more probable that these are also examples of a hsemic infection of a locus minoris resistantice. The well-known association of injury with other tuberculous conditions, such as tuberculosis of joints, is also very much to the point. Dr. Marsh’s statement (Oct. 5, p. 508) that " tubercle bacilli are not uncommon in the dust of hospital wards cannot be allowed to pass unchallenged, since it -tends to perpetuate the erroneous belief that sanatoria and tuberculosis wards are dangerous places in which to "
work because of the risks of infection from dust. Since Cornet, in 1889, claimed to have found tubercle bacilli in 40 out of 140 specimens of dust from various German hospitals, public buildings, and tuberculosis wards,1 belief in the role of dust- as one of the chief infective agents in tuberculosis has been widely held, although few modern tuberculosis pathologists now subscribe to 1.
Cornet,
G.
Z. Hyg.
InfektKr. 1889, 5, 191.
‘
618 this view (e.g., Gloyne 2 ; a good summary of the dust v.droplet controversy is given by Topley and Wilson,3 who point out that the English climate militates very strongly against the formation of dust containing living virulent tubercle bacilli). Even if one accepts Cornet’s work without question, few will deny that personal hygiene is now vastly improved since his day, largely as a result of public-health propaganda ; our tuberculous patients no longer spit on the ward floor ! Numerous investigators have failed to find living tubercle bacilli in the dust of modern hospitals and sanatoria. An investigation was recently made at this hospital into the possible infectivity of occupational-therapy articles made by patients. One hundred articles of all
been maintained but there is still considerable abdominal distension. The dosage of folic acid has been reduced gradually and he is now taking 10 mg. per day. All other treatment has been stopped since the institution of the folic acid. It is impossible, of course, to draw any general con- . clusions from a single case, but we feel strongly that improvement in this case can be attributed solely to folic acid. No doubt intensive trials in this direction are going on, but we have so far seen no recorded work on the treatment of coeliac disease in children with folic acid.
has
Sheffiel’d.
types (plastic, wood, wool, felt, &c.) made by patients degrees of lung involvement (many producing large amounts of positive sputum daily) were examined carefully in the hospital laboratory, where the technique
H. P. BRODY. L. GORE.
PERFORATED PEPTIC ULCER TREATED WITHOUT OPERATION
with all
SIR,—I am anxious to correct two impressions that of cultural examination for tubercle bacilli has been Mr. Deitch’s provocative and stimulating letter of brought to a high standard ; not one positive result wasOct. 19 may give. obtained. I am sure that this is in large measure due He mentions that for two years I have treated all to- the careful instruction in the hygiene of cough which cases of acute perforation conservatively and " with is given to all patients. The danger of infection from uniform success." This series was reported at a meeting patients with open pulmonary tuberculosis is not from of the Leeds Medico-Chirurgical Society in February, It is clear that . 194-6. ward dust but from unrestrained cough. I did not invent the conservative method any this fact needs to be emphasised at a time when hospital more than Hermon Taylor did. Many surgeons practise and sanatorium domestics are at a nremium. conservative treatment in selected cases, and it was not A. G. HOUNSLOW. until Bedford Turner reported 6 cases (Brit. med. J. County Sanatorium, Clare Hall, South Mimms, Barnet. 1935, i, 457) that I had the courage to treat all cases without selection. Further, I have lost 3 cases since the FOLIC ACID IN CŒLIAC DISEASE discussion in February, which makes the mortality SIR,—The course of coeliac disease in children is often 18 % in my small series. I agree with your leader of so protracted, and the prognosis so uncertain, that we Oct. 5 that since we have no means of determining which venture to draw attention to its treatment with folic ulcer will close spontaneously, conservative treatment will acid, a procedure which in a particular case has so far inevitably cause the surgeon more anxiety than simple successful. proved dramatically in Mr. Deitch’s hands, carries a mortality closure, which, A boy, aged 17 months, came under the care of one of of only 4%. This remarkable record, extending over us (L. G.) in May, 1946. There was a history of vomiting eight years, fully justifies his belief in spinal anaesthesia and diarrhoea with the passage of numerous pale bulky and no drainage-tube. and foul-smelling stools during the previous 6 months. Our experience in York differs from Hermon Taylor’ss He had been under treatment by another doctor during in two respects. We found considerable constitutional this period, with no improvement. disturbance in several cases, the pulse-rate rising to He presented the typical appearance of coeliac disease 130 per min. and the temperature to 103° F, falling - pale, apathetic,- with a dry skin and distended gradually to normal by the eighth day, and we had 2 abdomen and wasted buttocks, and with the stools as patients who developed subphrenic abscess, a complicadescribed above. His weight was 19 lb. Treatment with tion which I had never met after closure without drainage. parenteral liver extract 2 c.cm. on alternate days, We have been more by the results of together with ascorbic acid andBenerva ’ Compound prevention of perforationimpressed than with the conservative tablets by mouth and a fat-free diet was instituted. treatment after the catastrophe has occurred. By Improvement was rapid. The vomiting and diarrhoea treating all cases of peptic ulcer with severe symptoms ceased and he gained weight. as requiring urgent admission, and by accepting for The child was taken away on holiday, but after a month surgical treatment all cases who we think are unlikely he relapsed and became extremely ill with a return of to benefit permanently by medical treatment, we have his former symptoms. He was admitted. to hospital reduced the incidence of acute perforation by 44% weighing 21 lb., but after a fortnight’s stay his condition during the last three years. Acute perforation in the had deteriorated considerably and he was taken home York area has now become a rarity ; the majority of weighing only 141/2 lb. He was then seen in consultation cases admitted are visitors to the district, transport by one of us (H. P. B.) and admitted to hospital drivers, or passengers in trains. The few locals who The picture was typical of in a serious condition. perforate " out of the blue " will always defeat our coeliac disease. He was grossly dehydrated and passing efforts to anticipate, rather than wait for, this dreaded He could take only very small 15-16 stools a day. complication. milk with water and glucose. The quantities of skimmed A. HEDLEY VISICK. York. blood-count showed a secondary anaemia with 52 % c.mm. cells The red total and 4,200,000 per haemoglobin PRICE OF POLYTHENE.-In his article of Sept. 14 (p. 380) fat in the stools was 49 %. Dr. Kent remarked that polythene costs about ls. 2d. per lb. Treatment with parenteral liver extract and vitamin-B Chemical Industries Ltd. point out that the minimum complex on alternate days, together with other vitamin Imperial of ’Alkathene,’ the British grade of polythene they price supplements and iron by mouth, was begun, and during manufacture, is 3s. 3d. per lb. the next week there was no improvement although no SODA-LIME.—Already a familiar, laboratory reagent, sodadeterioration in his condition and his weight remained lime is now widely used in medical practice for the absorption stationary. of carbon dioxide. Apparatus for closed-circuit anaesthesia, At this stage a supply of folic acid was obtained and oxygen therapy, and metabolism determination are a few 25 mg. per day was administered by mouth. There was examples of its uses. Messrs. Sofnol Ltd., Westcombe Hill, immediate improvement. The following day only 2 stools Greenwich, S.E.10, the makers ofSofnol Brand ’ soda-lime, were passed, the appetite returned, and he became claim that their product possesses advantages such as conmuch calmer and brighter. From then on he progressed rapidly. His appetite became ravenous and he took a stancy of composition, high absorptive capacity, resistance to good mixed diet, fat-modified, and passed one or two abrasion, and non-heating and non-deliquescent properties. catalogue, illustrated by easily understood graphs, pale formed and non-offensive stools each day. At the Their describes in a simple way the experiments on which these end of a week he had gained 7 lb., and 9 days later he claims are based. These tests will be of interest to those had gained a further6 lb. At the moment improvement who are unfamiliar with the type of laboratory investigations 2. Gloyne, S. R. Social Aspects of Tuberculosis, 1946, p. 23. to which a specimen of soda-lime must be submitted before its 3. Topley, W. W. C., Wilson, G. S. Principles of Bacteriology and Immunity, 1936, pp. 1028-29. value as a CO2-absorbent for medical purposes can be assessed. ,
----
PILONIDAL SINUS SIR,—Mr. Patey and Professor Scarff (Oct. 5, p. 484) make two questionable assertions. (1) They say there is a world of difference between sacrococcygeal cysts and tumours of undoubted developmental origin and pilonidal sinus. They claim that the pilonidal sinus is higher in the natal cleft, but those of us whose lot it is to see a disproportionate number of children’s posteriors have seen many more than the 16 cysts and tumours of developmental origin which Raven collected in London museums. It is true that some of these are very near the anus but most are high up and all grades are seen from the massive dermoid to the short sinus and dimple. (2) They stress the importance of hair in the aetiology. Surely this very fact emphasises the developmental origin of the pilonidal sinus. The body hair does not grow until stimulated by puberty hormone levels, and it is the young adult in whom the symptoms first develop most commonly. It is difficult to believe that the tough tissues of the sacrococcygeal region can be pierced by a human hair which has been sat on. ,
One of the reasons for so many failures in treatment the war has been that the advent of powerful chemical bacteriostats has tempted the surgeon to " try his luck " and close primarily the gaping -chasm of his wise and wide excision. Healing of the bottom from the bottom must still remain a fundamental rite.
during
D. F. ELLISON NASH.
London.
TUBERCULOSIS FOLLOWING INJECTION
SIR,-Several interesting points
emerge from Mr. Ebrill
and Dr. Elek’s account of a tuberculous abscess arising at the site of a previous intramuscular injection of penicillin (Sept. 14, p. 379). Although the authors do
the term, it is clear that they regard the abscess example of primary tuberculosis (i.e., arising in a previously uninfected individual, who would have been tuberculin-negative had he been tested before One cannot, of course, be the penicillin injection). dogmatic, but the clinical details given are far more suggestive of a post-primary tuberculous abscess (i.e., arising in a previously infected allergic individual, whose Mantoux reaction would have been positive previously had it been tested). Such a post-primary abscess could, of course, havearisen as a result of introducing virulent tubercle bacilli during the penicillin injection, but this is extremely unlikely. Bacilli accidentally inoculated into tuberculo-allergic individuals in this way are usually effectively dealt with by the body’s defence mechanism, as was first shown many years ago by Koch when he described what is now known as the Koch phenomenon. The most likely explanation is, I think, the one which Ebrill and Elek dismiss as a practical impossibilitynamely, that the abscess arose as a blood-borne infection. Such disseminated tuberculous abscesses are by no means rare in sanatorium practice, particularly in the so-called haematogenous type of disease, and in the case not as
use
an
described the haematoma appears to have’ acted as a locus minoris resistantiœ. The fact that clinical and radiological examination has revealed no other tuberculous focus is, of course, inconclusive ; it is quite common not to find a primary tuberculous focus in persons undergoing Mantoux-conversion while under observation (e.g., in sanatorium staff). In such cases the site of infection may be in the alimentary tract. Two clinical details would have been helpful. Firstly, no mention is made of the presence or absence of inguinal adenitis. With a large primary tuberculous abscess of the thigh, caseous adenitis of the regional lymph-nodes would almost certainly have occurred, while " drainage glands of a post-primary abscess, if examined by biopsy, could have been distinguished histologically by the relative absence of caseation. Secondly, no mention is made of the type of bacillus recovered from the pus. The finding of bovine bacilli would have been a pointer, admittedly a weak one, to the presence of a bovine
°
‘
" °
alimentary infection. It might be of interest to note that by a curious coincidence two patients and a possible third have been admitted to this hospital during the last month, each with lupus verrucosus of the hand following an injury involving a breach of skin surface. It is tempting to picture the very natural reaction of sucking the injured member (and both patients have active pulmonary lesions), but it is far more probable that these are also examples of a hsemic infection of a locus minoris resistantice. The well-known association of injury with other tuberculous conditions, such as tuberculosis of joints, is also very much to the point. Dr. Marsh’s statement (Oct. 5, p. 508) that " tubercle bacilli are not uncommon in the dust of hospital wards cannot be allowed to pass unchallenged, since it -tends to perpetuate the erroneous belief that sanatoria and tuberculosis wards are dangerous places in which to "
work because of the risks of infection from dust. Since Cornet, in 1889, claimed to have found tubercle bacilli in 40 out of 140 specimens of dust from various German hospitals, public buildings, and tuberculosis wards,1 belief in the role of dust- as one of the chief infective agents in tuberculosis has been widely held, although few modern tuberculosis pathologists now subscribe to 1.
Cornet,
G.
Z. Hyg.
InfektKr. 1889, 5, 191.
‘
618 this view (e.g., Gloyne 2 ; a good summary of the dust v.droplet controversy is given by Topley and Wilson,3 who point out that the English climate militates very strongly against the formation of dust containing living virulent tubercle bacilli). Even if one accepts Cornet’s work without question, few will deny that personal hygiene is now vastly improved since his day, largely as a result of public-health propaganda ; our tuberculous patients no longer spit on the ward floor ! Numerous investigators have failed to find living tubercle bacilli in the dust of modern hospitals and sanatoria. An investigation was recently made at this hospital into the possible infectivity of occupational-therapy articles made by patients. One hundred articles of all
been maintained but there is still considerable abdominal distension. The dosage of folic acid has been reduced gradually and he is now taking 10 mg. per day. All other treatment has been stopped since the institution of the folic acid. It is impossible, of course, to draw any general con- . clusions from a single case, but we feel strongly that improvement in this case can be attributed solely to folic acid. No doubt intensive trials in this direction are going on, but we have so far seen no recorded work on the treatment of coeliac disease in children with folic acid.
has
Sheffiel’d.
types (plastic, wood, wool, felt, &c.) made by patients degrees of lung involvement (many producing large amounts of positive sputum daily) were examined carefully in the hospital laboratory, where the technique
H. P. BRODY. L. GORE.
PERFORATED PEPTIC ULCER TREATED WITHOUT OPERATION
with all
SIR,—I am anxious to correct two impressions that of cultural examination for tubercle bacilli has been Mr. Deitch’s provocative and stimulating letter of brought to a high standard ; not one positive result wasOct. 19 may give. obtained. I am sure that this is in large measure due He mentions that for two years I have treated all to- the careful instruction in the hygiene of cough which cases of acute perforation conservatively and " with is given to all patients. The danger of infection from uniform success." This series was reported at a meeting patients with open pulmonary tuberculosis is not from of the Leeds Medico-Chirurgical Society in February, It is clear that . 194-6. ward dust but from unrestrained cough. I did not invent the conservative method any this fact needs to be emphasised at a time when hospital more than Hermon Taylor did. Many surgeons practise and sanatorium domestics are at a nremium. conservative treatment in selected cases, and it was not A. G. HOUNSLOW. until Bedford Turner reported 6 cases (Brit. med. J. County Sanatorium, Clare Hall, South Mimms, Barnet. 1935, i, 457) that I had the courage to treat all cases without selection. Further, I have lost 3 cases since the FOLIC ACID IN CŒLIAC DISEASE discussion in February, which makes the mortality SIR,—The course of coeliac disease in children is often 18 % in my small series. I agree with your leader of so protracted, and the prognosis so uncertain, that we Oct. 5 that since we have no means of determining which venture to draw attention to its treatment with folic ulcer will close spontaneously, conservative treatment will acid, a procedure which in a particular case has so far inevitably cause the surgeon more anxiety than simple successful. proved dramatically in Mr. Deitch’s hands, carries a mortality closure, which, A boy, aged 17 months, came under the care of one of of only 4%. This remarkable record, extending over us (L. G.) in May, 1946. There was a history of vomiting eight years, fully justifies his belief in spinal anaesthesia and diarrhoea with the passage of numerous pale bulky and no drainage-tube. and foul-smelling stools during the previous 6 months. Our experience in York differs from Hermon Taylor’ss He had been under treatment by another doctor during in two respects. We found considerable constitutional this period, with no improvement. disturbance in several cases, the pulse-rate rising to He presented the typical appearance of coeliac disease 130 per min. and the temperature to 103° F, falling - pale, apathetic,- with a dry skin and distended gradually to normal by the eighth day, and we had 2 abdomen and wasted buttocks, and with the stools as patients who developed subphrenic abscess, a complicadescribed above. His weight was 19 lb. Treatment with tion which I had never met after closure without drainage. parenteral liver extract 2 c.cm. on alternate days, We have been more by the results of together with ascorbic acid andBenerva ’ Compound prevention of perforationimpressed than with the conservative tablets by mouth and a fat-free diet was instituted. treatment after the catastrophe has occurred. By Improvement was rapid. The vomiting and diarrhoea treating all cases of peptic ulcer with severe symptoms ceased and he gained weight. as requiring urgent admission, and by accepting for The child was taken away on holiday, but after a month surgical treatment all cases who we think are unlikely he relapsed and became extremely ill with a return of to benefit permanently by medical treatment, we have his former symptoms. He was admitted. to hospital reduced the incidence of acute perforation by 44% weighing 21 lb., but after a fortnight’s stay his condition during the last three years. Acute perforation in the had deteriorated considerably and he was taken home York area has now become a rarity ; the majority of weighing only 141/2 lb. He was then seen in consultation cases admitted are visitors to the district, transport by one of us (H. P. B.) and admitted to hospital drivers, or passengers in trains. The few locals who The picture was typical of in a serious condition. perforate " out of the blue " will always defeat our coeliac disease. He was grossly dehydrated and passing efforts to anticipate, rather than wait for, this dreaded He could take only very small 15-16 stools a day. complication. milk with water and glucose. The quantities of skimmed A. HEDLEY VISICK. York. blood-count showed a secondary anaemia with 52 % c.mm. cells The red total and 4,200,000 per haemoglobin PRICE OF POLYTHENE.-In his article of Sept. 14 (p. 380) fat in the stools was 49 %. Dr. Kent remarked that polythene costs about ls. 2d. per lb. Treatment with parenteral liver extract and vitamin-B Chemical Industries Ltd. point out that the minimum complex on alternate days, together with other vitamin Imperial of ’Alkathene,’ the British grade of polythene they price supplements and iron by mouth, was begun, and during manufacture, is 3s. 3d. per lb. the next week there was no improvement although no SODA-LIME.—Already a familiar, laboratory reagent, sodadeterioration in his condition and his weight remained lime is now widely used in medical practice for the absorption stationary. of carbon dioxide. Apparatus for closed-circuit anaesthesia, At this stage a supply of folic acid was obtained and oxygen therapy, and metabolism determination are a few 25 mg. per day was administered by mouth. There was examples of its uses. Messrs. Sofnol Ltd., Westcombe Hill, immediate improvement. The following day only 2 stools Greenwich, S.E.10, the makers ofSofnol Brand ’ soda-lime, were passed, the appetite returned, and he became claim that their product possesses advantages such as conmuch calmer and brighter. From then on he progressed rapidly. His appetite became ravenous and he took a stancy of composition, high absorptive capacity, resistance to good mixed diet, fat-modified, and passed one or two abrasion, and non-heating and non-deliquescent properties. catalogue, illustrated by easily understood graphs, pale formed and non-offensive stools each day. At the Their describes in a simple way the experiments on which these end of a week he had gained 7 lb., and 9 days later he claims are based. These tests will be of interest to those had gained a further6 lb. At the moment improvement who are unfamiliar with the type of laboratory investigations 2. Gloyne, S. R. Social Aspects of Tuberculosis, 1946, p. 23. to which a specimen of soda-lime must be submitted before its 3. Topley, W. W. C., Wilson, G. S. Principles of Bacteriology and Immunity, 1936, pp. 1028-29. value as a CO2-absorbent for medical purposes can be assessed. ,
----