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TUBERCULOUS RHEUMATISM
286
Letters
to
the Editor
CONGENITAL DEFECTS FROM GERMAN MEASLES am in a small way to carry out an Szt3.,-I trying investigation something like that you suggest in your leader of Feb. 9. I have devised a very simple form of questionnaire and have asked the heads of three large schools for the deaf to put it to the mothers of young children attending their schools. I have also asked Dr. and Mrs. Ewing, of the Department of the Education of the Deaf, Manchester University, to put the questionnaire to mothers who bring children to their clinic. All have expressed their willingness to cooperate and I am hoping to receive completed questionnaires from one of the schools shortly. I do not suggest that this small-scale inquiry is going to settle anything and welcome your suggestion that the problem should be the subject of full-scale investigation. I should be very willing to pass on such information as I mav be able to obtain and to give the investigator anv A. H. GALE. help I can. Ministry of Education (Medical Branch), London, S.W.1. NUTRITION IN NEWFOUNDLAND
SIR,—in your annotation of June 16, 1945 (p. 7b0), you drew attention to the high proportion of salted meat and salted fish in the Newfoundland diet. Benesch and Glynn (Dec. 22, p. 831) suggest that the high salt content of the diet in Newfoundland may be a factor, by virtue of its effect on the intestinal flora, in the occurrence of certain symptoms of deficiency of the
B-complex vitamins, more especially nicotinic acid. This immediately raises the question, is there in fact an abnormally high intake of sodium chloride in Newfoundland ? It is generally agreed by British and American workers that the usual sodium chloride intake is of the order of 7-15 g. daily, of which a large proportion is taken as added salt. In hot climates the intake may be much higher. For instance, according to a War Office report,2
" The total salt intake, including the amount of culinary salt likely to be taken, which is available on a fresh (Army) ration scale in the Middle East is from 17 to 20 g. ;; on a tinned ration scale, from 22 to 25 g." This report puts the daily salt requirement for those engaged in sedentary occupations at 12 g. and for those working hard for eight hours a day at 24 g. The sodium content of the average British diet, calculated by applying McCance and Widdowson’s tables of analyses3 two food-consumption data from a large prewar dietary survey, is approximately 920 mg. per head per day exclusive of sodium added as culinary salt in cooking or at table. This estimate agrees well with the -figure of 960 mg. sodium per day in the average American diet quoted by Shohl.4 If we assume that all the sodium is present as sodium chloride,- which is of course an overestimate, the British and American diet would provide on the average 2-5 g. of sodium chloride out of a total intake of 7-15 g. An estimate of the sodium content of the average Newfoundland diet can be obtained in the same way from the food-consumption data provided in the report of Adamson et all If all the meat used is taken as salt pork and all the fish as dry salt cod the sodium content of this diet is approximately 1770 mg. per head daily, or 4-5 g. sodium chloride. These figures indicate that although on the average the foods constituting the Newfoundland diet may provide twice as much sodium chloride as the foods in the average British diet they would provide only half or a third of the average British total intake of sodium chloride. Since the average intake of dietary sodium chloride in Newfoundland is 4-5 g. it is clear that in practice some people will get more and some less than this amount. A rough calculation of the per head intake
McCollum, E. V., Orent-Keiles, E., Day, H. G. Newer Knowledge of Nutrition, New York, 1939, p. 208 ; Macy, I. G. Handbook of Nutrition, Chicago, 1943, p. 91. 2. Army med. Dep. Bull. 1943, no. 21, p. 6. 3. McCance, R. A., Widdowson, E. M. Chemical Composition of Foods, Spec. Rep. Ser. med. Res. Coun., Lond. no. 235, 1940. 4. Shohl, A. T. Mineral Metabolism, New York, 1939, p. 317. o. Adamson, J. D. et al. Canad. med. Ass. J. 1945, 52, 227. 1.
of dietary sodium chloride of 25 Newfoundland families based -on the food purchases recorded by Aykroyd&bgr; during the winter of 1929 shows that although the diet of half of the families provided more than 4-5 g. per head daily none exceeded the upper estimate of total British It seems reasonable to suppose or American intake. that the Newfoundlander, who consumes meat and fish preserved with salt, and little fresh food, may consume less culinary salt than is usual on a diet of fresh foods. In the absence of studies to show the total intake from all sources, including culinary salt, it would be unwise to draw hasty conclusions about the salt intake in Newfoundland. A word of caution seems necessary also in the interpretation of the data of Eppright et al.7quoted by Benesch and Glynn as showing an inverse relationship between the intestinal coliforms and the salt content of the diet. Eppright et al. showed that, in rats, a diet almost free from mineral salts could not support the growth of L. acidophilus and favoured an increase in the intestinal flora of organisms of the Escherichia coli and Proteus types and of Streptococcus fcecalis. The L. acidophilus flora reappeared when a complete salt mixture or a mixture of calcium and phosphorus was added to the diet, but sodium chloride and potassium were not essential for L. acidophilus, so that their removal from the complete mixture had no effect on the flora. When they were the only salts added to the basal diet they could not support the growth of L. acidophilus, and the other organisms increased in numbers at first and then declined. In all of these experiments where salts were added to the basal ration they were given in the amounts usually consumed by rats from a salt mixture. The effect of high intakes was not tested. It does not follow that increasing the sodium chloride content of a diet which already supports the growth of L. acidophilus would result in replacement of this organism by others such as the coliform bacteria. In view of these considerations any attempt to explain the occurrence of symptoms of nicotinic acid deficiency in Newfoundland by postulating that a high intake of sodium chloride causes changes in the intestinal flora with resultant reduction in synthesis or increased destruction of nicotinic acid in the intestine seems to be, to the least. nremature. F. C. RUSSELL. Imperial Bureau of Animal Nutrition, Rowett Research Institute, Bucksburn, Aberdeenshire.
sav
TUBERCULOUS RHEUMATISM interested to read Dr. Sheldon’s article SiB,—I in your issue of Jan. 26, as I have recently seen three adults with rheumatic manifestations associated with active tuberculosis. CASE l.--Female, aged 30. Husband had died of pulmonary tuberculosis one year ago. She had had an attack of rheumatism at the age of 14, and had been in bed for 7 months with flitting joint pains which did not respond to treatment; in the last fortnight had developed severe cough and sputum. Pulse-rate 136; temp. 98.60 F; mitral systolic murmur; was
pulmonary
rhonchi and crepitations over left upper lobe ; no marked swelling of joints. Sputum found to contain .tubercle bacilli. CASE 2.-Male, aged 28. Brother had recently died of pulmonary tuberculosis. Sputum found to contain tubercle bacilli in 1933, but had refused treatment till 1935, when extensive infiltration was found in the left lung, with cavities in the upper lobe. Treated with artificial pneumothorax, ’Sanocrysin,’ and, later, phrenic evulsion. Discharged with negative sputum and disease mainly calcified, and worked from 1940 to 1944. In 1943 cavitation was again noted in the left lung, and in October, 1944, had to go to bed with acute rheumatism. Sputum now contained tubercle bacilli, and X-ray film showed bilateral cavitation. Has since been a chronic invalid, whose condition has slowly deteriorated. CASE 3.-Male, aged 42. Daughter had attended dispensary with tuberculous adenitis. Stopped work in June, 1944, complaining of pain and swelling of feet, and pains in arms and shoulders and across chest. Was referred for electrical treatment to hospital, where X-ray examination showed bilateral tuberculosis with a cavity on the right side. Was 6. 7.
Aykroyd, W. R. J. Hyg., Camb. 1930, 30, 357. Eppright, E. S., Valley, G., Smith, A. H. J. Bact. 1937, 34, 81.
287 treated in bed at home, where he
developed increasing pains affecting ankles, knees, hips, shoulders, and wrists, unresponsive to salicylates. Pulse-rate and temperature were normal. Blood-sedimentation rate 80 mm. in 1 hour (Westergren). Six months later still had these pains, and general condition
was
gradually deteriorating.
Rheumatic symptoms were presented by two of these patients when pulmonary tuberculosis became manifest, and by the third when a spread of the disease was found. It is interesting to speculate whether the rheumatic symptoms were due to tuberculous toxaemia, or whether the rheumatic condition was an intercurrent disease which lowered the body’s resistance to the tubercle bacillus. In favour of the second hypothesis is the fact that the first case had had a previous attack of rheumatism at the age of 14, before she had contracted tuberculosis. WILLIAM D. GRAY Temporary assistant tuberculosis officer, Durham County Council.
Bishop Auckland, co.
Durham.
POISONING BY BARIUM CARBONATE
Sin,—Lieut.-Colonel Morton’s article (Dec. 8) from the Iraq-Persia Command prompts me to record a similar instance from the Alexandria area. On Aug. 11, 1945, the local military authorities asked us to help them to investigate an isolated outbreak of foodpoisoning, involving a number of men of an Indian unit, who had fallen ill after eating pastries made with flour and a vegetable oil (ghi). There was one death.
Samples both
of the flour and the oil
were
supplied,
bacteriological and chemical examinations
and were
undertaken.
Nothing incriminating was found in the of either, but after incineration of the flour, and taking up the ashes in HCI, the solution gave the usual chemical tests for Ba, and certain tests for Al. The presence of Ba was confirmed spectroscopically. That it was present in the form of carbonate was proved by the evolution of CO2 when a drop of concentrated HCI was allowed to fall on a little of the sample spread on a glazed porcelain plate. Consequently we were able to report on Aug. 28 : " the marked presence of soluble salts of barium (as carbonate), also of aluminium, leads one to think that the barium content of the flour is the chief incriminating ingredient responsible for the poisoning." A quantitative report on Sept. 12 indicated: Ba (as carbonate) 6-25%, and Al (as oxide) 2.5 %." Misadventure by rat-poison flour may be more frequent and widespread in the Services than one might imagine. It has been suggested that such flour should be mixed with some colouring matter, but the rat is such a clever animal that it is doubtful whether coloured flour would achieve its purpose. When the poison is kept in the same store as ordinary flour distinctive exterior labelling is the obvious answer. As Chesterton’s postman story showed, one is apt to neglect the obvious. ARTHUR COMPTON. Municipal Laboratories, Alexandria.
bacteriology
NATIONALISATION OF MEDICINE ,
SiB,—Mr. Willson-Pepper’s article (Jan. 26) describing saw in a German military hospital shows what happen when medical science, art, and craft are dead and only the " service " remains. Here was no deliberate Belsen bestiality ; on the contrary, the medical personnel were carrying out their rotten technique under the illusion that it was good. I do not wish to suggest that similar regression is likely in England ; but the episode is nevertheless a reminder that the care and well-being of medicine rests solely in the hands of the doctors. No-one except doctors themselves can minister to this service, simply because medical wisdom is found only among medical men. This
what he can
in effect " the State service may be worse for you but it will be better for us." Which of course is absurd, because doctors and patients must sink or swim together. Medicine organised by the State was certainly not better for those patients in the German hospital, and orgapisation in England will improve on present conditions only if doctors as well as patients stay free. Freedom, like health, can be lost almost before we are aware of it ; for just as an insidious disease can advance under the cover of compensation, so we may become acclimatised to a progressive loss of freedom till decompensation suddenly sets in and closes the scene. A State medical service is coming, and our powers to mould its form are limited. Bearing in mind tl e size of the job-the substitution of a natural growth by a plan--we must not hope for much. But if we can get a service in which clinical acumen has pride of place over administrative ability, and in which financial reward is in direct proportion to technical skill and ability to shoulder responsibility, then we shall have done much to safeguard Buxted, Sussex.
W. R. E. HARRISON.
LOCAL ANÆSTHESIA OR ANALGESIA SiB,—May I associate myself with the views of Dr. Cartwright in your last issue ? Looking down the list of questions set for the diploma in anaesthetics it is interesting to note how, as time goes by, loosely worded terms such as local anaesthe8ia have hardened into the more accurate local analgesia. From this it would appear that the indiscriminate usage of the two terms is frowned upon in high places. I am afraid that we must admit that folk concerned with the " clinical " side of medicine are prone to a looseness of nomenclature of - which we are rather proud ; and in this connexion it is interesting to note that while surgeons and neurologists refer to hypercesthesia the ,hmainlno-ic1-. ralla i1-. homor.ir7roerr
A. H. GALLEY. TETANUS Sin,—All those concerned with the difficult problem of the setiology of postoperative tetanus must have read with great interest the article by Robinson, McLeod, and Downie in your issue of Feb. 2. Whether dust in surgical theatres proves on further investigation to be an important source of postoperative tetanus or not, the part played by infected catgut should never be forgotten however infrequent we may believe such an occurrence to be. Following my paper1 two the section of surgery of the Royal Society of Medicine on this subject in March, 1936, the Ministry of Health issued a memorandum2 in which some particulars were given of 9 cases which I had recently investigated, 5 of them in all of which the evidence pointed very . proving fatal, " strongly to home cured " catgut as the source of infection. So far as I can ascertain, this very undesirable practice of sterilising catgut in a hospital laboratory, which was fairly common at the time, has become much less common as the result of war-time conditions and the operations of the Emergency Medical Service. The practice mav however have survived in places and might even be revived in the future. Moreover, though the greatest care is taken to ensure that commercial catgut made by licensees under the Therapeutic Substances Act is free from pathogenic micro-organisms, including tetanus spores, the possibility of such spores surviving can never be completely excluded in a material like catgut, in which the lengths tested might be sterile but other portions of the same batch might contain spores if some mistake had been made in the approved process of London, W.1.
sterilisation. real importance today and needs is therefore of great importance, as I have pointed stressing, even at the risk of giving offence or exposing outItbefore, that hospitals should keep a record of the make ourselves to misunderstanding. Though the State has and batch number of catgut used in all operations, so that medical advisers (all of one colour), it is not really if postoperative tetanus should occur samples from the interested in medicine as such-only in the medical suspected batch, which are always retained for a considerorganisation which it is committed to launch. able time by the manufacturers, can be tested. The At any time now our profession will be caught up in keeping of such records should not be difficult as, in this organisation. Soon we shall become a part of the Substances (Amendwhole, and the great problem is how, under these circum-accordance with the Therapeutic article 6, the licence number ment) Regulations, 1937, to remain somefree. stances, Laymen professionally and the batch number must now be " indelibly marked times think this can easily be achieved, or, alternatively, that failure would not matter very much. Sometimes 1. Proc. R. Soc. Med. 1936, 29 (Sect. Surg. 35). 2. Memorandum no. 199 Med., August, 1936. they show a misconception of the situation by saying
point has taken
J
on a
Letters
to
the Editor
CONGENITAL DEFECTS FROM GERMAN MEASLES am in a small way to carry out an Szt3.,-I trying investigation something like that you suggest in your leader of Feb. 9. I have devised a very simple form of questionnaire and have asked the heads of three large schools for the deaf to put it to the mothers of young children attending their schools. I have also asked Dr. and Mrs. Ewing, of the Department of the Education of the Deaf, Manchester University, to put the questionnaire to mothers who bring children to their clinic. All have expressed their willingness to cooperate and I am hoping to receive completed questionnaires from one of the schools shortly. I do not suggest that this small-scale inquiry is going to settle anything and welcome your suggestion that the problem should be the subject of full-scale investigation. I should be very willing to pass on such information as I mav be able to obtain and to give the investigator anv A. H. GALE. help I can. Ministry of Education (Medical Branch), London, S.W.1. NUTRITION IN NEWFOUNDLAND
SIR,—in your annotation of June 16, 1945 (p. 7b0), you drew attention to the high proportion of salted meat and salted fish in the Newfoundland diet. Benesch and Glynn (Dec. 22, p. 831) suggest that the high salt content of the diet in Newfoundland may be a factor, by virtue of its effect on the intestinal flora, in the occurrence of certain symptoms of deficiency of the
B-complex vitamins, more especially nicotinic acid. This immediately raises the question, is there in fact an abnormally high intake of sodium chloride in Newfoundland ? It is generally agreed by British and American workers that the usual sodium chloride intake is of the order of 7-15 g. daily, of which a large proportion is taken as added salt. In hot climates the intake may be much higher. For instance, according to a War Office report,2
" The total salt intake, including the amount of culinary salt likely to be taken, which is available on a fresh (Army) ration scale in the Middle East is from 17 to 20 g. ;; on a tinned ration scale, from 22 to 25 g." This report puts the daily salt requirement for those engaged in sedentary occupations at 12 g. and for those working hard for eight hours a day at 24 g. The sodium content of the average British diet, calculated by applying McCance and Widdowson’s tables of analyses3 two food-consumption data from a large prewar dietary survey, is approximately 920 mg. per head per day exclusive of sodium added as culinary salt in cooking or at table. This estimate agrees well with the -figure of 960 mg. sodium per day in the average American diet quoted by Shohl.4 If we assume that all the sodium is present as sodium chloride,- which is of course an overestimate, the British and American diet would provide on the average 2-5 g. of sodium chloride out of a total intake of 7-15 g. An estimate of the sodium content of the average Newfoundland diet can be obtained in the same way from the food-consumption data provided in the report of Adamson et all If all the meat used is taken as salt pork and all the fish as dry salt cod the sodium content of this diet is approximately 1770 mg. per head daily, or 4-5 g. sodium chloride. These figures indicate that although on the average the foods constituting the Newfoundland diet may provide twice as much sodium chloride as the foods in the average British diet they would provide only half or a third of the average British total intake of sodium chloride. Since the average intake of dietary sodium chloride in Newfoundland is 4-5 g. it is clear that in practice some people will get more and some less than this amount. A rough calculation of the per head intake
McCollum, E. V., Orent-Keiles, E., Day, H. G. Newer Knowledge of Nutrition, New York, 1939, p. 208 ; Macy, I. G. Handbook of Nutrition, Chicago, 1943, p. 91. 2. Army med. Dep. Bull. 1943, no. 21, p. 6. 3. McCance, R. A., Widdowson, E. M. Chemical Composition of Foods, Spec. Rep. Ser. med. Res. Coun., Lond. no. 235, 1940. 4. Shohl, A. T. Mineral Metabolism, New York, 1939, p. 317. o. Adamson, J. D. et al. Canad. med. Ass. J. 1945, 52, 227. 1.
of dietary sodium chloride of 25 Newfoundland families based -on the food purchases recorded by Aykroyd&bgr; during the winter of 1929 shows that although the diet of half of the families provided more than 4-5 g. per head daily none exceeded the upper estimate of total British It seems reasonable to suppose or American intake. that the Newfoundlander, who consumes meat and fish preserved with salt, and little fresh food, may consume less culinary salt than is usual on a diet of fresh foods. In the absence of studies to show the total intake from all sources, including culinary salt, it would be unwise to draw hasty conclusions about the salt intake in Newfoundland. A word of caution seems necessary also in the interpretation of the data of Eppright et al.7quoted by Benesch and Glynn as showing an inverse relationship between the intestinal coliforms and the salt content of the diet. Eppright et al. showed that, in rats, a diet almost free from mineral salts could not support the growth of L. acidophilus and favoured an increase in the intestinal flora of organisms of the Escherichia coli and Proteus types and of Streptococcus fcecalis. The L. acidophilus flora reappeared when a complete salt mixture or a mixture of calcium and phosphorus was added to the diet, but sodium chloride and potassium were not essential for L. acidophilus, so that their removal from the complete mixture had no effect on the flora. When they were the only salts added to the basal diet they could not support the growth of L. acidophilus, and the other organisms increased in numbers at first and then declined. In all of these experiments where salts were added to the basal ration they were given in the amounts usually consumed by rats from a salt mixture. The effect of high intakes was not tested. It does not follow that increasing the sodium chloride content of a diet which already supports the growth of L. acidophilus would result in replacement of this organism by others such as the coliform bacteria. In view of these considerations any attempt to explain the occurrence of symptoms of nicotinic acid deficiency in Newfoundland by postulating that a high intake of sodium chloride causes changes in the intestinal flora with resultant reduction in synthesis or increased destruction of nicotinic acid in the intestine seems to be, to the least. nremature. F. C. RUSSELL. Imperial Bureau of Animal Nutrition, Rowett Research Institute, Bucksburn, Aberdeenshire.
sav
TUBERCULOUS RHEUMATISM interested to read Dr. Sheldon’s article SiB,—I in your issue of Jan. 26, as I have recently seen three adults with rheumatic manifestations associated with active tuberculosis. CASE l.--Female, aged 30. Husband had died of pulmonary tuberculosis one year ago. She had had an attack of rheumatism at the age of 14, and had been in bed for 7 months with flitting joint pains which did not respond to treatment; in the last fortnight had developed severe cough and sputum. Pulse-rate 136; temp. 98.60 F; mitral systolic murmur; was
pulmonary
rhonchi and crepitations over left upper lobe ; no marked swelling of joints. Sputum found to contain .tubercle bacilli. CASE 2.-Male, aged 28. Brother had recently died of pulmonary tuberculosis. Sputum found to contain tubercle bacilli in 1933, but had refused treatment till 1935, when extensive infiltration was found in the left lung, with cavities in the upper lobe. Treated with artificial pneumothorax, ’Sanocrysin,’ and, later, phrenic evulsion. Discharged with negative sputum and disease mainly calcified, and worked from 1940 to 1944. In 1943 cavitation was again noted in the left lung, and in October, 1944, had to go to bed with acute rheumatism. Sputum now contained tubercle bacilli, and X-ray film showed bilateral cavitation. Has since been a chronic invalid, whose condition has slowly deteriorated. CASE 3.-Male, aged 42. Daughter had attended dispensary with tuberculous adenitis. Stopped work in June, 1944, complaining of pain and swelling of feet, and pains in arms and shoulders and across chest. Was referred for electrical treatment to hospital, where X-ray examination showed bilateral tuberculosis with a cavity on the right side. Was 6. 7.
Aykroyd, W. R. J. Hyg., Camb. 1930, 30, 357. Eppright, E. S., Valley, G., Smith, A. H. J. Bact. 1937, 34, 81.
287 treated in bed at home, where he
developed increasing pains affecting ankles, knees, hips, shoulders, and wrists, unresponsive to salicylates. Pulse-rate and temperature were normal. Blood-sedimentation rate 80 mm. in 1 hour (Westergren). Six months later still had these pains, and general condition
was
gradually deteriorating.
Rheumatic symptoms were presented by two of these patients when pulmonary tuberculosis became manifest, and by the third when a spread of the disease was found. It is interesting to speculate whether the rheumatic symptoms were due to tuberculous toxaemia, or whether the rheumatic condition was an intercurrent disease which lowered the body’s resistance to the tubercle bacillus. In favour of the second hypothesis is the fact that the first case had had a previous attack of rheumatism at the age of 14, before she had contracted tuberculosis. WILLIAM D. GRAY Temporary assistant tuberculosis officer, Durham County Council.
Bishop Auckland, co.
Durham.
POISONING BY BARIUM CARBONATE
Sin,—Lieut.-Colonel Morton’s article (Dec. 8) from the Iraq-Persia Command prompts me to record a similar instance from the Alexandria area. On Aug. 11, 1945, the local military authorities asked us to help them to investigate an isolated outbreak of foodpoisoning, involving a number of men of an Indian unit, who had fallen ill after eating pastries made with flour and a vegetable oil (ghi). There was one death.
Samples both
of the flour and the oil
were
supplied,
bacteriological and chemical examinations
and were
undertaken.
Nothing incriminating was found in the of either, but after incineration of the flour, and taking up the ashes in HCI, the solution gave the usual chemical tests for Ba, and certain tests for Al. The presence of Ba was confirmed spectroscopically. That it was present in the form of carbonate was proved by the evolution of CO2 when a drop of concentrated HCI was allowed to fall on a little of the sample spread on a glazed porcelain plate. Consequently we were able to report on Aug. 28 : " the marked presence of soluble salts of barium (as carbonate), also of aluminium, leads one to think that the barium content of the flour is the chief incriminating ingredient responsible for the poisoning." A quantitative report on Sept. 12 indicated: Ba (as carbonate) 6-25%, and Al (as oxide) 2.5 %." Misadventure by rat-poison flour may be more frequent and widespread in the Services than one might imagine. It has been suggested that such flour should be mixed with some colouring matter, but the rat is such a clever animal that it is doubtful whether coloured flour would achieve its purpose. When the poison is kept in the same store as ordinary flour distinctive exterior labelling is the obvious answer. As Chesterton’s postman story showed, one is apt to neglect the obvious. ARTHUR COMPTON. Municipal Laboratories, Alexandria.
bacteriology
NATIONALISATION OF MEDICINE ,
SiB,—Mr. Willson-Pepper’s article (Jan. 26) describing saw in a German military hospital shows what happen when medical science, art, and craft are dead and only the " service " remains. Here was no deliberate Belsen bestiality ; on the contrary, the medical personnel were carrying out their rotten technique under the illusion that it was good. I do not wish to suggest that similar regression is likely in England ; but the episode is nevertheless a reminder that the care and well-being of medicine rests solely in the hands of the doctors. No-one except doctors themselves can minister to this service, simply because medical wisdom is found only among medical men. This
what he can
in effect " the State service may be worse for you but it will be better for us." Which of course is absurd, because doctors and patients must sink or swim together. Medicine organised by the State was certainly not better for those patients in the German hospital, and orgapisation in England will improve on present conditions only if doctors as well as patients stay free. Freedom, like health, can be lost almost before we are aware of it ; for just as an insidious disease can advance under the cover of compensation, so we may become acclimatised to a progressive loss of freedom till decompensation suddenly sets in and closes the scene. A State medical service is coming, and our powers to mould its form are limited. Bearing in mind tl e size of the job-the substitution of a natural growth by a plan--we must not hope for much. But if we can get a service in which clinical acumen has pride of place over administrative ability, and in which financial reward is in direct proportion to technical skill and ability to shoulder responsibility, then we shall have done much to safeguard Buxted, Sussex.
W. R. E. HARRISON.
LOCAL ANÆSTHESIA OR ANALGESIA SiB,—May I associate myself with the views of Dr. Cartwright in your last issue ? Looking down the list of questions set for the diploma in anaesthetics it is interesting to note how, as time goes by, loosely worded terms such as local anaesthe8ia have hardened into the more accurate local analgesia. From this it would appear that the indiscriminate usage of the two terms is frowned upon in high places. I am afraid that we must admit that folk concerned with the " clinical " side of medicine are prone to a looseness of nomenclature of - which we are rather proud ; and in this connexion it is interesting to note that while surgeons and neurologists refer to hypercesthesia the ,hmainlno-ic1-. ralla i1-. homor.ir7roerr
A. H. GALLEY. TETANUS Sin,—All those concerned with the difficult problem of the setiology of postoperative tetanus must have read with great interest the article by Robinson, McLeod, and Downie in your issue of Feb. 2. Whether dust in surgical theatres proves on further investigation to be an important source of postoperative tetanus or not, the part played by infected catgut should never be forgotten however infrequent we may believe such an occurrence to be. Following my paper1 two the section of surgery of the Royal Society of Medicine on this subject in March, 1936, the Ministry of Health issued a memorandum2 in which some particulars were given of 9 cases which I had recently investigated, 5 of them in all of which the evidence pointed very . proving fatal, " strongly to home cured " catgut as the source of infection. So far as I can ascertain, this very undesirable practice of sterilising catgut in a hospital laboratory, which was fairly common at the time, has become much less common as the result of war-time conditions and the operations of the Emergency Medical Service. The practice mav however have survived in places and might even be revived in the future. Moreover, though the greatest care is taken to ensure that commercial catgut made by licensees under the Therapeutic Substances Act is free from pathogenic micro-organisms, including tetanus spores, the possibility of such spores surviving can never be completely excluded in a material like catgut, in which the lengths tested might be sterile but other portions of the same batch might contain spores if some mistake had been made in the approved process of London, W.1.
sterilisation. real importance today and needs is therefore of great importance, as I have pointed stressing, even at the risk of giving offence or exposing outItbefore, that hospitals should keep a record of the make ourselves to misunderstanding. Though the State has and batch number of catgut used in all operations, so that medical advisers (all of one colour), it is not really if postoperative tetanus should occur samples from the interested in medicine as such-only in the medical suspected batch, which are always retained for a considerorganisation which it is committed to launch. able time by the manufacturers, can be tested. The At any time now our profession will be caught up in keeping of such records should not be difficult as, in this organisation. Soon we shall become a part of the Substances (Amendwhole, and the great problem is how, under these circum-accordance with the Therapeutic article 6, the licence number ment) Regulations, 1937, to remain somefree. stances, Laymen professionally and the batch number must now be " indelibly marked times think this can easily be achieved, or, alternatively, that failure would not matter very much. Sometimes 1. Proc. R. Soc. Med. 1936, 29 (Sect. Surg. 35). 2. Memorandum no. 199 Med., August, 1936. they show a misconception of the situation by saying
point has taken
J
on a