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URINARY EXCRETION OF CITRATE
731 I rang up the M.o.H., but he seemed reluctant to play ball with the idea that there could be five cases of poliomyelitis But in one household, and being only a locum I let it pass. what could possibly be the deciding factor which allowed one group of children to be infected and another group with a closer contact with a known case to be spared ?
I suggest that some very rewarding information might be gathered-especially by the field naturalists of medicine, the rural practitioners-by inquiring into what common virus diseases people who get poliomyelitis have not had and close contacts who do not get it have had. Personally my guess is that the villain, or rather hero, of the piece is herpes simplex. It is the most widespread viral infection in man. It is contracted in early childhood and is kept as a slightly irritable pet throughout life. Adults do not get it, but, of course, they periodically display their childhood’s infestation. Burnet and Williams found that 93% of hospital patients had antibody in their blood, but only 37% of the more hygienically brought up university graduates. "’ Over 60% are infected and remain carriers for life " says one of the authors of that mine of information Virus and Rickettsial Disease. In short I suspect that herpessimplex negatives are liable to become poliomyelitis cases. I suggest that there is a prima-facie case for investigation, which, I understand, has not been made. Or in words that Holmes himself might have used : " This herpes simplex fellow, my dear Watson, may be our man." C. G. LEAROYD. Beckley, Rye, Sussex. TRANSFUSION OF BLOOD-PLATELETS
SIR,-I think that your leading article on this subject (Sept. 19) calls for comment for the sake of full correctness. Your
about cerebral hemorrhage in idiopathic thrombocytopenic purpura is a bit theoretical. The incidence of cerebral haemorrhage in this condition is low-probably very low. During the past fifteen years I have personally followed up 20 cases ; these have included some with profuse bleeding, but none with cerebral hsemorrhage. This is perhaps a small number for firm conclusions, but, as personal series go, it is quite concern
large. You state that " commonly acute idiopathic thrombocytopenic purpura is clinically severe and responds poorly
splenectomy."
The first part of this statement may but the second be true; part does not harmonise with of in this the world. In my series, part experience 6 out of 14 cases had to be splenectomised immediately, owing to profuse bleeding. Of these patients 1 died of thrombosis and subphrenic abscess some time after splenectomy ; the rest are fully cured. Regarding transfusion of platelets before splenectomy, in my experience ordinary transfusion of fresh blood before or during splenectomy has a satisfactory effect. After the splenic vessels have been ligated, the remaining to
bleeding tendency disappears remarkably
soon.
St. Joseph’s Hospital,
A. SCHRUMPF
Porsagrunn, Norway.
Chief physician.
TOBACCO SMOKING SiR,-I should be grateful if you would allow me space to change the middle of the definition of addiction given in my letter last week from " tolerance to the physical effects of the incorporation on the basic psychic relations with ..." to read "... tolerance to the physical effects of the incorporation, the basic psychic relations with... " ...
Shc,tt,s, Lanarkshire.
R. GOOD.
SiR,-Dr. Good offers us a twelve-line definition of addiction. Might I, with very great respect, suggest that he should read what he has written aloud’1 ALEX COMFORT, COMFORT. Loughton, Essex.
URINARY EXCRETION OF CITRATE
SfR,—The interesting preliminary communication last week by Dr. Fourman and Dr. Robinson shows that a decrease of urinary citrate clearance may be associated with experimental potassium depletion in man, but there is no definite proof that this is directly due to the potassium loss. The clearance of citrate by the kidney is a very complex process, since urinary citrate as measured chemically consists of at least three different fractions-i.e., dissociated citrate anions balanced by sodium or potassium, undissociated citric acid itself, and un-ionised calcium citrate chelation complex. Gamble1 has shown that the degree of dissociation is governed by the urinary pH, and Hastings et a1.2 have studied the effect of citrate as a calcium chelating agent. As will be seen, there is reason to believe that these three moieties are handled differently by the renal
tubules. The renal clearance of citrate is greatly modified by at least five distinct factors : (a) plasma level of citrate, (b) pH of the urine, (c) calcium content of the urine, (d) cestrogenic and androgenic steroids, and (e) presence of urinary infection.
(a) Like most other substances reabsorbed by the tubules from the glomorular filtrate, the citrate clearance increases with rising plasma levels. Free citric acid appears to be reabsorbed preferentially ion, and therefore the citrate clearance increases 4as the urinary pH rises.3 (c) Calcium citrate chelation complex is less well reabsorbed, and therefore the citrate clearance increases with a rise of urinary calcium.5 (d) CEstrogens specifically increase and androgens decrease the renal citrate clearance by a direct action on the renal tubules.44. This is of little practical importance in the male, but accounts for the wide cyclical fluctuation of citrate excretion in the female during the menstrual cycle.6
(b)
to citrate
(e) Urinary infection diminishes citrate clearance since citrate is rapidly destroyed by many bacteria in the bladder and the renal pelves as well as in stored urine.7 In the course of an investigation on calcium metabolism,8all these facts were confirmed but no new information was elicited. In the data presented by Fourman and Robinson, it seems that the effect of variation of calcium content of the urine may have some bearing on the fall of citrate clearance observed. It is virtually impossible to produce an absolutely pure uncomplicated potassium depletion in man. In the method described by Fourman,9there is a complicating acidosis due to the use of a sulphonic resin in the ammonium cycle, and also there is preferential absorption by resin of divalent cations in the gut with a consequent
reduction in calcium and magnesium intake. Hypocalcaemia and tetany have been reported after relatively short periods of therapy with the sulphonic forms of cation exchangers,lO and urinary calcium usually drops very rapidly with ingestion of such resins. In experimental potassium depletion studied by Black and Milne,l1 1. Gamble, J. L. Chemical Anatomy, Physiology and Pathology of Extracellular Fluid. Cambridge, Mass., 1951 ; chart 20. 2. Hastings, A. B., McLean, F. C., Eichelberger, L., Hall, J. L., da Costa, E. J. biol. Chem. 1934, 107, 351. 3. Östberg, O. Skand. Arch. Physiol. 1931, 62, 81. 4. Shorr, E., Carter, A. C., Smith, R. W. jun., Taussky. H. Macy Foundation Conference on Metabolic Aspects of Convalescence. New York, 1948 ; 17th meeting. 5. Shorr, E., Almy, T. P., Sloan, M. H., Taussky, H., Toscani, V. Science, 1942, 96, 587. 6. Shorr, E., Bernheim, A. R., Taussky, H. Ibid, 1942, 95, 606. 7. Conway, N. S., Maitland, A. I. L., Rennie, J. B. Brit. J. Urol. 1949, 21, 30. 8. Milne, M. D. M.D. thesis, Victoria University of Manchester, 1951. 9. Fourman, P. Lancet, 1952, i, 1042. 10. Greenman, L., Shaler, J. B., Danowski, T. S. Amer. J. Med. 1953, 14, 391. 11. Black, D. A. K., Milne, M. D. Clin. Sci. 1952, ii, 397.
732 which differed from the method of Fourman in that a resin in the sodium cycle was used in the pre-treatment of the diet, the calcium content of my own urine dropped sharply from 53 to 5 m.eq. per day during the depletion period. I have confirmed the correlation between calcium and citrate excretion in my own case,8 the correlation coefficient being z- 0.92 at ordinary urinary pH range. The regression equation of citrate to calcium was of the formula y = 0.85x + 0-2 where y is citrate excretion in mg. per minute and x is calcium excretion in the same units. It is probable that the regression constants vary considerably from individual to individual. Applying these results to the data on potassium depletion, I would have expected a fall of citrate excretion from 1180 mg. per day to 370 mg. per day due to the effect of hypocalcuria alone. This is a greater fall than that recorded by Fourman and Robinson, but it must be admitted that the high-milk diet of our depletion experiment caused an abnormally high calcium excretion during the control period. Studies of citrate excretion will in future be included in a research on potassium depletion at present in progress in these laboratories. If it is finally shown that potassium depletion has a direct effect on citrate clearance, it is still difficult to agree with Fourman and Robinson that this would probably be secondary to abnormal glucose metabolism with disturbance of the metabolic processes of the tricarboxylic acid cycle. This should influence citrate clearance rather by alteration of plasma-citrate levels than by a direct action on the kidney. The publication in full of the -data of Fourman and Robinson, with details of the effect of variations of calcium excretion, will be awaited with great interest. Postgraduate Medical School of London, W.12.
M. D. MILNE.
EXTERNAL CEPHALIC VERSION
SIR,-In reply to Mr. Dalley’s letter (Sept. 12), I wish to point out that the two sets of figures he analyses are not comparable. In forecasting the probable outcome of 1000 cases of breech presentation diagnosed during the course of pregnancy in the Middlesex Hospital, he forgets the number of successful versions which would result from version without anaesthesia, and it is in 80% of the remainder that version would be likely to succeed with the help of anaesthesia. Thus the total number of cases in which version as a whole is likely to prove successful is necessarily much more than 80%, and will undoubtedly reduce the incidence of breech presentation in labour well below the 60 per 1000 estimated by Mr. Dalley. In fact our incidence of breech presentation in babies weighing more than 3-3 lb. at birth was slightly below 16 per 1000 (corrected figure). Middlesex Hospital, M. R. FELL. London, W.1. ACROPARÆSTHESIÆ IN THE SYNDROME
CARPAL-TUNNEL
very interested in the article on this Dr. Kremer and his colleagues 19), as I have dealt with quite a number of- these cases by operation. The procedure adopted by me has, however, been a more- extensive exploration through a vertical incision, which included examination of the flexor tendons and their sheath as well as the flexor retinaculum. The vertical incision has never caused any contracture, and the median nerve has never become adherent to the scar. With this more extensive exploration the flexor tendons are seen to be enveloped in cedematous synovial membrane ; this aedema, which is often severe, resembles, though it is more extensive than, that seen in tenovaginitis stenosans of the short extensor and long abductor tendonsof the thumb. I contend that this
SJR,łI
subject by
was
(Sept.
acroparaesthesise in the carpal-tunnel tenovaginitis stenosans involving the flexor tendons as they pass under the flexor retinaculum. In this particular instance, it is complicated by the passage of the median nerve through the same tunnel as the tendons. The nerve, being the more delicate structure, gives rise to earlier and distinct symptoms. The treatment is the same as for tenovaginitis stenosans elsewhere-i.e., division of the tight constricting
condition
syndrome
called is a
band.
G. K. MCKEE.
Norwich
" COIN " LESIONS OF THE LUNGS
SiR,-Your annotation of Sept. 19 indicates the risks which any person who " believes himself to be in perfect health may run if he submits himself to mass radiography ; for it tells us that if his radiograph shows the shadow of a small healed localised lesion he may be induced to submit in turn to multiple radiographic examinations, tomography, angiocardiography, radioactive isotopes, bronchoscopy, and biopsy. " When all these
investigations have been completed, the answer is very often still in doubt. The safest these lesions is in the hands of the pathologist, and it is probably wiser to remove them all, tuberculous and nontuberculous, except perhaps in patients under the age of 30 in whom the shadow lies at the apex of a lobe ..." however, place for
On this
would it not be logical to remove the you see a shadow on the radiograph!g This would surely save our overworked -radiologists, biochemists, pathologists, anaesthetists, and all their technical and nursing staffs-yes and the surgeonsa great deal of labour. Speaking of the alternative policy of waiting, watching, and operating only if the shadow enlarges or excavates," you say that " in view of the safety of modern surgery ... this course is seldom Is even anaesthesia always administered justified." without risk ? In Storey et al.’s series, of 40 patients (mostly healthy young men on active service) in whom a histological diagnosis was made, the lesion proved to be tuberculous in 70%. As a radiologist with extensive experience in chest work I should say that the majority of the remaining 30% of " isolated, well-defined, spherical shadows " in were shadows young Service patients with no without the slightest clinical significance. Patients have died after and during such investigations, and if they had no symptoms before operation they have not infrequently had them after it : the mental disturbance, alone, can be serious. Moreover, if the tuberculous lesion is already healed its resection is unlikely to confer the slightest benefit on the patient. True, if left alone it may break down ; but, if that happens, a lesion which has healed once will probably do so again if the resistance of the patient is assisted. Finally, have we any proof that resection of a malignant lesion will cure the patient1 Are not the " successes " possibly due to erroneous interpretation of histological material ? I have known a patient diagnosed as having malignant disease live twenty years after " mere biopsy " as the treatment, and I have seen some spectacular radiographic lesions remain unchanged for as many and more years-until death followed attempts to remove them. I have known of resections for pneumonia. In the same issue of your journal Dr. Bernard Lennox points out that medicine " has only slowly and painfully won through to some sort of scientific basis." Is not the fault in some sort of scientific basis " ? Dr. Dornhorst (Sept. 5) and Dr. Odium (Sept. 19) say that there is every need for reorientation in every branch of medicine. Recently a famous surgeon was quoted as saying:
lung
principle
as soon as
"
-
symptoms
"
"
over
I advise the
40, to have
who smokes heavily, especially if he is chest X-ray every six months-or preferably
man
a
I suggest that some very rewarding information might be gathered-especially by the field naturalists of medicine, the rural practitioners-by inquiring into what common virus diseases people who get poliomyelitis have not had and close contacts who do not get it have had. Personally my guess is that the villain, or rather hero, of the piece is herpes simplex. It is the most widespread viral infection in man. It is contracted in early childhood and is kept as a slightly irritable pet throughout life. Adults do not get it, but, of course, they periodically display their childhood’s infestation. Burnet and Williams found that 93% of hospital patients had antibody in their blood, but only 37% of the more hygienically brought up university graduates. "’ Over 60% are infected and remain carriers for life " says one of the authors of that mine of information Virus and Rickettsial Disease. In short I suspect that herpessimplex negatives are liable to become poliomyelitis cases. I suggest that there is a prima-facie case for investigation, which, I understand, has not been made. Or in words that Holmes himself might have used : " This herpes simplex fellow, my dear Watson, may be our man." C. G. LEAROYD. Beckley, Rye, Sussex. TRANSFUSION OF BLOOD-PLATELETS
SIR,-I think that your leading article on this subject (Sept. 19) calls for comment for the sake of full correctness. Your
about cerebral hemorrhage in idiopathic thrombocytopenic purpura is a bit theoretical. The incidence of cerebral haemorrhage in this condition is low-probably very low. During the past fifteen years I have personally followed up 20 cases ; these have included some with profuse bleeding, but none with cerebral hsemorrhage. This is perhaps a small number for firm conclusions, but, as personal series go, it is quite concern
large. You state that " commonly acute idiopathic thrombocytopenic purpura is clinically severe and responds poorly
splenectomy."
The first part of this statement may but the second be true; part does not harmonise with of in this the world. In my series, part experience 6 out of 14 cases had to be splenectomised immediately, owing to profuse bleeding. Of these patients 1 died of thrombosis and subphrenic abscess some time after splenectomy ; the rest are fully cured. Regarding transfusion of platelets before splenectomy, in my experience ordinary transfusion of fresh blood before or during splenectomy has a satisfactory effect. After the splenic vessels have been ligated, the remaining to
bleeding tendency disappears remarkably
soon.
St. Joseph’s Hospital,
A. SCHRUMPF
Porsagrunn, Norway.
Chief physician.
TOBACCO SMOKING SiR,-I should be grateful if you would allow me space to change the middle of the definition of addiction given in my letter last week from " tolerance to the physical effects of the incorporation on the basic psychic relations with ..." to read "... tolerance to the physical effects of the incorporation, the basic psychic relations with... " ...
Shc,tt,s, Lanarkshire.
R. GOOD.
SiR,-Dr. Good offers us a twelve-line definition of addiction. Might I, with very great respect, suggest that he should read what he has written aloud’1 ALEX COMFORT, COMFORT. Loughton, Essex.
URINARY EXCRETION OF CITRATE
SfR,—The interesting preliminary communication last week by Dr. Fourman and Dr. Robinson shows that a decrease of urinary citrate clearance may be associated with experimental potassium depletion in man, but there is no definite proof that this is directly due to the potassium loss. The clearance of citrate by the kidney is a very complex process, since urinary citrate as measured chemically consists of at least three different fractions-i.e., dissociated citrate anions balanced by sodium or potassium, undissociated citric acid itself, and un-ionised calcium citrate chelation complex. Gamble1 has shown that the degree of dissociation is governed by the urinary pH, and Hastings et a1.2 have studied the effect of citrate as a calcium chelating agent. As will be seen, there is reason to believe that these three moieties are handled differently by the renal
tubules. The renal clearance of citrate is greatly modified by at least five distinct factors : (a) plasma level of citrate, (b) pH of the urine, (c) calcium content of the urine, (d) cestrogenic and androgenic steroids, and (e) presence of urinary infection.
(a) Like most other substances reabsorbed by the tubules from the glomorular filtrate, the citrate clearance increases with rising plasma levels. Free citric acid appears to be reabsorbed preferentially ion, and therefore the citrate clearance increases 4as the urinary pH rises.3 (c) Calcium citrate chelation complex is less well reabsorbed, and therefore the citrate clearance increases with a rise of urinary calcium.5 (d) CEstrogens specifically increase and androgens decrease the renal citrate clearance by a direct action on the renal tubules.44. This is of little practical importance in the male, but accounts for the wide cyclical fluctuation of citrate excretion in the female during the menstrual cycle.6
(b)
to citrate
(e) Urinary infection diminishes citrate clearance since citrate is rapidly destroyed by many bacteria in the bladder and the renal pelves as well as in stored urine.7 In the course of an investigation on calcium metabolism,8all these facts were confirmed but no new information was elicited. In the data presented by Fourman and Robinson, it seems that the effect of variation of calcium content of the urine may have some bearing on the fall of citrate clearance observed. It is virtually impossible to produce an absolutely pure uncomplicated potassium depletion in man. In the method described by Fourman,9there is a complicating acidosis due to the use of a sulphonic resin in the ammonium cycle, and also there is preferential absorption by resin of divalent cations in the gut with a consequent
reduction in calcium and magnesium intake. Hypocalcaemia and tetany have been reported after relatively short periods of therapy with the sulphonic forms of cation exchangers,lO and urinary calcium usually drops very rapidly with ingestion of such resins. In experimental potassium depletion studied by Black and Milne,l1 1. Gamble, J. L. Chemical Anatomy, Physiology and Pathology of Extracellular Fluid. Cambridge, Mass., 1951 ; chart 20. 2. Hastings, A. B., McLean, F. C., Eichelberger, L., Hall, J. L., da Costa, E. J. biol. Chem. 1934, 107, 351. 3. Östberg, O. Skand. Arch. Physiol. 1931, 62, 81. 4. Shorr, E., Carter, A. C., Smith, R. W. jun., Taussky. H. Macy Foundation Conference on Metabolic Aspects of Convalescence. New York, 1948 ; 17th meeting. 5. Shorr, E., Almy, T. P., Sloan, M. H., Taussky, H., Toscani, V. Science, 1942, 96, 587. 6. Shorr, E., Bernheim, A. R., Taussky, H. Ibid, 1942, 95, 606. 7. Conway, N. S., Maitland, A. I. L., Rennie, J. B. Brit. J. Urol. 1949, 21, 30. 8. Milne, M. D. M.D. thesis, Victoria University of Manchester, 1951. 9. Fourman, P. Lancet, 1952, i, 1042. 10. Greenman, L., Shaler, J. B., Danowski, T. S. Amer. J. Med. 1953, 14, 391. 11. Black, D. A. K., Milne, M. D. Clin. Sci. 1952, ii, 397.
732 which differed from the method of Fourman in that a resin in the sodium cycle was used in the pre-treatment of the diet, the calcium content of my own urine dropped sharply from 53 to 5 m.eq. per day during the depletion period. I have confirmed the correlation between calcium and citrate excretion in my own case,8 the correlation coefficient being z- 0.92 at ordinary urinary pH range. The regression equation of citrate to calcium was of the formula y = 0.85x + 0-2 where y is citrate excretion in mg. per minute and x is calcium excretion in the same units. It is probable that the regression constants vary considerably from individual to individual. Applying these results to the data on potassium depletion, I would have expected a fall of citrate excretion from 1180 mg. per day to 370 mg. per day due to the effect of hypocalcuria alone. This is a greater fall than that recorded by Fourman and Robinson, but it must be admitted that the high-milk diet of our depletion experiment caused an abnormally high calcium excretion during the control period. Studies of citrate excretion will in future be included in a research on potassium depletion at present in progress in these laboratories. If it is finally shown that potassium depletion has a direct effect on citrate clearance, it is still difficult to agree with Fourman and Robinson that this would probably be secondary to abnormal glucose metabolism with disturbance of the metabolic processes of the tricarboxylic acid cycle. This should influence citrate clearance rather by alteration of plasma-citrate levels than by a direct action on the kidney. The publication in full of the -data of Fourman and Robinson, with details of the effect of variations of calcium excretion, will be awaited with great interest. Postgraduate Medical School of London, W.12.
M. D. MILNE.
EXTERNAL CEPHALIC VERSION
SIR,-In reply to Mr. Dalley’s letter (Sept. 12), I wish to point out that the two sets of figures he analyses are not comparable. In forecasting the probable outcome of 1000 cases of breech presentation diagnosed during the course of pregnancy in the Middlesex Hospital, he forgets the number of successful versions which would result from version without anaesthesia, and it is in 80% of the remainder that version would be likely to succeed with the help of anaesthesia. Thus the total number of cases in which version as a whole is likely to prove successful is necessarily much more than 80%, and will undoubtedly reduce the incidence of breech presentation in labour well below the 60 per 1000 estimated by Mr. Dalley. In fact our incidence of breech presentation in babies weighing more than 3-3 lb. at birth was slightly below 16 per 1000 (corrected figure). Middlesex Hospital, M. R. FELL. London, W.1. ACROPARÆSTHESIÆ IN THE SYNDROME
CARPAL-TUNNEL
very interested in the article on this Dr. Kremer and his colleagues 19), as I have dealt with quite a number of- these cases by operation. The procedure adopted by me has, however, been a more- extensive exploration through a vertical incision, which included examination of the flexor tendons and their sheath as well as the flexor retinaculum. The vertical incision has never caused any contracture, and the median nerve has never become adherent to the scar. With this more extensive exploration the flexor tendons are seen to be enveloped in cedematous synovial membrane ; this aedema, which is often severe, resembles, though it is more extensive than, that seen in tenovaginitis stenosans of the short extensor and long abductor tendonsof the thumb. I contend that this
SJR,łI
subject by
was
(Sept.
acroparaesthesise in the carpal-tunnel tenovaginitis stenosans involving the flexor tendons as they pass under the flexor retinaculum. In this particular instance, it is complicated by the passage of the median nerve through the same tunnel as the tendons. The nerve, being the more delicate structure, gives rise to earlier and distinct symptoms. The treatment is the same as for tenovaginitis stenosans elsewhere-i.e., division of the tight constricting
condition
syndrome
called is a
band.
G. K. MCKEE.
Norwich
" COIN " LESIONS OF THE LUNGS
SiR,-Your annotation of Sept. 19 indicates the risks which any person who " believes himself to be in perfect health may run if he submits himself to mass radiography ; for it tells us that if his radiograph shows the shadow of a small healed localised lesion he may be induced to submit in turn to multiple radiographic examinations, tomography, angiocardiography, radioactive isotopes, bronchoscopy, and biopsy. " When all these
investigations have been completed, the answer is very often still in doubt. The safest these lesions is in the hands of the pathologist, and it is probably wiser to remove them all, tuberculous and nontuberculous, except perhaps in patients under the age of 30 in whom the shadow lies at the apex of a lobe ..." however, place for
On this
would it not be logical to remove the you see a shadow on the radiograph!g This would surely save our overworked -radiologists, biochemists, pathologists, anaesthetists, and all their technical and nursing staffs-yes and the surgeonsa great deal of labour. Speaking of the alternative policy of waiting, watching, and operating only if the shadow enlarges or excavates," you say that " in view of the safety of modern surgery ... this course is seldom Is even anaesthesia always administered justified." without risk ? In Storey et al.’s series, of 40 patients (mostly healthy young men on active service) in whom a histological diagnosis was made, the lesion proved to be tuberculous in 70%. As a radiologist with extensive experience in chest work I should say that the majority of the remaining 30% of " isolated, well-defined, spherical shadows " in were shadows young Service patients with no without the slightest clinical significance. Patients have died after and during such investigations, and if they had no symptoms before operation they have not infrequently had them after it : the mental disturbance, alone, can be serious. Moreover, if the tuberculous lesion is already healed its resection is unlikely to confer the slightest benefit on the patient. True, if left alone it may break down ; but, if that happens, a lesion which has healed once will probably do so again if the resistance of the patient is assisted. Finally, have we any proof that resection of a malignant lesion will cure the patient1 Are not the " successes " possibly due to erroneous interpretation of histological material ? I have known a patient diagnosed as having malignant disease live twenty years after " mere biopsy " as the treatment, and I have seen some spectacular radiographic lesions remain unchanged for as many and more years-until death followed attempts to remove them. I have known of resections for pneumonia. In the same issue of your journal Dr. Bernard Lennox points out that medicine " has only slowly and painfully won through to some sort of scientific basis." Is not the fault in some sort of scientific basis " ? Dr. Dornhorst (Sept. 5) and Dr. Odium (Sept. 19) say that there is every need for reorientation in every branch of medicine. Recently a famous surgeon was quoted as saying:
lung
principle
as soon as
"
-
symptoms
"
"
over
I advise the
40, to have
who smokes heavily, especially if he is chest X-ray every six months-or preferably
man
a