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USE AND ABUSE OF PURGATIVES
478
LETTERS TO THE EDITOR "
THE NEW OUTLOOK IN PNEUMONIA "
SIR,-The leading article under this heading in your issue of Feb. 11 has somewhat astonished
me.
While there can be no doubt that the introduction of sulphapyridine is a great contribution to the treatment of pneumonia, it is my opinion that it is still too early to describe it as a specific remedy. The value of the large body of work on pneumococcus pneumonia performed in the United States of America lies not only in the proving of the efficacy of serum treatment. The American workers have themselves introduced a "new outlook on pneumonia " which, so far as I am aware, has not yet been taken fully into account in assessing the value of this new drug. Before any reasoned statement, in fact before even a general impression, can be made regarding the efficacy of M. & B. 693, a very large number of cases will require to be reported in which, before the onset of therapy, the infecting pneumococcus has been typed and blood-culture has been performed. These two factors alone introduce sufficient errors in any investigation of pneumonia to prevent an opinion being formed from the observation of untyped cases. I can see nothing but harm resulting from such a premature leading article and it seems to give small encouragement to those who are taking a more painstaking way of investigating the value of the I am, Sir, yours faithfully, drug. THOMAS ANDERSON. Ruchill Fever Hospital, Glasgow, Feb. 14.
ANEURYSM OF POPLITEAL ARTERY
SiR,-I was much interested in Mr. Cecil Flemming’s paper in your issue of Feb. 11 (p. 322). A recent case of my own appears to support his conclusion that
ligature
should be combined with excision
hyalinised, the vasa vasorum showed perivascular cuffing, and there was inflammatory fibrosis of media. These findings were considered consistent with
syphilis. Mr. Flemming states that " the femoral artery was ligatured immediately proximal to the sac " but he does not mention whether the femoral vein was also ligatured. It is pointed out in Carson’s " Modern Operative Surgery " (1934) that Makins in his Bradshaw lecture for 1913 (Lancet, 1913, 2, 1743) concluded that when it became necessary to ligature a main arterial trunk its accompanying vein should also be tied. I am, Sir, yours faithfully, CAMERON MACLEOD Harley Street, W.1, Feb. 20. USE AND ABUSE OF PURGATIVES
or
form of
plastic operation. A man, aged 73, a fishmonger, came under my care in August, 1938, complaining of a swelling in the posterior aspect of the left knee, which he had first noticed ten months previously owing to the aching pain associated with it. The pain was noticed especially on walking or long standing and occasionally The swelling was felt down the back of the leg. had increased steadily in size until a fortnight ago, some
and vein and a strong silk ligature was placed around both just proximal to the sac. The lower end of the sac was then exposed and the vessels were again ligatured with silk. The tourniquet which had been in position for about 40 minutes was removed. The aneurysmal sac was then incised and a very large clot removed. It was noted that there was almost no bleeding from collateral vessels into the sac and no ligatures or sutures were necessary. The sac was gently cleared of loose and slightly adherent clot and irrigated with flavine. It was then dissected away from the surrounding tissues to which it A corrugated rubber was not greatly adherent. drain was inserted through each extremity of the wound into the popliteal space. At the end of the operation the foot was warm and a good colour and no anxiety was at any time felt as to the viability of the limb. He was last seen on Jan. 20, 1939, when he complained of a slight aching and "tight" ness in the left foot. On microscopical examination (Dr. H. W. C. Vines) the clot showed all stages of organisation including at the periphery hyalinisation and early calcification. The arterial wall was almost entirely
when it suddenly became twice as large. During the last week it had become more painful. He had had varicose veins in the left leg for many years, and an operation for hydrocele in 1924. There was no history of venereal disease ; he had 5 children alive and well, and his wife had no miscarriages. A swelling with expansile pulsation was present in the left popliteal fossa with a well-marked systolic bruit. The left dorsalis pedis pulse was weaker and later than the right. Pupils normal. Mouth : leucoplakia inside angles of mouth and beneath right side of tongue. Lungs : emphysema. Heart : sounds weak, no murmurs. Radiography showed slight enlargement chiefly of the left ventricle and also aortic dilatation. Electrocardiogram : auricular fibrillation at a rate a little above the normal (Dr. K. Shirley Smith). Blood-pressure : systolic 144, diastolic 100. Urine normal. The blood Wassermann reaction was strongly positive (1/120 dilution of patient’s serum fixing standard amount of complement). A radiogram showed gross atheroma of the femoral artery in the popliteal space ; there was no bone erosion (Dr. S. Cochrane Shanks). Operation was done on Aug. 31, 1938, under gas, oxygen and ether. A tourniquet was applied and a long vertical incision made over the popliteal fossa. It was not possible to separate the popliteal artery
Srtt,,-In your account of the meeting of the Society of London in your last issue I am reported to have said that Sir Arthur Hurst had been responsible for the sale of paraffin in halfgallon bottles. Your excellent reporter, at a somewhat late hour in the evening, evidently did not catch the whole of my remark, in which I said that I believed that a late colleague of Sir Arthur Hurst had been responsible for the habit of buying paraffin in half-gallon bottles. It would be obviously uneconomic for a patient to purchase such large quantities if he limited himself to the small doses that Sir Arthur Hurst prescribes-one to two I am, Sir, yours faithfully, teaspoonfuls. Medical
Cavendish Square, W.1, Feb. 20.
J. E. H. ROBERTS.
PREGNANCY TESTS AND NOTIFICATION
SiR,-Dr. Joan Malleson’s suggestions for reducing the incidence of criminal abortion, published in your issue of Feb. 11, are admirably detailed and sympathetic. May I, as a laywoman, make one comment1 It occurs to me that the service of Aschheim-Zondek tests would need to include careful arrangements for anonymity, so as to ensure that positive reports could not be used for purposes of notification. Might not some system of complete privacy be devised, such as is embodied in our excellent service of venereal diseases prophylaxis and treatment1 Women who come for help ought to be quite sure that the help does not conceal a trap. ,
I am, Sir, yours faithfully, F. W. STELLA BROWNE. Chelsea, S.W.3,Feb. 20.
LETTERS TO THE EDITOR "
THE NEW OUTLOOK IN PNEUMONIA "
SIR,-The leading article under this heading in your issue of Feb. 11 has somewhat astonished
me.
While there can be no doubt that the introduction of sulphapyridine is a great contribution to the treatment of pneumonia, it is my opinion that it is still too early to describe it as a specific remedy. The value of the large body of work on pneumococcus pneumonia performed in the United States of America lies not only in the proving of the efficacy of serum treatment. The American workers have themselves introduced a "new outlook on pneumonia " which, so far as I am aware, has not yet been taken fully into account in assessing the value of this new drug. Before any reasoned statement, in fact before even a general impression, can be made regarding the efficacy of M. & B. 693, a very large number of cases will require to be reported in which, before the onset of therapy, the infecting pneumococcus has been typed and blood-culture has been performed. These two factors alone introduce sufficient errors in any investigation of pneumonia to prevent an opinion being formed from the observation of untyped cases. I can see nothing but harm resulting from such a premature leading article and it seems to give small encouragement to those who are taking a more painstaking way of investigating the value of the I am, Sir, yours faithfully, drug. THOMAS ANDERSON. Ruchill Fever Hospital, Glasgow, Feb. 14.
ANEURYSM OF POPLITEAL ARTERY
SiR,-I was much interested in Mr. Cecil Flemming’s paper in your issue of Feb. 11 (p. 322). A recent case of my own appears to support his conclusion that
ligature
should be combined with excision
hyalinised, the vasa vasorum showed perivascular cuffing, and there was inflammatory fibrosis of media. These findings were considered consistent with
syphilis. Mr. Flemming states that " the femoral artery was ligatured immediately proximal to the sac " but he does not mention whether the femoral vein was also ligatured. It is pointed out in Carson’s " Modern Operative Surgery " (1934) that Makins in his Bradshaw lecture for 1913 (Lancet, 1913, 2, 1743) concluded that when it became necessary to ligature a main arterial trunk its accompanying vein should also be tied. I am, Sir, yours faithfully, CAMERON MACLEOD Harley Street, W.1, Feb. 20. USE AND ABUSE OF PURGATIVES
or
form of
plastic operation. A man, aged 73, a fishmonger, came under my care in August, 1938, complaining of a swelling in the posterior aspect of the left knee, which he had first noticed ten months previously owing to the aching pain associated with it. The pain was noticed especially on walking or long standing and occasionally The swelling was felt down the back of the leg. had increased steadily in size until a fortnight ago, some
and vein and a strong silk ligature was placed around both just proximal to the sac. The lower end of the sac was then exposed and the vessels were again ligatured with silk. The tourniquet which had been in position for about 40 minutes was removed. The aneurysmal sac was then incised and a very large clot removed. It was noted that there was almost no bleeding from collateral vessels into the sac and no ligatures or sutures were necessary. The sac was gently cleared of loose and slightly adherent clot and irrigated with flavine. It was then dissected away from the surrounding tissues to which it A corrugated rubber was not greatly adherent. drain was inserted through each extremity of the wound into the popliteal space. At the end of the operation the foot was warm and a good colour and no anxiety was at any time felt as to the viability of the limb. He was last seen on Jan. 20, 1939, when he complained of a slight aching and "tight" ness in the left foot. On microscopical examination (Dr. H. W. C. Vines) the clot showed all stages of organisation including at the periphery hyalinisation and early calcification. The arterial wall was almost entirely
when it suddenly became twice as large. During the last week it had become more painful. He had had varicose veins in the left leg for many years, and an operation for hydrocele in 1924. There was no history of venereal disease ; he had 5 children alive and well, and his wife had no miscarriages. A swelling with expansile pulsation was present in the left popliteal fossa with a well-marked systolic bruit. The left dorsalis pedis pulse was weaker and later than the right. Pupils normal. Mouth : leucoplakia inside angles of mouth and beneath right side of tongue. Lungs : emphysema. Heart : sounds weak, no murmurs. Radiography showed slight enlargement chiefly of the left ventricle and also aortic dilatation. Electrocardiogram : auricular fibrillation at a rate a little above the normal (Dr. K. Shirley Smith). Blood-pressure : systolic 144, diastolic 100. Urine normal. The blood Wassermann reaction was strongly positive (1/120 dilution of patient’s serum fixing standard amount of complement). A radiogram showed gross atheroma of the femoral artery in the popliteal space ; there was no bone erosion (Dr. S. Cochrane Shanks). Operation was done on Aug. 31, 1938, under gas, oxygen and ether. A tourniquet was applied and a long vertical incision made over the popliteal fossa. It was not possible to separate the popliteal artery
Srtt,,-In your account of the meeting of the Society of London in your last issue I am reported to have said that Sir Arthur Hurst had been responsible for the sale of paraffin in halfgallon bottles. Your excellent reporter, at a somewhat late hour in the evening, evidently did not catch the whole of my remark, in which I said that I believed that a late colleague of Sir Arthur Hurst had been responsible for the habit of buying paraffin in half-gallon bottles. It would be obviously uneconomic for a patient to purchase such large quantities if he limited himself to the small doses that Sir Arthur Hurst prescribes-one to two I am, Sir, yours faithfully, teaspoonfuls. Medical
Cavendish Square, W.1, Feb. 20.
J. E. H. ROBERTS.
PREGNANCY TESTS AND NOTIFICATION
SiR,-Dr. Joan Malleson’s suggestions for reducing the incidence of criminal abortion, published in your issue of Feb. 11, are admirably detailed and sympathetic. May I, as a laywoman, make one comment1 It occurs to me that the service of Aschheim-Zondek tests would need to include careful arrangements for anonymity, so as to ensure that positive reports could not be used for purposes of notification. Might not some system of complete privacy be devised, such as is embodied in our excellent service of venereal diseases prophylaxis and treatment1 Women who come for help ought to be quite sure that the help does not conceal a trap. ,
I am, Sir, yours faithfully, F. W. STELLA BROWNE. Chelsea, S.W.3,Feb. 20.