259 observed the serious complication of crystal formation and renal involvement which may follow treatment with sulphadiazine. Our personal experience of the latter drug is small, but there is ample evidence from the literature that the risk of renal damage from both sulpha- diazine and ’sulphapyridine is a real one. The efricient therapeutic dose of sulphamezathine is higher than that of sulphapyridine, and its action is not quite sø dramatic ; but in mortality and morbidity rates there is little to choose between the various drugs. Sulphamezathine has decidedly fewer side-effects and is both safer and more pleasant to take. Our main reason for writing this letter, however, is to state categorically that Dr. Dick’s views regarding the efficacy of a fixed dosage of any sulphonamide, irrespec- tive of the clinical condition or evidence of effective absorption, are dangerous, and that we profoundly dis- agree with his conclu’sion. Crumpsall Hospital, Manchester. W. A. RAMSAY. R. W. LUXTON. LOCALISATION OF FOREIGN BODIES SIR,—In his extremely interesting article of Dec. 9, 1944, Dr. Brailsford complains of the number of un- successful operations for removal of foreign bodies. These unsuccessful operations are mainly due to error in judgment on the part of the surgeon, because, as Dr. Brailsford points out, a large number of foreign bodies are best left in situ. Dr. Brailsford omits one important point concerning foreign-body localisation. Over five years’ experience of Army radiology has taught me that the time factor is one of the most important. When a rush of patients comes, it is impossible to make accurate localisations in every case ; therefore this procedure should be carried out only in difficult cases. A general hospital is often called on to work on a CCS basis, with a rapid turnover of patients, only retaining such patients as cannot be moved on. The result is that a rapid stream of patients passes through the X-ray department, followed by successive streams as convoys arrive. -. My practice is to screen as many of these gunshot- wound cases as possible. This was essential in the Middle East in earlier days when films were scarce. If the foreign body or bodies are small- and innocuous, no marks are made on the skin. If I consider that the sur- geon may wish to know the site for possible operation, anterior (or posterior) and lateral (or medial) marks are made, depending on the position of the foreign body. If thought necessary, films- may be taken ; otherwise a drawing of the approximate size and shape-of the foreign body is included in the X-ray report. These skin mark- ings are usually a. sufficient guide to the surgeon, and I must say I have not seen " many unsuccessful operations for removal." During the screen examinations I decide which case requires accurate localisation. If any case is thought to be difficult from the surgeon’s point of view, a depth measurement is given quite rapidly by the use of Scott’s localiser, a simple method which recordsa scale on a film. This is fairly accurate. The Army supply all X-ray departments with the McGrigor localiser, which is an accurate method ; I have, however, found that a simple scale method is speedier when speed is necessary. The number of cases requiring accurate depth measure- ment is relatively small. Dr. Brailsford quotes your leading article of Oct. 28, 1944, which stated that " field surgical units have facilities to produce those rough plates which are all that the forward surgeon requires." What are "rough plates ? " Perhaps they are the plates kept unwashed in the operating-theatre for three days or more. The surgeon who relies on " rough plates " will be asking for trouble. Usually it is useless to give a depth measurement for abdominal foreign bodies, because they often move in position. Extraperitoneal foreign bodies deeply placed in the posterior abdomen are difficult and require very accurate localisation. The main radiological investiga- tion for abdominal foreign bodies should be directed to demonstrating the presence or absence of gas in the abdominal cavity. This is best done by first taking a lateral view with the patient on his back, when air can be seen between the liver and the anterior abdominal wall. A view is then taken from the side with the patient, still lying, turned on his left sideB This informa- tion is much more important to the surgeon than the supposed position of a potentially mobile foreign body. The investigation should not be considered complete without films of the chest and the pelvis. Like Dr. Brailsford, I would like to stress the import- ance of cooperation between surgeon and radiologist. Many of the troubles of both can be avoided if they take the small trouble of consulting each’ other, especially concerning the more difficult cases. JOHN A. ROSS. BACTERIOLOGY OF RESTAURANT CUPS SIR,—Much has been written about the dangers of infection arising from the cracks found in the cups in public cafes and restaurants, but little appears to have been done to discover what such dangers may be.’ I have now studied the bacteriology of about 20 cups obtained from various public restaurants. In general, no organism has been found which could be blamed for an outbreak of diphtheria or typhoid, but the findings suggest that if such organisms were to obtain a footing, then the particular article might be a danger. All the pottery used for the tests was carefully washed and then held in a stream of boiling water for 15 seconds. The article was then broken down the original crack and a culture made from the break. The cultures were made on blood-agar, McConkey’s agar and glucose-broth. In all cases, cracks on the side of the cup from which the user would drink were used. In no case was a sterile result obtained. The findings were as follows : What is surprising is the frequency of the haemolytic streptococcus, which one would imagine would be easily destroyed. There was also a fairly frequent appearance of intestinal organisms (Bact. coli, B. proteus, &c.), and one cup gave a heavy growth of Friedlander’s bacillus. The other common organism was the Staph. aureus. Nearly all the organisms found were such as are commonly associated with stomatitis, and with mouth and gum complaints generally. A cracked cup, then, may be a source of danger when some infected person has previously used it. The presence of Friedlander’s bacillus is also an indication that respiratory organisms may be a source of infection and it is a reasonable assumption that the Klebs- Loeffler bacillus may be found if the cups have been used by a carrier. The presence of hæmolytic strepto- cocci is also a reminder that a cracked cup may be an agent in the spread of scarlet fever. Syphilitic infection is unlikely but not impossible, and in the same category falls tuberculosis. These organisms, particularly the former, would be difficult to discover from cracks, but the fact that even relatively easily killed organisms can be found alive in such sites suggests that their trans- mission is not impossible. The most obvious danger of cracked and chipped crockery is however that of ulcerative stomatitis.
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259
observed the serious complication of crystal formationand renal involvement which may follow treatment withsulphadiazine. Our personal experience of the latterdrug is small, but there is ample evidence from theliterature that the risk of renal damage from both sulpha-diazine and ’sulphapyridine is a real one. The efricienttherapeutic dose of sulphamezathine is higher than thatof sulphapyridine, and its action is not quite sø dramatic ;but in mortality and morbidity rates there is little tochoose between the various drugs. Sulphamezathinehas decidedly fewer side-effects and is both safer andmore pleasant to take.Our main reason for writing this letter, however, is to
state categorically that Dr. Dick’s views regarding theefficacy of a fixed dosage of any sulphonamide, irrespec-tive of the clinical condition or evidence of effectiveabsorption, are dangerous, and that we profoundly dis-agree with his conclu’sion.
Crumpsall Hospital, Manchester.W. A. RAMSAY.R. W. LUXTON.
LOCALISATION OF FOREIGN BODIESSIR,—In his extremely interesting article of Dec. 9,
1944, Dr. Brailsford complains of the number of un-successful operations for removal of foreign bodies.These unsuccessful operations are mainly due to errorin judgment on the part of the surgeon, because, as Dr.Brailsford points out, a large number of foreign bodiesare best left in situ.
Dr. Brailsford omits one important point concerningforeign-body localisation. Over five years’ experience ofArmy radiology has taught me that the time factor isone of the most important. When a rush of patientscomes, it is impossible to make accurate localisations inevery case ; therefore this procedure should be carriedout only in difficult cases. A general hospital is oftencalled on to work on a CCS basis, with a rapid turnoverof patients, only retaining such patients as cannotbe moved on. The result is that a rapid stream ofpatients passes through the X-ray department, followedby successive streams as convoys arrive.
-.
My practice is to screen as many of these gunshot-wound cases as possible. This was essential in the MiddleEast in earlier days when films were scarce. If theforeign body or bodies are small- and innocuous, nomarks are made on the skin. If I consider that the sur-geon may wish to know the site for possible operation,anterior (or posterior) and lateral (or medial) marks aremade, depending on the position of the foreign body.If thought necessary, films- may be taken ; otherwisea drawing of the approximate size and shape-of the foreignbody is included in the X-ray report. These skin mark-ings are usually a. sufficient guide to the surgeon, and Imust say I have not seen " many unsuccessful operationsfor removal."During the screen examinations I decide which case
requires accurate localisation. If any case is thoughtto be difficult from the surgeon’s point of view, a depthmeasurement is given quite rapidly by the use of Scott’slocaliser, a simple method which recordsa scale on afilm. This is fairly accurate. The Army supply allX-ray departments with the McGrigor localiser, which isan accurate method ; I have, however, found that asimple scale method is speedier when speed is necessary.The number of cases requiring accurate depth measure-ment is relatively small.Dr. Brailsford quotes your leading article of Oct. 28,
1944, which stated that " field surgical units havefacilities to produce those rough plates which are allthat the forward surgeon requires." What are "roughplates ? " Perhaps they are the plates kept unwashedin the operating-theatre for three days or more. Thesurgeon who relies on
"
rough plates " will be asking fortrouble.Usually it is useless to give a depth measurement for
abdominal foreign bodies, because they often move inposition. Extraperitoneal foreign bodies deeply placedin the posterior abdomen are difficult and require veryaccurate localisation. The main radiological investiga-tion for abdominal foreign bodies should be directed todemonstrating the presence or absence of gas in theabdominal cavity. This is best done by first taking alateral view with the patient on his back, when air canbe seen between the liver and the anterior abdominal
wall. A view is then taken from the side with thepatient, still lying, turned on his left sideB This informa-tion is much more important to the surgeon than thesupposed position of a potentially mobile foreign body.The investigation should not be considered completewithout films of the chest and the pelvis.
Like Dr. Brailsford, I would like to stress the import-ance of cooperation between surgeon and radiologist.Many of the troubles of both can be avoided if they takethe small trouble of consulting each’ other, especiallyconcerning the more difficult cases. .
JOHN A. ROSS.
BACTERIOLOGY OF RESTAURANT CUPS
SIR,—Much has been written about the dangers ofinfection arising from the cracks found in the cups inpublic cafes and restaurants, but little appears to havebeen done to discover what such dangers may be.’ Ihave now studied the bacteriology of about 20 cupsobtained from various public restaurants. In general,no organism has been found which could be blamed foran outbreak of diphtheria or typhoid, but the findingssuggest that if such organisms were to obtain a footing,then the particular article might be a danger. All thepottery used for the tests was carefully washed and thenheld in a stream of boiling water for 15 seconds. Thearticle was then broken down the original crack and aculture made from the break. The cultures were madeon blood-agar, McConkey’s agar and glucose-broth. Inall cases, cracks on the side of the cup from which theuser would drink were used. In no case was a sterileresult obtained. The findings were as follows :
What is surprising is the frequency of the haemolyticstreptococcus, which one would imagine would be easilydestroyed. There was also a fairly frequent appearanceof intestinal organisms (Bact. coli, B. proteus, &c.), andone cup gave a heavy growth of Friedlander’s bacillus.The other common organism was the Staph. aureus.
Nearly all the organisms found were such as are
commonly associated with stomatitis, and with mouthand gum complaints generally.A cracked cup, then, may be a source of danger when
some infected person has previously used it. Thepresence of Friedlander’s bacillus is also an indicationthat respiratory organisms may be a source of infectionand it is a reasonable assumption that the Klebs- Loeffler bacillus may be found if the cups have beenused by a carrier. The presence of hæmolytic strepto-cocci is also a reminder that a cracked cup may be anagent in the spread of scarlet fever. Syphilitic infectionis unlikely but not impossible, and in the same categoryfalls tuberculosis. These organisms, particularly theformer, would be difficult to discover from cracks, butthe fact that even relatively easily killed organisms canbe found alive in such sites suggests that their trans-mission is not impossible. The most obvious dangerof cracked and chipped crockery is however that ofulcerative stomatitis.
260
The usual excuse offered for the use of cracked cups isshortage of crockery, but if the public health is to becared for such a consideration should have no weight,and legislation should be pressed to forbid the use of.I..asB.l..1.lJ vt7iDolin.
of Feb. 10 there is a remark at the end of phase 2 whichreads " and one that may yet save the merchant seamanfrom becoming a sort of animated ironclad." There isno further indication as to what special operativeprocedure this refers.
I know that when I was a house-surgeon at theDreadnought Seamen’s Hospital at Greenwich 20 yearsago a silver filigree was often used in the repair of hernise,and is still so used. In the last 19 years at sea as a ship’ssurgeon I have seen many of these cases afterwards,frequently for some years, and in my small experiencethe operation has been quite successful. ’
’
It would be a pity if a pithy and telling phrase wasallowed to discredit what has, in good hands, proved avery satisfactory procedure.
’
H. M. ROYDS JONES,Surgeon, Orient Steam Navigation Co.
A CHAIR OF PSYCHIATRY
SiR,-The letter from " Service Psychiatrist " in your
last issue has evidently been written without knowledgeof the full facts.The Goodenough Committee recommended that theLondon County Council’s plans for the development ofthe teaching of psychiatry should be implemented " atthe earliest possible moment." The filling of the vacantchair is the keynote of this development. There isnothing sacrosanct, however, about Sept. 1 as the dateon which the successful applicant should take up thepost. It was regarded, for the purpose of an estimateof the cost, as the earliest date by which the positioncould be filled.The advertisement for applicants will be issued by the
university. All the points raised in the letter aboutService applicants have been well in mind. The univer-sity will be recommended to ensure that at least threemonths should be allowed between the issue of theadvertisement and the receipt of applications. Advicewill be taken from the Service departments as to-whetherthree months is adequate. The directors-general of theServices will be asked to circulate information as to thevacancy through Service channels. There is no doubtthat if a serving officer, who could not be released, wereselected, there would be no difficulty in deferring thedate of his taking up the appointment until he was’free.The sentence " Your announcement suggests that the
LCC is prepared to pay him provided that the Universityof London accepts their nominee " seems to have beenwritten in a complete misunderstanding of how theseuniversity appointments are filled. The universityappointment is made by the senate on the recom-mendation of a university committee. The committeecomprise a few LCC representatives, three expertassessors appointed by the university, together with thevice-chancellor (in the chair), and the principal of theuniversity. Their nomination is submitted concur-
rently to the university and to the LCC.
County Hall, London,SE1.
J. W. BOWEN,Chairman, Mental Hospitals
Committee, London County Council.
SiB,—May I support the protest by Service Psychia-trist in your last -issue ? Three years as consultant toa Force overseas have impressed upon me the really vitalimportance of doing nothing at home that will distractor distress the thousands of Service doctors, many of the’
°
highest qualifications and skill, whose task for a longtime to come will be that of healing and assuaging thesickness and wounds of our fighting men on the land, atsea, and in the air. Every sympathy is felt for thosehospital and teaching bodies who have v acancies= ontheir staffs which they are anxious to fill, and who areperhaps suffering from the makeshift arrangementsrendered necessary by a long and arduous war ; but it is
urged most earnestly upon all bodies with medicalappointments to fill that such appointments shouldremain vacant until the end of the war so that doctorswho may have been overseas for years may share withthose who have spent the war at home at any rate theright to compete for positions for which many of themare eminently suited.
If our Service doctors are to go to fresh adventures inthe war East looking anxiously over their shoulders atthe doings of their brethren at home (who have alreadyenjoyed many advantages in addition to their un-
interrupted domestic felicity) the result will be a bittercleavage in our profession which may take many yearsto heal. I
London, SWl.
G. W. B. JAMES,Brigadier ; late consultant in psychiatry
to the Middle East Force.
Sm,-Surely a decision to, make any appointmentdepends not only on the prospect of suitable availablecandidates but also on the need for filling the vacancy ?A decision to call for applicants scarcely need take.account of the former issue. The importance whichService Psychiatrist seems to attach to this chair wouldseem to argue against its being left vacant untilJapan is defeated. Further, there is still ample timefor any overseas psychiatrist to apply for this post.Should one of these be appointed, I hope one mayreasonably anticipate that the Army authorities wouldsee fit to release him for such an important post, andthereby give one like myself the opportunity to " seethe world " in his place.
CIVILIAN PSYCHIATRIST(not aspiring to the chair).
ŒSTROGENS IN CANCER
SiR,-The Royal Society of Medicine has arranged fora scientific committee, composed of the following fellowsof the society, to investigate the effects of oestrogens incancer :
Chairman: Prof. E. C. Dodds.
C6-cAaM’M6[m : Dr. Alexander Haddow.Hon. secretary: Dr. Frank Ellis.Sectional representattves :
Experimental medicine and therapeutics : Mr. A. L. Bacharachand Dr. K. M. A. Perry.
Obstetrics and gynaecology : Mr. Malcolm Donaldson and Mr.James Wyatt.
Pathology: Dr. W. E. Gye and Dr. R. W. Scarff. ,
Radiology : Dr. Ralston Paterson and Prof. B. W. Windeyer.Surgery : Mr. Rupert Corbett.Urology: Mr. F. MeG. Loughnane and Mr. Clifford Morson.
Codpted: Mr. G. F. Stebbing and Dr. A. B. Bratton. ?Dr. K. M. Mather was coopted as statistical adviser.
The advisability of forming such a committee wasconsidered by the council of the society after a prelimin-ary investigation by the radiological section at 15 radio-therapeutic centres of the effects of stilbcestrol in morethan 100 cases of cancer of the breast (see Proc. 2!.Soc. Med. 1944, 37, 731)..At its first meeting thecommittee decided to concentrate attention on carcinomaof the prostate, breast, and oesophagus, to confine theinvestigation to dienoostrol at two prescribed dosagelevels, and to ask that records be kept on forms based onthose of the National Radium Commission, approvedfor use in the Ministry of Health’s scheme for cancer.It was further decided that to avoid statistical difficultiesthe decision regarding the dose of drug to be used shouldbe by random selection. ’
This letter is written on behalf of the committee so asto provide an opportunity for members of hospitalstaffs who might wish to cooperate in this investigationto communicate with the undersigned.Royal Society of Medicine, Wimpole Street,
London, W1.F. ELLIS.
THE death is announced in New York of Dr. FREDH. ALBEE, consulting surgeon to the New York Hospitalfor Joint Diseases and a former president of the AmericanOrthopedic Association. During the last war he usedliving bone grafts as internal splints, and the operationswhich bear his name make use of this technique. Hewas 68 years of age.
