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the patient’s general condition should be thoroughly in-’vestigated and appropriate studies of his blood chemistrymade. There is more inherent risk of contamination ingrafting, by whatever-- method, -than where surgery _terminates in a closed wound ; and precautions must becorrespondingly strict. If the necessary safeguards aretaken, however, highly gratifying results, of which onerecent example is illustrated here, are obtainable by themlaema.-fiya.i-.inn method ’

London, Wl. J. EASTMAN SHEEHAN.

CANCER IN A NATIONAL MEDICAL SERVICE

SIR,—I think Dr. Gordon Ward (Aug. 4) is being un- duly apprehensive. The directions for the use of cancer record cards do include a number of diseases which mightwell be excluded from the term " cancer," but the CancerAct was deliberately drafted to include in its provisions patients suspected to be suffering from cancer as well as patients known to be suffering from cancer. The list inthe directions was therefore purposely made very wide with ]the agreement of the Ministry of Health. The variousconditions noted in the list are all recorded by some (practitioners as being malignant, or as being precursiveof malignant change. This does not at all detract fromthe truth of Mr. Stebbing’s remark that " the diseasestarts in a small and localised lesion."

Ministry of Health. AMULREE.

OPHTHALMOLOGY IN THE ARMY

SIR,—It was somewhat of a surprise to read MajorHamilton’s statement in your issue of June 9, that theServices had given him such little ophthalmologicalexperience. I have talked with a number of Armyophthalmologists and we all agree that with the exceptionof cataract extractions and trephine for glaucoma thereis very little in the field of ophthalmology that we havenot encountered. We most of us have had our time inthe wilderness when refractions formed our staple diet,but we have also had our turn in the fruitful land whenthere has been an abundance of good things. At themoment I have in my ward :(a) 5 detachments. (b) 1 tumour of iris.

(c) 1 hypopyon ulcer. (d) 1 case of Coats’s disease.

(e) 1 case of papillcedema (f) 1 case of lime burns ofthe cornea.

in addition to the more usual cases of penetrating woundsand traumatic cataracts. Of course, to have all of theseat one time is in the nature of a banquet, but it serves toshow .,what viand-s are available.

J. E. L. BENDOR-SAMUEL.

- TOXICITY OF THIOURACIL

SIR,—In his letter of July 21, Dr. Pearson records theoccurrence of agranulocytosis, with " a typical clinicalpicture " of this condition, following 400 mg. daily ofthiouracil. He cites this case as an answer to Dr. Leys’squestion (July 7) whether " grave neutropenia " canoccur with a thiouracil dosage of less than 800 mg. daily.The answer appears to be a definite affirmative, andfurther, as I pointed out at this year’s meeting of theAssociation of Physicians, with doses as small as 100 mg.daily, after several months, even when an initial fewweeks of treatment with heavy doses (e.g., 800-1000 mg.daily) have had no obvious deleterious effects on thepolymorphonuclear cells. In one such case, the propor-tion of polymorphonuclear cells was maintained at 65%

for eight months, and in the ninth month the patientdeveloped pyrexia and sore throat and the polymorpho-nuclear cells had fallen to 13%, the total leucocyte countthen being 3000 per c.mm. Recovery followed cessationof therapy and pentnucleotide injections. During thelatter four months the patient had been taking only 200mg. of thiouracil every other day.

Linsell (Brit. naed. J., 1944, ii, 598) records a case ofclinical agranulocytosis, with a total of 1200 leucocytesper c.mm., and almost complete absence of polymorpho-nuclear cells, after four months’ therapy with thiouracil,the dosage during the latter three months being 200 mg.daily. Gargill and Lesses (J..,4rne1’. med. Ass., 1945, 127,890) record a fatal case of agranulocytosis after a year of

interrupted treatment with 200 mg. of thiouracil daily,there being no evidence of granulocytopenia until theweek of fatal illness, when the leucocytes numbered1000 per c.mm. and no granulocytes were present;a week before the total leucocytes were 6500 perc.mm. (the percentage of granulocytes then is notmentioned).The most important precautionary lesson to learn from

these cases of thyrotoxicosis treated with thiouracil isthat normal blood-counts after an initial few weeks’treatment with large doses of thiouracil (e.g., 800 mg.daily) do not mean that severe clinical and hsemato.logical agranulocytosis will not occur subsequently withsmall doses (e.g., 100 mg. daily), although the chances ofthis are smaller than if large doses are continued.

Thiouracil is not a hormone, but it is used in an endo-crine disorder, and as regards idiosyncrasy it appears tobe true of thiouracil,as of hormone preparations, especiallyglandular extracts, that where an idiosyncrasy is presentit may manifest itself even with very small doses. Theleast precaution one can take during thiouracil therapyis to have periodic leucocyte and polymorphonuclearcounts done throughout the duration of therapy.

Harley Street, W.1. S. L. SIMPSON.

DEMOBILISATION OF DOCTORS

SIR,—The LANCET of June 9 has just reached me. Iam amazed at the naivete of the correspondent who signshimself " Serving Medical Officer " and expresses thegratitude of all temporary serving officers to the CentralMedical War Committee for their communication of lastMay, in which the problems of release were enumeratedkindly and sympathetically. What comfort the servingspecialist could have derived from this blurb I cannotimagine. The general practitioner has at least the pros-pect of a whole fortnight of rehabilitation, in the form ofa " refresher course." The document in question hasbeen the object of derision and bitter comment in manymedical messes overseas. Suggestions are invited. Theonly suggestion I have heard is that the present CMWCdo resign, and that a competent committee be elected toreplace it in such a way that Service medical officersmay be properly represented. There would then be fewdifficulties in the demobilisation of doctors. It is atruism that no difficulties are so hard to overcome asthose we make for ourselves.From the very beginning, the call-up of medical men

has been a muddle and tainted with unfairness and self-interest. Local medical committees have retained andregarded’as indispensable certain medical men, who nowcomplain that they are overworked. This can easilybe put right. Alien medical men who have enjoyed ourhospitality for so many years can now be given the oppor-tunity to reinstate themselves in Central Europe bybeing mobilised in the Allied Commission, so settingfree numbers of British medical men. Doctors previ.ously rejected on medical or conscientious .grounds cannow be employed in the armies of occupation, whosemedical services can be organised on an area basis,instead of by units. A strong CMWC can bring pressureon the War Office to abate the appalling waste of medicalman-power in the Services. In Europe there is no longerany excuse for the familiar conditions where general hos-pitals and other medical units remain for months almostempty and idle. At no time in BNAF or in CMF hasthere been a shortage of medical officers-on the con-trary, they have not been able fully to utilise the medicalmen they have had. In these theatres, the bulk of themedical and surgical work has been done by specialists,and the general-duty medical officer has done only thesimplest and most elementary procedures. In manyunits he is little more than a clerk and could be replacedby a clerk.With an efficient committee it would appear that the

majority of the medical men who gave up their practicesin the first year of the war to enter the Services couldnow be permitted to return. They have borne theburden and heat of the day, while their indispensablecolleagues have reaped a rich financial harvest, albeitat the price of hard work (but who minds hard work ?).Now, let the boot be on the other leg. It is all a matterof organisation, and if the people who are at present

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being paid to organise it ’cannot do so, let them give wayto others. They have sat too long for any good that theyhave been doing. Let us have done with them !Does the Editor of THE LANCET really think that the

experience of " Medical Officer " is exceptional ? It is,

in fact, the rule rather than the exception. Many of us,who have acted as general duty medical officers for thepast five or nearer six years, have long ago given uphope of doing anything either interesting or usefulin the way of medical or surgical work, and we’haveachieved the ability to do nothing at all for hours on end.Others have written novels or plays, or collected butter-flies or beetles, or learnt languages, or studied contractbridge, or simply taken to drink and dissipation on ascale limited only by the regulations imposed by thefield cashier. I have accumulated a collection of about3000 photographs, covering North Africa, Sicily, Greece,and the whole of Italy, having luckily acquired a quan-tity of captured enemy film and developing materials.But all these pursuits, even with the delights of travel,are a poor compensation for loss of professional know-ledge and skill, financial embarrassments, and longseparation from wife and family. If the CMWC cannotpropose anything to equalise our condition with that ofour indispensable colleagues the sooner we are rid ofthem the better, .

The specialist, on the other hand, should not grumble.He is allowed to do the work which he likes doing, andis being paid at a higher rate for it. Particularly thesurgeon is to be envied. We reflect that if we had not

. been in such a hurry to volunteer, we might have steppedinto vacant hospital appointments for a number ofmonths, and then joined the Services as specialists too.Why did we not play our cards better ? Our colleagueswho had the good sense to wait till they were conscriptedhave scored heavily by so doing. The fiasco of the" Protection of Practices Scheme " will not easily beforgotten either. Perhaps " Serving Medical Officer "will inform us exactly why we should be grateful to theCMWC ? If their rehabilitation scheme of two weeks’refresher course turns out to be anything but anotherfiasco, we shall (in the words of George Robey) be morethan surprised, we shall be amazed.

" ANOTHER SERVING MEDICAL OFFICER.’’

ACETABULAR APPROACH TO THE HIP-JOINT

SIR,—The following case may interest brthopsedicsurgeons.

I operated on a soldier recently who had been wounded bya Jap rifleman. A standard -303 bullet had entered the leftiliac fossa, perforating some coils of gut, and had finallylodged in the head of his right femur. A laparotomy had beenperformed and the bowel sutured, and from this operation hemade an uneventful recovery. On returning to the UK sixmonths later, he started tb have pain and restricted move-ments in the right hip-joint, and finally an X-ray film wastaken which revealed a bullet in the head of his femur whichhad not been discovered during his previous period in hospital.

All movements at the right hip-joint were limited andpainful. The X-ray film showed that over half of the bulletwas embedded centrally in the region of the fovea capitis,the remainder projecting into the acetabulum. There was amoderate amount of rarefaction of bone immediately adjacentto the foreign body, in both the acetabulum and the femur.The bullet obviously had to be removed. The problem washow this could be done with the least trauma. A formalexposure of the hip-joint and a dislocation of the femoralhead from the acetabulum would have been a major procedureinflicting a considerable amount of trauma. It was decidedtherefore to approach the bullet through the roof of theacetabulum by an extraperitoneal exposure. This was

carried out under spinal anaesthesia.An incision was made 1 in. above the inguinal ligament.

The femoral vessels were retracted and the pectineus muscledivided in the line of its fibres. With the help of the radiolo-gist, a hole was made with a half-inch trephine in the roof ofthe acetabulum. The bullet was removed with a little

- difficulty because it was firmly embedded in the head of thefemur. The disc of bone was replaced in the roof of the aceta-bulum, and the wound was closed. Convalescence was similarto that following a trivial operation. Within a few weeks the

patient had practically full painless movements of thehip-joint.

The point of interest that arose out of this operationwas that through this relatively small hole the greaterpart of the articular surface of the head of the femurcould be inspected by rotating the limb. This might bean excellent approach in carrying out an intra-articulararthrodesis of the hip-joint. The cartilage of the femurand acetabulum could be denuded without muchdifficulty, and a bone-graft could easily be inserted, withthe lower limb in the optimum position. With modi-fications such an operation might be a more simple andeffective method of arthrodesing the hip-joint than thetwo-stage pin operation or other procedures whichinvolve opening the joint. D. LANG STEVENSON.

Public Health

Food Poisoning at Stoke-on-Trent .

ON July 6 the Public Health Department of Stoke-on-Trent learnt that two persons, Mr. and Mrs. A, had re-cently died from gastro-enteritis. It was found thatMrs. A had meat sandwiches from a shop in Longton onJune 26 and was taken ill on the 27th. Mr. A hadsandwiches from the same shop on June 27 and was takenill on the 28th. Mrs. A died on June 29 and Mr. A diedon July 5.The shop in question is a small lock-up cook-shop

supplying meat sandwiches, meat and potato pies, andcooked dinners off the premises. In addition a smalEmixed general grocery business was carried on. Theproperty is very old, in poor state of repair. While thegeneral superficial appearance was fairly clean, furtherinvestigation revealed an accumulation of old stock andneglected cupboards and shelves. The premises werealso infested to some extent by mice, and the occupierhad been in the habit of using Liverpool Virus ’ bait.As a result of further investigations the following cases

were revealed-. Bought Taken

sandwiches ill Died -

June June July

Miss B, aged 42 years .... 27 .. 27 .. 8

Mr. C, aged 42 years . _ .. 27 .. 27 .. 1

Mr. D, aged 68 years.... 27 .. 28 .. 11

Mrs. E, aged 58 years .... — .. 27 .. 4

There was no definite evidence that Mrs. E had takenfood from the shop, though she was a relative of theshopkeeper. It was found that 25 other people hadpurchased meat sandwiches or pies from this shop ondates between June 26 and 29 inclusive, and these peoplewere taken ill between June 26 and July 2 and are nowrecovering. The outbreak has been confined to thisparticular shop. Various samples of foodstuffs weresubmitted to the County Bacteriologist for examination,the results all being negative except for a partly con-sumed sandwich found in the pocket of Mr. C.The sale of cooked meats was stopped on July 7, and

the whole business was voluntarily closed down by theowner on July 9. The whole of the foodstuffs on thepremises have been examined, and a certain amount hasbeen surrendered as unfit for food (mainly tinned goodsin an unsaleable condition) ; other food likely to havebeen contaminated was removed bv the Public HealthDepartment, and the remaining stock—tinned, bottled, -and cartoned goods, which were in a sound conditionand not likely to be contaminated—has been taken overby a local wholesaler by arrangements with the FoodExecutive officer. The premises have been cleared of allfood stocks.

There were 6 deaths out of something over 30 cases-ahigh rate for food poisoning-and the cause of all thedeaths was Bacterium enteritidis of Gaertner. Many of thecases which recovered showed a positive agglutination toGaertner’s bacillus. The investigations were carried outby Dr. A. J. McCall. The actual " virus " used in theshop was not available, and other bottles were thereforepurchased for the investigations. Dr. Taylor of Oxfordcarried out further examinations of the " virus " andfound the Gaertner’s bacillus in the bottles sent to himwere of the Danysz type, whereas that found to be thecause of the fatal cases was of the J-ena type. In a

previous case in Stoke the " virus " had been of the Jenatype so perhaps the strain is still used.