178 THE FRENCH COLLAPSE are, moreover, many orthopaedically trained women who, because they are not state-registered nurses, cannot get employment in emergency surgical centres. If these young people were allocated to the work for which they have been trained, the occurrence of the " bottleneck to which Mr. Ogilvie refers would be obviated. I did not wish to convey the impression that plaster work is difficult and regret that Mr. Ogilvie should have gathered such an impression from my remarks. I do suggest, however, that to be an efficient plaster worker one should have had practice and training, and even the most enthusiastic apostle of muddle and makeshift cannot claim either of these qualifications for the dental officer. Mr. Ogilvie has my assurance that I have no " trade- union bias" in this matter. My letter was prompted by a desire to ensure that the injured should have the best possible treatment. We are on common ground when he states that this is a matter of saving lives. We have a better chance of saving limbs as well if we are in a position to utilise the reserves of trained people who, as things are at present, cannot possibly be in plaster teams, and in all probability will not get a game at all. Manchester. HENRY POSTON. SiR,-Many members of the massage corps formed by the Chartered Society of Massage and Medical Gymnastics have been trained in plaster work at orthopaedic hospitals. A considerable number have taught this work. Hospital authorities who require plaster teams should write to the director of the corps (Mount Lodge, Amersham, Bucks), who will probably be able at once to meet their require- ments. It would be a pity to import dental surgeons into this field until this supply of trained workers has been fully exploited. D. HARCOURT KITCHIN, Editor, Journal C.S.M.M.G. THE FRENCH COLLAPSE SiR,-In reply to Mr. Maxwell Ellis’s letter in which he criticises the opinion of your Medicus M.P. there is surely little doubt that Leon Blum’s front populaire first started the rot. The 40-hour week, the numerous strikes and the Communist propaganda undermined the morale of the French workers and later of the French soldiers. An Englishman living in Paris for many years has confirmed all this to me and the French workers them- selves have acknowledged it to him. Now Mr. Strauss, M.P., in the Tribune attacks his late Communist comrades and states that investigations have proved the allegations of war sabotage against the French Communist party and the efforts to create dissension between the French and British soldiers (" Down with the imperialist war and particularly British imperialism "). Lastly let me quote a French general writing in English for the TVeekly Revielc. " The French lost because of almost complete neglect of psychological principles of warfare, based on the experience of several thousand years... It was due to the’ democratic’ relax of discipline, to the false comradeship between the pri- vate and officer, to the neglectful saluting, to the big bellies and too much wine, to the false doctrine that we French are warriors, not soldiers,’ and that one must ask me politely and I am glad to die, but if one command me, I do not’ ..." Gloucester Gate, T,r.W°.1. RUSSELL V. STEELE. RUSSELL V. STEELE. EMERGENCY BED SERVICE SiR,—At the outbreak of war the Emergency Bed Service for London was closed, as the whole of the staff were seconded to the Ministry of Health for duties in connexion with the Emergency Hospital Scheme. When the service was re-started an endeavour was made to inform all London doctors of the fact, but owing to the rapid change of personnel which is now going on evidence is accumulating that there are numbers of doctors who are unaware of the facilities offered by the service. We therefore wish to inform any doctors new to London that the service can obtain immediate admission for any urgent or acute case on their behalf if they will ring Metropolitan 8781. A. M. H. GRAY, For the committee. Voluntary Hospitals Emergency Bed Service, London, E.C.2. THE TIME FOR UNITY SIR,-It is now clear to even the most conservative among us that the present desperate position of the nation as a whole is due largely to a lack of adequate planning and to the postponement of necessary and overdue reforms in our national economy. Whilst last- minute efforts to remedy these defects may well save the situation, it is abundantly obvious that had the necessary steps been taken years ago we should not have been in our present plight. These remarks apply with added force to the medical services. Medicine even lags behind other industries and professions in its almost complete lack of organisation and state of chaos. If we must put our house in order to win the war, surely the coming of peace need not be the signal for throwing everything into confusion again. Whatever the outcome of this war, it is clear that it will be followed by a long and difficult period of reconstruction which can only be successful if we maintain the maximum efficiency in every branch of national life. Medicine is most emphatically not a luxury. The health services are a prime necessity and are regarded as such in any country which claims to be civilised. It has for many years been clear to all who have devoted their attention to the matter that the provision of a comprehensive national medical service is long overdue. The Socialist Medical Association has prepared a carefully thought-out scheme for this purpose. Surely the adoption of such a permanent measure for the unification of the health services is preferable to a temporary arrangement designed primarily to save the profession from the threat of bankruptcy. B. H. KIRMAN. Socialist Medical Association of Great Britain. VOLVULUS OF CÆCUM SrR,-May I add a third, surviving, case of volvulus of the caecum associated with reversed rotation of the middle gut to the two fatal ones mentioned by Mr. Holman in your issue of July 27. A woman, aged 65, was admitted to Cardiff Roya i Infirmary under the care of Prof. Lambert Rogers on Dec. 22, 1939, with a five-days history of abdominal pain and vomiting. Con- stipation had been absolute for three days. The general condition on admission was good. There was generalised abdominal distension and borborygmi were audible, but there were no other abnormal physical signs. Laparotomy was performed through a right lower paramedian incision. The condition so well shown in Mr. Holman’s thumb-nail sketch was found to be present, with volvulus of the caecum and ascending colon, which were greatly distended. The volvulus was untwisted and the contents of the caecum evacuated through a small incision. The gut was viable throughout and the abdomen was closed after anchoring the caecum back into the right iliac fossa. Convalescence was uneventful. The three cases suggest that the reversed rotation of the middle gut is of little clinical importance by itself, the patients living a normal healthy existence until volvulus of the caecum, due to the abnormal mesentery, super- venes. Cardiff. W. H. GRAHAM JESSOP. W. H. GRAHAM JESSOP. MOTHERS UNDER SIXTEEN SIR,-I should like to express my appreciation of the interesting article by Dr. Letitia Fairfield in your issue of July 20. There are few more tragic cases in mid- wifery than these young mothers, but I agree that the problem they raise is not that of difficulty in labour as the confinement is sometimes surprisingly easy. On reflection perhaps this should not cause surprise. Obvi- ously the postponement of maternity in a civilised community is an artificial one. The tissues are less likely to be rigid and unyielding in a very young mother and it is the rigidity of soft parts which causes the pro- longed labour of primigravidae. In addition to easy labours I remember a certain number of almost painless labours in young unmarried primigravidee. The girl who " accepts the course of events as natural " is likely to have a labour unhindered by muscular spasm. In some of the cases where the child, a victim of her inexperience, was carried away by a primitive impulse of
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178 THE FRENCH COLLAPSE
are, moreover, many orthopaedically trained women who,because they are not state-registered nurses, cannot getemployment in emergency surgical centres. If theseyoung people were allocated to the work for which theyhave been trained, the occurrence of the " bottleneckto which Mr. Ogilvie refers would be obviated.
I did not wish to convey the impression that plasterwork is difficult and regret that Mr. Ogilvie should havegathered such an impression from my remarks. I dosuggest, however, that to be an efficient plaster workerone should have had practice and training, and even themost enthusiastic apostle of muddle and makeshift cannotclaim either of these qualifications for the dental officer.
Mr. Ogilvie has my assurance that I have no " trade-
union bias" in this matter. My letter was prompted by adesire to ensure that the injured should have the bestpossible treatment. We are on common ground whenhe states that this is a matter of saving lives. We havea better chance of saving limbs as well if we are in aposition to utilise the reserves of trained people who, asthings are at present, cannot possibly be in plaster teams,and in all probability will not get a game at all.
Manchester. HENRY POSTON.
SiR,-Many members of the massage corps formed bythe Chartered Society of Massage and Medical Gymnasticshave been trained in plaster work at orthopaedic hospitals.A considerable number have taught this work. Hospitalauthorities who require plaster teams should write to thedirector of the corps (Mount Lodge, Amersham, Bucks),who will probably be able at once to meet their require-ments. It would be a pity to import dental surgeonsinto this field until this supply of trained workers hasbeen fully exploited.
D. HARCOURT KITCHIN,Editor, Journal C.S.M.M.G.
THE FRENCH COLLAPSE
SiR,-In reply to Mr. Maxwell Ellis’s letter in whichhe criticises the opinion of your Medicus M.P. there issurely little doubt that Leon Blum’s front populaire firststarted the rot. The 40-hour week, the numerous strikesand the Communist propaganda undermined the moraleof the French workers and later of the French soldiers.An Englishman living in Paris for many years hasconfirmed all this to me and the French workers them-selves have acknowledged it to him. Now Mr. Strauss,M.P., in the Tribune attacks his late Communist comradesand states that investigations have proved the allegationsof war sabotage against the French Communist partyand the efforts to create dissension between the Frenchand British soldiers (" Down with the imperialist warand particularly British imperialism "). Lastly let mequote a French general writing in English for theTVeekly Revielc.
" The French lost because of almost complete neglect ofpsychological principles of warfare, based on the experienceof several thousand years... It was due to the’ democratic’relax of discipline, to the false comradeship between the pri-vate and officer, to the neglectful saluting, to the big belliesand too much wine, to the false doctrine that we Frenchare warriors, not soldiers,’ and that one must ask me politelyand I am glad to die, but if one command me, I do not’ ..."
Gloucester Gate, T,r.W°.1. RUSSELL V. STEELE.RUSSELL V. STEELE.
EMERGENCY BED SERVICE
SiR,—At the outbreak of war the Emergency BedService for London was closed, as the whole of the staffwere seconded to the Ministry of Health for duties inconnexion with the Emergency Hospital Scheme. Whenthe service was re-started an endeavour was made toinform all London doctors of the fact, but owing to therapid change of personnel which is now going on evidenceis accumulating that there are numbers of doctors whoare unaware of the facilities offered by the service. Wetherefore wish to inform any doctors new to London thatthe service can obtain immediate admission for anyurgent or acute case on their behalf if they will ringMetropolitan 8781.
A. M. H. GRAY,For the committee.
Voluntary Hospitals Emergency Bed Service, London, E.C.2.
THE TIME FOR UNITY
SIR,-It is now clear to even the most conservativeamong us that the present desperate position of thenation as a whole is due largely to a lack of adequateplanning and to the postponement of necessary andoverdue reforms in our national economy. Whilst last-minute efforts to remedy these defects may well save thesituation, it is abundantly obvious that had the necessarysteps been taken years ago we should not have been inour present plight. These remarks apply with addedforce to the medical services. Medicine even lags behindother industries and professions in its almost completelack of organisation and state of chaos.
If we must put our house in order to win the war,surely the coming of peace need not be the signal forthrowing everything into confusion again. Whateverthe outcome of this war, it is clear that it will be followedby a long and difficult period of reconstruction whichcan only be successful if we maintain the maximumefficiency in every branch of national life. Medicine ismost emphatically not a luxury. The health services area prime necessity and are regarded as such in anycountry which claims to be civilised. It has for manyyears been clear to all who have devoted their attentionto the matter that the provision of a comprehensivenational medical service is long overdue. The SocialistMedical Association has prepared a carefully thought-outscheme for this purpose.
Surely the adoption of such a permanent measure forthe unification of the health services is preferable to atemporary arrangement designed primarily to save theprofession from the threat of bankruptcy.
B. H. KIRMAN.Socialist Medical Association of Great Britain.
VOLVULUS OF CÆCUM
SrR,-May I add a third, surviving, case of volvulusof the caecum associated with reversed rotation of themiddle gut to the two fatal ones mentioned by Mr.Holman in your issue of July 27.A woman, aged 65, was admitted to Cardiff Roya i Infirmary
under the care of Prof. Lambert Rogers on Dec. 22, 1939, witha five-days history of abdominal pain and vomiting. Con-stipation had been absolute for three days. The generalcondition on admission was good. There was generalisedabdominal distension and borborygmi were audible, but therewere no other abnormal physical signs. Laparotomy wasperformed through a right lower paramedian incision. Thecondition so well shown in Mr. Holman’s thumb-nail sketchwas found to be present, with volvulus of the caecum andascending colon, which were greatly distended. The volvuluswas untwisted and the contents of the caecum evacuatedthrough a small incision. The gut was viable throughout andthe abdomen was closed after anchoring the caecum back intothe right iliac fossa. Convalescence was uneventful.
The three cases suggest that the reversed rotation of themiddle gut is of little clinical importance by itself, thepatients living a normal healthy existence until volvulusof the caecum, due to the abnormal mesentery, super-venes.
Cardiff. W. H. GRAHAM JESSOP.W. H. GRAHAM JESSOP.
MOTHERS UNDER SIXTEEN
SIR,-I should like to express my appreciation of theinteresting article by Dr. Letitia Fairfield in your issueof July 20. There are few more tragic cases in mid-wifery than these young mothers, but I agree that theproblem they raise is not that of difficulty in labour asthe confinement is sometimes surprisingly easy. Onreflection perhaps this should not cause surprise. Obvi-ously the postponement of maternity in a civilisedcommunity is an artificial one. The tissues are lesslikely to be rigid and unyielding in a very young motherand it is the rigidity of soft parts which causes the pro-longed labour of primigravidae. In addition to easylabours I remember a certain number of almost painlesslabours in young unmarried primigravidee. The girlwho " accepts the course of events as natural " is likelyto have a labour unhindered by muscular spasm.
In some of the cases where the child, a victim of herinexperience, was carried away by a primitive impulse of
179SULPHONAMIDES IN LUPUS ERYTHBMATOSUS
the mating instinct. I believe that conception took placewithout her entire realisation of the significance of whathad happened. The soft elastic hymen of the younggirl has not attained the rigidity which comes in lateryears and which, incidentally, is more often due to spasmthan to true resistance.of the tissues.
In spite of the attractive spontaneity of some of theseearly matings, precocious maternity is a tragedy.Although the girl of fourteen or fifteen may be physicallyprepared for child-bearing she is quite unfitted in otherrespects and our social system is not constructed to makethings easier for her. Moreover the character of thechildren produced, as shown in Dr. Fairfield’s series,does not encourage us to favour early maternity. Im-maturity in either male or female is an established causeof abortion in animals and one can see the influence ofimmaturity in Dr. Fairfield’s list of malformations andin the high prematurity rate. One might tentativelysuggest that this tendency to abortion and prematurelabour in young mothers of all species may be a naturalmethod of providing an easy first confinement, but if sothe result is not worth the price paid for it.
Kensington, W.8. VIOLET RUSSELL.VIOLET RUSSELL.
SULPHONAMIDES IN LUPUS ERYTHEMATOSUS
SiR,—Dr. Propert is hardly justified in the conclusionshe draws in your issue of July 6 (p. 5) from observationson a single case.
It does not necessarily follow that because his patienthad had tuberculous glands twenty years before theonset of her lupus erythematosus and gave a positivetuberculin test the eruption was of tuberculous origin.I should require much more definite evidence of theabsence of chronic streptococcal infection than thestatement " no sepsis of teeth or tonsils found."
If the lupus erythematosus were due to latent tubercu-losis, why, in the absence of any evidence of agranulo-cytosis, should the exhibition of sulphanilamide cause" white sloughs’’ on the tonsils, fauces, palate, andpharynx, and a bacteraemia due to a streptococcusviridans ? While admitting that a bacteraemia of thiskind is not uncommon as a terminal event I would pointout that in this country, as indicated by Roxburgh andothers, streptococcal septicaemia is the usual cause ofdeath in lupus erythematosus, and in many cases notrace of tuberculosis has been found post mortem.Surely Dr. Propert’s description suggests an acute
streptococcal infection, primarily of the upper respiratorytract with subsequent invasion of the blood-stream,pleura and pericardium. To maintain that it was
merely an example of drug fever is absurd.Dr. Propert states that in my opinion " people with
lupus erythematosus of tuberculous origin are not
hypersensitive to sulphonamides." That is not myopinion, nor have I ever said anything of the kind.Whether a person is tuberculous or not has nothingwhatever to do with hypersensitiveness to these drugs asregards either the development of drug fever or theincidence of symptoms such as gastro-intestinal dis-turbances, ulcers in the mouth, certain forms of eruption,paraesthesiae of the extremities, neuritis, and so on, towhich I specifically referred under the heading of " drugsensitivity." What I did say was that in a few cases,in which I thought tuberculosis was responsible for thelupus erythematosus, the reactions of the kind I hadobserved in other cases did not occur, and I gave reasonsfor regarding these reactions as distinct from drug-feverand from other symptoms due to drug-sensitivity. Ihave no doubt that in a series of cases of lupus erythema-tosus of tuberculous origin a certain percentage woulddevelop drug-fever and other symptoms of intolerance.The cause of drug-fever occurring during treatment
with the sulphonamides is, as far as I am aware, stillunknown. We understand from Cramer’s work how&bgr;-tetrahydronaphthylamine (" T.H.N.") produces fever,by intense stimulation of the adrenals and thyroidglands and thereby of the sympathetic nervous system.This drug evokes a type of fever that is comparable tothat of malaria, whereas prolonged thyroid feedingproduces one resembling the hectic fever of tuberculosis.But the fundamental mechanism of fever production isprobably the same in both septic and aseptic fevers, theessential factor being adrenal-thyroid activity. It seemsunlikely that drug-fever during sulphonamide therapy is
due directly to the drugs themselves owing to the latentperiod preceding its onset. It may, as Hageman andBlake suggest, be comparable to that which may occurin serum disease. It must be distinguished from thedirect toxic effects of the drugs. I am convinced,however, that febrile reactions following the administra-tion of the sulphonamides are not always examples ofdrug-fever, and I have adduced good reasons for thisview in an article shortly to be published, of which anabstract appeared in your issue of March 30.
Lastly I would emphasise a point that many seem tomiss. When an eruption that we recognise as being acutaneous reaction to a given antigen or toxin is present,it is clear that the antigen or toxin responsible must stillbe reaching the skin. For example, the presence ofnodules in the tuberculous form of ervthema induratumis certain evidence of the existence somewhere in thebody of an active focus of tuberculosis. The same mustbe true of active lesions of lupus erythematosus, if andwhen it is of tuberculous causation. Similarly if andwhen it is caused by acute or chronic streptococcal orother infection absorption of toxin from the responsibleorganism must exist.As already noted, in this country the majority of fatal
cases of lupus erythematosus, in which the eruptionbecomes widespread and acute, apparently die ofstreptococcal septicaemia, but in other reported casesdeath has been from general tuberculosis. It is reasonableto suppose that the transition of the usual localised formof the eruption into the acute disseminated type is dueto the flooding of the blood-stream with toxin, in theone case tuberculous, in the other streptococcal.
It is clear that, when Dr. Propert’s patient developedhigh fever with general extension of her eruption, shewas not suffering from general tuberculosis, for sherecovered. Surely it is likely that the febrile reactionand the exacerbation of the eruption were due tosepticaemia with the streptococcus that was obtained onblood-culture.
H. W. BARBER.
NURSERY-SCHOOL DIET
SIR,-In your review of Miss Abrahams’s pamphlet onnursery-school diet in THE LANCET of July 20 youcriticise her recommendation that " brown bread, forinstance, should be used as well as white, because of thelarger amount of calcium, iron and phosphorus it con-tains " on the grounds that such statements give anexaggerated idea of the quantities involved and maymislead the layman.A century ago, when all bread was wholemeal, the
average consumption was 21 oz. daily, and the total ironsupplied by bread was over 16 mg., of which over 12 mg.was " available." Bread alone thus supplied the fullphysiological requirements of the body for iron. Theaverage consumption of white bread to-day, 11 oz.,supplies only 3 mg. of total iron, of which 2-79 mg. isavailable ; the same amount of wholemeal bread gives8-5 mg. total iron, of which 6-7 mg. is available ; 2-7 mg.represents 22 % of the full iron requirements, whereas6-7 mg. represents 56 %.
Orr shows in " Food, Health and Income " that some22 million persons-about 50 % of the population-liveon diets whose total iron content is below their require-ments. Miss Abrahams’s recommendation of wholemealbread which gives 2 times the available iron present inwhite bread, and would supply in the quantities usuallyeaten over half the daily iron requirement, should there-fore be regarded as sound advice and in no way mis-leading to the layman.Wholemeal bread supplies 30 % more calcium than
ordinary white bread but this is admittedly less import-ant, as even the higher figure represents less than a tenthof the day’s requirements. The available phosphorusof wholemeal bread is approximately double that ofwhite bread and in the quantities usually eaten wouldsupply almost half the day’s requirements, but only asmall part of the population is deficient in phosphorus.
The use of wholemeal bread would represent a signi-ficant addition in phosphorus, important in povertydiets. Its increased contribution of available iron wouldbe of considerable benefit to about half the population.
MARGARET D. WRIGHT.Research Laboratories, Vitamins Ltd., July 25.
