Keith Ball

Acute Tuberculous Septicaemia with Leucopenia

taken that, at the time of gaining such control, new habits of living which cause ill-health should either be prevented or, if they arise, be controlled. Such errors in living are undoubtedly developing at the present time, and it is the duty of medical science to find out their relative disease-producing importance. The chemical manipulation of food may well be the basis of some of these errors, and the problem requires investigation. Official inquiry-both laboratory and judicial-and control want strengthening. There ought to be a practical counterpart in this country of the Food and Drug Administration of the U.S.A., in the form of either a public institute for such work or an extensive and close liaison with other institutions capable of making the necessary investigations. Official direction and control of and responsibility for all such matters should ultimately be placed with the Ministry of Health, as this is fundamentally a medical problem. Apart from chemicals long in use, a decision ought to be made on whether any new chemicals should be allowed in food processing and production before they have been adequately tested for their toxicological effects. No use of chemicals based on effective aesthetic or even practical advantages conferred on food by these substances should be countenanced if they have harmful effects on animals; and, apart from questions of toxicity, the present trend of lowering the nutritive value of extensively eaten food such as bread, both by chemicals and by other forms of manipulation, demands attention. One final suggestion is that if people want bread which has not been chemically treated in any way they ought to be able to purchase it. This is no doubt possible in the case of wholemeal bread, but the same ought to apply to bread made of flour of lower extraction. At least untreated flour of this kind ought to be freely available so that persons can bake their own bread if they wish.

First Year's Experience in Anti-smoking Clinic

His improvement seemed very rapid to all those who saw him. In retrospect it is possible that he had a superficial infarction of a portion of the brain near the motor face area. The infarction is postulated because of the xanthochromia and the considerable rise in protein. Presumably, recovery was due to a good collateral circulation and diminution of local oedema. To those who saw him initially the prognosis indeed appeared gloomy. At the end of a week it was almost unbelievable that this was indeed the same patient. Investigations.-Red blood cell count 3,700,000/c.mm.; haemoglobin 7.8 g./100 ml.; packed cell volume 30% ; M.C.H. 22 plug.; M.C.V. 82 cubic microns; total white-cell count 5,600/c.mm. (normal differential count); platelet count 1 80,000/c.mm. Peripheral blood film showed the red blood cells to be hypochromic with moderate anisocytosis and poikilocytosis. There were a few target cells and microcytes. Haemoglobin H inclusion bodies were present in a brilliant-cresyl-blue preparation. Alkali-resistant haemoglobin <1 %. Haemoglobin electrophoretic analysis: haemoglobin A+ H. Serum iron 221 jxg./100 ml. Unsaturated iron-binding capacity of serum <40 pg./100 ml. Bleeding, clotting, and prothrombin times within normal limits. Blood for lupus erythematosus phenomena and latex fixation test negative. Liver-function tests normal. Blood sugar (fasting specimen) 89 mg./100 ml. W.R. and Kahn test negative.

A new method of treating old ulcers of the legs.

taken two hours after the injection of the medium have shown complete absorption in normal cases. It is easy to inject, there is no tendency for the substance to crystallize out of solution, and it does not have to be warmed before use. The medium gives rise to no undue tubal spasm and easily penetrates narrow channels and sinuses. We have had one instance of iodism, but such sensitivity reactions appear to be inherent in all iodine-containing compounds. We regard pain of early onset (group 1) as being due to peritoneal irritation, and at least two of the five cases in which pain occurred after an interval of 24 hours also appear to be of this type. We have no explanation why there should be a delay between the injection of the material and the onset of pain. The occurrence of this reaction does not seem in any way to interfere with the passage of fertilization of the ovum, since of the 11 patients with early reactions three became pregnant in the same menstrual cycle and one in the subsequent cycle. The patient with the iodine-sensitivity reaction also became pregnant in the subsequent cycle. In attempting to assess the importance of this pain we should remember that Marshak et al. state that some pain and discomfort occurred from 80% of the 2,500 hysterosalpingographies undertaken, and it is worth restating that the pain did not seem to be severe enough to deter our patients from further investigation at the clinic. It is possible that the injection of endografin may interfere with pregnancy, since in one patient in whom there was a grossly irregular menstrual cycle it was subsequently stated that she had an early miscarriage. This, however, occurred in another hospital, and we have been unable to obtain confirmatory evidence. In relation to infection, one exacerbation of a tuboovarian abscess did occur; but we do not think that the medium alone could be blamed for this, since the timing of the investigation was a little premature. Three cases with tuberculous salpingitis were investigated; in only one of these was there a reaction (Case 2), and it was of a very mild nature, so that we feel that there is no undue risk, with this substance, of lighting up pre-existing pelvic infection. In conclusion, we feel that the occurrence of pain can be kept to a minimum if only the smallest satisfactory amount of the medium is injected. Whilst the production of pain is certainly a great disadvantage, we feel that in view of its other advantages endografin merits an extended trial.

Carbon monoxide yield of cigarettes

was particularly marked in one patient, who had been following an intensive endurance training programme for several years. On pindolol he was unable to complete his training programme and complained of an insatiable apetite, presumably owing to low blood glucose levels. On metoprolol these changes were not apparent. Similar differences in terms of working capacity have also been shown by Fellenius et al2 between the non-selective betablocker propranolol and metoprolol. Fatigue is a commonly encountered problem in patients treated with beta-blockers. On the basis of these findings it would appear that in these circumstances the predominantly cardioselective beta-blocker metoprolol may be preferable since it would appear to have less effect on energy metabolism during physical stress. RICHARD GOODFELLOW Astra Pharmaceuticals Ltd, St Albans, Herts ALl 3JW

Abacterial form of endocarditis with necrosis of the ears.

Hopkins, J. H. S. (1950). British Medical Journal, 1, 1230. Howitt, B. F., and Benefield, U. R. (1950). Proc. Soc. exp. Biol., N.Y., 73, 90. Jamieson, W. M., and Prinsley, D. M. (1947). British Medical Journal 2, 47. Jaworski, A. A., and West, E. J. (1949). J. Amer. med. Ass., 141, 902. McConnell, J. (1945). Amer. J. med. Sci., 209, 41. Melnick, J. L., Ledinko, N., Kaplan, A. S., and Kraft, L. M. (1950). J. exp. Med., 91, 185. Shaw, E. W., and Curnen, E. C. (1949). Proc. Soc. exp. Biol., N.Y., 71, 344.

Points: Paunches and the prediction of coronary heart disease

Miss M A HOCKING (Lewisham Hospital, London SE13) writes: I am sure that Dr R J Fairhurst (9 June, p 1762) is correct when he says that many of the injuries sustained in the Majorca coach disaster could have been avoided if the passengers had been wearing seat belts. Last summer I saw a number of elderly patients who had been in an Age Concern coach which had overturned, admittedly while travelling slowly. None of the occupants, however, sustained anything more than minor bruising, and I am sure that this was because all the seats in this coach had been provided with seat belts which had been used. The fight is now on to make the use of rear seat belts compulsory, and I feel strongly that some attempt should also be made to legislate for their use in coaches. As in the Majorcan tragedy, when these vehicles do crash there may be major injuries. There may be considerable opposition to this, as on long journeys people like to be able to move around a vehicle. A first step would be to ensure that coaches were fitted with belts which could be used by passengers if they so wished. It is obviously not possible to legislate for other countries, but we can at least try to make our own roads safer.

Points: Cigarette smoking after myocardial infarction

Similarly, we have found that mastectomy with immediate latissimus dorsi reconstruction is useful for treatment of recurrent carcinoma in a breast previously treated conservatively by primary excision and radiotherapy. We have found immediate latissimus dorsi reconstruction readily acceptable by our patients compared with standard mastectomy. In our opinion the cosmetic results are comparable to those for primary excision and radiotherapy with the added advantage of not requiring 4-6 weeks of treatment. It seems that direct evaluation of this procedure by randomised clinical trials is not possible until the ethical problems of such trials, particularly in relation to informed consent, are resolved.