195 cases to operation or necropsy, so oppordirect observation are uncommon ; but considerations are much against his view. rarely tunitjes for t...

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195 cases

to operation or necropsy, so oppordirect observation are uncommon ; but considerations are much against his view.






The area of a roughly elliptical orifice, 1-5 by 0-75 cm., can hardly be greater than 1 sq. cm., and we have seen that to obtain a cardiac output of only 6 litres per minute a pressure gradient across the valve in excess of 30 cm. of water is required. This would necessitate rise in left-auricular and pulmonary a considerable but catheterisation venous and capillary pressures, studies of this type of case, with outputs at this level (or higher), have shown normal pulmonary pressures.4 Department of Cardiology, Royal Infirmary, Manchester.



is not

during treatment with and there is no need to wait for swelling of the ankles or face in order to detect it. If the patient is weighed before and during treatment, it will be found that there is an increase in weight of 2-3 lb. within two or three days, and as much as 6-7 lb. at the end of seven to ten days. When the phenylbutazone is discontinued, the patient passes copious amounts of urine and the weight returns to the SiR,—(Edema


pheny]butazooe (butazolidine),

original. I feel that the action of this drug is analgesic rather than specific, because pain recurs fairly frequently if the injections are more than two to three days apart, and it does, in fact, relieve pain in other conditions. For example, I have observed dramatic relief on two to three occasions in severe dysmenorrhoea which had not responded to antispasmodic treatment. London, W.1.




interested in Dr. Vulliamy’s5 suggestion

that an increase in circulating adrenaline and noradrenaline might be responsible for the vascular disorder in pink disease, because we have ourselves been investigating this possibility following a suggestion made to us by Prof. J. H. Burn in November, 1951. We have made some preliminary observations on the urinary excretion of noradrenaline in normal children and in children with pink disease ; and one of us (G. P. B.) has also made studies on adults with proven phaeochromocytoma. In each case a 24-hour collection of urine was obtained. Noradrenaline was adsorbed on aluminium hydroxide, and subsequently assayed by intravenous injection into a cat.6 The urinary excretion of noradrenaline in 9 convalescent children, whose ages ranged from 3 months to 10 years, lay between 10 (Lg. and 27 g. per 24 hours. In 24 hours the child aged 3 months excreted 18 g. ;and 2 children aged 20 months and 2 years excreted 12 .g. and 14 g. 3 adults with proven phaeochromocytoma excreted 180 ,g., 300 {jLg., and 3700 (Lg. So far we have made estimations on only 2 children with Pink disease. Both were classical and fully estab-. lished examples of the syndrome, showing prominent neurovascular signs-that is to say, hypertension, tachycardia, sweating, and cold pink puffy hands and feet. One affected child excreted 16 .g., and the other 21 g., noradrenaline in 24 hours. These figures lie well within the normal range, and contrast sharply with the levels we have found in urines from adults with phaeochromocytoma. The excretion of noradrenaline fluctuates widely from day to day, and therefore a small average change in excretion would be difficult to detect. The scanty figures that we have so far obtained do not support the suggestion that noradrenaline output is 4. Wade, G. M.D. thesis, University of Manchester, 1952. 5. Vulliamy, D. G. Lancet, 1952, ii, 1248. 6. Von Euler, V. S., Hellner, S. Acta. physiol. scand. 1951, 22, 161.

greatly increased in pink disease. This does not in any way invalidate the use ofPriscol ’ in treatment. Further work is in progress. GEORGE P. BURN Departments of Pædiatrics CHRISTOPHER OUNSTED and Biochemistry, VICTORIA SMALLPEICE. Radcliffe Infirmary, Oxford. CHRONIC OTITIS MEDIA

Sm,—Mr. Layton (Jan. 10) seeks to revive the old idea that the acellular mastoid process is due to sclerotic obliteration of the air cells in a once " normal" pneumatised process. The cases he cites do not support this view : they show merely that inflammation may inhibit further pneumatisation. X-ray examination of the mastoid was practised long before twenty-four years ago when " the first mastoid X-ray picture was taken at the North Eastern Hospital," and since then has been a common procedure. Where is the evidence that a normally pneumatised mastoid (say in a child of 5) ever becomes an acellular or so-called "sclerotic" process ? Since hundreds of patients have been radiographed without such a finding we must reject the theory. Bristol.



SiR -Mr. Goligher (Jan. 10) states that the facts recorded in my paper (Jan. 3) do not warrant the conclusion that popliteal ligation is of any value. To refute this conclusion he considers one group only of the recorded cases (those with ulcers) and fails to remark that all of the second group (7 legs), where the patients complained of aching, swelling, &c., of the legs, were relieved of their symptoms. To return to the group he does consider, he simply states that 7 of the 11 patients showed no sign of recurrence and takes no note of the fact, clearly shown in the paper, that of the cases which failed (5 of 13 legs) 3 should not have been operated upon (in 1 the femoral and popliteal veins were occluded, in 2 there was an arterial deficiency) and were a failure of judgment, not of method ; 1 patient refused to wait for a graft but was relieved of her pain and swelling ; and 1 ulcer broke down after 2 years. Therefore of the 10 cases which were suitable 8 were successful, 1 partially so despite incomplete treatment, and 1 failed.

Mr. Goligher also " considers that the results are not very different from what might be obtained after bed rest and grafting alone." This, of course, may be so, but such a statement would bear more weight if backed by figures ; and it is of interest to note that of 5 cases treated by grafting alone in the Massachusetts General Hospitalnone remained healed, while of 13 treated by excision of the ulcer and grafting 10 broke down. The second half of Mr. Goligher’s letter concerns the results of superficial femoral vein ligation. He states that " the principle of this operation and that of ligation of the popliteal vein are the same, and the results should presumably be also similar." It might as well be said that because the principle of ligation of the superficial femoral artery and of the popliteal artery are the same, the results should also be similar. Bauer2 has given the reasons for ligation of the popliteal vein in preference to the superficial femoral; and it is worth noting that Linton 3 has given up ligation of the superficial femoral vein, although he was one of its chief advocates,1 because of a 30% rate of failure-the same percentage failure asthat of Glasser.4 I would suggest, then, that Mr. Goligher’s failures after superficial femoral vein ligation should not lead him to condemn out of hand ligation of the vein.


General Infirmary, Leeds.


1. Linton, R. R., Hardy, I. B. Surgery, 1948, 24, 452. 2. Bauer, G. J. int. Chir. 1948, 8, 937. 3. Linton, R. R. Angiologia, 1952, 3, 439. 4. Glasser, S. T. Surg. Gynec. Obstet. 1948, 89, 541.