23 wounds as a routine in all air-raid casualties. I suppose that as a result of his article first-aid posts and hospitals has died out and in young ...

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23 wounds as a routine in all air-raid casualties. I suppose that as a result of his article first-aid posts and hospitals

has died out and in young men has probably enormously increased, and yet we have only guesswork and vague clinical impressions to explain the cause. 4. Surely the right answer to our problems is that surgeons should notify the perforated ulcers which they suture and that we should accept that for the present as a rough guide to the incidence of ulceration-rough but better than nothing? The logical fallacy seems embedded amongst medical scientists in the English-speaking world that because problems already solved have turned out to be simpler than was previously supposed the same applies to problems not yet solved. But again and again the women

are making gallons of this mixture which completely flouts all M.R.C. advice. Over six months ago Sir Wilson Jameson formed a committee to revise the N.H.I. formulary. Why the long delay ? The matter is urgent. When the new

formulary appears I urge that its use shall be made compuisory-no prescribing from the present formulary should

be allowed. I do not know of any large hospital, local authority or county council which has yet compiled a war-time pharmacopoeia. In E.M.S. hospitals the same complacency rules. Memorandum A.B.H. 141, issued by the Department of Health for Scotland to auxiliary and base hospitals is the most sensible official circular I have seen. Paragraph 4 states : " The Department have decided that from June 1, 1941, until further notice the drugs and preparations specified in columns 1 and 2 of section i of the Appendix, being unnecessary under war conditions, shall not be purchased centrally or locally for use in their hospitals. Similarly, the drugs set forth in section 11 shall not be used in the form or for the purposes specified in column 2 and purchases, central and local, must be adjusted accordingly." Why has not a similar circular been issued and similar compulsion enforced in all E.M.S. hospitals throughout the United Kingdom ? The attitude of at least one county council appears to be that their total drug bill is small compared with other hospital expenditure, and therefore the problem is of minor importance. This attitude is fundamentally wrong. We should economise on drugs not for the sake primarily of saving j6 s. d. but as an important contribution to our war effort. I advocate compulsion and immediate action. M. H. PAPPWORTH. Mitcham. PEPTIC ULCER

history of pseudoscientific theories shows that the commonest reason for accepting an erroneous explanation is this strong popular prejudice in favour of simple and single explanations where highly elaborate ones would be more appropriate. As Alvarez long ago pointed out, no existing theory of peptic ulcer accounts for more than a fraction of the 20-30 anomalies in its life history and most of them can be countered by almost overwhelming arguments. I believe that half the organisation of curative medicine recommended by your correspondents would become unnecessary if only valid statistics compelled us to a more hygienic mode of life in which teeth, jaws, nose, sinuses and alimentary canal developed properly and the advertisement of aperients ceased to be a major source of revenue to magazines. DENYS JENNINGS. Oxford. ENDEMIC FLUOROSIS

SiR,-The problem of fluorosis, to which increasing importance is being attached, was raised from oblivion two Swiss investigators, H. Cristiani and R. Gautier by I A -IT.,,., moihl P,.,,,,’;c. 1091’;: 2 A 1) 91f1. . 1 QR .
1925, 92, 139, 946, 1276 kept in the environment of aluminium factories and feeding on fodder exposed to gases emanating from these factories all perished within a very short time, after having suffered from a disease diagnosed by veterinary surgeons as osteomalacia, since spontaneous fractures of the bones were one of the outstanding features of the disease. The investigators achieved precisely the same disease picture by feeding animals on fodder exposed experimentally to hydrofluoric and fluosilicic acids, or by administering fodder to which Biol. Paris, 261C.R. ASoc. herd of cattle

93, 911).

SiR,-I had hoped that when the needs of war brought out the great frequency of peptic ulcer in young males some active steps would be taken to determine the factors responsible. Instead the recent discussion at the Royal Society of Medicine produced no more constructive suggestion than the opener’s final remark that the " establishment of a special hospital for the study of gastroduodenal disease is long overdue." Might I make the following points based on experience in thesalts of these acids had been added. The disease was so Navy and four years of study devoted almost exclusively typical that they suggested for it the appropriate name of " fluorosis." The influence which cryolite (a fluorine to this problem ? mineral of the composition N asAIF 6’ used in the produc1. The clinical diagnosis of gastric or duodenal ulcer is almost worthless. In 410 first barium meals on males undertion of aluminium) exercises upon the health of the it in the process of mining, sorting, fifty at the Radcliffe Infirmary, where most of the physicians workmen who handle was described by K. Roholm (1937). packing, &c., have at some time or other interested themselves in dyspepsia, In your issue of Feb. 15 Dr. Dagmar Wilscn noted the ulcer was and radio64 times gastric diagnosed clinically I which some of the water-supplies in this country logically 25 times ; but only in 3 cases did clinical and X-rayeffect on the population of counties as widely diagnosis agree, and a little work with a slide rule will showare producing that on the basis of chance there should have been 4 agreeiseparated as Cornwall, Somerset, Gloucester, BuckingNo mention, has, ments. Duodenal ulcer was diagnosed clinically 102 timesham, Cumberland, and Durham. so far been made of the clinical observations however, and radiologically 51times ; but only in 17 cases did clinical ; and radiological diagnosis agree (chance expectation of which I published in 1928 (Franco-British med. Rev. 5, 1, 61) and in a monograph entitled The Clinical Aspect of agreement 13 times). I Chronic Poisoning by Aluminium and its Alloys (London, 2. The radiological demonstration of lesser curve gastric 1933). It was observed that amongst the symptoms niches is usually reliable ; but some X-ray work is done by in particular occurred very frequentlymen whose presbyopia does not give them proper accommoda-described one namely, paraesthejsiae affecting mainly the hands and tion to the screen image or by men who have insufficient time = especially the fingers supplied by the dorsal to get full light adaptation and in this way small niches onmore cutaneous branch of the ulnar nerve, that is to say the the posterior wall are easily missed. But in contrast to J side of the little finger and the adjacent sides of gastric ulcer, the radiological diagnosis of duodenal ulcer in inner the ring and little fingers. This last sensation was this country can only be described as a farce. There is no on many occasions in self-observation. valid evidence from the post-mortem room that the ratio Iexperienced There is to my knowledge one poison only which affects of D.U. : G.U. exceeds 1- 5: 1, but different radiologists working the ulnar nerve (just as lead affects the radial nerve)on the same material may produce ratios varying from 1 : 1 to =namely, fluorine and its compounds ; they also produce 4 : 1 and in extreme cases up to 10 : 1. And unfortunately, gastro-intestinal symptoms, urticaria, hypopiesis, and with the present economic structure of medicine, the radioall of which were described by me as an albuminuria, who with the the ratios and logist agrees produces highest The term clinicians most gets the reputation of being the cleverer man ’essential part of the symptom-complex. fluorosis " was adopted and introduced, so far as I and even the cleverer radiologist. know, for the first time by me in this country, and the 3. Granting the above facts and granting the notoriously selected nature of the ulcer population admitted to any hospitalendemic nature of the poisoning was demonstrated for treatment, it is obviously impossible for us to form even awithout knowledge on my part of any earlier work on the J by others. It is to be hoped that the possibility rough estimate of the liability of different occupations andsubject modes of life to produce ulceration. Hence we are faced withof fluorosis will be kept in mind when dealing with cases the absurd situation that with all the huge sums spent onof gastro-intestinal disturbances of obscure origin. ’





statistics and

public-health organisation peptic ulcer in


London, N.W.6.