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such long delays in getting much-needed hospital treat-ment. The published figures indicate that there- is noreason to be complacent and a real need to inquirefurther. -

F. AVERY JONES.Central Middlesex Hospital,

London, N.W.10.

ADRENOCORTICAL STEROIDS ANDCORTICOTROPHIN

H. F. WEST.Sheffield Centre for the Investigation and

Treatment of Rheumatic Diseases.

- SIR,—Your leading article of July 11 is in some mattersmisleading, as have been very many publications duringthe last few years.Any statement on the effect of administered cortico-

steroids must be accompanied by certain data : the

species concerned, the dose given, the duration oftreatment, and the state of the body concerned. Forinstance, to say that " 11-oxysteroids

" inhibit thenormal inflammatory response is on a par with sayingthat insulin causes coma. Both are natural products,and their effects depend on the body’s needs and thedose given. The oft-repeated statement about theeffects of steroids on total body sodium and potassiumand on carbohydrate and protein metabolism should bequalified by adding that the changes observed are

normally of a transitory nature.Rheumatoid arthritis, you say, is influenced by large

unphysiological doses of certain adrenocortical steroids.In my experience many patients with severe long-standing rheumatoid arthritis are markedly influencedby doses of cortisone that, at least for normal people,may well be physiological. The fact that the benefitmay not be maintained is another matter. There is no’evidence that 50 mg. of cortisone acetate administered

during 24 hours is an unphysiological dose for adults innormal circumstances. The smaller dose adequate inAddison’s disease is given after a long period of adrenalinsufficiency.

Three minor points remain. You suggest that deoxy-cortone acetate is a fraction from the adrenal-theevidence is against this. You speak of steroids used up.in the response to stress-we have no evidence that intheir action they are " used up."’ Finally you refer tothe steroids naturally released in response to stress. As

yet we have very little information regarding the typesof stress that cause increased adrenocortical activity inman. It is quite likely that in a number of

" stressfull "

states the adrenal cortex plays no part.

ADAPTATION OF BRAGG-PAUL RESPIRATOR

R. ATWOOD BEAVERSenior Anæsthetist,

London Chest Hospital andThe National Hospital.

The National Hospital forNervous Diseases, Queen Square,

London, W.C.1.

SIR,—In view of the present interest in pressurerespirators it was thought that an adaptation of the

Bragg-Paul machine might be of value. Many of thesemachines must exist throughout the country and couldbe used as satisfactory respirators.

The adaptation is shown in, the enclosed photograph.In normal form the bellows are of inadequate volume ;but, by inserting a packing-piece with spring clips, thisvolume is increased to 1400 c.cm. A plain angled piececarrying unidirectional valves completes the modification.The output side is connected to a normal corrugated tubeand expiratory valve. In this form the machine willdeliver up to 1400 c.cm. of air enriched by any desiredamount of oxygen .at speeds varying from five to fortyrevolutions per minute. T6 reconvert to its normal formis a matter of only a few moments; Messrs. Siebe, Gormanhave been extremely helpful in this matter and mythanks are due to them and to Mr. J. Jacob, the chiefengineer of The National Hospital.

HALLUX VALGUS

GEOFFREY G. SHERRIFF.London, W.8.

SIR,—Your valuable annotation (June 27) asks whatits to be done, and Dr. Booth logically replies (July 4)that " no shoe should be designed or allowed to be wornby children which can cause deformity." ,

- It is sentimental and unrealistic to hope for any effec.tive remedy except by compulsion. Numerous statutesalready exist to prohibit various menaces to health.My immediate suggestions would be as follows :

1. An Act of Parliament prohibiting the manufacture andsale of unhealthy children’s footwear after Dec. 31, 1954.Preferential taxation and other means would be included toencourage the manufacture of healthy footwear for adults.The Minister of Health would be empowered to issue thenecessary detailed regulations. ‘

,

2. Massive publicity under the direction of the Ministerof Health.

RESECTION FOR PULMONARY TUBERCULOSIS

SIR,—Mr. Dark and Mr. Jewsbury, in their excellentarticle (July 11), state that they advise a postoperativesanatorium stay of at least three or four months followingresection for pulmonary tuberculosis. They also- implythat most, if not all, of their patients had been in asanatorium or hospital for a considerable time beforeresections were carried out. It seems a pity that theydid not make more use of domiciliary treatment. ’ .

In view of the fact that prolonged medical treatmentis necessary before resections can be done safely, it isour practice, in consultation with our surgical colleagues,to carry out a good deal, and sometimes all, of thispart of the programme in the patient’s home if thehome conditions are at all suitable, then, as soon asthe immediate postoperative period is over, to have thepatient returned home for careful follow-up in thechest clinic as an outpatient. Most of the patients areaway in the surgical unit only for about six weeks and

then go- home to carry out theirprogramme of gradually increasingactivity.

This programme is of course notpossible in all cases. Between July,1950, and December, 1952, 65Wallasey patients - had resectionoperations for pulmonary tuber-culosis ; of these, 42 (65%) wereadmitted direct from home for theiroperations, and these were dis-

charged direct to their homes fromthe surgical unit. In no cases, exceptwhere the uncommon complicationof bronchopleural fistula super-vened, was institutional treatmentprolonged beyond three monthsafter the operation.

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The results in these 65 patients up to the present timeare: 58 cases completely satisfactory ; 1 death from

psychosis and empyema ’six months after pneumo-nectomy; 2 cases with -bronchopleural fistula whichhave now closed, associated with reactivation of a smallnodule; 1 case of bronchopleural fistula still open ;3 cases of reactivation of pre-existing disease, now settlingdown following chemotherapy. These results are almost

exactly comparable with the whole series publishedby Bickford et al.1 in which most of these patients areincluded.

If the principle of achieving maximum improvementbefore carrying out resection is accepted, then such adomiciliary programme is essential, and it -nearly alwayshelps the patients to deal with their disease. They cancome to terms with it in the environment in which theymust live after they are cured ; and their home con-valescence can be immediately followed by their returnto work, thus avoiding that dangerous period of readjust-ment to the outside world after a long stay in sana-torium. By this method not only can valuable bedsbe made available for urgent medical cases but the

patient can be returned to work four to six months afterthe operation.

JAMES BAXTERDAVID L. CALDWELL.

Mill Lane Chest Clinic,Wallasey.

1. Bickford, B. J., Edwards, F. R., Esplen, J. R., Gifford, J. G.,Thomas, D. F. Thorax, 1952, 7, 310.

2. Passe, E. R. G. Arch. otolaryng., Chicago, 1953, 3, 257.3. Hoogland, G. A. Acta otolaryngol., Stockh. 1952, 42, 379.

SPLEEN IN ADDISON’S DISEASE

S. SEVITT.Birmingham Accident Hospital.

SIR,-The role of the spleen in the removal of eosino-phils from the blood-stream is being investigated in thislaboratory, and I would like to know more about thecontent of eosinophils in the spleens of patients whohave died from Addison’s disease of the adrenals.As such necropsy material is becoming uncommon, I

would appeal to my fellow pathologists who possesstissues from cases of Addison’s disease to send me asmall piece of spleen in fixative. Relevant details wouldbe appreciated, including the age and sex of the patient,interval between death and necropsy, cause and durationof the disease, and whether or not the patient had beentreated with cortisone or deoxvcortone acetate.

MÉNIÈRE’S DISEASE

J. C. SEYMOUR.Ferens Institute of Oto-Laryngology,Middlesex Hospital, London. W.1.

SIR,—Without wishing to join in any controversyupon the relative merits of the various treatments forlleniere’s disease, -1 would welcome the opportunity tocorrect the impression gained from your annotation ofJune 27.You referred to the recent paper by Passe and made

two comments : one stated that no other workers had

reproduced his results ; and the other expressed concernthat the Horner’s syndrome might be

" an even greater

price to pay than the destruction of what little hearingmay remain by the time that destruction of the labyrinthis undertaken."Publications on sympathectomy or sympathetic block

as a form of treatment in Meniere’s disease have beenfew, but that of Hoogland,3 for example, who uses

multiple sympathetic blocks, reports results which I noteto be within 1% of those given by Passe.

Horner’s syndrome may have disadvantages, but itwas an attempt to preserve the hearing as well as relievethe vertigo that made Passe undertake sympathectomyearly in the course of the disease, but after medicaltreatment had failed to relieve the symptoms, and notto wait until little hearing remained. Further, awareof these disadvantages, he undertook a parallel seriesof upper dorsal sympathectomies, sparing the T 1 outflow,and hence avoiding Horner’s syndrome. Evaluating

his results, he expressed, in this paper, his view that

sympathetic block, permanent or temporary, was thetreatment of choice at the moment for selected casesof Ménière’s disease, but he had the impression thatprogress in the fields of vaso-active drugs and chemicalblocking agents might eventually provide a more

satisfactory answer to the problem.Great strides will never be made unless they are

attempted, albeit on occasion they may not be in quitethe right direction.

1. 32nd Report of the Local Government Board. Report of theMedical Officer, 1902-03 ; p. 129.

SUCCULENT BIVALVES

SUCCULENT BIPED.

SIR,—May I make two points in connection with yourannotation of July 4 ?

I have repeatedly noticed that the turbidity of theoyster’s liquor is immediately and visibly increased if afork is stuck into the fish-a reasonable assumptionbeing that a severe wound causes a considerable evacua-tion of its alimentary tract. If, then, this simple operationis performed and the liquor is not consumed, possibilitiesof infection should be reduced. It is fair to add that the

safety of British oysters is now such that this hint on

Oystermanship will be mainly of value during foreigntravel.

Secondly, you ask whether the concomitants usuallyeaten with oysters, including " a little Chablis," maynot aid in reducing infection. Some years ago, after

reading the report on the famous Winchester MayoralBanquet outbreak of 1902,1 to which you refer, I dis-cussed it with an elderly relative who had been presenton the occasion. He attributed his own immunity, andthat of the others who had eaten oysters but failed todevelop typhoid, to having consumed more alcohol thanthe sufferers, who had been relatively abstemious. Thisview, lie said, was widely held at the time. Unfortunatelythe addendum to the report, which lists each guest byinitials and the thirty (sic) items on the menu with aplus, minus, or query sign, according to the itemsconsumed by each guest, does not include the wines orother alcohol ; but support is perhaps lent to the theoryby the high proportion of those escaping who were, asjudged by the number of queries, unable to rememberwhat they had taken towards the end of the banquet !Lest my windows be broken by an angry mob of anti-vivisectionists and teetotallers, I trust that you willpermit me to sign myselfLondon N.6. SUCCULENT BIPED.

LUPUS ERYTHEMATOSUS TREATED WITH

CHLOROQUINESIR,—While hesitating to report results of a new

therapy in one case, I think the following story is ofinterest and justifies further trial of a treatment whichis inexpensive, innocuous, and simple.A female, aged 62, had suffered from chronic discoid

lupus erythematosus for fourteen years and had been treatedin England and Rhodesia. Two years ago a course of

mepacrine was given at a London teaching hospital withsome initial improvement in the skin condition. While

taking the mepacrine, she developed an " eczema " of thehands and feet. Attributing this to the drug, she stoppedtaking it. The history suggests the lichen-planus type ofrash which sometimes complicates prolonged mepacrinetherapy.In May this year she presented with typical lupus

erythematosus of the face with dissemination to both fore-arms and upper chest. There was atrophic lupus of the scalpwith baldness extending from vertex to brow. _

She refused to try mepacrine again. Accordingly, I pre-scribed chloroquine empirically, on the grounds that it is a

synthetic antimalarial drug with a similar antiplasmodial