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large rent, and tore further on the most gentle handling.Neither the surgeon, who was present, nor myself hadany doubt but that an excessive number of vessels hadbeen ligated in mobilising the stomach in the course of adifficult operation for a high lesser-curve ulcer, and thatthis had precipitated the condition.At the time I assumed, wrongly it would seem,

that this must be a well-recognised complication, andthought no more about it until I read Mr. Rutter’spaper. In view of his remarks, I feel that you mightbe interested in hearing of a similar case.

ROBERT P. TOWERS.United Liverpool Hospitals.

1. Pitcher, L. Lancet, 1952, ii, 1132.

TUBERCULOSIS

L. PITCHER.

SiR,-In your issue of Nov. 7 Professor Francis saysthat I have tried to show " that as one eradicates tubercu-losis from cattle the death-rate from pulmonary tubercu-losis increases." This is only partly true : my wholetheme about the inverse relationship between human andbovine tuberculosis is based on the increase in theincidence of the disease in countries and counties with a

high proportion of tuberculosis-free cattle. I have

published figures in your columns which support thisview. These figures showed a very much greater reductionin human notifications in those Scottish counties with fewtuberculin-tested cattle ; and this applied to both

pulmonary and non-pulmonary disease. I have alsocollected figures from the English counties, and thesesuggest a similar connection.

In my opinion, the recent small increase in notificationsof human tuberculosis in England is entirely due to theattested-cattle scheme. My conclusion is that the con-sumption of milk designated " Tuberculin-Tested" isnot only failing to prevent human tuberculosis in Englandbut is very substantially increasing it.High Wyeombe, Bucks. L. PITCHER.

HYALINE MEMBRANE IN THE NEONATAL LUNG

W. E. HUNT.Department of Pathology,

St. Mary’s Hospital,London, W.2.

SIR,-From observations made on the microscopicalappearances of the lungs in some 600 necropsies on still-births and neonatal deaths, I would agree with Dr.Claireaux’s conclusion, in his interesting paper of Oct. 10,that the primary factor in the production of this lesion isaspiration of liquor amnii, and not, as suggested byDr. Emery (Oct. 24), a local vascular change in the

intrapulmonary circulation. But, if hyalinisation of theinhaled squamous cells is a preliminary stage in theformation of the acidophil membrane in the infant’s

air-passages, and if such byalinisation can be producedexperimentally, merely by incubation in normal salineat 37°C, it is difficult to understand why Dr. Claireauxstates that " after aspiration, the squames deposited inthe lung undergo progressive hyalinisation

"

(my italics) ;for. it seems that hyalinisation could occur equally wellwhile these cells were floating in the liquor amnii, alsoat 37°C, before this is aspirated, unless some other factorpromoting hyalinisation is postulated-a factor that

operated only after the cells had found their way intothe foetal lung.

If, indeed, hyalinisation can occur before the squamesare aspirated, it is hard to understand why Dr.Claireaux’s rat no. 7, which - received an intratracheal

injection of centrifuged deposit from liquor amnii whichhad not been incubated after collection, failed to showthe formation of a true hyaline membrane. On the otherhand, if Dr. Claireaux is right in saying that hyalinisationof squames occurs only after aspiration of the liquoramnii by the foetus, it is surprising that a widespread,homogeneous membrane can be found in infants dyingwithin only- 24 hours of delivery, even though, as

Dr. Claireaux states, it is likely that many of theseexhibit intra-uterine respiration only just before delivery-as in those infants that take a gulp of liquor amnii

at delivery by csesarean section. In view of this it wouldbe interesting to know why Dr. Claireaux found it

necessary to incubate the specimens of centrifuged liquoramnii for as long as 8 days before injection, and whethera true hyaline membrane, as in rats nos. 1, 2, 3, 5, and 6,could be produced experimentally after a much shorterperiod of incubation.With regard to the staining properties of the mem-

brane, I agree with Dr. Claireaux that " often, but notalways, neutral fat can be detected." But I have foundthat sometimes very prolonged staining, often overnight,will reveal a sudanophilic reaction in hyaline membrane,which would not appear with normal methods of staining.It is possible, therefore, that vernix is a more frequent,and perhaps more important, component of hyalinemembrane than is suggested by Dr. Claireaux.

GASTRIC RESECTION

SiR,-Mr. Shepherd (Oct. 24), in commenting on myarticle (Oct. 10), emphasises the necessity for examina-tion, while the operation is in progress, of the portion ofstomach removed and if necessary of the remaininggastric segment. Since my article was accepted forpublication I have had a case which forcibly, and fatally,emphasised this point.A man, aged 53, who was bleeding furiously and was in

very poor condition, was subjected to laparotomy. No lesionwas detected and partial gastrectomy was done. There wasno ulcer to be seen when the specimen was examined. Bleedingrecurred on the following day, and despite further transfusionthe patient died some forty-eight hours later. The pathologistreported finding, post mortem, an acute ulcer less than fivemillimeters across and situated one inch below the cesophago-gastric junction ; the open mouth of a vessel projected fromthis ulcer.

As no fresh blood welled forth during the fashioning ofthe anastomosis, and none was aspirated from the intra-gastric tube, it can be assumed that, at the time of opera.tion, the bleeding had temporarily ceased. Despite thisit is possible that the lesion might have been detectedhad the gastric remnant been scrutinised, though Iremain unconvinced that so small an ulcer, not activelybleeding, would have been found on gastrotomy, havingregard to the much greater area to be examined.

Partial gastrectomy is advised by Mr. Shepherd in allcases for which laparotomy has been considered necessary.I think that there are rare exceptions, such as case 1

in my article ; it is in such cases that I regard gastrotomyas of potential value in that disclosure of the lesion as anacute ulcer or an acute erosive gastritis should influenceone to spare the stomach. Gastroscopy, excluded fromthe scope of my article, may be of help in these cases,since a finding, as above, would, in my opinion, excludeoperation. Dr. Avery Jones’s findings (Nov. 7) supportthis view.

Mr. Moloney (Oct. 24) takes me to task for a burst ofactivity " in that I advocate gastric resection rather thangastrotomy when no obvious ulcer is found. He goes onto describe his own technique, which involves an incisionfour to six inches long in the stomach wall, followed bydivision of the pylorus and opening of the first part of theduodenum ; if his investigations are still negative a sig-moidoscope is introduced into the duodenum and some-times even into the jejunum via a jejunotomy. Followingthis " burst of activity," if Mr. Moloney will allow me toborrow his phrase, he concludes that " if no ulcer is foundafter such methods, and an oesophageal source of bleedinghas been excluded, it is fair to do a partial gastrectomyon an empirical basis." This appears to get us back wherewe started-though considerably later-and it seems tome that had Mr. Moloney real faith in his method hewould, when it yielded negative results, confidently

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close the abdomen leaving the exonerated stomach andduodenum to rest in peace.Surgery has an important part to play in the manage-

ment of hsematemesis, and in the difficult circumstancesof the negative exploration one cannot afford to neglectany suggestion which may be of value to the patient.I would be interested to learn more of Mr. Lundsgaard-Hansen’s experience (Nov. 7) with Rovsing’s manoeuvre.One must not lose sight of the fact that the operation isdone as an emergency measure to control bleeding, andI believe that, with careful selection of cases, when noobvious lesion is found gastric resection offers the patienta better chance of recovery if performed before, ratherthan after, a series of gastrotomies, duodenotomies,and jejunotomies ; consequently, I think that whennext I operate for heematemesis I will, on the whole,leave the sigmoidoscope in the cupboard.Hastings. GORDON FERGUSON.GORDON FERGUSON.

1. Burnet, F. M., Lush, D. Lancet, 1939, i, 629.2. Weyer, E. R. Proc. Soc. exp. Biol. N.Y. 1932, 30, 309.

HYPOTHERMIA

JOHN BEARD.Postgraduate Medical Schoolof London, W.12.

SmR,-Your leading article last week suggests thatsurface cooling, while suitable for children, may not bethe method of choice for adults.After watching surgical colleagues using surface cooling

in their animal work, I have cooled two well-coveredadult females for surgery of the aorta, using simplyice-cold wet towels and two electric fans. In the secondcase cooling to just below 30°C took less than 11/2 hours.The simple " cooling-box " under which blue childrenlie during surgery is used, and the method seems bothsimple and relatively quick when applied to adults.

PREVENTION OF POLIOMYELITIS

C. G. LEAROYD.

SIR,-To return to the mysterious incidence of polio-myelitis and the suspicion that herpes virus may ward itoff by having got there first. I referred, in my letter ofOct. 10, to Burnet’s article in which he showed that inMelbourne there was a normal incidence of herpeticinfection among poliomyelitis patients, and to Weyer’spaper 2 which tells a very different story. The mostrelevant passage of Weyer’s is :Of the sera available for examination from the standpoint

of herpes antibody as reported above, 27 were specimensdrawn from children who proved to have been susceptible topoliomyelitis, all of them victims of the 1931 epidemic. Thebleedings were in most cases initial ’ ones-i.e., they weremade upon diagnosis of poliomyelitis for the purpose ofneutralisation tests with the virus of poliomyelitis. The resultsof the tests with herpes virus showed them to be individuallyand collectively devoid of any neutralising effect. A com-

parison of the results with the incidence for herpes virusneutralisation in the same normal age groups gives :

As far as a mere G.P. can see, the great differencebetween Burnet’s and Weyer’s material was that Weyergot his much earlier in the poliomyelitis disease. Thewhole subject could be of such vast importance that itsimply weeps for investigation.Only yesterday I came across a suggestive case-

history : a man of 21 contracted poliomyelitis ; his elderbrother had had it at the age of 14 ; the odds againstthis happening must be long, but if some early influencecommon to both like the contracting or not contractingof herpes were a necessary factor for getting poliomyelitisthe odds are much shorter.Beckley, Rye, Sussex. C. G. LEAROYD.

LACTIC ACID IN THE TREATMENT OFOSTEO-ARTHRITIS

: SrR,-The paper by Dr. Lawrence (Oct. 31) purports’ to be an objective analysis of 100 cases of osteo-arthritis

of various joints ; all the patients had physiotherapyand half of them were, in addition, given injections oflactic acid. On the surface, the argument appearsimpressive, but on closer examination it can be seen tocontain a number of faulty assumptions sufficient tovitiate its conclusions.

Dr. Lawrence criticises the reports of treatment bymyself and others mainly because there was " no com-parison with other methods of treatment or withuntreated cases." At the risk of implying a " tu quoque,"I must confess that for many years I have soughtwithout success for a statistical account of the relativevalues of the different forms of physiotherapy in treat-ment and return to work-the only really valuable

criterion-although many hundreds of thousands of

patients must have been so treated : so the chargerebounds.

There is a lack of precision in some parts of Dr.Lawrence’s article. He says that " standard methods of

physiotherapy" were used. A great range of methodsis available, but no indication of what combination ofthese was employed is given. Moreover, there is evidencein the paper that Dr. Lawrence does not recognise theimportant influence of rest and tissue support to thejoint in the earlier weeks of injection treatment.

" All the patients were male employees of the NationalCoal Board " : so the analysis was by no means ameasure of the results of treatment in a cross-section ofthe community, and therefore cannot be accepted as acompetent assessment. It is well recognised that bythe nature of his calling, and perhaps by his psychologicalapproach, the miner is the most difficult of workmen torefit for work.

Although the response to any form of treatmentvaries greatly in different joints, no information is givenon which joints were treated, beyond the statement that" the knees were most frequently affected, the hipsnext " : in fact the analysis seems to be based on thetreatment of a jumble of joints. Nor is there any evidencethat an attempt was made to correlate the degree ofseverity and loss of function with the radiologicalfindings-loss of joint space, lipping, bony deformity,and cyst formation.On the question of the technique of injection, any

penetration of a joint by a needle involves some trauma,but the finer the needle, the less the damage : unless

aspiration is called for, the needle should be of thefinest calibre. I use size - 19 hypodermic needles forthe smaller joints, and needles of 0 55 mm. bore forthe larger joints. If wider needles are used, the fluidwill usually show some degree of haemarthrosis.

Dr. Lawrence surprisingly says that " the accuracyof the injection was readily determined by injecting1 c.cm. of air with the solution, when the characteristicgurgling sound could be heard on subsequent movementof the joint." Does he really require this pump-handletechnique to assure himself that he has reached the

cavity of the joint ? It seems to be an entirely unsurgicaland unjustifiable procedure : let him mix 5 ml. of lacticacid with 2 ml. of joint effusion and a spot of bloodin a test-tube, shake it up, and note the frothy flocculentmess that results. The greatest care should be taken toavoid injecting air along with the solution.There are many other points that might be alluded

to-e.g., the number of cases that show excess of fluidin the joint (in knees, 1 in 5) ; or the doubtful value inosteo-arthritis of raised plasma viscosity (any significantrise can usually be found to be due to some coincident