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palms and soles, severe " raindrop " pigmentation, and a fewscattered vesicles of dermatitis herpetiformis. Despitedimercaprol, paracentesis, supportive measures, &c., he diedtwo weeks later. An accurate history was impossible to obtainowing to his desperately ill condition and language difficulties,but it seemed that he had been taking Fowler’s solution forthree or four years and was not attending a dermatologicalclinic.

CASE 3.-A woman, aged 38, was admitted to hospital in1951 complaining of abdominal pain, vomiting, anorexia, andpruritus. She had attended a dermatological clinic sevenyears previously, when dermatitis herpetiformis had beendiagnosed. Subsequently she remained under the care of herown practitioner, receiving Fowler’s solution during most ofthat time. On admission she had marked hyperkeratosis ofsoles and palms,

"

raindrop "

pigmentation, and activedermatitis herpetiformis ; the liver edge was just palpable.Treatment with dimercaprol and sulphapyridine produced anextraordinary change : the hyperkeratosis slowly resolved,and the dermatitis herpetiformis is now completely controlledwith 1 g. sulphapyridine daily.CASE 4.-A man, aged 47, was referred to a dermatological

department in 1951 suffering from hyperkeratosis of thehands. He had advanced hyperkeratosis of hands and feetand " raindrop " pigmentation on the trunk. The thickeningof his palms was so severe that he could not grip. properly,and this interfered with his work. He also showed traces of

psoriasis vulgaris on the left leg. His liver was not palpable.He had once been prescribed Fowler’s solution at anotherhospital in 1946, and since that time he had obtained regularsupplies from his local chemist without prescription. Hewas treated with dimercaprol and the hyperkeratosis is nowconsiderably improved.CASE 5.-An intelligent schoolmaster, aged 65, attended a

dermatological clinic in 1952 complaining of hyperkeratosis ofthe palms and soles. He had been treated for these with

radiotherapy at another hospital. Examination showedclassical arsenical keratoses of palms and soles, but no pig-mentation, liver enlargement, or evidence of peripheralneuritis. He admitted to taking an arsenic mixture for

thirty years but had ceased three years ago.The dangers of inorganic arsenic must be realised

particularly when given in small doses over a longperiod ; but its value in dermatitis herpetiformis is

unquestioned. Given over short periods in graduallyincreasing doses followed by decreasing doses, it controlsthe disease more rapidly than any other drug exceptA.c.T.H. The itch of this disease has a character and

intensity of its own, and patients will often plead for thedrug despite warnings concerning its cumulative dangers.It is not surprising, therefore, that some of them obtainthe drug by various means. The only other drug whichcontrols the disease to the same extent is sulphapyridine,usually in quite small doses of 0-5-2 g. per day. Actuallythis is a much safer drug to use (in these doses) despitethe pharmacologists’ warnings of its dangers. If sufferersfrom dermatitis herpetiformis were denied the controlleduse of arsenic and sulphapyridine their lot would indeedbe unhappy.

-Alanchester G. AUCKLAND.G. AUCKLAND.

SLEEP PARALYSIS

CHAPMAN PINCHERMedical correspondent.

SiR,-Having experienced sleep paralysis for manyyears, I can confirm the statement in your annotation

(Feb. 14) that one is quite conscious during an attack,though completely unable to move or speak.I would, however, question your statement that the

disorder is "rather rare." When I wrote about sleepparalysis in the Daily Express recently, stating thatdoctors believed it to be rare, I had more than 600 lettersfrom readers claiming they experienced the phenomenon.Most of them described it in such vivid detail as to leaveme in little doubt that they do so. The findings ofnewspaper circulation research would suggest that sucha heavy response means there must be many tens ofthousands of people in Britain who experience sleepparalysis.

The letters made it clear that many people, thoughthoroughly frightened by their experiences, do not reportthem to their doctors for fear of looking foolish or beingdisbelieved.

CRIAPAIAN --,CHAPMAN PINCHERDaily Express, London, E.C.4. Medical correspondent.

PAID SICK-LEAVE

P. D. H. CHAPMAN.

SIR,-In your annotation you quote the analysis byBuzzard and Shaw of two years’ experience of this scheme,which shows that sickness absence has doubled since itsintroduction. The conclusion would seem to be obvious-

namely, that if you pay people as much or more whennot at work, they will be reluctant to return to work.

There are exceptions, of course ; but, in general,human beings do not feel that work is a pleasurableactivity but rather an unpleasant necessity of existence.Do you therefore urge the immediate abolition of suchridiculous sick-leave schemes ? Not at all. The generalpractitioner must persuade, cajole, and implore the workerto return to work. Should he fail, for one moment only,to display the most exquisite tact in this thankless task,the worker will change his doctor. There is always onedoctor in any town who is known to give certificates ondemand. In my experience in general practice, thedanger of a sick person returning to work too soon is

negligible, except in the case of professional men andhousewives. These classes do not in any case benefitfrom paid-sick-leave schemes.

Bridlington. P. D. H. CHAPMAN.

SIR,-Your annotation last week on sick pay performsinvaluable service in attracting the attention of thosedoctors who, like myself, do not normally read theBritish Journal of Industrial Medicine.

Possibly the most important factor in the successfuloperation of a scheme for paid sick-leave is accurate

certification, which demands thorough examination, whichmay be difficult under conditions of general practice.One of my duties is to see employees who are off work

for more than 4 weeks. Immediately on receiving arequest to attend for examination, a proportion of themreturn to work. Is this purely coincidental ?

Judging by reports in the local press, there is muchsuspicion that sick-pay schemes operated in this area bylocal authorities are being abused, particularly those

affecting building workers. I do not know whethersimilar circumstances operate throughout the country.In the case of building workers, the scheme providesgreat food for thought, for it began in 1951 and coveredemployment that was traditionally " casual." Underthis scheme an employee enjoys up to 6 weeks’ sick payafter 6 months’ employment, with the usual provisions.At the same time this agreement does not affect buildingworkers employed by private firms. Under their agree-ment they have no sick pay, but enjoy a guaranteedminimum week, as did council employees until the newagreement came into force.

In those trades in which there is a shortage of labourthis produced an invidious position ; for when it wasfound that payment could not be made for loss of workowing to bad weather, employees left the council forprivate builders, even though they lost the benefit ofsick pay. Subsequently, there seems to have been a risein minor illnesses amongst council employees duringperiods of bad weather.

Another important factor in sick-pay schemes is theexample set by some workers. If one man is successfulin obtaining benefit, although justified, others may feelaggrieved or tend to follow his example. These diffi-culties cannot be entirely resolved by either purelymedical or purely lay considerations, as the followingexamples may show.As work on one site was nearly completed, the foreman

gave verbal notice to some labourers. Before seeing the last

491

man concerned, he was called away to take a telephone call.Later this man told him he wanted to report sick. In theman’s defence it should be stated that he had been off sickwithout pay in previous years for duodenal ulcer. Had his

symptoms been delayed by a matter of minutes, he wouldnot have received the 7 weeks’ pay (6 weeks’ sick, 1 week’s

notice)’that he was given.In another case the foreman was dissatisfied with the work

of a man he was trying out as a joiner’s labourer, and toldhim he would revert to his previous job of general labourer.The man immediately went sick, and later produced a medicalcertificate for " lumbago," although on subsequent examina-tion by me his symptoms were possibly those of a mildfibrositis in the shoulder. His own doctor said that he was

completely unaware of these circumstances when issuing thecertificate.

Employees do not perhaps sufficiently appreciate thatthere must be an economic limit to sick pay, and, if theload becomes too heavy, the employer would probablytry to stop these benefits in negotiating a later agreement-with consequent hardship to genuine cases.

Finally, there is another aspect to sickness. Theconscientious and sensitive man may well suffer pangsof conscience when he is up and about during con-valescence, feeling that he should be back at work. He

may feel that lay people regard him as a shirker.

Although there are admitted difficulties, it seems thatnot enough is being done to provide temporary lightduties that would enable him to return earlier.

M.O.H.

1. Turner Warwick, W. The Rational Treatment of VaricoseVeins and Varicocele. London, 1931.

A SURGICAL POLICY FOR PEPTIC ULCER

H. DAINTREE JOHNSON.

SiR,—I hope that in answering his one criticism Ishall not seem ungrateful to Professor Wells for the

generous remarks in his letter of Feb. 21.Our use of self-assessment questionnaires was not in

place of interviews, for all but very few now inaccessiblepatients were seen regularly and all possible symptomssought for and discussed. The questionnaires were usedin addition only to allow comparison between the resultsof two different surgical policies (our own and another),for we felt that only by standardising our method ofassessment in this way could we claim to have eliminatedour own bias: The method is not ideal, but we are stillat a loss for a more valid one and would welcomefurther suggestions.London, W. 1. H. DAINTREE JOHNSON.

THE ANKLE BLOW-OUT SYNDROME

JOHN FERGUSON.

SIR,-I would in no way wish to detract from thevaluable contribution which Mr. Cockett and Mr. ElganJones (Jan. 3) have made in directing the limelightonce again upon the surgical " Cinderella " of leg ulcers.But from their paper one infers that the anatomicalsites of the main perforating veins of the leg have notbeen well recognised in the past.

In 1931 the late Mr. W. Turner Warwick, surgeonto the Middlesex Hospital, described the site of theseveins accurately. 1 Though from his dissections heconcluded that they more often communicated with thelong saphenous vein, he was aware of the posteriorperforating communications mentioned in Gay’sLettsomian lecture of 1867, and he ascribed ulcerationto incompetence of these veins.At that time Turner Warwick was treating ulcers by

injection of the incompetent perforating vessels. Hecame to realise during the ensuing eighteen years thesuperiority of operative treatment, and it is unfortunatethat his untimely death prevented the revision of hisbook. In this he intended to include his teaching of thelast few years, which was that the success of surgery inthe ulcerous or non-ulcerous leg depended on theidentification and excision of as many " T-junctions

"

as possible.

It may be added that the experience of those conductingthe Middlesex Hospital varicose-vein clinic has ledus to believe that obdurate ulcers are usually a problemof fibrous tissue versus blood-supply, and excisionis often therefore the most necessary part of thetreatment when conservative measures have failed.

London, W.l. JOHK FERGUSON.

1. Simmons, H. T. Lancet, 1936, i, 73.2. Kissin, M., Stein, J. J., Adleman, R. J. Angiology, 1950, 1, 141.3. Hamilton, M., Wilson, G. M. Quart. J. Med. 1952, 21, 169.

VITAMIN E AND INTERMITTENT CLAUDICATION

SiR,—The suggestion made by Dr. Hamilton and hiscolleagues (Feb. 21) that the widespread use of vitamin Eis due to our publications is extremely flattering. Butwe cannot accept this as true of a substance whichis " of no value in the treatment of intermittentclaudication."

It is extremely difficult to criticise this report withregard to the statements which are made. We feel thatthe experimental work as described, using these criteriaand the same form of statistical analysis, will alwaysproduce an equivocal result. Before commenting on thispaper we would like to make our own position clear. Wedo not, and never did, regard vitamin E as a

" wonder

drug," but we feel that there have been worth-whileclinical results in a sufficient number of cases to justifyits use.

In our opinion vitamin E has two effects in the treat-ment of arterial disease : firstly, in those cases where aminor improvement in the condition makes a great dealof difference in the patient’s ability to carry on hisnormal daily life ; secondly, in slowing down the progressof the disease and therefore increasing the patient’sexpectation of life. The latter statement will, we feel,be borne out when we are in a position to make a reporton a minimum of 1000 patients observed over a periodof five years.We would like to make the following observations on

the report of Dr. Hamilton and his co-workers :Selection of Patients

There appears to have been no attempt to determine theunderlyirig clinical condition. Where there has been a secon-dary thrombosis of the femoral or popliteal arteries during thesix-month period preceding treatment, the patient’s exercisetolerance is extremely labile and such patients must beexcluded from the experiment. The variation observed issuch that it cannot be covered by any form of statisticalanalysis-the differential calculus cannot replace thedifferential diagnosis.Clinical GradingWe agree that by our own standards the clinical grading

will vary with the severity of the exercise-tolerance test. Onthe less severe test of the " claudicometer " we have shownthat the improvement of the grade-ui patient is too slight tobe assessed. If the test employed shows a patient to begrade m-even though he may be grade 11 by our standards-he will be equally difficult to assess by that test, and shouldbe excluded. More than half the patients on which this reportis made fall into grade 111 on the test used.

Duration of TreatmentIn our experience it is impossible to assess the effect of

vitamin E less than three months from the start of treatment ;and we feel that the period of observation should be at leastsix months; with continuous treatment.

Method of AssessmentObviously intermittent claudication must be assessed by

some form of exercise-tolerance test. Various mechanicaldevices have been produced with the idea of exercising thepatient under controlled conditions and measuring the amountof work done. Simmons 1 devised a treadle system : Kissinet a1.2-and later Hamilton and Wilson 3—have described a

simple method of making the patient climb up and downsteps at a known rate. Unfortunately, whatever the scientificmerits of exercise devices, they have in general one seriousdrawback : the patient gets the pain when -walking and it