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start to finish of this commonplace but importantlittle operation, and I have seen him deliver of a livingchild a woman with a grossly contracted pelviswho had already had three stillborn children in otherhands. But I would not have him condemned as ameddlesome midwife, for his skill did not rest merelyon his deftness with the forceps. Indeed, he wasreluctant to use them, and could be patience itselftransmitting his serenity and quiet confidence tothe most " defeatist " of parturient females. If onlythe practice of midwifery could be restricted to

persons of this type, there might be less alarm anddespondency among the laity about this business ofchild-bearing which is still quite often a physiologicalprocess and not a thing to be dreaded as a mortaldisease.Another story illustrates the natural competence

of my friend. One busy day, on his return from avisit to a distant farmhouse, he showed me severalgrape-like bodies wrapped in a piece of lint andasked me what they were. I plumped for hydatid-iform mole, a condition with which he was totallyunfamiliar, and he asked how it should be treated.I explained that the uterus must be emptied, hintingdarkly at the possibility of subsequent chorion-epithelioma if the job were not done thoroughly.His only reply was to suggest that I should give an

anaesthetic while he did so. When we arrived wefound the patient acutely ill with high fever. Usingsuch primitive instruments as he had and his bareneat fingers, he dilated and curetted that uterus

very carefully. "She ought to be all right now,"he said as he finished-and she was. She neverturned a hair, and a year later gave birth to a healthychild. This, I submit, was not the courage of ignor-ance but the courage of a simple mind which hadnot been inhibited by too much teaching.

* * *

Our rural system of diphtheria control is not yetperfect. A single case occurred in an outlyingvillage recently. The patient, a boy, was givenantitoxin immediately and removed to the isolationhospital. The remaining members of the householdwere all swabbed and found to be negative. The

patient was at length discharged from hospital,presumably after the usual routine of three negativeswabs, and returned home. Within a week of hisreturn, his brother took the disease very severely anddied soon after admission to hospital. The house-hold were again swabbed and were all again negative,except the boy who had just come back, who wasfound to be a carrier.

CORRESPONDENCE

HISTIDINE FOR PEPTIC ULCER

To the Editor of THE LANCET

SIR,-I was interested to see that Dr. R. H.Gardiner, in your issue of June 13th, dealing with thehistidine treatment of gastric and duodenal ulcers,had found that there is a "typical fall of gastricacidity " after treatment with histidine. He alsostates, later on in his article, " it is doubtful if histi-dine has any healing effect on the ulcer directly, itsaction probably being a reduction in gastric acidityand a lowering of gastric mobility."Like Dr. Gardiner I treated, in 1935, a conse-

cutive dozen cases with Larostidine injections only,and found in those in which a test-meal was carriedout before and after treatment that the acidity wasquite unchanged after treatment, although in somecases symptoms were alleviated as he found. Allthese cases had radiological evidence of ulceration.It was his statement about the typical fall in gastricacidity which prompted me to write, with a viewto hearing the findings of others. I note that " smalldoses of alkalis were prescribed at the beginning ofthe course when there was pain after meals." In mycases no alkalis were used.With the conclusions reached in your annotation

on p. 1365 of the same issue I am in entire agreement.I have ceased using histidine as a routine measurein peptic ulcers owing to doubt as to its efficacy.

I am, Sir, yours faithfully,A. P. MENZIES PAGE.

City General Hospital, Leicester, June 28th.

THE ORTHOPÆDIC OUTLOOK

To the Editor of THE LANCETSIR,-For long physiology was the preserve of the

pure physiologist, whose thoughts and language wereunintelligible to the average clinician. It was oftenseveral years therefore before any valuable physio-logical advance found its clinical application. Ofrecent years, this gap has been considerably lessenedby lectureships in applied physiology, surgical

physiology, &c. The late Sir Percy Sargent onceremarked that " among other things the war hadgiven us was that peculiar excrescence of surgerycalled orthopaedics." Orthopaedics having split offfrom surgery in many centres, orthopaedists are

gradually assuming that insularity of outlook formerlyso characteristic of the physiologists. They haveadopted a language of their own. The diseases,injuries, and operations of orthopaedic surgery forma catalogue of surnames, only known and (?) honouredin orthopaedic circles. As with members of all newcreeds and parties, the orthopsedist is jealous andsuspicious of anyone who is not of "pure Aryanstock "-i.e., one who confines his practice solely toorthopaedics.

In your columns of June 20th I read with interestand some amusement the criticism of the secondedition of Mercer’s " Orthopaedic Surgery." Thismost valuable book is written by a general surgeonwho has taken a special interest in orthopaedics. Itis the first serious attempt to bridge that slowlywidening gap between surgery and orthopaedics. It iswritten not for the orthop2edist, but for the generalsurgeon, the young surgeon, and one studying for thehigher surgical degrees. Your critic is obviously a"

pure " orthopaedist, who rather resents the appear-ance of a second edition of a successful book on

orthopaedic surgery, written by one who openly con-fesses in the preface that he is

"

non-Aryan " in theorthopaedic sense. While it is surely the privilegeand prerogative of any critic to " damn with faintpraise," as your critic has done-to allow his prejudiceand bigotry to be unmasked by his descent to cheapcynicism, as he does at the beginning of the thirdparagraph of his criticism-viz., " In spite of thesedefects this book is undoubtedly a useful one for thethird-year student "-renders his criticism, as such,worthless.As a general surgeon located about 200 miles away

from the nearest " pure orthopaedist," I have, of

necessity, often to seek orthopaedic aid in varioustext-books. I also am dependent to a certain extent

51

on journal criticisms for keeping my surgical libraryup to date. I therefore deprecate this departurefrom the usual impartial and helpful standard of thecriticisms that appear from time to time in yourjournal.-I am, Sir, yours faithfully, -

A. J. C. HAMILTON.

CHICKEN-POX AND SHINGLES

To the Editor of THE LANCET

SIR,-I have a small contribution to make whichmay be of interest. A baby aged 24 days was broughtto the infant welfare clinic at the Middlesex Hospital,having been born on the hospital district. It wasa first and only child, breast fed and not in contactwith anybody except its parents and the nurse untilit was taken out to come to the clinic. It there

presented an eruption which, although sparse, seemedcharacteristic of chicken-pox. My colleague, Dr.Henry MacCormac, who saw the child with me,agreed that the individual lesions were typical ofvaricella. They had been present for about threedays. Chicken-pox at three weeks of age is in itselfunusual and the mother volunteered the informationthat the father was suffering from shingles at the timeof the baby’s birth.

I am, Sir, yours faithfully,London, W., June 27th. ALAN MONCRIEFF.

To the Editor of THE LANCET

SIR,-For some considerable time I have been

considering asking you for the courtesy of yourcolumns to investigate the problems of the associationof herpes zoster and chicken-pox. Dr. Kyle’s letterin your last issue shows clearly the need for someauthoritative statement on this subject, and I believethe only way of obtaining this at present is by aclinical study of a large number of cases such as isunlikely to be the lot of one individual.My own experience may be of interest. In five

years, among a population of 600 boys from 13 to18 years of age, there have been nine cases of herpeszoster of which only one has given rise to an epidemicof chicken-pox. This was a boy of 16 who had hadchicken-pox. On Oct. 5th, 1932, he had numerouspatches of vesicles along the course of the third andfourth thoracic nerves on the right side and pain onmoving his shoulder. These vesicles were 5 mm. indiameter, and not clumped together. From Oct. 7thto 9th he had a temperature between 99°-100° F.

During this time he had a large boil in the left flankand one in the right axilla. He later had more boilswithout pyrexia, and my belief is that the herpesand not the boils caused his temperature. Four boyswho slept in the same dormitory contracted chicken-pox : one on Oct. 18th, one on the 19th, and twoon the 20th. The incubation period was therefore13-15 days. Further cases arose from these four,and the incubation period was slightly longer. Oneof the remaining seven had coincident chicken-poxand herpes in the middle of an epidemic. He hadhad a previous attack of chicken-pox. It is impos-sible to say whether he gave rise to further cases.

All the remaining seven had had chicken-pox. Innone was there a history of contact with chicken-poxor herpes, nor did they give rise to any further cases,despite the fact that they were not kept out of school,and mixed freely with many known not to have hadchicken-pox. All were apyrexial. The vesicles wereusually in groups of approximately 20 spread overan area 2 cm. by 1 cm., and each vesicle was approxi-mately 1 mm. in diameter. They scabbed withoutbecoming pustular. Pain of any severity was absent,

but this is a well-known feature of herpes in this age-group. Branches of the thoracic nerves were affectedin four: the trigeminal (first division) in two, and thecervical in one.

I have studied the literature fairly fully and amstruck by the absence of clinical details. I wouldbe very grateful if any readers would send me detailsof cases they see, mentioning particularly the physicalcharacteristics of the vesicles during the various

stages : the age, the presence of pain, the temperature,whether the attacked has had chicken-pox, thenumber of people in ultimate contact who have nothad a previous attack of chicken-pox or herpes, andthe number of them attacked. If the case shouldbe the origin of an epidemic, another interestingfact would be whether the incubation period of casesarising from exposure to herpes is the same as it isfor those developing chicken-pox in the same epidemic.

Cases of herpes such as arise from arsenical poison-ing or are secondary to metastatic deposits are

undesirable, because although some think they aredue to an activation of a virus there is no proofof this at present. It is also obviously desirablenot to report only cases giving rise to chicken-pox.I hope it is not presumptuous to think that an analysisof the records along these lines of some 50 to 100cases would provide an authoritative view. Whenthis is available I shall ask you to publish the results.

I am, Sir, yours faithfully,Rugby School Sanatorium, R. E. SMITH.

A NEW DYSTROPHY OF THE FIFTH FINGER

To the Editor of THE LANCET

SIR,-In THE LANCET of June 20th (p. 1412)Dr. Robinson Thomas has brought to the noticeof your readers an abnormality which is not rarebut is little recorded in literature. He classifiesthe condition as a "dystrophy," but subsequentlystates that "it seems probable that this lesion isdue to an osteochondritis." It is not stated whetherhe supposes the osteochondritis has affected the

epiphysis of the terminal phalanx (such a conditionhaving been reported in other phalangeal epiphyses),but he gives the impression that the changes hedescribes in the shaft result from osteochondritis ofthe shaft of the phalanx. The latter is not comparableto osteochondritis elsewhere in the skeleton. Thereis every reason to suppose that the condition is acongenital abnormality, and it is, I think, importantthat a new term such as " osteochrondritis " shouldbe limited to such lesions as are clearly in one category.This condition of the fingers is usually bilateral,may be associated with other abnormality of the

phalanges, and may occur in other members of thesame family. A comparable condition may occurin the toes.

This year I have seen a boy, aged 5, whose littlefingers deviated radially at the end of the finger,exactly as in Dr. Thomas’s skiagrams. The skiagramsshowed an increase in the density of the epiphysisof the terminal phalanx and a curve in the shaft.There was a notch in the distal part of the middlephalanx showing an attempt at a distal epiphysisto this phalanx which had a normal proximalepiphysis. There was a slight webbing of the secondand third toes. Mr. H. A. T. Fairbank, in a personalcommunication, informs me he has, amongst others,records of (1) a girl, aged 11, who had both littlefingers affected and in one hand a slight similar

deformity, of the first finger. This child had an

epiphysis at either end of the middle phalanx ;