640
BRITISH MEDICAL JOURNAL
early postoperative feeding when safe and Thyrotoxic vomiting practicable. S P DEACON SIR,-Dr F D Rosenthal and his colleagues (24 July, p 209) draw attention to this symptom London Road Hospital, Boston, Lincs and suggest that it is a rare feature of severe thyrotoxicosis. lBevan, J C, and Burn, M C, British Journal of Six months ago I saw a patient similar to Anaesthesia, 1973, 45, 115. 2Kelnar, C J H, British Medical Journal, 1976, 1, 751. their reported cases who had thyrotoxicosis 3 Thomas, D K M, British Journal of Anaesthesia, with severe and persistent vomiting. Since then 1974, 46, 66. 4 Fry, E N S, and Ibrahim, A A, British Medical Journal, I have recorded the incidence and severity of 1974, 3, 808. this symptom in new cases of thyrotoxicosis and have been surprised to find that of eight consecutive patients, only two had no nausea or vomiting. One patient complained of a constant feeling of nausea, two patients had Mechanism of action of antiallergic occasional vomiting, up to twice weekly, and drugs three suffered from frequent vomiting, particularly on rising in the morning. There SIR,-We should like to reply to the criticisms was no correlation with other symptoms, of our hypothesis on the mechanism of action physical signs, or biochemical results. of antiallergic drugs (3 April, p 820) made by It is my impression that nausea and vomiting Mr C J Vardey and Dr I F Skidmore (7 August, are common symptoms of thyrotoxicosis, p 369). They refer to the lack of correlation unrelated to severity and possibly caused by a between the ability of antiallergic drugs to direct effect of thyroid hormones on the inhibit cAMP phosphodiesterase and their medulla. In all my cases these symptoms were ability to inhibit the anaphylactic release of rapidly abolished by carbimazole. histamine.' However, the enzyme was isolated from human lung tissue (mostly non-mast cells) J M TEMPERLEY while histamine was released from rat peri- Department of Medicine, toneal mast cells. Thus we would argue that Royal Infirmary, the lack of correlation between effects in Preston different tissues from different species is neither surprising nor evidence against the hypothesis. Indeed, there is good reason to Lung cancer and smoking: Is there believe that cAMP metabolism is controlled proof? differently in the two tissues. Isoprenaline, a well-established stimulant of adenylate cyclase, SIR,-You state in your leading article (21 potently inhibits histamine release from human August, p 439) that I "must be virtually alone, lung2 but inhibits histamine release from rat however, in asserting that the usual hypothesis peritoneal cells only weakly, if at all.' 4 is 'a catastrophic and conspicuous howler."' Evidence on the mechanism of action of anti- This latter phrase, quoted by The Times allergic drugs is, therefore, difficult to interpret correspondent,' is in fact not mine: it was unless it is obtained using pure mast cell written by R A Fisher and published in the preparations from a single species. BMJ in 1957.2 The full quotation reads: "I do The time courses of inhibition of histamine not relish the prospect of this science [statistics release by antiallergic drugs and phospho- in medical research] being now discredited by diesterase inhibitors show less disparity than a catastrophic and conspicuous howler." I Mr Vardey and Dr Skidmore suggest because should add that I share Fisher's apprehension. studies so far published have been incomplete. Other inaccuracies in your leading article are In fact, cromoglycate, doxantrazole, and theo- too numerous to be discussed adequately in a phylline show close similarity in the time course short letter, but perhaps you will permit me to of inhibition of histamine release.5 mention two of them briefly. The claim that the The lack of synergism between 3-adrenergic secular trends in the sex ratio of mortality from receptor stimulants and antiallergics in rat lung cancer "provide no support for the mast cell studies is, again, not surprising constitutional view" is based on an unpublished, because of the relative insensitivity of these superficial, and incomplete examination of the cells to 5-agonists. evidence. You also state that, on the conThere is, as yet, no additional evidence to stitutional view, the enormous secular increase support the hypothesis that antiallergics inhibit in lung cancer rates has to be attributed entirely histamine release by maintaining a high level to improvements in diagnosis. This is incorrect. of cAMP within the cell which in turn inhibits In the first place constitutional and (smoking) calcium transport across the cell membrane. causal hypotheses are not mutually exclusive. However, it is not contradicted by the work But if it could be established that sex-specific quoted by Mr Vardey and Dr Skidmore. and age-specific death rates from lung cancer have genuinely increased in the course of the J C FOREMAN century we should need to consider at least the Department of Pharmacology, following additional hypotheses, singly or in University College London, London WC1 any combination: (1) the frequency of genes L G GARLAND predisposing to lung cancer has increased; (2) Pharmacology Laboratory, mortality from competing causes of deathWellcome Research Laboratories, Beckenham, Kent for example, from fatal infectious diseases genetically associated with lung cancer-has Fullarton, J, Martin, L E, and Varley, C J, Initer- diminished; and (3) extrinsic carcinogens national Archives of Allergy and Applied Immunology, 1973, 45, 84. unconnected with smoking, such as oncogenic Assem, E S K, and Schild, H 0, Nature, 1969, 224, viruses, have made an increasing impact. 1028. Johnson, A R, and Moran, N C, Journal of PharmaAs I see it,3 two main difficulties of intercology and Experimental Therapeutics, 1970, 175, pretation plague this field: (1) the phenomenon 632. Martin, L E, Postgraduate Medical Jrournal, 1971, 41, of self-selection: smokers, ex-smokers, and stippl p 26. Garland, L G, Ph D Thesis, University of London, non-smokers and even Mormons and Seventh Day Adventists are not selected randomly from 1975.
11 SEPTEMBER 1976
the general population; (2) the often demonstrated unreliability of the clinical diagnosis of lung cancer. Clinical diagnostic error has changed from drastic underdiagnosis at the beginning of the century to overdiagnosis in recent years.3 Although studies of monozygotic twins discordant for smoking habits are not entirely free from ambiguities of interpretation, they provide the best available control in human populations of the genetic variable.3 I am pleased to see that you show a greater awareness of interpretational problems than, for example, the 1971 report of the Royal College of Physicians, Smoking and Health Now. The clinician takes responsibility for the advice he gives his patients, but in turn he must rely on the opinions of experts whose duty it is to analyse the evidence as objectively and rigorously as possible. Many studies, including the crucial ones of twins, show that smoking helps to cause prolonged cough and morbidity from chronic bronchitis. In my view this causal connection must be regarded as established. However, in the case of cigarette-associated cancers I have given reasons:' for doubting the orthodox (causal) interpretation. You argue that the public expression of such doubts might encourage some people to smoke cigarettes. But if the orthodox causal hypothesis is incorrect the feelings of guilt and anxiety induced in habituated cigarette smokers by anti-smoking campaigners are unfortunate and unnecessary. Because of the difficulty of drawing up an accurate balance sheet it is, as you say, of more than academic importance that we get our interpretations as nearly correct as possible. P R J BURCH General Infirmary, Leeds
IHodgkinson, N, The Tinmes, 18 August, 1975, p 2. 2 Fisher, R A, British Medical Journzal, 1957, 2, 298. 3Burch, P R J, The Biology of Canicer. A New Approach. Lancaster, Medical and Technical Publishing, 1976.
Out-of-hours calls in general practice SIR,-I note that Dr M G F Crowe and his colleagues (26 June, p 1582) deal initially with a large proportion of requests for out-of-hours calls by rendering advice over the telephone. In their article they point out that they have the advantage over the deputies in the Sheffield study1 that they usually know the patients already and have immediate access to their NHS records. Even this advantage does not, in my view, provide a "fail-safe system." All general practitioners know that in assessing incoming telephone calls requesting visits one has to take into account the possibility of a failure by the caller to mention some factor which is medically significant but to a layman insignificant. There is also the possibility of human error on the part of the doctor in failing to ask one crucial question, the answer to which may totally alter the doctor's decision as to whether to visit or not. Equally, in giving "advice over the telephone with the proviso that the patient could ring again if the recommended treatment did not help" the doctor has to take into account infinitely varying reactions of callers to this advice. Some patients are put off too long; others ring again before the treatment has had time to work; yet others misunderstand the message and interpret it as meaning "do not worry; nothing is wrong." A number of cases of this kind regularly appear before service committees and in the
BRITISH MEDICAL JOURNAL
11 SEPTEMBER 1976
law courts. By the time that stage is reached the recollection of the caller may have been blurred (as may that of the doctor) so that the service committee or judge has to decide which of two conflicting accounts to believe as to the precise questions asked by the doctor, the information given to him, and the advice finally given. Both parties may be endeavouring to tell the truth and both may be mistaken. One knows that before certain tribunals the following argument is often used: (1) The doctor may deal with 60 patients per day. (2) A night telephone caller to a doctor is usually doing something unusual and is therefore unlikely to be confused in his recollection about what happened. (3) Accordingly the account of the caller is to be preferred to that of the doctor. These are some of the dangers which surround a doctor who upon receipt of a night telephone call decides not to visit the patient unless he is called a second time. H M HALLE Sheffield Williams, B T, Dixon, R A, and Knowelden, J, British Medical_Journal, 1973, 1, 593.
SIR,-No doubt the debate on who should do night visits will continue for some time. Perhaps I am not made of the stuff that other doctors are made of as I work badly after missing sleep. It takes me two days to return to feeling normal after a badly disturbed night. As I see between 45 and 60 patients on a normal day this means that around 100 patients are at risk from my fatigue after one bad night. The main argument against using a deputising service is that one's continuity of patient care is interrupted. I work in a partnership of six, and during the day we personalise our practice as much as possible by normally seeing our own patients. During the night the chance of a call being to one's own patient is obviously only 1 in 6. During the past 10 years I have carried out well over 100 000 consultations and visits. Of these, 210 have been between midnight and 7 am. Probably a sixth of these-35-have been to my own patients. This represents less than 0-035°o1 of the care given to my own patients. For this minuscule degree of continuity literally thousands of consultations and visits have been carried out when I have not been at my best because of lack of decent sleep. I feel that during the past 10 years my patients would have been better treated if I had used a deputising service for out-of-bed call, l aving me fresher to cope during the day. Runcorn, Cheshire
found. This infection of dairy cattle is enzootic in Dorset. Twenty-one herds were examined; all had evidence of infection, confirmed in 19 herds by electron microscopy and tissue culture.' There is evidence2 that the viruses of orf and milker's nodule, although having some similarities, are biologically distinct. G TEE Public Health Laboratory, Dorchester, Dorset Nagington, J, Tee, G H, and Smith, J S, Nature, 1965, 208, 505. Huck, R A, Veterinary Record, 1966, 78, 503.
Carpal tunnel syndrome in the blind
641
peripheral as well as autonomic nerves. As in our patient, diabetic enteropathy is usually encountered in patients with long-standing diabetes whose disease has been poorly controlled and is often punctuated by episodes of ketosis. Subclinical involvement of various organw systems in diabetes has been noted to occur for protracted periods before the onset of overt symptoms.2 McNally et al,3 in an attempt to determine the extent of this subclinical involvement of the small intestine in diabetic patients, found a progressive decrease in intestinal tone, a progressive increase in the large-wave activity produced by peristaltic complexes, and unchanged small-wave activity representing local segmental contractions. Their conclusion was that the subclinical involvement of the small intestine in diabetes is more common than is generally suspected and that these abnormalities become clinically manifest by diarrhoea in only a small number of patients. These changes in bowel tone and motility may well be the initiating mechanism in the development of a primary volvulus of the small bowel in a similar way to the changes produced by serotonin in Mr De Souza's
SIR,-I have recently had a blind patient with the carpal tunnel syndrome which seemed to have developed as a result of her using the long-cane technique for walking. In this instance the symptoms and signs were so severe that the patient was not able to use braille. I have made some inquiries in my area and it is apparent that the association of the syndrome and use of the cane in blind people is not patients. H FREUND perhaps all that uncommon. I am anxious to find out if this is a common association, and Department of Surgery, Hadassah University Hospital, I would be grateful, therefore, if anyone would Jerusalem, Israel get in touch with me and let me know of any other cases. Clearly it is of more than academic Katz, L A, and Spiro, H M, New England Joiirnal of Medicine, 1966,275, 1350. interest because, as in the patient mentioned 2 Ellenberg, M,Journal of the American Medical Associaabove, a very serious disability arises if they tion, 1963, 183, 926. 3 McNally, E F, Reinhard, A E, and Schwartz, P E, are unable to use braille. American Journal of Digestive Diseases, 1969, 14, 163. NIGEL H HARRIS 72 Harley Street, London WI
Porcine dermis dressing versus Bisgaard therapy for leg ulcers Volvulus of the small bowel in a diabetic patient
SIR,-I read with interest the paper by Dr J S H Rundle and others (24 July, p 216). We also are achieving successful results with lyophilised freeze-dried porcine dermis. However, for their control group the authors state that "conventional 'Bisgaard' treatment consisted of bandaging (Calaband or Quinaband) and elastic support with weekly dressing changes." This is not Bisgaard therapy and I would like to refer readers to Bisgaard's original description of his method.' The importance of this technique is daily massage, pressure bandaging, and elastic support. It does not involve occlusion for a week as stated by Dr Rundle and his colleagues.
SIR,-Dr L J De Souza (1 May, p 1055) reports 12 cases of primary volvulus of the small bowel in Ugandans associated with the ingestion of large amounts of local beer, which is known to contain high doses of serotonin. We would like to present a case of primary volvulus of the small bowel causing complete gangrene of the bowel in a diabetic patient. A 56-year-old man was admitted for the control of unbalanced and labile diabetes mellitus of five years' duration. While in hospital he developed an acute attack of severe abdominal pain and vomiting followed by abdominal distention and signs of peritoneal irritation, giving rise to the suspicion of acute mesenteric occlusion. At operation the entire CHRISTINE I HARRINGTON small bowel was found to be twisted clockwise 540° Hallam Department of around its mesentery, which was of normal length Rupert Dermatology, and attachment. No anatomical anomaly was Hallamshire Hospital, found to explain the volvulus. The bowel was Sheffield gangrenous from the ligament of Treitz to the Bisgaard, H, Ulcers and Eczema of the Leg, Sequels of PETER I VARDY ileocaecal valve. Small-bowel resection was perPhlebitis, etc. Copenhagen, Munksgaard, 1948. formed but to no avail and the patient died 36
Orf in Britain
SIR,-A clinical condition in man indistinguishable from orf virus infection derived from sheep (Dr M S Hall, 14 August, p 420) can be produced by milker's nodule virus infection. Of 32 patients with orf-like lesions seen during the past 25 years in West Dorset, 14 were considered to have milker's nodule virus infection. These 14 patients gave a history of milking cows but not of handling sheep. When the cows' teats were examined vesicles and characteristic ring sores were
hours later.
Searching the literature we were unable to find similar cases of primary small-bowel volvulus except for those described by Mr De Souza and the others cited by him. His cases and ours seem to be similar in that a motility disturbance may be the cause of volvulus. Diabetes mellitus affects every organ system, the gastrointestinal tract being no exception. The gastrointestinal manifestations, such as gastric atony, diminished acid secretion, and diarrhoea, are ascribed to diabetic neuropathy.' Diarrhoea, the more common symptom of diabetic enteropathy, occurs in patients in whom neuropathy is severe and affects
Acute gastric dilatation after trauma SIR,-I wish to add the following observations to the article on this subject by Mr A T Kasenally and others (3 July p 21) Acute gastric dilatation does not occur only after abdominal operations and abdominal injuries. It can occur as a reflex phenomenon in response to injuries other than to the lower
chest, abdomen, and pelvis, after application of a plaster jacket, and as a complication of shock.'2 A 10-year-old girl was admitted to an orthopaedic ward after being involved in a road accident.
BRITISH MEDICAL JOURNAL
early postoperative feeding when safe and Thyrotoxic vomiting practicable. S P DEACON SIR,-Dr F D Rosenthal and his colleagues (24 July, p 209) draw attention to this symptom London Road Hospital, Boston, Lincs and suggest that it is a rare feature of severe thyrotoxicosis. lBevan, J C, and Burn, M C, British Journal of Six months ago I saw a patient similar to Anaesthesia, 1973, 45, 115. 2Kelnar, C J H, British Medical Journal, 1976, 1, 751. their reported cases who had thyrotoxicosis 3 Thomas, D K M, British Journal of Anaesthesia, with severe and persistent vomiting. Since then 1974, 46, 66. 4 Fry, E N S, and Ibrahim, A A, British Medical Journal, I have recorded the incidence and severity of 1974, 3, 808. this symptom in new cases of thyrotoxicosis and have been surprised to find that of eight consecutive patients, only two had no nausea or vomiting. One patient complained of a constant feeling of nausea, two patients had Mechanism of action of antiallergic occasional vomiting, up to twice weekly, and drugs three suffered from frequent vomiting, particularly on rising in the morning. There SIR,-We should like to reply to the criticisms was no correlation with other symptoms, of our hypothesis on the mechanism of action physical signs, or biochemical results. of antiallergic drugs (3 April, p 820) made by It is my impression that nausea and vomiting Mr C J Vardey and Dr I F Skidmore (7 August, are common symptoms of thyrotoxicosis, p 369). They refer to the lack of correlation unrelated to severity and possibly caused by a between the ability of antiallergic drugs to direct effect of thyroid hormones on the inhibit cAMP phosphodiesterase and their medulla. In all my cases these symptoms were ability to inhibit the anaphylactic release of rapidly abolished by carbimazole. histamine.' However, the enzyme was isolated from human lung tissue (mostly non-mast cells) J M TEMPERLEY while histamine was released from rat peri- Department of Medicine, toneal mast cells. Thus we would argue that Royal Infirmary, the lack of correlation between effects in Preston different tissues from different species is neither surprising nor evidence against the hypothesis. Indeed, there is good reason to Lung cancer and smoking: Is there believe that cAMP metabolism is controlled proof? differently in the two tissues. Isoprenaline, a well-established stimulant of adenylate cyclase, SIR,-You state in your leading article (21 potently inhibits histamine release from human August, p 439) that I "must be virtually alone, lung2 but inhibits histamine release from rat however, in asserting that the usual hypothesis peritoneal cells only weakly, if at all.' 4 is 'a catastrophic and conspicuous howler."' Evidence on the mechanism of action of anti- This latter phrase, quoted by The Times allergic drugs is, therefore, difficult to interpret correspondent,' is in fact not mine: it was unless it is obtained using pure mast cell written by R A Fisher and published in the preparations from a single species. BMJ in 1957.2 The full quotation reads: "I do The time courses of inhibition of histamine not relish the prospect of this science [statistics release by antiallergic drugs and phospho- in medical research] being now discredited by diesterase inhibitors show less disparity than a catastrophic and conspicuous howler." I Mr Vardey and Dr Skidmore suggest because should add that I share Fisher's apprehension. studies so far published have been incomplete. Other inaccuracies in your leading article are In fact, cromoglycate, doxantrazole, and theo- too numerous to be discussed adequately in a phylline show close similarity in the time course short letter, but perhaps you will permit me to of inhibition of histamine release.5 mention two of them briefly. The claim that the The lack of synergism between 3-adrenergic secular trends in the sex ratio of mortality from receptor stimulants and antiallergics in rat lung cancer "provide no support for the mast cell studies is, again, not surprising constitutional view" is based on an unpublished, because of the relative insensitivity of these superficial, and incomplete examination of the cells to 5-agonists. evidence. You also state that, on the conThere is, as yet, no additional evidence to stitutional view, the enormous secular increase support the hypothesis that antiallergics inhibit in lung cancer rates has to be attributed entirely histamine release by maintaining a high level to improvements in diagnosis. This is incorrect. of cAMP within the cell which in turn inhibits In the first place constitutional and (smoking) calcium transport across the cell membrane. causal hypotheses are not mutually exclusive. However, it is not contradicted by the work But if it could be established that sex-specific quoted by Mr Vardey and Dr Skidmore. and age-specific death rates from lung cancer have genuinely increased in the course of the J C FOREMAN century we should need to consider at least the Department of Pharmacology, following additional hypotheses, singly or in University College London, London WC1 any combination: (1) the frequency of genes L G GARLAND predisposing to lung cancer has increased; (2) Pharmacology Laboratory, mortality from competing causes of deathWellcome Research Laboratories, Beckenham, Kent for example, from fatal infectious diseases genetically associated with lung cancer-has Fullarton, J, Martin, L E, and Varley, C J, Initer- diminished; and (3) extrinsic carcinogens national Archives of Allergy and Applied Immunology, 1973, 45, 84. unconnected with smoking, such as oncogenic Assem, E S K, and Schild, H 0, Nature, 1969, 224, viruses, have made an increasing impact. 1028. Johnson, A R, and Moran, N C, Journal of PharmaAs I see it,3 two main difficulties of intercology and Experimental Therapeutics, 1970, 175, pretation plague this field: (1) the phenomenon 632. Martin, L E, Postgraduate Medical Jrournal, 1971, 41, of self-selection: smokers, ex-smokers, and stippl p 26. Garland, L G, Ph D Thesis, University of London, non-smokers and even Mormons and Seventh Day Adventists are not selected randomly from 1975.
11 SEPTEMBER 1976
the general population; (2) the often demonstrated unreliability of the clinical diagnosis of lung cancer. Clinical diagnostic error has changed from drastic underdiagnosis at the beginning of the century to overdiagnosis in recent years.3 Although studies of monozygotic twins discordant for smoking habits are not entirely free from ambiguities of interpretation, they provide the best available control in human populations of the genetic variable.3 I am pleased to see that you show a greater awareness of interpretational problems than, for example, the 1971 report of the Royal College of Physicians, Smoking and Health Now. The clinician takes responsibility for the advice he gives his patients, but in turn he must rely on the opinions of experts whose duty it is to analyse the evidence as objectively and rigorously as possible. Many studies, including the crucial ones of twins, show that smoking helps to cause prolonged cough and morbidity from chronic bronchitis. In my view this causal connection must be regarded as established. However, in the case of cigarette-associated cancers I have given reasons:' for doubting the orthodox (causal) interpretation. You argue that the public expression of such doubts might encourage some people to smoke cigarettes. But if the orthodox causal hypothesis is incorrect the feelings of guilt and anxiety induced in habituated cigarette smokers by anti-smoking campaigners are unfortunate and unnecessary. Because of the difficulty of drawing up an accurate balance sheet it is, as you say, of more than academic importance that we get our interpretations as nearly correct as possible. P R J BURCH General Infirmary, Leeds
IHodgkinson, N, The Tinmes, 18 August, 1975, p 2. 2 Fisher, R A, British Medical Journzal, 1957, 2, 298. 3Burch, P R J, The Biology of Canicer. A New Approach. Lancaster, Medical and Technical Publishing, 1976.
Out-of-hours calls in general practice SIR,-I note that Dr M G F Crowe and his colleagues (26 June, p 1582) deal initially with a large proportion of requests for out-of-hours calls by rendering advice over the telephone. In their article they point out that they have the advantage over the deputies in the Sheffield study1 that they usually know the patients already and have immediate access to their NHS records. Even this advantage does not, in my view, provide a "fail-safe system." All general practitioners know that in assessing incoming telephone calls requesting visits one has to take into account the possibility of a failure by the caller to mention some factor which is medically significant but to a layman insignificant. There is also the possibility of human error on the part of the doctor in failing to ask one crucial question, the answer to which may totally alter the doctor's decision as to whether to visit or not. Equally, in giving "advice over the telephone with the proviso that the patient could ring again if the recommended treatment did not help" the doctor has to take into account infinitely varying reactions of callers to this advice. Some patients are put off too long; others ring again before the treatment has had time to work; yet others misunderstand the message and interpret it as meaning "do not worry; nothing is wrong." A number of cases of this kind regularly appear before service committees and in the
BRITISH MEDICAL JOURNAL
11 SEPTEMBER 1976
law courts. By the time that stage is reached the recollection of the caller may have been blurred (as may that of the doctor) so that the service committee or judge has to decide which of two conflicting accounts to believe as to the precise questions asked by the doctor, the information given to him, and the advice finally given. Both parties may be endeavouring to tell the truth and both may be mistaken. One knows that before certain tribunals the following argument is often used: (1) The doctor may deal with 60 patients per day. (2) A night telephone caller to a doctor is usually doing something unusual and is therefore unlikely to be confused in his recollection about what happened. (3) Accordingly the account of the caller is to be preferred to that of the doctor. These are some of the dangers which surround a doctor who upon receipt of a night telephone call decides not to visit the patient unless he is called a second time. H M HALLE Sheffield Williams, B T, Dixon, R A, and Knowelden, J, British Medical_Journal, 1973, 1, 593.
SIR,-No doubt the debate on who should do night visits will continue for some time. Perhaps I am not made of the stuff that other doctors are made of as I work badly after missing sleep. It takes me two days to return to feeling normal after a badly disturbed night. As I see between 45 and 60 patients on a normal day this means that around 100 patients are at risk from my fatigue after one bad night. The main argument against using a deputising service is that one's continuity of patient care is interrupted. I work in a partnership of six, and during the day we personalise our practice as much as possible by normally seeing our own patients. During the night the chance of a call being to one's own patient is obviously only 1 in 6. During the past 10 years I have carried out well over 100 000 consultations and visits. Of these, 210 have been between midnight and 7 am. Probably a sixth of these-35-have been to my own patients. This represents less than 0-035°o1 of the care given to my own patients. For this minuscule degree of continuity literally thousands of consultations and visits have been carried out when I have not been at my best because of lack of decent sleep. I feel that during the past 10 years my patients would have been better treated if I had used a deputising service for out-of-bed call, l aving me fresher to cope during the day. Runcorn, Cheshire
found. This infection of dairy cattle is enzootic in Dorset. Twenty-one herds were examined; all had evidence of infection, confirmed in 19 herds by electron microscopy and tissue culture.' There is evidence2 that the viruses of orf and milker's nodule, although having some similarities, are biologically distinct. G TEE Public Health Laboratory, Dorchester, Dorset Nagington, J, Tee, G H, and Smith, J S, Nature, 1965, 208, 505. Huck, R A, Veterinary Record, 1966, 78, 503.
Carpal tunnel syndrome in the blind
641
peripheral as well as autonomic nerves. As in our patient, diabetic enteropathy is usually encountered in patients with long-standing diabetes whose disease has been poorly controlled and is often punctuated by episodes of ketosis. Subclinical involvement of various organw systems in diabetes has been noted to occur for protracted periods before the onset of overt symptoms.2 McNally et al,3 in an attempt to determine the extent of this subclinical involvement of the small intestine in diabetic patients, found a progressive decrease in intestinal tone, a progressive increase in the large-wave activity produced by peristaltic complexes, and unchanged small-wave activity representing local segmental contractions. Their conclusion was that the subclinical involvement of the small intestine in diabetes is more common than is generally suspected and that these abnormalities become clinically manifest by diarrhoea in only a small number of patients. These changes in bowel tone and motility may well be the initiating mechanism in the development of a primary volvulus of the small bowel in a similar way to the changes produced by serotonin in Mr De Souza's
SIR,-I have recently had a blind patient with the carpal tunnel syndrome which seemed to have developed as a result of her using the long-cane technique for walking. In this instance the symptoms and signs were so severe that the patient was not able to use braille. I have made some inquiries in my area and it is apparent that the association of the syndrome and use of the cane in blind people is not patients. H FREUND perhaps all that uncommon. I am anxious to find out if this is a common association, and Department of Surgery, Hadassah University Hospital, I would be grateful, therefore, if anyone would Jerusalem, Israel get in touch with me and let me know of any other cases. Clearly it is of more than academic Katz, L A, and Spiro, H M, New England Joiirnal of Medicine, 1966,275, 1350. interest because, as in the patient mentioned 2 Ellenberg, M,Journal of the American Medical Associaabove, a very serious disability arises if they tion, 1963, 183, 926. 3 McNally, E F, Reinhard, A E, and Schwartz, P E, are unable to use braille. American Journal of Digestive Diseases, 1969, 14, 163. NIGEL H HARRIS 72 Harley Street, London WI
Porcine dermis dressing versus Bisgaard therapy for leg ulcers Volvulus of the small bowel in a diabetic patient
SIR,-I read with interest the paper by Dr J S H Rundle and others (24 July, p 216). We also are achieving successful results with lyophilised freeze-dried porcine dermis. However, for their control group the authors state that "conventional 'Bisgaard' treatment consisted of bandaging (Calaband or Quinaband) and elastic support with weekly dressing changes." This is not Bisgaard therapy and I would like to refer readers to Bisgaard's original description of his method.' The importance of this technique is daily massage, pressure bandaging, and elastic support. It does not involve occlusion for a week as stated by Dr Rundle and his colleagues.
SIR,-Dr L J De Souza (1 May, p 1055) reports 12 cases of primary volvulus of the small bowel in Ugandans associated with the ingestion of large amounts of local beer, which is known to contain high doses of serotonin. We would like to present a case of primary volvulus of the small bowel causing complete gangrene of the bowel in a diabetic patient. A 56-year-old man was admitted for the control of unbalanced and labile diabetes mellitus of five years' duration. While in hospital he developed an acute attack of severe abdominal pain and vomiting followed by abdominal distention and signs of peritoneal irritation, giving rise to the suspicion of acute mesenteric occlusion. At operation the entire CHRISTINE I HARRINGTON small bowel was found to be twisted clockwise 540° Hallam Department of around its mesentery, which was of normal length Rupert Dermatology, and attachment. No anatomical anomaly was Hallamshire Hospital, found to explain the volvulus. The bowel was Sheffield gangrenous from the ligament of Treitz to the Bisgaard, H, Ulcers and Eczema of the Leg, Sequels of PETER I VARDY ileocaecal valve. Small-bowel resection was perPhlebitis, etc. Copenhagen, Munksgaard, 1948. formed but to no avail and the patient died 36
Orf in Britain
SIR,-A clinical condition in man indistinguishable from orf virus infection derived from sheep (Dr M S Hall, 14 August, p 420) can be produced by milker's nodule virus infection. Of 32 patients with orf-like lesions seen during the past 25 years in West Dorset, 14 were considered to have milker's nodule virus infection. These 14 patients gave a history of milking cows but not of handling sheep. When the cows' teats were examined vesicles and characteristic ring sores were
hours later.
Searching the literature we were unable to find similar cases of primary small-bowel volvulus except for those described by Mr De Souza and the others cited by him. His cases and ours seem to be similar in that a motility disturbance may be the cause of volvulus. Diabetes mellitus affects every organ system, the gastrointestinal tract being no exception. The gastrointestinal manifestations, such as gastric atony, diminished acid secretion, and diarrhoea, are ascribed to diabetic neuropathy.' Diarrhoea, the more common symptom of diabetic enteropathy, occurs in patients in whom neuropathy is severe and affects
Acute gastric dilatation after trauma SIR,-I wish to add the following observations to the article on this subject by Mr A T Kasenally and others (3 July p 21) Acute gastric dilatation does not occur only after abdominal operations and abdominal injuries. It can occur as a reflex phenomenon in response to injuries other than to the lower
chest, abdomen, and pelvis, after application of a plaster jacket, and as a complication of shock.'2 A 10-year-old girl was admitted to an orthopaedic ward after being involved in a road accident.
