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if the treatment is continued sufficiently long. Smallcavities have often disappeared after only two or threemonths’ treatment. The healing effect of copper amino-acetate appears clinically very early. The rapid dis-appearance of exhausting perspiration and the decreaseof sputum bring physical and mental comfort to thepatient. But pyrexia, if present, remains unaffectedby copper amino-acetate, even in large doses. Intra-venous sodium salicylate should be used to combat thissymptom.

Properly used, copper amino-acetate never causes

toxic reactions except ’occasionally a transient rash,for which the treatment need not be stopped. Thedrug appears to be either partly excreted by the skin ordeposited in it. Consequently it gives benefit in tuber-culosis of the skin. In large doses it has even produced abeneficial result in psoriasis. In patients with healthykidneys the urine was not found to contain albuminduring treatment ; but copper amino-acetate is contra-indicated in renal disease. It is also contra-indicatedwhen the E.s.R. is more than 40 mm. in 1 hour (Wester-gren). Bloodstained sputum or haemorrhage is no

indication to stop treatment with copper amino-acetate.The scheme of treatment of pulmonary tuberculosis

can be recapitulated as follows : .

(1) Pyrexia and E.S.R. above 40 mm. in 1 hour (Westergren)call for sodium salicylate.

, (2) An approximately normal temperature with E.s.R.

below 40 mm. in 1 hour (Westergren) calls for copperamino-acetate. s(3) If pyrexia disappears under treatment with sodium

salicylate but E.s.R. remains high, copper amino-acetateshould be tried.

In cases with a slightly raised temperature and approxi-mately normal E.s.R. absence of response to copperamino-acetate seems to indicate that the illness is nottuberculosis. -

Warsaw. Z. MICHALSKI.

POST-MORTEM CÆSAREAN SECTION

SIR,-A woman, aged 35, was admitted to the teachinghospital in Bagdad on Oct. 29, 1946, in a late stage ofpregnancy with three days’ history of fever followed bycoma. Pneumococcal meningitis was diagnosed, and thepatient was transferred to the isolation hospital. Nextday the patient began to have convulsions, and I wascalled to see her. I decided to perform csesarean section,but the chief of the obstetric department refused per-mission ; so I tried to take the patient back to theteaching hospital, but’ she died before she reached theambulance. The body was taken to the M.o.’s office inthe isolation hospital, and there I performed a cesareansection, with a tracheotomy knife I found there, aboutfive minutes after the patient’s death. The baby (a girl)was in a condition of asphyxia pallida, and it took abouthalf an hour’s artificial respiration and changing thebaby from hot to cold water before she took her firstbreath. -

Kadumia Hospital, Bagdad. KHALID NAJI.

ORAL PENICILLIN

SiR,-Your leading article of Jan. 10, on PenicillinExcretory Blockade, contained an excellent expositionof the merits and demerits of Caronamide ’ in whichit was inferred that, given a suitable chemical of thistype, oral penicillin may become more feasible.As the largest manufacturers of penicillin preparations

in the Southern Hemisphere, we are particularly interestedin the future of penicillin administration, and we are ina position to flood the Australian and Far Easternmarket with tablets of penicillin for oral administration.We are, however, diffident about doing this as we realisethe complete impossibility of policing any regulationsprohibiting the sale of penicillin tablets except on

prescription.We contend that, once the tablets are made and issued

for sale, they will find their way to those suffering fromsuch conditions as gonorrhoea, who will resort to self-diagnosis and self-medication. Such persons would notcontinue the treatment after the obvious signs haddisappeared, and having insufficiently dosed themselveswould probably disseminate penicillin-resistant bacteria

to future contacts. That about 3 % of persons so treatedwould in addition be suffering from syphilis makes

. this possible practice all the more dangerous. In fact,it could lead to the loss of penicillin as a very usefulmedicament.We deprecate any tendency to enlarge the scope of oral

penicillin treatment, for we are sure this will eventuallylead to abuse, misuse, and finallv disuse of penicillin.

A. M. Bickford & Sons, Ltd., Adelaide. H. G. WILLIS.

ANÆMIAS

SiR,-In his article on April 10 Professor Sundaramstates that the observations of Wills and Evans ontropical macrocytic anaemia were made before sternalpuncture became the essential basis of differentialdiagnosis. In fact I performed sternal -punctures onall our cases in 1937-38. Professor Sundaram need notdoubt the nature of the cases we described as tropicalmacrocytic anaemia, since true megaloblasts of Ehrlichwere seen in the marrow-films of all cases before treatment.

Pathological Department,Queen Victoria Hospital,

East Grinstead.BARBARA D. F. EVANS.

RISKS OF STERNAL PUNCTURE

SiB,—I was interested in your annotation of April 10,especially as I was the coroner who held the inquestquoted therein.

I cannot help feeling that the fact that there have beenfew recorded fatalities from this procedure is a tribute tothe skill and care exhibited by the operators of thetechnique. It would indeed be unfortunate if others wereencouraged to embark on such examinations withoutfull appreciation of the potential dangers.At the inquest in question it appeared in evidence

that the operation was carried out by an experiencedpathologist. In spite of this the sternuin was trans-fixed and the heart punctured with resulting fatalhaemopericardium. An independent autopsy was carriedout by Dr. Keith Simpson, and to my mind he summedup the danger inherent in the procedure when he pointedout that the margin of safety between a successfulexamination and sudden death was one-eighth of an inch.Where, as was stated in this case, there is some patho-logical condition present which alters the normalconsistence of the bone, it appears to be an unjustifiablerisk to take. I was glad to see that you had stressedthis point in your article.

I therefore feel ’that, although sternal puncture maybe a useful and justifiable procedure, my remarks on thecase in question that it was a " highly dangerous pro-cedure were justified.

London, E.C.4.

J. M. ROBERTSONDeputy Coroner, County of London,Northern and Southern Districts.

MASSIVE ADRENAL HÆMORRHAGE

SIR,-Reviewing Dr. Kappert’s book in your issue ofMarch 27, you apparently take the view that the so-calledWaterhouse-Friderichsen syndrome should have beennamed after E. Graham Little, who collected some

cases and published a paper in 1901.1If eponymous nomenclature is to persist, then the

disease should correctly be named after Voelcker, whoadequately described- the clinical and post-mortempicture in 1894.2 Furthermore, the condition was sub-sequently described by Andrewes,3 Garrod and Drysda1e,4batten and Talbot 6-all before Little’s paper in 1901.

Banks and McCartney used the term " meningococcal-

adrenal syndrome," which would seem suitable since mostauthors believe the meningococcus is the only organismthat causes massive haemorrhage into the adrenals.8The evidence for this is debatable and if not concededthe phrase " acute adrenal insufficiency " would seemthe best choice.

1. Little, E. G. Brit. J. Derm. 1901, 13, 445.2. Voelcker, A. F. Rep. med. surge path. Registrars Middleser

Hosp. 1894, p. 279.3. Andrewes, F. W. Trans. path. Soc. Lond. 1898, 49, 259.4. Garrod, A. E., Drysdale, J. H. Ibid, p. 257.5. Batten, F. E. Ibid, p. 258.6. Talbot, E. St Bart’s Hosp. Rep. 1900, 36, 207.7. Banks, H. S., McCartney, J. E. Lancet, 1943, i, 771.8. Herbut, P. A., Manges, W. E. Arch. Path. 1943, 36, 413. Mart-

land, H. S. Ibid, 1944, 37, 147. Thomas, H. B., Leiphart,C. D. J. Amer. med. Ass. 1944, 125, 884.

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Little, even though much earlier in the literature of thesubject than either Waterhouse (1911) or Friderichsen(1918), has no greater claim to the original descriptionthan they.

- --

East Molesey, Surrey. PETER P. TURNER.

TREATMENT OF VARICOSE VEINS

SIR,—I feel that there are some points in your summarylast week of my paper read at the Royal Society ofMedicine on April 7 which may be misleading if leftwithout a little further clarification.

1. Microscopic or serial X-ray film examinations of radio-opaque injections into varicosities show that the dye remainswhere it is injected as long as the leg remains horizontal andat rest-not merely for a minute or two. Sclerosing solutioncan, under these circumstances, be left in contact with theintima as long as desired. Five minutes was the arbitrarytime suggested before vigorous movement to sweep away thesolution.

2. " However carefully it was done, large amounts ofmedium collected rapidly in the deep veins." This was true

only under certain circumstances. With amounts up to 1-5ml., using empty-vein technique with the leg horizontal,direct injection into the leg varicosities can be accurate andeffective, and the deep veins and their valves and communica-tions escape damage. ,

3. The veins removed for section showed pathologicalchanges despite the absence of clinical " take." The changeswere marked in the neighbourhood of valves.

It is suggested that ineffective injections which do notproduce permanent obliteration may do harm bydamaging valves in deep and communicating veins. Thisis most likely to happen with the retrograde injectiontechnique, or when injections are made with the patientstanding.

Surgical Professorial Unit,St. Bartholomew’s Hospital,

London, E.C.1. J. B. KINMONTH.

OVERCOMPENSATION IN DISABLEMENT

SiB,—An inherent weakness of the Disabled Persons(Employment) Act, 1944, is that, though jobs are foundfor the disabled, more attention is paid to the ortho-paedic than to the psychological aspect of their care. Itis not fully realised that the psychological damageincurred after an accident or injury is often out of allproportion to the extent of the lesion when judged bypurely orthopaedic standards.My own experience illustrates the phenomena asso-

ciated with disablement. Two years ago I sustained afracture-dislocation of the head of the right humerusand ended with an almost complete paralysis of theulnar and median nerves. Since I am right-handed andmy work consists almost entirely of surgery, midwifery,and anaesthetics, this disablement was a severe handicap.For the first few days after the accident pain over-shadowed everything else. As the weeks went by thepain passed, but the realisation that my right arm wasalmost completely paralysed caused severe bouts ofdepression and. nightmares. I can well imagine that inthis stage, if the doctor in charge does not keep a closewatch on the patient, a complete breakdown and evensuicide can follow. The next stage--the stage of compen-sation-developed in my case some three months afterthe injury. This stage, however, does not develop in allcases of injury or disablement; and where the medical.treatment is inadequate, or the make-up of the patientweak, no compensation takes place, and the patient goesfrom bad to worse, ending as an unemployable cripple.Fortunately the incidence of this type of case is probablynot more than 5 % of all disabled. The rest, like myself,adjust themselves to the handicap.Some patients require a lot of encouragement to

restore their self-confidence, but much harm can be doneby giving this encouragement indiscriminately. Whenpatients with leg injuries are encouraged to " throwaway their crutches," some can carry on without theircrutches, but others fall and break their legs or arms,and when this happens it may be impossible to restoretheir confidence.This leads me to the.subject of overcompensation, by

which I mean excessive self-confidence in the disabled

person. I have known blind men become so confident thatthey have discarded their white walking-sticks and beeninjured or killed by traffic. Again, it is very commonfor a man with a disabled arm or hand to attempt moreintricate work than he would have attempted if -he hadnot been disabled, with the result that he has had to betreated for injuries or even loss of fingers through toomuch confidence in using machines. In my own caseI became so determined that I could and would use myright hand that I turned out a dozen original papers inthe first year of my disablement ; unfortimately, thisexcessive activity caused an intense ulnar neuritis whichput me off all work for several months. Doctors, shopstewards, and others must be made aware of this dangerif it is to be avoided. I have encountered this tendencyto overcompensation in about half the patients who havecome under my care.

Psychotics or people with a family history of nervousinstability sometimes develop so much overcompensationthat they not only claim that they can work better thannormal people but have delusions that they have per-formed imaginary feats of skill. These cases, if notrecognised, can become a menace to their fellow-workersand to themselves, since they will take the most appallingrisks at their work. I hand these patients over to apsychiatrist, and the ultimate results in skilled handshave been good. This condition was seen in about 1 %of the disabled people under my care. Seven of themrecovered after narco-analysis ; only one did not respondto any treatment and had to be certified for his ownprotection.Evans Biological Institute,

Runcorn, Cheshire. JOHN H. HANNAN.

Parliament

FROM THE PRESS GALLERY

Capital Punishment .

IN the House of Commons on April 14, at the reportstage of the Criminal Justice Bill, Mr. S. S. SILVERMANmoved a new clause to suspend the death penalty formurder for a probationary period of five years in thefirst instance. Capital punishment he described as a

revolting and barbaric procedure surrounded withmelodrama and sensationalism. Until human judgmentwas infallible we had no right to inflict irrevocable doom.Above all, the penalty denied the principle on whichwe claimed the right to inflict it-the sanctity of humanlife. The only possible justification for its retentionwas to protect society, and in his view there was noproof that it was necessary.

Mr. M. C. HoLLZS, in seconding the clause, argued thatincreased efficiency in the detection of crime was a.

more important deterrent. To abnormal pathologicaltypes capital punishment might even be a slight encour-agement to murder, for it gave such men extra thrilland satisfied their mania for publicity. Public opinionalready demanded a reprieve wherever there was thesmallest scintilla of doubt. Thus we offered to theabnormal type all the thrills of risking his life and

comparatively little of the dangers of actually losing it.Sir JOHN ANDERSON on the other hand, who for

ten years was the permanent head of the Home Office,believed that the death penalty did reinforce the pro-tection of society, and diminished the risks to which thepolice were exposed. If capital punishment went, what,he asked, was to be substituted for it ? Experiencedpeople held that we ought not to contemplate holdingcriminals in prison for longer periods than are now

maintained. Would public opinion stand letting prisonersconvicted of murder of the worst kind return to thecommunity after 10 to 15 years of detention ? Thiswas not a good time to choose; when standards all overthe world had been relaxed and human life cheapenedby the experience of war. He suggested that a safermethod to deal with the problem would be by an adminis-trative adjustment of the criterion upon which theprerogative of mercy was exercised by the HomeSecretary.

In the debate which followed, Mrs. AYRTON Gour.nreminded the House that a long term of imprisonment