576 SECONDARY PEPTIC 1TLUT’1ZATI()N

experience the wonderful results observed at ItuberyHill or at Trenton following the drainage of thesesinuses in cases under Dr. T. C. Graves and the lateDr. Henry Cotton.

In conclusion, Dr. Parfit states that indicationsfor treatment can be discovered by ordinary routineexamination,

"

proof-puncture of all sinuses beingunnecessary." What he includes under routineexamination I do not know, but in doubtful casesat any rate I find radiograms and endorhinoscopicinspection most helpful, although I rely on the

bacteriological examination of samples aspiratedfrom the suspected sinuses for evidence of actualinfection, more particularly when grave issues are

at stake.-I am, Sir, yours faithfully,P. WATSON-WILLIAMS, M.D.

Clifton, Bristol, March 4th.

THE OXYGEN TENT

To the Editor of THE LANCET

SIR,-In your review last week (p. 496) of the book"Oxygen and Carbon Dioxide Therapy," by Dr.

Argyll Campbell and Dr. E. P. Poulton, the followingsentence occurs referring to the oxygen tent : "Itis doubtful whether this apparatus, which must berather frightening to even the least claustrophobicof patients, will ever rival the nasal catheter in

general clinical usefulness." This would suggest tothe reader who has not a practical experience of thetwo methods that the nasal catheter is as efficaciousas the tent for the administration of oxygen.

I have recently had under mv care in the MiddlesexHospital a patient suffering from severe bronchitisand emphysema, with a tendency to asthma. The

patient was admitted to hospital with an exacerbationof bronchitis and signs of circulatory failure rapidlyensued. The breathing was very distressed with

orthopnoea. The legs and feet became swollen, cold, andblue. Nasal oxygen was administered continuously,at the greatest rate which the patient could tolerate,from Jan. 14th to Feb. 7th, with very little relief.The patient now appeared moribund, and at middayon Feb. 7th he was placed in an oxygen tent, suppliedby the Oxygen Therapeutic Service, with dramaticresults. The breathing rapidly became perfectlycalm and natural and the cyanosis disappeared. The

patient was kept in the tent until 4 P.M. on Feb. 18th,and since then his breathing has been comparativelyeasy although he has required some nasal oxygen.During the greater part of this time the oxygen contentof the tent was maintained at 40 to 50 per cent.,during the last two or three days the oxygen waslowered to 20 per cent. The patient’s only complaintwhile he was in the tent was that he was not ableto smoke. This practical experience serves todemonstrate the overwhelming superiority of the tentas opposed to the nasal catheter in the administrationof oxygen in this desperate case.

I am, Sir, yours faithfully,AViiiipole -street, W., March 4th. G. E. BEAUMONT.

SECONDARY PEPTIC ULCERATION

To the Editor of THE LANCET

SiR,—Mr. Ogilvie’s view, presented in his addressto the Oxford Medical Society (TILE LANCET, Feb. 23rd,p. 419), that the operation of gastrojejunostomyshould be confined to cases of stenosis or stasis is

one, I believe, which deserves more attention fromsurgeons in this country. 1 find his article mis-

leading, however, in its reference to the incidence

of Hccondary ulceration after gastrojejunostomyfor duodenal ulcer. lIe quotes the following figures(I add the references 1) :-

And he criticises the last two authors on thegrounds that only 78 and 65 per cent. respectivelyof their cases could be traced. Lewisohn, however,was able to trace less than half of his cases, and hishigh estimate was based on the unreasonable assump.tion that all patients doing badly at the time of

inquiry had anastomotic ulcers. Hurst and Stewart’sfigure refers to post-mortem material and cannotbe considered representative. Mr. Ogilvie does notmention Walton’s recently published series whichcommands respect because every case was traced.The incidence was 3-24 per cent.

The leading article in your last issue (p. 499)puts the position very clearly. You neglect to

point out, however, that Garnett Wright’s figureof 8-6 per cent. includes those cases in which secondaryulceration was suspected but not proved, and must betaken as the highest possible incidence. The incidenceof proved secondary ulceration in the duodenalulcer cases was 4-14 per cent., and if the gastriculcer cases are included, the figure drops to 3-1 percent. Walton’s corresponding figure is 1-6 per cent.

Until operation the diagnosis of gastrojejunalulcer is rarely certain, and it is unreasonable toassume that most of the 10 to 20 per cent. of patientswho do badly after gastrojejunostomy are sufferingfrom secondary ulceration. It is inevitable that

great discrepancies in the published figures shouldoccur in view of the different methods of statisticalapproach to the problem and the variation in severityof peptic ulcer in different countries. Nevertheless,it would be interesting to know whether Mr. Ogilvie’sestimate of at least 20 per cent. is based on personalimpressions or on a reasoned follow-up inquiry.

I am, Sir, yours faithfully,J. A. MARTINEZ.

David Lewis Northern Hospital, Liverpool, March 4th.

PROGNOSIS IN CARBUNCLE

To the Editor of TiiE LANCET

SiR,—We may logically, I think, go further thanMr. Mitchiner does in his article last week in yourprognosis series and suggest that all carbuncles-not only those " spreading or still unlocalised,"those affecting the face and carbuncles occurring indiabetics-should be spared surgical interference.I do not think Mr. Mitchiner’s observations andstatistics support his plea for drastic surgical treat-ment in the very least. In my opinion treatmentshould be even more conservative than his con-

servative measures, and should always include X raytheraov. 1 am, Sir. vours faithfully.March 5th. JOHN T. INGRAM.

1 Lewisohn, R. : Surg., Gyn., and Obst., 1925, xl., 70 ; Hurst,A. F., and Stewart, M. J. : THE LANCET, 1928, ii., 742 ; Luff,A. P. : Brit. Med. Jour., 1929, ii., 1074 ; and Wright, Garnett :Brit. Jour. Surg., January, 1935, p. 433.

HOSPITAL SATURDAY FUND’S RECORD.-A chequefor 81,000, the largest single cheque ever drawn byti similar organisation in this country, was handed onbehalf of the Birmingham Hospital Saturday Fund to thechairman of the Birmingham Hospitals’ ContributoryAssociation last week.