Correspondence

6 June 1964
The figures quoted for infection rates of dogs
and cats with Toxocara species come as no
surprise to veterinary research workers in this
field; indeed it is the impression of many that
almost all untreated young puppies carry this
parasite.
The veterinary profession recognizes the
risks, and judicious medication of dogs and
cats is recommended. Young puppies and
their mothers during the suckling period are
most important as disseminators of eggs and
required special attention. Treatment of the
puppies and the bitch at approximately 3, 6,
9, and 12 weeks after birth with an efficient
ascaricide is suggested ; this will eliminate
worms present at the time of birth and prevent
the establishment of infection in the bowel, as
opposed to the tissues, of the bitch. In the
case of older dogs (other than post-parturient
bitches) and of cats, less frequent treatment
possibly based on faecal examination is indicated at, say, six-monthly intervals.
Although the piperazine compounds are
very efficient ascaricides and are most widely
used, they are only fully effective against
mature stages of the worm, having less activity against immature stages in the bowel and
none against worm larvae in the tissues.
Further research directed to the development
of compounds with such a range of activity
is required.
While the veterinary profession can suggest
effective means of control of toxocara infection in dogs and cats it is often up to the
family's general practitioner to point out the
dangers and to suggest the part that treatment of pets against these parasites can play
in the control of human infestations. There
is no doubt that more publicity should be

JORNAL

given to this problem in order to persuade

the public to seek the advice of their veterinary surgeon about regular dosing of their
pets and thus to reduce the contamination of
gardens, streets, and open spaces with the
eggs of Toxocara.-I am, etc.,
R. M. ARNOLD.
Wellcome Veterinary Research
Station,
Frant, Kent.

When Was the First Gastrectemy ?

SIR,-Your correspondents have contributed useful information concerning the
first gastrectomy. But as well as knowing
about the pioneers of a surgical procedure,
we should also be interested in the idea that
stimulated them, and why it came to practical fruition in the minds of several
surgeons at approximately the same time. In
the case of pylorectomy, the idea was first
conceived as far back as 1780 by a German
surgeon, C. F. Michaelis. One of his
students, D. K. T. Merrem, actually carried
out some animal experiments on the problem
in 1809, but the technical difficulties of the
operation in man were not solved until 70
years later. This story has been recounted
by Professor Owsei Temkin: " Merrem's
youthful dream. The early history of
2 I am, etc.,
experimental pylorectomy."1 '
EDWIN S. CLARKE.
Wellcome Historical Medical Library
and Museum,
London NWW 1.
REFERENCES

Temkin, O., Bull. Hist. Med., 1957, 31, 29.

- ibid., 1960, 34, 74.

Lead Poisoning
SIR,-We were interested to read your
leading article on lead poisoning in children
(9 May, p. 1200). As lead poisoning can be
present without any of the usual characteristic
laboratory features, such as punctate basophilia (which are best estimated by Lane's
method') and coproporphyrinuria, the diagnosis often rests on the finding in the urine or
blood of a raised content of lead. One of the
difficulties in diagnosis has been the small
amounts of lead which are indicative of
poisoning. For example, if the upper limit of
normal blood lead is 36 Pg./100 ml.2 then
even if 2 ml. of blood is used only 0.72 jug.
of lead is available for detection.
In conjunction with Dr. G. A. Matthews
we have been carrying out a series of tests of
men working with lead in the Hemel Hempstead area. The normal tests these men
undergo consist of stipple-cell counts, urine
coproporphyrin, blood- and urine-lead determination, Hb determination, and reticulocyte
counts. Often there is a discrepancy between
the results to the tests, some indicating
excessive absorption and some giving results
in the normal range, though if the results of
such tests are summated' some idea of the
degree of lead absorption can be obtained.
In order to assess the amount of lead
absorbed by these men we have tried the
effect of giving a test dose of 1 g. of calcium
disodium versenate orally and determining the
urine lead before and eight hours after the
dose. This technique results in an enormous
output of lead in the urine of lead-poisoned
men, and the results of this simple procedure

compare well with the results of the usual

series of tests. These results will be presented
in more detail elsewhere, but the Table shows
the ranges of urinary lead we have found in
various groups of patients. In the normal
person unexposed to lead very little change
occurs in the lead excretion before and after
Patient Group

Urine Lead (mg./litre)

After
Before
Versenate
Versenate

..
Normal males ..
30-40
Mild lead absorption ..
70-140
Moderate lead absorption
180-240
Lead poisoning
. . 200 upwards

45-80
160-700
600-1,000
900-2,700

the test dose, but up to 3,000 ug. Pb per

litre has been found in the urine of men
showing excessive absorption of lead. Thomas,
using a similar provocative test in a group of
" abnormal " children, found several with a
raised excretion of lead in the urine.'
With regard to the treatment of lead
poisoning, it should have been made clear that
it is the calcium disodium salt of E.D.T.A.
that is used in treatment and not the acid
itself. This salt may also be given by mouth,
and following good reports of its use in lead
poisoning by Shiels and his colleagues,' we
have used this oral compound in treating mild
cases of lead poisoning.6 We found that a
seven-day course of oral CaNa2 versenate
resulted in as good an excretion of lead as a
five-day course of the intravenous compound.
As the intravenous compound needs to be

1511

given diluted in large volumes of saline, the

oral method of giving CaNa2 versenate considerably eases the treatment of men in
industry, and the advantages no doubt apply
even more in the treatment of children.
The amount of lead removed by versenate
salts appears to be rather more than that
excreted following treatment with penicillamine.7 The toxicity of CaNa2 versenate is
probably low. Thomas has treated several
hundred men with this compound without
complications and Burnett' has used longterm versenate without clinical or laboratory
toxicity even after four years' treatment.We are, etc.,
J. D. WILLIAMS.

D. A. LEIGH.
Department of Pathology,
General Hospital,
Edgware
Edgware, Middx.
REFERENCES

1 Lane, R. E., Brit. 7. industr. Med., 1949, 6, 125

2 Moncrieff, A. A., Koumides, 0. P., Clayton
B. E., Patrick, A. D., Renwick, A. G. C., and
Roberts, G. E., Arch. Dis. Childh., 1964, 39, 1
3 King, E., and Thompson, A. R., Ann. occup
Hyg., 1961, 3, 247.
Thomas, D. L. G., personal communication, 1963
5 Shiels, D. O., Thomas, D. L. G., and Kearley
E., A.M.A. Arch. industr. Hlth, 1956, 13, 489
6 Williams, J. D., Matthews, G. A., and Judd
A. W., Brit. 7. industr. Med., 1962, 19, 211.
7 Goldberg, A., Smith, J. A., and Lochhead, A. C.
Brit. med. 7., 1963, 1, 1270.
Burnett, J. M., Alabama gen. Pract., 1959, 9, 6

Self-made Martyrdom ?
SIR,-Dr. J. S. K. Stevenson's article
(23 May, p. 1370) highlights the difference
between certain practices in terms of work
load. He asks a number of questions which
no one can answer. May I ask some more
questions ?
Is all the general-practitioner work really
necessary ? How much of his time is spent
chauffeuring himself on visits and return
visits which are not essential ? If a doctor
is paid at the rate of 2 per hour is it
economical for him to visit a second case of
chicken-pox or measles in a house ? Is it
common sense for him to spend time on
social problems which most health visitors
or social workers can tackle with greater
success ? Many doctors will insist on daily
visits to give penicillin intramuscularly and
to syringe ears, when a nurse can do this for
him. Many write their own letters rather
than employ a secretary.
I am convinced that most practitioners are
inefficient and will not, or cannot, arrange
their work to reduce their burden. They
over-visit and over-consult because they like
to be regarded by the public as always busy
and well-nigh suffering martyrdom in their
professional calling.
The day's work of most family doctors
simply will not stand up to statistical
analysis, for when one looks with criticism
at the doctor's work one sees that much of it
is unnecessary or can be relegated to others
at less cost to the community and with
increased efficiency.
When general practitioners have learned
to organize their lives then they will have
time to undertake other interesting professional activities. Efficient practice does not
mean that a doctor is insincere or callous or
inhuman; it simply means that he devotes
his energy into those channels where it will
reap the greatest reward in the relief of
human suffering.
We at Darbishire House have learned a
lesson over the past 10 years. We have