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Correspondence.

"BLIND CÆCOSTOMY."

" Audi alteram partem."

To the Editor of THE LANCET.

SIR,-Mr. J. E. Adams’s criticism of the operationof " blind caecostomy

" in your issue of April 5th will,I am sure, meet with considerable support amongthe younger surgeons, to whom falls the task of

operating upon many of these cases of acute intestinalobstruction in old people. During two years of

emergency operating at Guy’s Hospital I developedan increasing aversion to this expedient, and thisdislike is shared by my surgical contemporaries.Mr. Adams has pointed out the occasional occurrence

of a simultaneous obstruction of the large and smallintestines by a growth, a condition which cannot bediagnosed without laparotomy, and in which a blindcsecostomy would not only be useless, but wouldallow the chance of a life-saving operation to slip by.A further disadvantage is that a second operation isalways required if the patient survives, and that nodata are available for the information of the patientor the guidance of the surgeon. Laparotomy allowsus, if the growth be inoperable, to perform at once apermanent colostomy in the correct position, and ifit be removable, to drain the intestine at a pointwhich will best relieve the obstruction and facilitatesubsequent resection. I do not believe that caecostomyprovides really efficient drainage of the colon exceptin its proximal half. I was deeply impressed by acase of acute obstruction due to a growth at the pelvi-rectal junction, which died from rupture of thebowel just above the site of obstruction four daysafter I had established a csecostomy.Where the obstruction is in the ascending or trans-

verse colon caecostomy is in any case the operationof choice, but the caecum is often found distendedalmost to bursting-point with multiple linear rupturesof the peritoneal coat, and drainage is more easily,rapidly, and safely performed through a medianincision into which the caecum can be brought outand packed off, than through a small opening directlyover it, which involves the risk of rupture and escapeof highly toxic contents into the peritoneum. Thesecases die after the relief of the obstruction, in manyinstances, from a low-grade peritonitis due to thepresence in the abdomen of infected fluid and bloodwhich has exuded from the distended bowel. Blindcaecostomy will not avert this tragedy ; laparotomy,on the other hand, allows gauze to be packed into thepelvis to mop up fluid while drainage is beingestablished.

I do not believe that a rapid exploration under gasand oxygen carries greater risk to the patient than ablind cæcostomy, and it is undoubtedly a moresurgical procedure.

I am, Sir, yours faithfully,W. H. OGILVIE.

Wimpole-street, W., April 6th, 1924.W. H. OGILVIE.

THE UNITED KINGDOM FREE HOSPITALINSURANCE FUND:

A CORRECTION FROM KING EDWARD’S HOSPITALFUND FOR LONDON.

To the Editor of THE LANCET.SIR,-It has come to the knowledge of King

Edward’s Hospital Fund that a circular addressedto " Employers of Labour, Tradesmen, and Philanthro-pists " has been issued by the " United KingdomFree Hospital Insurance Fund," 17, Ironmonger-lane,E.C. The second paragraph of the circular reads :"In a speech on 13th April, 1921, the Prince ofWales expressed a desire that the King Edward’sHospital Fund should be assisted through somemeans of insurance, and the present scheme has been

outlined by the copyright holder of free insurance,the success of which has been phenomenal as

evidenced by all the leading newspapers of to-day."No such statement was made by His Royal High-

ness. The King’s Fund published on April 13th,1921, a report which mentioned insurance as a

method that should be thoroughly explored. TheKing’s Fund has since declared itself in favour of thegeneral principle of schemes of mass contributions assuggested by Lord Cave’s Committee, and thisprinciple has already been adopted by varioushospitals and by the Hospital Saving Association.But the scheme of the United Kingdom Free HospitalInsurance Fund is not one which the King’s Fundcould approve.

I am, Sir, yours faithfully,SOMERLEYTON,

Hon. Secretary, King Edward’s Hospital Fundfor London.

Walbrook, K.C., April 7th, 1924.

SOMERLEYTON,Hon. Secretary, King Edward’s Hospital Fund

for London.

THE PANCREAS AND DIABETICMETABOLISM.

To the Editor of THE LANCET.SIR,-In THE LANCET of April 5th Prof. Horst

Oertel has attacked the view that the islands ofLangerhans are secretory units for purpose of aninternal secretion and produce insulin. He has notbrought forward any new work, but has restated thecase against this view. He has, however, completelyomitted all reference to the work of F. M.Allen (Jour.Exper. Medicine, 1920, xxxi., 593). Allen showed thatwhen one-eighth of the pancreas of a dog was removedit was possible to produce definite changes in the&bgr; cells of the islands of Langerhans if the animal wasoverfed with either sugar or starch. The a cells ofthe islands and the cells of the acinous portion werequite unaffected. It would take too long to describethe experiments fully, but the work seems to showconclusively that there is a very close relation betweenthe 13 cells and sugar metabolism.

I am, Sir, yours faithfully,GEORGE GRAHAM.

Devonshire-place, W., April 5th, 1924.GEORGE GRAHAM.

NEGLECT OF THE EARLY SYMPTOMS OFINSANITY.

To the Editor of THE LANCET.SIR,-A Royal Commission to study the adminis-

tration of the Lunacy Laws being about to be appointed,the present seems an opportune occasion to drawattention to an important aspect of lunacy adminis-tration.

I have notes of 296 cases of suicide by personssane and insane, and of murders by insane persons,including four cases where the crime was onlyattempted, reported in the press of England andWales between Jan. 1st and March 13th, 1924-i.e.,in 73 days, or one-fifth of the year. These figures,however, only give a rate of less than 1500 a year.Evidently they do not include more than one-thirdof the total number of suicides that have occurred,as statistics for the year 1921 show that 3759 suicideswere reported in that year, besides 1187 other deathsby violence as to which open verdicts were recorded,many, if not nearly all, of which were due to suicide.Evidently two-thirds of the suicides occurring werenot reported in the press, or were overlooked by mypress-cutting agency. It is therefore probably justi-fiable to multiply my figures as regards suicides bythree in order to arrive at the real facts.The 296 cases reported may be classified as follows :

Suicides, 274 ; joint suicides, 3 ; attempted suicide, 1 ;murders and suicides, 5 ; double murder and suicide, 3 ;treble murder and suicide, I ; suicides after attemptedmurder, 3 ; murders, 2 ; attempted murders, 2 ;attempted murder and attempted suicide, 1 ; murderand attempted suicide, 1. In all, 292 suicides and17 murders, besides attempts, occurred in 73 days-