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In (a) and (b), which are likely to be of long standing,particularly in mitral disease, thickening of the alveolarbasement membrane prevents the easy access ofinterstitial fluid into the alveoli.10

It is fundamentally important to interpret radiographicsigns logically (hence radi-ology) in terms of anatomicalsite, disordered physiology, and pathological processes.This valuable radiographic sign, appreciated years agoby Kerley,l1 should be regarded as indicating oedema ofthe peripheral interlobular pulmonary septa and not

necessarily as indicating pulmonary hypertension. Theanatomical site is the interlobular septa ; the disorderedphysiology is oedema ; and the pathogenesis is either

pulmonary capillary hypertension, lymphatic obstruc-tion, or, less commonly, increased permeability of

capillary membrane or hypoprotinaemia, depending onthe particular clinical associations.Now that the basic mechanisms responsible for these

lines are better appreciated, we are no longer justifiedin naming them in purely visual (and verbose) terms(e.g.,

" basal horizontal lines on chest radiographs ") or byeponymous reference. This valuable radiological signshould be given an anatomical designation (e.g.,

"

peri-pheral or [basal] interlobular septal lines ") or should bedescribed in pathological terms (e.g.,

" lines of interstitialpulmonary cedema "). When described in such terms,their significance will become more widely appreciated :they represent the only objective evidence of waterloggingof the pulmonary interstitial tissue and its lymphatics.

SIR,—We were most interested to read the paper byDr. Rossall and Mr. Gunning. The findings agree sub-stantially with our own. 12 As we stated, " when lines Bwere absent the pulmonary capillary pressures were

usually well below 30 mm. Hg. When present the pres-sures were almost invariably above 30 mm. Hg." We

agree with Rossall and Gunning on aetiology also : " It

appears likely that when the pulmonary capillarypressure approaches plasma osmotic pressure, there isexudation of fluid with deficient reabsorption."We, too, found at first some difficulty in seeing basal

lines in patients with heavy breast shadows, but this wasovercome by taking an additional postero-anterior chestfilm of the bases with the mammary tissue well elevatedby the patient’s own hands. The film, however, is likelyto be too dark for diagnostic purposes unless somereduction is made in exposure-usually of the order of3 kV.Our present studies suggest that, although the raised

pulmonary capillary pressure plays a major part in theproduction of basal horizontal lines in mitral-valvedisease, in the other conditions in which the lines occurthere are other factors of greater importance.

J. H. E. CARMICHAELLiverpool. D. G. JULIAN.

RONALD G. GRAINGER.St. Thomas’s Hospital,

London, S.E.1.

J. H. E. CARMICHAELD. G. JULIAN.

10. Parker, F., Weiss, S. Amer. J. Path. 1936, 12, 573.11. Kerley, P. J. Brit. med. J. 1933, ii, 594.12. Carmichael, J. H. E.. Julian, D. G., Penrhyn Jones, G., Wren,

E. M. Brit. J. Radiol. 1954, 27, 393.

TREATMENT OF BURNS AND SCALDS

SiR,-Last November, my wife, who is 80, scalded herfoot very badly, although it was the result of upsettingonly half a pint of boiling water. Her doctor said thatno ointment or oil should be applied, and the foot mustbe exposed to the air, even to the extent of keeping itout of bed for two nights, in none-too-warm weather.For weeks my wife was confined to bed, with severe

pain for which no soothing substance was applied. Lateron penicillin injections were given. It is only within thepast two or three weeks that she has been able to getabout, while the foot has been, and still is, very painful.

There is a large scab of wrinkled flesh right across thetoes, from the stretching of which, during walldng,blood has appeared in two places.Can this be considered a successful example of the

modern method for dealing with burns and acalds In contrast, I would instance the case of a local bakerwho badly burned his arms. He was treated in the old.fashioned way, by applying ointment and covering upthe arms. Within a fortnight he was back at work.

UNCONVINCED.

1. Nitch, C. A. R. Brit. J. Surg. 1923, 11, 714.2. Mathews, F. J. C. Brit. med. J. 1954, i, 851.3. Griffiths, J. D., Nash, D. F. E. Ibid, 1955, ii, 1602.4. Jones, J. D. T. Brit. J. Surg. 1948, 36 49.

CYSTIC PNEUMATOSIS

SIR,—Cystic pneumatosis, although comparativelyuncommon, cannot be so rare as is imagined. Since1951 two cases have occurred in this hospital. Bothwere detected during routine barium meals and weresubsequently proved at operation.Most workers agree that this condition occurs in

association with intestinal obstruction.

Nitch 1 described 85 cases and stated that 50% of the caseswere associated with gastric or duodenal ulcer and in 83% ofthese p lorie stenosis was present.Mathews 2 reported a case of’ enteric pneumatosis in which

the pelvic colon was mainly affected, the cysts being submucousand subserous.

Griffiths and Ellison Nash 3 report a case of gastric ulcerwith associated ileal pneumatosis. the affected loop beingunder the diaphragm and in a suprahepatic position andleading to a diagnosis of peptic perforation.The commonest complications are pneumoperitoneum

and intestinal obstruction, including intussusception.Nitch is of the opinion that the cysts and the affectedportion of the intestine are best left alone unless causingobstruction by pressure, adhesions, or projection into thelumen of the bowel. The cysts disappear in the majorityof cases after the cure of the coexisting lesion.Jones 4 described a case in which a chronic volvulus

of the sigmoid colon was associated with cystic pneuma-tosis of the large gut. However, I am unable to find a

reported case in which chronic volvulus of the jejunumwas the obstructing lesion.

CASE I.—A man, age 49, was admitted to this hospital onDec. 6, 1951, with a two-year history of intermittent draggingpain on the left side of the abdomen, associated with attacksof diarrhoea and constipation. Subsequent barium enemarevealed no abnormality, but straight radiography of theabdomen showed mild pneumoperitoneum and several fluidlevels in moderately distended loops of small intestine in theleft upper quadrant. Barium meal and follow-through showedpartial obstruction of the upper small gut but no abnormalityin the stomach and duodenum.

Laparotomy on Dec. 23, 1951, revealed volvulus of theupper jejunum. The mesenteric border of the affected jejunumcontained multiple large diverticulæ ranging in diameter from1/2 to 2 in. The terminal ileum was affected by cysticpneumatosis, the cysts being subserous and situated both onthe mesenteric and the antemesenteric borders. All weresmall (about 3.1, to 3 /16 in. in diameter) and sessile. Thevolvulus was reduced and the affected jejunum resected,continuity being restored by end-to-end anastomosis.

Convalescence was marred by a burst abdomen, but thepatient was finally discharged as an inpatient on Feb. 5, 1952.CASE 2.-A woman, age 60, was admitted to this hospital

on April 6, 1954, with a two-year history of vomiting andindigestion indicative of pyloric stenosis. The patient wasthin and had a vague, tender, small epigastric mass. Radio-graphic examination on April 14, 1954, showed free gas underboth halves of the diaphragm and evidence of a small pyloriculcer with severe spasm.Laparotomy was undertaken on April 20, 1954, when a

firm hypertrophied pylorus was found in association withcystic pneumatosis of the terminal ileum, involving two isolatedlengths 6 in. and 9 in. long. The cysts, which were about

751

1/8 in. in diameter, were situated both on the mesenteric andon the antemesenteric borders of the affected gut beneaththe peritoneum. Partial gastrectomy was undertaken, andthe postoperative convalescence was uneventful. Pathologicalexamination revealed pyloric hypertrophy with a small

pyloric ulcer.R. F. READ.Hackney Hospital,

London, E.9.

GIANT HYPERTROPHIC GASTRITIS

W. D. PARK.

SIR,—Giant hypertrophic gastritis is so rare that fewhave. the opportunity to treat many cases. As stated byDr. Williams (April 7), gastrectomy is u,ually considerednecessary when this condition gives rise to severe blood-loss. I have devised a less mutilating operation, andreport here two cases in which it was undertaken.CASE 1.—A woman, aged 67, gave a history of many years’

indigestion, worse for the past twelve months. Her appetitehad for this time been extremely poor, and she had lost alittle weight. On examination she was a frail old lady. Therewas tenderness and a rather doubtful mass in the epigastrium.Barium meal showed a filling defect in the mid-zone, thoughtto be a carcinoma.

Laparotomy was performed on Dec. 11, 1952. The stomach,though it felt curiously thickened, was clearly not the site ofa typical carcinoma. The anterior wall was incised and

immediately the gastric mucosa protruded, at first resemblinga papilloma. However, it was soon clear that it was a caseof giant hypertrophic gastritis. The mucosa could be liftedout of the opening without dimpling the muscle and serosallayers. I was then faced with the question whether to performa total gastrectomy. The ease with which the mucosa couldbe lifted out of the stomach suggested that it might be possibleto remove some of the redundant mucosa only. To mydelight, after incising the mucosa I was able to separate about3 square inches from the muscularis. Bleeding was slight andeasily controlled without clamps. Suture of the mucosarestored the continuity of the lining. Recovery was uneventfuland she remained well until the middle of 1955. She has at

present symptoms similar to those of a gastric ulcer, butX-ray examination shows only the enlarged mucosal folds.Her appetite is not very good but she remains reasonably wellon the medical regime used in peptic-ulcer cases. Re-examina-tion of the preoperative radiographs shows appearances typicalof giant mucosal folds.CASE 2.-A man, aged 30, had had severe, almost con-

tinuous epigastric pain for about twelve days, slightly betterfor the last two days. He had vomited several times. He hada past history of indigestion, with pain about an hour afterfood. This had been investigated elsewhere, without a

definite diagnosis being made. On examination he was asallow, anxious man. There was no mass but some tendernessin the epigastrium. Barium meal showed a filling defect onthe greater curve, but it was not typical of a carcinoma.Gastroscopy showed no tumour but large folds ; it was notrealised, however, how large they were.Laparotomy was undertaken on March 3, 1953. The

stomach was palpably thickened and felt somewhat like a

bag of worms. It was incised, and again the mucosa protrudedlike a papilloma. I decided to follow the same course as in theprevious case, and I removed 4-5 square inches of mucosa.Bleeding was not severe and suture restored the lining satis-factorily. He was followed up for over eighteen months andremained quite well, although for some months he occasionallyhad indigestion. He had had a great fear of cancer which hadto be overcome. Barium meal in May, 1953, showed hyper-trophic folds but considerably less pronounced than beforeoperation.On reflection I am sure I should have removed more

mucosa in the first case. I also think it would be quiteeasy to remove more mucosa than in case 2. This couldperhaps be better done through two incisions. Diagnosisshould be easy before operation, as the radiographicappearances are so typical, but operation may still beundertaken to rule out a carcinoma. Fortunately, if thediagnosis has not been made it will become obvious onlaparotomy, especially if the stomach is opened. Shouldthe operation of mucosal resection fail, it could be

repeated, or a total gastrectomy performed.

t Shenfield, Essex. W. D. PARK.

RESIN-REINFORCED PLASTER CASTS

DAVID F. THOMAS.County Hospital, Lincoln.

SIR,—I feel obliged to attempt to dampen the enthu-siasm expressed by Mr. Morrison (April 21) for theresin-reinforced bandages (’ Gypsona-Extra ’).Through the kindness of Messrs. Smith & Nephew I

had an opportunity to try these bandages when theywere in the experimental stage, and my first reactionwas one of enthusiasm. Since the gypsona-extra havecome on the market for ordinary use I have used themexclusively in the sizes in which they are available. Myenthusiasm has by now considerably diminished.

I agree that there is very little wasting of the plastercontent. I am not so convinced of the other advantagesclaimed for these plasters. I have been particularlyimpressed by the fact that they take a long time tobecome quite rigid, compared with the ordinary gypsonabandages, in spite of the catalyst.

I did not form this impression when I was using the experi-mental bandages on clinical trial, but I have observed thisslowness particularly in the gypsona-extra bandages nowon the market. This difficulty is overcome to some extent

by squeezing the water out of the bandage very strongly,but it is not eliminated by this. Between the moment ofinitial drying of the plaster and the development of completerigidity there is a rather long phase in which the plasterappears hard but can be easily indented with moderate

pressure of the hand. Unless one is aware of the long durationof this phase there is a danger that the shape of the plastermay become distorted from the pressure of the surface onwhich it rests if it is not protected by suitable padding. This

long phase of plasticity has a further disadvantage if one isapplying a plaster which has to be moulded on a limb. Itmakes it difficult to mould the plaster accurately around bonypoints. When it is moulded in at one place it tends to bulgeout nearby like a rubber ball partly distended with air.

Because of the slow drying of these plasters I have found itnecessary to use for a cast a quantity of plaster not verymuch less than that used with ordinary gypsona. The onlyalternative to this is to keep the patient a long time in theplaster room, because if the patient is transported back to theward while the plaster is still in the " plastic

"

stage thereis a strong likelihood that the plaster will be spoilt.Though it is not a point of great importance, the finish

of these plasters does not compare with the finish of theordinary gypsona plaster.

I would like once again to make a plea for the moreuniversal use of the casts made out of a combination of’ Glassona ’ and ordinary gypsona. By using a light baseof gypsona on which the glassona can subsequently setslowly it is possible to make a very light cast for anyregion. These casts are possessed of excellent rigidity sothat, for instance, a spinal jacket can be split on oneside and slipped off and put on again without losing itsshape, and the forearm cast applied, say, for tenosynovitiscan be split on one side and slipped off and reappliedand used in much the same way as a block leather support.

I think it would be a great pity if either gypsona orglassona were taken off the market and replaced by thenew gypsona-extra bandages.

ADDICTION TO METHYLATED SPIRIT

SiR,-Many features described by Dr. MacDougall andMr. MacAulay (April 21) were also present in methylated-spirit drinkers among alcoholics admitted to WarlinghamPark Hospital in recent years-for instance,

" emotional

blunting, a tendency to vagrancy, pessimism, and

depression." As Dr. MacDougall says, quite a few

methylated-spirit drinkers can be rehabilitated. The

proportion of methylated-spirit drinkers was somewhathigher among our alcoholic patients (varying over theyears from 10 to 20%) and there were several womenamong them, including one with optic atrophy. Theaverage age at which these people began to take methy-lated-spirit was 35.6 years (i.e., in the " chronic phase "of alcohol addiction), after having consumed excessive