JUVENILE DELINQUENCY IN NORTH AMERICA

733 every three months-so that the physician cancer, if one develops, while surgery can still

can cure

find the

it."

has any right to claim can be proved that smoking is the certain cause, to prohibit smoking ? I say this though the radiologist, the physician, and the surgeon would be deprived of work. Has the theory of cellular pathology given us so much It help that we need not consider " reorientation " Apart from the truth

a

that

cure, would it not be

no-one

wiser, if it

to me that the clinicians of the past learned more of the patient. observation by JAMES F. BRAILSFORD. Birmingham. seems

SURGICAL TREATMENT OF VARICOSE VEINS SIR,-Shortly after my arrival in Canada I first watched, with horrified fascination, the removal in toto of a varicose vein of the lower limb, from saphenous opening to internal malleolus. Since then the horror I believe has lessened and the fascination increased. this to be a satisfactory operation, at its worst not less effective than high ligation with or without retrograde

injection. Smithers,

British Columbia.

KENNETH M. LEIGHTON.

SUCCINYLCHOLINE CHLORIDE AND LIVER DAMAGE

SiR,-In his letter of July 11, Professor Macintosh states that

during his visit to India and Indonesia he " despite malnutrition and an2emia-and presumably’liver damage ’-patients needed curare in larger doses than I had anticipated." He also states that he found that succinylcholine (’ Scoline/ ’Brevidil M ’) found that

behaved in a similar manner. Two-winters ago I spent the best part of three months on a lecture-demonstration tour of Pakistan (East and West), India, Ceylon, Burma, and Iraq and gained the

following impressions : Intravenous Anaesthetics Anaesthetic drugs which are given intravenously and are known respiratory depressants had to be used with caution ; otherwise long periods of apnoea resulted. Many patients showed marked muscular relaxation with what we in England would regard as modest doses of thiopentone ; for instance, Dr. H. Barat, anaesthetist at the Eden Hospital, Calcutta, demonstrated two anaesthetics for sterilisation of female patients using thiopentone alone (i.e., without additional inhalation anaesthesia) in doses of 11-5 ml. and 14 ml. respectively. By and large, I gained the impression that the dosage of thiopentone required (’ Pentothal ’ or ’Intraval ’) was about two-thirds of that which I had been accustomed to giving at home in England. Postoperative respiratory depression was most marked when pethidine had been used during operations (perhaps because it is detoxicated almost entirely by the liver), and great vigilance had to be observed to prevent morphine being given as a routine after operations instead of being withheld until the patient complained of

pain. muscular Relaxants Except in Iraq d-tubocurarine and

gallamine (’Flaxedil’)

in about two-thirds to four-fifths of the dose one was accustomed to use in England. Scoline was not demonstrated as it was thought inadvisable to demonstrate a drug which at that time was still in the experimental

were

required

stage.

Spinal and Extradural Ancesthesia Owing no doubt to the patients’

shortness of stature spinal anaesthesia could often be induced with surprisingly small doses. For instance, in Colombo I achieved spinal anaesthesia for a panhysterectomy using only 8 ml. of 1 in 1500 solution of’ Nupercaine.’ Admittedly the injection was given in the sitting-up position, but the patient was placed on her back as soon as the injection had been finished and the puncturemark swabbed with iodine. Skin analgesia rose to the level of about the eighth thoracic segment. I feel quite sure that few anxsthetists would stake money on achieving analgesia

to this height with such small doses given to an average patient in the British Isles. Iraqis needed doses similar to our own, particularly if they came from Kurdistan. Owing to the low salt intake and the prevalence of vegetarianism (with the

consequent consumption of second-class proteins)

blood-

pressures in the Indian subcontinent are rather low, and anuesthetists there are in the habit of giving spinal anaesthesia to any patient with a systolic blood-pressure above 100 mm. Hg. When used for csesarean section I found that spinal anaesthesia caused a similar drop in blood-pressure to that in English patients ; it was, however, sometimes difficult to restore the blood-pressure to normal by the use of vasopressors. In one Chinese patient instance-a in Rangoon-prophylactic

ephedrine and doses of methylamphetamine (’Methedrine’) during the operation failed to prevent a dangerous fall of blood-pressure ; intravenous noradrenaline did, however, bring the blood-pressure back to normal. Using lignocaine (’ Xylocaine ’) extradural anaesthesia (sacral extradural and spinal extradural) required much the same dosage as is used for patients in Europe and the U.S.A. Resuscitant Drugs The effect of thiopentone and pethidine could be reversed quite readily by nikethamide (and a similar experimental drug issued privately by Imperial Chemicals [Pharmaceuticals] Ltd.) in the usual doses. Neostigmine (with atropine) proved an adequate antidote to d-tubocurarine and gallamine. It is, of course, difficult to know what Professor Macintosh had in mind when he used the words " larger doses than I anticipated " ; and it may be that he found, as I did, that the dose of d-tubocurarine and gallamine ranged around 70% of that used in England. Again, when using several intravenous agents each of which is a central or peripheral respiratory depressant, it is often difficult to judge which of these drugs is responsible for any excessive apnoeaŇi.e.. Professor Macintosh may have used smaller doses of thiopentone than I was using and therefore required larger doses of the curare drug to secure quiet respiration and muscular relaxation. I would be interested to know whether Professor Macintosh agrees with me that intravenous anaesthesia must only be administered to Asian patients in cautious doses. King’s College Hospital, London, S.E.5.

JUVENILE

A. H. GALLEY.

DELINQUENCY IN NORTH AMERICA

SiR,-In your article last week on this subject you state that it is rare in this country for ajuvenile case to be heard in a criminal court. What I assume you mean is that it is rare for a juvenile case to be heard in an adult court, since all our juvenile courts are in fact criminal courts. In this country the age of criminal responsibilitv is fixed at 8 years, which is much less than that fixed by any other country outside the British Commonwealth. On the Continent it is generally 13 or 14. Children under that age, some of whom would here be regarded as lawbreakers, are dealt with by a child-welfare organisation and not by any judicial process. Our exceptionally low age of criminal responsibility is apt to strike foreign observers as both absurd and shocking, and there are very real practical drawbacks to it. Sometimes a child may appear before a juvenile court for whom some special treatment is clearly necessary ; but the magistrates may find their hands tied, either because the evidence is not sufficient to prove the particular offence, or because the police charge is not exactly in accordance with the facts. Whatever steps they might like to take for the child’s welfare, they have no option but to dismiss the case. Another drawback of the status of our juvenile courts is that it leads to a hard and fast division between the treatment of the child labelled delinquent and the child labelled maladjusted, though as a matter of common sense such a division is meaningless. So many maladjusted children are delinquent and so many delinquent children

734

maladjusted. In a school where the staff is alive to the problems of the maladjusted, a child may be recognised as such at an early stage, and sent to a special school under the educational authorities. Elsewhere a child of much the same type will be left to carry on until he finds himself in a juvenile court when he will be dealt with by the Home Office machinery, being either put on probation or sent to an approved school. One cannot hope to get the most suitable treatment for the individual when it is so often a matter of chance which of two entirely different systems the child comes under. If we had welfare organisations on the Continental lines instead of criminal courts for children of school age, any child needing special treatment could be dealt with according to his needs. Results would not be influenced by a rigid and artificial distinction.

are

Howard League for Penal Reform, Parliament Mansions, Abbey Orchard Street, London, S.W.1.

W. A. ELKIN Hon. librarian.

LEGAL RESPONSIBILITY IN BLOOD-TRANSFUSION

SIR,-May I have the opportunity, perhaps, of allaying the fears expressed by Dr. Leyton in his letter last week. I think I am correct in saying that the allergic manifestations of migraine are rather unlike those of the allergic conditions mentioned in my paper, in that it can only very rarely, if ever, be treated on allergic grounds, and secondly, if there is a sensitivity basis present, skin tests are never positive-i.e., indicating that there are no circulating non-precipitating antibodies that can be demonstrated. Furthermore, recent workshows that, genetically, there does not seem to be any evidence that migraine can be included among those allergic conditions which are considered unsuitable in a donor. The possibility, however, of mendelian characteristics being transmitted by transfusion, an idea regretfully abandoned in the 17th century, reopens a vista of limitless extent. Where cases of the passive transfer of sensitivity from donor to recipient have occurred, the sensitisation is not of long duration, and, in fact, the chief problem in transfusion work is to avoid producing reactions in donors who have " reagins " in their plasma. Finally, I should be most grateful to Dr. Leyton if he could produce any evidence, published or personal, that migraine is transmitted by transfusion. North London Blood Transfusion Centre, Deansbrook Road, Edgware, Middlesex.

J. D. JAMES

CIRCUMCISION

According to the Bible, circumcision symbolised God’s covenant with the people of Abraham-i.e., all those belonging to the House of Abraham, including those of non-Jewish origin. (" And ye shall circumcise the flesh of your foreskin and he that is eight days old shall be circumcised among you, every man child in your generations, he that is borne in the house, or bought with money of any stranger, which is not thy seed.") This latter circumstance supports the hypothesis that circumcision was only a form of tribal marking, enabling the nomadic Jews to produce a secret sign of the All other explanations fact of belonging to one tribe. of the purposive character of circumcision are of modern ...

origin. Jews, circumcision

was

not

practised by the Semitic tribes who surrounded them. This transpires from the Bible in connection with the amorous adventure of Shehem, who wished to marry Dinah, Jacob’s daughter, and was given permission on condition that " every male of you be circumcised." 1.

Schwartz, M. Heredity in Kbh. 1952, 5, suppl. 2.

Genetical

Asthma.

Acta

Modern Mohammedans and modern Jews try to submit modern justification for the practice of circumcision. But the prepuce is no hindrance to personal hygiene if a person wishes to wash properly ; its removal has not increased resistance to venereal diseases ; and circumcision does not reduce sexual desire. The statements of Sir Daniel Whiddon should, however, be amended in one or two particulars. First, the human prepuce is not only a protective covering for the glans penis, but, by the secretion of its glands (smegma), it gives the glans a greasy surface which facilitates its entry into the vagina. Secondly, Sir Daniel says that the prepuce unfolds as the penis advances through the vagina ; but actually a normal prepuce is already unfolded, and the glans is uncovered, at the time of erection. Thirdly, in asking " Is there such a thing as " a baby with phimosis ? he replies " I have never seen one." But phimosis is not uncommon among babiesthough rarely sufficient to obstruct urination, and all male babies have to be examined after birth to see whether they have phimosis or the condition termed adhsesio cellularis preputii ad glandem which can be relieved easily after birth, but not so easily later. On the other hand, phimosis, when it is present, can be relieved easily by plastic surgery even without recourse to circumcision; and the advantage of such operations is that the prepuce survives to perform its physiological function. I share Sir Daniel’s opinion that circumcision is a barbarian practice, to be avoided wherever possible. a

European Hospital, Alexandria, Egypt.

D. A. KENEDY.

Appointments HOPKINS, G. B., M.B. Birm., B.PHARM. Lond. : asst. county M.o., Bucks County Council. asst. pathologist (s.H.M.o.), JONES, 0. G., M.R.C.S., D.C.P.: Caernarvon and Anglesey H.M.c.

Director.

SiR,-May I add a few remarks to those of " Sir Daniel Whiddon " ? First of all some historical notes :

At the time of the ancient

Apart from Jews, only Mohammedans practise circumcision. (The term Mohammedan is not synonymous with Arab.) In the Koran we find no references to circumcision : only the Hadish, the explanatory text of the Koran, mentions this. According to the latter Mohammed declared Ka (circumcision) to be compulsory on all his followers. Why then was it made compulsory ? No-one knows with any degree of certainty. Educated Mohammedans, like Jews, mention hygienic reasons. However, it is more likely that Mohammed, who claimed that he and his people were the descendants of Ishmael (who was one of the sons of Abraham and the Egyptian Hagar), intended to establish a closer relationship between himself, his people, and Abraham himself by affirming the ritual of circumcision. Abraham, by the way, is one of the most imposing figures in the Koran. Even the great festival of Beyraam commemorates the sacrifice of Isaac.

allerg.,

Regional Hospital Board: CosTELLO, SHEILA, M.B. Mane., D.A. :: consultant anesthetist, Bolton and district hospital centre. EDGE, J. R., M.D. Leeds, M.R.C.P.: consultant chest physician,

Manchester

Barrow in Furness

hospital

centre.

FLETCHER, D. E., M.B. Leeds, F.F.R., D.M.R.D. : consultant radiologist, Barrow in Furness hospitals. MAY, W. R., M.B. Lond., M.R.C.P., D.C.H. : consultant chest physician, Rochdale and district hospital centre. WARD, JAMES, M.B. Lpool, D.C.P. : asst. pathologist, Barrow in Furness hospital centre. South East Metropolitan Regional Hospital Board: ANDERSON, A. W., M.D. Lond. : consultant in chest diseases, Hastings hospital group. Spain, R. H. F., M.B. Birm., F.x.c.s. : consultant thoracic surgeon, Brighton and Lewes and Preston Hall hospital group.

COPE, D. H. P., M.B. Lond., 1".F.A. R.C.S.: consultant anaesthetist, Lewisham hospital group. HART, W. S., M.B. Madras, D.A. :consultant aneesthetist, Woolwich hospital group. HUGHES, D.R., M.B., B.sc. Wales, M.R.C.O.G. : consultant obstetrician and gynaecologist, Woolwich hospital group. KING, M. B., M.D. Lond. : asst. pathologist, Bromley, Orpington, and Sevenoaks hospital group. MITCHELL, P. H., M.A., M.B. Camb., D.P.M. : asst. psychiatrist, Oakwood hospital group. TRETHOWAN, J. D., M.B. Camb., F.R.C.S., D.L.O. : consultantinE.N.T. surgery, Seamen’s hospital group. WHITE, S. E., M.R.C.S., D.O.M.S. : ophthalmologist, Bermondsey and Southwark hospital group.