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A CHRISTMAS APPEAL.
1045
CORRESPONDENCE A CHRISTMAS APPEAL.
To the Editor
of
TiiE LANCET.
SIR,-For many years I have asked members of the medical profession to subscribe at this time of the year in order that the Royal Medical Benevolent Fund may distribute Christmas gifts. These gifts are made to poor widows and daughters of our professional colleagues and also to medical men who are infirm or unable to work through illness, and whose savings are exhausted. I know the times are difficult for everyone, but I feel confident that those who can spare even a small donation will do so again this year so that even greater hardship should not fall on those least able to bear it. It has been the hope of the committee to distribute 30’? to each of the annuitants and the poorest of the grantees at Christmas. I am most anxious that none should look in vain this Christmas for the gift which can bring a few additional necessities of life and extra comfort to their homes. It is difficult for us to realise that these " homes " are often only a bed-sitting room of a very cheap rental. May I ask your readers to forward their donations however small they may be ? Cheques, postal orders, or even stamps should be addressed to the Hon. Treasurer, Royal Medical Benevolent Fund, 11, Chandos-street, Cavendish-square, London, W. 1. I am, Sir, yours faithfully, THOMAS BARLOW, President, Royal Medical Benevolent Fund.
if it is true that the of first due to haemorrhage attacks not are majority but to thrombosis. The latter is usually the result of insufficient pressure, and therefore a rise in pressure seems to be indicated in threatening apoplexy. In my experience dizziness too is due to the fact that the pressure is not sufficiently high in cerebral cases
of
threatening apoplexy,
circulation. We all agree that high blood pressure ought to be done away with where the causal factor can be dealt with, but to aim at reducing pressure simply as a symptomatic treatment is a different proposition altogether. After experimenting with various methods of reducing pressure I only employ now mistura alba of uncomplicated as routine treatment in cases the In suitable cases hypertony. drinking of large of and so water beneficial, very quantities proves does exercise. The only cases rejected from our series are cases which showed a pronounced variability in pressure. I am not in a position to say whether the causal factor of our cases was nervous, toxic, or organic, for I do not believe that it is generally possible to make such distinctions by ordinary clinical methods. I am not even sure whether such clean-cut clinical types really exist. The point I should like to make, which applies to all other branches of medicine, as well as to hypertension, is that it is not safe to interfere with an adaptation unless the mechanism of this adaptation is thoroughly well known. In the absence of such thorough knowledge interference is undesirable. I am,
Sir,
To the Editor or THE LANCET.
SIR,-Prof. Rudolf suggests that the accumulation of undesirable material in cases of hypertony after reduction of arterial pressure is due to the impairment of the kidney from damage by sulphur. The following facts prove this contention to be untenable. 1. Broadly the same results were obtained after the administration of erythrol tetranitrate (half a grain every three hours), a drug which cannot possibly impair the
kidney.
2. Cases of hypertension in which the arterial pressure became low solely as a result of heart failure show abnormal an increase which disappears increase in blood-urea, &c., when the arterial pressure regains its usual high level. 3. In cases of heart disease with normal kidneys there as a result of the lowering is an accumulation of urea, &c., of arterial pressure brought about by heart failure. The increase of blood-urea in our cases was without a doubt due solely to the lowering of the arterial pressure.
He has disregarded our findings in regard to the cardiac function which is definitely impaired as a result of the treatment. Actually our treatment has brought about a condition which is very much akin to heart and kidney failure, and it is difficult to believe that in the routine treatment of uncomplicated high blood pressure we ought to aim to impair the cardiac and renal function. There remain two complications of hypertony in which a reduction of pressure may be desirableviz., threatening heart failure and apoplexy. In regard to the former, we must ask ourselves how a case of threatening heart failure will benefit by a treatment which impairs coronary circulation, even if it lessens the resistance against which the heart is working. There does not seem to be even a clear indication for the lowering of arterial pressure in
yours
faithfully, I. HARRIS.
SHOULD HIGH BLOOD PRESSURE BE REDUCED?
GAS-OXYGEN ANÆSTHESIA.
To the Editor
of THE LANCET. Sm,-Dr. Macklin’s interesting and able paper in your issue of Oct. 24th (p. 897) raises theoretical questions of fundamental importance, in so far as the cell-asphyxiation theory of the nature of aiawsthesia is made to fit in with the practical results of gas-oxygen administration. Arguing from this theory, Dr. Macklin arrives at the conclusion that there is no theoretical objection to cyanosis during gas-oxygen anaesthesia, so long as it is due to deliberately caused anoxaemia and not to congestion. From the practical point of view, any anaesthetist accustomed to the use of gas-oxygen knows that the main objection to this carefully regulated cyanosis is the immediate and almost automatic protest of the surgeon, to whose mind any sign of blueness is a presage of disaster, unless at once abolished. The patient can never be shown to suffer. One may hope that Dr. Macklin’s paper will make more generally understood this essential difference between deliberately caused cyanosis and that due to respiratory obstruction or failure. So far so good. But with Dr. Macklin’s advocacy of gas-oxygen alone for so wide a range of cases I cannot agree. Granted that there is no disadvantage to the patient in pushing the gas to the point of anoxaemia, the results of so doing from the point of view of the surgeon are simply not good enough, since so experienced an administrator as Dr. Macklin himself admits that he is far from being satisfied with one case in three of upper abdominal operations. The ideal anaesthetic is yet to be found, but most
CORRESPONDENCE A CHRISTMAS APPEAL.
To the Editor
of
TiiE LANCET.
SIR,-For many years I have asked members of the medical profession to subscribe at this time of the year in order that the Royal Medical Benevolent Fund may distribute Christmas gifts. These gifts are made to poor widows and daughters of our professional colleagues and also to medical men who are infirm or unable to work through illness, and whose savings are exhausted. I know the times are difficult for everyone, but I feel confident that those who can spare even a small donation will do so again this year so that even greater hardship should not fall on those least able to bear it. It has been the hope of the committee to distribute 30’? to each of the annuitants and the poorest of the grantees at Christmas. I am most anxious that none should look in vain this Christmas for the gift which can bring a few additional necessities of life and extra comfort to their homes. It is difficult for us to realise that these " homes " are often only a bed-sitting room of a very cheap rental. May I ask your readers to forward their donations however small they may be ? Cheques, postal orders, or even stamps should be addressed to the Hon. Treasurer, Royal Medical Benevolent Fund, 11, Chandos-street, Cavendish-square, London, W. 1. I am, Sir, yours faithfully, THOMAS BARLOW, President, Royal Medical Benevolent Fund.
if it is true that the of first due to haemorrhage attacks not are majority but to thrombosis. The latter is usually the result of insufficient pressure, and therefore a rise in pressure seems to be indicated in threatening apoplexy. In my experience dizziness too is due to the fact that the pressure is not sufficiently high in cerebral cases
of
threatening apoplexy,
circulation. We all agree that high blood pressure ought to be done away with where the causal factor can be dealt with, but to aim at reducing pressure simply as a symptomatic treatment is a different proposition altogether. After experimenting with various methods of reducing pressure I only employ now mistura alba of uncomplicated as routine treatment in cases the In suitable cases hypertony. drinking of large of and so water beneficial, very quantities proves does exercise. The only cases rejected from our series are cases which showed a pronounced variability in pressure. I am not in a position to say whether the causal factor of our cases was nervous, toxic, or organic, for I do not believe that it is generally possible to make such distinctions by ordinary clinical methods. I am not even sure whether such clean-cut clinical types really exist. The point I should like to make, which applies to all other branches of medicine, as well as to hypertension, is that it is not safe to interfere with an adaptation unless the mechanism of this adaptation is thoroughly well known. In the absence of such thorough knowledge interference is undesirable. I am,
Sir,
To the Editor or THE LANCET.
SIR,-Prof. Rudolf suggests that the accumulation of undesirable material in cases of hypertony after reduction of arterial pressure is due to the impairment of the kidney from damage by sulphur. The following facts prove this contention to be untenable. 1. Broadly the same results were obtained after the administration of erythrol tetranitrate (half a grain every three hours), a drug which cannot possibly impair the
kidney.
2. Cases of hypertension in which the arterial pressure became low solely as a result of heart failure show abnormal an increase which disappears increase in blood-urea, &c., when the arterial pressure regains its usual high level. 3. In cases of heart disease with normal kidneys there as a result of the lowering is an accumulation of urea, &c., of arterial pressure brought about by heart failure. The increase of blood-urea in our cases was without a doubt due solely to the lowering of the arterial pressure.
He has disregarded our findings in regard to the cardiac function which is definitely impaired as a result of the treatment. Actually our treatment has brought about a condition which is very much akin to heart and kidney failure, and it is difficult to believe that in the routine treatment of uncomplicated high blood pressure we ought to aim to impair the cardiac and renal function. There remain two complications of hypertony in which a reduction of pressure may be desirableviz., threatening heart failure and apoplexy. In regard to the former, we must ask ourselves how a case of threatening heart failure will benefit by a treatment which impairs coronary circulation, even if it lessens the resistance against which the heart is working. There does not seem to be even a clear indication for the lowering of arterial pressure in
yours
faithfully, I. HARRIS.
SHOULD HIGH BLOOD PRESSURE BE REDUCED?
GAS-OXYGEN ANÆSTHESIA.
To the Editor
of THE LANCET. Sm,-Dr. Macklin’s interesting and able paper in your issue of Oct. 24th (p. 897) raises theoretical questions of fundamental importance, in so far as the cell-asphyxiation theory of the nature of aiawsthesia is made to fit in with the practical results of gas-oxygen administration. Arguing from this theory, Dr. Macklin arrives at the conclusion that there is no theoretical objection to cyanosis during gas-oxygen anaesthesia, so long as it is due to deliberately caused anoxaemia and not to congestion. From the practical point of view, any anaesthetist accustomed to the use of gas-oxygen knows that the main objection to this carefully regulated cyanosis is the immediate and almost automatic protest of the surgeon, to whose mind any sign of blueness is a presage of disaster, unless at once abolished. The patient can never be shown to suffer. One may hope that Dr. Macklin’s paper will make more generally understood this essential difference between deliberately caused cyanosis and that due to respiratory obstruction or failure. So far so good. But with Dr. Macklin’s advocacy of gas-oxygen alone for so wide a range of cases I cannot agree. Granted that there is no disadvantage to the patient in pushing the gas to the point of anoxaemia, the results of so doing from the point of view of the surgeon are simply not good enough, since so experienced an administrator as Dr. Macklin himself admits that he is far from being satisfied with one case in three of upper abdominal operations. The ideal anaesthetic is yet to be found, but most