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A LONG-ACTING LOCAL ANÆSTHETIC
799 infection. The fourth patient was found at necropsy to have widespread secondaries in the pancreas and liver, but the immediate cause of death was pneumonitis due in part to Staphylococcus aureus, resistant to all antibiotics except penicillin, which had no clinical effect even in enormous doses.
muscular injection of 1 ml. morning and evening from birth to five or six days of age-that is, until the danger period for the development of kernicterus was probably over. The results were as follpws : Kernicterus Group Transfusions
It is common experience that latent infection may be exacerbated in patients undergoing treatment by these hormones for any condition, and, in the animal experiments referred to above, the animals submitted to radiation and cortisone injections suffered much more seriously from secondary infection than the control animals without cortisone. It is felt that A.c.T.H. was in part responsible for the infection which supervened in two of the above patients. In order to avoid this known complication of prolonged hormone therapy, the period of A.C.T.H. administration was covered by injections of streptomycin twice weekly and penicillin daily. It is probable that this prolonged prophylactic course of antibiotics was unhelpful and even predisposed to the development of resistant organisms. Investigations are proceeding to evaluate the possible use of A.C.T.H. in combination with radiotherapy in the treatment of carcinoma of the lung, but it is obvious that the risk of so treating a lung which may well be heavily infected at the start of treatment must receive very serious consideration. These cases and further animal experiments will be reported more fully in a later communication. Harefield Hospital, Middlesex. L. E. HOUGHTON. Middlesex Hospital, B. WALTER.
J.
London 1 W.1. London, W.
RENAL DUCTS OF BELLINI
SIR,—Dr. Duran-Jorda states, in his article last week, that he is sceptical of accepting the existence of openings of the ducts of Bellini, and is considering the possibility that in the normal kidney the urine is dialysed through a pelvic epithelium and not excreted by the ducts of The views of other Bellini into the renal pelvis. histologists on this should prove interesting. It is quite easy to make a cast of the ducts of Bellini in man by injecting ’Neoprene ’ (latex) up the ureter, thus proving irrefutably that openings of the ducts into thecalyses do exist. The ducts of Bellini are also demonstrated from time to time in retrograde pyelogramsthe phenomenon of pyelotubular back-flow. Pyelotubular back-flow, though not as common as pyelovenous back-flow, is well known to urologists and radiologists. When it occurs, it clearly demonstrates the continuity of the ducts of Bellini with the renal calyces. Photographs of pyelotubular back-flow, and of a neoprene cast of a kidney showing tufts of pyelotubular back-flow into the ducts of Bellini, are included in an article by me on pyelorenal back -flow.These should give
Dr. Duran-Jorda some proof that, whatever the state in the newborn, openings of the ducts of Bellini into the renal calyces certainly do exist in the adult. JAMES A. Ross. KERNICTERUS
SIR,—Dr. Govan and Dr. Scott (March 28) ascribe
kernicterus to brain lesions from anoxia at the time of birth. Another explanation seems possible to me. Kernicterus usually makes its appearance a few days
after birth,
and
might
be due to the withdrawal of an neutralising substance or substances present in utero but unavailable to the infant after birth. This substance might originate in the placenta, and by its presence prevent kernicterus in the unborn infant. The withdrawal of this factor after birth might permit the development of kernicterus within a few days. On this hypothesis placental extract was administered to a group of infants with haumolytic disease by intra-
inhibiting
or
-
1. Ross, J. A.
Brit. J. Urol.
1952, 24,
27.
While these results would appear to warrant further
investigation, they may be fortuitous or related to the somewhat higher rate of exchange transfusion in the treated than in the control group. This investigation continues, but meanwhile it would be interesting to have the opinions of other workers in this field. COLMAN M. SAUNDERS National Maternity Hospital, Dublin.
Director
of Pædiatrics.
HUGH OWEN THOMAS
writing a new Life of Hugh Owen Thomas, with a revised edition of his collected works. together Any assistance in this task would be welcomed ; in particular, I am anxious to have access to previously unpublished material. Letters or documents relating to any aspect of Thomas’s private or professional life, or to the history of the family, will be carefully handled and returned to the owners as soon as possible. 10, Harley Street, DAVID LE VAY. London, W.1. SIR,—I
am
A LONG-ACTING LOCAL ANÆSTHETIC Mr J. I. M. JONES, D.se., writes from the research departYour annotation. ment of Crookes Laboratories Ltd. : of March 28 implies thatEfocaine ’ remains stable for about three months. This view is evidently based on the paper by Ansbro and his colleagues to which you refer. Later results show that for practical purposes the preparation is stable for an indefinite period." "
Medicine and the Law A Doctor’s Cross-examination from convictions for murder are often The with insubstantial prospect of success. brought recent appeal in R. v. Holmes 1; was based on a complaint that a question to a medical witness was wrongly allowed. The appellant, after making what his own counsel described as a savage and frenzied attack on his landlady, went to the police and said he wanted to give himself up for murder ; he wrote out a detailed account of his actions. At the trial a doctor, called by the defence, was asked in cross-examination whether, in his opinion, such conduct, immediately after the murder, would indicate that Holmes knew that what he was doing was of the unlawful-i.e., wrong in law, within the meaning " McNaughten rules. The witness answered "Yes. Counsel cited judicial dicta to the effect that medical opinion must never usurp the function of the jury in finding the facts ; the witness, he contended, could not be asked what was in the accused person’s mind when the homicidal assault The question and answer were inadwas committed.
APPEALS
missible. The Lord Chief Justice interrupted counsel’s argument with the suggestion that the appeal seemed to raise a merely academic question. The doctors on both sides now agreed that Holmes was certifiably insane ; he would be dealt with under the Trial of Lunatics Act, 1883, and kept in custody during Her Majesty’s pleasure. Counsel replied that a long line of authorities laid it down that medical men, however eminent, could not be allowed to take on the functions of a jury by giving an opinion on the question which the jury had to answer. The Lord Chief Justice observed that, whatever fine distinctions had been drawn in some of the cases cited, 1. Times, March 31.
muscular injection of 1 ml. morning and evening from birth to five or six days of age-that is, until the danger period for the development of kernicterus was probably over. The results were as follpws : Kernicterus Group Transfusions
It is common experience that latent infection may be exacerbated in patients undergoing treatment by these hormones for any condition, and, in the animal experiments referred to above, the animals submitted to radiation and cortisone injections suffered much more seriously from secondary infection than the control animals without cortisone. It is felt that A.c.T.H. was in part responsible for the infection which supervened in two of the above patients. In order to avoid this known complication of prolonged hormone therapy, the period of A.C.T.H. administration was covered by injections of streptomycin twice weekly and penicillin daily. It is probable that this prolonged prophylactic course of antibiotics was unhelpful and even predisposed to the development of resistant organisms. Investigations are proceeding to evaluate the possible use of A.C.T.H. in combination with radiotherapy in the treatment of carcinoma of the lung, but it is obvious that the risk of so treating a lung which may well be heavily infected at the start of treatment must receive very serious consideration. These cases and further animal experiments will be reported more fully in a later communication. Harefield Hospital, Middlesex. L. E. HOUGHTON. Middlesex Hospital, B. WALTER.
J.
London 1 W.1. London, W.
RENAL DUCTS OF BELLINI
SIR,—Dr. Duran-Jorda states, in his article last week, that he is sceptical of accepting the existence of openings of the ducts of Bellini, and is considering the possibility that in the normal kidney the urine is dialysed through a pelvic epithelium and not excreted by the ducts of The views of other Bellini into the renal pelvis. histologists on this should prove interesting. It is quite easy to make a cast of the ducts of Bellini in man by injecting ’Neoprene ’ (latex) up the ureter, thus proving irrefutably that openings of the ducts into thecalyses do exist. The ducts of Bellini are also demonstrated from time to time in retrograde pyelogramsthe phenomenon of pyelotubular back-flow. Pyelotubular back-flow, though not as common as pyelovenous back-flow, is well known to urologists and radiologists. When it occurs, it clearly demonstrates the continuity of the ducts of Bellini with the renal calyces. Photographs of pyelotubular back-flow, and of a neoprene cast of a kidney showing tufts of pyelotubular back-flow into the ducts of Bellini, are included in an article by me on pyelorenal back -flow.These should give
Dr. Duran-Jorda some proof that, whatever the state in the newborn, openings of the ducts of Bellini into the renal calyces certainly do exist in the adult. JAMES A. Ross. KERNICTERUS
SIR,—Dr. Govan and Dr. Scott (March 28) ascribe
kernicterus to brain lesions from anoxia at the time of birth. Another explanation seems possible to me. Kernicterus usually makes its appearance a few days
after birth,
and
might
be due to the withdrawal of an neutralising substance or substances present in utero but unavailable to the infant after birth. This substance might originate in the placenta, and by its presence prevent kernicterus in the unborn infant. The withdrawal of this factor after birth might permit the development of kernicterus within a few days. On this hypothesis placental extract was administered to a group of infants with haumolytic disease by intra-
inhibiting
or
-
1. Ross, J. A.
Brit. J. Urol.
1952, 24,
27.
While these results would appear to warrant further
investigation, they may be fortuitous or related to the somewhat higher rate of exchange transfusion in the treated than in the control group. This investigation continues, but meanwhile it would be interesting to have the opinions of other workers in this field. COLMAN M. SAUNDERS National Maternity Hospital, Dublin.
Director
of Pædiatrics.
HUGH OWEN THOMAS
writing a new Life of Hugh Owen Thomas, with a revised edition of his collected works. together Any assistance in this task would be welcomed ; in particular, I am anxious to have access to previously unpublished material. Letters or documents relating to any aspect of Thomas’s private or professional life, or to the history of the family, will be carefully handled and returned to the owners as soon as possible. 10, Harley Street, DAVID LE VAY. London, W.1. SIR,—I
am
A LONG-ACTING LOCAL ANÆSTHETIC Mr J. I. M. JONES, D.se., writes from the research departYour annotation. ment of Crookes Laboratories Ltd. : of March 28 implies thatEfocaine ’ remains stable for about three months. This view is evidently based on the paper by Ansbro and his colleagues to which you refer. Later results show that for practical purposes the preparation is stable for an indefinite period." "
Medicine and the Law A Doctor’s Cross-examination from convictions for murder are often The with insubstantial prospect of success. brought recent appeal in R. v. Holmes 1; was based on a complaint that a question to a medical witness was wrongly allowed. The appellant, after making what his own counsel described as a savage and frenzied attack on his landlady, went to the police and said he wanted to give himself up for murder ; he wrote out a detailed account of his actions. At the trial a doctor, called by the defence, was asked in cross-examination whether, in his opinion, such conduct, immediately after the murder, would indicate that Holmes knew that what he was doing was of the unlawful-i.e., wrong in law, within the meaning " McNaughten rules. The witness answered "Yes. Counsel cited judicial dicta to the effect that medical opinion must never usurp the function of the jury in finding the facts ; the witness, he contended, could not be asked what was in the accused person’s mind when the homicidal assault The question and answer were inadwas committed.
APPEALS
missible. The Lord Chief Justice interrupted counsel’s argument with the suggestion that the appeal seemed to raise a merely academic question. The doctors on both sides now agreed that Holmes was certifiably insane ; he would be dealt with under the Trial of Lunatics Act, 1883, and kept in custody during Her Majesty’s pleasure. Counsel replied that a long line of authorities laid it down that medical men, however eminent, could not be allowed to take on the functions of a jury by giving an opinion on the question which the jury had to answer. The Lord Chief Justice observed that, whatever fine distinctions had been drawn in some of the cases cited, 1. Times, March 31.