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AMBULANCES AND STRETCHERS
1137 of the local medical and panel committee and of payments to practitioners for the cost of the provision of ansesthetists and emergency treatment. It will be clear that, although at the source the central practitioners’ fund has been based on an estimate of the insured population multiplied by 9s., the areal practitioners’ fund as calculated does not necessarily represent the local insured population multiplied by 9s. ; it may be either above or below this figure. In the administrative county of London up to 1933 the unit value was actually less than the nominal 9s. value, but the clearance of the medical register, which took effect as from Jan. 1st, 1934,
expenditure
reduced the number of units of credit upon which practitioners’ remuneration was based without affecting the calculation of the areal practitioners’ fund. The result was that whereas for 1933 the value of a unit of credit in London was 7s. 11-46524., in 1934 the equivalent value was 8s. 7-4932d. This was at a time when economy deductions were being made from the remuneration of practitioners. For the year 1935 the figure rose to 9s. 1-17192d., but this increase was accounted for mainly by the restoration of the economy deduction of 5 per cent. which operated only for the first six months of that year. For the year 1936 the total payment will amount to 9s. 2-5254d.
CORRESPONDENCE AMBULANCES AND STRETCHERS
To the Editor
of THE
LANCET
SIR,-I am -glad that Dr. Lockhart noticed my letter because it was his letter, published in your columns two years ago, which stimulated my interest in this subject. I quite agree with him that the universal adoption of a standard stretcher with telescopic or folding handles would simplify our problem, but I do not think that the fighting services of any nation would They would not consider such stretchers agree. capable of standing up to the rough usages of war. I realise the great advantages of short stretchers when it comes to carrying them in lifts, railway-carriages, air-ambulances, and boats (we in the Navy have a short stretcher), but I cannot envisage the abolition of long stretchers and I still think that ambulances capable of carrying long or short stretchers should be adopted where practicable. Standardisation of gauge, as Dr. Lockhart points out, is essential. I am, Sir, yours faithfully,
4. It is an advantage that the secretion obtained is not mixed with any fluid given as test stimulus. 5. The optimal amount of insulin was found to be 12-15 units (Heller 2). The secretion starts about 20-40 minutes after intravenous (or about one hour after subcutaneous) injection. In patients with normal gastric secretion 55-75 are the highest values for free acidity, and 75-95 the highest values for total acidity. 6. The stimulating action of insulin on the gastric secretion shows that the administration of insulin is contra-indicated in fattening cures in patients with
hyperacidity. Each of these points has already been made by Meyer and/or Heller. May I take this opportunity to remind your readers that in distinguishing hyper- from hypo-glycsemic coma a positive Babinski sign proves the coma to be hypoglycsemic. Whereas the differential diagnostic value of flaccidity in hyper-, and of spasticity in hypo-glycsemic, coma is mentioned in many textbooks and papers, a reference to Babinski’s sign is very rarely to be found. I am, Sir, yours faithfully,
R. A. W. FORD,
HERBERT LEVY.
Surgeon-Commander, Royal Navy. INSULIN AND GASTRIC SECRETION
To the Editor
of
THE LANCET
SIR,-At meeting at the Royal Society of Medicine on March 9th Prof. E. C. Dodds and Dr. R. L. Noble reported1 observations on the action of insulin on the gastric secretion of cats. Having several years’ experience with insulin as " mealfor fractional tests I should like to bring out the following points. a
1. Insulin stimulates
gastric secretion sufficiently to discriminate between pseudo-anacidity and true anacidity just as often as one can with histamine. 2. The stimulus to the stomach is the hypoglycsemia, enable
one
to
acting through the vagus (as stated, for example, by Heller2 and by Dodds and Noble,l but questioned by Meyer 3). The test is therefore not suitable for diabetic patients. 3. Whereas histamine sometimes produces undesirable side-effects which may be difficult to overcome, the insulin test, using the doses stated below, rarely causes symptoms requiring treatment. In the few cases which developed hypoglycsemic symptoms that were at all serious I have nearly always been able to control them by oral administration of sugar, and it has very seldom been necessary to give intravenous glucose injections.
1 Dodds,
30, 815; 2
E. C., and Noble, R. L. (1937) Proc. R. Soc. Med. also Lancet, March 20th, p. 692. H. (1931) Med. Klinik, 27, 1451 ; (1931) Z. ges. exp.
see
Heller,
Med. 99, 607. 3
Meyer, P. F. (1930) Klin.
Wschr. 9, 1578.
PRURITUS ANI
To the Editor
of THE LANCET about pruritus
ani is as SIR,-Surgical news attractive as it is varied, and the announcement in your issue of April 17th, of the " prepruritic stage of pruritus ani " is quite delightful. I suspect that Mr. Riddoch wrote his article with his tongue in his cheek, but he has allowed fiction so heavily to outweigh fact that some little protest must be entered. The cedema of the skin which might seem to give the stamp of reality to his theory is in fact the finding common to all itching and rubbed skins though it is more readily provoked in the skin of the genitalia and perineum and of the areolae. It is not true that " itching is apt to occur more frequently about the various body orifices than elsewhere " ; it is not even true of the vulva and anus, it is less true of the eyes, ears, nose, mouth, and urethra. Does Mr. Riddoch seriously suggest that X ray therapy is curative because of its destructive effect on the vessels7 This is alarming. With the courage characteristic of the surgeon he dismisses the psychological side of the problem, but Carlyle was wiser than Mr. Riddoch imagines. There is no doubt of the pleasure associated with itching, especially anal itching, as the majority of subjects Indeed it is the with pruritus ani will confess.
expenditure
reduced the number of units of credit upon which practitioners’ remuneration was based without affecting the calculation of the areal practitioners’ fund. The result was that whereas for 1933 the value of a unit of credit in London was 7s. 11-46524., in 1934 the equivalent value was 8s. 7-4932d. This was at a time when economy deductions were being made from the remuneration of practitioners. For the year 1935 the figure rose to 9s. 1-17192d., but this increase was accounted for mainly by the restoration of the economy deduction of 5 per cent. which operated only for the first six months of that year. For the year 1936 the total payment will amount to 9s. 2-5254d.
CORRESPONDENCE AMBULANCES AND STRETCHERS
To the Editor
of THE
LANCET
SIR,-I am -glad that Dr. Lockhart noticed my letter because it was his letter, published in your columns two years ago, which stimulated my interest in this subject. I quite agree with him that the universal adoption of a standard stretcher with telescopic or folding handles would simplify our problem, but I do not think that the fighting services of any nation would They would not consider such stretchers agree. capable of standing up to the rough usages of war. I realise the great advantages of short stretchers when it comes to carrying them in lifts, railway-carriages, air-ambulances, and boats (we in the Navy have a short stretcher), but I cannot envisage the abolition of long stretchers and I still think that ambulances capable of carrying long or short stretchers should be adopted where practicable. Standardisation of gauge, as Dr. Lockhart points out, is essential. I am, Sir, yours faithfully,
4. It is an advantage that the secretion obtained is not mixed with any fluid given as test stimulus. 5. The optimal amount of insulin was found to be 12-15 units (Heller 2). The secretion starts about 20-40 minutes after intravenous (or about one hour after subcutaneous) injection. In patients with normal gastric secretion 55-75 are the highest values for free acidity, and 75-95 the highest values for total acidity. 6. The stimulating action of insulin on the gastric secretion shows that the administration of insulin is contra-indicated in fattening cures in patients with
hyperacidity. Each of these points has already been made by Meyer and/or Heller. May I take this opportunity to remind your readers that in distinguishing hyper- from hypo-glycsemic coma a positive Babinski sign proves the coma to be hypoglycsemic. Whereas the differential diagnostic value of flaccidity in hyper-, and of spasticity in hypo-glycsemic, coma is mentioned in many textbooks and papers, a reference to Babinski’s sign is very rarely to be found. I am, Sir, yours faithfully,
R. A. W. FORD,
HERBERT LEVY.
Surgeon-Commander, Royal Navy. INSULIN AND GASTRIC SECRETION
To the Editor
of
THE LANCET
SIR,-At meeting at the Royal Society of Medicine on March 9th Prof. E. C. Dodds and Dr. R. L. Noble reported1 observations on the action of insulin on the gastric secretion of cats. Having several years’ experience with insulin as " mealfor fractional tests I should like to bring out the following points. a
1. Insulin stimulates
gastric secretion sufficiently to discriminate between pseudo-anacidity and true anacidity just as often as one can with histamine. 2. The stimulus to the stomach is the hypoglycsemia, enable
one
to
acting through the vagus (as stated, for example, by Heller2 and by Dodds and Noble,l but questioned by Meyer 3). The test is therefore not suitable for diabetic patients. 3. Whereas histamine sometimes produces undesirable side-effects which may be difficult to overcome, the insulin test, using the doses stated below, rarely causes symptoms requiring treatment. In the few cases which developed hypoglycsemic symptoms that were at all serious I have nearly always been able to control them by oral administration of sugar, and it has very seldom been necessary to give intravenous glucose injections.
1 Dodds,
30, 815; 2
E. C., and Noble, R. L. (1937) Proc. R. Soc. Med. also Lancet, March 20th, p. 692. H. (1931) Med. Klinik, 27, 1451 ; (1931) Z. ges. exp.
see
Heller,
Med. 99, 607. 3
Meyer, P. F. (1930) Klin.
Wschr. 9, 1578.
PRURITUS ANI
To the Editor
of THE LANCET about pruritus
ani is as SIR,-Surgical news attractive as it is varied, and the announcement in your issue of April 17th, of the " prepruritic stage of pruritus ani " is quite delightful. I suspect that Mr. Riddoch wrote his article with his tongue in his cheek, but he has allowed fiction so heavily to outweigh fact that some little protest must be entered. The cedema of the skin which might seem to give the stamp of reality to his theory is in fact the finding common to all itching and rubbed skins though it is more readily provoked in the skin of the genitalia and perineum and of the areolae. It is not true that " itching is apt to occur more frequently about the various body orifices than elsewhere " ; it is not even true of the vulva and anus, it is less true of the eyes, ears, nose, mouth, and urethra. Does Mr. Riddoch seriously suggest that X ray therapy is curative because of its destructive effect on the vessels7 This is alarming. With the courage characteristic of the surgeon he dismisses the psychological side of the problem, but Carlyle was wiser than Mr. Riddoch imagines. There is no doubt of the pleasure associated with itching, especially anal itching, as the majority of subjects Indeed it is the with pruritus ani will confess.