- Email: [email protected]
AN ARTIFICIAL-ORGAN SOCIETY
1276 to take the place of drugs, herbs, and ment of Muslim rule in India, a dark
With the establishage supervened in the Indian system of medicine because the invaders brought their own doctors and their own science. So Indian medicine slipped down into obscurity, and similar was the fate of the languageSanskrit-in which it was written. Muslim Hakeems flourished practising the Arabic and Greek systems of medicine, and Persian became the official language. By the 17th century the Europeans-first Portuguese, then Dutch, French, and English -had established themselves in India. By then the fire of the Indian medicine was nearly extinguished. Ultimately the Greek and the Arab systems of medicine also met nearly the same fate. The Western system of medicine replaced all these and is the most prevalent system at present in India. But the old Indian systems of medicine still smoulder in the remote villages of India, where the Ayurvedic system in a distorted and superstitious way, with charms and amulets, has still a
logic.
following. Recent researches have established that Greece in relation to India was the learner and not the teacher. Greece was not the parent of our modern medicine but its nurse: the birth-place of the medicine of the World was India.
organisation-the London School of Medical Photographyis most unsatisfactory and has resulted in a chronic shortage of qualified medical photographers throughout the country. Department of Medical Photography, Charing Cross Hospital, London, W.C.2. Department of Medical Photography, St. James’ Hospital, Balham, London, S.W.12.
P. M. TURNBULL. E. MASON.
SIR,-Mr. Martin’s letter (May 16) is important and his Council of the London School of Medical Photography deserves the full support of all engaged in academic medicine. I have one plea: to change the terminology. " Medical photography " is but one vital branch of medical illustration. Department of Pediatrics, University of Louisville Medical School, Children’s Hospital, Louisville, Kentucky, U.S.A.
FRANK FALKNER.
PSYCHIATRY FOR STUDENTS are the prerogative of the reviewer, but distortions of fact betray at best his bias; at worst his prejudice or inattentive disaffection. In your notice (May 23) of Psychiatry for Students you refer to the author’s " hostility to paraldehyde ", but your quotation is taken from a phrase specifically related to the disadvantages of massive intramuscular injection of this otherwise harmless preparation. You select a further passage in quotation marks so deliberately wrenched from its context as to be wantonly misleading. Chronic schizophrenia, repeatedly mentioned, is described as not having been discussed. Wisely or unwisely, one author has been driven to correct, in this respect, a captious
SIR,-Opinions
errors or
Institute of Ophthalmology,
Judd Street, London, W.C.1.
that the Ministry should ensure training for medical photographers. The present method of relying upon the good will of senior staff to teach, if time allows, and upon one small voluntary
SOHAN SINGH HAYREH.
MACKINTOSH SHEETS AT OPERATIONS
SiR,—Iwas interested to read the article by Dr. Weatherall and his coworkers (May 23). Some fifteen years ago we were having considerable difficulty sterilising mackintosh sheets owing to defective autoclaves, and investigation proved that the mackintosh sheets were not sterile. Since that time I have never used a mackintosh sheet to cover a patient in such operations as exploration of an intervertebral disc, or a spinal bone-graft, which I do with the patient in the crouch position, or for operations on the hip-joint. I have not attempted to check the contamination of the towels, but there is no doubt at all that the operation wounds have been very satisfactory. Perspiration on the skin, which used to be quite conspicuous when the mackintosh sheets were removed, is no longer present. Sàlford Royal Hospital, W. SAYLE-CREER. Salford, 3.
in
MEDICAL PHOTOGRAPHY
SIR,-Mr. Martin’s letter (May 16) has brought to light situation which has disturbed many medical photographers for years.
a
The Ministry of Health, in its Whitley Council circular " 149, defines a trainee medical photographer as a person under instruction to qualify as a medical photographer ". But the Ministry does nothing to ensure that this category of staff receive any training whatever, let alone the training necessary to pass the final examination (medical section) of the Institute of British Photographers. Cases are known where trainee medical photographers, with no medical experience, have been in sole charge of medical photographic departments. How are these unfortunate trainees to obtain their training, and what of the patients with whom they are dealing ? It would be difficult to imagine a preclinical student being allowed to run a clinic with no qualified supervision, yet the Ministry seems unperturbed by the lack of medical experience in photographers who are permitted to photograph ill people without qualified P.T.B.
supervision. The employing authorities are forced to engage trainees as medical photographers, because they are unable to obtain qualified medical photographers. Trainees are leaving the field of medical photography because they cannot support wives and families on the trainee salary-scale, and because they see no prospect of obtaining adequate training with subsequent qualification. If medical photography is an integral part of a modern hospital service, then it is surely in the public interest
critic. Guy’s Hospital, London, S.E.1.
DAVID STAFFORD-CLARK.
* * * Three sentences in Dr. Stafford-Clark’s book which refer to paraldehyde read: "
while less pernicious than bromide, is a nauseating draught-with no compensatory advantages; as an intramuscular injection, it is crude, cruel, cumbersome, and carries a significant risk of abscess
Paraldehyde,
malodorous and
formation." " The other measures to be considered in the treatment of acute toxic confusional states have been outlined in detail, together with the contraindications of certain traditional but disastrous specifics such as intramuscular paraldehyde, in the relevant section." Paraldehyde intramuscularly is brutally painful, can cause local abscess formation, frequently produces an exacerbation of confusion, and may lead the confused delirious patient to believe that he has suffered a further unpremeditated assault; as indeed he has." "
It "
was
had in mind when paraldehyde ".-ED. L.
these remarks
hostility
to
we
we
spoke of
AN ARTIFICIAL-ORGAN SOCIETY
SiR,—The growing body of knowledge (part technical, part clinical) relating to replacement of organ function by devices like the artificial kidney is of interest mainly to people working in this specialised field. For this reason a society was formed in North America nearly ten years ago for the study of Artificial Internal Organs (the A.S.A.1.0.), and the need for a similar society in Europe has been felt by some workers in this country and on the Continent. A European society has
now
been formed and will hold
1277
its first conference in Amsterdam on Sept. 25. Like its American counterpart, the European society has been started by people interested in replacement of renal function (by haemodialysis, peritoneal dialysis, &c.), and the first conference will be confined to this subject. The organising committee has tried to contact personally medical and scientific workers who are likely to be interested in the society, but any who have been overlooked and who would like to join the society or attend the Amsterdam conference should contact the undersigned as soon as possible. Royal Victoria Infirmary, Newcastle upon Tyne, 1.
DAVID KERR.
GOOD LIVING
SIR,-Your leading article of May 16 says that some sacrifice is necessary for those wanting to be healthy. You imply that people are in for a.gloomy restricted life. I am wondering whether the opposite approach is not better. Show people how serene and happy those in first-rate condition are. The publicity and television cameras might show teenagers how graceful some of the athletes of their age can be. Are doctors, in fact, the right people to lead the nation to what must be a revolution in living? The mental associations with doctors are those of death, pain, and anxiety. It is difficult for a doctor to put over the fact that happiness comes from health. If Stirling Moss advised people to get out of their cars and walk for pleasure this might work. Again, to promote a change in eating habits, the women’s journals would be more valuable than pamphlets from the National Health Service. Chester. G. WHITWELL. own
MEGALOBLASTIC ANÆMIA DUE TO DIETARY DEFICIENCY SIR,-Ihave been interested to read of the recent
plethora of cases of nutritional folic-acid deficiency3 reported from Bristol,l Liverpool,2 and now Sheffield the incidence in this last analysis approaching that of addisonian pernicious anaemia. It seems that either the criteria for establishing the diagnosis must vary considerably between centres, or the incidence of nutritional megaloblastic anaania must differ greatly in various parts of the country-or perhaps both factors operate. In the South-Eastern region of Scotland I have yet to see a patient with megaloblastic anaemia that has clearly been established as due to primary deficiency of folic acid (other than in relation to pregnancy), and this is despite a search for such cases for many years and with all the various tests as these have been developed. The dietary tables used in the past for establishing the folic-acid content of foodstuffs are quite valueless,45 and there is still no agreement as to how such estimations should be carried out. There is considerable controversy as to the value of various tests of folic-acid absorption,6 and no likelihood of general agreement as to how many absorption tests must be positive before a diagnosis of primary malabsorptive disease (idiopathic steatorrhcea) is accepted. I do not see how a diagnosis of nutritional megaloblastic ansmia can be made without jejunal biopsy; and even one biopsy may give a completely misleading impression of a normal mucosa, since laparotomy may then show widespread 1.
Gough,
2. 3. 4. 5.
Forshaw, J., Moorhouse, E. H., Harwood, L. Lancet, 1964, i, 1004. Varadi, S., Elwis, A. ibid. p. 1162. Herbert, V. Amer. J. clin. Nutr. 1963, 12, 17. Butterworth, C. E., Jr., Santini, R., Jr., Frommeyer, W. B., Jr. Personal
K. R., Read, A. Med. 1963, 32, 243.
E., McCarthy, C. F., Waters,
A. H.
communication. 6. Girdwood, R. H., Delamore, I. W. Scot. med. J. 1961, 6, 44.
Quart. J.
mucosal changes of primary malabsorptive disease.No doubt’ nutritional deficiency of folic acid is commoner in certain areas, but the criteria for diagnosis must be precise; and the tests must include jejunal biopsy, which may have to be repeated more than once.
Nevertheless there is obviously need for regional surveys of folic-acid deficiency, particularly in the older age-groups. RONALD H. GIRDWOOD. University of Edinburgh. ARTERIOGRAPHY IN DIAGNOSIS OF SUBDURAL HÆMATOMA
SIR,-In his interesting paper (May 16) Dr. Gilmartin records that in 15 cases (25% of his series) the hxmatoma was not the result of trauma, and in 6 no conclusive cause was found. This prompts us to report the occurrence of apparently non-traumatic subdural hasmatoma in two brothers. A man, aged 47, had had headaches for three months; these made worse by suddenly sitting up or leaning forward. Change in his personality was noticed, and he became drowsy, disoriented and confused, though there were lucid intervals. There was no papilloedema, and neurological examination was negative. The patient’s blood-pressure was 115/65 mm. Hg. Lumbar puncture produced clear colourless fluid at a pressure of 75 mm., containing 6 lymphocytes per c.mm. and 140 mg. protein per 100 ml. Plain X-rays of skull were normal, but bilateral carotid angiography showed bilateral subdural hsematomas. Bilateral parietal burr-holes were made, and dark blood was tapped from each side. Subsequently the patient made a complete recovery from his symptoms, though he was treated for an anxiety state the following year. His brother, aged 45, was first seen two and a half years later. He had had headaches for five months, and he, also, said that these were made worse by standing up after lying, or on leaning forward, or on coughing. He had become drowsy, neglectful, and sometimes fell asleep during the day. There were no abnormal neurological signs. His blood-pressure was 125/75 mm. Hg. Plain X-rays of skull were normal. He was transferred (like his brother before him) to Mr. Ian McCaul’s neurosurgical unit at the Whittington Hospital. Bilateral posterior burr-holes for ventriculography were made, and bilateral chronic subdural hasmatomas were drained. The patient’s postoperative course was satisfactory and he remained well a year later. were
There was no history of abnormal bleeding or bruising in either brother, though no detailed haematological tests were
made.
No
previous injury, significant illness, known and there
drug therapy family history. The development was
was no
or
other relevant
of almost identical non-traumatic subdural hxmatomas in two brothers raises again the question whether, in fact, this condition depends mainly upon a congenital tendency of the dura to split, with progressive leakage of blood between the inner and outer layer. As was suggested by Wells and Dicksonall organised cystic collections of fluid and blood now generally considered to be subdural in origin may be intradural. The meningeal and endosteal layers represent the two embryonic sources of the dura. Putnam and Gushing," describing chronic subdural hoematoma, wrote: "
The enveloping membrane on the side toward the arachnoid is thin and covered with mesothelium. On the dural side it is more dense and composed of organising granulation tissue containing large mesothelium lined spaces containing blood and fibrin, which appear to anastomose with each other and with the capillaries." Girdwood, R. H., Wynn Williams, A., McManus, J. P. A., Dellipiani, A. W., Delamore, I. W., Kershaw, P. W. Unpublished. Wells, A. H., Dickson, F. H. Minnesota Med. 1946, 29, 253. 9. Putnam, J. C., Cushing, H. Arch. Surg. 1925, 11, 329.
7.
8.
With the establishage supervened in the Indian system of medicine because the invaders brought their own doctors and their own science. So Indian medicine slipped down into obscurity, and similar was the fate of the languageSanskrit-in which it was written. Muslim Hakeems flourished practising the Arabic and Greek systems of medicine, and Persian became the official language. By the 17th century the Europeans-first Portuguese, then Dutch, French, and English -had established themselves in India. By then the fire of the Indian medicine was nearly extinguished. Ultimately the Greek and the Arab systems of medicine also met nearly the same fate. The Western system of medicine replaced all these and is the most prevalent system at present in India. But the old Indian systems of medicine still smoulder in the remote villages of India, where the Ayurvedic system in a distorted and superstitious way, with charms and amulets, has still a
logic.
following. Recent researches have established that Greece in relation to India was the learner and not the teacher. Greece was not the parent of our modern medicine but its nurse: the birth-place of the medicine of the World was India.
organisation-the London School of Medical Photographyis most unsatisfactory and has resulted in a chronic shortage of qualified medical photographers throughout the country. Department of Medical Photography, Charing Cross Hospital, London, W.C.2. Department of Medical Photography, St. James’ Hospital, Balham, London, S.W.12.
P. M. TURNBULL. E. MASON.
SIR,-Mr. Martin’s letter (May 16) is important and his Council of the London School of Medical Photography deserves the full support of all engaged in academic medicine. I have one plea: to change the terminology. " Medical photography " is but one vital branch of medical illustration. Department of Pediatrics, University of Louisville Medical School, Children’s Hospital, Louisville, Kentucky, U.S.A.
FRANK FALKNER.
PSYCHIATRY FOR STUDENTS are the prerogative of the reviewer, but distortions of fact betray at best his bias; at worst his prejudice or inattentive disaffection. In your notice (May 23) of Psychiatry for Students you refer to the author’s " hostility to paraldehyde ", but your quotation is taken from a phrase specifically related to the disadvantages of massive intramuscular injection of this otherwise harmless preparation. You select a further passage in quotation marks so deliberately wrenched from its context as to be wantonly misleading. Chronic schizophrenia, repeatedly mentioned, is described as not having been discussed. Wisely or unwisely, one author has been driven to correct, in this respect, a captious
SIR,-Opinions
errors or
Institute of Ophthalmology,
Judd Street, London, W.C.1.
that the Ministry should ensure training for medical photographers. The present method of relying upon the good will of senior staff to teach, if time allows, and upon one small voluntary
SOHAN SINGH HAYREH.
MACKINTOSH SHEETS AT OPERATIONS
SiR,—Iwas interested to read the article by Dr. Weatherall and his coworkers (May 23). Some fifteen years ago we were having considerable difficulty sterilising mackintosh sheets owing to defective autoclaves, and investigation proved that the mackintosh sheets were not sterile. Since that time I have never used a mackintosh sheet to cover a patient in such operations as exploration of an intervertebral disc, or a spinal bone-graft, which I do with the patient in the crouch position, or for operations on the hip-joint. I have not attempted to check the contamination of the towels, but there is no doubt at all that the operation wounds have been very satisfactory. Perspiration on the skin, which used to be quite conspicuous when the mackintosh sheets were removed, is no longer present. Sàlford Royal Hospital, W. SAYLE-CREER. Salford, 3.
in
MEDICAL PHOTOGRAPHY
SIR,-Mr. Martin’s letter (May 16) has brought to light situation which has disturbed many medical photographers for years.
a
The Ministry of Health, in its Whitley Council circular " 149, defines a trainee medical photographer as a person under instruction to qualify as a medical photographer ". But the Ministry does nothing to ensure that this category of staff receive any training whatever, let alone the training necessary to pass the final examination (medical section) of the Institute of British Photographers. Cases are known where trainee medical photographers, with no medical experience, have been in sole charge of medical photographic departments. How are these unfortunate trainees to obtain their training, and what of the patients with whom they are dealing ? It would be difficult to imagine a preclinical student being allowed to run a clinic with no qualified supervision, yet the Ministry seems unperturbed by the lack of medical experience in photographers who are permitted to photograph ill people without qualified P.T.B.
supervision. The employing authorities are forced to engage trainees as medical photographers, because they are unable to obtain qualified medical photographers. Trainees are leaving the field of medical photography because they cannot support wives and families on the trainee salary-scale, and because they see no prospect of obtaining adequate training with subsequent qualification. If medical photography is an integral part of a modern hospital service, then it is surely in the public interest
critic. Guy’s Hospital, London, S.E.1.
DAVID STAFFORD-CLARK.
* * * Three sentences in Dr. Stafford-Clark’s book which refer to paraldehyde read: "
while less pernicious than bromide, is a nauseating draught-with no compensatory advantages; as an intramuscular injection, it is crude, cruel, cumbersome, and carries a significant risk of abscess
Paraldehyde,
malodorous and
formation." " The other measures to be considered in the treatment of acute toxic confusional states have been outlined in detail, together with the contraindications of certain traditional but disastrous specifics such as intramuscular paraldehyde, in the relevant section." Paraldehyde intramuscularly is brutally painful, can cause local abscess formation, frequently produces an exacerbation of confusion, and may lead the confused delirious patient to believe that he has suffered a further unpremeditated assault; as indeed he has." "
It "
was
had in mind when paraldehyde ".-ED. L.
these remarks
hostility
to
we
we
spoke of
AN ARTIFICIAL-ORGAN SOCIETY
SiR,—The growing body of knowledge (part technical, part clinical) relating to replacement of organ function by devices like the artificial kidney is of interest mainly to people working in this specialised field. For this reason a society was formed in North America nearly ten years ago for the study of Artificial Internal Organs (the A.S.A.1.0.), and the need for a similar society in Europe has been felt by some workers in this country and on the Continent. A European society has
now
been formed and will hold
1277
its first conference in Amsterdam on Sept. 25. Like its American counterpart, the European society has been started by people interested in replacement of renal function (by haemodialysis, peritoneal dialysis, &c.), and the first conference will be confined to this subject. The organising committee has tried to contact personally medical and scientific workers who are likely to be interested in the society, but any who have been overlooked and who would like to join the society or attend the Amsterdam conference should contact the undersigned as soon as possible. Royal Victoria Infirmary, Newcastle upon Tyne, 1.
DAVID KERR.
GOOD LIVING
SIR,-Your leading article of May 16 says that some sacrifice is necessary for those wanting to be healthy. You imply that people are in for a.gloomy restricted life. I am wondering whether the opposite approach is not better. Show people how serene and happy those in first-rate condition are. The publicity and television cameras might show teenagers how graceful some of the athletes of their age can be. Are doctors, in fact, the right people to lead the nation to what must be a revolution in living? The mental associations with doctors are those of death, pain, and anxiety. It is difficult for a doctor to put over the fact that happiness comes from health. If Stirling Moss advised people to get out of their cars and walk for pleasure this might work. Again, to promote a change in eating habits, the women’s journals would be more valuable than pamphlets from the National Health Service. Chester. G. WHITWELL. own
MEGALOBLASTIC ANÆMIA DUE TO DIETARY DEFICIENCY SIR,-Ihave been interested to read of the recent
plethora of cases of nutritional folic-acid deficiency3 reported from Bristol,l Liverpool,2 and now Sheffield the incidence in this last analysis approaching that of addisonian pernicious anaemia. It seems that either the criteria for establishing the diagnosis must vary considerably between centres, or the incidence of nutritional megaloblastic anaania must differ greatly in various parts of the country-or perhaps both factors operate. In the South-Eastern region of Scotland I have yet to see a patient with megaloblastic anaemia that has clearly been established as due to primary deficiency of folic acid (other than in relation to pregnancy), and this is despite a search for such cases for many years and with all the various tests as these have been developed. The dietary tables used in the past for establishing the folic-acid content of foodstuffs are quite valueless,45 and there is still no agreement as to how such estimations should be carried out. There is considerable controversy as to the value of various tests of folic-acid absorption,6 and no likelihood of general agreement as to how many absorption tests must be positive before a diagnosis of primary malabsorptive disease (idiopathic steatorrhcea) is accepted. I do not see how a diagnosis of nutritional megaloblastic ansmia can be made without jejunal biopsy; and even one biopsy may give a completely misleading impression of a normal mucosa, since laparotomy may then show widespread 1.
Gough,
2. 3. 4. 5.
Forshaw, J., Moorhouse, E. H., Harwood, L. Lancet, 1964, i, 1004. Varadi, S., Elwis, A. ibid. p. 1162. Herbert, V. Amer. J. clin. Nutr. 1963, 12, 17. Butterworth, C. E., Jr., Santini, R., Jr., Frommeyer, W. B., Jr. Personal
K. R., Read, A. Med. 1963, 32, 243.
E., McCarthy, C. F., Waters,
A. H.
communication. 6. Girdwood, R. H., Delamore, I. W. Scot. med. J. 1961, 6, 44.
Quart. J.
mucosal changes of primary malabsorptive disease.No doubt’ nutritional deficiency of folic acid is commoner in certain areas, but the criteria for diagnosis must be precise; and the tests must include jejunal biopsy, which may have to be repeated more than once.
Nevertheless there is obviously need for regional surveys of folic-acid deficiency, particularly in the older age-groups. RONALD H. GIRDWOOD. University of Edinburgh. ARTERIOGRAPHY IN DIAGNOSIS OF SUBDURAL HÆMATOMA
SIR,-In his interesting paper (May 16) Dr. Gilmartin records that in 15 cases (25% of his series) the hxmatoma was not the result of trauma, and in 6 no conclusive cause was found. This prompts us to report the occurrence of apparently non-traumatic subdural hasmatoma in two brothers. A man, aged 47, had had headaches for three months; these made worse by suddenly sitting up or leaning forward. Change in his personality was noticed, and he became drowsy, disoriented and confused, though there were lucid intervals. There was no papilloedema, and neurological examination was negative. The patient’s blood-pressure was 115/65 mm. Hg. Lumbar puncture produced clear colourless fluid at a pressure of 75 mm., containing 6 lymphocytes per c.mm. and 140 mg. protein per 100 ml. Plain X-rays of skull were normal, but bilateral carotid angiography showed bilateral subdural hsematomas. Bilateral parietal burr-holes were made, and dark blood was tapped from each side. Subsequently the patient made a complete recovery from his symptoms, though he was treated for an anxiety state the following year. His brother, aged 45, was first seen two and a half years later. He had had headaches for five months, and he, also, said that these were made worse by standing up after lying, or on leaning forward, or on coughing. He had become drowsy, neglectful, and sometimes fell asleep during the day. There were no abnormal neurological signs. His blood-pressure was 125/75 mm. Hg. Plain X-rays of skull were normal. He was transferred (like his brother before him) to Mr. Ian McCaul’s neurosurgical unit at the Whittington Hospital. Bilateral posterior burr-holes for ventriculography were made, and bilateral chronic subdural hasmatomas were drained. The patient’s postoperative course was satisfactory and he remained well a year later. were
There was no history of abnormal bleeding or bruising in either brother, though no detailed haematological tests were
made.
No
previous injury, significant illness, known and there
drug therapy family history. The development was
was no
or
other relevant
of almost identical non-traumatic subdural hxmatomas in two brothers raises again the question whether, in fact, this condition depends mainly upon a congenital tendency of the dura to split, with progressive leakage of blood between the inner and outer layer. As was suggested by Wells and Dicksonall organised cystic collections of fluid and blood now generally considered to be subdural in origin may be intradural. The meningeal and endosteal layers represent the two embryonic sources of the dura. Putnam and Gushing," describing chronic subdural hoematoma, wrote: "
The enveloping membrane on the side toward the arachnoid is thin and covered with mesothelium. On the dural side it is more dense and composed of organising granulation tissue containing large mesothelium lined spaces containing blood and fibrin, which appear to anastomose with each other and with the capillaries." Girdwood, R. H., Wynn Williams, A., McManus, J. P. A., Dellipiani, A. W., Delamore, I. W., Kershaw, P. W. Unpublished. Wells, A. H., Dickson, F. H. Minnesota Med. 1946, 29, 253. 9. Putnam, J. C., Cushing, H. Arch. Surg. 1925, 11, 329.
7.
8.