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ANÆSTHETICS AND THE MIDWIFE
ANOTHER ACTIVE CONSTITUENT OF ERGOT
,of the title pages, and is accompanied by explanatory and extremely interesting descriptions. In an .attractively modest preface the difficulties inherent in compiling a seventeenth century scientific bibliography are confessed, and the method which the modern bibliographer must adopt to obtain a result that satisfies his conscience and ideals is revealed to the reader. As the author remarks, "bibliography is indeed an all-absorbing occupation, but its devotee is frequently face to face with those who fail to under.stand the source of his enjoyment." This fine work, like the splendid " Bibliotheca Osleriana " (1929), must earn the sincere gratitude of those interested in ,the bibliography of medical science to the Oxford University Press.
1373
bag is passed into the uterus, and connected by waterfilled tubing to a mercury manometer. By means of a light float on the manometer variations of intrauterine pressure are recorded on a slowly revolving In this way, not only the spontaneous drum. contractions of the puerperal uterus are clearly shown, but also the variations of activity brought about by suckling or by the administration of drugs. Moir demonstrates that while both ergotoxine and ergotamine are active in stimulating contractions of the puerperal uterus, they are comparatively slow in taking effect, requiring 15 to 45 minutes after intramuscular injection, and 35 to 40 minutes or longer when given by mouth. Furthermore, their action when given orally is erratic. On the other hand, the administration by mouth of different samples of the B.P. 1914 Ext. ergotæ liq. in 2-drachm doses and of ANOTHER ACTIVE CONSTITUENT OF ERGOT Ext. ergotae in grs. 10 doses, results within a the A REMARKABLE paper by Dr. Chassar Moir, from few minutes in marked activity of the puerperal the obstetric unit of University College Hospital, the tone of which is also increased to an uterus, that is a there reasonable - concludes with the statement much extent greater than that seen with any other ,certainty that the characteristic action of ergot known oxytocic drug. The rapid effect demonstrated in this to the old obstetricians is due to a substance which in is entire agreement with recorded clinical facts. way has a prompt and energetic action, and which is not could never have had a in obstetrics had Ergot ergotoxine, ergotamine, tyramine, or histamine ; its action not been swift andplace It would powerful. that, in fact, the ergot alkaloids, hitherto supposed also that these extracts have remarkable to be all-important, play but a subsidiary part in the appear .clinical action of the drug. This is an astonishing keeping properties, samples known to have been in a partly used stock bottle with a cork stopper finding to those who have followed the controversy kept for more than 15 months being still very active. It regarding the activity of the B.P. extracts of ergot. is difficult to resist the conclusion that the characterNearly a quarter of a century ago, G. Barger and istic and traditional effect of ergot is due to a substance F. H. Carr isolated from ergot an alkaloid which as yet unidentified, and that the clinicians who they called ergotoxine, and which was believed to be maintained that watery extracts of ergot were useful responsible for the only characteristic pharmaco- were entirely right. It should be a warning to the logical action of the drug. Later on, histamine and laboratory worker not to be too severe in his criticism tyramine were found in ergot, but it was soon of clinical observation, which might be as accurate .demonstrated that these amines had no effect on the as his own. Fortunately, by what may be described uterus when given by mouth. The view has since been as a fluke, the alcoholic ergot extract of the happy strongly pressed by pharmacologists that the processes new B.P. appears to be as active as the watery extract by which the pharmacopceial extracts of ergot were of the old B.P., when given by mouth. made might have been conceived with the definite ’object of ensuring that these extracts should contain none of the only active principle peculiar to, and ANÆSTHETICS AND THE MIDWIFE .characteristic of, the drug ; the inference being that THE demand among women of all classes that the B.P. extracts were absolutely inert and therefore shall know as little as possible of the pains of useless. Clinical opinion demurred to this conclusion. they childbirth appears to be increasing, but at present It seemed almost unbelievable that the watery extracts the women whose labour is conducted in their own used by clinicians for over a century, and concerning little relief from pain the efficacy of which there seemed to be convincing homes by midwives can expect The suggestion even at the stage of actual delivery. clinical proof, should be valueless. But the work of small of chloroform that doses should be put up in A. Bourne and J. H. Burn2 on the human parturient for this and used was made purpose recently uterus appeared to confirm the views of the pharmaco- capsules Miss E. M. Pye,1 president of the Midwives by that and alkaloid (an logists ergotoxine ergotamine Each capsule contains Tllxg of chloroisolated by Stoll in 1920, closely related to ergotoxine, Institute. and is form enclosed in a roll of gauze ; it can be though probably not chemically identical) were crushed between the fingers so that the chloroform solely responsible for the therapeutic efficacy of any soaks into the gauze roll. One capsule tucked into the preparation of ergot, and that the watery extracts side of a mask is said to be sufficient to secure analwere inactive. This view came to be generally 7 to 10 minutes. Mr. Rivett, who has given for gesia accepted, except perhaps by those who were actually in the habit of employing ergot in their practice ; the capsules extensive trial both at Queen Charlotte’s .and in the new pharmacopoeia, to be published and the Middlesex Hospitals, allows their use early in the first stage of labour. The patient sniffs the shortly, methods of extraction with acid alcohol mask whenever she feels a pain beginning, and a are substituted for the old watery extracts, so as to small of chloroform-" little more very quantity ensure the presence of what were regarded as the of than the smell it," in Mr. Rivett’s experience.active alkaloids. Now the whole controversy has to suffices procure analgesia. No attempt is made taken a new turn. to induce surgical anæsthesia ; the patient remains Moir employed a modification of Bourne and Burn’s conscious of the contractions, but these are method to obtain records in graphic form of the painless. At a meeting of the Section of Obstetrics - contractions of the puerperal uterus. About the and Gynaecology of the Royal Society of Medicine seventh day of the puerperium, a sterilised rubber (reported on p. 1361), at which Mr. Rivett described the success obtained with the capsules, several 1 Brit. Med. Jour., June 18th, 1119. ____
p.
2
Jour. Obst. and
Gyn., 1927, xxxiv., 249.
1 See THE LANCET, April 2nd, p. 727.
1374
ANOTHER CLINIC FOR
THE " NERVOUS
speakers suggested that the action of chloroform, used in such a way, was largely psychological. Mr. Eardley Holland is able to achieve a similar happy result during the first stage of labour by reassurance, persuasion, and grs. 40 of chloral; and he deprecates the prolonged use of chloroform, even in such small dosage. Most speakers, however, seemed to think the capsules harmless enough, though some feared to place a drug as dangerous as chloroform in the hands of the midwife. Dr. Fairbairn, president of the Central Midwives Board, expressed interest in the device, and the opinion of the Section of Anaesthetics of the Royal Society of Medicine is being enlisted on the question whether midwives, after preliminary training, could safely be trusted with the capsules. ____
ANOTHER CLINIC FOR THE "NERVOUS" CHILD
THE movement towards the rational treatment of the so-called " nervous " or difficult child has been gaining ground through the pioneer work of a variety of organisations throughout the country. In London alone we have one under the auspices of the Child Guidance Council of Great Britain, the East London Child Guidance Clinic of the Jewish Health Organisation, a special department at the Institute of Medical Psychology, and the National Institute of Child Psychology; while Guy’s Hospital, the Children’s
Hospital, Great Ormond-street, University College Hospital, and Maudsley Hospital each have departments devoted to this work. The two first mentioned, and those in Birmingham and Liverpool, are planned on the American system of a clearly defined unit of psychiatrist, psychologist, and social worker who deal with the cases in close collaboration. The others are mostly equipped with the same basic staff, but the unit is closely organised and is related to the hospital to which each is attached. The West End Hospital for Nervous Diseases now proposes to establish a similar unit in the autumn, to which members of the hospital staff will be able to refer cases for special treatment, though cases will also be accepted from other sources. This will mean that not only will those " nervous " and difficult children be seen who have been diagnosed as free from organic disease, but that such organically afflicted children as have behaviour sequelae will be considered for psychological assessment (intelligence estimation, and so forth), and perhaps for treatment too. Observation beds will be available. This venture is of interestin that, for the first time, a hospital for organic nervous diseases is considering the more psychological aspects of child disorders on modern lines. Clinics that are not directly associated with hospitals tend to attract a large number of cases of the " behaviour " type, largely from the schools. The cases are chosen in consequence of the teachers’ attitude and the demands of school life, its curriculum and its discipline. Such clinics may fail to attract the attention of medical practitioners, or may not win their confidence because of the fear of entanglements with new theories away from the beaten track of medical tradition. It is important that such fears should be dispelled, but this will be only a gradual process. Meanwhile, the advantage of the West End Hospital clinic may lie in the fact that most doctors have, through tradition, associated disorders of behaviour and emotion with the action of the nervous system in the widest sense, despite the fact that disturbances in other systems are not without their psychological implications. It is, moreover, an admission that while careful differential diagnosis of nervous disorder
is the first
"
CHILD
requisite,
treatment must follow
on
specific
lines, psychological and perhaps sociological.
The
fact that London is now being rapidly provided with a variety of children’s clinics, bearing a basic resemblance to each other in the recognition of the need for medical, psychological, and sociological investigation, is satisfactory ; and since each is related to different hospitals and different forms of psychological or psychiatric organisation, their study of behaviour and emotional disorders in children will soon be approached from many fresh angles. A GROWTH-PROMOTING FACTOR
paper presented to the Biochemical Society June 11th, Mr. L. W. Mapson, of Cambridge, stated1 that fresh ox liver has been shown to contain a substance which stimulates the growth of rats, maintained on a full synthetic diet, to approximately twice the normal rate. This accelerative growthresponse is relatively more marked in the male than in the female. It has been transmitted from parent to offspring by the feeding of liver to the parents, and the stimulation of growth is greater under these conditions than when the liver is fed directly to the young. This growth-promoting principle, according to Mapson’s observations, is distinct from hitherto known accessory food factors. Preliminary investigations show that it is soluble in water and is not precipitated by high alcohol concentrations. Commercial liver extracts such as Eli Lilley No. 343 contain only traces of it. A beneficial effect of feeding fresh ox liver has also been noted in connexion with lactation ; 30 per cent. only of the control animals succeeded in the rearing of their offspring, whereas no such failure of lactation occurred in those litters whose parents received liver in supplement to the basal diet. Evidence of some stimulation of ovarian activity by the feeding of liver is indicated by the readiness with which the animals breed and the increased numbers of young born in the liver-fed litters. Whether the substance active in promoting the growth rate is identical with that stimulating lactation remains to be determined, and a fuller account of the work is shortly to be published. IN
a
on
Ray and Radium Protection Committee is inquiry into the blood changes which occur in workers in radiological departments. Sir Humphry Rolleston (chairman), and Prof. Sidney Russ and Dr. Stanley Melville (hon. secretaries) have issued to hospitals a questionnaire inviting information. Copies THE X
making
an
may be had from Dr. Melville at 9, Chandos-street,
London, W. 1.
____
IT is announced that Sir John Marnoch is retiring Sept. 30th from the Regius chair of surgery in the University of Aberdeen. on
Miss Ruth Darwin has been appointed a senior commissioner of the Board of Control, in succession to Mrs. Ellen F. Pinsent, who will retire on July 31st. Mrs. Pinsent was an honorary commissioner from 1913 to 1920 and a commissioner from 1921 to 1930 ; she has been a senior commissioner since Jan. 1st, 1931, when the Board was recognised under the Mental Miss Darwin, who is a daughter Treatment Act. of the late Sir Horace Darwin, was an honorary sommissioner from 1920 to 1930, and has been a sommissioner since 1931. 1 Jour. Soc. Chem. Industry, 1932, li., 535.
,of the title pages, and is accompanied by explanatory and extremely interesting descriptions. In an .attractively modest preface the difficulties inherent in compiling a seventeenth century scientific bibliography are confessed, and the method which the modern bibliographer must adopt to obtain a result that satisfies his conscience and ideals is revealed to the reader. As the author remarks, "bibliography is indeed an all-absorbing occupation, but its devotee is frequently face to face with those who fail to under.stand the source of his enjoyment." This fine work, like the splendid " Bibliotheca Osleriana " (1929), must earn the sincere gratitude of those interested in ,the bibliography of medical science to the Oxford University Press.
1373
bag is passed into the uterus, and connected by waterfilled tubing to a mercury manometer. By means of a light float on the manometer variations of intrauterine pressure are recorded on a slowly revolving In this way, not only the spontaneous drum. contractions of the puerperal uterus are clearly shown, but also the variations of activity brought about by suckling or by the administration of drugs. Moir demonstrates that while both ergotoxine and ergotamine are active in stimulating contractions of the puerperal uterus, they are comparatively slow in taking effect, requiring 15 to 45 minutes after intramuscular injection, and 35 to 40 minutes or longer when given by mouth. Furthermore, their action when given orally is erratic. On the other hand, the administration by mouth of different samples of the B.P. 1914 Ext. ergotæ liq. in 2-drachm doses and of ANOTHER ACTIVE CONSTITUENT OF ERGOT Ext. ergotae in grs. 10 doses, results within a the A REMARKABLE paper by Dr. Chassar Moir, from few minutes in marked activity of the puerperal the obstetric unit of University College Hospital, the tone of which is also increased to an uterus, that is a there reasonable - concludes with the statement much extent greater than that seen with any other ,certainty that the characteristic action of ergot known oxytocic drug. The rapid effect demonstrated in this to the old obstetricians is due to a substance which in is entire agreement with recorded clinical facts. way has a prompt and energetic action, and which is not could never have had a in obstetrics had Ergot ergotoxine, ergotamine, tyramine, or histamine ; its action not been swift andplace It would powerful. that, in fact, the ergot alkaloids, hitherto supposed also that these extracts have remarkable to be all-important, play but a subsidiary part in the appear .clinical action of the drug. This is an astonishing keeping properties, samples known to have been in a partly used stock bottle with a cork stopper finding to those who have followed the controversy kept for more than 15 months being still very active. It regarding the activity of the B.P. extracts of ergot. is difficult to resist the conclusion that the characterNearly a quarter of a century ago, G. Barger and istic and traditional effect of ergot is due to a substance F. H. Carr isolated from ergot an alkaloid which as yet unidentified, and that the clinicians who they called ergotoxine, and which was believed to be maintained that watery extracts of ergot were useful responsible for the only characteristic pharmaco- were entirely right. It should be a warning to the logical action of the drug. Later on, histamine and laboratory worker not to be too severe in his criticism tyramine were found in ergot, but it was soon of clinical observation, which might be as accurate .demonstrated that these amines had no effect on the as his own. Fortunately, by what may be described uterus when given by mouth. The view has since been as a fluke, the alcoholic ergot extract of the happy strongly pressed by pharmacologists that the processes new B.P. appears to be as active as the watery extract by which the pharmacopceial extracts of ergot were of the old B.P., when given by mouth. made might have been conceived with the definite ’object of ensuring that these extracts should contain none of the only active principle peculiar to, and ANÆSTHETICS AND THE MIDWIFE .characteristic of, the drug ; the inference being that THE demand among women of all classes that the B.P. extracts were absolutely inert and therefore shall know as little as possible of the pains of useless. Clinical opinion demurred to this conclusion. they childbirth appears to be increasing, but at present It seemed almost unbelievable that the watery extracts the women whose labour is conducted in their own used by clinicians for over a century, and concerning little relief from pain the efficacy of which there seemed to be convincing homes by midwives can expect The suggestion even at the stage of actual delivery. clinical proof, should be valueless. But the work of small of chloroform that doses should be put up in A. Bourne and J. H. Burn2 on the human parturient for this and used was made purpose recently uterus appeared to confirm the views of the pharmaco- capsules Miss E. M. Pye,1 president of the Midwives by that and alkaloid (an logists ergotoxine ergotamine Each capsule contains Tllxg of chloroisolated by Stoll in 1920, closely related to ergotoxine, Institute. and is form enclosed in a roll of gauze ; it can be though probably not chemically identical) were crushed between the fingers so that the chloroform solely responsible for the therapeutic efficacy of any soaks into the gauze roll. One capsule tucked into the preparation of ergot, and that the watery extracts side of a mask is said to be sufficient to secure analwere inactive. This view came to be generally 7 to 10 minutes. Mr. Rivett, who has given for gesia accepted, except perhaps by those who were actually in the habit of employing ergot in their practice ; the capsules extensive trial both at Queen Charlotte’s .and in the new pharmacopoeia, to be published and the Middlesex Hospitals, allows their use early in the first stage of labour. The patient sniffs the shortly, methods of extraction with acid alcohol mask whenever she feels a pain beginning, and a are substituted for the old watery extracts, so as to small of chloroform-" little more very quantity ensure the presence of what were regarded as the of than the smell it," in Mr. Rivett’s experience.active alkaloids. Now the whole controversy has to suffices procure analgesia. No attempt is made taken a new turn. to induce surgical anæsthesia ; the patient remains Moir employed a modification of Bourne and Burn’s conscious of the contractions, but these are method to obtain records in graphic form of the painless. At a meeting of the Section of Obstetrics - contractions of the puerperal uterus. About the and Gynaecology of the Royal Society of Medicine seventh day of the puerperium, a sterilised rubber (reported on p. 1361), at which Mr. Rivett described the success obtained with the capsules, several 1 Brit. Med. Jour., June 18th, 1119. ____
p.
2
Jour. Obst. and
Gyn., 1927, xxxiv., 249.
1 See THE LANCET, April 2nd, p. 727.
1374
ANOTHER CLINIC FOR
THE " NERVOUS
speakers suggested that the action of chloroform, used in such a way, was largely psychological. Mr. Eardley Holland is able to achieve a similar happy result during the first stage of labour by reassurance, persuasion, and grs. 40 of chloral; and he deprecates the prolonged use of chloroform, even in such small dosage. Most speakers, however, seemed to think the capsules harmless enough, though some feared to place a drug as dangerous as chloroform in the hands of the midwife. Dr. Fairbairn, president of the Central Midwives Board, expressed interest in the device, and the opinion of the Section of Anaesthetics of the Royal Society of Medicine is being enlisted on the question whether midwives, after preliminary training, could safely be trusted with the capsules. ____
ANOTHER CLINIC FOR THE "NERVOUS" CHILD
THE movement towards the rational treatment of the so-called " nervous " or difficult child has been gaining ground through the pioneer work of a variety of organisations throughout the country. In London alone we have one under the auspices of the Child Guidance Council of Great Britain, the East London Child Guidance Clinic of the Jewish Health Organisation, a special department at the Institute of Medical Psychology, and the National Institute of Child Psychology; while Guy’s Hospital, the Children’s
Hospital, Great Ormond-street, University College Hospital, and Maudsley Hospital each have departments devoted to this work. The two first mentioned, and those in Birmingham and Liverpool, are planned on the American system of a clearly defined unit of psychiatrist, psychologist, and social worker who deal with the cases in close collaboration. The others are mostly equipped with the same basic staff, but the unit is closely organised and is related to the hospital to which each is attached. The West End Hospital for Nervous Diseases now proposes to establish a similar unit in the autumn, to which members of the hospital staff will be able to refer cases for special treatment, though cases will also be accepted from other sources. This will mean that not only will those " nervous " and difficult children be seen who have been diagnosed as free from organic disease, but that such organically afflicted children as have behaviour sequelae will be considered for psychological assessment (intelligence estimation, and so forth), and perhaps for treatment too. Observation beds will be available. This venture is of interestin that, for the first time, a hospital for organic nervous diseases is considering the more psychological aspects of child disorders on modern lines. Clinics that are not directly associated with hospitals tend to attract a large number of cases of the " behaviour " type, largely from the schools. The cases are chosen in consequence of the teachers’ attitude and the demands of school life, its curriculum and its discipline. Such clinics may fail to attract the attention of medical practitioners, or may not win their confidence because of the fear of entanglements with new theories away from the beaten track of medical tradition. It is important that such fears should be dispelled, but this will be only a gradual process. Meanwhile, the advantage of the West End Hospital clinic may lie in the fact that most doctors have, through tradition, associated disorders of behaviour and emotion with the action of the nervous system in the widest sense, despite the fact that disturbances in other systems are not without their psychological implications. It is, moreover, an admission that while careful differential diagnosis of nervous disorder
is the first
"
CHILD
requisite,
treatment must follow
on
specific
lines, psychological and perhaps sociological.
The
fact that London is now being rapidly provided with a variety of children’s clinics, bearing a basic resemblance to each other in the recognition of the need for medical, psychological, and sociological investigation, is satisfactory ; and since each is related to different hospitals and different forms of psychological or psychiatric organisation, their study of behaviour and emotional disorders in children will soon be approached from many fresh angles. A GROWTH-PROMOTING FACTOR
paper presented to the Biochemical Society June 11th, Mr. L. W. Mapson, of Cambridge, stated1 that fresh ox liver has been shown to contain a substance which stimulates the growth of rats, maintained on a full synthetic diet, to approximately twice the normal rate. This accelerative growthresponse is relatively more marked in the male than in the female. It has been transmitted from parent to offspring by the feeding of liver to the parents, and the stimulation of growth is greater under these conditions than when the liver is fed directly to the young. This growth-promoting principle, according to Mapson’s observations, is distinct from hitherto known accessory food factors. Preliminary investigations show that it is soluble in water and is not precipitated by high alcohol concentrations. Commercial liver extracts such as Eli Lilley No. 343 contain only traces of it. A beneficial effect of feeding fresh ox liver has also been noted in connexion with lactation ; 30 per cent. only of the control animals succeeded in the rearing of their offspring, whereas no such failure of lactation occurred in those litters whose parents received liver in supplement to the basal diet. Evidence of some stimulation of ovarian activity by the feeding of liver is indicated by the readiness with which the animals breed and the increased numbers of young born in the liver-fed litters. Whether the substance active in promoting the growth rate is identical with that stimulating lactation remains to be determined, and a fuller account of the work is shortly to be published. IN
a
on
Ray and Radium Protection Committee is inquiry into the blood changes which occur in workers in radiological departments. Sir Humphry Rolleston (chairman), and Prof. Sidney Russ and Dr. Stanley Melville (hon. secretaries) have issued to hospitals a questionnaire inviting information. Copies THE X
making
an
may be had from Dr. Melville at 9, Chandos-street,
London, W. 1.
____
IT is announced that Sir John Marnoch is retiring Sept. 30th from the Regius chair of surgery in the University of Aberdeen. on
Miss Ruth Darwin has been appointed a senior commissioner of the Board of Control, in succession to Mrs. Ellen F. Pinsent, who will retire on July 31st. Mrs. Pinsent was an honorary commissioner from 1913 to 1920 and a commissioner from 1921 to 1930 ; she has been a senior commissioner since Jan. 1st, 1931, when the Board was recognised under the Mental Miss Darwin, who is a daughter Treatment Act. of the late Sir Horace Darwin, was an honorary sommissioner from 1920 to 1930, and has been a sommissioner since 1931. 1 Jour. Soc. Chem. Industry, 1932, li., 535.