- Email: [email protected]
CHLOROFORM CAPSULES
1132 tuberculosis specialist, if possible M.D., M.R.C.P. Until then we shall drift along in this hopeless condition, deceiving the public and wasting thousands I am, Sir, yours faithfully, a year. J. D. MACFIE. MACF[E.
CHLOROFORM CAPSULES To the Editor of THE L4rCET
SrR,-The administration of chloroform capsules in maternity practice by midwives is perhaps not quite so simple a problem as some may come to believe. Winaley Sanatorium, near Bath, Oct. 28th, 1932. These capsules are now being tried by experienced administrators in our most up-to-date clinics in the UNEMPLOYMENT AND RESEARCH best of circumstances, and I have no doubt that they will give rise to considerable approval. I shall take To the Editor of THE LANCET as a text for my argument a recent extract from the SiR,—Two and a half days have not been enough to pool half the experience and suggestions on daily press. Mr. -, - deputy-coroner, held an inquest yesterunemployment from the back benches of the House day on -, wife of a dock labourer, and the aged 39, "
-
of Commons. But there has been at least one con- mother of nine children, who died in the Maternity Hospital from asphyxia, while under an anaesthetic for an spicuous omission from the debate-namely, the part on Fridayexamination. science must play in the problem. Mr. Lansbury obstetric " Miss -, the matron, said she administered the quoted a recent writer as saying " Science is pro- anaesthetic, which she made up from chloroform and ether, the presence of Dr. --, the honorary surgeon. She was gressively diminishing the demand for man-power." in This is a glaring fallacy. So said the mob that broke a certified midwife, but not a qualified ansesthetist, although she had administered anaesthetics many times. During the up the first spinning-jenny. What could industry do examination the patient’s face changed colour. Oxygen without steam, gas, electricity, fine chemicals, the and other restoratives were applied, but the patient did not internal combustion engine-all the products of revive. A post-mortem was made by Dr. -, who found science ?‘ Labour-saving machinery is but a by- that death was due to asphyxia, following the administration of an anaesthetic, accelerated by haemorrhage and the product of science. It is to science we must look for necessary obstetric procedure which were a predisposing fresh developments of individual and corporate life, factor by reducing the woman’s strength. The deputy-coroner, who returned a verdict in accorcreating fresh desires and interests in all parts of the dance with the medical evidence, said it was a matter for world, and increasing the demand for man-power. serious concern to discover that it was the practice in this The basis of scientific discovery is research, real hospital for an anaesthetic to be administered by a person and not spurious, well guided but free, alike in the who was not fully qualified. He did not attach any blame basic arts and sciences and in their application to life either to the matron or to Dr. -for following what was and industry. In this country we starve research ; evidently a practice established by their predecessors. In all probability even if a qualified anaesthetist had adminiwe appreciate the results, but not the necessary stered the anaesthetic in this case the same result would precedents. Honour is given to those who explore have occurred. He thought the anaesthetic was properly skilfully administered, and that every effort was made mountain-heights, deserts, and polar regions ;little and to those who explore Nature and substance at our to restore the patient. At the same time, in view of modern medicine and the use of anaesthesia as much as possible in. very doors. The encouragement of research-both confinement cases, he thought the hospital should disconin pure and applied science-must be one of the most tinue the present practice, and arrange for the attendance vital, as it is one of the few hopeful, factors in the of a qualified anaesthetist." future expansion of industry and solution of This patient, then, died from asphyxia and not from primary cardiac failure. I can imagine the unemployment. I am, Sir, yours faithfully, scene. The reflex disturbance in the larynx and FRANCIS FREMANTLE. respiratory mechanism, set up by manipulations or House of Commons, Nov. 9th, 1932. the stretching of the pelvic floor, the rapidly developing muscular rigidity, the clenched jaws and contracted throat muscles, the swelling and retracted THE ROYAL MEDICAL BENEVOLENT FUND tongue, the deepening cyanosis passing into lividity To the Editor of THE LANCET as the heart fails to cope with the obstructed SIR,-I should like to endorse Sir Thomas Barlow’s pulmonary circulation, and finally the few terminal appeal to his fellow practitioners for generosity to gasps as the respiratory centre gives out. Here is aa the Royal Medical Benevolent Fund. The good work condition which if once established, especially in which this Fund has been doing during the last 96 bad light and the poor circumstances which a feather years is well known, but it may not be so well under- bed offers, might well tax the skill, resource, and stood that much more urgent assistance could be presence of mind of an experienced administrator. I am not antagonistic to the administration of given if funds were available. Will each member of chloroform as an analgesic in obstetrics, for if not the our profession consider this to be a debt of honour, and one not lightly to be put on one side. I suggest best it is probably the most practical agent for again, as I suggested in your columns three years ago, general use at the present time. But will Mr. Rivett that when we have benefited by the advice of con- and his co-workers be able to arrange with certainty sulting physicians and surgeons in reference to the that the use of these capsules will never lead a stout health of ourselves, or wives or children, we might plethoric woman into the unfortunate circumstances well be expected to show our gratitude by sending which I have described, and should such a train of some help, even if small, to this Fund. There are events develop in the dim light of a cottage bedroom, cases of who have fallen doctors out at which end of the case will the perplexed midwife always piteous of the ranks on account of permanent ill-health, or be the more successful. ?‘ I am, Sir, yours faithfully, their widows and children for whom the father has W. HOWARD JONES. not had a chance to make an adequate provision. London, W., Nov. 12th, 1932. Donations may be sent to the hon. treasurer, R.M.B.F., 11, Chandos-street, London, W.I. I need To the Editor of THE LANCET that all for are most say applications hardly help SIR,-I have been interested lately in discussions carefully examined before assistance is given. on the need for new methods of easing the pains ot I am, Sir, yours faithfully, childbirth. For many years I was in the habit, in cases in which I had previously used chloroform, of JAMES G. MACASKIE. Nov. 14th, 1932. "
Harrogate,
1133 of hyoscine hydrobromide "bronchial spirochaetosis " of Castellani, Chalmers, of mine, when she saw her O’Farrell, and many others. Mason2 described I child, said "is that mine I thought someone else was " pleural spirochaetosis," and Lamb and Paton a having a baby and I was taking an interest in it." I case of vegetative endocarditis said to be caused by first learned the use of hyoscine at St. Andrew’s the same organisms. In one of my cases a chronic Hospital in 1882. While suggesting its use in mid- syphilitic pulmonary fibrosis may possibly have wifery, I can tell you much more of it in cases of complicated the condition. Whether "a streptococcus mental derangement, other than maniacal cases. I or a pneumococcus acts as a sort of pilot " for the found gr. 1/100 taken by mouth-it is tasteless in fusiform bacillus and spirochaete in these conditions water-the most useful sedative I knew. It much seems to me a matter of minor importance. astonished me from the evidence at the Crippen trial Obviously, many other organisms may be responhow very little the medical profession knew of it. sible for similar conditions. In another case of mine, Dr. D. J. Leech, of Manchester, asked me to write on met with in a young farmer in 1931, dyspnoea, loss of it nearly 40 years ago, and I then gave him all my weight, and sweating were associated with a purulent bronchitis. The sputum contained mycelial threads extensive notes.-I am, Sir, yours faithfully, in large amount. The mycelium was identified by WILLIAM STANWELL. New Milton, Hants, Nov. llth. Dr. Gloyne as that of Penicillium glaucum, a mould found on decaying fruit, hay, and cattle foodstuffs. DECOMPRESSION IN ENCEPHALITIS After a prolonged course of treatment with arsenical LETHARGICA preparations by the mouth, the mycelium disappeared To the Editor of THE LANCET from the after which the condition cleared
giving a hypodermic gr. 1/100. One patient
sputum
completely. My suggestion
SIR,-In Kenya, although we have had a fair number of cases of encephalitis lethargica, I have never known of any to survive. I was therefore justified, when I saw no hope of recovery, in trying anything reasonable on two cases recently under my care. Both were Europeans : one aged 23 and the other 5 years. The diagnosis was clinically, and according to laboratory findings, as definite as it could be. Both were treated in the ordinary way, by repeated lumbar punctures, until it was quite evident that without continuous drainage of the brain they must die. Subtemporal decompression immediately above the zygoma was done, and the dura entirely removed so that drainage would take place into the depth of the temporal muscle and the fluid be there absorbed. In both, on opening the dura, there was a big flow
up
buried anaerobic spirochaetes from their entrenchments. Arsenicals are now being used intravenously even in Vincent’s stomatitis.3 I am, Sir, yours faithfully, P. HEFFERNAN. Nov. 1932. Buxton, 7th, THE INCREASE IN ARSENIC-RESISTANT SYPHILIS
To the Editor
of water. After this comparatively simple operation to obtain continuous drainage the worst symptoms immediately disappeared. It took a fortnight in one case and a month in the other before cerebral irritation was quite gone. They are now both well, and without One I operated on three any unpleasant results. the one other years ago, year ago. I am, Sir, yours faithfully, R. W. BURKITT. Nairobi, Oct. 10th, 1932. FUSO-SPIROCHÆTAL DISEASES OF THE LUNGS To the Editor of THE LANCET
,
first
SiR,-If Dr. A. S. Hall will look up the referenceIgave in my paper he will find his question answered very fully by Dr. David T. Smith, of the New York State Hospital for Incipient Pulmonary Tuberculosis, together with a full bibliography, up to that date, of the conditions. Dr. Smith writes : " The disease may manifest itself as : (1) pulmonary gangrene ; (2) post-operative pulmonary abscess ; (3) non.
operative pulmonary abscess ; (4) abscess secondary to (a) aspiration of a foreign body, (b) pulmonary neoplasm, or even (c) pulmonary tuberculosis ; (5) unresolved pneumonia ; (6) acute bronchitis ; (7) bloody bronchitis ; (8) putrid bronchitis ; or (9) chronic bronchiectasis. In all these different clinical forms of the disease bacteriological flora have been present."
exactly
the
same
The two acute
cases reported by me were obviously post-operative putrid lung abscess, the particular type of lung abscess for which the Bacillus
cases
"
of
"
fusiformis
and Spirochceta vincenti are believed to be The chronic cases I believe to correspond bloody " or " putrid bronchitis " of Smith, the
responsible. to the
"
1 Tubercle, 1928, ix., 420.
is that intravenous arsenical treat-
ment is desirable in all the pulmonary forms of Vincent’s disease, in order to dislodge the deeply
of THE
LANCET
SiR,-I am gratified to find the thesis of Dr. Drake and Dr. Thomson, that a more resistant form of spironema is making its appearance, supported by Dr. Semon. My reason for bringing this matter before the profession is to have a thorough investigation of the late results of modern syphilotherapy. What I earnestly desire is to get a comparison between these results and what one may call the natural history of late syphilis as demonstrated by Bruusgaard’s masterly analysis of Cesar Boeck’s patients who had 4 no specific treatment whatever. The venereologist does not come into the inquiry. It demands a cardiologist, a radiologist, a neurologist, and a serologist, working in collaboration with asylum and hospital authorities. After 20 years of arsenical therapy the time appears to me ripe for such an inquiry. Investigation of the immediate results of many thousands of cases, as I understand is being prosecuted by the League of Nations, would have no value in comparison with (say) 1000 cases worked out on the lines of Bruusgaard. May I assure Colonel Burke that I did not " assume " that syphilis was decreasing in severity before " 606 " was introduced. As a pupil of Hutchinson, Waren Tay, and others who knew syphilis, I learned that what was described as its " trivial " cutaneous manifestations were the outward and visible signs of a general disease, and in my own clinic that was always my teaching. As students we learned also that there was an aetiological relationship between aneurysm and aortic disease and lues, and although we knew naught of the spironema and had no serologist to make our diagnoses, we knew there was a connexion between it and G.P.I., tabes, and ocular paralyses. As we still
2 Bull. Johns Hopkins Hosp., 1920, xxxi., 435. 3 Caskey, C. R.: Urol. and Cut. Rev., June, 1932, p. 370. 4 Norsk Mag. f. Laegevidensk, 1928, lxxxix., 1222; Arch. f. Dermat. u. Syph., 1929, clvii., 309; see THE LANCET, 1929, i., 135.
I
CHLOROFORM CAPSULES To the Editor of THE L4rCET
SrR,-The administration of chloroform capsules in maternity practice by midwives is perhaps not quite so simple a problem as some may come to believe. Winaley Sanatorium, near Bath, Oct. 28th, 1932. These capsules are now being tried by experienced administrators in our most up-to-date clinics in the UNEMPLOYMENT AND RESEARCH best of circumstances, and I have no doubt that they will give rise to considerable approval. I shall take To the Editor of THE LANCET as a text for my argument a recent extract from the SiR,—Two and a half days have not been enough to pool half the experience and suggestions on daily press. Mr. -, - deputy-coroner, held an inquest yesterunemployment from the back benches of the House day on -, wife of a dock labourer, and the aged 39, "
-
of Commons. But there has been at least one con- mother of nine children, who died in the Maternity Hospital from asphyxia, while under an anaesthetic for an spicuous omission from the debate-namely, the part on Fridayexamination. science must play in the problem. Mr. Lansbury obstetric " Miss -, the matron, said she administered the quoted a recent writer as saying " Science is pro- anaesthetic, which she made up from chloroform and ether, the presence of Dr. --, the honorary surgeon. She was gressively diminishing the demand for man-power." in This is a glaring fallacy. So said the mob that broke a certified midwife, but not a qualified ansesthetist, although she had administered anaesthetics many times. During the up the first spinning-jenny. What could industry do examination the patient’s face changed colour. Oxygen without steam, gas, electricity, fine chemicals, the and other restoratives were applied, but the patient did not internal combustion engine-all the products of revive. A post-mortem was made by Dr. -, who found science ?‘ Labour-saving machinery is but a by- that death was due to asphyxia, following the administration of an anaesthetic, accelerated by haemorrhage and the product of science. It is to science we must look for necessary obstetric procedure which were a predisposing fresh developments of individual and corporate life, factor by reducing the woman’s strength. The deputy-coroner, who returned a verdict in accorcreating fresh desires and interests in all parts of the dance with the medical evidence, said it was a matter for world, and increasing the demand for man-power. serious concern to discover that it was the practice in this The basis of scientific discovery is research, real hospital for an anaesthetic to be administered by a person and not spurious, well guided but free, alike in the who was not fully qualified. He did not attach any blame basic arts and sciences and in their application to life either to the matron or to Dr. -for following what was and industry. In this country we starve research ; evidently a practice established by their predecessors. In all probability even if a qualified anaesthetist had adminiwe appreciate the results, but not the necessary stered the anaesthetic in this case the same result would precedents. Honour is given to those who explore have occurred. He thought the anaesthetic was properly skilfully administered, and that every effort was made mountain-heights, deserts, and polar regions ;little and to those who explore Nature and substance at our to restore the patient. At the same time, in view of modern medicine and the use of anaesthesia as much as possible in. very doors. The encouragement of research-both confinement cases, he thought the hospital should disconin pure and applied science-must be one of the most tinue the present practice, and arrange for the attendance vital, as it is one of the few hopeful, factors in the of a qualified anaesthetist." future expansion of industry and solution of This patient, then, died from asphyxia and not from primary cardiac failure. I can imagine the unemployment. I am, Sir, yours faithfully, scene. The reflex disturbance in the larynx and FRANCIS FREMANTLE. respiratory mechanism, set up by manipulations or House of Commons, Nov. 9th, 1932. the stretching of the pelvic floor, the rapidly developing muscular rigidity, the clenched jaws and contracted throat muscles, the swelling and retracted THE ROYAL MEDICAL BENEVOLENT FUND tongue, the deepening cyanosis passing into lividity To the Editor of THE LANCET as the heart fails to cope with the obstructed SIR,-I should like to endorse Sir Thomas Barlow’s pulmonary circulation, and finally the few terminal appeal to his fellow practitioners for generosity to gasps as the respiratory centre gives out. Here is aa the Royal Medical Benevolent Fund. The good work condition which if once established, especially in which this Fund has been doing during the last 96 bad light and the poor circumstances which a feather years is well known, but it may not be so well under- bed offers, might well tax the skill, resource, and stood that much more urgent assistance could be presence of mind of an experienced administrator. I am not antagonistic to the administration of given if funds were available. Will each member of chloroform as an analgesic in obstetrics, for if not the our profession consider this to be a debt of honour, and one not lightly to be put on one side. I suggest best it is probably the most practical agent for again, as I suggested in your columns three years ago, general use at the present time. But will Mr. Rivett that when we have benefited by the advice of con- and his co-workers be able to arrange with certainty sulting physicians and surgeons in reference to the that the use of these capsules will never lead a stout health of ourselves, or wives or children, we might plethoric woman into the unfortunate circumstances well be expected to show our gratitude by sending which I have described, and should such a train of some help, even if small, to this Fund. There are events develop in the dim light of a cottage bedroom, cases of who have fallen doctors out at which end of the case will the perplexed midwife always piteous of the ranks on account of permanent ill-health, or be the more successful. ?‘ I am, Sir, yours faithfully, their widows and children for whom the father has W. HOWARD JONES. not had a chance to make an adequate provision. London, W., Nov. 12th, 1932. Donations may be sent to the hon. treasurer, R.M.B.F., 11, Chandos-street, London, W.I. I need To the Editor of THE LANCET that all for are most say applications hardly help SIR,-I have been interested lately in discussions carefully examined before assistance is given. on the need for new methods of easing the pains ot I am, Sir, yours faithfully, childbirth. For many years I was in the habit, in cases in which I had previously used chloroform, of JAMES G. MACASKIE. Nov. 14th, 1932. "
Harrogate,
1133 of hyoscine hydrobromide "bronchial spirochaetosis " of Castellani, Chalmers, of mine, when she saw her O’Farrell, and many others. Mason2 described I child, said "is that mine I thought someone else was " pleural spirochaetosis," and Lamb and Paton a having a baby and I was taking an interest in it." I case of vegetative endocarditis said to be caused by first learned the use of hyoscine at St. Andrew’s the same organisms. In one of my cases a chronic Hospital in 1882. While suggesting its use in mid- syphilitic pulmonary fibrosis may possibly have wifery, I can tell you much more of it in cases of complicated the condition. Whether "a streptococcus mental derangement, other than maniacal cases. I or a pneumococcus acts as a sort of pilot " for the found gr. 1/100 taken by mouth-it is tasteless in fusiform bacillus and spirochaete in these conditions water-the most useful sedative I knew. It much seems to me a matter of minor importance. astonished me from the evidence at the Crippen trial Obviously, many other organisms may be responhow very little the medical profession knew of it. sible for similar conditions. In another case of mine, Dr. D. J. Leech, of Manchester, asked me to write on met with in a young farmer in 1931, dyspnoea, loss of it nearly 40 years ago, and I then gave him all my weight, and sweating were associated with a purulent bronchitis. The sputum contained mycelial threads extensive notes.-I am, Sir, yours faithfully, in large amount. The mycelium was identified by WILLIAM STANWELL. New Milton, Hants, Nov. llth. Dr. Gloyne as that of Penicillium glaucum, a mould found on decaying fruit, hay, and cattle foodstuffs. DECOMPRESSION IN ENCEPHALITIS After a prolonged course of treatment with arsenical LETHARGICA preparations by the mouth, the mycelium disappeared To the Editor of THE LANCET from the after which the condition cleared
giving a hypodermic gr. 1/100. One patient
sputum
completely. My suggestion
SIR,-In Kenya, although we have had a fair number of cases of encephalitis lethargica, I have never known of any to survive. I was therefore justified, when I saw no hope of recovery, in trying anything reasonable on two cases recently under my care. Both were Europeans : one aged 23 and the other 5 years. The diagnosis was clinically, and according to laboratory findings, as definite as it could be. Both were treated in the ordinary way, by repeated lumbar punctures, until it was quite evident that without continuous drainage of the brain they must die. Subtemporal decompression immediately above the zygoma was done, and the dura entirely removed so that drainage would take place into the depth of the temporal muscle and the fluid be there absorbed. In both, on opening the dura, there was a big flow
up
buried anaerobic spirochaetes from their entrenchments. Arsenicals are now being used intravenously even in Vincent’s stomatitis.3 I am, Sir, yours faithfully, P. HEFFERNAN. Nov. 1932. Buxton, 7th, THE INCREASE IN ARSENIC-RESISTANT SYPHILIS
To the Editor
of water. After this comparatively simple operation to obtain continuous drainage the worst symptoms immediately disappeared. It took a fortnight in one case and a month in the other before cerebral irritation was quite gone. They are now both well, and without One I operated on three any unpleasant results. the one other years ago, year ago. I am, Sir, yours faithfully, R. W. BURKITT. Nairobi, Oct. 10th, 1932. FUSO-SPIROCHÆTAL DISEASES OF THE LUNGS To the Editor of THE LANCET
,
first
SiR,-If Dr. A. S. Hall will look up the referenceIgave in my paper he will find his question answered very fully by Dr. David T. Smith, of the New York State Hospital for Incipient Pulmonary Tuberculosis, together with a full bibliography, up to that date, of the conditions. Dr. Smith writes : " The disease may manifest itself as : (1) pulmonary gangrene ; (2) post-operative pulmonary abscess ; (3) non.
operative pulmonary abscess ; (4) abscess secondary to (a) aspiration of a foreign body, (b) pulmonary neoplasm, or even (c) pulmonary tuberculosis ; (5) unresolved pneumonia ; (6) acute bronchitis ; (7) bloody bronchitis ; (8) putrid bronchitis ; or (9) chronic bronchiectasis. In all these different clinical forms of the disease bacteriological flora have been present."
exactly
the
same
The two acute
cases reported by me were obviously post-operative putrid lung abscess, the particular type of lung abscess for which the Bacillus
cases
"
of
"
fusiformis
and Spirochceta vincenti are believed to be The chronic cases I believe to correspond bloody " or " putrid bronchitis " of Smith, the
responsible. to the
"
1 Tubercle, 1928, ix., 420.
is that intravenous arsenical treat-
ment is desirable in all the pulmonary forms of Vincent’s disease, in order to dislodge the deeply
of THE
LANCET
SiR,-I am gratified to find the thesis of Dr. Drake and Dr. Thomson, that a more resistant form of spironema is making its appearance, supported by Dr. Semon. My reason for bringing this matter before the profession is to have a thorough investigation of the late results of modern syphilotherapy. What I earnestly desire is to get a comparison between these results and what one may call the natural history of late syphilis as demonstrated by Bruusgaard’s masterly analysis of Cesar Boeck’s patients who had 4 no specific treatment whatever. The venereologist does not come into the inquiry. It demands a cardiologist, a radiologist, a neurologist, and a serologist, working in collaboration with asylum and hospital authorities. After 20 years of arsenical therapy the time appears to me ripe for such an inquiry. Investigation of the immediate results of many thousands of cases, as I understand is being prosecuted by the League of Nations, would have no value in comparison with (say) 1000 cases worked out on the lines of Bruusgaard. May I assure Colonel Burke that I did not " assume " that syphilis was decreasing in severity before " 606 " was introduced. As a pupil of Hutchinson, Waren Tay, and others who knew syphilis, I learned that what was described as its " trivial " cutaneous manifestations were the outward and visible signs of a general disease, and in my own clinic that was always my teaching. As students we learned also that there was an aetiological relationship between aneurysm and aortic disease and lues, and although we knew naught of the spironema and had no serologist to make our diagnoses, we knew there was a connexion between it and G.P.I., tabes, and ocular paralyses. As we still
2 Bull. Johns Hopkins Hosp., 1920, xxxi., 435. 3 Caskey, C. R.: Urol. and Cut. Rev., June, 1932, p. 370. 4 Norsk Mag. f. Laegevidensk, 1928, lxxxix., 1222; Arch. f. Dermat. u. Syph., 1929, clvii., 309; see THE LANCET, 1929, i., 135.
I