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DENTURES AND ANÆSTHESIA
789
quantity ; indeed, its rapid hydrolysis renders this virtually impossible. Thirdly, injection in the human of up to 80 mg. acetylcholine intra-arterially has not been followed by thrombosis.44 in any
Dr. Wyburn-Mason does not give the authorities for his " accelerates statement that acetylcholine blood-clotting ; 9 Zunz and Vesselowsky have shown that with high concentrations such as 1/1000 to 1/50, clotting was actually slightly "
retarded. Wilson and Stoner -1 found that the intra-arterial injection of 40-80 mg. of acetylcholine in 2 ml. was followed in the "
"
by burning," crushing pain," muscle flush-very similar to that of other accidental drug injections-and, be it noted, despite2% procaine
of cases spasm, and a skin
majority
persuaded by the evidence called by the prosecution lady gave a dishonest opinion, did not act in good faith, and was therefore advising something that was are
that that
unlawful."
After this remarkable legal pronouncement, does it not seem unlikely that, on the grounds described by Dr. Haire, a jury would convict a medical practitioner who had " in good faith " performed or advised the operation ? And therefore the risk of imprisonment and loss of livelihood by doctors who show courage in relation to the practice of therapeutic abortion, would seem to be now considerably less than formerly. ALICE JENKINS
53. Gloucester Terrace, Hon. Secretary, infiltration. These effects were attributed to the Abortion Law Reform Association. London, W.2. peri-arterial " muscarine" responses of the acetylcholine, butam given DENTURES AND ANÆSTHESIA to understand that the above solution has a pH of about 3-5 and this may be the explanation. Pain and other effects were SIR,-Some of your correspondents seem to have not a constant feature ; as in other accidental drug injections, difficulty in getting an airtight fit for the edentulous. this probably depended, as Wilson and Stoner observed, A thick piece of ’Gamgee ’ will mould to fill all except on whether the solution was distributed to skin or muscle. the most hollow cheeks. Clamping a face-piece on Quite obviously thrombosis has nothing to do with the pain. without any padding has been condemned in the past for producing nervepalsies ; but rubber face-pieces 8. Finally, Dr. Wyburn-Mason presents a case which can be moulded slightly in the hands to give a better fit. the " of brachial " after neuritis thiodeveloped signs I have found stuffing the sides of a face-piece less effective pentone injection, and comments : ’’ it is difficult to and more easily dislodged than the more usual and as due to arterial I dam?g°." explain quite agree, simpler gamgee with a hole in it for the nose and mouth. but find it even more difficult to interpret as due to local for packing round an air-way or tube, why increase injection around the brachial artery or major nerves. As the number of items which can be " left behind," except I have never known the brachial plexus to palsy itself of course when a pack is essential as for a dental as a sympathetic gesture to one of its irritated branches. week by operation ? The large masks suggested last Similar " shoulder-girdle syndrome "a cases have been " Dr. Barnard increase the " dead space in which described following T.A.B. and other inoculations, and oddly enough, after operations. Dr. Wyburn-Mason carbon dioxide and other gases can collect in too large proportions. has himself contributed to the subject ; the condition Lastly, many of the old and toothless have small has been called " neuralgic amyotrophy by Parsonage shrunken faces. and Turner.6 They attribute the effects to brachial- and S. SHUBSACHS. Manchester. and the of plexus perineural oedema, complications intravenous injections may be one of many mechanisms PROPRIETARY MEDICINES UNDER THE responsible for this. NATIONAL HEALTH SERVICE ACT It has been well said that an hypothesis, even if wrong, SIR,-It was, of course, to deal with such difficulties dies an honourable death if it has provoked thought as borderline cases (which Dr. Forster says I omitted and discussion. to consider) that I suggested an expert advisory comSOL. M. COHEN. London, W.I. mittee to the Minister. I cannot quite see how Dr. Forster can state, as he did in his letter on Oct. 30, ABORTION, STERILISATION, AND THE LAW that " proprietary articles ordered on N.H.I. and private prescription were all of the truly ethical type," and yet SIR,-The letter from Dr. Maire in your issue of fail to find anything significant in the fact that practiOct. 23 provides an opportunity for reference to the tioners were effectively discouraged from prescribing clarification of abortion law during the trial of Dr. such " truly ethical " preparations. (Average of proEleanor Bergmann and Dr. Mary Bell Ferguson, who prietary medicines prescribed in the three areas quoted last May were acquitted of criminal abortion after a by me : private 31-5%, N.H.I. 6-2%.) four days’ hearing at the Old Bailey. Dr. Forster’s criticisms of the Chemists Federation In his summing-up the judge quoted the following would not, I think, have been made had he been better words from the Bourne case (1938) : acquainted with its work over the past few years. (The If the doctor is of opinion, on reasonable grounds and federation, for example, has concerned itself little with with adequate knowledge, that the probable consequence of price protection.) Following the adoption of a selective the continuance of the pregnancy will be to make the, policy the standards committee have applied the federawoman a physical or mental wreck, the jury are quite tion’s rules in respect of formulae, conditions of manuentitled to take the view that the doctor who, under those facture and presentation, and claims made on labels circumstances and in that honest belief, operates, is operatand packings and in literature and advertisements. for of the life of the the mother." preserving ing purpose Preparations on the list before the adoption of standards And he added : "Ifully adopt those words and invite have - airo been reviewed with the result that much you to bear them very much in mind." unsound literature has been revised and certain products removed altogether from the list. This work has required Later on he told the jury : the sacrifice of a great deal of time by the members of " You are not concerned with the question as to whether the standards committee, whose qualifications are Dr. Ferguson arrived at the right conclusion ; you have pharmaceutical, scientific, and legal. Medical advice, not to decide whether Dr. Ferguson did or did not make a including that of a permanent medical adviser, is readily mistake. Between medical people there may often be taken. In addition, specialist medical opinion is sought differences of opinion ; sometimes it is difficult to assert wh-never necessary. which of two opinions is to be preferred, but you are not I think it is important to remember that there are two here to weigh up whether Dr. Ferguson was correct or related but distinct problems : (1) to establish the safety incorrect in the view that she had formed. You have to ofdomestic " proprietaries for use by the public, and (2) be satisfied by the prosecution that she expressed a disto ensure that " ethical " proprietaries have sufficient honest opinion, and that when she advised, if you think merit to justify the State paying for them under the she did advise, the termination of pregnancy by her letters National Health Service. An almost complete solution in these two cases, you will have to consider whether you to the first problem may be found in the further develop4. Wilson, A., Stoner, H. B. Quart. J. Med. 1947, 16, 237. ment of the work of the Chemists Federation, advertising Harvey, A. M., Lilienthal, J. L. Bull. Johns Hopk. Hosp. J. Pharmacol. 1932, 4, associations, and other interested bodies, always provided Ellis, L. B., Weiss, S. 1941, 69, 566. 235. that the services of the pharmacist are fully utilised. 5. Zunz, E., Vesselowsky, O. Arch. int. Pharmacodyn. 1938, 60, The high standard of the information services provided 146. " 6. Parsonage, M. J.. Turner, J. W. A. Lancet, 1948, i, 973. by the great majority of the manufacturers of ethical "
-
"
quantity ; indeed, its rapid hydrolysis renders this virtually impossible. Thirdly, injection in the human of up to 80 mg. acetylcholine intra-arterially has not been followed by thrombosis.44 in any
Dr. Wyburn-Mason does not give the authorities for his " accelerates statement that acetylcholine blood-clotting ; 9 Zunz and Vesselowsky have shown that with high concentrations such as 1/1000 to 1/50, clotting was actually slightly "
retarded. Wilson and Stoner -1 found that the intra-arterial injection of 40-80 mg. of acetylcholine in 2 ml. was followed in the "
"
by burning," crushing pain," muscle flush-very similar to that of other accidental drug injections-and, be it noted, despite2% procaine
of cases spasm, and a skin
majority
persuaded by the evidence called by the prosecution lady gave a dishonest opinion, did not act in good faith, and was therefore advising something that was are
that that
unlawful."
After this remarkable legal pronouncement, does it not seem unlikely that, on the grounds described by Dr. Haire, a jury would convict a medical practitioner who had " in good faith " performed or advised the operation ? And therefore the risk of imprisonment and loss of livelihood by doctors who show courage in relation to the practice of therapeutic abortion, would seem to be now considerably less than formerly. ALICE JENKINS
53. Gloucester Terrace, Hon. Secretary, infiltration. These effects were attributed to the Abortion Law Reform Association. London, W.2. peri-arterial " muscarine" responses of the acetylcholine, butam given DENTURES AND ANÆSTHESIA to understand that the above solution has a pH of about 3-5 and this may be the explanation. Pain and other effects were SIR,-Some of your correspondents seem to have not a constant feature ; as in other accidental drug injections, difficulty in getting an airtight fit for the edentulous. this probably depended, as Wilson and Stoner observed, A thick piece of ’Gamgee ’ will mould to fill all except on whether the solution was distributed to skin or muscle. the most hollow cheeks. Clamping a face-piece on Quite obviously thrombosis has nothing to do with the pain. without any padding has been condemned in the past for producing nervepalsies ; but rubber face-pieces 8. Finally, Dr. Wyburn-Mason presents a case which can be moulded slightly in the hands to give a better fit. the " of brachial " after neuritis thiodeveloped signs I have found stuffing the sides of a face-piece less effective pentone injection, and comments : ’’ it is difficult to and more easily dislodged than the more usual and as due to arterial I dam?g°." explain quite agree, simpler gamgee with a hole in it for the nose and mouth. but find it even more difficult to interpret as due to local for packing round an air-way or tube, why increase injection around the brachial artery or major nerves. As the number of items which can be " left behind," except I have never known the brachial plexus to palsy itself of course when a pack is essential as for a dental as a sympathetic gesture to one of its irritated branches. week by operation ? The large masks suggested last Similar " shoulder-girdle syndrome "a cases have been " Dr. Barnard increase the " dead space in which described following T.A.B. and other inoculations, and oddly enough, after operations. Dr. Wyburn-Mason carbon dioxide and other gases can collect in too large proportions. has himself contributed to the subject ; the condition Lastly, many of the old and toothless have small has been called " neuralgic amyotrophy by Parsonage shrunken faces. and Turner.6 They attribute the effects to brachial- and S. SHUBSACHS. Manchester. and the of plexus perineural oedema, complications intravenous injections may be one of many mechanisms PROPRIETARY MEDICINES UNDER THE responsible for this. NATIONAL HEALTH SERVICE ACT It has been well said that an hypothesis, even if wrong, SIR,-It was, of course, to deal with such difficulties dies an honourable death if it has provoked thought as borderline cases (which Dr. Forster says I omitted and discussion. to consider) that I suggested an expert advisory comSOL. M. COHEN. London, W.I. mittee to the Minister. I cannot quite see how Dr. Forster can state, as he did in his letter on Oct. 30, ABORTION, STERILISATION, AND THE LAW that " proprietary articles ordered on N.H.I. and private prescription were all of the truly ethical type," and yet SIR,-The letter from Dr. Maire in your issue of fail to find anything significant in the fact that practiOct. 23 provides an opportunity for reference to the tioners were effectively discouraged from prescribing clarification of abortion law during the trial of Dr. such " truly ethical " preparations. (Average of proEleanor Bergmann and Dr. Mary Bell Ferguson, who prietary medicines prescribed in the three areas quoted last May were acquitted of criminal abortion after a by me : private 31-5%, N.H.I. 6-2%.) four days’ hearing at the Old Bailey. Dr. Forster’s criticisms of the Chemists Federation In his summing-up the judge quoted the following would not, I think, have been made had he been better words from the Bourne case (1938) : acquainted with its work over the past few years. (The If the doctor is of opinion, on reasonable grounds and federation, for example, has concerned itself little with with adequate knowledge, that the probable consequence of price protection.) Following the adoption of a selective the continuance of the pregnancy will be to make the, policy the standards committee have applied the federawoman a physical or mental wreck, the jury are quite tion’s rules in respect of formulae, conditions of manuentitled to take the view that the doctor who, under those facture and presentation, and claims made on labels circumstances and in that honest belief, operates, is operatand packings and in literature and advertisements. for of the life of the the mother." preserving ing purpose Preparations on the list before the adoption of standards And he added : "Ifully adopt those words and invite have - airo been reviewed with the result that much you to bear them very much in mind." unsound literature has been revised and certain products removed altogether from the list. This work has required Later on he told the jury : the sacrifice of a great deal of time by the members of " You are not concerned with the question as to whether the standards committee, whose qualifications are Dr. Ferguson arrived at the right conclusion ; you have pharmaceutical, scientific, and legal. Medical advice, not to decide whether Dr. Ferguson did or did not make a including that of a permanent medical adviser, is readily mistake. Between medical people there may often be taken. In addition, specialist medical opinion is sought differences of opinion ; sometimes it is difficult to assert wh-never necessary. which of two opinions is to be preferred, but you are not I think it is important to remember that there are two here to weigh up whether Dr. Ferguson was correct or related but distinct problems : (1) to establish the safety incorrect in the view that she had formed. You have to ofdomestic " proprietaries for use by the public, and (2) be satisfied by the prosecution that she expressed a disto ensure that " ethical " proprietaries have sufficient honest opinion, and that when she advised, if you think merit to justify the State paying for them under the she did advise, the termination of pregnancy by her letters National Health Service. An almost complete solution in these two cases, you will have to consider whether you to the first problem may be found in the further develop4. Wilson, A., Stoner, H. B. Quart. J. Med. 1947, 16, 237. ment of the work of the Chemists Federation, advertising Harvey, A. M., Lilienthal, J. L. Bull. Johns Hopk. Hosp. J. Pharmacol. 1932, 4, associations, and other interested bodies, always provided Ellis, L. B., Weiss, S. 1941, 69, 566. 235. that the services of the pharmacist are fully utilised. 5. Zunz, E., Vesselowsky, O. Arch. int. Pharmacodyn. 1938, 60, The high standard of the information services provided 146. " 6. Parsonage, M. J.. Turner, J. W. A. Lancet, 1948, i, 973. by the great majority of the manufacturers of ethical "
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