- Email: [email protected]
ESTIMATION OF BLOOD-LOSS
1125
tion of the rule of professional secrecy in the case of mental defectives. There may well be occasions when it would be fitting and proper for the police to intervene by the institution of legal proceedings against a suspected offender and there may also be sound reasons in law for issuing the advice described above. I feel, however, that before a change of this order is sponsored by official Governmental departments relating to an important ethical tenet the least that the Association could expect would be a communication from the parties who propose an alteration setting out their reasons and any legal sanction that might be invoked for their support. I hope that opportunity will be afforded in the near future for representatives of the Association and of the Ministry to meet to discuss the situation created by the issue of the memorandum. ROBERT FORBES The Medical Defence Union, Secretary.
London, W.C.1.
ESTIMATION OF BLOOD-LOSS
SiR,ńYour editorial of May 14 on the difficulty of estimating accurately the amount of blood lost at
operation its close.
or as a
result of trauma
was
excellent-until
Having rightly stressed that blood-loss is usually
underestimated, you continue "... there is still insufficient evidence to justify the very large transfusions of blood recommended by Prentice et al. Early surgical treatment should be combined with rapid transfusion of enough blood to maintain the blood-pressure within normal limits." But one of the reasons that Prentice et al. gave these very large quantities of blood was to do this very thing. And surely the fallacy of relying only on the blood-pressure as a measure of circulatory normality is the reason why blood-loss is so frequently underestimated. This recurrent canard is continually being shot down, and some of the best shots are included in thereferences to your editorial. These references point out that a loss of blood-volume of up to 2 litres can be associated with a normal blood-pressure. They point out that such patients are liable to develop alarming and sometimes lethal falls of blood-pressure under anaesthesia and there is also evidence that they are liable to develop acute anuria. The temperature and colour of the nose and extremities and the size of the subcutaneous veins are far better clinical indications of the normality of blood-flow than is the blood-pressure. Prentice and his colleagues were aware of these facts which is another reason why they gave such large quantities of blood. Finally, the group which they transfused included many suffering from multiple gunshot wounds which continued to bleed until and during operation. It is unfair to criticise the quantity of blood (10-20 litres) found necessary in these cases, by contrasting them with the amounts found to be adequate for civilian casualties with closed injuries or a single open lesion. St. Thomas’s Hospital Medical School, H. E. DE WARDENER. London, S.E.1. CORPORAL PUNISHMENT IN SCHOOL
SiR,-Dr. Jackson’s letter of May
14
sponsors a point of view that has been carried to absurd and dangerous extremes in the United States. Without commenting upon his gestalt theories, I feel compelled to warn British readers that the " permissive " attitude can lead to serious lowering of intellectual and moral standards in the schools. A Californian teacher has recently been discharged, not for using corporal punishment, but for teaching school by " traditional " instead of " progressive " methods. He testified that fourth-grade children do not know the alphabet, and that when he attempted to teach the multiplication tables by drills he was rebuked by a superior. The teacher was not allowed to discipline
who called him obscene names for three months. was not allowed to punish a child who attacked her and broke her nose. The " progressive " school authorities would not listen when these and other teachers sought disciplinary measures. Dr. Jackson’s gestalt theories lead him to believe that punishment will render children susceptible to illness. Years of experience with "progressive education " convince me that lack of intellectual and moral discipline can be a serious danger to children, to the community, and, ultimately, to the survival of all civilised values. a
boy
Another teacher
Edinburgh.
RONALD W. ANGEL.
ADENOSINE TRIPHOSPHATE IN PAROXYSMAL TACHYCARDIA 1929 SiR,-In Drury and Szent-Gy6rgyi1 pointed out that adenosine triphosphate (A.T.P.), adenosine monophosphate (A.M.P.), and adenosine dilated the coronary
arteries and slowed atrioventricular conduction. The work of Green,2 Bielschowsky et al.,3 and others made it clear that these substances act by inducing a " shock " comparable to that produced, under certain conditions, by histamine, adrenaline, or insulin. Moreover, it was found that the adenyl root is responsible for the vasodepressor effect, while the pyrophosphate is the shockinducing factor in A.T.P. ; also, that magnesium phosphate is the most active shock-inducing member of this group of substances. Accordingly I have tried, over the past ten years, to bring about the cessation of paroxysmal tachycardia, by producing a mitigated shock with intravenous adenosine triphosphate. 18-20 seconds after an intravenous injection (given as rapidly as possible) of 2 ml. (20 mg.) of A.T.P.,
complete asystole, lasting
2-4
seconds, usually
This asystole is sometimes interrupted by ventricular extrasystoles originating from various foci, or by isolated auricular contractions : in these circumstances the patient is asked to swallow once or twice, and subsequently he reports with relief that his galloping heart action has slowed down. The electrocardiogram (E.C.G.) shows a nodal impulse formation for 3-4 complexes or, after a few atypical auricular-ventricular complexes, transitional auricle activity without ventricular stoppage. Subsequently regular sinus rhythm is established, differing from normal rhythm only in that the conduction-time from auricle to ventricle is longer ; but after 3-4 complexes this too returns to normal. Judging from the E.C.G. changes during the injection, there seems no doubt that the A.T.P. substances arrest the heart action and temporarily cause complete asystole. While the impulse formation is slowly recovering they inhibit impulse conduction and so prevent recurrence of the paroxysmal tachycardia.
ensues.
The effective dose is 20 mg. (2 ml.), provided that the vein sufficiently wide to allow rapid injection. If the veins are thin and weak-walled, I adminster 30 mg. at the outset. In no case have I observed any toxic side-effects. Since the effect is due to the high blood level, intramuscular injection is unsuitable.
is
In 1947 I reported 96 onsets successfully treated in this and in 1949 an additional 118 onsets,Komor and Garas6 last year reported success in 250 episodes among 50 patients. The response of supraventricular paroxysmal tachycardia to adenosine triphosphate is so striking that it may be taken as one of the chief criteria in the diagnosis of the condition.
way,4
Postgraduate Institute of Medicine, ERNÖ E RN 0.. OML. SOMLÓ. e A Budapest, Hungary. 1. Drury, A. N., Szent-Györgyi, A. J. Physiol. 1929, 68, 213. 2. Green, H. N. Brit. med. Bull. 1945, 3, 102. 3. Bielschowsky, M., Green, H. N., Stoner, H. B. J. Physiol. 1946, 104, 239. 4. Somló, E. Orv. Lapja, 1947, 3, 1431. 5. Somló, E. Pesti Izr. Kórház Évkönyv. 1949. 6. Komor, K., Garas, Z. Orv. Hétil. 1954.
tion of the rule of professional secrecy in the case of mental defectives. There may well be occasions when it would be fitting and proper for the police to intervene by the institution of legal proceedings against a suspected offender and there may also be sound reasons in law for issuing the advice described above. I feel, however, that before a change of this order is sponsored by official Governmental departments relating to an important ethical tenet the least that the Association could expect would be a communication from the parties who propose an alteration setting out their reasons and any legal sanction that might be invoked for their support. I hope that opportunity will be afforded in the near future for representatives of the Association and of the Ministry to meet to discuss the situation created by the issue of the memorandum. ROBERT FORBES The Medical Defence Union, Secretary.
London, W.C.1.
ESTIMATION OF BLOOD-LOSS
SiR,ńYour editorial of May 14 on the difficulty of estimating accurately the amount of blood lost at
operation its close.
or as a
result of trauma
was
excellent-until
Having rightly stressed that blood-loss is usually
underestimated, you continue "... there is still insufficient evidence to justify the very large transfusions of blood recommended by Prentice et al. Early surgical treatment should be combined with rapid transfusion of enough blood to maintain the blood-pressure within normal limits." But one of the reasons that Prentice et al. gave these very large quantities of blood was to do this very thing. And surely the fallacy of relying only on the blood-pressure as a measure of circulatory normality is the reason why blood-loss is so frequently underestimated. This recurrent canard is continually being shot down, and some of the best shots are included in thereferences to your editorial. These references point out that a loss of blood-volume of up to 2 litres can be associated with a normal blood-pressure. They point out that such patients are liable to develop alarming and sometimes lethal falls of blood-pressure under anaesthesia and there is also evidence that they are liable to develop acute anuria. The temperature and colour of the nose and extremities and the size of the subcutaneous veins are far better clinical indications of the normality of blood-flow than is the blood-pressure. Prentice and his colleagues were aware of these facts which is another reason why they gave such large quantities of blood. Finally, the group which they transfused included many suffering from multiple gunshot wounds which continued to bleed until and during operation. It is unfair to criticise the quantity of blood (10-20 litres) found necessary in these cases, by contrasting them with the amounts found to be adequate for civilian casualties with closed injuries or a single open lesion. St. Thomas’s Hospital Medical School, H. E. DE WARDENER. London, S.E.1. CORPORAL PUNISHMENT IN SCHOOL
SiR,-Dr. Jackson’s letter of May
14
sponsors a point of view that has been carried to absurd and dangerous extremes in the United States. Without commenting upon his gestalt theories, I feel compelled to warn British readers that the " permissive " attitude can lead to serious lowering of intellectual and moral standards in the schools. A Californian teacher has recently been discharged, not for using corporal punishment, but for teaching school by " traditional " instead of " progressive " methods. He testified that fourth-grade children do not know the alphabet, and that when he attempted to teach the multiplication tables by drills he was rebuked by a superior. The teacher was not allowed to discipline
who called him obscene names for three months. was not allowed to punish a child who attacked her and broke her nose. The " progressive " school authorities would not listen when these and other teachers sought disciplinary measures. Dr. Jackson’s gestalt theories lead him to believe that punishment will render children susceptible to illness. Years of experience with "progressive education " convince me that lack of intellectual and moral discipline can be a serious danger to children, to the community, and, ultimately, to the survival of all civilised values. a
boy
Another teacher
Edinburgh.
RONALD W. ANGEL.
ADENOSINE TRIPHOSPHATE IN PAROXYSMAL TACHYCARDIA 1929 SiR,-In Drury and Szent-Gy6rgyi1 pointed out that adenosine triphosphate (A.T.P.), adenosine monophosphate (A.M.P.), and adenosine dilated the coronary
arteries and slowed atrioventricular conduction. The work of Green,2 Bielschowsky et al.,3 and others made it clear that these substances act by inducing a " shock " comparable to that produced, under certain conditions, by histamine, adrenaline, or insulin. Moreover, it was found that the adenyl root is responsible for the vasodepressor effect, while the pyrophosphate is the shockinducing factor in A.T.P. ; also, that magnesium phosphate is the most active shock-inducing member of this group of substances. Accordingly I have tried, over the past ten years, to bring about the cessation of paroxysmal tachycardia, by producing a mitigated shock with intravenous adenosine triphosphate. 18-20 seconds after an intravenous injection (given as rapidly as possible) of 2 ml. (20 mg.) of A.T.P.,
complete asystole, lasting
2-4
seconds, usually
This asystole is sometimes interrupted by ventricular extrasystoles originating from various foci, or by isolated auricular contractions : in these circumstances the patient is asked to swallow once or twice, and subsequently he reports with relief that his galloping heart action has slowed down. The electrocardiogram (E.C.G.) shows a nodal impulse formation for 3-4 complexes or, after a few atypical auricular-ventricular complexes, transitional auricle activity without ventricular stoppage. Subsequently regular sinus rhythm is established, differing from normal rhythm only in that the conduction-time from auricle to ventricle is longer ; but after 3-4 complexes this too returns to normal. Judging from the E.C.G. changes during the injection, there seems no doubt that the A.T.P. substances arrest the heart action and temporarily cause complete asystole. While the impulse formation is slowly recovering they inhibit impulse conduction and so prevent recurrence of the paroxysmal tachycardia.
ensues.
The effective dose is 20 mg. (2 ml.), provided that the vein sufficiently wide to allow rapid injection. If the veins are thin and weak-walled, I adminster 30 mg. at the outset. In no case have I observed any toxic side-effects. Since the effect is due to the high blood level, intramuscular injection is unsuitable.
is
In 1947 I reported 96 onsets successfully treated in this and in 1949 an additional 118 onsets,Komor and Garas6 last year reported success in 250 episodes among 50 patients. The response of supraventricular paroxysmal tachycardia to adenosine triphosphate is so striking that it may be taken as one of the chief criteria in the diagnosis of the condition.
way,4
Postgraduate Institute of Medicine, ERNÖ E RN 0.. OML. SOMLÓ. e A Budapest, Hungary. 1. Drury, A. N., Szent-Györgyi, A. J. Physiol. 1929, 68, 213. 2. Green, H. N. Brit. med. Bull. 1945, 3, 102. 3. Bielschowsky, M., Green, H. N., Stoner, H. B. J. Physiol. 1946, 104, 239. 4. Somló, E. Orv. Lapja, 1947, 3, 1431. 5. Somló, E. Pesti Izr. Kórház Évkönyv. 1949. 6. Komor, K., Garas, Z. Orv. Hétil. 1954.