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FISTULA OF THE PENILE URETHRA
761 the calcium level in the blood-serum was not much changed, but the level in the serum is not necessarily a reliable guide to the concentration in the tissues. On the other hand, in a relatively high proportion of cases of chronic nephritis hypocalcsemia is found,5 and congestive heart failure associated with chronic nephritis is often refractory to digitalis treatment. Combined digitalis and calcium therapy may be beneficial in certain cases, but special care must be taken with the dosage of digitalis, because it cannot be pre.dicted to what extent calcium will sensitise the heart muscle to that drug. P. SZEKELY. London, W.2.
hypocalcsemia,
THINGS TO COME
SIR,-Mr. Aleck Bourne’s stimulating letter of Nov. 23 provokes thought which I hope will lead to action. He suggests that the medical profession can cooperate in bringing in the new age that is breaking on this troubled world. Signs are not lacking of the growing consciousness in the profession of our responsibility for more than the physical condition of our patients. That a new level of health both for the individual and the world is desirable will be agreed by all; the problem is how this can be brought about. Mr. Bourne emphasises the need for our cooperation in accordance with the demands of the changing world. What are these demands ?2 Does not the world demand that men and nations should know how to live free from the forces of greed, selfishness, fear, domination and destructive competition ? If we were to show that such A life is not only possible but practicable and results in a. new quality of health, would not this point the way to the new order ? In my own practice I have seen this happen on a small scale. I have seen enough examples to convince me that change in personality is a potent factor in creating a new world order. Individuals once dominated by fear, selfishness, greed, duplicity and irresponsibility become fear-free, unselfish, truthful and responsible with a corresponding improvement in their own health and the health of their social unit. Investigation into the methods and mechanism of personality change would be a fruitful field of research and a first step in preparing for this new health. It would provide the practitioner with the means of preventing and treating the origin of much ill health as well as social and world unrest. This would be a remedy for a sick world which the medical profession is in a position to
apply. E. E. CLAXTON.
St. Albans.
SIR,-Perhaps
you will allow
me
to
reply
to
some
comments, personal to myself, in recent letters in your columns. 1. Sir Francis Fremantle is a medical officer of health. In the House of Medicine there are many mansions ; one of these is occupied by the consultant section of the profession ; another of equal status, but with diametrically different outlook, by medical officers of health, who are salaried members of a State medical service whereas consultants, who mostly staff the voluntary hospitals, are as a body opposed to an extension of state service which would necessarily destroy the voluntary principle in medicine. The death of Colonel Sinclair, deeply regretted by his colleagues, removed from the Parliamentary Medical Committee the only member, other than myself, belonging to the consultant section of the profession, which is, I repeat, inadequately represented at the moment on that committee. Sir Francis writes : " Parliament does not believe in proportional representation of interests on advisory bodies." Surely the facts are precisely opposite. In appointing selective committees of the House (a category which does not include the Parliamentary Medical Committee) the most meticulous care is exercised to secure the strictest " proportional representation " of opposing interests. 2. A " select committee " of the House fulfils the functions and enjoys the sanctions of a judicial body. Its verdict must outweigh the opinion of any private individual. The Select Committee on National Expenditure thus records its summing up of the genesis of the E.M.S. (8th Report, p. 10). 5. Schmitz, H. W. et al. Arch. intern. Med. 1926, 37, 233.
" The scheme for an Emergency Medical Service was worked out in the spring and summer of 1939 after long discussions with the Central Emergency Committee of the British Medical Association (which became after the outbreak of war the Central Medical War Committee) and a special
sub - c ommittee.’’
I readily accept the correction by this committee, where correction is necessary, if any statements I may have previously made on this subject, and I submit that Dr. Scott Stevenson must do likewise. 3. In opposition to my friend, Dr. Geoffrey Evans, I submit that the Royal College of Physicians of London is wholly justified in deprecating the planning commission proposed by the B.M.A., an outline of which was given, from inside knowledge, by Sir Francis Fremantle in debate in Parliament (Hansard, Oct. 17, col. 887). The arrangements contemplated would clearly assign to the B.M.A. the dominant role in moulding the medical services of the future. E. GRAHAM-LITTLE. &RAHAM-LITTLE. Wimpole Street, W.1. FISTULA OF THE PENILE URETHRA SiR,-Prof. Grey Turner’s radical cure of a penile urethral fistula (Lancet, Nov. 23, p. 649) reminds me of a An oval case I operated on about sixteen years ago. incision a few millimetres away was made enclosing the fistula in such a way that the latter lay somewhat distal to the centre of the oval-i.e. the proximal future flap The skin was dissected up to was larger than the distal. the edge of the opening and turned as a cuff into the urethra, the upper longer flap overlapping the lower. The fistula was then closed transversely with catgut without entering the mucosa and the skin with silkworm gut. As far as I recollect a rubber catheter was left in for a few days. No leakage of urine occurred and the wound healed quickly. J. W. RIDDOCH. Birmingham, 16. ANÆSTHESIA FOR CHEST INJURIES SIR,-Writing in your issue of Nov. 30 on anaesthesia. in chest injuries Dr. Halton says, " Ether must be used whenever possible, but when there is excessive bronchial secretion or excessive interstitial inflammation, or when diathermy has to be employed, chloroform is indicated ..." He makes no mention of intravenous anaesthesia, which, combined with endotracheal insufflation of oxygen under pressure, supplemented by nitrous oxide if necessary, I have found excellent. It avoids the irritation of ether and the toxicity and depression of chloroform. In Venesetic (sodium iso-amyl-ethyl-thiobarbiturate, P.D. & Co.) I have found the ideal anaesthetic for emergency thoracic surgery. This agent, despite the warning issued in the manufacturer’s pamphlet, does not seem to cause respiratory depression in doses adequate to give proper relaxation for intubation, either " blind " or under direct vision, nor does it seem to be unduly toxic. I find 6 to 10 c.cm. of a 7-5% solution sufficient for induction, and after intubation I give either gas and oxygen or oxygen alone under pressure, with fractional venesetic as required. If an intravenous blood- or saline-drip is in progress, venesetic is given into the rubber lead just proximal to the cannula, through a small serum needle. By this method anaesthesia is induced smoothly in a patient whose respiration is already embarrassed and who fears the further embarrassment of a mask, and peaceful sleep for 1-2 hours often follows the operation without further sedatives. I have had little trouble from laryngeal spasm in these cases. Incidentally, I have used intravenous induction followed by endotracheal gas and oxygen, with or without ether, for several years in burns or scalds of the face to avoid further trauma to an already vesicated surface by pressure of a mask. UNA M. WESTELL. Redhill County Hospital, Edgware. HÆMOPHILIA AND EGG-WHITE DERIVATIVES SIR,-In the review of my book on page 454 of your issue of Oct. 12, it is stated that other workers in this country and in America have tried without success to reproduce my results. This is not strictly correct ; for, while an expert appointed by a medical research body in
hypocalcsemia,
THINGS TO COME
SIR,-Mr. Aleck Bourne’s stimulating letter of Nov. 23 provokes thought which I hope will lead to action. He suggests that the medical profession can cooperate in bringing in the new age that is breaking on this troubled world. Signs are not lacking of the growing consciousness in the profession of our responsibility for more than the physical condition of our patients. That a new level of health both for the individual and the world is desirable will be agreed by all; the problem is how this can be brought about. Mr. Bourne emphasises the need for our cooperation in accordance with the demands of the changing world. What are these demands ?2 Does not the world demand that men and nations should know how to live free from the forces of greed, selfishness, fear, domination and destructive competition ? If we were to show that such A life is not only possible but practicable and results in a. new quality of health, would not this point the way to the new order ? In my own practice I have seen this happen on a small scale. I have seen enough examples to convince me that change in personality is a potent factor in creating a new world order. Individuals once dominated by fear, selfishness, greed, duplicity and irresponsibility become fear-free, unselfish, truthful and responsible with a corresponding improvement in their own health and the health of their social unit. Investigation into the methods and mechanism of personality change would be a fruitful field of research and a first step in preparing for this new health. It would provide the practitioner with the means of preventing and treating the origin of much ill health as well as social and world unrest. This would be a remedy for a sick world which the medical profession is in a position to
apply. E. E. CLAXTON.
St. Albans.
SIR,-Perhaps
you will allow
me
to
reply
to
some
comments, personal to myself, in recent letters in your columns. 1. Sir Francis Fremantle is a medical officer of health. In the House of Medicine there are many mansions ; one of these is occupied by the consultant section of the profession ; another of equal status, but with diametrically different outlook, by medical officers of health, who are salaried members of a State medical service whereas consultants, who mostly staff the voluntary hospitals, are as a body opposed to an extension of state service which would necessarily destroy the voluntary principle in medicine. The death of Colonel Sinclair, deeply regretted by his colleagues, removed from the Parliamentary Medical Committee the only member, other than myself, belonging to the consultant section of the profession, which is, I repeat, inadequately represented at the moment on that committee. Sir Francis writes : " Parliament does not believe in proportional representation of interests on advisory bodies." Surely the facts are precisely opposite. In appointing selective committees of the House (a category which does not include the Parliamentary Medical Committee) the most meticulous care is exercised to secure the strictest " proportional representation " of opposing interests. 2. A " select committee " of the House fulfils the functions and enjoys the sanctions of a judicial body. Its verdict must outweigh the opinion of any private individual. The Select Committee on National Expenditure thus records its summing up of the genesis of the E.M.S. (8th Report, p. 10). 5. Schmitz, H. W. et al. Arch. intern. Med. 1926, 37, 233.
" The scheme for an Emergency Medical Service was worked out in the spring and summer of 1939 after long discussions with the Central Emergency Committee of the British Medical Association (which became after the outbreak of war the Central Medical War Committee) and a special
sub - c ommittee.’’
I readily accept the correction by this committee, where correction is necessary, if any statements I may have previously made on this subject, and I submit that Dr. Scott Stevenson must do likewise. 3. In opposition to my friend, Dr. Geoffrey Evans, I submit that the Royal College of Physicians of London is wholly justified in deprecating the planning commission proposed by the B.M.A., an outline of which was given, from inside knowledge, by Sir Francis Fremantle in debate in Parliament (Hansard, Oct. 17, col. 887). The arrangements contemplated would clearly assign to the B.M.A. the dominant role in moulding the medical services of the future. E. GRAHAM-LITTLE. &RAHAM-LITTLE. Wimpole Street, W.1. FISTULA OF THE PENILE URETHRA SiR,-Prof. Grey Turner’s radical cure of a penile urethral fistula (Lancet, Nov. 23, p. 649) reminds me of a An oval case I operated on about sixteen years ago. incision a few millimetres away was made enclosing the fistula in such a way that the latter lay somewhat distal to the centre of the oval-i.e. the proximal future flap The skin was dissected up to was larger than the distal. the edge of the opening and turned as a cuff into the urethra, the upper longer flap overlapping the lower. The fistula was then closed transversely with catgut without entering the mucosa and the skin with silkworm gut. As far as I recollect a rubber catheter was left in for a few days. No leakage of urine occurred and the wound healed quickly. J. W. RIDDOCH. Birmingham, 16. ANÆSTHESIA FOR CHEST INJURIES SIR,-Writing in your issue of Nov. 30 on anaesthesia. in chest injuries Dr. Halton says, " Ether must be used whenever possible, but when there is excessive bronchial secretion or excessive interstitial inflammation, or when diathermy has to be employed, chloroform is indicated ..." He makes no mention of intravenous anaesthesia, which, combined with endotracheal insufflation of oxygen under pressure, supplemented by nitrous oxide if necessary, I have found excellent. It avoids the irritation of ether and the toxicity and depression of chloroform. In Venesetic (sodium iso-amyl-ethyl-thiobarbiturate, P.D. & Co.) I have found the ideal anaesthetic for emergency thoracic surgery. This agent, despite the warning issued in the manufacturer’s pamphlet, does not seem to cause respiratory depression in doses adequate to give proper relaxation for intubation, either " blind " or under direct vision, nor does it seem to be unduly toxic. I find 6 to 10 c.cm. of a 7-5% solution sufficient for induction, and after intubation I give either gas and oxygen or oxygen alone under pressure, with fractional venesetic as required. If an intravenous blood- or saline-drip is in progress, venesetic is given into the rubber lead just proximal to the cannula, through a small serum needle. By this method anaesthesia is induced smoothly in a patient whose respiration is already embarrassed and who fears the further embarrassment of a mask, and peaceful sleep for 1-2 hours often follows the operation without further sedatives. I have had little trouble from laryngeal spasm in these cases. Incidentally, I have used intravenous induction followed by endotracheal gas and oxygen, with or without ether, for several years in burns or scalds of the face to avoid further trauma to an already vesicated surface by pressure of a mask. UNA M. WESTELL. Redhill County Hospital, Edgware. HÆMOPHILIA AND EGG-WHITE DERIVATIVES SIR,-In the review of my book on page 454 of your issue of Oct. 12, it is stated that other workers in this country and in America have tried without success to reproduce my results. This is not strictly correct ; for, while an expert appointed by a medical research body in