- Email: [email protected]
GALLOP RHYTHM
275
military staff college, needa to be taught the full range of tactics, so that whatever his ultimate department he may take his part intelligently and cooperatively in
combined operations. MARGARET M. BURTON. Birmingham. SUDDEN SENESCENCE your issue of Aug. 7 Greene and Paterson Sm,-In interesting history seems obscured report a case whose by its irrelevant title and the discussion. The lack of evidence of generalised atrophy should surely have ruled out- the title" sudden senescence." A " wrinkled face," feeling " a feeble old man," a haemoglobin level of 86%, and achlorhydria do not seem remarkable consequences of months of anorexia associated with a loss of 1 stone in weight, anxious depression and alopecia. The syndrome need not have suggested Simmonds’s disease. The order of the loss and subsequent return of the patient’s hair were typical of alopecia : scalp and eyebrow hair are never more than thinned in undomplicated Simmonds’s disease. Impotence without evidence of an associated prostatic atrophy suggests neither Simmonds’s disease nor hypothalamic disorder, unless the latter be conceded a probable but unproved feature of typical depressions. The symptoms of Simmonds’s disease are extremely non-specific, but, to my knowledge, no typical Simmonds’s syndrome has ever been proved to be associated with hypothalamic damage which did not also involve the pituitary. Alopecia totalis, and allied anomalies of hair growth, have often been noted as occasional complications both of severe infections and of mood disorders, especially those of sudden onset and with associated impotence, anorexia and weight loss. The interest of such a concurrence is considerable but available evidence does not justify ascribing it to the hypothalamus, nor does such a relatively localised syndrome justify the term " premature old age." RUSSELL FRASER. The University, Birmingham. GALLOP RHYTHM W x.,--1 was surprisea to read in your annotation 01 Aug. 14 that of the various types of gallop rhythm the protodiastolic is the only one which for practical purposes carries a grim prognosis. This view was formerly advanced especially by French clinicians but modern authors (e.g., Bramwell and King: Principles and Practice of Cardiology), supporting their statements by mechanical recordings of the heart sounds, have expressed an entirely different opinion-that although protodiastolic gallop may occur in gravely damaged hearts it is found also in some healthy persons (physiological third heart-sound), and in cases of mitral stenosis. The prognosis of true or presystolic gallop is invariably. bad ; thus only 15 of Bramwell’s 62 cases survived for more than 18 months after gallop was noted, while on the other hand he says, " Protodiastolic gallop is not of any significance in prognosis." D. G. MCINTOSH. Dundee.
many
,
FEEDING WITH AMINO-ACIDS one whose work was commented on in your leading article of June 12, I feel impelled to write to you acknowledging our failure to express ourselves, in our previous publications on intravenous feeding with amino-acids, in such a manner that we might be understood. You say " It is hard to see why a solution of mixed amino-acids prepared, from casein should be any better. for a man than a good glass of milk." The answer to this is simply that many patients who have just undergone major surgical procedures cannot receive g,ood glasses of milk, and the next best supportive measure is to give them the amino-acids by vein that they would have received had they been able to drink large quantities of milk. The initial studies on intravenous injection of amino-acids were carried on, for the most part, in patients with carcinomatosis because there was no certainty that such injections were entirely innocuous in man. It was not to prolong-the lives of patients with advanced cancer that intravenous alimentation with amino-acids was developed. Its purpose is to afford supportive treatment of a type previously not possible for all surgical patients whose nutritional status leaves something to be desired. No-one, to my know-
SiR,-As
ledge, no matter how enthusiastic he may be over the intravenous use of amino-acids or casein digests, has ever thought’ of this method of alimentation as a substitute for the natural one per os. ALEXANDER BRUNSCHWIG. University of Chicago. *** The leading article goes on : " It is hard to see, therefore, why they should ever be given by mouth.... By vein they have an obvious value ..."-ED. L. BABEL IN THE
DRUG TRADE
SiR,,-With reference to your leading article of Aug. 14, may I record an experience ? In 1938 when
taking
over
an
African station my
predecessor showed me two boxes in the refrigerator labelled :’ -arsen- " (I do not give the actual name) which he said was a sample of Canadian NAB just received. Some weeks later, two men came, each for his fifth injection of NAB, 0-6 g. Supplies of the ordinary NAB used having run out, I told the dispenser to fetch this "-arsen-" and administered it in the usual way, noticing only that the powder did not dissolve very quickly. Whiles washing out the syringe after the second injection, _I heard a gurgle behind me, turned, and found that the man was dead. Then a nurse came in to report that the first man was collapsed and vomiting-he subsequently recovered. I then examined this " -arsen- " more closely and found that it was a preparation of the old " 606 " ; that is, the solution should have been neutralised, diluted to about 150 c.cm., and given very slowly. I had qualified in 1924, but had never even seen " 606 " used, and thought that it had completely dropped out of ordinary practice. Admittedly there was a little carelessness, but I think it was a trap into which most would have fallen ; and as long as trade names mean nothing in particular such disasters are bound to occur. GEORGE L. ALEXANDER. Clifton, Bristol.
IN reply to Dr. Murray and Dr. Wilson (June 26, p. 818), Captain Spira and Dr. Grimbleby point out that it is the presence in drinking-water of calcium bicarbonate in solution which is instrumental in reducing the amount of fluorine by the boiling method.
Births, Marriages and Deaths BIRTHS HoFF.-On June 23, at New Haven, Connecticut, the wife of Dr. Ebbe Hoff-a son. McLEAN.-On Aug. 11, in London, the wife of Surgeon-Lieutenant I. E. D. McLean, RNVR-a son. NEWSHOMiE.—On Aug. 16, at Birmingham, the wife of Captain A. D. Newsholme, RAMC—a daughter. PHiLLipsoN.—On Aug. 17, at Fleet, Hants, the wife of Lieut.Colonel R. V. Phillipson, BAMC—a daughter. PBATT.—On Aug. 7, at Durban, S. Africa, the wife of Dr. E. P. Pratt, Sudan Medical Service-a daughter. RowoRTH.-On Aug. 15, at Woking, the wife of Dr. Guy Roworth -a
daughter.
SPICER.-On Aug. 16, at Kampala, Uganda, the wife of Dr. J. R. C. Spicer, Uganda Medical Service-a daughter. TATTERSALL.-On July 6, in London, to Dr. Edith Booth, the wife of Dr.
Stanley Tattersall, Stone,
near
Aylesbury-a
son.
THORNLEY.-On Aug. 27, at Cleethorpes, Lines, the wife of Major Roland Thornley, RAMc-a daughter, stillborn.. WADIA.—On Aug. 14, in London, the wife of Surgeon Lieutenant Richard Wadia, BNVB—a son.
MARRIAGES
FRAzER-GARROD.-On Aug. 14, in London, Alastair Campbell Frazer, major BAMO, to Hilary Garrod. TAYLOR-WATT.-On July 30, at Aberdeen, Alexander Robertson Taylor, Nii3, to Alice Cromble Watt, WRNS. SwiK-NEY—SHAND.—On Aug. 12, at Aberdeen, George Ewen Swinney, lieutenant RAMO, to Alison Shand.
DEATHS CLEMitfsoN.—On Aug. 21, Frederick John Cleminson, M OHIR CAM]3., FRCS, of Ongar, Essex, aged 65. CRAio.-On Aug. 17, at Bournemouth, Eric Stanley Craig, MB ]UDIN. GETHING.—On Aug. 20, at York, John Eills Gething, BA CAMB., MB M*boL, of Harrogate. HANDFIELD-JONES.—On Aug. 21, at Reading, Charles Ranald Handfield-Jones, MD DUBH., aged 78. JACOB.-On June 19, at North Stoke, Oxford, Norman Bremer Vickers Jacob, MRCS, surgeon lieut.-commander RN. MURRAY.-On Aug. 16, at Exmouth, John Murray, MB DUBL., FRCS. PEEK.-On Aug. 18, at Beaconsfield, John Harold Peek, MD EDIN., DPH, aged 64. SIMEY.—On Aug. 20, Athelstane Iliff Simey, MD CAMB., FRCP, of
Fordingbridge,
and of
Matterdale, aged
70.
SODDY.—At sea, by enemy action, in July, James Rawdou Soddy, MRCS, Colonial Medical Service, aged 24. STRINGER.—On July 12, at Christchurch, New Zealand, Louis Bruce Stringer, MRCS.
’
military staff college, needa to be taught the full range of tactics, so that whatever his ultimate department he may take his part intelligently and cooperatively in
combined operations. MARGARET M. BURTON. Birmingham. SUDDEN SENESCENCE your issue of Aug. 7 Greene and Paterson Sm,-In interesting history seems obscured report a case whose by its irrelevant title and the discussion. The lack of evidence of generalised atrophy should surely have ruled out- the title" sudden senescence." A " wrinkled face," feeling " a feeble old man," a haemoglobin level of 86%, and achlorhydria do not seem remarkable consequences of months of anorexia associated with a loss of 1 stone in weight, anxious depression and alopecia. The syndrome need not have suggested Simmonds’s disease. The order of the loss and subsequent return of the patient’s hair were typical of alopecia : scalp and eyebrow hair are never more than thinned in undomplicated Simmonds’s disease. Impotence without evidence of an associated prostatic atrophy suggests neither Simmonds’s disease nor hypothalamic disorder, unless the latter be conceded a probable but unproved feature of typical depressions. The symptoms of Simmonds’s disease are extremely non-specific, but, to my knowledge, no typical Simmonds’s syndrome has ever been proved to be associated with hypothalamic damage which did not also involve the pituitary. Alopecia totalis, and allied anomalies of hair growth, have often been noted as occasional complications both of severe infections and of mood disorders, especially those of sudden onset and with associated impotence, anorexia and weight loss. The interest of such a concurrence is considerable but available evidence does not justify ascribing it to the hypothalamus, nor does such a relatively localised syndrome justify the term " premature old age." RUSSELL FRASER. The University, Birmingham. GALLOP RHYTHM W x.,--1 was surprisea to read in your annotation 01 Aug. 14 that of the various types of gallop rhythm the protodiastolic is the only one which for practical purposes carries a grim prognosis. This view was formerly advanced especially by French clinicians but modern authors (e.g., Bramwell and King: Principles and Practice of Cardiology), supporting their statements by mechanical recordings of the heart sounds, have expressed an entirely different opinion-that although protodiastolic gallop may occur in gravely damaged hearts it is found also in some healthy persons (physiological third heart-sound), and in cases of mitral stenosis. The prognosis of true or presystolic gallop is invariably. bad ; thus only 15 of Bramwell’s 62 cases survived for more than 18 months after gallop was noted, while on the other hand he says, " Protodiastolic gallop is not of any significance in prognosis." D. G. MCINTOSH. Dundee.
many
,
FEEDING WITH AMINO-ACIDS one whose work was commented on in your leading article of June 12, I feel impelled to write to you acknowledging our failure to express ourselves, in our previous publications on intravenous feeding with amino-acids, in such a manner that we might be understood. You say " It is hard to see why a solution of mixed amino-acids prepared, from casein should be any better. for a man than a good glass of milk." The answer to this is simply that many patients who have just undergone major surgical procedures cannot receive g,ood glasses of milk, and the next best supportive measure is to give them the amino-acids by vein that they would have received had they been able to drink large quantities of milk. The initial studies on intravenous injection of amino-acids were carried on, for the most part, in patients with carcinomatosis because there was no certainty that such injections were entirely innocuous in man. It was not to prolong-the lives of patients with advanced cancer that intravenous alimentation with amino-acids was developed. Its purpose is to afford supportive treatment of a type previously not possible for all surgical patients whose nutritional status leaves something to be desired. No-one, to my know-
SiR,-As
ledge, no matter how enthusiastic he may be over the intravenous use of amino-acids or casein digests, has ever thought’ of this method of alimentation as a substitute for the natural one per os. ALEXANDER BRUNSCHWIG. University of Chicago. *** The leading article goes on : " It is hard to see, therefore, why they should ever be given by mouth.... By vein they have an obvious value ..."-ED. L. BABEL IN THE
DRUG TRADE
SiR,,-With reference to your leading article of Aug. 14, may I record an experience ? In 1938 when
taking
over
an
African station my
predecessor showed me two boxes in the refrigerator labelled :’ -arsen- " (I do not give the actual name) which he said was a sample of Canadian NAB just received. Some weeks later, two men came, each for his fifth injection of NAB, 0-6 g. Supplies of the ordinary NAB used having run out, I told the dispenser to fetch this "-arsen-" and administered it in the usual way, noticing only that the powder did not dissolve very quickly. Whiles washing out the syringe after the second injection, _I heard a gurgle behind me, turned, and found that the man was dead. Then a nurse came in to report that the first man was collapsed and vomiting-he subsequently recovered. I then examined this " -arsen- " more closely and found that it was a preparation of the old " 606 " ; that is, the solution should have been neutralised, diluted to about 150 c.cm., and given very slowly. I had qualified in 1924, but had never even seen " 606 " used, and thought that it had completely dropped out of ordinary practice. Admittedly there was a little carelessness, but I think it was a trap into which most would have fallen ; and as long as trade names mean nothing in particular such disasters are bound to occur. GEORGE L. ALEXANDER. Clifton, Bristol.
IN reply to Dr. Murray and Dr. Wilson (June 26, p. 818), Captain Spira and Dr. Grimbleby point out that it is the presence in drinking-water of calcium bicarbonate in solution which is instrumental in reducing the amount of fluorine by the boiling method.
Births, Marriages and Deaths BIRTHS HoFF.-On June 23, at New Haven, Connecticut, the wife of Dr. Ebbe Hoff-a son. McLEAN.-On Aug. 11, in London, the wife of Surgeon-Lieutenant I. E. D. McLean, RNVR-a son. NEWSHOMiE.—On Aug. 16, at Birmingham, the wife of Captain A. D. Newsholme, RAMC—a daughter. PHiLLipsoN.—On Aug. 17, at Fleet, Hants, the wife of Lieut.Colonel R. V. Phillipson, BAMC—a daughter. PBATT.—On Aug. 7, at Durban, S. Africa, the wife of Dr. E. P. Pratt, Sudan Medical Service-a daughter. RowoRTH.-On Aug. 15, at Woking, the wife of Dr. Guy Roworth -a
daughter.
SPICER.-On Aug. 16, at Kampala, Uganda, the wife of Dr. J. R. C. Spicer, Uganda Medical Service-a daughter. TATTERSALL.-On July 6, in London, to Dr. Edith Booth, the wife of Dr.
Stanley Tattersall, Stone,
near
Aylesbury-a
son.
THORNLEY.-On Aug. 27, at Cleethorpes, Lines, the wife of Major Roland Thornley, RAMc-a daughter, stillborn.. WADIA.—On Aug. 14, in London, the wife of Surgeon Lieutenant Richard Wadia, BNVB—a son.
MARRIAGES
FRAzER-GARROD.-On Aug. 14, in London, Alastair Campbell Frazer, major BAMO, to Hilary Garrod. TAYLOR-WATT.-On July 30, at Aberdeen, Alexander Robertson Taylor, Nii3, to Alice Cromble Watt, WRNS. SwiK-NEY—SHAND.—On Aug. 12, at Aberdeen, George Ewen Swinney, lieutenant RAMO, to Alison Shand.
DEATHS CLEMitfsoN.—On Aug. 21, Frederick John Cleminson, M OHIR CAM]3., FRCS, of Ongar, Essex, aged 65. CRAio.-On Aug. 17, at Bournemouth, Eric Stanley Craig, MB ]UDIN. GETHING.—On Aug. 20, at York, John Eills Gething, BA CAMB., MB M*boL, of Harrogate. HANDFIELD-JONES.—On Aug. 21, at Reading, Charles Ranald Handfield-Jones, MD DUBH., aged 78. JACOB.-On June 19, at North Stoke, Oxford, Norman Bremer Vickers Jacob, MRCS, surgeon lieut.-commander RN. MURRAY.-On Aug. 16, at Exmouth, John Murray, MB DUBL., FRCS. PEEK.-On Aug. 18, at Beaconsfield, John Harold Peek, MD EDIN., DPH, aged 64. SIMEY.—On Aug. 20, Athelstane Iliff Simey, MD CAMB., FRCP, of
Fordingbridge,
and of
Matterdale, aged
70.
SODDY.—At sea, by enemy action, in July, James Rawdou Soddy, MRCS, Colonial Medical Service, aged 24. STRINGER.—On July 12, at Christchurch, New Zealand, Louis Bruce Stringer, MRCS.
’