- Email: [email protected]
HYPERBARIC OXYGEN IN RESUSCITATION OF THE NEWBORN
220 to the same careful follow-up study as this series, routine outpatient follow-up has been used. I have not yet seen a carcinoma develop in the stomach after vagotomy.
There are a number of surgeons now in this country who have a considerably greater experience of this operation than I have, and who have used it for a longer time. It would be interesting for us to know what their experiences have been. West London Hospital, HAROLD
BURGE.
London, W.6.
RESPIRATORY FUNCTION TESTS IN MINERS
SIR,-In the otherwise comprehensive paper by Dr. Catterall and Mr. Hunter (Jan. 16) there is no mention of their miners’ cigarette consumption. 4 had lung cancer, 11 obstructive airway disease, and another 13 combined obstructive and diffusion defects; this strongly suggests that smoking may have been an important factor in the disabilities found. May one, therefore, ask if details of the miners’ previous and current smoking habits are available ? Without these, one can hardly blame pneumoconiosis alone for the considerable degree of ventilatory dysfunction revealed. Taunton Isolation and Chest Somerset.
Hospital,
J. P. ANDERSON.
PLEASE TAKE THIS DOWN
SIR,-Your annotation last week is timely. The need for proper secretarial help for senior clinicians does not seem to be appreciated by our hospital authorities. For seven years I had the help of a clinical secretary who accompanied me on ward rounds and outpatient clinics. She took shorthand notes of cases in the wards which were later transcribed into a " ward book " which was available for reference to both medical and nursing staff. This was a great help in providing continuity of observation during changes or holidays of doctors and ward sisters, as well as proving a valuable aide-memoire to the consultant. She also took down all notes in the outpatient clinics and made out request forms for pathology and X-rays. Knowing the routine of the clinics and also being acquainted with the patients themselves, she was able to arrange appointments for both visitors and patients at the most suitable time. Local general practitioners appreciated very greatly her help in such matters.
Since I lost this secretary, her successors have not attended my ward rounds and outpatients clinics. They have no knowledge of the medical aspects of my routine. There has been a very definite falling off in the efficiency of my unit which could have been prevented if the example of Copenhagen had been followed. Is it possible that hospital administrators do not have sufficient experience of what takes place on ward rounds and in clinics ? St. John’s Hospital, London. S.W.11.
TREVOR H. HOWELL.
MEASUREMENT AND MECHANISM IN MEDICINE SIR,-Sir George Godber (Dec. 5) asks for greater collaboration between doctors and scientists (chiefly engineers) from other disciplines, and points to the benefits likely to accrue from such collaboration. I should like to go further and plead for the greater recognition of those of us who have been trained in both For several years now, medicine and engineering. been running a ten has Imperial College, London, months’ full-time course to train doctors in the applications of engineering to medicine; and, at the moment, they are turning out about 4 doctors a year with a detailed knowledge of applied mathematics, medical electronics, and the application of digital computational techniques to a variety of problems. There is, I fear, a tendency amongst doctors to dismiss us as Jacks-of-all-trades and
masters
of none,
but, despite this, I think that with
our
have much to offer to medicine. unique training It is to be hoped that the day will soon come when every large medical research centre has on its permanent staff a specialist in medical engineering, who, in addition to carrying out his own teaching and research programme, will act as a consultant to medical specialists on the possible applications of engineering methods to their problems and on the best ways of applying these methods. we
Department of Anæsthesia, University of Leeds, Leeds, 2.
G. R. KELMAN.
WHO WILL CURE MY ULCERS ?
SIR,- Your annotation 1 remarks on the strange name given to the operation for dividing a part or the whole of the vagus nerves in the transhiatal or subhiatal position. The correct term for this operation should be subhiatal, or just abdominal vagal transection. In common usage, however, the term vagotomy has become accepted and has "
"
undoubtedly come
to stay. Far more strange, perhaps, is the use of the word " selective " as applied to vagotomy. This term seems to be given to any type of selection without specification of the organ. Further, it is not made clear whether the selection is for preservation of particular vagal branches or for their division. If a selection is to be made, we should surely indicate exactly which organ is selected and what it is selected for. We plead for the adoption of more accurate terms, and suggest that " total abdominal vagotomy " should be used when both nerves are transected, and " specific gastric vagotomy " should be used when the vagal fibres to the stomach alone are divided.
Perhaps the surgical dresser wrote better than he knew when he spelt it " vagueotomy ". The well-known vagaries of the " wandering " nerve should not be increased by inexactitude in terminology. W. M. CAPPER L. R. CELESTIN Bristol Royal Infirmary, K. G. BUCKLER. Bristol. ,
HYPERBARIC OXYGEN IN RESUSCITATION OF THE NEWBORN
SIR,-Dr. Hutchison and his coworkers (Sept. 26) question the relevance to asphyxia neonatorum of the laboratory experiments of Professor Cross and his colleagues (Sept. 12) in their statement that the efficacy of hyperbaric oxygen as a method of resuscitation in the human infant can only be decided by "
observations made on human infants under everyday conditions of obstetric practice ". It is obvious that in the final analysis every new drug or mode therapy has to be tested on man. The results of animal experimentation can rarely, if ever, be directly extrapolated to man with absolute assurance of the outcome. But this does not deny the relevance or the necessity of experimental observations. Comparative physiology provides us with a means of acquiring knowledge that without incurring grave risks can be derived in no other way. Would Dr. Hutchison recommend the use of ’ Dulcin ’ (p-phenethylurea)-a compound 200 times as sweet,as sugar-for human consumption, even though animal studies have revealed that it produces liver tumours in animals ? Asphyxia implies not only hypoxia but also respiratory acidosis. Intermittent positive-pressure breathing (LP.P.B.) not only improves oxygenation but, in contrast to hyperbaric oxygenation, also assists respiratory gas exchange. The correctness of this logic was excellently demonstrated by Professor Cross and his colleagues. There may be cases in which l.p.p.B. may have to be used under hyperbaric conditions. Dr. Hutchison and his coworkers give no indication that this possibility exists. Neither is there any indication that they have thought of
of
1. Lancet,
1964, ii, 1282.
221 the obvious use of hypothermia, alone or in conjunction with I.P.P.B., with or without compression to 2 or 3 atmospheres. Because it is ill conceived, because it has no logical basis, and because it goes counter to sound physiological principles as shown by Professor Cross and his coworkers and by Dr. Crawford (Oct. 10), I believe that the Glasgow group’s plans for a controlled study of the comparative efficacy of hyperbaric oxygenation and I.P.P.B. as means of resuscitation of the newborn are unsound. They might first try to reproduce the experiments of Professor Cross and his colleagues. Certainly the results of these experiments reveal LP.P .B. to be far superior to hyperbaric oxygenation for resuscitation of the newborn. Department of Anesthesiology, Jefferson Medical College, Philadelphia, U.S.A.
SHELDON F. GOTTLIEB.
CLINICAL TRIAL OF FRUSEMIDE SIR,-Dr. Verel’s letter (Jan. 2), which expresses surprise at some of our criticisms1 of his joint paper,and also makes new and controversial assertions, cannot be left
unanswered.
REPRINTS
SIR,-After publication of
preprinted request postcards not even signed.
paper
a
steady
of
stream
arrives: many of these
are
During 1964 a dozen papers were published from this laboratory, and 1304 reprints or off-prints were distributed at a total cost, including postage, of some E80. This represents about 8% of the limited research funds available for recurrent expenditure; moreover, some of the larger organisations awarding grants do not accept the cost of reprints as a justifiable
expenditure. Such is the catholicity of demand that one might question the importance of the reprint to the average inquirer; many are presumably filed away and seldom consulted. It seems that a great deal of money is being spent on a fruitless interchange of literature, the more salient aspects of which are adequately abstracted in various periodicals. In addition much time and energy is spent in addressing envelopes.
Is it too much to expect that the distribution of reprints could be restricted to those who value them sufficiently to
The greater part of the paper was not concerned merely with the clinical use of frusemide, for it was designed to compare the efficacy of this diuretic with hydrochlorothiazide, mersalyl, chlorthalidone, triamterene, and cyclopenthiazide. We consider that such investigations, already difficult to evaluate satisfactorily, should not be further complicated by the inclusion of patients with renal failure. In case 9 the urinary excretion of water, sodium, potassium, and chloride appears to have been more or less fixed and was little altered by chlorthalidone, mersalyl, or frusemide. We must repeat that the statement that chlorthalidone " conserves potassium better than does frusemide, but it is a much less efficient diuretic " is totally unjustified on the evidence presented in this paper. Dr. Verel in his letter admits that accurate metabolicbalance studies are difficult, but with such a small number of subjects they are vital if valid conclusions are to be drawn. He states that the " report omitted many data which did not add to the appraisal of the drugs compared-e.g., details of change in weight, electrolytes, and blood urea. These are relevant to the care of the patient, but not to the comparison of drugs given alternately every other day ". But accurate daily weighing must remain the most satisfactory method of assessing the comparative diuretic efficacy of drugs in a general ward, and has been advocated for this purpose by many-notably Gold et al. 34 We are interested in the comment that the general practitioner is the greatest user of oral diuretics. In this unit, for at least a year, we have not used a parenteral diuretic agent other than frusemide, and this solely for the emergency treatment of acute pulmonary oedema. We believe that parenteral therapy is
a
write
a
personal
note
when making their request ?
Hæmatology Department, St. George’s Hospital, London, S.W.17.
J. L. STAFFORD.
SCREENING TESTS FOR BACTERIURIA IN PREGNANCY
SIR,-I read with great interest the article by Dr. Kincaid-Smith and her colleagues (July 11) since we have been studying the same problem in the U.S.A. We found that vulvar cleansing was necessary in some groups of women and not in others. We also found that some women needed direct supervision and others did not. I believe that it is essential to determine whether supervision of vulvar cleansing is needed for the population concerned. The chances are that in the series reported by Dr. KincaidSmith and her coworkers external contamination was responsible not only for the presence of coagulase-negative staphylococci, but also for the presence of Streptococcus viridans, Staphylococcus aureus, mixed infections, haemolytic streptococcus, and some of the coliform organisms. As to placing reliance on tests of midstream specimens, Kass 1and other workers have shown that only when 2 consecutive cultures are taken can one expect 95% accuracy. With one random midstream culture there is only 80% accuracy.
In
evaluating screening tests for bacteriuria where the important data are colony-counts, greater attention should be given to these factors.
most
Saint Michael Hospital,
Newark, New Jersey,
LEON G. SMITH.
U.S.A.
rarely necessary.
1. 2.
Dr. Verel’s statement in his letter that " the figures published taken from the first week of therapy " seems irrelevant and is inconsistent with the description of the plan of the trial in his report. An approximate estimate of the average duration of the investigations from which the results in table I were compiled is thirty-one days.
Kass, E. H. Arch. intern. Med. 1960, 105, 194. Kass, E. H. Ann. intern. Med. 1962, 56, 46.
are
Whatever Dr. Verel’s views may be on " the amount of detail which should be included in a scientific report dealing with the trial of a new drug ", we strongly disagree with any editorial policy which would sanction the publication of original articles containing inadequately
supported
statements.
I. W. B. GRANT Unit, N. W. HORNE City Hospital, W. J. H. LECKIE. Edinburgh. 1. Grant, I. W. B., Horne, N. W., Leckie, W. J. H. Lancet, 1964, ii, 1239. 2. Verel, D., Stentiford, N. H., Rahman, F., Saynor, R. ibid. p. 1088. 3. Gold, H., Kwit, N. T., Golfinos, A. J., Bross, I. D. J. Amer. J. med. Sci. 1960, 239, 665. 4. Gold, H., Kwit, N. T., Messeloff, C. R., Kramer, M. L., Golfinos, A. J., Greiner, T. H., Goessel, E. A., Hughes, J. H., Warshaw, L. J. Amer. med. Ass. 1960, 173, 745. Chest
Medicine and the Law Inquest
on a
Boxer
SOME months ago a 21-year-old featherweight boxer was knocked down in the last round of a bout, apparently hit his head on the rope, and was unconscious for two or three minutes. Later he died of intracerebral haemorrhage.1 There was evidence that the boxer had previously suffered injuries to his brain, but Prof. F. E. Camps did not think that these injuries had caused his death, which was probably due to his
hitting the
rope. The coroner, Dr. Ian Milne, recording a verdict of accidental " death, said: I suppose it is for the public and boxers to decide what they want, and for the conscience of the nation as a whole to decide whether boxing is a suitable sport for a
Christian country."2 1. 2.
Times, Jan. 14. Guardian, Jan. 14.
There are a number of surgeons now in this country who have a considerably greater experience of this operation than I have, and who have used it for a longer time. It would be interesting for us to know what their experiences have been. West London Hospital, HAROLD
BURGE.
London, W.6.
RESPIRATORY FUNCTION TESTS IN MINERS
SIR,-In the otherwise comprehensive paper by Dr. Catterall and Mr. Hunter (Jan. 16) there is no mention of their miners’ cigarette consumption. 4 had lung cancer, 11 obstructive airway disease, and another 13 combined obstructive and diffusion defects; this strongly suggests that smoking may have been an important factor in the disabilities found. May one, therefore, ask if details of the miners’ previous and current smoking habits are available ? Without these, one can hardly blame pneumoconiosis alone for the considerable degree of ventilatory dysfunction revealed. Taunton Isolation and Chest Somerset.
Hospital,
J. P. ANDERSON.
PLEASE TAKE THIS DOWN
SIR,-Your annotation last week is timely. The need for proper secretarial help for senior clinicians does not seem to be appreciated by our hospital authorities. For seven years I had the help of a clinical secretary who accompanied me on ward rounds and outpatient clinics. She took shorthand notes of cases in the wards which were later transcribed into a " ward book " which was available for reference to both medical and nursing staff. This was a great help in providing continuity of observation during changes or holidays of doctors and ward sisters, as well as proving a valuable aide-memoire to the consultant. She also took down all notes in the outpatient clinics and made out request forms for pathology and X-rays. Knowing the routine of the clinics and also being acquainted with the patients themselves, she was able to arrange appointments for both visitors and patients at the most suitable time. Local general practitioners appreciated very greatly her help in such matters.
Since I lost this secretary, her successors have not attended my ward rounds and outpatients clinics. They have no knowledge of the medical aspects of my routine. There has been a very definite falling off in the efficiency of my unit which could have been prevented if the example of Copenhagen had been followed. Is it possible that hospital administrators do not have sufficient experience of what takes place on ward rounds and in clinics ? St. John’s Hospital, London. S.W.11.
TREVOR H. HOWELL.
MEASUREMENT AND MECHANISM IN MEDICINE SIR,-Sir George Godber (Dec. 5) asks for greater collaboration between doctors and scientists (chiefly engineers) from other disciplines, and points to the benefits likely to accrue from such collaboration. I should like to go further and plead for the greater recognition of those of us who have been trained in both For several years now, medicine and engineering. been running a ten has Imperial College, London, months’ full-time course to train doctors in the applications of engineering to medicine; and, at the moment, they are turning out about 4 doctors a year with a detailed knowledge of applied mathematics, medical electronics, and the application of digital computational techniques to a variety of problems. There is, I fear, a tendency amongst doctors to dismiss us as Jacks-of-all-trades and
masters
of none,
but, despite this, I think that with
our
have much to offer to medicine. unique training It is to be hoped that the day will soon come when every large medical research centre has on its permanent staff a specialist in medical engineering, who, in addition to carrying out his own teaching and research programme, will act as a consultant to medical specialists on the possible applications of engineering methods to their problems and on the best ways of applying these methods. we
Department of Anæsthesia, University of Leeds, Leeds, 2.
G. R. KELMAN.
WHO WILL CURE MY ULCERS ?
SIR,- Your annotation 1 remarks on the strange name given to the operation for dividing a part or the whole of the vagus nerves in the transhiatal or subhiatal position. The correct term for this operation should be subhiatal, or just abdominal vagal transection. In common usage, however, the term vagotomy has become accepted and has "
"
undoubtedly come
to stay. Far more strange, perhaps, is the use of the word " selective " as applied to vagotomy. This term seems to be given to any type of selection without specification of the organ. Further, it is not made clear whether the selection is for preservation of particular vagal branches or for their division. If a selection is to be made, we should surely indicate exactly which organ is selected and what it is selected for. We plead for the adoption of more accurate terms, and suggest that " total abdominal vagotomy " should be used when both nerves are transected, and " specific gastric vagotomy " should be used when the vagal fibres to the stomach alone are divided.
Perhaps the surgical dresser wrote better than he knew when he spelt it " vagueotomy ". The well-known vagaries of the " wandering " nerve should not be increased by inexactitude in terminology. W. M. CAPPER L. R. CELESTIN Bristol Royal Infirmary, K. G. BUCKLER. Bristol. ,
HYPERBARIC OXYGEN IN RESUSCITATION OF THE NEWBORN
SIR,-Dr. Hutchison and his coworkers (Sept. 26) question the relevance to asphyxia neonatorum of the laboratory experiments of Professor Cross and his colleagues (Sept. 12) in their statement that the efficacy of hyperbaric oxygen as a method of resuscitation in the human infant can only be decided by "
observations made on human infants under everyday conditions of obstetric practice ". It is obvious that in the final analysis every new drug or mode therapy has to be tested on man. The results of animal experimentation can rarely, if ever, be directly extrapolated to man with absolute assurance of the outcome. But this does not deny the relevance or the necessity of experimental observations. Comparative physiology provides us with a means of acquiring knowledge that without incurring grave risks can be derived in no other way. Would Dr. Hutchison recommend the use of ’ Dulcin ’ (p-phenethylurea)-a compound 200 times as sweet,as sugar-for human consumption, even though animal studies have revealed that it produces liver tumours in animals ? Asphyxia implies not only hypoxia but also respiratory acidosis. Intermittent positive-pressure breathing (LP.P.B.) not only improves oxygenation but, in contrast to hyperbaric oxygenation, also assists respiratory gas exchange. The correctness of this logic was excellently demonstrated by Professor Cross and his colleagues. There may be cases in which l.p.p.B. may have to be used under hyperbaric conditions. Dr. Hutchison and his coworkers give no indication that this possibility exists. Neither is there any indication that they have thought of
of
1. Lancet,
1964, ii, 1282.
221 the obvious use of hypothermia, alone or in conjunction with I.P.P.B., with or without compression to 2 or 3 atmospheres. Because it is ill conceived, because it has no logical basis, and because it goes counter to sound physiological principles as shown by Professor Cross and his coworkers and by Dr. Crawford (Oct. 10), I believe that the Glasgow group’s plans for a controlled study of the comparative efficacy of hyperbaric oxygenation and I.P.P.B. as means of resuscitation of the newborn are unsound. They might first try to reproduce the experiments of Professor Cross and his colleagues. Certainly the results of these experiments reveal LP.P .B. to be far superior to hyperbaric oxygenation for resuscitation of the newborn. Department of Anesthesiology, Jefferson Medical College, Philadelphia, U.S.A.
SHELDON F. GOTTLIEB.
CLINICAL TRIAL OF FRUSEMIDE SIR,-Dr. Verel’s letter (Jan. 2), which expresses surprise at some of our criticisms1 of his joint paper,and also makes new and controversial assertions, cannot be left
unanswered.
REPRINTS
SIR,-After publication of
preprinted request postcards not even signed.
paper
a
steady
of
stream
arrives: many of these
are
During 1964 a dozen papers were published from this laboratory, and 1304 reprints or off-prints were distributed at a total cost, including postage, of some E80. This represents about 8% of the limited research funds available for recurrent expenditure; moreover, some of the larger organisations awarding grants do not accept the cost of reprints as a justifiable
expenditure. Such is the catholicity of demand that one might question the importance of the reprint to the average inquirer; many are presumably filed away and seldom consulted. It seems that a great deal of money is being spent on a fruitless interchange of literature, the more salient aspects of which are adequately abstracted in various periodicals. In addition much time and energy is spent in addressing envelopes.
Is it too much to expect that the distribution of reprints could be restricted to those who value them sufficiently to
The greater part of the paper was not concerned merely with the clinical use of frusemide, for it was designed to compare the efficacy of this diuretic with hydrochlorothiazide, mersalyl, chlorthalidone, triamterene, and cyclopenthiazide. We consider that such investigations, already difficult to evaluate satisfactorily, should not be further complicated by the inclusion of patients with renal failure. In case 9 the urinary excretion of water, sodium, potassium, and chloride appears to have been more or less fixed and was little altered by chlorthalidone, mersalyl, or frusemide. We must repeat that the statement that chlorthalidone " conserves potassium better than does frusemide, but it is a much less efficient diuretic " is totally unjustified on the evidence presented in this paper. Dr. Verel in his letter admits that accurate metabolicbalance studies are difficult, but with such a small number of subjects they are vital if valid conclusions are to be drawn. He states that the " report omitted many data which did not add to the appraisal of the drugs compared-e.g., details of change in weight, electrolytes, and blood urea. These are relevant to the care of the patient, but not to the comparison of drugs given alternately every other day ". But accurate daily weighing must remain the most satisfactory method of assessing the comparative diuretic efficacy of drugs in a general ward, and has been advocated for this purpose by many-notably Gold et al. 34 We are interested in the comment that the general practitioner is the greatest user of oral diuretics. In this unit, for at least a year, we have not used a parenteral diuretic agent other than frusemide, and this solely for the emergency treatment of acute pulmonary oedema. We believe that parenteral therapy is
a
write
a
personal
note
when making their request ?
Hæmatology Department, St. George’s Hospital, London, S.W.17.
J. L. STAFFORD.
SCREENING TESTS FOR BACTERIURIA IN PREGNANCY
SIR,-I read with great interest the article by Dr. Kincaid-Smith and her colleagues (July 11) since we have been studying the same problem in the U.S.A. We found that vulvar cleansing was necessary in some groups of women and not in others. We also found that some women needed direct supervision and others did not. I believe that it is essential to determine whether supervision of vulvar cleansing is needed for the population concerned. The chances are that in the series reported by Dr. KincaidSmith and her coworkers external contamination was responsible not only for the presence of coagulase-negative staphylococci, but also for the presence of Streptococcus viridans, Staphylococcus aureus, mixed infections, haemolytic streptococcus, and some of the coliform organisms. As to placing reliance on tests of midstream specimens, Kass 1and other workers have shown that only when 2 consecutive cultures are taken can one expect 95% accuracy. With one random midstream culture there is only 80% accuracy.
In
evaluating screening tests for bacteriuria where the important data are colony-counts, greater attention should be given to these factors.
most
Saint Michael Hospital,
Newark, New Jersey,
LEON G. SMITH.
U.S.A.
rarely necessary.
1. 2.
Dr. Verel’s statement in his letter that " the figures published taken from the first week of therapy " seems irrelevant and is inconsistent with the description of the plan of the trial in his report. An approximate estimate of the average duration of the investigations from which the results in table I were compiled is thirty-one days.
Kass, E. H. Arch. intern. Med. 1960, 105, 194. Kass, E. H. Ann. intern. Med. 1962, 56, 46.
are
Whatever Dr. Verel’s views may be on " the amount of detail which should be included in a scientific report dealing with the trial of a new drug ", we strongly disagree with any editorial policy which would sanction the publication of original articles containing inadequately
supported
statements.
I. W. B. GRANT Unit, N. W. HORNE City Hospital, W. J. H. LECKIE. Edinburgh. 1. Grant, I. W. B., Horne, N. W., Leckie, W. J. H. Lancet, 1964, ii, 1239. 2. Verel, D., Stentiford, N. H., Rahman, F., Saynor, R. ibid. p. 1088. 3. Gold, H., Kwit, N. T., Golfinos, A. J., Bross, I. D. J. Amer. J. med. Sci. 1960, 239, 665. 4. Gold, H., Kwit, N. T., Messeloff, C. R., Kramer, M. L., Golfinos, A. J., Greiner, T. H., Goessel, E. A., Hughes, J. H., Warshaw, L. J. Amer. med. Ass. 1960, 173, 745. Chest
Medicine and the Law Inquest
on a
Boxer
SOME months ago a 21-year-old featherweight boxer was knocked down in the last round of a bout, apparently hit his head on the rope, and was unconscious for two or three minutes. Later he died of intracerebral haemorrhage.1 There was evidence that the boxer had previously suffered injuries to his brain, but Prof. F. E. Camps did not think that these injuries had caused his death, which was probably due to his
hitting the
rope. The coroner, Dr. Ian Milne, recording a verdict of accidental " death, said: I suppose it is for the public and boxers to decide what they want, and for the conscience of the nation as a whole to decide whether boxing is a suitable sport for a
Christian country."2 1. 2.
Times, Jan. 14. Guardian, Jan. 14.