LESIONS OF CERVICAL INTERVERTEBRAL DISCS

464

growing

of beds is required, there is a opinion in favour of much smaller institutions and greater decentralisation. In conclusion, I feel that planning has lately become too technical and functional, with the result that the human factor has been unconsciously neglected. More than once a hospital planned by first-class experts has somehow failed to give satisfaction to either patients or staff. Efficiency is necessary, but it is evidently not enough in itself to ensure success. There are many other points, such as the size of windows, the height of wards, and heating and ventilation, which might well be madethe subject’ of careful study for the guidance of future hospital builders. The keynote of such an investigation should be simplicity and economy not only in capital cost but in maintenance. L. G. PEARSON. London, W.C.I. ’

APPLIED PHOTOGRAPHY

8m,—The article on applied photography by Dr. Hansell and Dr. Ollerenshaw (Nov. 1) is timely and of great interest. This is a subject in which I am particularly interested and of which I have had some

experience. The tendency to regard photography merely as an additional department of the hospital is wrong, and this is rightly stressed. However, I was rather surprised to see that the authors advocated a photographic section separate from the museum. Surely the time has now come when the various hospital museums should be reorganised in the light of modern experience. Instead of consisting of a collection of pathological specimens in bottles, they should be classified into sections each

covering

one

disease

or

a

group of diseases.

Each

section should have details of symptoms, diagnosis, and treatment, and should also include pathological speci-

mens, wherever possible supplemented by photographs. This principle is followed in the museums of the Wellcome Research Institution and the London School of Hygiene and Tropical Medicine, both of which are outstandingly good. A museum can best help the student by a graphic display of diseases. Unlike these authors, I consider that the normal lantern-size transparency is the ideal medium for displaying radiograms and colour work; the miniature size is too small unless it is shown through a lantern. I was disappointed to see no reference to stereoscopic photography, which is useful in all kinds of medical work and illustrates certain diseases much better than the straight - photograph. Other points were not included. A photograph coloured in oils by an expert is reasonably permanent and should be part of the work of the photographic department. Line drawings from photographs can be made easily and accurately and the irrelevant parts faded out. Photography is such a valuable aid for teaching, record work, and routine use that it would be a great pity if it was to start as a separate entity rather than as a universal aid to every department of the hospital. J. F. E. BLOSS. Sndan. MM&kaI, SUFFOCATION BY MILK FEEDS

SiB,—To support the evidence of Professor Polson and Dr. Price in their letter on Feb. 28, we present a few figures culled from our post-mortem findings in this department during the past six months. In this period 7 babies under the age of six months were found to have died from the effects of inhalation of vomited milk. Of these, 4 were the subjects of coroners’ inquiries, because the infants had been found dead in their cots or prams. In each of these cases vomited milk had been seen on the pillows, and autopsy revealed the presence of milk in the trachea, bronchi, and lungs ; and early bronchopneumonia had developed in 2. The other 3 infants died in hospital; in 1, death was undoubtedly due to asphyxia, for the right main bronchus was completely blocked by vomit, but’ in the other 2, although vomited milk was present in the air passages, a definite bronchopneumonia had developed, pus as well as milk being expressible from the cut surface of the lungs. The points to which we would draw attention are : 1. Although suffocation from inhaled vomit may :,udden death in infants, inhalation of small

cause

quantities

of

milk may give rise to aspiration bronchopneumonia. Deaths " may then be certified as due to bronchopneumonia without the essential cause being recognised. 2. The pernicious practice of " pinioning " babies in their cots or prams by wrapping blankets or shawls firmly round their chests and tucking the blankets well into the sides of the " cot or pram to keep them quiet " or tidy " is certainly for some deaths. The unfortunate of these responsible infants are unable to expand their chests to breathe properly or to eject vomited milk from their mouths effectively ; and when some milk trickles into the trachea they are unable to cough it up. Definite evidence on this point was found in 2 of our cases. 3. We agree with Polson and Price that infants are often given bottle-feeds whilst lying down, and that this practice predisposes to suffocation. 4. Education of mothers, nurses, and others in charge of young infants should be specially directed towards teaching the correct method of tending, feeding, and " be,4ding." A decrease in these preventable deaths would surely follow. 5. The claims of extraneous interests should be subordinated "

"

to tho-o of motherhood

Department of Pathology, General Hospital, Northampton.

R. M. HEGGIE RUBY O. STERN.

LESIONS OF CERVICAL INTERVERTEBRAL DISCS at the Royal Society of Mediyour issue of March 13, only a. fleeting made by one speaker to treatment by

SiR,-In the discussion cine, reported in reference

was

manipulation. During the last eighteen monthsI havee seen 15 patients presenting unequivocal evidence of the monoradicular type of cervical disc prolapse, and 6 of these were suffering from severe pain which persisted for more than a few weeks. These were treated by manipulation of the neck under thiopentone anses-

thesia ;

5 made an immediate and dramatic recovery, and the sixth patient was quite unaffected ; her symptoms were abolished by skull traction over a period of seventy-two hours. These results justify my previous advocacy of manipulation1 as safe and effective. Manipulation is not indicated for paraesthesiee alone. however troublesome, but only for pain, and two or three weeks should be allowed for the chance of spontaneous

palliative management. Recently two surgical colleagues consulted me. One had distressingly severe pain, but this cleared up after ten days ; the other has recurrent parsesthesias without pain, but though these are a serious nuisance, and though there are all the objective neurological and radiological features of disc prolapse, one must be content in this type of case to recognise the lesion and to make a mental reservation in favour of manipulation should severe pain supervene, for premature manipulation might well provoke an

recovery with

There is of course the fear of producing cord symptoms, but this appears groundless in purely monoradicular syndromes, and my use of the method is based on the personal knowledge of large numbers of manipulations performed by different surgeons- in past years for

attack.

diagnosed as cervical arthritis with referred which it is now clear included many instances of disc prolapse. I do not know of a single patient in whom cord symptoms appeared following manipulation, while the frequency of improvement was gratifying. Ultimate recurrence is likely, and indeed probable with this treatment, but that is no rear deterrent, for the therapeutic problem in these cases is essentially a shortterm one, with the patient needing to be helped over acute episodes as they arise. Nevertheless, the period of remission after manipulation of the cervical spine is a good deal longer than occurs after manipulation for lumbar prolapses, while the likelihood of relief is much greater. As regards the relativefrequency of the different causes of brachial neuralgia, during the same period of eighteen months I collected from the same clinics only 12 patients with well-marked thoracic-outlet or firstrib syndromes of all kinds, so that cases of disc prolapse cases

then

pain,

cases

slightly more common. Finally, on a point of terminology,

were

Russell Brain syndromes " to

I note that Dr. the expression costoclavicular include all thoracic-outlet disorders "

uses

1. Proc. R. Soc. Med.

1947, 40,

496.

465 the brachial plexus on its way to the arm. I suggest that " costoclavicular should be restricted to the specific condition which the name implies, and for which it was employed by Falconer and Weddellcompression of the plexus and possibly the subclavian vessels between first rib and clavicle.

affecting

"

DAVID LE VAY.

London, W.I.

Parliament ,

FROM THE PRESS GALLERY

United Services SPEAKING in the debate on the Army Estimates in the House of Commons on March 9, Dr. HADEN GUEST stressed the additional responsibilities which the war of the future would lay on the Army to reinforce civildefence services. The atom bomb, bacteriological warfare, and new forms of chemical warfare could attack and destroy large communities. The atom bomb, he continued, was costly, but bacteriological warfare was cheap, and the resources of a good county public-health laboratory were sufficient for the manufacture of the deadliest germ weapons. In any future war there must therefore be greater integration between the military and civil sides of the nation’s life, and the greatest economy in the use of scientific and technical personnel. The problem as it applied to the medical officers in the Services was an example of the difficulties to be faced. There was great difficulty in supplying the full quota of medical specialists to the Army, and a lesser difficulty in the other Services, because medical officers of an age liable to be called up had not had time to take the highest specialist qualifications. A man under 30 who was called up could not be expected to be capable of acting as consultant medical officer or surgical medical officer to a division or a command. But it was upon highly placed consultant officers that the efficiency of the medical services would depend. This was a grave difficulty which was increased by the demands made on medical manpower in other fields, notably that of the new National Health Service which would come into operation on July 5. Shortly afterwards there would be a demand for an increase in the number of general practitioners. Demands were also, quite rightly, being made on medical man-power for the Colonial Service. During and since the war it had been necessary to make an ad-hoc arrangement in West Africa and in another Colony by which medical men who were recruited for what normally would have been military duty had been allocated to service in these Colonies and that service had been accepted in discharge of their military obligations. The expansion of civil defence, Dr. Guest pointed out, would be another large drain on our medical man-power. Referring to this problem the Minister of Defence had said that the Government had not closed the door to unification of common services within the Forces, but that for the time being he rejected the idea of unification Dr. Guest in favour of administrative coordination. trusted that this coordination among the Services would be carried out immediately. There was no sense in the

medical services of the Navy, Army, and Air Force having three different kinds of forms on which to report the same disability ; it meant confusion and extra sorting work when the patients got into hospital. The demands of the Services for specialists and administrative officers, he added, could, for the most part, be met only by creating a large number of regular commissions or short-term commissions of fiveyears. But economy was heeded and he understood that unification of the medical services of the three Forces would involve a saving of medical personnel of 5-10%. Dr. Guest had seen how the medical services cooperated in Malta, and how they were working together in Hong-Kong. Again, during the war most of the hospitalisation of casualties was carried out by the Army, whether the casualties were from the Navy, the Army, the Air Force, or civilian. Dr. Guest also recalled that our big medical base had been in this country largely in the form of the Emergency Medical Service-a civilian organisation which acted admirably. Unification of the Services, he therefore suggested, should be extended over civilian and industrial medicine,

the Defence Services, and Colonial needs, and this single service should include the National Health Service, general and special services, and the Army, Navy, and Air Force, and Colonial Services. In such a unified medical service, hepointed out, superannuation and pension schemes could be completely interchangeable between one branch and another. There would be no need to tie anyone down to lifelong work in any branch, and some might spend their early years in the Colonies or one of the Services without being handicapped on returning to work at home. Dr. Guest believed that this practical proposal would go a long way to solve our immediate problems, though he recognised it had certain Service objections. partly of a sentimental character. In his reply to the debate Mr. MICHAEL STEWART, Under-Secretary of State for War, admitted frankly that there was a shortage of specialists. It was extremely difficult, he added, to see any immediate remedy for it. It was part of the general shortage of medical specialists from which the Army was not by any means the only sufferer. It was important, therefore, that we should make the best use of the specialists we had. As Dr. Guest had suggested, it might be possible to obtain further economies by measures of coordination between the medical departments of the three Defence Services. A recently appointed committee was already working on that problem, and Mr. Stewart hoped that it would help to provide a solution. ,

QUESTION TIME Pensioners and Treatment Allowances Mr. J. L. WILLIAMS asked the Minister of Pension.s whether he proposed to alter the practice of making a deduction from treatment allowances in respect of sick pay or wages received during a course of treatment.-Mr. ARTHUR BLENKINSOP replied : As from the first pay day in April, the allowances at the 100% pension-rate, which are payable during a course of approved treatment which prevents a pensioner from working, will be paid without any deduction on account of sick pay or wages..-

Medical Records and Pension Appeals Mr. E. G. WILLIS asked the Minister if he would make available to an appellant’s doctor, before a case was taken to the tribunal, the medical evidence to be submitted on behalf of the Minister.-Mr. BLENKINSOP replied : Before an appeal is sent to the tribunal the appellant is provided with two copies of a statement containing all the relevant medical and other facts of his case, and is, therefore, in a position to seek the assistance and advice of his doctor on matters contained in the statement. The Minister is, however, prepared to supply to a claimant’s doctor, subject to the claimant’s written consent, information from the medical records of his department if this is required before an appeal is formally lodged. ’

Milk Ration Anomaly Mr. J. B. HYND asked the Minister of Food whether any decision had yet been reached to remove the discrimination whereby mothers purchasing National Dried Milk must surrender the child’s liquid-milk ration whereas those purchasing more expensive dried-milk foods need not do so.Dr. EDITH SUMMERSKILL replied : The Minister is considering this matter but has not yet reached a decision. Mr. HYND : Is the Parliamentary Secretary aware that this matter has been under consideration for a number of months, and that mothers who are being deprived of the liquid-milk ration while others are enjoying it are wondering when they will get the same treatment ?-Dr. SUMMERSKILL: I agree, but there is one important point-namely, that we cannot immediately deprive all babies of proprietary foods. We have to make some arrangements to ensure that those mothers who have been buying proprietary foods for their children can continue to do so.

Scholarships Dr. S. JEGER asked the Minister of Education (1) the number of medical students whose fees were paid wholly, and partly, from public funds ; (2) the number at present receiving maintenance grants from public funds.—Mr. G. TOMLINSON replied : At present 2540 grants for medical students from my department are current. Of these, 2509 provide for the

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