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LONDON UNIVERSITY AND ITS MEDICAL SCHOOLS
51
CORRESPONDENCE PROGNOSIS IN PUERPERAL SEPSIS To the Editor of THE LANCET on p. 1459 of your last issue makes the suggestion, which is I admit Wrigley in text-books, that infection forward put frequently in puerperal sepsis spreads to the peritoneum by the tubes. This explanation, although generally accepted, is not confirmed by our findings here. Examination of our post-mortem records for the past three years shows that out of 50 deaths from hsemolytic streptococcus infection 39 have shown generalised peritonitis, while 3 others have shown an early pelvic peritonitis which had not become generalised up to the time of death. In these 42 cases of peritonitis the tubes were examined as a routine, both macroscopically and microscopically, and only 2 showed macroscopic pus in the tubes, while 5 others showed microscopically an early salpingitis, usually in one tube only, consisting simply of a polymorphonuclear infiltration of the submucosa. The remaining 35 cases showed healthy tubes, except for inevitable inflammation of the peritoneal surface. As a result of these findings I have come to regard spread of infection through the tubes as an uncommon occurrence. On the other hand, sections of the uterus show that the essential lesion in these cases is a septic thrombophlebitis in the small vessels of the uterine wall, especially in the region of the placental site. By suitable staining methods it is often possible to demonstrate streptococci in the vessels of the uterus within one or two millimetres of the peritoneal surface, and it seems probable that a direct spread of the infection through the uterine wa,ll to the peritoneum is by far the most common cause of
SiR,-In his article
Mr.
puerperal peritonitis. There is one other point in Mr. Wrigley’s article which seems to me a little misleading. After saying that the finding of the haemolytic streptococcus in the blood stream is of grave significance, he adds : " It seems that a less gloomy prognosis can be offered if the organism is found only on anaerobic culture." I fear that some confusion may have crept in here between the strictly anaerobic streptococci, which are itot haemolytic, and the haemolytic streptococcus isolated under anaerobic conditions as we have been advocating in this laboratory for the past year. If it is the anaerobic streptococcus to which Mr. Wrigley refers, the prognosis is certainly less gloomy ; but it must be remembered that we are then dealing with a completely different organism from the hsemolytic streptococcus, giving rise to a disease with a different clinical picture, with a marked tendency to thrombophlebitis especially in the iliac veins and vena cava, septic infarction of the lungs and possibly of the spleen and kidneys, and practically never a general peritonitis. If on the other hand it is the haemolytic streptococcus to which he refers, the prognosis is the same whether the organism is isolated under aerobic or anaerobic conditions. I am, Sir, yours faithfully, R. M. FRY. Bernhard Baron Memorial Research Laboratories, Queen Charlotte’s Hospital, W., Dec. 31st, 1934.
SOME RECENT ADVANCES IN CARDIOLOGY To the Editor of THE LANCET
Sm,-Dr. Crighton Bramwell’s interesting address published in your last issue rouses me to point out that probably the greatest advance in that subject,
only in this but in other countries-and possibly greatest since the time of Harvey-has been the demonstration, not once but repeatedly, of the experimental production of carditis not only from active rheumatic lesions but from streptococci
not
the
obtained from inflamed tonsils. This advance is the basis of the prevention of heart disease which in the last 20 years has gradually impressed its importance, not perhaps so much upon the British mentality, as upon the medical world in general., The recognition that the preventive study of heart disease in childhood is one of the master-keys of so-called " cardiology " is surely almost as valuable as the conception of a cardiac X ray, and almost as worthy of notice. I am, Sir, yours faithfully, F. JOHN POYNTON. Harley House, Upper Harley-street, W., Dec. 28th, 1934.
LONDON UNIVERSITY AND ITS MEDICAL SCHOOLS
To the Editor
of THE LANCET SIR,-In your excellent leading article of Dec. last you comment upon my suggestion that
1st
the examinations for the first and second M.B. should be so altered as to adapt them to afford graduation with the second M.B. The faculty in which this degree should be placed seems to me of secondary importance. London, unlike the older universities, has particularised its degrees, and it would not be possible, as Dr. Norris proposes in your issue of the 22nd, to give the " B.A. (Lond.) degree " upon passing the second M.B., B.S. Perhaps, as you yourself suggest, a " B.Sc." would be the most appropriate award, but the faculty of science is in this matter of new degrees one of the most " sticky " in the University; it refused, for instance, to accept the " B. Pharm. which ultimately was assigned to the faculty of medicine and has been a very promising innovation. Your correspondent who signs himself " A successful candidate " says that London can learn much from Cambridge. I agree, and the recent change of regulations at Cambridge operating from September last still further facilitates the path of the medical student to the B.A. degree when he has completed his pre-clinical studies. The Court has to justify its distribution of the grants it receives from the Treasury and the London County Council. Justification would be considerably easier if the number of graduates at the London medical schools could be increased on orthodox lines and in accordance with elementary fairness. I submit this would be the case if the suggestion I have made could be adopted, and the demand which you describe as legitimate met-namely, that grants designed to aid in the maintenance of a university standard of education for doctors should bear fruit in the production of university graduates." Your leading article points out that London University through its Court is really spending money upon the education of medical students who perhaps ought to be the responsibility of other bodies receiving grants from the Treasury-e.g., in the last year for which figures are available Cambridge received E158 ’000 and Oxford E125,000. But I feel sure that I am reflecting the opinion of my colleagues upon the Court when I say that the Court is, at present at any rate, content to regard all the students at the London medical schools, whether proceeding for the London degree "
"
"
"
52 students of the University. In this connexion perhaps point out that the medical schools can materially help the Court in maintaining this attitude by impressing upon the non-London students at the London medical schools the importance of registering in the new class created by the present Statutes (No. 23), that of " Associate Students." The University has been disappointed to find how infrequently students who are eligible to become
or
not,
as
I may
associate students avail themselves of the privilege by the payment of the very small fee (10s. 6d.) demanded for registration. The correspondence which my first letter has evoked suggests that the present character of the final examination is largely responsible for the diminished number of students who actually graduate in medicine. Some figures furnished to me by the academic registrar’s department bear out this contention in the low percentage of passes recorded during the past seven years. Candidates who sat for any part of the examination for the final
Candidates
who
passed both or either parts of the examination for the finaIM.B., B.S.
-A,I.B., B.S. 420 1927.... 412.... 1928.... 444 1929.... 452 1930.... 1931.... 445 1932.... 443 1933.... 475.... ....
....
....
....
....
Percentage of passes.
288 68-6 216 52-4 270 60.88 246 54-4 246 55-3 224 50-6 25 ... 53-5 ....
....
....
....
....
Failures amounting to nearly 50 per cent. are in my submission unduly high for a first qualifying examination, and although this position in no way invalidates my plea for the new degree in the place of the second M.B., it suggests that the final examination is in urgent need of overhauling. There can, I think, be no doubt that the present curriculum is grossly overloaded, and the actual strain of the examination itself, lasting as it does for 25 days, is a serious fault, as pointed out by your contributor " A successful candidate." But I fear that unless the schools themselves take action little will be done to alter the curriculum. The Medical Curriculum Committee appointed by the University two years ago shows no signs of life, and its composition, comprising as it does a large variety of clashing interests, does not give much hope of any practical outcome of its labours. I may say that I have been a member of the Court inspection of the medical schools of London upon nearly every occasion when an inspection was made, and I assert without hesitation that the present correspondence has been far more useful in suggesting reasons for the paucity of students taking the final medical examination in medicine than the information given at the inspections in answer to the question invariably put by the chairman at each visit : " How do you explain the small numbers of medical students If the medical schools who take London degrees ? can only be persuaded to think out these problems for themselves, to come to some agreed opinion and to impart that opinion to the Senate, much good would I am convinced result. As chairman of the External Council for the past 12 years, I am extremely sympathetic with the letter from an external student in your issue of the 15th instant. His point that at the final examination the examiners should have some consideration of the fact that external students taught out of London may present views other than those of London teachers, illustrates the importance of the provision which was "
part of the old statutes and has been unfortunately removed from the new-viz., that one examiner at least should be an external teacher. The External Council in its recommendation of examiners has endeavoured, with some success, to maintain this rule in practice notwithstanding that it is no longer statutory.-I am, Sir, yours faithfully, E. GRAHAM-LITTLE. a
Wimpole-street, W., Dec. 28th, 1934. SEVERE
GASTRIC AND DUODENAL HÆMORRHAGE
To the Editor
of THE
LANCET
SiR,—I am surprised to note the complacency with which blood transfusion is accepted as the routine method of treatment in severe gastric or duodenal haemorrhage, and would suggest the use of liver extract as an alternative. At autopsy on cases treated by transfusion extreme oedema of the lungs is frequently noted. The patient has literally drowned himself. As soon as a patient is admitted in an exsanguinated condition, the medical attendant only too often orders an immediate blood transfusion regardless of the unnecessary movement which such a procedure entails, especially when veins are none too easy to find. I am quite certain that blood transfusion has by itself a certain mortality, and also that unless the vessel in the stomach is tightly sealed it will cause the bleeding to recommence. I have made blood counts on patients, who on admission have had only about 1,000,000 red cells per c.mm. and 20 per cent. of haemoglobin and have received a transfusion of a pint or more, and three or four days later I have found their counts raised by 3-400,000 red cells, provided there has been no recurrence of bleeding. I have also found that if one has the courage to wait, although a patient is obviously getting more and more anaemic, a stage is reached at which the bleeding ceases and this is usually not much lower than 1,000,000 red cells per c.mm. Those patients who bleed to death will do so in spite of all medical treatment, as it means that a large vessel has been eroded, and the only measure to adopt would be to open the abdomen and tie the bleeding point-a procedure usually out of the question, as by the time such a decision would be made, the patient is moribund. We know that as soon as bleeding ceases, provided there is no sepsis, the bone-marrow starts turning immature red cells into the circulation, as a blood film the next day shows marked poikilocytosis, anisocytosis, polychromasia, and nucleated red cells. For some time I used blood transfusion for these cases, but was not impressed with the results, and when potent liver extract preparations came on the market it appeared to me that we had a weapon which could be used to stimulate the marrow and accelerate blood regeneration. In a few cases where daily injections of liver extract were used I found that not only did the blood count rise in three or four days by the same amount as with blood transfusion, but on examining a film the red cells were far more regular in size and shape, suggesting that maturer cells were being turned into the circulation. There is also some evidence that liver increases the coagulability of the blood. Iron may be given with advantage after a few days in order that the haemoglobin may keep pace with the increase of red cells. My suggestion is that patients with severe gastric or duodenal haemorrhage should be treated by giving on admission an injection of a potent liver extract
CORRESPONDENCE PROGNOSIS IN PUERPERAL SEPSIS To the Editor of THE LANCET on p. 1459 of your last issue makes the suggestion, which is I admit Wrigley in text-books, that infection forward put frequently in puerperal sepsis spreads to the peritoneum by the tubes. This explanation, although generally accepted, is not confirmed by our findings here. Examination of our post-mortem records for the past three years shows that out of 50 deaths from hsemolytic streptococcus infection 39 have shown generalised peritonitis, while 3 others have shown an early pelvic peritonitis which had not become generalised up to the time of death. In these 42 cases of peritonitis the tubes were examined as a routine, both macroscopically and microscopically, and only 2 showed macroscopic pus in the tubes, while 5 others showed microscopically an early salpingitis, usually in one tube only, consisting simply of a polymorphonuclear infiltration of the submucosa. The remaining 35 cases showed healthy tubes, except for inevitable inflammation of the peritoneal surface. As a result of these findings I have come to regard spread of infection through the tubes as an uncommon occurrence. On the other hand, sections of the uterus show that the essential lesion in these cases is a septic thrombophlebitis in the small vessels of the uterine wall, especially in the region of the placental site. By suitable staining methods it is often possible to demonstrate streptococci in the vessels of the uterus within one or two millimetres of the peritoneal surface, and it seems probable that a direct spread of the infection through the uterine wa,ll to the peritoneum is by far the most common cause of
SiR,-In his article
Mr.
puerperal peritonitis. There is one other point in Mr. Wrigley’s article which seems to me a little misleading. After saying that the finding of the haemolytic streptococcus in the blood stream is of grave significance, he adds : " It seems that a less gloomy prognosis can be offered if the organism is found only on anaerobic culture." I fear that some confusion may have crept in here between the strictly anaerobic streptococci, which are itot haemolytic, and the haemolytic streptococcus isolated under anaerobic conditions as we have been advocating in this laboratory for the past year. If it is the anaerobic streptococcus to which Mr. Wrigley refers, the prognosis is certainly less gloomy ; but it must be remembered that we are then dealing with a completely different organism from the hsemolytic streptococcus, giving rise to a disease with a different clinical picture, with a marked tendency to thrombophlebitis especially in the iliac veins and vena cava, septic infarction of the lungs and possibly of the spleen and kidneys, and practically never a general peritonitis. If on the other hand it is the haemolytic streptococcus to which he refers, the prognosis is the same whether the organism is isolated under aerobic or anaerobic conditions. I am, Sir, yours faithfully, R. M. FRY. Bernhard Baron Memorial Research Laboratories, Queen Charlotte’s Hospital, W., Dec. 31st, 1934.
SOME RECENT ADVANCES IN CARDIOLOGY To the Editor of THE LANCET
Sm,-Dr. Crighton Bramwell’s interesting address published in your last issue rouses me to point out that probably the greatest advance in that subject,
only in this but in other countries-and possibly greatest since the time of Harvey-has been the demonstration, not once but repeatedly, of the experimental production of carditis not only from active rheumatic lesions but from streptococci
not
the
obtained from inflamed tonsils. This advance is the basis of the prevention of heart disease which in the last 20 years has gradually impressed its importance, not perhaps so much upon the British mentality, as upon the medical world in general., The recognition that the preventive study of heart disease in childhood is one of the master-keys of so-called " cardiology " is surely almost as valuable as the conception of a cardiac X ray, and almost as worthy of notice. I am, Sir, yours faithfully, F. JOHN POYNTON. Harley House, Upper Harley-street, W., Dec. 28th, 1934.
LONDON UNIVERSITY AND ITS MEDICAL SCHOOLS
To the Editor
of THE LANCET SIR,-In your excellent leading article of Dec. last you comment upon my suggestion that
1st
the examinations for the first and second M.B. should be so altered as to adapt them to afford graduation with the second M.B. The faculty in which this degree should be placed seems to me of secondary importance. London, unlike the older universities, has particularised its degrees, and it would not be possible, as Dr. Norris proposes in your issue of the 22nd, to give the " B.A. (Lond.) degree " upon passing the second M.B., B.S. Perhaps, as you yourself suggest, a " B.Sc." would be the most appropriate award, but the faculty of science is in this matter of new degrees one of the most " sticky " in the University; it refused, for instance, to accept the " B. Pharm. which ultimately was assigned to the faculty of medicine and has been a very promising innovation. Your correspondent who signs himself " A successful candidate " says that London can learn much from Cambridge. I agree, and the recent change of regulations at Cambridge operating from September last still further facilitates the path of the medical student to the B.A. degree when he has completed his pre-clinical studies. The Court has to justify its distribution of the grants it receives from the Treasury and the London County Council. Justification would be considerably easier if the number of graduates at the London medical schools could be increased on orthodox lines and in accordance with elementary fairness. I submit this would be the case if the suggestion I have made could be adopted, and the demand which you describe as legitimate met-namely, that grants designed to aid in the maintenance of a university standard of education for doctors should bear fruit in the production of university graduates." Your leading article points out that London University through its Court is really spending money upon the education of medical students who perhaps ought to be the responsibility of other bodies receiving grants from the Treasury-e.g., in the last year for which figures are available Cambridge received E158 ’000 and Oxford E125,000. But I feel sure that I am reflecting the opinion of my colleagues upon the Court when I say that the Court is, at present at any rate, content to regard all the students at the London medical schools, whether proceeding for the London degree "
"
"
"
52 students of the University. In this connexion perhaps point out that the medical schools can materially help the Court in maintaining this attitude by impressing upon the non-London students at the London medical schools the importance of registering in the new class created by the present Statutes (No. 23), that of " Associate Students." The University has been disappointed to find how infrequently students who are eligible to become
or
not,
as
I may
associate students avail themselves of the privilege by the payment of the very small fee (10s. 6d.) demanded for registration. The correspondence which my first letter has evoked suggests that the present character of the final examination is largely responsible for the diminished number of students who actually graduate in medicine. Some figures furnished to me by the academic registrar’s department bear out this contention in the low percentage of passes recorded during the past seven years. Candidates who sat for any part of the examination for the final
Candidates
who
passed both or either parts of the examination for the finaIM.B., B.S.
-A,I.B., B.S. 420 1927.... 412.... 1928.... 444 1929.... 452 1930.... 1931.... 445 1932.... 443 1933.... 475.... ....
....
....
....
....
Percentage of passes.
288 68-6 216 52-4 270 60.88 246 54-4 246 55-3 224 50-6 25 ... 53-5 ....
....
....
....
....
Failures amounting to nearly 50 per cent. are in my submission unduly high for a first qualifying examination, and although this position in no way invalidates my plea for the new degree in the place of the second M.B., it suggests that the final examination is in urgent need of overhauling. There can, I think, be no doubt that the present curriculum is grossly overloaded, and the actual strain of the examination itself, lasting as it does for 25 days, is a serious fault, as pointed out by your contributor " A successful candidate." But I fear that unless the schools themselves take action little will be done to alter the curriculum. The Medical Curriculum Committee appointed by the University two years ago shows no signs of life, and its composition, comprising as it does a large variety of clashing interests, does not give much hope of any practical outcome of its labours. I may say that I have been a member of the Court inspection of the medical schools of London upon nearly every occasion when an inspection was made, and I assert without hesitation that the present correspondence has been far more useful in suggesting reasons for the paucity of students taking the final medical examination in medicine than the information given at the inspections in answer to the question invariably put by the chairman at each visit : " How do you explain the small numbers of medical students If the medical schools who take London degrees ? can only be persuaded to think out these problems for themselves, to come to some agreed opinion and to impart that opinion to the Senate, much good would I am convinced result. As chairman of the External Council for the past 12 years, I am extremely sympathetic with the letter from an external student in your issue of the 15th instant. His point that at the final examination the examiners should have some consideration of the fact that external students taught out of London may present views other than those of London teachers, illustrates the importance of the provision which was "
part of the old statutes and has been unfortunately removed from the new-viz., that one examiner at least should be an external teacher. The External Council in its recommendation of examiners has endeavoured, with some success, to maintain this rule in practice notwithstanding that it is no longer statutory.-I am, Sir, yours faithfully, E. GRAHAM-LITTLE. a
Wimpole-street, W., Dec. 28th, 1934. SEVERE
GASTRIC AND DUODENAL HÆMORRHAGE
To the Editor
of THE
LANCET
SiR,—I am surprised to note the complacency with which blood transfusion is accepted as the routine method of treatment in severe gastric or duodenal haemorrhage, and would suggest the use of liver extract as an alternative. At autopsy on cases treated by transfusion extreme oedema of the lungs is frequently noted. The patient has literally drowned himself. As soon as a patient is admitted in an exsanguinated condition, the medical attendant only too often orders an immediate blood transfusion regardless of the unnecessary movement which such a procedure entails, especially when veins are none too easy to find. I am quite certain that blood transfusion has by itself a certain mortality, and also that unless the vessel in the stomach is tightly sealed it will cause the bleeding to recommence. I have made blood counts on patients, who on admission have had only about 1,000,000 red cells per c.mm. and 20 per cent. of haemoglobin and have received a transfusion of a pint or more, and three or four days later I have found their counts raised by 3-400,000 red cells, provided there has been no recurrence of bleeding. I have also found that if one has the courage to wait, although a patient is obviously getting more and more anaemic, a stage is reached at which the bleeding ceases and this is usually not much lower than 1,000,000 red cells per c.mm. Those patients who bleed to death will do so in spite of all medical treatment, as it means that a large vessel has been eroded, and the only measure to adopt would be to open the abdomen and tie the bleeding point-a procedure usually out of the question, as by the time such a decision would be made, the patient is moribund. We know that as soon as bleeding ceases, provided there is no sepsis, the bone-marrow starts turning immature red cells into the circulation, as a blood film the next day shows marked poikilocytosis, anisocytosis, polychromasia, and nucleated red cells. For some time I used blood transfusion for these cases, but was not impressed with the results, and when potent liver extract preparations came on the market it appeared to me that we had a weapon which could be used to stimulate the marrow and accelerate blood regeneration. In a few cases where daily injections of liver extract were used I found that not only did the blood count rise in three or four days by the same amount as with blood transfusion, but on examining a film the red cells were far more regular in size and shape, suggesting that maturer cells were being turned into the circulation. There is also some evidence that liver increases the coagulability of the blood. Iron may be given with advantage after a few days in order that the haemoglobin may keep pace with the increase of red cells. My suggestion is that patients with severe gastric or duodenal haemorrhage should be treated by giving on admission an injection of a potent liver extract