MEDICAL PHYSICS.

768 MEDICAL PHYSICS. l’o the Editor of THE LANCET. SIR,—We desire to bring before your readers our views regarding the teaching of medical physics in the later years of the curriculum.We understand that it is suggested in Edinburgh that the student might obtain some teaching of medical physics from the physiologist, some from the ophthalmologist, some from the laryngologist, &c., but we are of opinion that unless a definite course by a definite teacher, who is qualified to teach medical physics, is attended, and unless this is followed by a definite examination ad hoc, the subject would not receive the study and attention which it deserves. The information would be patchy, important points would inevitably be omitted, and the instruction would lack the consecutive and coherent character which is essential for an efficient course.

We

are.

Sir,

ALFRED DAWSON

vours

faithfullv.

DANIELL. M.A., LL.B., D.Sc., TURNER, B.A., M.D., F.R.C.P.E.,

M.R.C.P. Lond., WILLIAM GEORGE SYM M.D., F.R.C.S.E., Examiners in Physics for the Triple Qualification. Edinburgh, March 31st, 1923.

THE

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administer 8000 units in cases provisionally diagnosed as diphtheria. Butas my colleague Dr. Frederic Thomson, of the North-Eastern Hospital, exactly expresses m y views on the subject, I need not repeat the arguments he uses in his letter to you of March 31st. Dr. Ker states that an unreasonable dread of anaphylactic shock deters many practitioners from injecting That is Dr. Ker’s experience in antitoxin early. Edinburgh, but it is not mine in London. I attribute the lack of early specific treatment to two causes, the delay in waiting for the results of a culture and the failure on the part of the patient or his friends to seek medical advice at a sufficiently early moment. Dr. Ker calls attention to the remarkable fall in the casemortality of diphtheria which followed the introduction of serum treatment and was undoubtedly effected by very moderate and even actually small doses. It may interest him and your readers to know that so far back as July, 1896, Lord (then Sir Joseph) Lister pointed out the same fact in a letter which I have in my possession, wherein he was discussing the question of the necessity of increasing the strength of ttie serum supplied by what was then known as the British Institute of Preventive Medicine. I am,

Sir. vours faithfully,

E. W. GOODALL GOODALL. North-Western Hospital, Hampstead, N.W., April 9th, 1923.

ADMINISTRATION OF ANTIDIPHTHERITIC SERUM.

To the Editor of THE LANCET. To the Editor° of THE LANCET. SIR,—In your issue of April 7th I notice a reference an article by the late Dr. J. Biernacki and myself SiR,—May I be permitted, as one who has been for to on this subject made in 1004. In this it is inferred many years and still is responsible for the care of a that we recommended the method. I have not the of to of cases offer large number diphtheria annually, paper before me. and it was written many years ago, a few remarks on the two points connected with the treatment of that disease which havebeen discussed but T have a clear recollection that we were very in your columns during the last fortnight ? First, doubtful, after trying it in a number of cases, whether in respect of the intravenous injection of the antitoxic it presented any definite advantage over the usual subcutaneous method, and we practically discontinued serum, of the superiority of which Dr. Poul Iversen, to use it at Plaistow Hospital. I had quite forgotten as you state in your annotation on p. 709. writes with such conviction. Judging by the results of experi- that we practised giving an anesthetic to small children ments on animals the intravenous method should be for intravenous injection, and I think it must have been I cannot help the best. Hut has it been proved in practice to be so ? in a very small number of cases. Dr. Iversen does not help us to decide this point, for thinking at any rate that a method presents grave he gives no details of the therapeutic results of the drawbacks if it needs a general anaesthetic in a disease like severe diphtheria, where the blood pressure and cases he treated ; he does not even tell us how many of his patients died ; nor has he given any information output of urine are already seriously affected and where the danger of setting up vomiting is so grave. The as to the ages of the patients and the nature of the attacks. Apparently, however. the sole object of his intravenous method would have to show very decided to make habitual general anesthesia paper is to show how the patients stood the injections. superiority Now if one thing is certain in respect of the anti- I justifiable. Yet it is precisely in small children that gravest cases occur. toxin treatment of diphtheria it is that if patients are I am, Sir, yours faithfully, brought under treatment early—that is, on the tirst or J. C. MUIR. second day-they nearly all recover and rarely suffer Whipps Cross hospital, Leytonstone, E., April 9th, 1923. from complications. That result has been obtained by the method of subcutaneous injection and by the use of small and moderate doses. It would, therefore, SERUM DOSAGE IN DIPHTHERIA. appear to be quite unnecessary and, in view of the To the Editor of THE LANCET. possibility of the occurrence of rigors and collapse such as are recorded by Dr. Iversen, even undesirable to reference to Dr. Claude Ker’s note on this SIR,— In employ the intravenous method in mild attacks. But subject in your issue of March 31st, he has not taken it might be beneficial in severe cases, which are usually into consideration the great differences there may be also late. The method was tried in a few such cases in the virulence of diphtheria in different places at many years ago at the Eastern Hospital. I was not different times. For the type of diphtheria present in impressed with the results ; nor was I impressed with Bristol from 1910 to 1921 doses of from 4000 to 10,000 the results of the series of 45 cases reported by Dr..J. units were in all cases sufficient to obtain arrest of Biernacki and Dr. J. C. Muir and the 20 reported by the disease and disappearance of the membrane. In Dr. D. L. Cairns. There is certainly a practical 1921 the type of disease suddenly altered and a type objection-namely, the difficulty of getting the serum of disease arose in which the membrane still rapidly into a vein in the case of a resisting child who is suffer- grew with the onset of great cervical oedema on giving ing from a severe attack of diphtheria. In such cases these doses. This type was characterised by great the superficial veins are collapsed anll empty, and it is cedema of fauces and neck and delayed formation of anything but easy to get the needle into a vein and membrane, which frequently did not show itself until keep it there. Dr. Biernacki and Dr. Muir I)oi-e the third or fourth day, causing great difficulties in witness to the reality of this difficulty when they diagnosis, by which time the patient was moribund. advocated the dissection of a vein under a general The disease was highly infectious and many of the anaesthetic. staff were attacked, with one death from acute Secondly, as regards the question of dosage raised toxaemia, in spite of injections totalling 30,000 units, by Dr. Ker, while I am in agreement with him generally, of which 10.000 were given on the first day without I do not agree that the Ministry of Health are extra- influencing the disease. (These disasters are now vagant in recommending general practitioners to avoided by Schick’s method.) In fact, so great was

the