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OBSTETRIC SHOCK
119 way, I
am sure
that Dr. Parnell would not assert that by
regular examinations all handicaps
are
discovered ;
but there is no doubt whatever that by such attention a great many remediable defects can be pointed out, and cured, before they have become a source of morbidity
mortality. Finally, I entirely agree with Dr. Petch that our knowledge of the range of normal variation is woefully inadequate. If those conducting health examinations make good use of .their opportunities this ignorance will be rapidly dispelled. This alone is an excellent reason for the continuance of such work, and the encouragement of those engaged in it. or
---
ALAN WATSON.
London, .1.
CENSORSHIP OF MEDICAL ARTICLES
SIR,-I have read with interest Dr. Willcox’s letter of Jan. 3 and your leading article. I entirely agree with every word you say, and I think your article is it may not be fully realised that in civilian life there is a precedent to censorship of medical articles which could be used in the National Health Service. I am referring to the fact that in many Government departments, which have a medical branch attached, it is not even sufficient to get the permission of the medical man in charge of the department in order to publish a medical article : every publication has also to be submitted to the lay people in charge, for their MEDICUS. imprimatur. SiR,-During my war service in the R.A.M.C. I was allowed, and indeed encouraged, to forward articles of professional interest direct to the consulting physician of the Command in which I was serving. Most specialists considered that articles intended for publication could be submitted in this way, and in my experience the consultant forwarded the manuscript without delay to the editor of the journal indicated. It is true that this simple and speedy method of censorship conflicted with King’s Regulations (as explained by Dr. Willcox in your issue of Jan. 3), but most of us were willing to take the risk, especially since our consultant also stood to lose by being a party to our indiscretion. Dr. -Willcox’s account of the frustrations and delays which he experienced at various relay stations makes lamentable reading, but I question his conclusion that valuable historical matter was lost by the general state of affairs in the Army Medical Services ; and I know of apt least one consultant who forwarded an article written by a specialist attempting to prove that his consultant’s views were sadly out of date. STEPHEN WHITTAKER. Warwick.
particularly timely because
-
---
PARA-AMINOSALICYLIC ACID IN TUBERCULOSIS
SiR,-With reference to our recent preliminary communication (Dec. 13), we are asked by Mr. D. E. Seymour to point out that the new method of synthesis of para-aminosalicylic acid was evolved jointly by F. S. Spring and D. D. Martin, at Glasgow Royal Technical College, and by himself at Herts Pharmaceuticals Ltd. ; and that the joint publication of their method will appear
in due
course.
Grove Park
(L.C.C.) Hospital, London, S.E.12.
T. G. DEMPSEY M. H. LOGG.
MONOCULAR SEASICKNESS Sir,- was interested to read the remarks of your peripatetic correspondents about one-eyed persons being immune to seasickness (Dec. 13 and 27). There must be many doctors like myself who lost an eye during the war, and it would be amusing to know if any of them have noticed a change in their susceptibility to this
distressing malady. Anyone
who
noticed
my
pitiable state when the one day last October
Channel steamer reached Folkestone
could only conclude that I may havebecome a worse sailor but hardly a better one. Actually when I was binocular I was an indifferent sailor, and monocularism has not made the slightest difference. (In my own defence I may say it was pretty rough that day in the Channel.) Next time-if and when the travel ban is removed-I must try blocking the centralateral ear. CLAUD C. M. WATSON. Edinburgh.
BLOOD SAMPLES FROM INFANTS
SIR,-In your issue of Dec. 27, Dr. A. V. Magee enumerates various methods for collecting blood from infants. He omitted from his list a very simple methodcollection from the superficial scalp veins, which are usually prominent in infants. The procedure adopted is as follows : The child is wrapped snugly in a blanket to prevent interference by kicking legs or by arms and hands ; the hair is cut over the site chosen to display the vein, and while an assistant steadies the child’s head the operator introduces the needle ; a free flow of blood ensues ; the more vigorous the child’s cry, the freer the flow. When enough has been collected the needle is removed and the flow is stopped by firm pressure over the bleeding point with a swab of sterile cottonwool. This method was employed extensively by the late Prof. Leonard Findlay, of Glasgow, and has been practised by his many former house-physicians.’ I should like to add that the route via the anterior fontanelle is not devoid of risk. Several marasmic infants on whom this method was used showed at autopsy thrombosis of the superior sagittal sinus. London Chest Hospital, CECILIA SHISKIN. Victoria Park, E.2.
OBSTETRIC SHOCK
SIR,-I have read with great pleasure and interest Professor Sheehan’s article of Jan. 3. As he points out, the same picture of circulatory collapse may be produced by different mechanisms, and in obstetrics the analysis of causal factors is especially difficult. I should like to draw attention to one point which may be important and which is rarely considered. It is always recognised that blood lost must be replaced. In a few cases this will fail to restore circulatory balance, and occasionally the It is blood-loss is not large enough to be important. in such cases that the difficulties begin, and the progressive character of the syndrome is impressive. In my opinion a state of marked dehydration is often of great importance in these patients. During labour, especially if it is protracted, the excretion of urine and of chloride may fall to a very low level for many hours. The woman often vomits and looks dried up, with parched lips, although she will drink only small amounts. These features may be evidence of serious dehydration which may perhaps initiate or exaggerate a state of circulatory failure. I should like to suggest that transfusion ,of saline should be beneficial to these patients, and I have had most encouraging results after using this upon two occasions for shock which resisted other treatment. On theoretical grounds excessive and continued transfusion of blood may be actually harmful to these women. L. G. HIGGINS. Woking. VISCERAL PAIN
Sir,-Professor Cohen in his interesting paper of Dec. 27, stated that whereas I had enunciated the
principle of the summation of visceral and cutaneous pain stimuli, I had failed to face the obvious corollary that subliminal pain stimuli must constantly travel along afferent pain pathways, both from the skin and from the viscera. In the monograph I to which he refers, I
in Colombo in 1941, " that impulses are always travelling along the cutaneous sensory nerves, but that pain is only appreciated if they reach a certain intensity, or if the threshold to pain of the relevant cells in the pain apperception centre be lowered." I did not postulate that subliminal pain impulses constantly travel along visceralafferent pain pathways for two main reasons : (1) so far as I am aware there is no proof that any viscus, other than the uterus, is supplied with visceral afferent nerves which mediate the sensation of pain ; and (2) there is no experimental evidence which warrants such an assumption. Visceral pain can be abolished by anaesthetising the cutaneous areas to which it is referred, but there is, so far as I know, no evidence that cutaneous pain can be relieved by anaesthetising visceral afferent nerves. G. W. THEOBALD. Idle, Bradford.
published postulated
am sure
that Dr. Parnell would not assert that by
regular examinations all handicaps
are
discovered ;
but there is no doubt whatever that by such attention a great many remediable defects can be pointed out, and cured, before they have become a source of morbidity
mortality. Finally, I entirely agree with Dr. Petch that our knowledge of the range of normal variation is woefully inadequate. If those conducting health examinations make good use of .their opportunities this ignorance will be rapidly dispelled. This alone is an excellent reason for the continuance of such work, and the encouragement of those engaged in it. or
---
ALAN WATSON.
London, .1.
CENSORSHIP OF MEDICAL ARTICLES
SIR,-I have read with interest Dr. Willcox’s letter of Jan. 3 and your leading article. I entirely agree with every word you say, and I think your article is it may not be fully realised that in civilian life there is a precedent to censorship of medical articles which could be used in the National Health Service. I am referring to the fact that in many Government departments, which have a medical branch attached, it is not even sufficient to get the permission of the medical man in charge of the department in order to publish a medical article : every publication has also to be submitted to the lay people in charge, for their MEDICUS. imprimatur. SiR,-During my war service in the R.A.M.C. I was allowed, and indeed encouraged, to forward articles of professional interest direct to the consulting physician of the Command in which I was serving. Most specialists considered that articles intended for publication could be submitted in this way, and in my experience the consultant forwarded the manuscript without delay to the editor of the journal indicated. It is true that this simple and speedy method of censorship conflicted with King’s Regulations (as explained by Dr. Willcox in your issue of Jan. 3), but most of us were willing to take the risk, especially since our consultant also stood to lose by being a party to our indiscretion. Dr. -Willcox’s account of the frustrations and delays which he experienced at various relay stations makes lamentable reading, but I question his conclusion that valuable historical matter was lost by the general state of affairs in the Army Medical Services ; and I know of apt least one consultant who forwarded an article written by a specialist attempting to prove that his consultant’s views were sadly out of date. STEPHEN WHITTAKER. Warwick.
particularly timely because
-
---
PARA-AMINOSALICYLIC ACID IN TUBERCULOSIS
SiR,-With reference to our recent preliminary communication (Dec. 13), we are asked by Mr. D. E. Seymour to point out that the new method of synthesis of para-aminosalicylic acid was evolved jointly by F. S. Spring and D. D. Martin, at Glasgow Royal Technical College, and by himself at Herts Pharmaceuticals Ltd. ; and that the joint publication of their method will appear
in due
course.
Grove Park
(L.C.C.) Hospital, London, S.E.12.
T. G. DEMPSEY M. H. LOGG.
MONOCULAR SEASICKNESS Sir,- was interested to read the remarks of your peripatetic correspondents about one-eyed persons being immune to seasickness (Dec. 13 and 27). There must be many doctors like myself who lost an eye during the war, and it would be amusing to know if any of them have noticed a change in their susceptibility to this
distressing malady. Anyone
who
noticed
my
pitiable state when the one day last October
Channel steamer reached Folkestone
could only conclude that I may havebecome a worse sailor but hardly a better one. Actually when I was binocular I was an indifferent sailor, and monocularism has not made the slightest difference. (In my own defence I may say it was pretty rough that day in the Channel.) Next time-if and when the travel ban is removed-I must try blocking the centralateral ear. CLAUD C. M. WATSON. Edinburgh.
BLOOD SAMPLES FROM INFANTS
SIR,-In your issue of Dec. 27, Dr. A. V. Magee enumerates various methods for collecting blood from infants. He omitted from his list a very simple methodcollection from the superficial scalp veins, which are usually prominent in infants. The procedure adopted is as follows : The child is wrapped snugly in a blanket to prevent interference by kicking legs or by arms and hands ; the hair is cut over the site chosen to display the vein, and while an assistant steadies the child’s head the operator introduces the needle ; a free flow of blood ensues ; the more vigorous the child’s cry, the freer the flow. When enough has been collected the needle is removed and the flow is stopped by firm pressure over the bleeding point with a swab of sterile cottonwool. This method was employed extensively by the late Prof. Leonard Findlay, of Glasgow, and has been practised by his many former house-physicians.’ I should like to add that the route via the anterior fontanelle is not devoid of risk. Several marasmic infants on whom this method was used showed at autopsy thrombosis of the superior sagittal sinus. London Chest Hospital, CECILIA SHISKIN. Victoria Park, E.2.
OBSTETRIC SHOCK
SIR,-I have read with great pleasure and interest Professor Sheehan’s article of Jan. 3. As he points out, the same picture of circulatory collapse may be produced by different mechanisms, and in obstetrics the analysis of causal factors is especially difficult. I should like to draw attention to one point which may be important and which is rarely considered. It is always recognised that blood lost must be replaced. In a few cases this will fail to restore circulatory balance, and occasionally the It is blood-loss is not large enough to be important. in such cases that the difficulties begin, and the progressive character of the syndrome is impressive. In my opinion a state of marked dehydration is often of great importance in these patients. During labour, especially if it is protracted, the excretion of urine and of chloride may fall to a very low level for many hours. The woman often vomits and looks dried up, with parched lips, although she will drink only small amounts. These features may be evidence of serious dehydration which may perhaps initiate or exaggerate a state of circulatory failure. I should like to suggest that transfusion ,of saline should be beneficial to these patients, and I have had most encouraging results after using this upon two occasions for shock which resisted other treatment. On theoretical grounds excessive and continued transfusion of blood may be actually harmful to these women. L. G. HIGGINS. Woking. VISCERAL PAIN
Sir,-Professor Cohen in his interesting paper of Dec. 27, stated that whereas I had enunciated the
principle of the summation of visceral and cutaneous pain stimuli, I had failed to face the obvious corollary that subliminal pain stimuli must constantly travel along afferent pain pathways, both from the skin and from the viscera. In the monograph I to which he refers, I
in Colombo in 1941, " that impulses are always travelling along the cutaneous sensory nerves, but that pain is only appreciated if they reach a certain intensity, or if the threshold to pain of the relevant cells in the pain apperception centre be lowered." I did not postulate that subliminal pain impulses constantly travel along visceralafferent pain pathways for two main reasons : (1) so far as I am aware there is no proof that any viscus, other than the uterus, is supplied with visceral afferent nerves which mediate the sensation of pain ; and (2) there is no experimental evidence which warrants such an assumption. Visceral pain can be abolished by anaesthetising the cutaneous areas to which it is referred, but there is, so far as I know, no evidence that cutaneous pain can be relieved by anaesthetising visceral afferent nerves. G. W. THEOBALD. Idle, Bradford.
published postulated