OVERBREATHING TETANY

291

manufacturers of insulin to avoid the chaos which if the firms concerned were to issue insulin possessing different degrees of protamine retarded action.-I am, Sir, yours faithfully, FRANCIS H. CARR. The British Drug Houses Ltd., Graham-street,

would

ensue

London, N.1, Jan. 25th.

THE LEGAL POSITION OF HERBALISTS

of THE LANCET SIR,-The summing up by Mr. Justice To the Editor

Atkinson of Sones v. Foster, tried in the Court of King’s Bench on Jan. 21st, calls, I think, for medical comment. The learned judge is reported in the Times to have said that " Herbalists have been recognised legally since the passing of a statute in the reign of Henry VIII which has never been repealed " ; and as the defendant in the case seems to have claimed to be a herbalist as well as a naturopath the inference to be drawn was that he was exonerated by that Act as far as its application went. I recall a previous occasion when the learned judge, Mr. Atkinson as he then was, evinced an interest in unqualified practice, for he moved an amendment in the House of Commons on Feb. 9th, 1926, to a motion which I had introduced: "That, in the opinion of this House, an authoritative enquiry, with the object of making recommendations to Parliament for dealing with the whole position of irregular practice in medicine and surgery, is urgently necessary." Mr. Atkinson’s amendment was " That in the opinion of this House an authoritative enquiry with the object of securing the recognition and registration of manipulative practitioners having approved qualifications is urgently necessary." With all respect I submit that the learned judge’s exposition of the present position of herbalists is inaccurate and his description of the effect of the statute incomplete. The history of this statute is interesting. The first attempt to regulate medical practice in England was made by Act 3 Henry VIII, by which no person was allowed to practise as a physician or a surgeon within the City of London or a radius of seven miles from it without examination or approval by the Bishop of London, or, outside that area, by the Bishop of the diocese concerned. A curious survival of this prerogative of the bishops is the privilege, still existing but never put into operation, of the Archbishop of Canterbury to confer degrees in medicine. The Act 34 and 35 Henry VIII, which is the Act referred to by the learned judge, was apparently passed to allow certain persons to administer medicines without having the licence from the bishops provided for by the earlier statute. The permission given by it for herbalists to practise was limited to the use of external applications or, in the event of internal medication, to the treatment of three specified diseases, " stone, strangury, or agues." Judicial interpretations subsequent to the passage of the Act declared limitations further restricting its scope. Thus it was early laid down that its effect is that " it does not extend either in words or intent or meaning to give liberty to any person to practise or exercise for gain or profit." The parties licensed by that statute are " such persons as shall be good honest people, as old women and such as are inclined to give their neighbours physic from charity and piety " ; and indeed the original Act contained the stipulation that the privilege should be restricted to those who " minister to the sick without fee." As the original Act made no provision for testing the knowledge of the herbalist in the

case

for any responsible body to administer the Act, it remained practically inoperative and this circumstance, as well as its implied supersession by later Medical Acts, no doubt explains the omission to repeal it formally. Surely any claim that the statute of Henry VIII legalises the general practice of medicine and surgery by herbalists and that their position is unaffected by the Medical Acts which have since been placed upon the Statute Book could not be sustained. I am, Sir, yours faithfully, E. GRAHAM-LITTLE. or

-

PERFORATED GASTRIC ULCER

To the Editor

of

THE LANCET

SIR,-The annotation

on p. 216 of your last issue of "a hollow sound" by Dr. Robert Leclercq, in treating a perforated gastric ulcer which could not be sutured, reminds me that it is some seven or eight years since I first employed a similar I do not suppose that the procedure manoeuvre. was " original " on my part, though it is not mentioned in most books on operative surgery. Being faced, like Dr. Leclercq, with a large perforation which could not be closed, I introduced into the stomach a large soft rubber catheter which fitted the hole. This was not employed afterwards, however, for emptying the stomach, for I pushed it on into the duodenum, and used it for giving the patient large amounts of fluids directly into his alimentary canal. The catheter was brought out through a layer of omentum and then through a stab wound in the abdominal wall. No leakage took place and after a few days, when adhesions had formed, the catheter was removed and the opening quickly healed. I have used the method on two or three occasions since that time with the same success. Small perforations can often be successfully "plastered" with a tag of omental fat, but this method may fail when the perforation is large. The catheter may then be on

the

use

employed with confidence. There can be few surgeons in this country who would contemplate the alternative of performing a partial gastrectomy in the presence of any perforated ulcer. To save the patient’s life is the first consideration, without prejudice to whatever further treatment may be necessary afterwards when the crisis has been passed. I

am.

Sir.

vours

faithfully. GEOFFREY KEYNES.

OVERBREATHING TETANY To the Editor of THE LANCET were much interested in the two papers McCance and Watchorn, and Drs. Cumings Drs. by and Carmichael in your issue of Jan. 23rd. These workers record their failure to confirm some experimental findings published by us last year, and their papers call for some comments. In the second case recorded by Drs. Cumings and Carmichael, the level of the calcium in the cerebrospinal fluid (C.S.F.) rose from 4-2 mg. per 100 c.cm. to 4’4 mg. in eighteen minutes and to 4’8 in the course of twenty-eight minutes. Whilst these workers state that the first alteration is within their limits of experimental error, they do not say whether this applies to the total rise. If it does so their results in no way vitiate our own, for we recorded alterations of only 0’5 mg. per 100 c.cm. and this would fall within their limits of experimental error. There is no record in their paper of the volumes of C.S.F. used in their estimations of calcium. We

SIR,-We

292 ourselves calculated our experimental error in a preliminary series of determinations on known solutions, and reduced it by using 60 c.cm. of fluid in each estimation. This necessitated the removal of 15 c.cm. of C.S.F. from the patient for each determination of calcium and phosphate. One of the reasons why we did not take our resting specimens immediately before the period of tetany, but on the previous day, was our fear that we might produce severe post-lumbar puncture headaches in our patients if we removed as much as 30 or 45 c.cm. of C.S.F. within half an hour. The other reason was that our first patient seemed to develop symptoms of tetany gradually, and had premonitory symptoms and signs such as paraesthesise and Chvostek’s sign for four or five hours before overbreathing brought on carpopedal spasm and laryngismus stridulus. It seemed reasonable to assume that during this period changes in the diffusible calcium might already have been occurring. If this alteration recorded by Drs. Cumings and Carmichael in the C.S.F. calcium is outside their limit of experimental error it becomes of importance, for it shows that changes were occurring in the level of the C.S.F. calcium during that period of twentyeight minutes-although in a direction opposite to that recorded by ourselves. Clearly determinations of the ultrafiltrate calcium of the serum were desirable in our patients, but we had not the facilities for overcoming the great practical difficulties involved in such estimations-as, for example, keeping the serum in gaseous equilibrium throughout the ultrafiltration. We were therefore interested to read that Drs. McCance and Watchorn had performed this determination (presumably on serum, although this is not made clear by them) but regret that experimental details were not given. If one sets aside theoretical considerations as to the mechanism by which the C.S.F. is formed, on which we do not find ourselves in agreement with these workers, the experiments of Drs. McCance and Watchorn suggest that the drop which we found in the C.S.F. calcium was not related to the tetany itself. Were this the case the changes found by us and by Drs. Cumings and Carmichael would indicate that the calcium content of this fluid does not remain constant for any individual, but varies by as much as 10 or 12 per cent. from day to day and from hour to hour. This would be of great importance in the interpretation of the work which has been done, and is being done, on the calcium content of the C.S.F. in other conditions. We are not aware that such variations have been reported. We are, Sir, yours faithfully, C. G. BARNES, R. I. N. GREAVES.

and occasionally, and who are the masters rather than the slaves of the drug concerned. It would be superfluous for me to emphasise the iifferentiation between the two categories. I am, Sir, yours faithfully, DENIS P. S. CONAN DOYLE. HOSPITAL AMALGAMATION IN LIVERPOOL

To the Editor

of

THE LANCET

SiR,-The alterations in the Liverpool United Hospital Bill, of which the secretary of the Associated Voluntary Hospitals Board gives particulars (p. 232), are interesting, especially the exclusion of the purchase of surgical instruments and appliances from the purview of the medical board. As regards the representation of sections of the medical staff on the board my letter, in spite of the secretary’s assertion to the contrary, stated clearly that " there is a power to coopt within limits of particular offices set forth in a schedule." The point, of course, is whether the old phraseology of legal documents referring to medical and surgical staffs " is adequate in view of the development of special departments, especially since the establishment of the British College of Obstetricians and Gynaecologists. I am, Sir, yours faithfully, "

C. E. A. BEDWELL, King’s College Hospital, Denmarkhill, S.E., Jan. 25th.

House Governor.

OMENTOPEXY

To the Editor

of THE LANCET SIR,-In Mr. O’Shaughnessy’s admirable account of the surgical treatment of cardiac ischsemia, there is one point that deserves correction. The author refers to the

omentopexy of Rutherford Morison operation for cirrhosis of the liver and-he comments on this matter as though that operation might be expected to influence favourably this obscure disease. May I say that Drummond and Morison devised their operation not with the idea that it might cure cirrhosis, but as a method of dealing with the ascites, which may be such a distressing sequel of the changes in the liverWhen used for as

an

this purpose alone, and in the circumstances which the authors of the operation indicated as being necessary to hold out a prospect of success, it has been most valuable. In showing its usefulness, may I be permitted to say that the patient to whom Mr. O’Shaughnessy referred and on whom I operated-and who is now well thirty years after the operation-was rapidly going downhill at the time of the intervention. He was accustomed to be tapped every fortnight and as a rule 22 pints of fluid were removed. A year after the operation he underwent a further intervention for the radical cure of hernia and for many years afterwards he was to all intents and purposes perfectly well and able to follow the laborious occupaWAS SHERLOCK HOLMES A DRUG ADDICT ? tion of a stoker in a gas works. For some years To the Editor of THE LANCET now he has lived in retirement, but when I heard SIR,-I am writing to comment upon a recent from him in November last he was still enjoying good health. reference in your columns concerning the character Experience of this operation extending over many of Sherlock Holmes, the fictional creation of my years has emphasised, what Rutherford Morison father, the late Sir Arthur Conan Doyle, M.D. Your contributor’s interesting notes on cocaine originally pointed out, that if these patients are to remain well they must give up the use of alcohol. poisoning give the erroneous impression that Holmes The successful cases with which I am familiar have a matter of As actual fact, was a " drug addict." always faithfully observed that rule. my father neither conceived nor depicted Sherlock I am, Sir, yours faithfully, Holmes as a drug addict. He was represented as one G. GREY TURNER. of those rare individuals who use drugs sparingly