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PENTAMETHONIUM BROMIDE
768 consternation that the meal was over, and I had to urge collapsing frame on an endless peregrination through the long passages, wards, and grounds of the institution until the next feed six weary hours later. Experientia docet. So next day, having fortified myself with an enormous late breakfast, I knew just what to do at this hospital lunch. Boy, did I make that sm0rrebrød look silly-all 57 varieties of it ! But was I dreaming ? I was at once brought a plate of thick vegetable soup containing a poached egg. Before I could protest, which took time as I had to look up each word in my pocket dictionary, the waiter had brought me another plate of the same. This was followed by half a spring chicken with vegetables to match, then the other half, then a sweet, then an ice, and then a pause to smoke a cigarette and toast each other in schnapps. And then How did I we began the whole business over again. feel this time, and how did I stagger over the equally long passages, wards, and grounds ? The gastronomic exertions expected of us in foreign parts are indeed formidable to the visitor from austere England.
Letters
my
*
*
*
My Irish colleagues and I spent the afternoon being conducted round Linnseus’s house and garden. We followed this by suitable celebration. Proceedings livened up in the train back with " Give us a song Michael, before the dhrink dies in yez." So we all sang, except the dour Scot in the corner who tried to look as if he did not belong to our party. But the journey was long, the dhrink died in us, and as sleep overtook us I heard two voices : " Why, before this afternoon, Pat, Oi’d never even heard of Linnaeus." " Shure, Molly, and had ye not ? And wasn’t it himself that invented the stethoscopes "
*
*
*
Like many of your seriously minded readers, on Saturday mornings I always turn first to " In England Now." Today I opened my Lancet at page 712, and being
at breakfast folded the copy back.to keep it out of the margarine, so I did not and could not see page 713. As I enjoyed the first two items, I had a counter-current of thought. " No-one ever seems to write about dreams in I.E.N." I said to myself. " There is a fine scope for speculative wit and humorous incident in that direction. Must scribble out something about these funny compression dreams of mine." Then I turned the page to find that another Peripatetic had done just that. Now this seems more than a simple coincidence ; indeed, it looks to be a pretty fair example of the precognition phenomena described by Dunne in his Experiment with Time. I have had several experiences of the kind before, but this is one of the best because of the agreement on several points. But when these incidents do occur why are they almost always so trivial ? ‘
*
:
*
was the disingenuous fellow who first that tobacco would not grow in this Some crafty chap, I suspect, with a packet invested in the American Colonies. In point of fact, of course, the stuff grows here like the weed it is. There are two beds of it in my garden, the result of sowing a thimbleful of dust-like seed, and I am hard put to it to find time to cut and string the leaves ready for drying ; but the prospect of smoking 25 lb. of the stuff at fourpence an ounce keeps me wonderfully cheerful.
Who,
I
persuaded country ?
wonder, us
*
*
*
We’re a little bit late With the news in Kuwait, But it seems strange to me That sugar in tea Thrown into a pot, As likely as not Kept under the bed, Can turn Fehling’s solution from blue into red.
*** peripatetic correspondent of Sept. 10 (p. 487) Blast ! I should have asked Mrs. Brown whether replies : her lodger took dextrose, laevulose, mannitose, lactose, galactose, aribinose, pyrocatechin, hydroquinone, or salicylates in his tea." Our
"
to
the Editor
SEEING THE PATIENT THROUGH me to thank your correspondents this theme They have done some valuable underlining and suggested new aspects of an unlimited topic. Professor Witts (Sept. 24) hunted in vain for the almoners. He will find them taking part in a wardconference half-way down column 4 ; but I grant that the brevity of the reference may have hidden my conviction of their immense importance in any scheme of hospital coördination. We can be grateful for his description of their highly developed function in his own unit. Mr. Roy Goulding has sought to define a place for the student in the dealings between patient and hospital; I am certain that the systematic weekly wardround he suggests is the right way to keep him au fait with his patients’ progress-in order that he may answer their questions sensibly-and of emphasising the patient’s identity as something more than a teaching case. Two main issues have crystallised out of this correspondence ; first, the internal hospital organisation for seeing the patient through, with which I concerned myself particularly in my paper ; secondly, what one may call the hospital-doctor relationship. I believe that the machinery for seeing the patient through hospital is usually in existence, although it is often faltering for lack of drive or creaking for lack of lubrication. Miss G. L. John, medical records officer to the Bermondsey and Southwark Hospital Management Committee, a " specialist in coordination," (Sept. 24) gives an alarmingly comprehensive account of her functions ; she slides her tentacles around hospital departments like a well-meaning octopus and I feel that when her work is finished not only the " absent-minded leave-taking houseman " (who will take this description to heart, no doubt !) but the rest of the medical staff also will be able to go on indefinite furlough. No ; the agencies are already there, under the control of housegovernor or medical superintendent, and I fear that in the long run the coordinator will sap rather than stimulate their initiative ; voluntary and sustained concentration on the welfare of the patient by each agency is a much better recipe. Lastly, the hospital-doctor relationship. To my mind, the most valuable letters in the correspondence have come from general practitioners ; I am particularly indebted to Dr. Lindsey W. Batten (Oct. 1) and agree with every word he writes. This is really the crux, that it is the patient’s doctor and not the hospital who must see hirrz through. With the present hierarchical system of medicine in which the technical rules supreme, there is a tendency for the hospital to skim the cream off general practice and monopolise all that is important or interesting. This process rnust be reversed if general practice is not to be impoverished ; the hospital must emulate the best standards of consultant practice by taking infinite pains over the patient and feeding him back to his doctor with a garnish of helpful information and advice. Taking infinite pains is the only possible formula. In the midst of many medical frustrations it is a guide to the lasting satisfaction of seeing the patient through. J. M. LIPSCOMB. St. George’s Hospital, London, W.1.
SIR,-Will you allow
for their letters
on
PENTAMETHONIUM BROMIDE
SiB,—Pentamethonium bromide is
at present under shadow in the anaesthetic world because of side-effects, which the physician may be able to use. a
A substantially fit woman of 47 had a cholecystectomy under anaesthesia with thiopentone, nitrous oxide and oxygen 40%, and decamethonium iodide. During 13/4 hours she had
769 three doses of decamethonium iodide 5, 4, and 3 mg., each producing at least momentary respiratory arrest which was followed by normal recovery. At the end of the operation there was slight respiratory depression from the last dose and it was resolved to test the effect of pentamethonium bromide of which 20 mg. was given and then after two minutes a The pulse-volume decreased slightly, but further 20 mg. respiration was abolished after a further three minutes and the total volume after one hour was still only 100 ml. It was then suggested that she might be a submyasthenic and that pentamethonium bromide might have its small curarising effect in the same way as d-tubocurarine. Accordingly 1 mg. of neostigmine was given with surprising and immediate recovery of respiration. The patient showed no overt signs of myasthenia and refused a curare-sensitivity test.
that before pentamethonium bromide is all extensively-especially in " medical" therapeutics-the possibility of its risk in myasthenics should be further investigated. It used
seems
at
London, E.11.
J. BARNARD.
VACCINATION UNDER THE N.H.S. ACT
SIR,-In his report1 on infant vaccination in England and Wales during the six months, July-December, 1948, Dr. E. T. Conybeare, of the Ministry of Health, shows that in this period, the first half-year under the new Act, the proportion of infants vaccinated fell to about half what it was before the Act came into force. He concludes his article by saying : " If the figures for 1949, when they become available, show that the decline of infant vaccination under the National Health Service is not temporary, measures, such as an increase in the number of vaccination clinics ... and the working out of some plan to facilitate domiciliary infant vaccination in areas not served by such clinics, may be urgently required. Such measures, pursued with the energy put into the campaign for immunisation against diphtheria, might well produce similar results and make the child population of this country as well vaccinated as that of the United States or other countries, where protection against smallpox is regarded as the important matter that it undoubtedly is."
Is not Dr. Conybeare rather begging a highly debatable when he makes that final assertion ? Is a wellvaccinated child population really so very important in protecting a community against smallpox ? Surely there is a great deal of valid evidence pointing to the opposite conclusion. Decline in infant vaccination is not a new phenomenon-it has been going on continuously for over half a century-but, so far from its having been followed by an increase in smallpox mortality, the mortality has fallen steadily until now it is practically
question
negligible. Moreover, in those parts of the country where the decline in infant vaccination has been greatest the same decrease in smallpox mortality has been witnessed. Thus, in the city.of Leicester the average proportion of infants vaccinated has for very many years been under 5% (Dr. Conybeare tells us that it has now fallen to 1’4%), yet during the past 40 years there have been only two deaths from smallpox, and other places have had a similar experience. After all, it is adults who are most exposed to the danger of smallpox, and the effect of infant vaccination in protecting this section of the community is very doubtful. It may reasonably be argued that infant vaccination, by masking the disease in adults, when the protection conferred on the individual is wearing off, neutralises-or more than neutralises-any value to the community derived from the partial immunity conferred on the individual adult. Incidentally, in the 14 years, 1932-46, there were in England and Wales only 28 smallpox deaths (an average of 2 per annum in a population of 40,000,000), and not 1. Mon. Bull. Min. Hlth, P.H.L.S. October, 1949, p. 204.
one of those deaths was in an infant under one year of age. Yet in the same period there were 51 deaths from vaccination in infants under one year of age. Dr. Conybeare mentions admiringly the United’States " and other countries." What other countries, including the U.S.A., can show better results in dealing with smallpox than Great Britain’l So I venture to suggest, with all respect to Dr. Conybeare, that perhaps infant vaccination is not so very important a matter in protecting a community such as ours as he seems to think. C. KILLICK MILLARD. Leicester.
CONTROL OF TUBERCULOSIS have read with great interest Dr. Hoffstaedt’s SiR,-I letter of Oct. 8. Like him, I admire the efforts of frustrated chest physicians in anticipating the sanatoriumapplicants’ treatment during their waiting period, but I feel that a word of warning would not be out of place. We are, many of us, becoming accustomed to admitting patients in whom some form of collapse therapy has been undertaken in the home. The results of such treatment have not, however, been uniformly successful ; often the requisite period of bed rest before the induction of collapse therapy has not been observed, and in many cases we should have preferred to receive the patient with an untouched pleural space. I cannot subscribe to Dr. Hoffstaedt’s statement that some scheme of early ambulatory collapse treatment should be adopted. It is our experience that collapse therapy should not be undertaken lightly-certainly not until after some months of bed rest. After induction, the patient requires careful and prolonged observation and grading if the onset of effusion and other complications is to be avoided. By getting patients into hospital, inducing collapse, and quickly returning them to their home environment, thereby short-circuiting sanatorium treatment, we shall, in my opinion, be courting disaster. Furthermore, with streptomycin and p-aminosalicylic acid now available " over the counter," another possible danger arises in that chest physicians will be greatly tempted to prescribe these drugs during the waiting period, with the result that the sanatorium physician may be further misled as to the patient’s natural powers of resistance. In short, I feel that many sanatorium physicians would agree with me that, whenever possible, they would prefer to receive their patients " preconditioned " by bed rest only. F. TEMPLE OLIVE Preston Hall Hospital, Maidstone, Kent.
Physician-Superintendent.
INTERPERSONAL FACTORS IN ILLNESS
Sm,—In his article last week, Dr. Casson referred to the possible benefit of bringing together patients with similar ailments. Dr. Bohler, in Vienna, made excellent use of this factor. Before the days of plaster-jackets spinal fractures meant long invalidism, and in order to convince patients of the freedom of movement the jacket provided, there New arrivals saw were separate wards for spinal cases. exercises performed and weights lifted a few days after application of the jacket. One man, a taxi-driver, continued his duties while wearing it. The, emotional uplift thus provided encouraged even the most fearful Similar arrangements for other fracture to respond. cases worked eauallv well. H. SYMONDS. Romford, Essex.
SiE,—The following passage in Dr. Casson’s article the almost universal fallacy that addiction to tobacco and alcohol are vices :
supports
" The average doctor... may also condemn in his patients what his conscience does not allow in himself, and this moral severity may cloak itself as professional solicitude. For instance, the doctor may forbid alcohol or tobacco...
Letters
my
*
*
*
My Irish colleagues and I spent the afternoon being conducted round Linnseus’s house and garden. We followed this by suitable celebration. Proceedings livened up in the train back with " Give us a song Michael, before the dhrink dies in yez." So we all sang, except the dour Scot in the corner who tried to look as if he did not belong to our party. But the journey was long, the dhrink died in us, and as sleep overtook us I heard two voices : " Why, before this afternoon, Pat, Oi’d never even heard of Linnaeus." " Shure, Molly, and had ye not ? And wasn’t it himself that invented the stethoscopes "
*
*
*
Like many of your seriously minded readers, on Saturday mornings I always turn first to " In England Now." Today I opened my Lancet at page 712, and being
at breakfast folded the copy back.to keep it out of the margarine, so I did not and could not see page 713. As I enjoyed the first two items, I had a counter-current of thought. " No-one ever seems to write about dreams in I.E.N." I said to myself. " There is a fine scope for speculative wit and humorous incident in that direction. Must scribble out something about these funny compression dreams of mine." Then I turned the page to find that another Peripatetic had done just that. Now this seems more than a simple coincidence ; indeed, it looks to be a pretty fair example of the precognition phenomena described by Dunne in his Experiment with Time. I have had several experiences of the kind before, but this is one of the best because of the agreement on several points. But when these incidents do occur why are they almost always so trivial ? ‘
*
:
*
was the disingenuous fellow who first that tobacco would not grow in this Some crafty chap, I suspect, with a packet invested in the American Colonies. In point of fact, of course, the stuff grows here like the weed it is. There are two beds of it in my garden, the result of sowing a thimbleful of dust-like seed, and I am hard put to it to find time to cut and string the leaves ready for drying ; but the prospect of smoking 25 lb. of the stuff at fourpence an ounce keeps me wonderfully cheerful.
Who,
I
persuaded country ?
wonder, us
*
*
*
We’re a little bit late With the news in Kuwait, But it seems strange to me That sugar in tea Thrown into a pot, As likely as not Kept under the bed, Can turn Fehling’s solution from blue into red.
*** peripatetic correspondent of Sept. 10 (p. 487) Blast ! I should have asked Mrs. Brown whether replies : her lodger took dextrose, laevulose, mannitose, lactose, galactose, aribinose, pyrocatechin, hydroquinone, or salicylates in his tea." Our
"
to
the Editor
SEEING THE PATIENT THROUGH me to thank your correspondents this theme They have done some valuable underlining and suggested new aspects of an unlimited topic. Professor Witts (Sept. 24) hunted in vain for the almoners. He will find them taking part in a wardconference half-way down column 4 ; but I grant that the brevity of the reference may have hidden my conviction of their immense importance in any scheme of hospital coördination. We can be grateful for his description of their highly developed function in his own unit. Mr. Roy Goulding has sought to define a place for the student in the dealings between patient and hospital; I am certain that the systematic weekly wardround he suggests is the right way to keep him au fait with his patients’ progress-in order that he may answer their questions sensibly-and of emphasising the patient’s identity as something more than a teaching case. Two main issues have crystallised out of this correspondence ; first, the internal hospital organisation for seeing the patient through, with which I concerned myself particularly in my paper ; secondly, what one may call the hospital-doctor relationship. I believe that the machinery for seeing the patient through hospital is usually in existence, although it is often faltering for lack of drive or creaking for lack of lubrication. Miss G. L. John, medical records officer to the Bermondsey and Southwark Hospital Management Committee, a " specialist in coordination," (Sept. 24) gives an alarmingly comprehensive account of her functions ; she slides her tentacles around hospital departments like a well-meaning octopus and I feel that when her work is finished not only the " absent-minded leave-taking houseman " (who will take this description to heart, no doubt !) but the rest of the medical staff also will be able to go on indefinite furlough. No ; the agencies are already there, under the control of housegovernor or medical superintendent, and I fear that in the long run the coordinator will sap rather than stimulate their initiative ; voluntary and sustained concentration on the welfare of the patient by each agency is a much better recipe. Lastly, the hospital-doctor relationship. To my mind, the most valuable letters in the correspondence have come from general practitioners ; I am particularly indebted to Dr. Lindsey W. Batten (Oct. 1) and agree with every word he writes. This is really the crux, that it is the patient’s doctor and not the hospital who must see hirrz through. With the present hierarchical system of medicine in which the technical rules supreme, there is a tendency for the hospital to skim the cream off general practice and monopolise all that is important or interesting. This process rnust be reversed if general practice is not to be impoverished ; the hospital must emulate the best standards of consultant practice by taking infinite pains over the patient and feeding him back to his doctor with a garnish of helpful information and advice. Taking infinite pains is the only possible formula. In the midst of many medical frustrations it is a guide to the lasting satisfaction of seeing the patient through. J. M. LIPSCOMB. St. George’s Hospital, London, W.1.
SIR,-Will you allow
for their letters
on
PENTAMETHONIUM BROMIDE
SiB,—Pentamethonium bromide is
at present under shadow in the anaesthetic world because of side-effects, which the physician may be able to use. a
A substantially fit woman of 47 had a cholecystectomy under anaesthesia with thiopentone, nitrous oxide and oxygen 40%, and decamethonium iodide. During 13/4 hours she had
769 three doses of decamethonium iodide 5, 4, and 3 mg., each producing at least momentary respiratory arrest which was followed by normal recovery. At the end of the operation there was slight respiratory depression from the last dose and it was resolved to test the effect of pentamethonium bromide of which 20 mg. was given and then after two minutes a The pulse-volume decreased slightly, but further 20 mg. respiration was abolished after a further three minutes and the total volume after one hour was still only 100 ml. It was then suggested that she might be a submyasthenic and that pentamethonium bromide might have its small curarising effect in the same way as d-tubocurarine. Accordingly 1 mg. of neostigmine was given with surprising and immediate recovery of respiration. The patient showed no overt signs of myasthenia and refused a curare-sensitivity test.
that before pentamethonium bromide is all extensively-especially in " medical" therapeutics-the possibility of its risk in myasthenics should be further investigated. It used
seems
at
London, E.11.
J. BARNARD.
VACCINATION UNDER THE N.H.S. ACT
SIR,-In his report1 on infant vaccination in England and Wales during the six months, July-December, 1948, Dr. E. T. Conybeare, of the Ministry of Health, shows that in this period, the first half-year under the new Act, the proportion of infants vaccinated fell to about half what it was before the Act came into force. He concludes his article by saying : " If the figures for 1949, when they become available, show that the decline of infant vaccination under the National Health Service is not temporary, measures, such as an increase in the number of vaccination clinics ... and the working out of some plan to facilitate domiciliary infant vaccination in areas not served by such clinics, may be urgently required. Such measures, pursued with the energy put into the campaign for immunisation against diphtheria, might well produce similar results and make the child population of this country as well vaccinated as that of the United States or other countries, where protection against smallpox is regarded as the important matter that it undoubtedly is."
Is not Dr. Conybeare rather begging a highly debatable when he makes that final assertion ? Is a wellvaccinated child population really so very important in protecting a community against smallpox ? Surely there is a great deal of valid evidence pointing to the opposite conclusion. Decline in infant vaccination is not a new phenomenon-it has been going on continuously for over half a century-but, so far from its having been followed by an increase in smallpox mortality, the mortality has fallen steadily until now it is practically
question
negligible. Moreover, in those parts of the country where the decline in infant vaccination has been greatest the same decrease in smallpox mortality has been witnessed. Thus, in the city.of Leicester the average proportion of infants vaccinated has for very many years been under 5% (Dr. Conybeare tells us that it has now fallen to 1’4%), yet during the past 40 years there have been only two deaths from smallpox, and other places have had a similar experience. After all, it is adults who are most exposed to the danger of smallpox, and the effect of infant vaccination in protecting this section of the community is very doubtful. It may reasonably be argued that infant vaccination, by masking the disease in adults, when the protection conferred on the individual is wearing off, neutralises-or more than neutralises-any value to the community derived from the partial immunity conferred on the individual adult. Incidentally, in the 14 years, 1932-46, there were in England and Wales only 28 smallpox deaths (an average of 2 per annum in a population of 40,000,000), and not 1. Mon. Bull. Min. Hlth, P.H.L.S. October, 1949, p. 204.
one of those deaths was in an infant under one year of age. Yet in the same period there were 51 deaths from vaccination in infants under one year of age. Dr. Conybeare mentions admiringly the United’States " and other countries." What other countries, including the U.S.A., can show better results in dealing with smallpox than Great Britain’l So I venture to suggest, with all respect to Dr. Conybeare, that perhaps infant vaccination is not so very important a matter in protecting a community such as ours as he seems to think. C. KILLICK MILLARD. Leicester.
CONTROL OF TUBERCULOSIS have read with great interest Dr. Hoffstaedt’s SiR,-I letter of Oct. 8. Like him, I admire the efforts of frustrated chest physicians in anticipating the sanatoriumapplicants’ treatment during their waiting period, but I feel that a word of warning would not be out of place. We are, many of us, becoming accustomed to admitting patients in whom some form of collapse therapy has been undertaken in the home. The results of such treatment have not, however, been uniformly successful ; often the requisite period of bed rest before the induction of collapse therapy has not been observed, and in many cases we should have preferred to receive the patient with an untouched pleural space. I cannot subscribe to Dr. Hoffstaedt’s statement that some scheme of early ambulatory collapse treatment should be adopted. It is our experience that collapse therapy should not be undertaken lightly-certainly not until after some months of bed rest. After induction, the patient requires careful and prolonged observation and grading if the onset of effusion and other complications is to be avoided. By getting patients into hospital, inducing collapse, and quickly returning them to their home environment, thereby short-circuiting sanatorium treatment, we shall, in my opinion, be courting disaster. Furthermore, with streptomycin and p-aminosalicylic acid now available " over the counter," another possible danger arises in that chest physicians will be greatly tempted to prescribe these drugs during the waiting period, with the result that the sanatorium physician may be further misled as to the patient’s natural powers of resistance. In short, I feel that many sanatorium physicians would agree with me that, whenever possible, they would prefer to receive their patients " preconditioned " by bed rest only. F. TEMPLE OLIVE Preston Hall Hospital, Maidstone, Kent.
Physician-Superintendent.
INTERPERSONAL FACTORS IN ILLNESS
Sm,—In his article last week, Dr. Casson referred to the possible benefit of bringing together patients with similar ailments. Dr. Bohler, in Vienna, made excellent use of this factor. Before the days of plaster-jackets spinal fractures meant long invalidism, and in order to convince patients of the freedom of movement the jacket provided, there New arrivals saw were separate wards for spinal cases. exercises performed and weights lifted a few days after application of the jacket. One man, a taxi-driver, continued his duties while wearing it. The, emotional uplift thus provided encouraged even the most fearful Similar arrangements for other fracture to respond. cases worked eauallv well. H. SYMONDS. Romford, Essex.
SiE,—The following passage in Dr. Casson’s article the almost universal fallacy that addiction to tobacco and alcohol are vices :
supports
" The average doctor... may also condemn in his patients what his conscience does not allow in himself, and this moral severity may cloak itself as professional solicitude. For instance, the doctor may forbid alcohol or tobacco...