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PHYSICAL CHANGES IN THE PROLAPSED DISC
584
evidence. We do not claim infallibility for our preliminary inquiry, but in reply to Dr. Paulley’s arguments against it we can only repeat " the value of the present method cannot be adequately tested by argument, but only by a carefully controlled prospective inquiry, which we propose to do ". M. SIM The Queen Elizabeth Hospital, B. N. BROOKE. Birmingham, 15. UNIDENTIFIED DRUGS
SIR,-Patients often come to hospital with tablets which their general practitioners have been giving them for a long time, and the name of which they do not know. The houseman has to find out the name of the drug, and this often results in delay in treatment. Would it not be better if the general practitioner told the hospital of any chronic illness in a patient referred for some acute condition, and the treatment that is being given ? This would be a great help for the inexperienced iunior members of the hosnital staff. like mvself. St. Albans City Hospital, St. Albans, Hertfordshire.
BISWARUP BHATTACHARYA.
PHYSICAL CHANGES IN THE PROLAPSED DISC
SIR,-Your annotation,l combined with Mr. Charnley’s (July 5), has reminded me that we lack a basic philosophy which might illuminate our search for the cause of pain. The pathology of pain is ill-understood but accepted in general as pressure; therefore he who first propounds a plausible theory of pressure wins the
LEARNING TO LEARN
SIR The Students’ Guide (Aug. 30) outlines presentday medical education in your usual lively manner. Especially interesting is your treatment of the faculty of learning. Teachers, absorbed in planning curricula, over. look that even more important than the science of teaching is this art of learning. Not all of us have to instruct, but we all need to assimilate, and we painfully rediscover what Hippocrates told us-that in a brief lifetime it takes a long while to learn. We get less from regular teachers than from irregular sources. How can we best acquirea habit of receptivity to unconventional means of knowledge ?Of course, each of us must work out his private technique. Learning does not deal with external knowledge alone: we have to revalue our own capacity for handling experience. In the past, many doctors changed over to a line of medicine different from that in which they began. What this means is that they fathomed their own inclinations later than the average. General practitioners sometimes became successful consultants, for the best of all reasons - they found that people wished to consult them. A young doctor today is not encouraged to change his course, but for any individual the start of true learning
comments
honours. But let
suddenly
may be the moment he realises he had taken a wrong direction. Some advice from late beginners, who found a vocation through their own efforts and not from teachers, would he illuminating
next vear-
HARLEY WILLIAMS. GLUTETHIMIDE POISONING
examine Mr. Charnley’s invention of a expanded disc causing pressure like that in an us
abscess. This is the ghost of turgor again; and I thought that that had been laid fourteen years ago. Self-expansibility, said Ffrangcon Roberts,2 is a quality unknown in physics: " to ascribe turgor or power of expansion to the nucleus is to invoke some property quite unknown in the physical world and takes Medicine back to the obscurantism of the Middle Ages ". Instead of turgor, Mr. Charnley calls it hydrophilia; dried discs swell when placed in water. Of course they do, as does any piece of dead cartilage. The disc is nothing but a resilient bit of fibrocartilage, more cartilaginous at its centre and more
SIR,--A patient with glutethimide poisoning has previously been reported from this hospital by one of us.’1 It was noted at that time that respiratory depression was very slight, that the condition responded to the administration of bemegride and amiphenazole, and that the patient, during the period of coma, had attacks of carpopedal spasm closely resembling tetany. These attacks were exacerbated by the administration of bemegride. We have recently seen the identical features in another patient with glutethimide poisoning.
A married woman, aged 39, who had a long history of depression, was admitted to the Royal Victoria Infirmary on fibrous at its marsin. Nucleus nulnnsus and annulus fibrosus July 30, 1958, in deep coma. Three and a half hours before are verbal expressions and not entities. Like other cartilaginous admission she had taken 22 tablets (5’5 g.) of glutethimide structures the disc cushions sudden or intermittent pressure by (’ Doriden ’). Her pupils were of normal size and failed to the and it is restored to its when react to light, and the corneal reflexes were absent. The tendon flattening, previous shape shown the force is Its resilience is removed. by jerks were depressed and the plantar responses were flexor, compressing rarity of disc lesions in compression fractures of the vertebral Respiration was not markedly depressed. Gastric lavage was bodies. performed and bemegride administered as a continuous intraLike other cartilage, the disc cannot have a weight-bearing venous infusion; in all, 850 mg. was given in two hours. The function; continuous pressure causes its absorption or degen- limb reflexes returned within thirty-five minutes and the pupil reflexes within three hours of starting bemegride. eration. The weight-bearing structures in the back are the Soon after admission transient attacks of spasm of the limbs, pedicles and articular processes; narrowing of an intervertebral associated with tetanic spasm of the hands, were noticed, disc is always secondary to failure of these structures through Trousseau’s and Chvostek’s signs were negative, the sennn decalcification.3 Narrowing of the space, therefore, is not the cause of the pain but a later effect of the decalcifying calcium and phosphorus were normal,and intravenous calcium gluconate was without effect. Bemegride increased th&c edil; process. spasms. The patient also had intermittent head retraction. I am glad to read: (1) that Mr. Charnley has never seen the acutely swollen discs; (2) that protrusions are rare in and attacks of laryngeal spasm. The muscles in spasm changed frequently, both flexor and extensor groups being involved acute lumbago; (3) that pain in acute lumbago is not intermittently and quite independently in all four limbs. Thi’ proportional to the change in the disc. Could this not resulted in an appearance in the upper limbs sometimes simupossibly mean that the disc is not the cause of the pain- lating tetany and sometimes a posture reminiscent of Erb that the pain, as elsewhere, arises in muscular, synovial, palsy. The attacks of spasm decreased in severity and disor ligamentous structures ? appeared within fourteen hours. MICHAEL KELLY. The clinical features of this case were so similar to thosç of the previous one that we feel that there is no double 1. Lancet, 1958, i, 1214. ,
2. Roberts, F. Brit. J. Radiol. 1944, 17, 54. 3. Roberts, R. A. Chronic Structural Low Backache.
London,
1947.
1. Rowell, N. R. Lancet, 1957,
i, 407.
evidence. We do not claim infallibility for our preliminary inquiry, but in reply to Dr. Paulley’s arguments against it we can only repeat " the value of the present method cannot be adequately tested by argument, but only by a carefully controlled prospective inquiry, which we propose to do ". M. SIM The Queen Elizabeth Hospital, B. N. BROOKE. Birmingham, 15. UNIDENTIFIED DRUGS
SIR,-Patients often come to hospital with tablets which their general practitioners have been giving them for a long time, and the name of which they do not know. The houseman has to find out the name of the drug, and this often results in delay in treatment. Would it not be better if the general practitioner told the hospital of any chronic illness in a patient referred for some acute condition, and the treatment that is being given ? This would be a great help for the inexperienced iunior members of the hosnital staff. like mvself. St. Albans City Hospital, St. Albans, Hertfordshire.
BISWARUP BHATTACHARYA.
PHYSICAL CHANGES IN THE PROLAPSED DISC
SIR,-Your annotation,l combined with Mr. Charnley’s (July 5), has reminded me that we lack a basic philosophy which might illuminate our search for the cause of pain. The pathology of pain is ill-understood but accepted in general as pressure; therefore he who first propounds a plausible theory of pressure wins the
LEARNING TO LEARN
SIR The Students’ Guide (Aug. 30) outlines presentday medical education in your usual lively manner. Especially interesting is your treatment of the faculty of learning. Teachers, absorbed in planning curricula, over. look that even more important than the science of teaching is this art of learning. Not all of us have to instruct, but we all need to assimilate, and we painfully rediscover what Hippocrates told us-that in a brief lifetime it takes a long while to learn. We get less from regular teachers than from irregular sources. How can we best acquirea habit of receptivity to unconventional means of knowledge ?Of course, each of us must work out his private technique. Learning does not deal with external knowledge alone: we have to revalue our own capacity for handling experience. In the past, many doctors changed over to a line of medicine different from that in which they began. What this means is that they fathomed their own inclinations later than the average. General practitioners sometimes became successful consultants, for the best of all reasons - they found that people wished to consult them. A young doctor today is not encouraged to change his course, but for any individual the start of true learning
comments
honours. But let
suddenly
may be the moment he realises he had taken a wrong direction. Some advice from late beginners, who found a vocation through their own efforts and not from teachers, would he illuminating
next vear-
HARLEY WILLIAMS. GLUTETHIMIDE POISONING
examine Mr. Charnley’s invention of a expanded disc causing pressure like that in an us
abscess. This is the ghost of turgor again; and I thought that that had been laid fourteen years ago. Self-expansibility, said Ffrangcon Roberts,2 is a quality unknown in physics: " to ascribe turgor or power of expansion to the nucleus is to invoke some property quite unknown in the physical world and takes Medicine back to the obscurantism of the Middle Ages ". Instead of turgor, Mr. Charnley calls it hydrophilia; dried discs swell when placed in water. Of course they do, as does any piece of dead cartilage. The disc is nothing but a resilient bit of fibrocartilage, more cartilaginous at its centre and more
SIR,--A patient with glutethimide poisoning has previously been reported from this hospital by one of us.’1 It was noted at that time that respiratory depression was very slight, that the condition responded to the administration of bemegride and amiphenazole, and that the patient, during the period of coma, had attacks of carpopedal spasm closely resembling tetany. These attacks were exacerbated by the administration of bemegride. We have recently seen the identical features in another patient with glutethimide poisoning.
A married woman, aged 39, who had a long history of depression, was admitted to the Royal Victoria Infirmary on fibrous at its marsin. Nucleus nulnnsus and annulus fibrosus July 30, 1958, in deep coma. Three and a half hours before are verbal expressions and not entities. Like other cartilaginous admission she had taken 22 tablets (5’5 g.) of glutethimide structures the disc cushions sudden or intermittent pressure by (’ Doriden ’). Her pupils were of normal size and failed to the and it is restored to its when react to light, and the corneal reflexes were absent. The tendon flattening, previous shape shown the force is Its resilience is removed. by jerks were depressed and the plantar responses were flexor, compressing rarity of disc lesions in compression fractures of the vertebral Respiration was not markedly depressed. Gastric lavage was bodies. performed and bemegride administered as a continuous intraLike other cartilage, the disc cannot have a weight-bearing venous infusion; in all, 850 mg. was given in two hours. The function; continuous pressure causes its absorption or degen- limb reflexes returned within thirty-five minutes and the pupil reflexes within three hours of starting bemegride. eration. The weight-bearing structures in the back are the Soon after admission transient attacks of spasm of the limbs, pedicles and articular processes; narrowing of an intervertebral associated with tetanic spasm of the hands, were noticed, disc is always secondary to failure of these structures through Trousseau’s and Chvostek’s signs were negative, the sennn decalcification.3 Narrowing of the space, therefore, is not the cause of the pain but a later effect of the decalcifying calcium and phosphorus were normal,and intravenous calcium gluconate was without effect. Bemegride increased th&c edil; process. spasms. The patient also had intermittent head retraction. I am glad to read: (1) that Mr. Charnley has never seen the acutely swollen discs; (2) that protrusions are rare in and attacks of laryngeal spasm. The muscles in spasm changed frequently, both flexor and extensor groups being involved acute lumbago; (3) that pain in acute lumbago is not intermittently and quite independently in all four limbs. Thi’ proportional to the change in the disc. Could this not resulted in an appearance in the upper limbs sometimes simupossibly mean that the disc is not the cause of the pain- lating tetany and sometimes a posture reminiscent of Erb that the pain, as elsewhere, arises in muscular, synovial, palsy. The attacks of spasm decreased in severity and disor ligamentous structures ? appeared within fourteen hours. MICHAEL KELLY. The clinical features of this case were so similar to thosç of the previous one that we feel that there is no double 1. Lancet, 1958, i, 1214. ,
2. Roberts, F. Brit. J. Radiol. 1944, 17, 54. 3. Roberts, R. A. Chronic Structural Low Backache.
London,
1947.
1. Rowell, N. R. Lancet, 1957,
i, 407.