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SPINAL ANALGESIA.
90 Services may consider will lead to stagnation, and possibly to rapid retrogression of Western medicine in India. The medical administration of the military side deals with approximately 300,000 men ; the civil medical administration deals with a few hundred millions of people. Whilst undue haste is to be deprecated in dealing with the Lee Commission’s ’, Report, it is earnestly hoped that it will not share the fate of some of its predecessors, which became obsolete before any action was taken on them. Political opinion in India is shifting rapidly. Many serious questions hang on the decisions to be arrived at-recruitment, financial relief, leave, &c.-of the European services ; the settlement of these should meet with no unnecessary
operation and may prove embarrassing. Postoperative paresis of the gut and incontinence of faeces are rarer but more dangerous events. (4) Urinary complications. Loss of bladder control has occasionally led to ascending infection. (5) Various ocular paralyses leading to persistent strabismus, diplopia, and ptosis. (6) Persistent headache. One othéT indirect complication is reactionary haemorrhage. Where the fall of blood pressure is marked, vessels may not bleed at the time of operation, but begin to leak when the patient is back in bed. Such a case proved nearly fatal quite recently. the
It may be contended that these unfortunate events occur when the technique is faulty. This, howdelay. ever, is not so, as the mortality has not been appreciThe Lee Commission’s Report will not be ably lowered by using " heavy " solutions or by discussed in the Central Legislative Assembly in employing the various substitutes for stovaine which India until next September, and I understand that are now on the market. I think that enough has been neither the Secretary of State for India nor the said to indicate that while spinal analgesia may be an Government of India will take any action on the admirable procedure for selected cases in skilled hands, proposals until this discussion is over. It is highly yet it is by no means devoid of risk. I am, Sir, yours faithfully, probable that certain Indian politicians will attempt to withhold the grant of concessions to the European C. LANGTON HEWER. Civil Services until their demand of February last York-terrace, Regent’s Park, July 4th, 1924. for further constitutional advance has been conceded. I am, Sir, yours faithfully, THE WORK OF WELFARE CENTRES. P. HEHIR, To the Editor of THE LANCET. Major-General, I.M.S. (ret.) Westward Ho ! July 5th, 1924. SiR,—Welfare centres have undoubtedly been of enormous value in reducing infant mortality, and of still greater value in raising the physical standard of SPINAL ANALGESIA. the children, but I venture to suggest that more could To the Editor of THE LANCET. be done if it were possible to standardise the advice SIR,-Iwas-extremely interested in the article by given by doctors, midwives, and health visitors. Mr. B. H. Slater on spinal analgesia in THE LANCET All these are advising to the best of their ability, and I think, the advice they give necessarily varies with their of June 21st and your comments thereon. however, that the views put forward are unduly experience. Most of the work at an infant welfare optimistic. For instance, the general statement is is concerned with healthy infants, those that are made that " it is safer than general." While really sick being taken usually to hospitals for treatadmitting that reliable statistics are extremely difficult ment. The mothers of the healthy infants desire to to obtain, I doubt whether the most enthusiastic know if what they are doing is the best for their " spinal " advocate would claim a lower total mortality babes. It is reasonable to suppose that the average due to the method than 1 in 500. As a matter of fact, infant of healthy parents is born healthy, and that I know of several series of cases showing a considerable subsequent minor ailments are due to lack of knowhigher mortality. Turning now to general anaesthesia, ledge of the best way to feed, clothe, and house the the average immediate and remote mortality due to infant on the part of the mother. Infants are like the anaesthesia (partly or entirely) ranges from any other healthy young animals, and at any rate up 1 in 1500 to about 1 in 4000 in most London hospitals. to nine months could all be reared exactly alike Again, the statement is made that " there are no chest without any distinction being made between them as complications." I have myself seen four cases of regards diet and clothing. serious chest complications following spinal analgesia, As examples of the type of question asked by It is true that pulmonary mothers, I select the following as illustrating the need one of which was fatal. complications are, on the average, less with spinal of a standard. than with general anaesthesia, but is this not due to 1. What is the best time-table of infant feeding the fact that the former method is seldom used in at birth ? The answers vary from two-hourly during operations involving much interference with the the day and twice at night, to five feeds a day at diaphragm and adjoining peritoneum—e.g., gastrec- four-hourly intervals and none at night. On the latter time-table the infants thrive well and there is no tomy, cholecystectomy, splenectomy, &c. ? Mr. Slater also says that " there are practically no question which is the more restful to the mother. anaesthetic anxieties." I think that most anaesthetists 2. At what age should a healthy baby be weaned, will agree that spinal cases involve more worry than do and when should it be given such articles of diet as " general " ones. Few situations are so unpleasant meat, potatoes, bread, and so on ? as to have a spinal patient with a progressively falling Here the variation in the advice given by individuals blood pressure in spite of an exaggerated " Trendelen- must be very great, so great, in fact, that the opinions burg " position. Complete muscular relaxation is of two doctors each running a welfare centre in the also claimed as an advantage of spinal analgesia, but same town can be, and often are, diametrically opposed is by no means confined to this method. Endo- to each other, while midwives in the same centre tracheal gas-oxygen with a surprisingly small amount each have their own opinions. These opinions are of ’added ether provides the most complete relaxation not concerned with the treatment of sickness about that can be demanded, and does so with absolute which there must be very often wide differences, but certainty, owing to the perfectly clear airway which is with the diet of a healthy child. I expect to be considered wrong in so advising, but I find that meat, at all times assured. Finally, it is suggested that if the technique be chopped fine, is digested and well liked by many correct, there are no disadvantages to spinal analgesia infants from nine months upwards. There is, too, a great sum of money wasted annually except some extra work. The following complications have all occurred, some of them fairly commonly : in almost every household upon various medicines, (1) Pulmonary troubles, including bronchitis, pneu- particularly aperients. These latter are given for monia, embolism, and acute pulmonary oedema,i no reason whatever, more often than not with the (2sudden cardiac failure during operation. Practi- mistaken idea of keeping a baby fit. If there should cally all cases show marked fall of blood pressure i be a reason, what is required is some alteration in soon after the injection of the drug. (3) AlimentaryI the diet rather than an aperient. They certainly do complications. Vomiting is not uncommon during far more harm than good, when given indiscrimihately,
only
operation and may prove embarrassing. Postoperative paresis of the gut and incontinence of faeces are rarer but more dangerous events. (4) Urinary complications. Loss of bladder control has occasionally led to ascending infection. (5) Various ocular paralyses leading to persistent strabismus, diplopia, and ptosis. (6) Persistent headache. One othéT indirect complication is reactionary haemorrhage. Where the fall of blood pressure is marked, vessels may not bleed at the time of operation, but begin to leak when the patient is back in bed. Such a case proved nearly fatal quite recently. the
It may be contended that these unfortunate events occur when the technique is faulty. This, howdelay. ever, is not so, as the mortality has not been appreciThe Lee Commission’s Report will not be ably lowered by using " heavy " solutions or by discussed in the Central Legislative Assembly in employing the various substitutes for stovaine which India until next September, and I understand that are now on the market. I think that enough has been neither the Secretary of State for India nor the said to indicate that while spinal analgesia may be an Government of India will take any action on the admirable procedure for selected cases in skilled hands, proposals until this discussion is over. It is highly yet it is by no means devoid of risk. I am, Sir, yours faithfully, probable that certain Indian politicians will attempt to withhold the grant of concessions to the European C. LANGTON HEWER. Civil Services until their demand of February last York-terrace, Regent’s Park, July 4th, 1924. for further constitutional advance has been conceded. I am, Sir, yours faithfully, THE WORK OF WELFARE CENTRES. P. HEHIR, To the Editor of THE LANCET. Major-General, I.M.S. (ret.) Westward Ho ! July 5th, 1924. SiR,—Welfare centres have undoubtedly been of enormous value in reducing infant mortality, and of still greater value in raising the physical standard of SPINAL ANALGESIA. the children, but I venture to suggest that more could To the Editor of THE LANCET. be done if it were possible to standardise the advice SIR,-Iwas-extremely interested in the article by given by doctors, midwives, and health visitors. Mr. B. H. Slater on spinal analgesia in THE LANCET All these are advising to the best of their ability, and I think, the advice they give necessarily varies with their of June 21st and your comments thereon. however, that the views put forward are unduly experience. Most of the work at an infant welfare optimistic. For instance, the general statement is is concerned with healthy infants, those that are made that " it is safer than general." While really sick being taken usually to hospitals for treatadmitting that reliable statistics are extremely difficult ment. The mothers of the healthy infants desire to to obtain, I doubt whether the most enthusiastic know if what they are doing is the best for their " spinal " advocate would claim a lower total mortality babes. It is reasonable to suppose that the average due to the method than 1 in 500. As a matter of fact, infant of healthy parents is born healthy, and that I know of several series of cases showing a considerable subsequent minor ailments are due to lack of knowhigher mortality. Turning now to general anaesthesia, ledge of the best way to feed, clothe, and house the the average immediate and remote mortality due to infant on the part of the mother. Infants are like the anaesthesia (partly or entirely) ranges from any other healthy young animals, and at any rate up 1 in 1500 to about 1 in 4000 in most London hospitals. to nine months could all be reared exactly alike Again, the statement is made that " there are no chest without any distinction being made between them as complications." I have myself seen four cases of regards diet and clothing. serious chest complications following spinal analgesia, As examples of the type of question asked by It is true that pulmonary mothers, I select the following as illustrating the need one of which was fatal. complications are, on the average, less with spinal of a standard. than with general anaesthesia, but is this not due to 1. What is the best time-table of infant feeding the fact that the former method is seldom used in at birth ? The answers vary from two-hourly during operations involving much interference with the the day and twice at night, to five feeds a day at diaphragm and adjoining peritoneum—e.g., gastrec- four-hourly intervals and none at night. On the latter time-table the infants thrive well and there is no tomy, cholecystectomy, splenectomy, &c. ? Mr. Slater also says that " there are practically no question which is the more restful to the mother. anaesthetic anxieties." I think that most anaesthetists 2. At what age should a healthy baby be weaned, will agree that spinal cases involve more worry than do and when should it be given such articles of diet as " general " ones. Few situations are so unpleasant meat, potatoes, bread, and so on ? as to have a spinal patient with a progressively falling Here the variation in the advice given by individuals blood pressure in spite of an exaggerated " Trendelen- must be very great, so great, in fact, that the opinions burg " position. Complete muscular relaxation is of two doctors each running a welfare centre in the also claimed as an advantage of spinal analgesia, but same town can be, and often are, diametrically opposed is by no means confined to this method. Endo- to each other, while midwives in the same centre tracheal gas-oxygen with a surprisingly small amount each have their own opinions. These opinions are of ’added ether provides the most complete relaxation not concerned with the treatment of sickness about that can be demanded, and does so with absolute which there must be very often wide differences, but certainty, owing to the perfectly clear airway which is with the diet of a healthy child. I expect to be considered wrong in so advising, but I find that meat, at all times assured. Finally, it is suggested that if the technique be chopped fine, is digested and well liked by many correct, there are no disadvantages to spinal analgesia infants from nine months upwards. There is, too, a great sum of money wasted annually except some extra work. The following complications have all occurred, some of them fairly commonly : in almost every household upon various medicines, (1) Pulmonary troubles, including bronchitis, pneu- particularly aperients. These latter are given for monia, embolism, and acute pulmonary oedema,i no reason whatever, more often than not with the (2sudden cardiac failure during operation. Practi- mistaken idea of keeping a baby fit. If there should cally all cases show marked fall of blood pressure i be a reason, what is required is some alteration in soon after the injection of the drug. (3) AlimentaryI the diet rather than an aperient. They certainly do complications. Vomiting is not uncommon during far more harm than good, when given indiscrimihately,
only