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SUBLINGUAL ABSORPTION OF MORPHINE.
885
Ogilvie that tonsillectomy is likely to reduce the SUBLINGUAL ABSORPTION OF MORPHINE. severity of cardiac complications, but this was not the To the Editor of THE LANCET. point under investigation by me ; it was the statistical adequacy of the numbers adduced to support the SIR,—In an annotation in your last issue reference is contention that I was investigating. made to the sublingual method of administration of My rearrangement of Table IV. was due to the morphine sulphate. It is stated that Dr. David arithmetical discrepancy that the numbers given in Davis and Dr. David Ayman suggest the discontinunot with the two columns the do tally right-hand of administration of the drug by this route. I total number given in the left-hand column, the children ance have been using this method for many years successwith glands but no tonsils having been excluded, and a crusted tablet under the. I reproduce the table from your issue of March 31st. fully by simply placingit first in cases of deficient tongue, but I powder salivation. Absorption by the sublingual gland takes TABLE IV.-Rheumatic Children. place rapidly and the effect of the drug is satisfactory.. I am employing the sublingual method with all the alkaloids almost exclusively in my practice, making of hypodermic injections principally for the use induction of local anaesthesia in surgical operations. If a patient accidentally swallows the tablet I repeat the sublingual administration. Much time is saved by this method, and asepsis is assured. Many years ago I published1 my experience of the sublingual method, illustrating my remarks with selected cases. The paraphrase of " normal tonsils " for " healthy In one case-poisoning by carbolic acid-where throats " was inadvertent. I was led into this error swallowing movements were absent and the patient because in Table V. the 37 children with " healthy was moribund, the administration of apomorphine throats " are described as having the throat condition by the sublingual method produced vomiting. Whatnormal." But my paraphrase has led to the ever may be the explanation of the American findings shall continue the sublingual practice with which disclosure of the fact, not revealed in Table IV., that a number of the children with " healthy throats " for many years I have been highly satisfied. "
had had their tonsils removed. It would now seem that the cases included under the rubric " healthy throats " consist partly of children who have normal tonsils and partly of children who have had their tonsils removed, presumably on account of tonsillar disease. As this group is not homogeneous it is not possible to draw inferences from it in the manner that I
I
C.
Sir.
vours
To the Editor of THE LANCET. SIR,—The Council of the Society of Medical Officers of Health has had before it the letter appearing in the Times of April 3rd, over the signatures of certain obstetricians, as to the need for research into the above subject. The Council is in agreement that the research required calls for a close alliance between the physician, the biochemist, and the bacteriologist, and the close apposition of the laboratory to the bedside, but it is not of opinion that an investigation by local health authorities of all maternal deaths should be excluded or discredited, and the Council regrets that the signatories have seen fit to take this view. The Council would further put on record that the signatories are in error in suggesting that a knowledge of the cause of a disease is necessarily a sine qua non for its prevention, and in this connexion would refer to the control of small-pox by vaccination ; the diminished incidence of enteric fever following on the betterment of sanitary and living conditions ; and the reduction of deaths from scarlet fever as the result of the measures taken by health authorities. The Council of this Society feels that matters of this kind are best discussed in the professional journals. I am, Sir, yours faithfully, E. H. SNELL, Acting President, Society of Medical Officers
the usual statistical criteria that, though suggestive, the numbers of cases are insufficient to be beyond the reach of variations due to chance, however strong the clinical grounds may be for belief in the value of tonsillectomy in rheumatic cases. April 21st, 1928.
am.
INVESTIGATION OF MATERNAL MORTALITY.
attempted.
I fear that the conclusion must be
faithfullv. A. P. MURTZ. Queen’s-road, Finsbury Park, N., April 21st, 1928. I
on
O. STALLYBRASS,
Asst. M.O.H., City of Liverpool.
CUTANEOUS AND VISUAL HALLUCINATIONS IN THE CHRONIC HALLUCINATORY PSYCHOSIS.
To the Editor of THE LANCET. SIR,—In connexion with the article by Dr. Macnamara in your issue of April 21st it may be of some interest to mention a case of a similar kind which came under my notice at the Maudsley Hospital. This patient, like those of Dr. Macnamara, was a woman who had passed the menopause, and her skin sensations and the hallucinations and delusions arising therefrom were subject to marked fluctuations according to the state of her general health and of the weather. She showed some evidences of thyroid deficiency, and under thyroid administration her skin of Health. became less dry and scaly, less sensitive to cold, and 1, Upper Montague-street, W.C., April 24th, 1928. less irritable ; this seemed to react upon her mental state, and although she never completely lost her *** It is noteworthy that in Circular 888, issued this belief that she was infected with vermin, it became week by the Ministry of Health to local authorities, much less prominent and affected her conduct and attention is called to a previous circular recommending emotional state to a much slighter extent, so that she an investigation in every area by an experienced became more cheerful, and was able to resume social medical officer of all maternal deaths and all cases contacts and her occupation of teaching music. of puerperal fever. The Minister regrets to learn Since these patients are mainly elderly or middle- that such inquiries have, so far, been adopted in aged women it seems possible that thyroid and ovarian few areas, possibly because it has not been secretions are deficient, causing dryness, scaliness, and very apparent to local authorities what practical results irritability of the skin which act as the basis upon might follow. The Minister explains that the object which hallucinations and delusions are formed ; the is to obtain and study a mass of properly classified case mentioned above suggests that it is at least information as to the causes of death in a large worth while to try the effect of glandular therapy number of cases, and to this end a Maternity Mortalityupon such patients. Committee is to be set up at the Ministry. This-
I
I
T am. Sir. Lincoln, April 20th, 1928.
yours
faitTifn11v. MARY R. BARKAS.
1 Practitioner, 1916.
Ogilvie that tonsillectomy is likely to reduce the SUBLINGUAL ABSORPTION OF MORPHINE. severity of cardiac complications, but this was not the To the Editor of THE LANCET. point under investigation by me ; it was the statistical adequacy of the numbers adduced to support the SIR,—In an annotation in your last issue reference is contention that I was investigating. made to the sublingual method of administration of My rearrangement of Table IV. was due to the morphine sulphate. It is stated that Dr. David arithmetical discrepancy that the numbers given in Davis and Dr. David Ayman suggest the discontinunot with the two columns the do tally right-hand of administration of the drug by this route. I total number given in the left-hand column, the children ance have been using this method for many years successwith glands but no tonsils having been excluded, and a crusted tablet under the. I reproduce the table from your issue of March 31st. fully by simply placingit first in cases of deficient tongue, but I powder salivation. Absorption by the sublingual gland takes TABLE IV.-Rheumatic Children. place rapidly and the effect of the drug is satisfactory.. I am employing the sublingual method with all the alkaloids almost exclusively in my practice, making of hypodermic injections principally for the use induction of local anaesthesia in surgical operations. If a patient accidentally swallows the tablet I repeat the sublingual administration. Much time is saved by this method, and asepsis is assured. Many years ago I published1 my experience of the sublingual method, illustrating my remarks with selected cases. The paraphrase of " normal tonsils " for " healthy In one case-poisoning by carbolic acid-where throats " was inadvertent. I was led into this error swallowing movements were absent and the patient because in Table V. the 37 children with " healthy was moribund, the administration of apomorphine throats " are described as having the throat condition by the sublingual method produced vomiting. Whatnormal." But my paraphrase has led to the ever may be the explanation of the American findings shall continue the sublingual practice with which disclosure of the fact, not revealed in Table IV., that a number of the children with " healthy throats " for many years I have been highly satisfied. "
had had their tonsils removed. It would now seem that the cases included under the rubric " healthy throats " consist partly of children who have normal tonsils and partly of children who have had their tonsils removed, presumably on account of tonsillar disease. As this group is not homogeneous it is not possible to draw inferences from it in the manner that I
I
C.
Sir.
vours
To the Editor of THE LANCET. SIR,—The Council of the Society of Medical Officers of Health has had before it the letter appearing in the Times of April 3rd, over the signatures of certain obstetricians, as to the need for research into the above subject. The Council is in agreement that the research required calls for a close alliance between the physician, the biochemist, and the bacteriologist, and the close apposition of the laboratory to the bedside, but it is not of opinion that an investigation by local health authorities of all maternal deaths should be excluded or discredited, and the Council regrets that the signatories have seen fit to take this view. The Council would further put on record that the signatories are in error in suggesting that a knowledge of the cause of a disease is necessarily a sine qua non for its prevention, and in this connexion would refer to the control of small-pox by vaccination ; the diminished incidence of enteric fever following on the betterment of sanitary and living conditions ; and the reduction of deaths from scarlet fever as the result of the measures taken by health authorities. The Council of this Society feels that matters of this kind are best discussed in the professional journals. I am, Sir, yours faithfully, E. H. SNELL, Acting President, Society of Medical Officers
the usual statistical criteria that, though suggestive, the numbers of cases are insufficient to be beyond the reach of variations due to chance, however strong the clinical grounds may be for belief in the value of tonsillectomy in rheumatic cases. April 21st, 1928.
am.
INVESTIGATION OF MATERNAL MORTALITY.
attempted.
I fear that the conclusion must be
faithfullv. A. P. MURTZ. Queen’s-road, Finsbury Park, N., April 21st, 1928. I
on
O. STALLYBRASS,
Asst. M.O.H., City of Liverpool.
CUTANEOUS AND VISUAL HALLUCINATIONS IN THE CHRONIC HALLUCINATORY PSYCHOSIS.
To the Editor of THE LANCET. SIR,—In connexion with the article by Dr. Macnamara in your issue of April 21st it may be of some interest to mention a case of a similar kind which came under my notice at the Maudsley Hospital. This patient, like those of Dr. Macnamara, was a woman who had passed the menopause, and her skin sensations and the hallucinations and delusions arising therefrom were subject to marked fluctuations according to the state of her general health and of the weather. She showed some evidences of thyroid deficiency, and under thyroid administration her skin of Health. became less dry and scaly, less sensitive to cold, and 1, Upper Montague-street, W.C., April 24th, 1928. less irritable ; this seemed to react upon her mental state, and although she never completely lost her *** It is noteworthy that in Circular 888, issued this belief that she was infected with vermin, it became week by the Ministry of Health to local authorities, much less prominent and affected her conduct and attention is called to a previous circular recommending emotional state to a much slighter extent, so that she an investigation in every area by an experienced became more cheerful, and was able to resume social medical officer of all maternal deaths and all cases contacts and her occupation of teaching music. of puerperal fever. The Minister regrets to learn Since these patients are mainly elderly or middle- that such inquiries have, so far, been adopted in aged women it seems possible that thyroid and ovarian few areas, possibly because it has not been secretions are deficient, causing dryness, scaliness, and very apparent to local authorities what practical results irritability of the skin which act as the basis upon might follow. The Minister explains that the object which hallucinations and delusions are formed ; the is to obtain and study a mass of properly classified case mentioned above suggests that it is at least information as to the causes of death in a large worth while to try the effect of glandular therapy number of cases, and to this end a Maternity Mortalityupon such patients. Committee is to be set up at the Ministry. This-
I
I
T am. Sir. Lincoln, April 20th, 1928.
yours
faitTifn11v. MARY R. BARKAS.
1 Practitioner, 1916.