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TECHNIQUE OF PREFRONTAL LEUCOTOMY
473 at the outset to have such five years of trial before it could be passed the experimental stage. Curare,, which appears to be of even greater value than cyclopropane, will probably require an even longer trial. I hope that, unlike ’Pentothal,’ it will not prove to be a drug " fatally easy " to administer. (2) When we examine the dosage of drugs used in this case, it would appear that the coroner’s verdict was charitable. An old lady of 70, suffering for two days from an acute abdominal infection, and with early peritonitis, was given morphine gr. 1/s and atropine gr. 11100’ I would presume to say that the former drug was superfluous. This was followed by 1 g. of pentothal. In my opinion this was an excessive dose, even had nitrous oxide been the only additional anaesthetic to be given. With curare in a fit subject in first-class condition I personally hesitate to give more than half this dosage. Prescott, Organe, and Rowbotham (Lancet, July 20, p. 80) have pointed out the danger of giving two such respiratory depressants together in full dosage. The present case illustrates this danger. I am not surprised that the patient required continuous oxygen. This was followed by’Intocostrin ’ 9 c.cm.-180 units. Presumably this was given intravenously in a single dose. So far as I am aware. 100 units of this drug is regarded by authorities as a maximum single dose even in fit subjects. In any case, we are warned that in the very young, or the very old. or in bad risk cases, this dose must be considerably reduced. I hope that those who are more competent than myself to express an opinion will let us know in your columns whether this dosage should be regarded as excessive. I have the deepest sympathy with the anaesthetist in this case, of whose identity I am ignorant. " There, but for the grace of God, go I." But I should like to obtain the opinions of my colleagues on the following four principles : (1) New anaesthetic drugs must be assessed in comparison with ether. (2) Final assessment cannot be made until -many hundreds of thousands of administrations have been recorded. During this period of trial such drugs should be regarded
cyclopropane, which appeared promise, required great said to have
as
experimental.
(3) Such experimental drugs should (4)
not be
risk cases. The dosage of such
given
experimental drugs should fully regulated according to the published
to bad
be
care-
recom-
mendations of senior anaesthetists.
It is only ciples that,
with the object of establishing these prinwith humility and hesitation, I have sought the hospitality of your columns at such length. R. BLAIR GOULD. London, W.l. SIGMOIDOSCOPY IN AMŒBIC DYSENTERY SiR,—I should like to add a postscript to my article of Oct. 13, 1945 (p. 460). Two points call for revision in the light of subsequent experience. The first of these concerns technique. I havesince found that the most satisfactory method of producing a " clean " lower bowel, whether for the diagnostic purpose of a sigmoidoscopy or for the therapeutic purpose of a retention enema, is by the simple administration of a weak bicarbonate enema, after which a period of 4-6 hours must be allowed to elapse. At the end of this period, regardless of the taking of meals meanwhile, the lower eight inches of bowel are almost invariably clean and dry," in the sense that all traces of enema fluid have been evacuated or absorbed. An important point, and one often overlooked, is that the evacuant enema must be of just that volume which will produce an effective call to stool: this will be one pint in some, considerably more or less in others. There are still undesirable methods in use involving the exhibition of castor oil, &c., and I have known retention enemata given within a few minutes of the evacuant enema, thereby reducing the strength of the medicament used to quite ineffectual proportions. Such errors in technique not only defeat their object but often involve a sore trial for the long-suffering patient. Secondly, a point in diagnosis. Recently I have seen a number of cases in which the ulcers are minute : with the ordinary magnifying lens they catch the eye merely "
as tiny points of extreme congestion. They are scattered in small groups, and frequently only one such group can be found. With a special magnifying attachment, first shown me by Lieut.-Colonel A. M. Khan, R.A.M.C., it is possible to detect the actual tissue loss. C. F. J. CROPPER. Keighley, Yorks.
NON-SPECIFIC EPIDIDYMITIS SiB,—Dr. Whitwell’s letter of Sept. 7, recalling Slesinger’s suggestion that non-specific epididymitis may be due to stress reflux of normal urine, prompts me to describe an experiment carried out at my suggest, tion by Dr. G. L. Timms, pathologist to Kenya Government Medical Service. A rabbit was anaesthetised and 5 c.cm. of urine withdrawn by vesical puncture. Of this, a part was cultured and proved sterile. Of the remainder, 0-5 c.cm. was injected into the previously exposed vas deferens on one side. As this was done the epididymis could be felt to inflate with urine. The animal remained clinically normal after this operation ; after 10 days the testis and epididymis on both sides were removed and sectioned. They were all normal. As Handley says (Lancet, 1946, i, 779), the reflux theory does not seem very feasible ; and this experimentappears to show that normal urine is not an irritant in the epididymis, at least in the rabbit. F. RAY BETTLEY. London, W.I.
’
TUBERCULOUS GLANDS AND CALCIFEROL
SiR,-With reference to the treatment of tuberculous glands with high dosage of calciferol (July 20, p. 88), there seems to be some evidence that such treatment, while helpful when sinus formation is present, has a clinically adverse effect on glands which have not broken down. In the absence of more detailed investigation this is little more than an impression, but it would be in keeping with the observation that in the early stages of treatment of lupus vulgaris with calciferol there is not infrequently a local exacerbation of the disease. It would also be in keeping with similar observations the influence of tuberculin in tuberculous lesions and of arsenic in untreated syphilis. Until further evidence is forthcoming it would appear advisable to use the calciferol treatment with caution when lung tuberculosis is present, since such a reaction in the lung might have on
disastrous senuels. London, W.l.
H. J. WALLACE.
NEW WORDS ABOUT OLD AGE SiR,—In your issue of August 10 (p. 214) Dr. Howell discusses " the nomenclature of old age." It would be a benefit to medicine if you would help to get the " new words " fixed in correct form before it is too late.
From pais (stem
paid-)
a
child,
we
have "
paediatrics,"
and from geron (stem geront-), an old person, we should have " gerontiatrics," not " geriatrics." There is no word geria in Greek, though there is eugeria, meaning a good old age. Gerontiatrics therefore is the word for the medical care of the aged and eugeria is its goal. H. ST. H. VERTUE. Orpington, Kent.
TECHNIQUE OF PREFRONTAL LEUCOTOMY SIR,-In order to avoid incision of the grey matter, I suggest that prefrontal leucotomy might be performed through an approach from the midline underneath the angular gyrus by an incision of the corpus callosum in the direction of its fibres. No doubt a special knife would have to be designed and a new technique devised for the new approach. -
Taunton.
-
-
--
T. F. G. MAYER.
** * We are informed that section from this would carry an appreciable risk of damage to the nerves.—ED. L.
angle optic
THE Medical Research Council have received from Sir Leonard Rogers, F.R.s., a further addition to the endowment for research in tropical medicine with which he entrusted them in 1926. The capital value of this fund is now about 15,000, and the income is applicable to special purposes within the general field of tropical medical research.
cyclopropane, which appeared promise, required great said to have
as
experimental.
(3) Such experimental drugs should (4)
not be
risk cases. The dosage of such
given
experimental drugs should fully regulated according to the published
to bad
be
care-
recom-
mendations of senior anaesthetists.
It is only ciples that,
with the object of establishing these prinwith humility and hesitation, I have sought the hospitality of your columns at such length. R. BLAIR GOULD. London, W.l. SIGMOIDOSCOPY IN AMŒBIC DYSENTERY SiR,—I should like to add a postscript to my article of Oct. 13, 1945 (p. 460). Two points call for revision in the light of subsequent experience. The first of these concerns technique. I havesince found that the most satisfactory method of producing a " clean " lower bowel, whether for the diagnostic purpose of a sigmoidoscopy or for the therapeutic purpose of a retention enema, is by the simple administration of a weak bicarbonate enema, after which a period of 4-6 hours must be allowed to elapse. At the end of this period, regardless of the taking of meals meanwhile, the lower eight inches of bowel are almost invariably clean and dry," in the sense that all traces of enema fluid have been evacuated or absorbed. An important point, and one often overlooked, is that the evacuant enema must be of just that volume which will produce an effective call to stool: this will be one pint in some, considerably more or less in others. There are still undesirable methods in use involving the exhibition of castor oil, &c., and I have known retention enemata given within a few minutes of the evacuant enema, thereby reducing the strength of the medicament used to quite ineffectual proportions. Such errors in technique not only defeat their object but often involve a sore trial for the long-suffering patient. Secondly, a point in diagnosis. Recently I have seen a number of cases in which the ulcers are minute : with the ordinary magnifying lens they catch the eye merely "
as tiny points of extreme congestion. They are scattered in small groups, and frequently only one such group can be found. With a special magnifying attachment, first shown me by Lieut.-Colonel A. M. Khan, R.A.M.C., it is possible to detect the actual tissue loss. C. F. J. CROPPER. Keighley, Yorks.
NON-SPECIFIC EPIDIDYMITIS SiB,—Dr. Whitwell’s letter of Sept. 7, recalling Slesinger’s suggestion that non-specific epididymitis may be due to stress reflux of normal urine, prompts me to describe an experiment carried out at my suggest, tion by Dr. G. L. Timms, pathologist to Kenya Government Medical Service. A rabbit was anaesthetised and 5 c.cm. of urine withdrawn by vesical puncture. Of this, a part was cultured and proved sterile. Of the remainder, 0-5 c.cm. was injected into the previously exposed vas deferens on one side. As this was done the epididymis could be felt to inflate with urine. The animal remained clinically normal after this operation ; after 10 days the testis and epididymis on both sides were removed and sectioned. They were all normal. As Handley says (Lancet, 1946, i, 779), the reflux theory does not seem very feasible ; and this experimentappears to show that normal urine is not an irritant in the epididymis, at least in the rabbit. F. RAY BETTLEY. London, W.I.
’
TUBERCULOUS GLANDS AND CALCIFEROL
SiR,-With reference to the treatment of tuberculous glands with high dosage of calciferol (July 20, p. 88), there seems to be some evidence that such treatment, while helpful when sinus formation is present, has a clinically adverse effect on glands which have not broken down. In the absence of more detailed investigation this is little more than an impression, but it would be in keeping with the observation that in the early stages of treatment of lupus vulgaris with calciferol there is not infrequently a local exacerbation of the disease. It would also be in keeping with similar observations the influence of tuberculin in tuberculous lesions and of arsenic in untreated syphilis. Until further evidence is forthcoming it would appear advisable to use the calciferol treatment with caution when lung tuberculosis is present, since such a reaction in the lung might have on
disastrous senuels. London, W.l.
H. J. WALLACE.
NEW WORDS ABOUT OLD AGE SiR,—In your issue of August 10 (p. 214) Dr. Howell discusses " the nomenclature of old age." It would be a benefit to medicine if you would help to get the " new words " fixed in correct form before it is too late.
From pais (stem
paid-)
a
child,
we
have "
paediatrics,"
and from geron (stem geront-), an old person, we should have " gerontiatrics," not " geriatrics." There is no word geria in Greek, though there is eugeria, meaning a good old age. Gerontiatrics therefore is the word for the medical care of the aged and eugeria is its goal. H. ST. H. VERTUE. Orpington, Kent.
TECHNIQUE OF PREFRONTAL LEUCOTOMY SIR,-In order to avoid incision of the grey matter, I suggest that prefrontal leucotomy might be performed through an approach from the midline underneath the angular gyrus by an incision of the corpus callosum in the direction of its fibres. No doubt a special knife would have to be designed and a new technique devised for the new approach. -
Taunton.
-
-
--
T. F. G. MAYER.
** * We are informed that section from this would carry an appreciable risk of damage to the nerves.—ED. L.
angle optic
THE Medical Research Council have received from Sir Leonard Rogers, F.R.s., a further addition to the endowment for research in tropical medicine with which he entrusted them in 1926. The capital value of this fund is now about 15,000, and the income is applicable to special purposes within the general field of tropical medical research.