- Email: [email protected]
THE DEATH PENALTY
506 natal testing is an admirable training for work in bloodtransfusion. Although in my laboratory we crossmatch about 350 bottles a month, we also study about 200 new antenatal blood samples, screen 30 or 40 sera for antibodies, titrate out 5-10 sera, and do a varying number of direct Coombs tests : certainly without this solid block of work my technical staff and I would be far less confident in our reagents and our techniques -and this would affect not only our transfusion work but also our diagnostic work in, for example, suspected haemolytic anaemias. I should like to hand over to the regional centre all sera in which antibodies have been demonstrated, or in which, on clinical grounds, antibodies are expected but cannot be demonstrated. This would ensure that the transfusion centre would acquire the sera it needs. Centralisation of antenatal testing is administratively elegant, but, as Dr. Bowley (Aug. 6) is now finding, not always convenient. In a large city such as Sheffield there are several hospitals and a transfusion centre competing with each other and with industry for suitable technical staff. The transfusion centre is the most highly specialised of all these-and few intelligent young men are likely to enter a field in which promotion is slow and from which transfer is likely to be difficult because of this specialisation. And if, by some mischance, such a man does enter that field, he will leave it as soon as he realises his error. In smaller centres, where there may be but one hospital laboratory, a pathologist who establishes contact with the local secondary schools should, in a few years’ time, have built up an excellent technical staff.’ Reasonably frequent broadsheets from the centre or one-day revision courses should then maintain a high standard of work, so that in spite of some increase in the use of sera and of man-power, the regional centre and the hospital laboratory could balance their demands more evenly. -
Central Middlesex Hospital, London, N.W.10.
’
D. A. Lancet, 1948, ii, 939. L. A., Auld, W. H. R., Bowman, W.
715.
3. Hubble, D.
Ibid, 1955, i, 1.
THE DEATH PENALTY
SIR,- With the greatest respect to some of your correspondents, I think that they are making this matter Ethical problems may indeed have too complicated. been occupying the minds of men of genius for over two thousand years ; yet it is a strange fact that most great ethical advances, such as the abolition of slavery, have not, I think, arisen out of brilliant, logical, and lucid expositions of the philosophers. One of the great failings of our generation is the deification of the intellect; yet as Christians-and we are a Christian countrywe know that wisdom is granted to quite simple people, unversed in the language of philosophy, where matters of right and wrong are concerned. This may be dubbed as mere emotional thought; but many of us believe that the death penalty, like war, is neither effective in its object nor in line with our interpretation of the Christian way of life. To such simpler folk this is sufficient answer to the problem. Leicester.
PAUL HICKINBOTHAM.
SiR,-Sir Francis Walshe (Aug. 13) asks for the rational
SIR,-May I comment on the interesting letter from Dr. Wilson and his colleagues (Aug. 13) ? The writers have now established that their case 6? suffered from primary hypothyroidism and, in addition, some degree of pituitary insufficiency. They conclude that a pituitary lesion might have aggravated a preexisting thyroid deficiency. It must appear equally possible to anyone, and to me more probable, that a pre-existing hypothyroidism conditioned a pituitary inadequacy, with an increased liability to postpartum haemorrhage, and finally a minor degree of postpartum necrosis. In a male cretin, aged 26, under my care (case 63) thyroid therapy increased his output of folliclestimulating hormone (F.s.H.) from 0 to 18 mouse units per 24 hours. D’Angelo and his co-workers have demonstrated that thyroid-stimulating hormone may actually disappear in hypothyroidism only to reappear when the hypothyroidism is cured. What hypothyroidism may do to the functions of the pituitary is the subject of recent and, as yet, scanty consideration. The further investigation of their case 7 has now established that both thyroid and adrenocortical failure can occur in hypopituitarism in the absence of sexual failure. This is an important observation,and to complete the record may we have the result of the F.s.H. assay in this patient ?? This is an exception to the usual sequence of pituitary failure, but these exceptions may have more importance than the general rule when we understand the formation of the pituitary hormones. The usual human sequence has recently been demonGray, J. Wilson,
how admirable was the conduct ofthis scientific debate ! The experts had criticised the conclusions of the junior authors, who rejoined courteously and were thereupon given facilities for the further investigation of their cases, to the enlargement of our understanding of disease in the pituitary. DOUGLAS HUBBLE. Derby.
GEORGE DISCOMBE.
INCOMPLETE PITUITARY INSUFFICIENCY
1. 2.
occur also in dogs by Ganong and Hume (Boston) by progressive ablation of the hypophysis, and in them sex, thyroid, and adrenocortical failure proceeded in this order. In a patient of mine (case 7 s) witha craniopharyngioma this sequence was not observed and both sex and adrenocortical failure were established, but no evidence of thyroid failure could be obtained. In congratulating Dr. Wilson and his colleagues on the conclusion of their investigations, may I’point out
strated to
Ibid, 1954, ii,
argument against capital punishment. May I quote sans m’engager ? The object of the death penalty is primarily to deter potential murderers. In some countries and parts of countries the penalty has been abolished or temporarily suspended. In these circumstances neither the rate nor the trend of the rate of murder has been significantly changed. If these propositions are correct, then capital punishment fails in its main object, and, unless there are other arguments for maintaining it, it should be abolished. it,
Oxford.
C. W. W. M. WHITTY. WHITTY.
am what James Thurber would describe as a with big brown eyes and a tiny mind; and so discussion on ethics, Aristotle, and philosophy is well above my head. In theory I may support abolition of capital punishment, but, as a father of small children, in the event of their murder I should naturally desire revenge. Hatred is as natural a feeling as love. The important point that has so far been missed is that the final responsibility for the continuance of the death penalty rests upon the electorate. If people want murderers to be hanged, they will be. If they desire the penalty to be changed, they must mandate their representatives accordingly. Dr. Day’s letter of Aug. 13 calls for comment. He suggests severe penalties for the unauthorised carrying of lethal weapons. But how many murders are committed by lethal weapons (and I take it Dr. Day means guns, knives, and coshes)z Surely the common methods of murder are hammers, axes, carving-knives, and last, but by no means least, a pair of hands. Are these everyday articles to be outlawed ?
SIR,-I
man
507
morning that Ruth paying the penalty for
On the was
Ellis died I realised she cold-blooded murder :
a
at my watch at 9.15 A.M. I felt sick. But not as sick as the day the Rosenbergs were electrocuted. Hanging may be right or wrong, I just don’t know. But from a practical point of view, it is the public that must decide to retain the rope, or find another method of coping with this particular crime. F. E. D. GRIFFITHS. Kenihvorth.
and
yet when I looked
little
a
"
SIR,-Sir Francis Walshe asks for a lucid and logical statement in support of the case against capital "
punishment. I wonder whether he regards this as a logical statement :to take deliberately somebody’s life is today regarded as the most abominable crime man can commit. (I do not know whether there are any logical " reasons for this general conviction or whether it is a purely " emotional " attitude.) How then can we, in spite of our severe condemnation of deliberate killing, empower and pay a person to do just this ? I know society allows-and may even order-men to kill in self-protection, but only in cases of utter emergency. A handcuffed prisoner does not confront us with such an emergency. The potential danger which he may still represent can effectively be dealt with without anybody having to commit the crime which everybody professes most deeply to abhor. May this abhorrence be founded on a logical or psychological basis, the abolition of’ the death penalty must be the logical consequence of this generally professed abhorrence. "
St. Lawrence’s Hospital,
Caterham, Surrey.
LISE GELLNER.
SIR,-Sir Francis Walshe says that it is
a pity that of your correspondents make a lucid and logical statementagainst capital punishment. But surely no-one, least of all a doctor, needs to find elaborate excuses to save a life. On the contrary, the onus lies on those who wish to see their fellow humans put to death to find a very good reason why it should be done. "
none
Geneva.
W. NORMAN TAYLOR.
ACUTE CHOREO-ATHETOSIS DURING RESERPINE THERAPY
SiR,-In view of the attention recently drawn to
neurological complications of reserpine therapy, particularly the observations of Barsa and Kline/ Huchtemann and Pflugfelder,2and Stead and Wing,3 on the development of extrapyramidal symptoms during the administration of this drug, the following case may
the
be of interest.
A housewife, aged 54, had had no ill health, in spite of ten fullterm pregnancies, until the age of 50. She then had frontal headon exertion, and palpitations, admitted to this hospital with early hypertensive cardiac failure in 1952. Her blood-pressure averaged 220/130 during her stay in hospital. Retinal changes were slight and she was free from albuminuria. X-ray examination showed a typical enlarged hypertensive heart with pulmonary congestion. The electrocardiogram showed left heart strain and auricular fibrillation. She did well on digitalis, mercurial diuretics, aminophylline, and sedatives. She was readmitted in June, 1955, with a recurrence of symptoms, and, in addition, nocturnal paroxysmal dyspnoea and haemoptysis. Her condition on admission was substantially similar to that on her previous admission, but bilateral papillcedema with extensive retinal haemorrhages and exudates were now present. Her cedema was more massive, she was cyanosed and congested, and heavy albuminuria was present initially but cleared later. Her blood-pressure was 240/145 on admission. A salt-free fluid-restricted diet, in digitalis, full dosage mercurial diuretics, and intravenous aminophylline were
aches, giddiness, dyspnoea
and she
was
Barsa, J. A., Kline, N. S. J. Amer. med. Ass. 1955, 158. 110. Huchtemann, K., Pflugfelder, G. Schweiz. med. Wschr. 1955, 85, 627. 3. Stead. J. S., Wing, J. K. Lancet, 1955, i, 823.
1. 2.
and for the first time anti-hypertensive drugs were administered. 1’5 mg. daily (in divided doses) of reserpine (’Serpasil’) was given and oral pentolinium tartrate, in increasing doses, until she was taking 150 mg. daily. On this regime the blood-pressure fell to 162/90 and her cardiac failure improved greatly. Two days after the first dose of reserpine some twitching of her right hand was noted and she complained of severe epigastric pain and vomiting. The following day the muscular twitching had progressed to a typical choreiform movement now extending to her face, right leg, and thorax. Next day there was emotional instability, alternate weeping and giggling, and great restlessness. A severe generalised chorea with wild uncontrollable movements was now present. Writhing athetoid movements, particularly of the right hand, were associated with the typical athetoid position of the fingers and hand for long periods. Her epigastric pain was severe and vomiting was frequent. Apart from these involuntary movements no abnormal neurological signs were ever detected in her central nervous system. Reserpine was stopped on the third day of therapy and all other drugs continued as before. The involuntary movements gradually subsided and had disappeared in fourteen days. Her emotional instability disappeared in a few days and her abdominal pain and vomiting within ten days. She made a good recovery from her cardiac failure in spite of this alarming upset and has remained in reasonable health in the last few months as an outpatient.
prescribed
*
completely
This case is instructive because of the small quantity of reserpine given before the onset of symptoms and the very real severity of the extrapyramidal symptoms. A coincidental Sydenham’s chorea was rejected as a cause for obvious reasons-the age of the patient and the absence of previous or concomitant rheumatism. A vascular cause is more difficult to reject, but the rapid disappearance of symptoms following the withdrawal of reserpine pointed strongly to its guilt. -
Law Hospital, Carluke, Lanarkshire.
A. MUIR.
CALCIFICATION WITHIN THE LIVER
SiR,—I have read with great interest the article by Dr. Smallwood and his colleagues (Aug. 20) describing a case of intrahepatic calcification of probable syphilitic origin. Since January, 1953, I have had under my care a young man in whom the healing of multiple hepatic gummata following treatment has been accompanied’ by the development of progressive calcification as seen in serial radiographs. A full report of this case will, I hope, be published in the near future. Liverpool,
1.
C. D. ALERGANT.
CONTINUOUS NARCOSIS regorted in your issue-of Aug. 13 that at a recent inquest Prof. J. M. Webster, speaking of continuous narcosis, said : "I think it is a very dangerous treatment. You pour barbiturates into a body. You don’t know what happens to them, and you are living very dangerously when you employ massive doses of barbiturates." I have been using this treatment extensively for over twenty years. In the earlier years, using ’Somnifaine,’ I agree there were from time to time unpleasant complications. Since 1947 amylobarbitone sodium has been employed at this hospital, and well over 100 patients have been treated annually without unpleasant complications. The dose varies between gr. 18 and gr. 30 daily. Reputable textbooks in edition after edition reiterate the dangers of this treatment. Maybe this is based on the experiences of early workers or perhaps on later experience on small numbers before the nursing staff were adequately trained. Further it is tentatively suggested that the physician has a better idea of what he is doing or may do than he has when he advises prefrontal leucotomy
SiR,—It is
or even
electroplexy.
St. Lawrence’s Hospital, Bodmin, Cornwall.
STANLEY M. COLEMAN.
Central Middlesex Hospital, London, N.W.10.
’
D. A. Lancet, 1948, ii, 939. L. A., Auld, W. H. R., Bowman, W.
715.
3. Hubble, D.
Ibid, 1955, i, 1.
THE DEATH PENALTY
SIR,- With the greatest respect to some of your correspondents, I think that they are making this matter Ethical problems may indeed have too complicated. been occupying the minds of men of genius for over two thousand years ; yet it is a strange fact that most great ethical advances, such as the abolition of slavery, have not, I think, arisen out of brilliant, logical, and lucid expositions of the philosophers. One of the great failings of our generation is the deification of the intellect; yet as Christians-and we are a Christian countrywe know that wisdom is granted to quite simple people, unversed in the language of philosophy, where matters of right and wrong are concerned. This may be dubbed as mere emotional thought; but many of us believe that the death penalty, like war, is neither effective in its object nor in line with our interpretation of the Christian way of life. To such simpler folk this is sufficient answer to the problem. Leicester.
PAUL HICKINBOTHAM.
SiR,-Sir Francis Walshe (Aug. 13) asks for the rational
SIR,-May I comment on the interesting letter from Dr. Wilson and his colleagues (Aug. 13) ? The writers have now established that their case 6? suffered from primary hypothyroidism and, in addition, some degree of pituitary insufficiency. They conclude that a pituitary lesion might have aggravated a preexisting thyroid deficiency. It must appear equally possible to anyone, and to me more probable, that a pre-existing hypothyroidism conditioned a pituitary inadequacy, with an increased liability to postpartum haemorrhage, and finally a minor degree of postpartum necrosis. In a male cretin, aged 26, under my care (case 63) thyroid therapy increased his output of folliclestimulating hormone (F.s.H.) from 0 to 18 mouse units per 24 hours. D’Angelo and his co-workers have demonstrated that thyroid-stimulating hormone may actually disappear in hypothyroidism only to reappear when the hypothyroidism is cured. What hypothyroidism may do to the functions of the pituitary is the subject of recent and, as yet, scanty consideration. The further investigation of their case 7 has now established that both thyroid and adrenocortical failure can occur in hypopituitarism in the absence of sexual failure. This is an important observation,and to complete the record may we have the result of the F.s.H. assay in this patient ?? This is an exception to the usual sequence of pituitary failure, but these exceptions may have more importance than the general rule when we understand the formation of the pituitary hormones. The usual human sequence has recently been demonGray, J. Wilson,
how admirable was the conduct ofthis scientific debate ! The experts had criticised the conclusions of the junior authors, who rejoined courteously and were thereupon given facilities for the further investigation of their cases, to the enlargement of our understanding of disease in the pituitary. DOUGLAS HUBBLE. Derby.
GEORGE DISCOMBE.
INCOMPLETE PITUITARY INSUFFICIENCY
1. 2.
occur also in dogs by Ganong and Hume (Boston) by progressive ablation of the hypophysis, and in them sex, thyroid, and adrenocortical failure proceeded in this order. In a patient of mine (case 7 s) witha craniopharyngioma this sequence was not observed and both sex and adrenocortical failure were established, but no evidence of thyroid failure could be obtained. In congratulating Dr. Wilson and his colleagues on the conclusion of their investigations, may I’point out
strated to
Ibid, 1954, ii,
argument against capital punishment. May I quote sans m’engager ? The object of the death penalty is primarily to deter potential murderers. In some countries and parts of countries the penalty has been abolished or temporarily suspended. In these circumstances neither the rate nor the trend of the rate of murder has been significantly changed. If these propositions are correct, then capital punishment fails in its main object, and, unless there are other arguments for maintaining it, it should be abolished. it,
Oxford.
C. W. W. M. WHITTY. WHITTY.
am what James Thurber would describe as a with big brown eyes and a tiny mind; and so discussion on ethics, Aristotle, and philosophy is well above my head. In theory I may support abolition of capital punishment, but, as a father of small children, in the event of their murder I should naturally desire revenge. Hatred is as natural a feeling as love. The important point that has so far been missed is that the final responsibility for the continuance of the death penalty rests upon the electorate. If people want murderers to be hanged, they will be. If they desire the penalty to be changed, they must mandate their representatives accordingly. Dr. Day’s letter of Aug. 13 calls for comment. He suggests severe penalties for the unauthorised carrying of lethal weapons. But how many murders are committed by lethal weapons (and I take it Dr. Day means guns, knives, and coshes)z Surely the common methods of murder are hammers, axes, carving-knives, and last, but by no means least, a pair of hands. Are these everyday articles to be outlawed ?
SIR,-I
man
507
morning that Ruth paying the penalty for
On the was
Ellis died I realised she cold-blooded murder :
a
at my watch at 9.15 A.M. I felt sick. But not as sick as the day the Rosenbergs were electrocuted. Hanging may be right or wrong, I just don’t know. But from a practical point of view, it is the public that must decide to retain the rope, or find another method of coping with this particular crime. F. E. D. GRIFFITHS. Kenihvorth.
and
yet when I looked
little
a
"
SIR,-Sir Francis Walshe asks for a lucid and logical statement in support of the case against capital "
punishment. I wonder whether he regards this as a logical statement :to take deliberately somebody’s life is today regarded as the most abominable crime man can commit. (I do not know whether there are any logical " reasons for this general conviction or whether it is a purely " emotional " attitude.) How then can we, in spite of our severe condemnation of deliberate killing, empower and pay a person to do just this ? I know society allows-and may even order-men to kill in self-protection, but only in cases of utter emergency. A handcuffed prisoner does not confront us with such an emergency. The potential danger which he may still represent can effectively be dealt with without anybody having to commit the crime which everybody professes most deeply to abhor. May this abhorrence be founded on a logical or psychological basis, the abolition of’ the death penalty must be the logical consequence of this generally professed abhorrence. "
St. Lawrence’s Hospital,
Caterham, Surrey.
LISE GELLNER.
SIR,-Sir Francis Walshe says that it is
a pity that of your correspondents make a lucid and logical statementagainst capital punishment. But surely no-one, least of all a doctor, needs to find elaborate excuses to save a life. On the contrary, the onus lies on those who wish to see their fellow humans put to death to find a very good reason why it should be done. "
none
Geneva.
W. NORMAN TAYLOR.
ACUTE CHOREO-ATHETOSIS DURING RESERPINE THERAPY
SiR,-In view of the attention recently drawn to
neurological complications of reserpine therapy, particularly the observations of Barsa and Kline/ Huchtemann and Pflugfelder,2and Stead and Wing,3 on the development of extrapyramidal symptoms during the administration of this drug, the following case may
the
be of interest.
A housewife, aged 54, had had no ill health, in spite of ten fullterm pregnancies, until the age of 50. She then had frontal headon exertion, and palpitations, admitted to this hospital with early hypertensive cardiac failure in 1952. Her blood-pressure averaged 220/130 during her stay in hospital. Retinal changes were slight and she was free from albuminuria. X-ray examination showed a typical enlarged hypertensive heart with pulmonary congestion. The electrocardiogram showed left heart strain and auricular fibrillation. She did well on digitalis, mercurial diuretics, aminophylline, and sedatives. She was readmitted in June, 1955, with a recurrence of symptoms, and, in addition, nocturnal paroxysmal dyspnoea and haemoptysis. Her condition on admission was substantially similar to that on her previous admission, but bilateral papillcedema with extensive retinal haemorrhages and exudates were now present. Her cedema was more massive, she was cyanosed and congested, and heavy albuminuria was present initially but cleared later. Her blood-pressure was 240/145 on admission. A salt-free fluid-restricted diet, in digitalis, full dosage mercurial diuretics, and intravenous aminophylline were
aches, giddiness, dyspnoea
and she
was
Barsa, J. A., Kline, N. S. J. Amer. med. Ass. 1955, 158. 110. Huchtemann, K., Pflugfelder, G. Schweiz. med. Wschr. 1955, 85, 627. 3. Stead. J. S., Wing, J. K. Lancet, 1955, i, 823.
1. 2.
and for the first time anti-hypertensive drugs were administered. 1’5 mg. daily (in divided doses) of reserpine (’Serpasil’) was given and oral pentolinium tartrate, in increasing doses, until she was taking 150 mg. daily. On this regime the blood-pressure fell to 162/90 and her cardiac failure improved greatly. Two days after the first dose of reserpine some twitching of her right hand was noted and she complained of severe epigastric pain and vomiting. The following day the muscular twitching had progressed to a typical choreiform movement now extending to her face, right leg, and thorax. Next day there was emotional instability, alternate weeping and giggling, and great restlessness. A severe generalised chorea with wild uncontrollable movements was now present. Writhing athetoid movements, particularly of the right hand, were associated with the typical athetoid position of the fingers and hand for long periods. Her epigastric pain was severe and vomiting was frequent. Apart from these involuntary movements no abnormal neurological signs were ever detected in her central nervous system. Reserpine was stopped on the third day of therapy and all other drugs continued as before. The involuntary movements gradually subsided and had disappeared in fourteen days. Her emotional instability disappeared in a few days and her abdominal pain and vomiting within ten days. She made a good recovery from her cardiac failure in spite of this alarming upset and has remained in reasonable health in the last few months as an outpatient.
prescribed
*
completely
This case is instructive because of the small quantity of reserpine given before the onset of symptoms and the very real severity of the extrapyramidal symptoms. A coincidental Sydenham’s chorea was rejected as a cause for obvious reasons-the age of the patient and the absence of previous or concomitant rheumatism. A vascular cause is more difficult to reject, but the rapid disappearance of symptoms following the withdrawal of reserpine pointed strongly to its guilt. -
Law Hospital, Carluke, Lanarkshire.
A. MUIR.
CALCIFICATION WITHIN THE LIVER
SiR,—I have read with great interest the article by Dr. Smallwood and his colleagues (Aug. 20) describing a case of intrahepatic calcification of probable syphilitic origin. Since January, 1953, I have had under my care a young man in whom the healing of multiple hepatic gummata following treatment has been accompanied’ by the development of progressive calcification as seen in serial radiographs. A full report of this case will, I hope, be published in the near future. Liverpool,
1.
C. D. ALERGANT.
CONTINUOUS NARCOSIS regorted in your issue-of Aug. 13 that at a recent inquest Prof. J. M. Webster, speaking of continuous narcosis, said : "I think it is a very dangerous treatment. You pour barbiturates into a body. You don’t know what happens to them, and you are living very dangerously when you employ massive doses of barbiturates." I have been using this treatment extensively for over twenty years. In the earlier years, using ’Somnifaine,’ I agree there were from time to time unpleasant complications. Since 1947 amylobarbitone sodium has been employed at this hospital, and well over 100 patients have been treated annually without unpleasant complications. The dose varies between gr. 18 and gr. 30 daily. Reputable textbooks in edition after edition reiterate the dangers of this treatment. Maybe this is based on the experiences of early workers or perhaps on later experience on small numbers before the nursing staff were adequately trained. Further it is tentatively suggested that the physician has a better idea of what he is doing or may do than he has when he advises prefrontal leucotomy
SiR,—It is
or even
electroplexy.
St. Lawrence’s Hospital, Bodmin, Cornwall.
STANLEY M. COLEMAN.