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VARIATIONS IN RESPONSE TO RELAXANT DRUGS
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day-and incidentally high respiratory mortality-rates also. The time is ripe, I believe, to free the
tuberculosis
use of B.c.G. vaccine from restrictions and to allow those responsible for the prevention of tuberculosis to use it as they consider fit, in the best interests of the area for which- they are responsible. Considering the different immunological backgrounds of thepopulation of the various areas of Britain, I doubt very inirch if the results of an attempted controlled experiment in the use of this vaccine would be applicable to any area other than that in which the experiment was carried out.
County Public Health Department, Dingwall, Ross-shire.
J. LANDESS HORNE.
VARIATIONS IN RESPONSE TO RELAXANT DRUGS
SiR,-Dr. Dundee and Dr. Gray in their interesting article (Dec. 1) state that drugs acting by depolarisation block produce a normal effect in myasthenic patients. The work of Paton and Zaimisin animals has shown that those muscles which are hypersensitive to d-tubocurarine chloride are resistaht to decamethonium iodide. Consequently, it might be anticipated that the muscles of patients with myasthenia gravis, which are known to be sensitive to d-tubocurarine chloride, would in fact be tolerant to decamethonium iodide. Dr. Dundee and Dr. Gray gave 0-95 mg. decamethonium iodide in divided doses to one patient with myasthenia gravis and noted the effect on the volume of respiration. As there were no signs of sensitivity they concluded that the response df their " myasthenic patient to decamethonium iodide was within the limits of normality." Our findings,2 based on an investigation of eleven cases of myasthenia gravis, indicate that the peripheral musculature of these patients is resistant to the depolarising action of decamethonium iodide. H. C. CHURCHILL-DAVIDSON St. Thomas’s Hospital, A. T. RICHARDSON. London, S.E.1. LYSOGENICITY IN BACTERIOPHAGE STRAINS SiR,—May I point out a mistake in your annotation of Nov. 24? You state that Bertani’s3 work was accomplished by ultraviolet irradiation. Almost the reverse was true, since he was unable to induce lysis ,by this method. Animal Health Trust Livestock Research Station, Houghton, Ttmit,iTis’f)nTishiT’e-
H. WILLIAMS SMITH.
THE TIME OF DEATH
SiR,-At
an
inquest
held
on
Dec. 11
on a man
hanged
at Lincoln Gaol, the medical officer of the prison, when asked by the coroner if death was instantaneous, said : I wish to add one thing in explanation of something your predecessor remarked to me. He told me I should not say that a man’s death was instantaneous if his heart continued to beat. The man is to all intents and purposes dead the minute his neck is dislocated. He cannot breathe any more, and the loss of consciousness is instantaneous. But the heart does continue to beat for anything up to 20 minutes. It is a purely automatic function and does not mean that that man is alive. I think I should make that clear in view of the observation of your predecessor."4 I believe my father, the late Dr. Llewellyn A. Morgan, who was medical officer at the old Newgate Prison between the years 1882 and 1887, was the first to demonstrate the heart-beats following judicial hangings "
there. At that time Professor Dudgeon of St. Thomas’s Hospital an instrument to record the radial pulse, known as Dudgeon’s sphygmograph. This little instrument, actuated by a clockwork mechanism, recorded the pulse on a strip
invented
1. 2. 3. 4.
Paton, W. D. M., Zaimis, E. J. J. Physiol. 1951, 112, 311. J. Neurol. Neurosurg. Psychiat. (in the press). Bertani, G. J. Bact. 1951, 62, 293. Times, Dec. 12, 1951, p. 3.
of carbon paper, and my father used to dash into the pit immediately after the drop, attach the sphygmograph to the man’s wrist, and run off tracings. These tracings showed clearly that the heart stopped for a few seconds immediately after the drop, and then recovered, resuming an apparently normal beat for a period as long as 8 minutes, after which the beats became more and more feeble, finally fading out. The heart would no doubt beat a little longer than would be discernible at the pulse and maybe for as long as 20 minutes. My father’s tracings were reproduced in Buchanan’s Medical Jurisprudence and Toxicology, published, I think, in 1912.
An interesting medicolegal point arises from the coroner’s question and the prison medical officer’s reply. According to Glaister,5 " death may be defined as complete and persistent cessation of respiration and circulation " (italics mine). Consequently, in the case in question death did not take place until the heart ceased to beat, and the reply, on strictly legal grounds, to the coroner’s question would appear to be that while there was instantaneous oblivion, death (i.e., somatic death) took place some minutes after the process of execution. I am not disputing the appropriateness of the answer of the prison medical officer before a coroner’s jury, but the coroner’s question is pertinent. There are cases where respiration is arrested-for instance by paralysis of the respiratory centre-in which circulation is unaffected and artificial respiration will reproduce the of life though the patient is in fact appearance " somatically " dead ; or is he ? The point at issue is perhaps academic but may have a bearing on the validity of a death certificate signed before a person is legally dead. M. T. MORGAN. Guildhall, London, E.C.2.
QUICK TESTS articles on haemophilia that Dr. various SiB,—In has Merskey recently published, including one written jointly with Dr. Macfarlane and published in THE LANCET,6 he describes a procedure which he has designated Quick’s test for haemophilia. This method, which I published ten years ago,7 depends on the effect of differential
centrifugation on the clotting-time of recalcified plasma. Until recently the test served as a useful means for diagnosing haemophilia although it has limitations similar to those of the clotting-time. If my
name
is to be attached to
a
method for the
diagnosis of haemophilia I should prefer that it be to the prothrombin-consumption time,8 or to a modification of this test9 in which the prothrombin is determined in the serum obtained from blood to which heated rabbitbrain extract has been added. To avoid the absurdity of calling this Quick’s test for haemophilia no. 3, it has been tentatively designated " the thromboplastinogenactivity time." Irrespective of whether the name meets the approval of the coagulationists, the test appears to be the most promising means for detecting exceedingly mild cases of haemophilia. I have devoted much thought and effort to selecting a specific name for every test which I have devised. I did this to obviate its becoming a Quick test. Perhaps I have been over-conscientious. Within a short time, I " am sure, the capital " Q will change to a small " q." Since the prothrombin-time for normal blood is 12 seconds and the prothrombin-consumption time for haemophilic blood is 8-12 seconds, no-one-not even my severest critics-should find too much objection to having the name Quick attached to these tests, especially since will eventually lose its there is the hope that the " Q capital status. "
Marquette University School of Medicine, ARMAND J. QUICK. Milwaukee, Wisconsin, U.S.A. 5. Glaister, J. Medical Jurisprudence and Toxicology. Edinburgh. 1945.
6. 7. 8. 9.
Merskey, C., Macfarlane, R. G. Lancet, 1950, i, 487. Amer. J. med. Sci. 1941, 201, 469. Ibid, 1947, 214, 212. J. Lab. clin. Med. (in the press).
day-and incidentally high respiratory mortality-rates also. The time is ripe, I believe, to free the
tuberculosis
use of B.c.G. vaccine from restrictions and to allow those responsible for the prevention of tuberculosis to use it as they consider fit, in the best interests of the area for which- they are responsible. Considering the different immunological backgrounds of thepopulation of the various areas of Britain, I doubt very inirch if the results of an attempted controlled experiment in the use of this vaccine would be applicable to any area other than that in which the experiment was carried out.
County Public Health Department, Dingwall, Ross-shire.
J. LANDESS HORNE.
VARIATIONS IN RESPONSE TO RELAXANT DRUGS
SiR,-Dr. Dundee and Dr. Gray in their interesting article (Dec. 1) state that drugs acting by depolarisation block produce a normal effect in myasthenic patients. The work of Paton and Zaimisin animals has shown that those muscles which are hypersensitive to d-tubocurarine chloride are resistaht to decamethonium iodide. Consequently, it might be anticipated that the muscles of patients with myasthenia gravis, which are known to be sensitive to d-tubocurarine chloride, would in fact be tolerant to decamethonium iodide. Dr. Dundee and Dr. Gray gave 0-95 mg. decamethonium iodide in divided doses to one patient with myasthenia gravis and noted the effect on the volume of respiration. As there were no signs of sensitivity they concluded that the response df their " myasthenic patient to decamethonium iodide was within the limits of normality." Our findings,2 based on an investigation of eleven cases of myasthenia gravis, indicate that the peripheral musculature of these patients is resistant to the depolarising action of decamethonium iodide. H. C. CHURCHILL-DAVIDSON St. Thomas’s Hospital, A. T. RICHARDSON. London, S.E.1. LYSOGENICITY IN BACTERIOPHAGE STRAINS SiR,—May I point out a mistake in your annotation of Nov. 24? You state that Bertani’s3 work was accomplished by ultraviolet irradiation. Almost the reverse was true, since he was unable to induce lysis ,by this method. Animal Health Trust Livestock Research Station, Houghton, Ttmit,iTis’f)nTishiT’e-
H. WILLIAMS SMITH.
THE TIME OF DEATH
SiR,-At
an
inquest
held
on
Dec. 11
on a man
hanged
at Lincoln Gaol, the medical officer of the prison, when asked by the coroner if death was instantaneous, said : I wish to add one thing in explanation of something your predecessor remarked to me. He told me I should not say that a man’s death was instantaneous if his heart continued to beat. The man is to all intents and purposes dead the minute his neck is dislocated. He cannot breathe any more, and the loss of consciousness is instantaneous. But the heart does continue to beat for anything up to 20 minutes. It is a purely automatic function and does not mean that that man is alive. I think I should make that clear in view of the observation of your predecessor."4 I believe my father, the late Dr. Llewellyn A. Morgan, who was medical officer at the old Newgate Prison between the years 1882 and 1887, was the first to demonstrate the heart-beats following judicial hangings "
there. At that time Professor Dudgeon of St. Thomas’s Hospital an instrument to record the radial pulse, known as Dudgeon’s sphygmograph. This little instrument, actuated by a clockwork mechanism, recorded the pulse on a strip
invented
1. 2. 3. 4.
Paton, W. D. M., Zaimis, E. J. J. Physiol. 1951, 112, 311. J. Neurol. Neurosurg. Psychiat. (in the press). Bertani, G. J. Bact. 1951, 62, 293. Times, Dec. 12, 1951, p. 3.
of carbon paper, and my father used to dash into the pit immediately after the drop, attach the sphygmograph to the man’s wrist, and run off tracings. These tracings showed clearly that the heart stopped for a few seconds immediately after the drop, and then recovered, resuming an apparently normal beat for a period as long as 8 minutes, after which the beats became more and more feeble, finally fading out. The heart would no doubt beat a little longer than would be discernible at the pulse and maybe for as long as 20 minutes. My father’s tracings were reproduced in Buchanan’s Medical Jurisprudence and Toxicology, published, I think, in 1912.
An interesting medicolegal point arises from the coroner’s question and the prison medical officer’s reply. According to Glaister,5 " death may be defined as complete and persistent cessation of respiration and circulation " (italics mine). Consequently, in the case in question death did not take place until the heart ceased to beat, and the reply, on strictly legal grounds, to the coroner’s question would appear to be that while there was instantaneous oblivion, death (i.e., somatic death) took place some minutes after the process of execution. I am not disputing the appropriateness of the answer of the prison medical officer before a coroner’s jury, but the coroner’s question is pertinent. There are cases where respiration is arrested-for instance by paralysis of the respiratory centre-in which circulation is unaffected and artificial respiration will reproduce the of life though the patient is in fact appearance " somatically " dead ; or is he ? The point at issue is perhaps academic but may have a bearing on the validity of a death certificate signed before a person is legally dead. M. T. MORGAN. Guildhall, London, E.C.2.
QUICK TESTS articles on haemophilia that Dr. various SiB,—In has Merskey recently published, including one written jointly with Dr. Macfarlane and published in THE LANCET,6 he describes a procedure which he has designated Quick’s test for haemophilia. This method, which I published ten years ago,7 depends on the effect of differential
centrifugation on the clotting-time of recalcified plasma. Until recently the test served as a useful means for diagnosing haemophilia although it has limitations similar to those of the clotting-time. If my
name
is to be attached to
a
method for the
diagnosis of haemophilia I should prefer that it be to the prothrombin-consumption time,8 or to a modification of this test9 in which the prothrombin is determined in the serum obtained from blood to which heated rabbitbrain extract has been added. To avoid the absurdity of calling this Quick’s test for haemophilia no. 3, it has been tentatively designated " the thromboplastinogenactivity time." Irrespective of whether the name meets the approval of the coagulationists, the test appears to be the most promising means for detecting exceedingly mild cases of haemophilia. I have devoted much thought and effort to selecting a specific name for every test which I have devised. I did this to obviate its becoming a Quick test. Perhaps I have been over-conscientious. Within a short time, I " am sure, the capital " Q will change to a small " q." Since the prothrombin-time for normal blood is 12 seconds and the prothrombin-consumption time for haemophilic blood is 8-12 seconds, no-one-not even my severest critics-should find too much objection to having the name Quick attached to these tests, especially since will eventually lose its there is the hope that the " Q capital status. "
Marquette University School of Medicine, ARMAND J. QUICK. Milwaukee, Wisconsin, U.S.A. 5. Glaister, J. Medical Jurisprudence and Toxicology. Edinburgh. 1945.
6. 7. 8. 9.
Merskey, C., Macfarlane, R. G. Lancet, 1950, i, 487. Amer. J. med. Sci. 1941, 201, 469. Ibid, 1947, 214, 212. J. Lab. clin. Med. (in the press).