1355

An important disadvantage of metformin 2 is the latent

period before the drug exerts its hypoglycxmic action. This

delay may extend to 14 days. Phenformin, on the other hand,has an immediate effect, and in our view the disadvantage ofusing a small initial dose with gradual increments is therebycompensated.While the drugs differ in details, we find both useful and

cannot agree with your correspondents’ frank preference. Acomparative review of our experience with diguanides is to bepublished.

R. HANNAHR. S. WALKER.Law Hospital, Carluke,

Lanarkshire.

2. Rambert, P., Canivet, J., Quichaud, J., Spitz, B. Sem. Hôp. Paris,1961, 37, 247.

3. Richard, D. R. Brit. med. J. May 13, 1961, p. 1382.4. Lancet, 1960, ii, 1333.

ANÆSTHESIA IN DOMICILIARY OBSTETRICS

BRYAN WILLIAMS.

SiR,ňThe article of May 6 by Dr. Argent and Dr.Evans, though written from the viewpoint of the anaes-thetic specialist, will be read with interest by all who

practise domiciliary obstetrics. It might, however, havebeen of even greater interest if they had given some moredetails, such as the number of cases treated, the results tothe mother and to the baby, where applicable, how themanoeuvres were carried out on the usual domestic bed,and the size of van required to carry the equipment.

It seems that in this country operative obstetrics in the homeis largely becoming a thing of the past, except for the work offlying squads, though I think this tendency is likely to bereversed to some extent as the disadvantages of hospitaldelivery under present conditions becomes obvious to all.I cannot believe that these complicated methods are eitherpracticable or desirable in the home, or indeed as safe as openether, and it was interesting to note that in a recent televisionprogramme the Bristol Flying Squad appeared to use theopen-drop method.It is sometimes grudgingly admitted that open ether is

relatively safe for the inexperienced, but, if so, it should be bothsafe and satisfactory in the hands of the experienced. The nowdreaded complication of regurgitation and inhalation of vomit is,I believe, largely the outcome of what might be termedmachinery anaesthesia, and is almost unknown with thederided " rag-and-bottle

"

technique. I hope to be able topublish my evidence for this belief before long. It is hardly acredit to the present teaching of anxsthesia in this countrythat graduates are being turned out who may be faced with allsorts of cases, obstetric and otherwise, in all parts of the world,and be unable to give an anxsthetic with equipment which canbe carried by hand, or even in a baby car.Those who think that rag-and-bottle methods are of

historical interest might profit from a fascinating article 3 onorthopaedics in Northern Nigeria, which describes theadministration of anaesthetics by Nigerian nurses, " who weremost efficient both with rag and bottle and with thiopentoneMiddlesbrough. BRYAN WILLIAMS.

CARDIAC ARREST AND RESUSCITATION

PETER NIXON.The General Infirmary,

Leeds.

SIR,-The heart may stop beating from heart-block,ventricular fibrillation, or asystolic arrest,4 and deathfollows from cerebral ischaemia. Experience in cardiologyand cardiac surgery has shown that these disorders offunction may result from trivial incidents and procedureswhen the heart is little damaged and still capable of longlife.

Knowledge of the reversible nature of cardiac arrest hadrelatively little practical importance outside the operating-theatre so long as the chest had to be opened for effectivemassage and treatment. I have opened the chest on nine occa-sions and restored heart-beat and blood-pressure; but onlyonce was I present soon enough for the patient to survive.

Now the Johns Hopkins method of external cardiac massagewill provide sufficient circulation for survival as long as oneyour. 56 In other words it is possible for effective first-aidtreatment to support life until definitive treatment can be givento the arrested heart.

The management of a patient with cardiac arrest falls

naturally into the following phases:Phase i. Lower the head.

Raise the legs.Thump the precordium.

Phase 11. Closed chest external cardiac massage.Mouth-to-mouth or mouth-to-nose insufflation.

Phase ill. Tracheal intubation and artificial respiration with

oxygen from an anxsthetic rubber bag.Phase iv. Recording the electrocardiogram to determine the

nature of the arrest.

Phase v. Applying definitive treatment-the open or closedchest defibrillator or pacemaker, or open massage.

It seems that asystolic arrest is by far the commonest causeof cessation of ventricular action; and it is readily treated bymechanical stimulation of the heart.

It might be an advantage if hospitals trained nurses, tech-nicians, and porters in the first-aid treatment of cardiac arrest,and provided a readily available trolley bearing:A board to place under the back to give firm support for external

massage.Laryngoscope, endotracheal tubes, oxygen cylinder, anaesthetic

rubber bag.Knife, gloves, rib-retractors.Electrocardiograph monitor.External and internal defibrillator and pacemaker.

5. Kouwenhoven, W. B., Jude, J. R., Knickerbocker, G. G. J. Amer. med.Ass. 1960, 173, 1064.

6. Sabiston, D. C. Personal communication.

JOURNAL OF MENTAL SCIENCE

Prof. G. M. CARSTAIRS writes:" The department of psychological medicine of Edinburgh

University has recently received a generous gift from Mrs. Ken-nedy in the form of back numbers of the Journal of MentalScience, 1936-54, which had been in the possession of the lateProf. Alexander Kennedy. Unfortunately, 2 numbers are miss-ing, and I am wondering if any of your readers have copieswhich they would consider giving to the department, so that thevolumes may be completed and bound. The numbers are

January, 1942, and January, 1944. The address of the depart-ment is 2, George Square, Edinburgh, 8."

Public Health

Immunisation against PoliomyelitisPARENTS who have not yet had their children vaccinated

against poliomyelitis have been urged to do so now by theMinister of Health, in a message issued this week. Everyone upto the age of 40 who has not been immunised can obtain injectionsbefore the period of greatest danger comes round again. It is

important, says the Minister, for everyone to take the secondand third injections, and for children over the age of 5 and upto 12 to take the fourth injections now being offered to reinforcethe protection. Up to the end of March the acceptance-ratefor vaccination in England and Wales was 77% for childrenup to the age of 18, and 55% for young people aged 18-28.

Dr. George Godber, chief medical officer of the Ministry,in a letter to medical officers of health, remarks that enoughchildren may remain unprotected for the incidence of polio-myelitis to increase if the virus becomes more widelydistributed in the community. The number of cases so far thisyear is well above the low figure recorded at the same timelast year.