1
773 the principle that is deficient in one type of congenital hypoprothrombinaæmia which I recently described.3 The term " component B " remains reserved for the factor which’is diminished in dicoumarol poisoning and in the first type of congenital hypoprothrombinscmia which I reported. 4 Terms such as " accelerator " were inten- tionally avoided to prevent confusion with thrombo- plastin. The concentration of the labile factor varies greatly in different species ; it is abundant in dog blood and low in human blood. It appears likely that it was this factor that was lacking in the patient of Rhoads and Fitz-Hugh,5 the first reported case of idiopathic hypo- prothrombinæmia, and also in Owren’s6 case (although it is for Dr. Owren to make the final decision). The one-stage method, by estimating the composite prothrombin activity of blood, has become increasingly valuable clinically and has in addition yielded much scientific information. The two-stage method is now employed relatively seldom for clinical purposes because it is rather complicated technically and because it yields perplexing results in certain conditions-as for example in early infancy.? Dr. Seegers’s expression " the more reliable two-stage method for measuring pro- thrombin activity" must be considered as relative. In his type of investigation with the use of purified reagents it has yielded valuable results, and every worker in the field is appreciative of Dr. Seegers’s contri- butions. Unfortunately the problem of haemostatic dysfunction cannot yet be bodily transferred to the test-tube. Much information must still be sought by a direct study of blood, and for this purpose the one- stage method has proved its value by the test of time. At present both approaches are still necessary, and the two types of effort should complement each other rather than antagonise. Ultimately it will likely be found that much of the present confusion is one of terminology rather than of basic facts. Marquette University School of Medi- cine, Milwaukee, Wisconsin. ARMAND J. QUICK. THE BARBITURATES SIR,—Your leading article of Oct. 18 was most timely, and will cause many to reflect. In vour issue of the following week Dr. G. Thurston wrote protesting that ’’ it would be impossible for a busy doctor to see, say, every week all his patients who took phenobarbitone." May I suggest a simpler mode of caution ? State upon the prescription that the supplies are to be issued weekly to the patient. S. P. VENABLES. "JUGGED HAIR" SIR,—On the cover of the July 27, 1946, British Medical Journal appeared in large print "Vinesthene Anæsthesia for Repair of Hair-lip and Cleft Palate." I expected to see some apology for this mis-spelling or at least a letter from some wag cleverly pulling the leg of the editor who had allowed it to pass him. Either it went unnoticed or I overlooked reference to it in subsequent issues of the journal. In the Oct. 18 Lancet, p. 588, in an annotation I read : "... since the feeding of a child with a double hair-lip is at best tedious, ..." In the three issues since that, date I have seen no correction of this mis-spelling. It is perhaps to be expected that a surgeon who receives a great many letters about this condition from parents and general practitioners should have come across this mistake frequently, but it seems odd that the editors of our two leading medical journals should have allowed it to pass. For twenty years or more I have refused to use the term at all ; and I and those who have worked with me have adopted the terminology " cleft, lip " first suggested, I believe, by Ritchie, of St. Paul, Minnesota-more descriptive, less inapt and less likely to lead to incorrect spelling. Nuffield Department of Plastic Surgery, Churchill Hospital, Oxford. T. POMFRET KILNER. 4. Quick, A. J. Amer. J. lab. clin. Med. 1946, 31, 79. 5. Rhoads, J. E., Fitz-Hugh, T. jun. Amer. J. med. Sci. 1941, 202, 662. 6. Owren, P. A. Lancet, 1947, i, 446. 7. Brinkhous, K. M., Smith, H. P., Warner, E. D. Amer. J. med. Sci. 1937, 193. 475. TEACHING APPOINTMENTS SIR,—In your leading article (Oct. 25) dealing with Dr. Clark-Kennedy’s new textbook you state : *’He has concluded that medicine is in serious danger from the dominance of specialism. Increasingly narrow specia- lists are not the best people to control the teaching of the undergraduate student." The importance of this is not generally realised, and few seem to appreciate what is happening in most of the teaching schools. Several recently appointed pro- fessors of medicine are primarily not clinicians but physiologists or workers in some other branch of research ; and this tendency has spread to recent appointments of readers and senior lecturers. Knowledge of general medicine, clinical experience; ability to lecture, enthusiasm and flare for teaching- these apparently are of little consequence. Research- workers are dominating the teaching schools and obtain- ing most of the full-time teaching appointments; and research-workers are often bad clinicians and poor teachers. From personal experience and the opinions of interested friends, I know that the teaching of medicine to undergraduates in many schools is of poor quality ; and the much-boosted and advertised postgraduate teaching is often worse. M.R.C.P. RUPTURE OF THE SPLEEN SIR,—I should like to call attention to the leucocytosis with relative and absolute decrease of lymphocytes in the case reported by Dr. Druitt (Nov. 1). This con- dition of the blood is found with traumatic rupture of spleen, according to Bieri,l and it is therefore a useful sign in establishing the diagnosis. Institute for Morbid Anatomy, University of Bratislava, Czechoslovakia. F. KLEIN. EFFECT OF BENADRYL ON GASTRIC ACIDITY SIR,—Mr. Doran’s letter of Sept. 27 is an important contribution in that it demonstrates that anti-histamine drugs are probably bad treatment for hyperacidity, and in that it helps to uncover a very significant physio- logical fact. The conclusion however that his results " throw some doubt on the hypothesis that the ultimate stimulus to the parietal cells is normally histamine may be challenged. The position is briefly this. Histamine is widely regarded as the physiological stimulus for acid gastric secretion. Certain drugs have been proved to exert an anti-histamine action, and from quantitative studies it is concluded that this action is in the nature of substrate competition. It was thus natural to attempt to reduce gastric acidity by the administration of these drugs, but these attempts have not only failed but often actually resulted in increased acid gastric secretion. From this paradoxical result Doran concludes that histamine may after all not be the physiological stimulus of acid gastric secretion. This conclusion overlooks the fact that if histamine were unconcerned with acid gastric secretion the admini- stration of anti-histamine drugs should make no difference either way. Doran’s line of thought, followed to its logical end, would lead to the conclusion that histamine is actually an inhibitor of acid secretion-a view which seems untenable in the present state of our knowledge. Assuming that the histamine theory of acid gastric secretion is correct, we must conclude from the above experiments that the administration of anti-histamine drugs led in these cases to an increased supply of hista- mine to the gastric mucosa. Now, if we accept the idea that these drugs act by substrate competition, then their administration must, ceteris paribus, lead to an increase of circulating histamine by an equivalent amount, as the drug interferes with the fixation of histamine to the H-sensitive cells. This excess could, however, have no influence on the acid gastric secretion unless the mechanism by which histamine affects the parietal cells of the gastric mucosa is different from that by which it produces its effects in other tissues, and such that it is either less or not at all interfered with by the anti-histamine drugs. 1. Bieri, J. Schweiz. med. Wschr. 1946, p. 1053.

TEACHING APPOINTMENTS

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Page 1: TEACHING APPOINTMENTS

773

the principle that is deficient in one type of congenitalhypoprothrombinaæmia which I recently described.3 Theterm " component B " remains reserved for the factorwhich’is diminished in dicoumarol poisoning and in thefirst type of congenital hypoprothrombinscmia whichI reported. 4 Terms such as " accelerator " were inten-tionally avoided to prevent confusion with thrombo-plastin. The concentration of the labile factor variesgreatly in different species ; it is abundant in dog bloodand low in human blood. It appears likely that it wasthis factor that was lacking in the patient of Rhoadsand Fitz-Hugh,5 the first reported case of idiopathic hypo-prothrombinæmia, and also in Owren’s6 case (althoughit is for Dr. Owren to make the final decision).The one-stage method, by estimating the composite

prothrombin activity of blood, has become increasinglyvaluable clinically and has in addition yielded muchscientific information. The two-stage method is nowemployed relatively seldom for clinical purposes becauseit is rather complicated technically and because ityields perplexing results in certain conditions-as forexample in early infancy.? Dr. Seegers’s expression " themore reliable two-stage method for measuring pro-thrombin activity" must be considered as relative.In his type of investigation with the use of purifiedreagents it has yielded valuable results, and everyworker in the field is appreciative of Dr. Seegers’s contri-butions. Unfortunately the problem of haemostaticdysfunction cannot yet be bodily transferred to thetest-tube. Much information must still be sought bya direct study of blood, and for this purpose the one-stage method has proved its value by the test of time.At present both approaches are still necessary, and the

two types of effort should complement each otherrather than antagonise. Ultimately it will likely be foundthat much of the present confusion is one of terminologyrather than of basic facts.

Marquette University School of Medi-cine, Milwaukee, Wisconsin.

ARMAND J. QUICK.

THE BARBITURATES

SIR,—Your leading article of Oct. 18 was most timely,and will cause many to reflect. In vour issue of thefollowing week Dr. G. Thurston wrote protesting that’’ it would be impossible for a busy doctor to see, say,every week all his patients who took phenobarbitone."May I suggest a simpler mode of caution ? State upon theprescription that the supplies are to be issued weeklyto the patient.

S. P. VENABLES.

"JUGGED HAIR"

SIR,—On the cover of the July 27, 1946, BritishMedical Journal appeared in large print "VinestheneAnæsthesia for Repair of Hair-lip and Cleft Palate."I expected to see some apology for this mis-spelling orat least a letter from some wag cleverly pulling the legof the editor who had allowed it to pass him. Eitherit went unnoticed or I overlooked reference to it insubsequent issues of the journal.In the Oct. 18 Lancet, p. 588, in an annotation I

read : "... since the feeding of a child with a doublehair-lip is at best tedious, ..." In the three issues sincethat, date I have seen no correction of this mis-spelling.

It is perhaps to be expected that a surgeon whoreceives a great many letters about this condition fromparents and general practitioners should have comeacross this mistake frequently, but it seems odd that theeditors of our two leading medical journals should haveallowed it to pass. For twenty years or more I haverefused to use the term at all ; and I and those whohave worked with me have adopted the terminology" cleft, lip " first suggested, I believe, by Ritchie, ofSt. Paul, Minnesota-more descriptive, less inapt andless likely to lead to incorrect spelling.

Nuffield Department of PlasticSurgery, Churchill Hospital, Oxford.

T. POMFRET KILNER.

4. Quick, A. J. Amer. J. lab. clin. Med. 1946, 31, 79.5. Rhoads, J. E., Fitz-Hugh, T. jun. Amer. J. med. Sci. 1941,

202, 662.6. Owren, P. A. Lancet, 1947, i, 446.7. Brinkhous, K. M., Smith, H. P., Warner, E. D. Amer. J. med.

Sci. 1937, 193. 475.

TEACHING APPOINTMENTS

SIR,—In your leading article (Oct. 25) dealing withDr. Clark-Kennedy’s new textbook you state : *’Hehas concluded that medicine is in serious danger from thedominance of specialism. Increasingly narrow specia-lists are not the best people to control the teaching ofthe undergraduate student."The importance of this is not generally realised, and

few seem to appreciate what is happening in most ofthe teaching schools. Several recently appointed pro-fessors of medicine are primarily not clinicians butphysiologists or workers in some other branch of research ;and this tendency has spread to recent appointmentsof readers and senior lecturers.Knowledge of general medicine, clinical experience;

ability to lecture, enthusiasm and flare for teaching-these apparently are of little consequence. Research-workers are dominating the teaching schools and obtain-ing most of the full-time teaching appointments; andresearch-workers are often bad clinicians and poorteachers. From personal experience and the opinionsof interested friends, I know that the teaching of medicineto undergraduates in many schools is of poor quality ;and the much-boosted and advertised postgraduateteaching is often worse. M.R.C.P.

RUPTURE OF THE SPLEEN

SIR,—I should like to call attention to the leucocytosiswith relative and absolute decrease of lymphocytesin the case reported by Dr. Druitt (Nov. 1). This con-dition of the blood is found with traumatic ruptureof spleen, according to Bieri,l and it is therefore a usefulsign in establishing the diagnosis.

Institute for Morbid Anatomy, Universityof Bratislava, Czechoslovakia.

F. KLEIN.

EFFECT OF BENADRYL ON GASTRIC ACIDITY

SIR,—Mr. Doran’s letter of Sept. 27 is an importantcontribution in that it demonstrates that anti-histaminedrugs are probably bad treatment for hyperacidity,and in that it helps to uncover a very significant physio-logical fact. The conclusion however that his results" throw some doubt on the hypothesis that the ultimatestimulus to the parietal cells is normally histaminemay be challenged.The position is briefly this. Histamine is widely

regarded as the physiological stimulus for acid gastricsecretion. Certain drugs have been proved to exert ananti-histamine action, and from quantitative studies itis concluded that this action is in the nature of substratecompetition. It was thus natural to attempt to reducegastric acidity by the administration of these drugs, butthese attempts have not only failed but often actuallyresulted in increased acid gastric secretion. From thisparadoxical result Doran concludes that histamine mayafter all not be the physiological stimulus of acid gastricsecretion.

This conclusion overlooks the fact that if histaminewere unconcerned with acid gastric secretion the admini-stration of anti-histamine drugs should make no differenceeither way. Doran’s line of thought, followed to its logicalend, would lead to the conclusion that histamine is

actually an inhibitor of acid secretion-a view whichseems untenable in the present state of our knowledge.Assuming that the histamine theory of acid gastric

secretion is correct, we must conclude from the aboveexperiments that the administration of anti-histaminedrugs led in these cases to an increased supply of hista-mine to the gastric mucosa. Now, if we accept the ideathat these drugs act by substrate competition, thentheir administration must, ceteris paribus, lead to anincrease of circulating histamine by an equivalent amount,as the drug interferes with the fixation of histamine tothe H-sensitive cells. This excess could, however, haveno influence on the acid gastric secretion unless themechanism by which histamine affects the parietal cellsof the gastric mucosa is different from that by which itproduces its effects in other tissues, and such thatit is either less or not at all interfered with by theanti-histamine drugs.

1. Bieri, J. Schweiz. med. Wschr. 1946, p. 1053.