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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.