103

maximal level of parotid-secretion calcium was not equalon the two sides of the body. We must reluctantly con-clude that plasma ultrafilterable calcium cannot be

correlated with either c.s.F. or parotid-gland-secretioncalcium.

G. ALAN ROSE.University College Hospital Medical School,London, W.C.1.

PROSTATECTOMY

SIR,-I studied with great interest the excellent articleby Mr. Ellis and Dr. Leatherdale (Dec. 6) on an

anesthetic technique for prostatectomy, especially in thepoor-risk patient.

In Bristol, urologists perform a cystoscopic examinationbefore deciding whether to continue with a transurethralresection or a retropubic prostatectomy. I do not know

how common this routine is in other areas, but where it isthe rule the technique of low-spinal and abdominal-fieldblock does not offer the most desirable conditions foreither the patient or the surgeon.

If it is decided to continue with a transurethral resec-

tion, the low-spinal block does not adequately cover all theoperative stimuli and the field block is, of course,

unnecessary. The answer seems to lie in a choice between

spinal, epidural, or caudal analgesia.With spinal analgesia, there will always remain a low

irreducible minimum of chance neurological sequelx, naturallydiminished by experience and skill. But chance is still a factorof a talking if not of a walking advertisement which speaksagainst the technique.

Successful caudal analgesia gives safe and excellent operatingconditions, but anatomical difficulties may prevent its use, and,of course, there is no certain test of having entered the caudalcanal as there is with spinal or epidural analgesia.Purposely induced hypotension is not only unsafe but

unnecessary in these poor-risk cases. The surgeon requires anarea of operation which is completely relaxed, whether for theresectoscope or the bladder and abdominal-wall retractors,and in which the vessels do not bleed too much. These con-ditions are seldom achieved by the general-anaesthesia-with-relaxant technique. If controlled ventilation is performed agreater strain may be thrown on the heart and circulation,diminishing cardiac output by interference with the normalvenous return, and increasing oozing from the vessels of theprostatic cavity. Assisted respiration is even worse: here themuscles themselves and the type of respiration make exposureextremely difficult.Epidural block aims to paralyse the parasympathetic sacral

outflow with minimal sympathetic block and thus avoid toogreat a fall in blood-pressure and yet obtain good constrictionof the prostatic bed. Sympathetic tone in the worst-risk casesof elderly patients with cerebral and coronary atheroma maybe present.To limit the sympathetic block to safe levels, one must assess

very carefully how high to extend the sensory block. Anyslight discrepancy of anxsthesia may be overcome with lightgeneral narcosis, and this usually concerns only the skinincision.These poor-risk and often elderly hypertensive patients

receive 15-20 ml. of 1.2%, xylocaine, with 1 in 200,000adrenaline, in the space between the 3rd and 4th lumbarvertebrae. The table is held horizontal as long as the blood-pressure does not fall too much. Spread towards the dorsalregion will follow if the table is tilted head down, at the expenseof the sacral area. Such a dose gives little more than an hour’sanaesthesia in many cases and extends 4-5 segments on eitherside of the injection. Bleeding is diminished if only becauseof a diminution in venous return due to loss of skeletal tonefrom the complete sensory block. The total dose of xylocaineis less than with the technique of spinal and abdominal fieldblock described. Light general narcosis by means of an endo-

tracheal tube prevents CO2 build-up, yet increases the tidalvolume and obviates stagnant anoxia.

It is generally agreed that a wide-bore tube in the tracheahelps to reduce oozing from cut tissues.

Even mild degrees of respiratory obstruction with a loweredblood-pressure can produce medullary failure and cardiacischaemia.

Wound haematoma and infection can be avoided if the blood-

pressure is allowed to return to normal gradually, whichit usually does as soon as the light general anaesthesia isremoved.

Regarding reactionary hoemorrhage, close cooperationbetween surgeon and anxsthetist is essential. The surgeonmust attend to every vessel that bleeds. Those that are more

readily seen are ligated; others seal themselves with gentletechnique and minimal swabbing.

Clot retention with this technique is far less common thanwith general anxsthesia, because there is less bleeding at

operation and after. Here the question of the head-downposition is of interest. Unless the prophylactic treatment ofspinal headache has changed recently, a head-down tilt isadvised for from 12 to 24 hours after operation under spinalanalgesia. But after prostatectomy a head-down position shouldbe maintained for only as long as the blood-pressure takesto return to a satisfactory level; otherwise clot retention maybe encouraged from a collection of blood in some relativelyinsensitive area of the bladder wall, such as the posterior wall,which may become firmly organised and cause obstruction tothe passage of urine. There will then be increasing distensionwith urine and clot, followed by bladder spasm and severe pain,with shock out of all proportion to the amount of blood-loss.The foreign body in the bladder then does nothing to preventfurther bleeding but actually interferes with the normalmechanism for arresting hxmorrhage, and it becomes essentialto remove the clot.

May I end this letter by expressing my admirationfor the clear account of their technique which is, Iam certain, desirable and effective in their patients.I definitely jib at performing it upon fat and excitable

subjects, though I have seen my colleague, Dr. T. R.Steen, perform it on a number of occasions, supplementinga caudal for the spinal block, the whole simplified bygreat dexterity applied to a suitably premedicated oftenanxsthetised patient.

Southmead Hospital, W M MAIDLOW.Bristol. W. M. MAIDLOW.

SIR,-In reply to Dr. Rollason’s letter of Jan. 3, maywe point out that he has inadvertently misquoted ourfigures ? Our analysis was of 340 prostatectomies, not240 as he states : the overall mortality was therefore

10-9% and not 15-4%.In assessing results of different anaesthetic techniques

for prostatectomy the point we wished to make was thatcomparable series of cases should be studied. As Dr.

Ainley-Walker said in his letter of Dec. 20, our series didnot completely fulfil this criterion, and for that reason noattempt was made to draw conclusions of any statistical

significance. This point we believe to be particularlyimportant in respect of the preoperative condition of thepatients. In the only series 1 quoted by Dr. Rollasonwhere an analysis comparable to ours was carried out,patients were divided into three groups-good, fair, andpoor. The mortality of these groups was respectively3-7%, 16-2%, and 40%. In addition the overall uncor-rected mortality (27) of Gardner’s 258 cases was 10-5%compared to our 10-9%.The main purpose of our paper was to describe an

anaesthetic technique which we have found useful, which

W. M. MAIDLOW.Southmead Hospital,

Bristol.

1. Gardner, E. K. Anœsthesia, 1958, 13, 406.

104

seems to be inadequately represented in the literature,and which has increased the operability-rate in the poor-risk patient. H. ELLIS

Oxford. R. A. L. LEATHERDALE.H. ELLISR. A. L. LEATHERDALE.

1. Brockbank, W., Pengelly, C. D. R. Lancet, 1958, i, 187.2. Herxheimer, H., McAllen, M. ibid. 1956, i, 537.3. Lake, C. F., Logan, G. B., Peters, G. A. (1957) Proc. Mayo Clin. 1957,

32, 641.4. Morris-Owen, R. M., Truelove, S. C. Brit. med. J. 1958, i, 969.5. Hajos, M. Allerg. Asthma, 1956, 2, 363.6. Porter, K. A., Murray, J. E. J. nat. Canc. Inst., Wash., 1958, 20, 189.7. Lindsley, D. L., Odell, T. T., Tausche, F. G. Proc. Soc. exp. Biol.,

N.Y. 1955, 90, 512.8. Ford, C. E., Hamerton, J. L., Barnes, D. W. H., Loutit, J. F. Nature,

Lond., 1956, 177, 452.9. Nowell, P. C., Cole, L. J., Habermeyer, J. G., Roan, P. O. Cancer Res.,

1956, 16, 258.10. Parkes, A. S. Trans. Bull., 1958, 5, 45.11. Billingham, R. E., Sparrow, E. M. J. Embryol. exp. Morph., 1955, 3, 265.12. Billingham, R. E., Brent, L., Medawar, P. B. Trans. Bull., 1956, 3, 84.* Now supported by a grant from the Medical Research Council.

HYDROCORTISONE INHALATION IN ASTHMA

H. HERXHEIMER.

SIR,-Dr. Morrison Smith (Dec. 13) reported nega-tive results in a trial of hydrocortisone inhalation inasthmatic children. He rightly points out that such trialsshould give reliable results both statistically and clinically.I find his statistical method admirable, but even the mostexcellent statistical methods will not be satisfactory if thedose of the drug used is too small to have an effect on thedisorder under investigation. Dr. Smith has given only5 mg. per day of the hemisuccinate, whilst Brockbankand Pengelly and we,2 whom he quotes, have used15 mg. per day of the acetate. Our success with this dosehas been confirmed from various other quarters,3-5 andI suspect that Dr. Smith’s failure is due to this low dosagewhich may have been decreased further by the use of anunsuitable inhaler. The droplet size delivered by theinhaler (which Dr. Smith does not specify) is of the

greatest importance for the penetration of the aerosolinto the finer bronchi. Many commercial nebulisersdeliver their output in large droplets which are depositedin the pharynx or trachea and never reach the finer airpassages. In such a case the effective daily dosage ofhydrocortisone would have been still lower than 5 mg.

London, N.3. H. HERXHEIMER.

PENETRATING THE HOMOGRAFT BARRIER

H. E. M. KAYM. CONSTANDOULAKIS.

Royal Marsden Hospital,London, S.W.3.

SiR,ŇYour leading article last week is timely but insome particulars rather maladroit.

It is, for example, curiously selective to quote only theexperiments of Porter and Murray 6 to support the theoryof bone-marrow recolonisation, when the work of Linds-ley et al. 7, of Ford et al. 8, and of Nowell et al.9, usingrespectively red-cell antigens, chromosome markers, andthe leucocyte phosphatase reaction, were all publishedpreviously and are perhaps to be preferred as evidence.

Secondly, it is quite untrue to say that all mice withsurviving mouse-marrow implants die within fourmonths. Such a state of affairs would indeed discourageall therapeutic efforts.No mention is made of the possibility of homograft

" enhancement ". The use of prior injections of lyo-philised tissue to enhance the survival of normal cellshas been demonstrated by Parkes,10 using the rat ovary, andthere are suggestions of a similar effect with skin grafts.ll 12

Finally, you refer to the " prospect of providing a

store ... of frozen embryonic tissues for treating irradia-tion casualties ". Such a store* has been in existence atthis hospital for over a year, during which time haemo-poietic tissues have been supplied to six London hospi-tals and to centres as far apart as Portsmouth and Edin-

burgh. Most of the cases so treated have suffered from fidiopathic aplastic anaemia, but unfortunately, and in tcommon with the experience of Tocantins, no permanent

Ibenefit, such as was claimed by Dameshek in four out oftwelve cases, has been obtained.13 An incidental advan-

tage of a centre of this sort, which receives well over ahundred foetuses a year, is that workers in many differentfields of research have access to a reasonably steady supply tof foetal tissues.

Royal Marsden Hospital, H. E. M. KAY rLondon, S.W.3. M. CONSTANDOULAKIS.

*** We are obliged to Dr. Kay and Dr. Constandoulakisfor enabling us to record this application at the Roya1 -Marsden Hospital of the principles that were discussed inour leader.-ED. L.

13. Blood, 1958, 13, 1096.

ObituaryHUGH CRICHTON-MILLER

M.A., M.D. Edin., M.D. Pavia, F.R.C.P.

Dr. H. Crichton-Miller, the founder of the Tavistock Clinic, died at Harrow-on-the-Hill on Jan. 1 at the age of 81. He was a pioneer of his specialty in this country, and those who have come after him are still im- pressed by his early understanding of the importance of!preventive psychological medicine.

Born at Genoa, where his father,the Rev. Donald Miller, D.D., was Presbyterian chaplain, he was educated at Fettes College, Edin- burgh, and at Edinburgh and Pavia Universities. He qualifiedin 1898. After holding house- "

appointments at Edinburgh Royal Infirmary he spent ten years in

general practice, in summer at

Aviemore and in winter at SanRemo. He then decided to

specialise in psychotherapy and

opened Bowden House, Harrow- ’on-the-Hill, as a nursing-home for =functional nervous disorders. This ;new approach to the treatment of ’,

neurosis claimed his interest till shortly before his death. In the 1914-18 war he was in charge of functional nervous

cases at the 21st General Hospital in Egypt, with the rank oflieut.-colonel, and he was also consulting neurologist to the4th London General Hospital. The attention paid to shell-shock during the war created a demand for the treatment of -,

psychoneurosis and similar disabilities. To meet this need hefounded and became the honorary director of the TavistockClinic. He was vice-president and a member of the executive com-

mittee of the National Association for Mental Health and also ! a member of the International Committee for Mental Hygiene. He became chairman of the medical section of the British Psychological Society and later president of the psychiatricsection of the Royal Society of Medicine and president of theInternational Society for Psychotherapy. In 1938 he was

Charles Hastings lecturer of the British Medical Association.Between 1939 and 1941 he was in charge of the E.M.S.Psychiatric Hospital at Stanborough, Watford. Beyond theage to return to the Army himself, lie encouraged the membersof the staff at the Tavistock Clinic to join one or other Service, ,and many of them did so. One of the two consultants inpsychiatry to the Army, and five out of six of the commandspecialists in psychological medicine, were drawn from the

Istaff of the clinic.As a writer he had an easy style with special skill in expound.

ing the complexities of psychology for the educated public,