will we never learn ?

642

decreased considerably ; interscapular brown fat was reducedin amount and had taken the appearance of white adiposetissue.

From our results it appears that cortisone increases

the fat content of liver, probably through an increaseof fat mobilisation. Fatty liver produced by A.C.T.H.may be regarded as a consequence of adrenal stimulation.

Anatomo-Pathological Institute,University of Milan, and Farmitalia

Research Laboratories.

G. SALAA. AMIRAM. BOKASIC. CAVALLERO.

METHONIUM COMPOUNDS IN HYPERTENSION

Sm,-In their letter last week, Dr. Hirson and Dr.Kelsall describe a fatality due to excessive low blood-pressure after administration of hexamethonium. Anattempt was made to raise the blood-pressure by anintravenous drip containing adrenaline ; and the reportnotes that the " pressure always dropped precipitatelyduring the brief periods when the drip was discontinued."

It does not appear to be generally known that thisresult is to be expected, since it has been shown thatadrenaline itself has a blocking action on sympatheticganglia. If an intravenous infusion of adrenaline is

given, the adrenaline by direct action on the vesselwalls causes vasoconstriction ; but, by its action onsympathetic ganglia, it prevents the stream of impulsesemitted by the vasomotor centres from reaching thevessels. When the adrenaline infusion is stopped, thedirect action on the vessels disappears ; and, becausetonic impulses from the centre cannot pass the ganglia,the blood-pressure falls precipitately. In this respectnoradrenaline has the same action as adrenaline.

Fortunately, however, posterior-lobe extract of the

pituitary gland has no such effect ; and, so far as animalexperiments afford a guide, the right treatment of a

patient in whom the blood-pressure has fallen lowbecause of the action of hexamethonium would seem tobe to give an intravenous drip containing 10 units

pituitary (posterior-lobe) extract in each 50 ml. saline.We have some evidence, which is too little to be con-clusive, that posterior-lobe extract may increase

ganglionic transmission, and therefore it may prove tobe a positive antidote to ganglionic block. Howeverthis may be, the interruption of a drip containingposterior-lobe extract would certainly not be followedby the precipitate fall of blood-pressure which occursat the end of an adrenaline drip.

In using an intravenous drip containing posterior-lobe extract, the effect on the coronary vessels will beconstrictor, and therefore the drip should be given slowly.The evidence for the action of adrenaline on ganglionic

transmission will be found in the ,70urnal of Physiology(1942, 101, 289).Department of Pharmacology,

Oxford University. J. H. BURN.

ANTITOXINS AND ANTIBIOTICS

Snt,—Some of the most potent poisons known at thepresent time are bacterial toxins; so-called" bacterio-logical warfare " is based on knowledge of thesesubstances.

Antibiotics deal faithfully with bacteria but offer noprotection against their products. Antitoxic treatment isa routine for cases of diphtheria, tetanus, and botulism ;and with less effect for gas-gangrene due to Olostridium,welchii with its multiplicity of toxins, occupying halfthe letters of the Greek alphabet. It is not generallyrealised that Streptococcus pyogenes can produce a

powerful multi-type toxin ; and also the common

Staphylococcus pyogenes, in certain instances, can producean

" enterotoxin" and, more often, cell-destroying andblood-clotting toxins. Before antibiotics came into use,streptococcal antiserum and staphylococcal antitoxinwere often used, with uneven results.

The brilliant effects of treatment with antibiotics seemto have discouraged the serologists who formerly workedenthusiastically on the improvement of antisera. Oneor two recent tragedies have underlined our lack ofeffective sera, and also the fact that the present genera-tion seems to have forgotten that such things exist orcan be used with success.One such case was a young woman with a (staphylococcal)

infected wisdom root. This was operated on, and the womandied two days later of a pulmonary embolism, despite activeantibiotic therapy. I think she might have been saved bysimultaneous antibiotic and staphylococcal-antitoxin treat-ment. Another young woman developed localised osteo-

myelitis in a metatarsal bone, and died of general peripheralcirculatory failure, despite the exhibition of astronomicaldoses of antibiotics.

I think that a streptococcal toxin was to blame forthe unfortunate outcome in the second case, but it neveroccurred to anybody to try antistreptococcal serum.

Nobody was really to blame for the fatal termination ineither case ; but I would like to suggest that the sero-logists be encouraged to get busy again, and developtheir art to the utmost ; and perhaps advertise theirproducts.

- --

Epping, Essex. FRANK MARSH.

WILL WE NEVER LEARN ?

SIR,-After an interval of five weeks the first commentappears on a report by Surgeon Commander Latta(Lancet, Jan. 27) on casualties in the Korean campaign.He stressed two important points : (1) that primarysuture of war wounds is usually disastrous ; (2) thatrapid evacuation of casualties from a war zone can bea mixed blessing. That he has to stress these pointsbears out Sir Heneage Ogilvie’s text " Will we neverlearn " I think Commander Latta has done a consider-able service in making his clear and unbiased report.As Sir Heneage indicates (March 3), there is something

wrong with the training of the military surgeon. As areservist in one Service before the late war I used to doperiods of training. In my youthful enthusiasm I

expected to be taught something about war surgery.But no-one seemed very interested, and the Service

journals in periods of peace bear witness to this extra-ordinary lack of attention to a subject which shouldbe very much in the minds of Service doctors-particu-larly surgical specialists. The non-medical branches ofthe Services in peace-time prepare for war, but for somereason the doctors do not. There should be intensive

training in the surgery of trauma for both regulars andreservists. Suitable courses could easily be arranged andinterested tutors would not be lacking. The individualis not usually prepared to educate himself in thesematters, and so he must be subjected to some disciplineas Sir Heneage suggests. It would at least be possibleto drum into everyone concerned the principles oftreatment of soft-tissue wounds. No-one would expectto train abdominal surgeons, thoracic surgeons, or neuro-

surgeons in a night, but it ought to be feasible to teachmost Service medical officers how to diminish mortalityand morbidity in the major group of war wounds.

I have long believed that the conscientious perusalof Professor Trueta’s small monograph on war surgerypublished in 1939 would have saved a lot of needlesssuffering. I still think that most of the answers are inthis book. (For one thing it scarcely mentions chemo-therapy or antibiotic therapy-an unwarranted faith inthese has often lead to the neglect of surgical principles.)Jolly’s Field Surgery in Total War was another bookof great value in those early years. The point is thatremarkably few bothered to read these books in 1939and 1940, and it does look as if appropriate study must -be directed.

If there is another war and if, as is all too likely, thereis intensive bombin-atomic or otherwise-casualties

643

will be far greater in number than ever before. In theouter zone of a bombed area there may be thousands of

injured and the majority will have limb injuries. Admit-tedly radiation effects may complicate management,and at the moment this problem occupies much attention.At the same time it seems essential to plan for a moreadequate instruction of surgeons who can handle thesecasualties. Just as with burns, some standard methodof treatment is necessary ; so some direction is urgentlyrequired for the.care of large numbers of limb injuries.There is a danger of complacency here with the

suggestion that anyone can sew up a few flesh woundsor set fractures. This is the careless attitude which

produced the disasters of primary suture, inadequatewound excision or decompression, and faulty splintage-disasters repeated so often in the last war. Such errorsare avoidable and there should be no excuse for theirrepetition.Department of Surgery,University of Liverpool.

JOHN A. SHEPHERD.

ObituaryPERCY STANLEY TOMLINSON

K.B.E., C.B., D.S.O., F.R.C.P., F.R.C.P.E.MANY who served in the Royal Army Medical Corps

during the late war will have learnt with deep regret ofthe death on March 6 of Major-General Sir PercyTomlinson.Born in 1884, he was the son of Colonel W. W.

Tomlinson, R.A.M.C., and was educated at CliftonCollege and Bristol University. He entered the Corpsin 1909, and during the first world war served in France

and Macedonia, gainingthree mentions in des-patches and the D.S.O.

After service at home andin India, he found himselfat the outbreak of thesecond world war D.D.M.S.to British troops in Egypt.In April, 1940, he was

appointed D.M.S. to, theMiddle East Force, and heheld that post during thecritical years of the fightingin Africa. In 1943 hehanded over this post toMajor-General W. C.Hartgill, and in 1944 hewas appointed D.M.s. inNorth-west Europe.He will be remembered

above all for his magnificent work in Egypt, where hefaced problems of the greatest difficulty, many of themnew to military medicine. He was in charge of a largecomposite force, whose medical units came from everypart of the British Empire and its Allies. He was dealingwith a territory that stretched two thousand miles fromnorth to south and two thousand miles from east to west,in which every terrain and every climate might beencountered, in which epidemic diseases were as mucha danger to the armies as the warfare of the enemy, andin which hygiene and preventive medicine were ofsupreme importance. He directed the medical serviceof a force that till the last phases was outnumbered andunder-equipped, that had to face misfortune and retreatas well as victory. He held office during the lightningchanges of the early desert campaigns, and during thefighting in Greece and Crete, in Syria, Iraq, and Eritrea.He had to plan for possible disaster when Rommelstood within a day’s march of the Cairo-Alexandriaroad ; and had to improvise an emergency medical baseon the Red Sea near the Abyssinian border in preparationfor a possible loss of the Suez Canal ; within a few monthshe was organising the medical preparations for the battleof Alamein, and coping with the difficulties of the chaseof Rommel from Alexandria to Tunis-the longest andfastest advance in military history, with the sole excep-tion of Cunningham’s dash from Kenya to Addis Ababa.

In all this work he was not merely accessible to hissubordinates ; he sought out experts in every branch ofmedicine, posed his problems, and used their advice.He had a sound knowledge of clinical medicine, a fineadministrative brain, and the power of leadership to anunusual degree. He could think clearly and decidequickly and impartially.The changes that occurred under his leadership were

fundamental. Forward surgery was reorganised to meetthe needs of mechanised warfare. The field surgical unitswere planned and improved. The blood-transfusionservice was organised and developed till blood became thechief factor in the remarkable rise in recovery from abdomi-nal injuries and fall in the incidence of gas-gangrenethat marked the desert campaigns, and the field trans-fusion officer became the key man of the advancedoperating centres. Advanced parties of the neuro-

surgical, faciomaxillary, and ophthalmic units were forthe first time grouped at casualty-clearing stations withina few hours of the front line. At the same time ourarmies were kept almost free from the infective diseases,particularly the dysenteries, that seriously hampered ourenemies.In the second world war Tomlinson was mentioned four

times in despatches. In 1941 he was made an honoraryphysician to the King and was appointed c.B. ; in 1943 hereceived a knighthood in the Order of the British Empire;and he held the Croix de Guerre, the Legion of Honour, andthe Legion of Merit of the U.S.A. He was elected a fellowof the Royal College of Physicians in 1943, and an honoraryfellow of the Royal College of Physicians of Edinburgh in1946.

General Tomlinson married Miss Gertrude Barr in1920. He had one son, who was killed on active service,and one daughter.

GEORGE MILTON SMITHM.D. Columbia, LL.D. Yale

As director of the Anna Fuller Fund Dr. G. M. Smithwas able to foster Anglo-American cooperation in medicalresearch, and many scientific workers will rememberthe warm kindliness which he added to official grants.

George Milton Smith graduated A.B. at Yale in 1901and M.D. at Columbia University three years later.In 1910 he became associate professor of pathology inWashington University, St. Louis, where he worked till1934. He then returned to Yaleto take up his appointmentwith the Anna Fuller Fund,which he still held at the time ofhis death. While in Yale he alsoacted as research associate inanatomy. In later years hisresearch interests lay mainly inthe comparative pathology oftumours, on which he publishedpapers in Zoologica and else-where, and in historical medi-cine. His greatest achievement,however, rests in the advance-ment of medical research, notonly in the United States but ’,in other countries, through hiswork for the Anna Fuller Fundand as adviser to the Jane Coffin IChi Ids Memorial Fund for Medi-cal Research. Much of his con-tribution lay in cancer research, and he also actedas a member of the National Advisory Cancer Councilfrom 1939 to 1942. Yale conferred on him the honorarydegree of LL.D. in 1947. A devoted supporter of theAllied cause in the late war, he served as chairman ofthe National Research Council committee on armouredvehicles.A British colleague writes : "In George Smith we

admired his intense loyalty to his country and to Yale,his complete unselfishness, and his lasting belief in inter-national cooperation in science and medicine. He wasalso able, and wont, to accompany his practical bene-factions with the warmth of encouragement to a raredegree. His loss,will be mourned, and his memoryhonoured, by a host of colleagues and friends the worldover."..’ ....... . ’

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