453REVIEWS OF BOOKS

calcium. Nahum and Hoff (1937) obtained no increase in thecalcium effect on the rabbit heart after large doses of digitalis.On the other hand Fischer (1928) and Nyiri and Dubois(1930) in frogs found that digitalis increased the action ofcalcium on the heart. Golden and Brams (1938) working withdogs obtained a lower M.L.D. of calcium after the intravenousadministration of one of the digitalis glucosides and La Barreand Van Heerswynghels (1939) reported that digitalisationof cats rendered them much more susceptible to the action ofcalcium.

It seems wise, therefore, to be cautious when calciumis being given intravenously to a patient whose tissuescontain a considerable amount of digitalis glucosides.The administration of digitalis by mouth to a subjectwith hypercalcsemia is not, however, likely to be danger-ous since the digitalis is relatively slow in affecting theheart.

’

Bower and Mengle (1936) were the first to statedefinitely that it is dangerous to use calcium and digitalissimultaneously. An unfortunate experience in two casesled them to this conclusion. Both patients were fullydigitalised when they received intravenous injections ofcalcium salts and both died within a few minutes. Theproblem was then investigated in dogs and it was foundthat although previous digitalisation reduced the M.L.D.of calcium previous administration of calcium had noeffect on the M.L.D. of digitalis.

ILLUSTRATIVE CASES

In the past three years the effect of calcium therapyhas been investigated in 110 patients, of whom 2 de-veloped symptoms of poisoning which are probably tobe attributed to a combined calcium-digitalis effect.CASE I.—A woman, aged 30, was admitted to Stobhill

Hospital on Feb. 8, 1938 with severe dyspnoea, cyanosis andextensive oedema and auricular fibrillation. There was a

history of cardiac trouble dating from an attack of acuterheumatism in childhood. She was given rest, appropriatediet, digitalis and Mersalyl. Improvement was noted, butsome cyanosis still remained and the oedema was not muchreduced. The heart remained irregular. After 23 days ondigitalis (pulv. digitalis gr. 6 daily) she was given a dailyintravenous injection of 10 c.cm. of 10% calcium gluconate,while digitalis therapy was continued. On March 7, after thefourth injection of calcium gluconate, the heart slowed con-siderably and coupling of beats was noted. Calcium anddigitalis were then stopped. On the 10th digitalis wasresumed but was stopped again on the 16th owing to theappearance of numerous extrasystoles verified by electro-cardiograph tracings. On the 19th digitalis was againgiven for two days, but again had to be stopped because of afall in pulse-rate and the reappearance of extrasystoles.On the 22nd, 23rd and 24th 10 c.cm. of 10% calcium gluconatewas given intravenously once daily. Half an hour after thethird injection the patient had a severe rigor lasting for three-quarters of an hour and she vomited and became verycyanosed. The heart-rate jumped from 44 to 132 per minute.The cyanosis and tachycardia persisted until the patient diedtwelve hours later. Permission for post-mortem examina-tion was not granted.

It is difficult to be certain that the patient would nothave died without calcium therapy, but the events weresufficiently dramatic to make one sensible of the dangerof administering calcium intravenously to anyonereceiving digitalis.CASE 2.-A man, aged 52, had had his right leg amputated

in 1937 because of arterial embolism and gangrene. He wasadmitted to Stobhill Hospital on April 4, 1938, suffering fromembolism of the left femoral artery. Expectant treatmentwas adopted and eventually the big toe and the distal partof the second toe developed dry gangrene. The conditionwas complicated by severe cardiosclerosis ; the heart soundswere almost inaudible, the blood-pressure was 105/80, andthe lips were cyanosed. The cardiac rhythm was regular.After the acute conditions had subsided and the gangrenehad developed, cedema appeared in the foot, ankle and to aslight extent in the leg up to the knee. Pulv. digitalis gr. 1t.i.d. was given from May 2 till June 3, but the cedema wasunchanged. Accordingly, 10 c.cm. of 10% calcium gluconatewas given on June 3, 4, 6, 7 and 8. The oedema persisted andsince there was no improvement in the general condition theinjections of calcium gluconate were stopped ; the digitalis

was, however, continued. On the afternoon of June 9 the

patient vomited and the heart-rate fell by 20 beats per minute.Next day there was striking clinical improvement and threedays later the oedema had completely disappeared.

In this case digitalis had been given for 32 days beforethe administration of calcium without evidence of re-sponse. Calcium seems to have increased the sensitivityof the patient to the drug and led to the production oftoxic symptoms.

These two experiences decided us to make it a rulenot to give an intravenous injection of calcium gluconateuntil at least four days after the last dose of digitalis.In this interval if a patient has been receiving full dosesof the drug and is completely saturated the amount ofdigitalis in the tissues will be reduced by the excretionof gr. 8-9-i.e., by about 35%. Since this procedurewas followed no toxic effects have been observed,although many patients with varying degrees of heartfailure have received intravenous injections of calciumgluconate.

SUMMARY

The intravenous injection of 10 c.cm. of 10% calciumgluconate does not lead to toxic manifestations providedat least two minutes are allowed for the administration. _

Literature is summarised indicating the additiveeffects of digitalis and calcium on the heart.Two cases are described showing the danger of giving

calcium gluconate intravenously to digitalised patients.It is recommended that when patients are receivingdigitalis this drug should be stopped for four days beforecalcium is administered.

I should like to express my thanks to Prof. Noah Morrisand to Dr. W. Martin for their help and to the MedicalResearch Council for a grant towards expenses.

REFERENCES

Billigheimer, E. (1924) Z. klin. Med. 100, 411.Bower, J. O. and Mengle, H. A. K. (1936) J. Amer. med. Ass. 106,

1151.Cheinisse, L. (1922) Pr. méd. 30, 81.Fischer, H. (1928) Arch. exp. Path. Pharmak. 130, 194.Gold, H. and Edwards, D. J. (1927) Amer. Heart J. 3, 45.Golden, J. S. and Brams, W. A. (1938) Ann. intern. Med. 11, 1084.La Barre, J. and van Heerswynghels, J. (1939) Arch. int. Pharma-

codyn. 61, 233.Liebermann, A. L. (1933) J. Pharmacol. 47, 183.Lloyd, W. D. M. (1928) Brit. med. J. 1, 662.Loewi, O. (1918) Arch. exp. Path. Pharmak. 82, 141.Mandelstamm, M. (1926), Z. ges. exp. Med. 51, 633.McGuigan, R. A. and Higgins, J. A. (1938) J.Lab. clin. Med. 23, 839.Nahum, L. H. and Hoff, H. E. (1937) Proc. Soc. exp. Biol. Med.,

N.Y. 36, 860.Nyiri, W. and Dubois, L. (1930) J. Pharmacol. 39, 111.

Reviews of Books

Diseases Affecting the VulvaBy ELIZABETH HUNT, M.D. Lpool, hon. physician to theskin department of the South London Hospital for Women.London : Henry Kimpton. Pp. 215. 21s.

THis book is written by a dermatologist for gyneecolo-gists and general practitioners who are called on to treatthe numerous affections of the vulva. When one recallsthe empirical and haphazard way in which most vulvalaffections are dismissed in outpatient departments with adouche or calamine lotion it is clear that Dr. Hunt istackling a genuine problem in this concise and readablebook well fortified with illustrations. The histo-pathology of each lesion is carefully examined and thereare many microphotographs, all of which are understand-able even to the inexpert histologist. Treatment followssound conservative lines, but it is up to date and based onscientific principles. Each chapter is a self-containedunit, and though the book is a small one it completelycovers every rare and common skin lesion found in theregion of the vulva.

Diseases of Infancy and Childhood(3rd ed.) By WILFRID SHELDON, M.D. Lond., F.R.C.P.London : J. and A. Churchill. Pp. 756. 24s.

Dr. Sheldon’s teaching is based on practice, but hehas included accounts of rare conditions without makingthe volume unwieldly. This edition has been thoroughlyrevised and a few omissions have been repaired. As inall recent books on medicine there are many new

454 REVIEWS OF ROOS

references to sulphanilamide and sulphapyridine, but Dr.Sheldon has taken a critical attitude to these drugs, anddoes not look upon them as a panacea. The appendixon their administration is useful but gives scantyinformation about intramuscular and intravenousinjection. Another new appendix is a useful guide to themyriad of vitamin preparations.Annual Review of Biochemistry

Vol. IX. Edited by J. M. LucK and J. H. C. SMITH,Stanford University, California. California : AnnualReviews Inc. Pp. 744. 27s. 6d.

,

THE publication of the Annual Review of Physiologyhas had the effect of confining the reviews in this volumemore strictly to biochemistry, which lessens the appealof the book to the general medical reader, an appealwhich in any case was slight since few general readerscould be expected to plunge into the midstream ofcurrent biochemical progress. To the biochemist thevolume is most useful, but it would be an advantage ifthe authors would arrange their references in a standardform. At present some bibliographies are given in

alphabetical order and others in the order in whichreferences appear in the text, which is less satisfactory.The form of the book deserves consideration ; specialistworkers are unlikely to be interested in more than a fewof the many articles, and few research workers in thiscountry can afford the purchase price for the sake ofone or two articles. The Revue annuelle de physiologieset an example by publishing its reviews separately andcheaply in paper bindings. The complete bound volumecould still be available for libraries and anyone else whowanted it. An enterprise in scientific publishing onthese lines might meet with a surprisingly large response.The preface to the book, written in California in the earlydays of April, deplores the fact that it is almost im-possible to write calmly and with a sense of detachment.Prof. Samson Wright has already remarked that whileEnglish scientists are getting used to the cold water theAmericans are still standing on the edge shivering.Apart from this aspect, the war has had more seriousrepercussions in that for the first time there are nocontributions from Germany. Have biochemists in thatcountry ceased to do work of international importance ?If not it is surely up to America to make their findingsknown. A review on muscle by Prof. Parnas of Lwowwhich should have appeared was not received. Thereare, in fact, only ten contributions from outside America--six from Britain and four from Scandinavia.

Haemophilia and Egg-White DerivativesCoagulan,t, Anti-Coagulant and Bactericidal Effects. ByW. A. TIMPERLEY, M.B., M.Sc. Sheff. Leeds : Printed forthe author by Jowett and Sowry. Pp. 63.SINCE Dr. Timperley published with Professors

A. E. Naish and G. A. Clark (Lancet, 1936, 2, 1142)his claim to reduce the clotting-time of blood withderivatives of egg-white other workers in this countryand in America have tried without success to reproducehis results. On the other hand Dam’s researches on thecoagulating defect in jaundice have not only been con-firmed, but have been widened in application and haveled to the synthesis of pure vitamin K. In this littlemonograph Dr. Timperley summarises his researches.Haemophilia is a long and crippling disease, in which thepatient may well acquire faith in a physician who treatshim with enthusiasm and inspires him with hope, butthis record of crises overridden will leave most readersunpersuaded that the treatment has specific value.

Anatomy of the Female Pelvis(3rd ed.) By F. A. MAGUIRE, M.D. Sydney, F.R.C.S.,F.R.C.O.G. London: Angus and Robertson. Pp. 162.10s. 6d.

THE good name of this little book is simply explained.It is written by a surgeon and an anatomist who usesfirst principles, simple language and exceptionally well-drawn diagrams to unravel the pons asinorum of allstudents starting the study of gynaecology and obstetrics.The book is based on the dissection and serial sectionof 16 female pelves. It should be kept by the teacherfor reference, and should be read by all students about toembark on their six months’ gynaecological and obstetric

clerkship. It could also be used with profit by thesecond-year student dissecting the female pelvis. Ifbefore making his first vaginal examination the studentreads the last chapter on physical examination he willfind himself missing very little clinical detail. Thosefacing their final examination should spend a quiet halfhour rereading the chapters on the pelvic muscles andfascia, the pelvic connective tissue and the supports ofthe uterus.

Forensic ChemistryBy HENRY T. F. RHODES, Dip. Inst. C. (Lyon), hon.research assistant, Conan Doyle Laboratory of ChemicalResearch, Technical Police, Prefecture of the Rhone,France. London: Chapman and Hall. Pp. 214. 12s. 6d.IN this elementary little book the author has collected

the details of forensic analysis in a manner that is notwithout attractions, although to a limited public owingto the author’s particular interests in the detection ofcrime. Fully three-quarters of the book is taken upwith the identification of prints, dusts, metals, ashes,stains, firearm powders, questioned documents andcounterfeit money, the remainder dealing with theanalysis for poisons. In the former Rhodes shows anunusual grip of the subject which enables him to presentit lucidly. Extensive indexes, both subject and author,add value to what is a pleasing and helpful laboratorydetective handbook.

Histological TechnicIncluding a Discussion of Botanical Microtechnic. ByABRAM A. KRAJIAN, department of pathology, Los AngelesCounty Hospital. London: Henry Kimpton. Pp. 272. 18s.

THE methods described in this book cover the investi-gation of normal and pathological material, with theexception of the pituitary and pineal glands. Theauthor gives a detailed exposition of the preparation andstaining of frozen sections ; preparations of the kind canbe quickly and inexpensively made and those who wishto use them will find many helpful suggestions here.Modifications of known methods suggested by the authorinvite trial, since he is clearly an enthusiastic technician.The reproduction of the microphotographs is good exceptfor those in colour, which probably do insufficient justiceto the original preparations. An unusual feature is the28-page section on botanical methods by Dr. E. D.Woodhouse ; this may be helpful to pathologists whowish to extend their observations to the plant kingdom.

Elementary Pathological Histology(2nded.) By W. G. BARNARD. London : H. K. Lewis andCo. Pp. 70. 10s.

THE war-time student who does not find his instructiontoo easy to come by should cordially welcome the secondedition of Prof. Barnard’s book. First published in1928, the book was originally intended for use on thebench when sections were being examined, and theauthor has been content that it should so remain-adescription of the common things of morbid histologywithout theories and without padding. Each chapterconsists of a short description of the pathological processunder review, together with a series of excellent blackand white photomicrographs. Prof. Barnard urges thestudent not to be content with looking down a microscopeand " spotting " what a section is, but to try and resolvethe section into the various cells and particles and sub-stances of which it is compounded. As he says, there isnothing inherently indelicate in a curiosity which bringsan oil-immersion lens to bear on a tumour or an inflamma-tion. It is only by minute examination that we canexpect to be in a position to explain the series of eventswhich have taken place and to assess the effect of thechanges of function. The book is essentially concernedwith the general principles of morbid histology, such asinfection, inflammation, regeneration, necrosis, and soon. Regional pathology therefore takes its place as astudy of the general morbid process applied to a par-ticular organ. The student who expects to have hisknowledge potted and labelled ready for him to assimilatewill find the time and trouble spent on these generalprinciples well repaid. Prof. Barnard is a wise guide whodoes not confound knowledge with words. The illustra-tions, especially the colour plates, deserve high praise.

455DOCTORS IN NEED.-INFECTION IN THE SHELTER

DOCTORS IN NEED

-

THE LANCETLONDON : SATURDAY, OOTOBER 12, 1940

WE are only at the end of the first year of the warand there is already economic distress among membersof our profession which needs instant attention. Itwas at about the same period in the last war that anappeal was made which took a rather different form.The appeal was then rather to those who remained incivil practice to take a sort of monastic vow not to livemore luxuriously than those who went to the front.There is little need now to curb luxury, for in commonwith other citizens we are rationed for our essentialsand have no time for accessories, and the situation isprofoundly altered by the fact that the battle frontnow covers the whole country. The extent offinancial distress can as yet hardly be estimated.We know that a few practitioners in London havebeen killed at their work and our obituary columnscontain week by week the names of some who havebeen cut off at the outset of their career. Whateverthe needs of their dependants it is for the professionas a whole to make sure that there is no distress.Others of our members have lost property, whilesome have been evacuated at short notice from thetowns where they normally practise. Numericallythe need cannot be overwhelming, and in time theunemployment resulting from the movement of

population should adjust itself. Many retired menhave in fact come back into practice. While, therefore,in the majority of cases nothing more may be neededthan some assistance in the form of a loan repayableon very easy terms when the recipient has been ableto re-establish himself there must be others where a

young practitioner has been cut off before he had timeto make provision for the future ; in such cases theeducation of his children should be a charge on hisprofessional colleagues. Our profession has alwaysresponded generously to special appeals, though it hasbeen less sensitive to the prolonged need made evidentin the work of the R.M.B.F. That body has under-taken to distribute the monies received in the lightof long experience in helpful and tactful work. We

publish on another page a complete list of subscrip-tions to the relief fund up to Monday last totallingsome 94400 and we commend the fund to the heartsand pockets of our readers according to their capacity.

INFECTION IN THE SHELTERTHE Government is at last tackling the public-

health aspects of air-raid shelters seriously. A com-mittee with Lord HORDER as chairman has made itsrecommendations with commendable promptitudeafter a four-day (and night) tour of the Londonshelters, and these are to be implemented by aninterdepartmental committee of the Ministries ofHealth and Home Security. Admiral Sir EDWARDEvANs has been appointed to give his full time toshelter administration, and the Horder committeeremains in session. This is good news, for manyshelters-tube stations, basement, Anderson, surfaceor underground-hold the ingredients necessary for theepidemic spread of infection. The communal shelterswere originally intended for the protection of people

caught in the streets by daylight raids, but with thenight bombing of London a new problem arose. Thesurface shelters became unpopular and there was awholesale flocking to the deep shelters and the tubes,which could offer freedom from noise, fellowship, lightand (sometimes) room to lie down. The shelterbecame a dormitory instead of a temporary refuge.To the most popular people came from long distances,bringing their bedding, and friends found places forold people, the bedridden and infirm while the queueswaited outside. Gross overcrowding has resulted,and the lack of sanitation and sanitary supervision,of heating and ventilation, coupled with lack of sleep,nervous strain and improvised meals, has brought thedanger of typhoid and dysentery, and, more menacingstill, the respiratory infections.The first essentials are some regulation of those who

use the public shelters at night, proper sanitaryarrangements, bunks to sleep in, heating, and healthsupervision of the regular habitues. Many peopleuse the communal shelters when they could provide ;

themselves with adequate protection at home. Areissue of the excellent pamphlet

" Your Home as anAir-raid Shelter," incorporating fresh ideas like usingthe dining-room table as a house-kennel, supple-mented perhaps by visits from the A.R.P. staff togive advice and guidance, would encourage many folksto sleep in the comparative peace and comfort of theirown warm, dry homes. The dispersal of women andchildren and of the old and infirm to billets in the

country will also help to relieve congestion. Above all,shelters must be regularly inspected by the M.O.H.What further provisions can be made to minimise

respiratory infections during the coming winter ? 1Can we on the one side raise the resistance of theindividual and on the other take measures againstrespiratory cross-infection ? The first need is for an

adequate, well-balanced and protective diet. For-

tunately the Minister of Food is alive to this, andwhile no vitamin can lay claim to being specificallyanti-infective the addition of vitamins A and D tomargarine and of Bl to bread are wise precautions,though C has yet to be taken care of. As a nation wedo not eat enough fresh fruit and vegetables, and asupply of synthetic vitamin C might well be madeavailable for those who cannot afford to buy it.There is no evidence that any process of " hardening "by physical exercises, cold baths and the like protectsagainst infection. But chilling and sudden falls inthe mean temperature do have an association withcolds which in turn may lead to bronchitis or pneu-monia, so that the shelters must be warmed and theirinhabitants should provide themselves with warmnight-attire. If the proportion of children in theshelters is small the principal respiratory infectionsto be guarded against are colds, influenza, pulmonarytuberculosis and cerebrospinal fever. The infectivityof the first two, the virus diseases, is high, of the otherslow, but all may be spread by direct contact throughdroplets ejected while coughing, sneezing or speaking,and most may also be spread under suitable con-

ditions by infective particles carried in air-currents.Direct droplet infection can probably be preventedonly by some system of masking, and no doubt aneffective mask could be designed which would becheap and comfortable enough to be accepted as therecognised shelter wear.