MARCH 14, 1953
It is always possible that the rise in blood pressure is
due to the accumulation of carbon dioxide during the period
This is unlikely, as the second blood-pressure
reading was taken as soon as the succinylcholine had exerted
its full effect, usually less than a minute after injection.
The period of diminished respiration is obviously much less.
The hypothesis can be tested very easily in at least two
different ways, but the onus of proof is upon those who
proposed it. The advice of John Hunter to William Jenner
is still good.-We are, etc.,
l Irish J. med. Scd., 1952, 65, 315.
2J. Irish med. Ass., 1952, 31, 240.
Intra-arterial Injection of Thiopentone
SIR,-In the light of the recent correspondence by Dr.
J. W. Dundee (February 14, p. 402) and Dr. J. N. Fell
(January 10, p. 95) on intra-arterial injection of thiopentone,
the following experience may be of interest.
An obese young woman of 21 was operated upon for acute
and scopolamine 0.4 mg. one hour before operation. The needle
of a 20-ml. all-glass syringe was inserted into what was thought
to be the median cubital vein.
quantity of red blood, 5 ml. of 5% thiopentone was injected.
After pausing for a moment it was noticed that blood was spurting
into the syringe, driving back the piston.
complain of pain, even when asked the leading question.
change in the colour or temperature of the skin took place, and
the radial pulse did not alter in volume.
ment was given, as it was assumed that with the lack of pain
and unaltered pulse volume no spasm of the arteries or arterioles
could have occurred.
The needle was withdrawn after about
two minutes, and 0.5 g. of thiopentone was injected into a small
median vein of the other wrist, anaesthesia being maintained with
nitrous oxide, oxygen, pethidine, and tubocurarine. No change in
the patient's arm could be detected during operation, but about
three hours afterwards a slight mottling of the skin of the front
of the forearm was seen.
there were no further effects.
The following points of interest arise.
aspirated blood may be misleading, as venous blood may
vary from almost black to quite bright red.
depends on the percentage of oxygen desaturation of the
venous blood, which in turn is probably due to psychologi-
cal factors acting before the operation.
patient with a relatively low cardiac output the venous blood
oxygenated than in an apprehensive patient with a relatively
high cardiac output.
the aspirated blood was quite bright red was not considered
of significance, with what might have been serious results.
It is evident that 5% thiopentone solution can be injected
intra-arterially without causing pain or spasm of the arteries.
The importance of carefully observing the aspirated blood
for pulsations in an unhurried manner is clearly indicated.-
I am, etc.,
Death after Intravenous Injection of lodoxyl
Snt,-With reference to the report by Mr. G. S. Ramsay
administration of iodoxyl, I should like to record a further
fatality due to this substance.
The patient, a woman of 63 in good health, was being investi-
gated for pain in the left loin and haematuria.
" pyelectan " (iodoxyl) was injected into the right antecubital
vein, four minutes being taken to give the injection.
time she complained of faintness, and at the end of the injection
said that she felt giddy and had a slight burning feeling in her
less and complained that she could not breathe. She sat upand
then lay back in a collapsed state.
the throat, but no marked expectoration.
cyanosed and unconscious.
injection she was deeply unconscious, with a weak pulse. feeble
respirations, and marked cyanosis.
Premedication consisted of " omnopon " 20 mg.,
After aspiration of a small
The patient did not
No immediate treat-
This disappeared within 24 hours and
The colour of the
In a well-sedated
will be considerably more
In the case described, the fact that
P. HEX VENN.
p. 439) of a death following intravenous
Twenty ml. of
She looked flushed. Three minutes later she became rest-
There was a gurglingnoise in
Ten minutes after the end of the
She rapidly became
A diagnosis of peripheral
circulatory failure was made, .but it was also thought that she
might have had a pulmonary or cardiac infarct.
nikethamide was given
adrenaline subcutaneously, and oxygen was administered.
ficial respiration was started. No pulse or heart beat could be felt
20 minutes after the injection.
abdominal incision was then instituted, but the heart was-quite
inert, so this was abandoned after five minutes.
death appeared to have resulted from circulatory failure presum-
ably due to the injected material.
In view of the recent report' that deaths following intra-
venous pyelography have been due to the administration of
diodone, I think it is important to record any deaths due
to iodoxyl.-I am, etc.,
Lancet, 1953, 1, 281.
Six ml. of
Cardiac massage through an
Smoking and Lung Cancer
SIR,-Dr. R. Doll and Professor A. Bradford Hill (Febru-
ary 28, p. 505) mention one possible non-causal explanation
of the relationship they have demonstrated between smoking
and cancer of the lung. This is that subjects with a particular
constitution may be prone both to smoking heavily and to
Although I agree with them that the weight
of present evidence favours taking preventive action now,
I still think that the constitutional explanation deserves ex-
This could be done by taking certain physical
anthropometric measurements, more especially height and
bone width, in cancer patients and controls.
height, mesomorphs have larger bones than endomorphs,
and the measurements required are not subject to the
vagaries of photographic interpretation of somatotype in ill
Apart from inequalities in smoking, Doll and Hill found
more patients with carcinoma of the lung to have had a
previous history of pneumonia and bronchitis.
undergraduates I found smoking commonest where endo-
morphy and mesomorphy were both rated high,' but there
are the additional facts that a history of pneumonia in child-
hood was commonest in endomorphic mesomorphs, a history
of bronchitis in ectomorphic mesomorphs.
smoking seems a less likely cause of these diseases than, for
example, the comparatively large air passages which meso-
On the other side of the constitutional pic-
ture, women, who are mostly endomorphic, are found to
suffer less from lung cancer.
in the suggestion that a habitual pipe smoker is usually a
more contented person than a cigarette smoker, he may
owe his contentment to a viscerotonic temperament, and his
relative freedom from lung cancer to an associated and
dominantly endomorphic constitution.-I am, etc.,
1 Lancet, 1951, 1, 963:
In relation to
Lastly, if there is any truth
R. W. PARNELL.
The Medical Practitioner and the Law
SIR,-The growing number of medico-legal cases reported
in the medical and lay press is very disquieting, but even
more disquieting is the nature of the judgmentspronounced.
These are almost invariably unfavourable to the doctor,and
not infrequently I have been unable to follow the reasoning
that has led to the judgment.
of cases the doctor does not suffer any financial loss, but
he is subjected to considerable anxiety, loss of time,possible
loss of practice, and his reputation
smeared with an unproved charge of negligence.
these cases reveal a disturbing lack of supportfor the junior
doctor by his senior and more experienced colleagues,some
of whom appear to be a little out of touch with the pro'b-
lems of the newly qualified doctor working in a health
service that has not as yet provided unlimited beds for all
potentially serious cases.
of us have not had the opportunity to benefit from their
particular brand of teaching and practice.
I realize that in the majority
is not infrequently
They appear to 'forget that many