956
respect. To counteract the possibility of drug substitution we have suggested that hospitals should keep records of all pentazocine prescriptions. Dose increases do not really reflect the
classic picture of pentazocine consumption. Patients with continuous pain usually alter their consumption in relation to the severity of their pain. The mechanism of an antagonist tends to produce dysphoria. Even our real pentazocine addicts did not describe euphoria in the psychiatrically defined sense. One should not treat such a difficult subject as dependence as cursorily as it was in this report. For example, no analyses of the personality structures of the patients were included in the report. Our experience, which we reported in 1977 in the Munchener medizinische Wochenschrift, is based on 60 cases, whereas Drs King and Betts report on only six cases. This leads us to regard this contribution with scepticism. ST KUBICKI Berlin
***We sent a copy of this letter to Dr Betts, whose reply is printed below.-ED, BM7. SIR,-We feel that in his somewhat arrogant dismissal of our short report Professor St Kubicki has failed to understand our purpose. We separately became aware in our clinical practice of patients' abuse of pentazocine. Discussion of this with colleagues revealed general ignorance among them of the addictive potential of pentazocine. Our patients made us aware of the large "black market" sale of this drug in Birmingham and of its widespread abuse in the drug-taking subculture of this city. We therefore decided to pool our experience and draw it to the attention of our colleagues in Britain in a short report. We were not trying to write a formal review of the whole subject. "Increasing evidence" means exactly what Professor Kubicki eventually decides it must mean-that is, the steady trickle of publications from all over the world reporting fresh examples of pentazocine abuse. We are interested that Professor Kubicki's experience of pentazocine withdrawal is so different from ours. We stand by our description. It is likely that our patients were drawn from a different population from those described by the professor, who quotes only his own paper in support of his views; other authors have described similar withdrawal states to the ones we saw. We reported what we saw, not what we ought to have seen from theoretical considerations of the properties of the drug. Thus a few of our patients did report mild euphoria during parenteral abuse of the drug, although this was not a prominent feature. Since we are not quite as green as Professor Kubicki implies, we are aware that drug substitution can take place and therefore only reported those patients in whom by repeated (and random) drug screening we were certain that only pentazocine was being abused. Professor Kubicki comes from a medical culture which believes in the usefulness of "analysis of the personality structure." We do not share this belief; such an analysis anyway would have been out of place in a short report. Professor Kubicki's description of drug substitution with pentazocine among medical personnel is one good reason for placing the drug under stricter control. Putting it under
BRITISH MEDICAL JOURNAL
the same control as other narcotic analgesics will not diminish its efficacy as an analgesic but will make doctors -think twice before prescribing it and will -diminish over-prescribing, thus leading to a diminution in "black market" supply. We know that some glues are used for abuse, but doctors do not normally prescribe them. Incidentally, for reasons of brevity we described one of the patients in the table in our paper as a pharmacist when in fact she was a pharmacy technician. We apologise for any embarrassment this may have caused our
pharmacist colleagues. T A BETTS University Department of Psychiatry, Queen Elizabeth Hospital, Birmingham
Swaddling and congenital dislocation of the hip
30 SEPTEMBER 1978
"known births surviving to maturity." (Incidentally, Henry Fitzroy, Duke of Richmond, mature or not at 17, did marry.) Though Henry VIII did call Henry Fitzroy his "only bastard son," that only means his only acknowledged bastard son. Henry Carey (1526-96), Lord Hunsdon, ostensibly son of Sir William Cary and Mary Boleyn, is the best instance. The Complete Peerage' calls Queen Elizabeth "probably, in fact, his half-sister." Henry's adultery with Mary Boleyn was common knowledge in 15292 and the dispensation in 1533 to marry Ann Boleyn was "even in the first degree of affinity." The wardship of Henry Carey was later granted to Ann Boleyn.3 In 1535 a monk of Syon showed "yongge Master Care, saying that he was our suffren Lord the Kynge's son by our suffren Lady the Qwyen's sister."4 His upkeep was accepted as a Crown responsibility5 and likewise his placement in a career; he became a confidential agent of Queen Elizabeth. He had many children, and many descendants are living today. Elizabeth greeted Sir Henry Neville of Billingbear with the words "I am glad to see thee, brother Henry."6 Elizabeth was the last person to make jokes on such matters, and, whereas "cousin'? was a normal greeting to a peer, "brother" could mean nothing more remote than stepbrother, brother-in-law, and combinations of these-none of which applied to Sir Henry. He also has living descendants, including the Braybrooke peerage. There are other reputed bastards of Henry VIII, but the evidence is not enough to get an affiliation order. You write (29 July, p 307), "If Catherine had already been sensitised by her first husband, who was Henry's brother, Arthur," but Scarisbrick argues convincingly that "the non-consummation of Catherine's first marriage is a moral certainty."7 Catherine Parr, incidentally, had a child by her last marriage after Henry VIII's death but its fate is a matter of rumour rather than fact. The last word on the genetics of Henry VIII will not be said for a very long time. I myself am working on three separate aspects-one almost ready for publication.
SIR,-The letter (19 August, p 569) from Mr M A Smith referred to an article in the Sunday Times. This article was based on a paper by Dr James Chisholm and myself which will soon appear in Early Human Development. In this paper we discuss the suggested connection between swaddling and congenital dislocation of the hip. However, the connection is far from being as clearcut as Mr Smith suggests. Studies of native Americans have shown that the cradleboard (and associated swaddling) can exacerbate the developmental problems associated with pre-existing congenital hip disease but apparently only when traditional shredded bark or a thin cloth is used as a nappy. Thicker cloth nappies or modern disposable plastic nappies in combination with swaddling do not give rise to problems and may be an effective treatment for congenital hip disease.' Mr Smith suggests that the incidence of congenital dislocation of the hip is well established and is closely associated with swaddling. The former is far from the case, as recent British studies indicate,' and Mr Smith provides no support for his statements that high rates of swaddling and hip dislocation are found in northern Italy and Germany. Our paper sets out some of the evidence of ROBERT J HETHERINGTON the positive effects of swaddling on infant Birmingham development and suggests that it might be of great value in some specific cases as, for Cokayne, G E C, The Complete Peerage, vol 6, p 628. London, St Catherine Press, 1926. example, with mildly hyperactive nightG A, et al, ed, Calendar of Letters and waking babies. However, we urge caution and 2 Bergenroth, Despatches and State Papers Relating to the Negotiathe need for careful evaluative -studies which tions between England and Spain, vol 4(1), p 369. London, Longmans and HMSO, 1862-1954. we plan to undertake. Like any intervention, 3 Brewer, J S, et al, ed, Letters and Papers Foreign and Domestic of the Reign of Henry VIII, vol 5, p 11. swaddling is open to misuse and probably can London, Longmans and HMSO, 1862-1910. very occasionally cause damage. But there is no 4 Ibid, vol 8, p 215. basis in the existing research for Mr Smith's 5 Ibid, vol 13 (1), pp 361, 527. 6 Notes and Queries, 1st series, 1850, 2, 307. universal condemnation. Such closed attitudes 7 Scarisbrick, J J, Henry VIII, p 189. London, Eyre are unlikely to bring improvements in child and Spottiswoode, 1968. health. MARTIN RICHARDS Medical Psychology Unit, Aminoglycosides in patients with University of Cambridge impaired renal function 2
Rabin, D L, et al, American journal of Public Health, 1965, 55, suppl, p 1. Place, M J, Parkin, D M, and Fitton, J M, Lancet, 1978, 2, 249.
Health of King Henry VIII
SIR,-As a descendant of Henry VIII's uncle Arthur Plantagenet, I declare an interest in his genetics alongside that of Drs M Skoblo and J Leslau (2 September, p 700). My investigations are incomplete but I can add to his
SIR,-Dr Paul Noone and his colleagues are to be congratulated on their excellent paper (12 August, p 470) showing that, with proper monitoring, aminoglycosides can be used safely even in patients with severely impaired renal function. However, from the information presented it is difficult to understand their statement in the discussion that renal function appeared to be adversely affected by a combination of an aminoglycoside with cephalosporins. It would appear from the results
BRITISH MEDICAL JOURNAL
30 SEPTEMBER 1978
957
given that of five patients with deteriorating renal function, three were on gentamicin alone and two on gentamicin plus a cephalosporin. Of the three on gentamicin alone they say, "All three patients were also suffering from transplant rejection and toxaemia, and interpretation of these results is therefore difficult." Of the two on gentamicin plus a cephalosporin they say, "Although in both cases rejection was occurring, we could not exclude nephrotoxicity." They do not present any evidence to explain why in the one situation they conclude, "attributable nephrotoxicity not observed," while in the other they conclude, "may have produced nephrotoxicity." Furthermore, in view of the accumulating evidence that gentamicin appears to be potentially more nephrotoxic than some other aminoglycosidesl-3 attention might have been drawn to the fact that, whether or not it was attributable, all five patients who showed deteriorating renal function were actually receiving gentamicin and not one of the other aminoglycosides included in the study. KEITH WOODCOCK Medical Adviser, Eli Lilly and Co Ltd
The Year of the Child: an objective for have this requirement and in my opinion rich nations should not be used. JOSEPH L PETERS SIR,-The United Nations has designated 1979 University College Hospital, as the Year of the Child. In the wealthy London WC1 countries there is still widespread ignorance of I File No R/B 1026/18 DS (Supply) 6/72. the fact that a mother's ability to love and 2 DHSS Goy, J A E, British MedicalJ'ournal, 1976, 2, 21. enjoy her baby but yet accept the privation 3 Medical Defence Union, Annual Report, 1977, p 23. which caring for children brings may be damaged irreparably by lack of close and continuous contact between mother and infant SIR,-Drs A C Edwards and Edgar Sowton in the immediate postnatal period.' (2 September, p 669) have presented an Western culture has "forgotten" that such admirable case for the removal of lost catheters contact, and in particular the suckling of an by percutaneous technique. It should be infant in intimate peaceful surroundings, emphasised that this technique is applicable produces physical arousal in the mother which only to the retrieval of foreign bodies recently gives her pleasure and helps her develop the lost into the vascular system. Catheters which have been in the circulation for months become essential attachment to her baby. We should like to propose that one objective epithelialised and firmly attached to vessel for this Year of the Child should be to ensure walls where they happen to touch them. We that babies are placed in their mother's arms as have been unable to remove pacing catheters soon as possible after birth to be handled and and broken pieces of Holter valve systems kissed and suckled. In this matter we in which have become so attached. Leaving such Western countries have much to learn from intravascular jetsam in situ does not appear the third world, where in most cultures close to cause trouble once epithelialisation has skin-to-skin contact is established immediately occurred. However, pulmonary emboli may be and suckling occurs freely throughout the post- generated by clot forming on plastic tubing natal period. recently introduced into the circulation. Basingstoke, Hants To avoid the risk of such embolisation and ISABEL SMITH DAVID MORLEY to allow the removal of the lost catheter by Neu, H L, and Bendush, C L, J7ournal of Infectious Diseases, 1976, 134, suppl, p S206. snaring it early referral of such cases to a Institute of Child Health, 2 Kahlmeter, G, Hallberg, T, and Kamme, C, Journal centre with the necessary skill is desirable. of Antimicrobial Chemotherapy, 1978, 4, suppl A, London WCI p 47.
Whelton, A, et al, Cuirrent Chemotherapy, Proceedings of the 10th International Congress of Chemotherapy,
3
1977.
'Kennel, J H, and Klaus, M H, Maternal Infant Bonding, Mosby, St Louis, 1976.
Sheffield
***We sent a copy of this letter to Dr Noone, whose reply is printed below.-ED, BM7.
SIR,-The reason for the different assessment of the patients with deteriorating renal functioning is as follows. Of the three patients on gentamicin alone, two were undergoing severe rejection with acute loss of renal function and received gentamicin for suspected (but unconfirmed) sepsis. The third patient on gentamicin alone had very poor renal function and was receiving regular haemodialysis in the unit. He was admitted in a very ill state with Pseudomonas aeruginosa septicaemia and his already deteriorating renal function continued to decline during his treatment with carbenicillin and gentamicin. It was considered that the modest rise in blood urea observed could be accounted for by his septic state. On the other hand the two patients who were receiving cephalosporin and gentamicin together had a much milder degree of rejection and still had useful renal function which deteriorated during antibiotic therapy. So although rejection was occurring, one could not rule out the possibility of- a nephrotoxic affect. As regards Dr Woodcock's other comments, most of the work comparing the nephrotoxicity of gentamicin and tobramycin has been performed in experimental animals and it is well known that there are marked interspecies differences in susceptibility to the toxic affect of aminoglycosides. In the only double-blind trial performed in humans there was no significant difference in nephrotoxicity between gentamicin and tobramycin.1 PAUL NOONE Royal Free Hospital, London NW3 I
Wade, J C, et al, Lancet, 1978, 2, 604.
D VEREL Sheffield Cardiothoracic Unit, Northern General Hospital,
Central venous catheter embolism SIR,-I was interested to read the timely reminder from Drs A C Edwards and Edgar Sowton concerning, the management of central venous catheter embolism (2 September, p 669). To their credit, the Department of Health and Social Security issued a letter in March 19721 suggesting to all supplies officers that the "Through-needle" variety of catheter be withdrawn. This move arose from the disturbingly high incidence of this serious complication being reported in the world literature. Apart from the danger of embolism occuring during insertion, the flimsy plastic needle protector provided does not always prevent the movement of the catheter against the needle. The patient is thus potentially at risk the whole time. This is especially the case if the antecubital fossa route is used and the patient is restless or confused. The catheters need not be wasted; they can be introduced as mentioned via a large Sherwood Argyle Medicut needle or using a guide-wire technique.' Alternatively, one of the more modern central venous catheters could be used. Although the Bard might say "Much ado about nothing," the litigation which follows3 is usually directed at the operator and not the manufacturers producing an instrument which can cause such complications and deaths. The patients reported by Drs Edwards and Sowton were fortunate that the catheters were radio-opaque. I feel that this is a vital requirement for central venous lines. The placement of a radiotranslucent catheter can of course be checked by injecting contrast medium. However, if during its life the catheter kinks and fractures or is accidentally cut during a dressing or removal procedure embolism could occur and the fragment would be almost impossible to detect. Some of the recently introduced catheters fail to
Misuse of hypnosis SIR,-While in general agreement with the spirit of Dr D Waxman's letter (19 August, p 571), I am afraid that the letter may give some impressions which were not perhaps intended. People with medical and dental qualifications are not the only therapists using hypnosis under the NHS in a responsible and proper manner and it is surely for this reason that the Metropolitan Branch of the British Society of Medical and Dental Hypnosis, of which Dr Waxman is president, admits such people to its training courses. First we must consider just what hypnosis is, and second just how in modern practice the therapeutic process is implemented by a number of differently trained specialists. Without going into the matter in too great detail, I think that we can agree that "hypnosis" is a technique by which people's behaviour and experience can be modified. There is nothing specially "medical" or "dental" about it. In current NHS practice much behaviour modification is in the hands of clinical psychologists, some of whom use hypnosis as an adjunct to the process if they see fit. Behaviour modification is also operated by specially trained nurses,' and I know of a clinic where physiotherapists use a form of hypnosis. Regarding my second point, I would refer to the reception which the Royal College of Psychiatrists' memorandum to the Trethowan Committee received from a fair number of psychiatrists of the younger generation2 to make it quite clear that it is now accepted that the therapeutic process is a matter for teams of differently qualified specialists working in
harmony. Naturally we want people to act only within
respect. To counteract the possibility of drug substitution we have suggested that hospitals should keep records of all pentazocine prescriptions. Dose increases do not really reflect the
classic picture of pentazocine consumption. Patients with continuous pain usually alter their consumption in relation to the severity of their pain. The mechanism of an antagonist tends to produce dysphoria. Even our real pentazocine addicts did not describe euphoria in the psychiatrically defined sense. One should not treat such a difficult subject as dependence as cursorily as it was in this report. For example, no analyses of the personality structures of the patients were included in the report. Our experience, which we reported in 1977 in the Munchener medizinische Wochenschrift, is based on 60 cases, whereas Drs King and Betts report on only six cases. This leads us to regard this contribution with scepticism. ST KUBICKI Berlin
***We sent a copy of this letter to Dr Betts, whose reply is printed below.-ED, BM7. SIR,-We feel that in his somewhat arrogant dismissal of our short report Professor St Kubicki has failed to understand our purpose. We separately became aware in our clinical practice of patients' abuse of pentazocine. Discussion of this with colleagues revealed general ignorance among them of the addictive potential of pentazocine. Our patients made us aware of the large "black market" sale of this drug in Birmingham and of its widespread abuse in the drug-taking subculture of this city. We therefore decided to pool our experience and draw it to the attention of our colleagues in Britain in a short report. We were not trying to write a formal review of the whole subject. "Increasing evidence" means exactly what Professor Kubicki eventually decides it must mean-that is, the steady trickle of publications from all over the world reporting fresh examples of pentazocine abuse. We are interested that Professor Kubicki's experience of pentazocine withdrawal is so different from ours. We stand by our description. It is likely that our patients were drawn from a different population from those described by the professor, who quotes only his own paper in support of his views; other authors have described similar withdrawal states to the ones we saw. We reported what we saw, not what we ought to have seen from theoretical considerations of the properties of the drug. Thus a few of our patients did report mild euphoria during parenteral abuse of the drug, although this was not a prominent feature. Since we are not quite as green as Professor Kubicki implies, we are aware that drug substitution can take place and therefore only reported those patients in whom by repeated (and random) drug screening we were certain that only pentazocine was being abused. Professor Kubicki comes from a medical culture which believes in the usefulness of "analysis of the personality structure." We do not share this belief; such an analysis anyway would have been out of place in a short report. Professor Kubicki's description of drug substitution with pentazocine among medical personnel is one good reason for placing the drug under stricter control. Putting it under
BRITISH MEDICAL JOURNAL
the same control as other narcotic analgesics will not diminish its efficacy as an analgesic but will make doctors -think twice before prescribing it and will -diminish over-prescribing, thus leading to a diminution in "black market" supply. We know that some glues are used for abuse, but doctors do not normally prescribe them. Incidentally, for reasons of brevity we described one of the patients in the table in our paper as a pharmacist when in fact she was a pharmacy technician. We apologise for any embarrassment this may have caused our
pharmacist colleagues. T A BETTS University Department of Psychiatry, Queen Elizabeth Hospital, Birmingham
Swaddling and congenital dislocation of the hip
30 SEPTEMBER 1978
"known births surviving to maturity." (Incidentally, Henry Fitzroy, Duke of Richmond, mature or not at 17, did marry.) Though Henry VIII did call Henry Fitzroy his "only bastard son," that only means his only acknowledged bastard son. Henry Carey (1526-96), Lord Hunsdon, ostensibly son of Sir William Cary and Mary Boleyn, is the best instance. The Complete Peerage' calls Queen Elizabeth "probably, in fact, his half-sister." Henry's adultery with Mary Boleyn was common knowledge in 15292 and the dispensation in 1533 to marry Ann Boleyn was "even in the first degree of affinity." The wardship of Henry Carey was later granted to Ann Boleyn.3 In 1535 a monk of Syon showed "yongge Master Care, saying that he was our suffren Lord the Kynge's son by our suffren Lady the Qwyen's sister."4 His upkeep was accepted as a Crown responsibility5 and likewise his placement in a career; he became a confidential agent of Queen Elizabeth. He had many children, and many descendants are living today. Elizabeth greeted Sir Henry Neville of Billingbear with the words "I am glad to see thee, brother Henry."6 Elizabeth was the last person to make jokes on such matters, and, whereas "cousin'? was a normal greeting to a peer, "brother" could mean nothing more remote than stepbrother, brother-in-law, and combinations of these-none of which applied to Sir Henry. He also has living descendants, including the Braybrooke peerage. There are other reputed bastards of Henry VIII, but the evidence is not enough to get an affiliation order. You write (29 July, p 307), "If Catherine had already been sensitised by her first husband, who was Henry's brother, Arthur," but Scarisbrick argues convincingly that "the non-consummation of Catherine's first marriage is a moral certainty."7 Catherine Parr, incidentally, had a child by her last marriage after Henry VIII's death but its fate is a matter of rumour rather than fact. The last word on the genetics of Henry VIII will not be said for a very long time. I myself am working on three separate aspects-one almost ready for publication.
SIR,-The letter (19 August, p 569) from Mr M A Smith referred to an article in the Sunday Times. This article was based on a paper by Dr James Chisholm and myself which will soon appear in Early Human Development. In this paper we discuss the suggested connection between swaddling and congenital dislocation of the hip. However, the connection is far from being as clearcut as Mr Smith suggests. Studies of native Americans have shown that the cradleboard (and associated swaddling) can exacerbate the developmental problems associated with pre-existing congenital hip disease but apparently only when traditional shredded bark or a thin cloth is used as a nappy. Thicker cloth nappies or modern disposable plastic nappies in combination with swaddling do not give rise to problems and may be an effective treatment for congenital hip disease.' Mr Smith suggests that the incidence of congenital dislocation of the hip is well established and is closely associated with swaddling. The former is far from the case, as recent British studies indicate,' and Mr Smith provides no support for his statements that high rates of swaddling and hip dislocation are found in northern Italy and Germany. Our paper sets out some of the evidence of ROBERT J HETHERINGTON the positive effects of swaddling on infant Birmingham development and suggests that it might be of great value in some specific cases as, for Cokayne, G E C, The Complete Peerage, vol 6, p 628. London, St Catherine Press, 1926. example, with mildly hyperactive nightG A, et al, ed, Calendar of Letters and waking babies. However, we urge caution and 2 Bergenroth, Despatches and State Papers Relating to the Negotiathe need for careful evaluative -studies which tions between England and Spain, vol 4(1), p 369. London, Longmans and HMSO, 1862-1954. we plan to undertake. Like any intervention, 3 Brewer, J S, et al, ed, Letters and Papers Foreign and Domestic of the Reign of Henry VIII, vol 5, p 11. swaddling is open to misuse and probably can London, Longmans and HMSO, 1862-1910. very occasionally cause damage. But there is no 4 Ibid, vol 8, p 215. basis in the existing research for Mr Smith's 5 Ibid, vol 13 (1), pp 361, 527. 6 Notes and Queries, 1st series, 1850, 2, 307. universal condemnation. Such closed attitudes 7 Scarisbrick, J J, Henry VIII, p 189. London, Eyre are unlikely to bring improvements in child and Spottiswoode, 1968. health. MARTIN RICHARDS Medical Psychology Unit, Aminoglycosides in patients with University of Cambridge impaired renal function 2
Rabin, D L, et al, American journal of Public Health, 1965, 55, suppl, p 1. Place, M J, Parkin, D M, and Fitton, J M, Lancet, 1978, 2, 249.
Health of King Henry VIII
SIR,-As a descendant of Henry VIII's uncle Arthur Plantagenet, I declare an interest in his genetics alongside that of Drs M Skoblo and J Leslau (2 September, p 700). My investigations are incomplete but I can add to his
SIR,-Dr Paul Noone and his colleagues are to be congratulated on their excellent paper (12 August, p 470) showing that, with proper monitoring, aminoglycosides can be used safely even in patients with severely impaired renal function. However, from the information presented it is difficult to understand their statement in the discussion that renal function appeared to be adversely affected by a combination of an aminoglycoside with cephalosporins. It would appear from the results
BRITISH MEDICAL JOURNAL
30 SEPTEMBER 1978
957
given that of five patients with deteriorating renal function, three were on gentamicin alone and two on gentamicin plus a cephalosporin. Of the three on gentamicin alone they say, "All three patients were also suffering from transplant rejection and toxaemia, and interpretation of these results is therefore difficult." Of the two on gentamicin plus a cephalosporin they say, "Although in both cases rejection was occurring, we could not exclude nephrotoxicity." They do not present any evidence to explain why in the one situation they conclude, "attributable nephrotoxicity not observed," while in the other they conclude, "may have produced nephrotoxicity." Furthermore, in view of the accumulating evidence that gentamicin appears to be potentially more nephrotoxic than some other aminoglycosidesl-3 attention might have been drawn to the fact that, whether or not it was attributable, all five patients who showed deteriorating renal function were actually receiving gentamicin and not one of the other aminoglycosides included in the study. KEITH WOODCOCK Medical Adviser, Eli Lilly and Co Ltd
The Year of the Child: an objective for have this requirement and in my opinion rich nations should not be used. JOSEPH L PETERS SIR,-The United Nations has designated 1979 University College Hospital, as the Year of the Child. In the wealthy London WC1 countries there is still widespread ignorance of I File No R/B 1026/18 DS (Supply) 6/72. the fact that a mother's ability to love and 2 DHSS Goy, J A E, British MedicalJ'ournal, 1976, 2, 21. enjoy her baby but yet accept the privation 3 Medical Defence Union, Annual Report, 1977, p 23. which caring for children brings may be damaged irreparably by lack of close and continuous contact between mother and infant SIR,-Drs A C Edwards and Edgar Sowton in the immediate postnatal period.' (2 September, p 669) have presented an Western culture has "forgotten" that such admirable case for the removal of lost catheters contact, and in particular the suckling of an by percutaneous technique. It should be infant in intimate peaceful surroundings, emphasised that this technique is applicable produces physical arousal in the mother which only to the retrieval of foreign bodies recently gives her pleasure and helps her develop the lost into the vascular system. Catheters which have been in the circulation for months become essential attachment to her baby. We should like to propose that one objective epithelialised and firmly attached to vessel for this Year of the Child should be to ensure walls where they happen to touch them. We that babies are placed in their mother's arms as have been unable to remove pacing catheters soon as possible after birth to be handled and and broken pieces of Holter valve systems kissed and suckled. In this matter we in which have become so attached. Leaving such Western countries have much to learn from intravascular jetsam in situ does not appear the third world, where in most cultures close to cause trouble once epithelialisation has skin-to-skin contact is established immediately occurred. However, pulmonary emboli may be and suckling occurs freely throughout the post- generated by clot forming on plastic tubing natal period. recently introduced into the circulation. Basingstoke, Hants To avoid the risk of such embolisation and ISABEL SMITH DAVID MORLEY to allow the removal of the lost catheter by Neu, H L, and Bendush, C L, J7ournal of Infectious Diseases, 1976, 134, suppl, p S206. snaring it early referral of such cases to a Institute of Child Health, 2 Kahlmeter, G, Hallberg, T, and Kamme, C, Journal centre with the necessary skill is desirable. of Antimicrobial Chemotherapy, 1978, 4, suppl A, London WCI p 47.
Whelton, A, et al, Cuirrent Chemotherapy, Proceedings of the 10th International Congress of Chemotherapy,
3
1977.
'Kennel, J H, and Klaus, M H, Maternal Infant Bonding, Mosby, St Louis, 1976.
Sheffield
***We sent a copy of this letter to Dr Noone, whose reply is printed below.-ED, BM7.
SIR,-The reason for the different assessment of the patients with deteriorating renal functioning is as follows. Of the three patients on gentamicin alone, two were undergoing severe rejection with acute loss of renal function and received gentamicin for suspected (but unconfirmed) sepsis. The third patient on gentamicin alone had very poor renal function and was receiving regular haemodialysis in the unit. He was admitted in a very ill state with Pseudomonas aeruginosa septicaemia and his already deteriorating renal function continued to decline during his treatment with carbenicillin and gentamicin. It was considered that the modest rise in blood urea observed could be accounted for by his septic state. On the other hand the two patients who were receiving cephalosporin and gentamicin together had a much milder degree of rejection and still had useful renal function which deteriorated during antibiotic therapy. So although rejection was occurring, one could not rule out the possibility of- a nephrotoxic affect. As regards Dr Woodcock's other comments, most of the work comparing the nephrotoxicity of gentamicin and tobramycin has been performed in experimental animals and it is well known that there are marked interspecies differences in susceptibility to the toxic affect of aminoglycosides. In the only double-blind trial performed in humans there was no significant difference in nephrotoxicity between gentamicin and tobramycin.1 PAUL NOONE Royal Free Hospital, London NW3 I
Wade, J C, et al, Lancet, 1978, 2, 604.
D VEREL Sheffield Cardiothoracic Unit, Northern General Hospital,
Central venous catheter embolism SIR,-I was interested to read the timely reminder from Drs A C Edwards and Edgar Sowton concerning, the management of central venous catheter embolism (2 September, p 669). To their credit, the Department of Health and Social Security issued a letter in March 19721 suggesting to all supplies officers that the "Through-needle" variety of catheter be withdrawn. This move arose from the disturbingly high incidence of this serious complication being reported in the world literature. Apart from the danger of embolism occuring during insertion, the flimsy plastic needle protector provided does not always prevent the movement of the catheter against the needle. The patient is thus potentially at risk the whole time. This is especially the case if the antecubital fossa route is used and the patient is restless or confused. The catheters need not be wasted; they can be introduced as mentioned via a large Sherwood Argyle Medicut needle or using a guide-wire technique.' Alternatively, one of the more modern central venous catheters could be used. Although the Bard might say "Much ado about nothing," the litigation which follows3 is usually directed at the operator and not the manufacturers producing an instrument which can cause such complications and deaths. The patients reported by Drs Edwards and Sowton were fortunate that the catheters were radio-opaque. I feel that this is a vital requirement for central venous lines. The placement of a radiotranslucent catheter can of course be checked by injecting contrast medium. However, if during its life the catheter kinks and fractures or is accidentally cut during a dressing or removal procedure embolism could occur and the fragment would be almost impossible to detect. Some of the recently introduced catheters fail to
Misuse of hypnosis SIR,-While in general agreement with the spirit of Dr D Waxman's letter (19 August, p 571), I am afraid that the letter may give some impressions which were not perhaps intended. People with medical and dental qualifications are not the only therapists using hypnosis under the NHS in a responsible and proper manner and it is surely for this reason that the Metropolitan Branch of the British Society of Medical and Dental Hypnosis, of which Dr Waxman is president, admits such people to its training courses. First we must consider just what hypnosis is, and second just how in modern practice the therapeutic process is implemented by a number of differently trained specialists. Without going into the matter in too great detail, I think that we can agree that "hypnosis" is a technique by which people's behaviour and experience can be modified. There is nothing specially "medical" or "dental" about it. In current NHS practice much behaviour modification is in the hands of clinical psychologists, some of whom use hypnosis as an adjunct to the process if they see fit. Behaviour modification is also operated by specially trained nurses,' and I know of a clinic where physiotherapists use a form of hypnosis. Regarding my second point, I would refer to the reception which the Royal College of Psychiatrists' memorandum to the Trethowan Committee received from a fair number of psychiatrists of the younger generation2 to make it quite clear that it is now accepted that the therapeutic process is a matter for teams of differently qualified specialists working in
harmony. Naturally we want people to act only within
