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tion of the rule of professional secrecy in the case ofmental defectives.There may well be occasions when it would be fitting

and proper for the police to intervene by the institutionof legal proceedings against a suspected offender andthere may also be sound reasons in law for issuing theadvice described above. I feel, however, that before achange of this order is sponsored by official Governmentaldepartments relating to an important ethical tenetthe least that the Association could expect would be acommunication from the parties who propose an altera-tion setting out their reasons and any legal sanction thatmight be invoked for their support. I hope that oppor-tunity will be afforded in the near future for repre-sentatives of the Association and of the Ministry tomeet to discuss the situation created by the issue of thememorandum.

ROBERT FORBESSecretary.

The Medical Defence Union,London, W.C.1.

ESTIMATION OF BLOOD-LOSS

H. E. DE WARDENER.St. Thomas’s Hospital

Medical School,London, S.E.1.

SiR,ńYour editorial of May 14 on the difficulty of

estimating accurately the amount of blood lost at

operation or as a result of trauma was excellent-untilits close. Having rightly stressed that blood-loss is usuallyunderestimated, you continue "... there is still insuffi-cient evidence to justify the very large transfusions ofblood recommended by Prentice et al. Early surgicaltreatment should be combined with rapid transfusion ofenough blood to maintain the blood-pressure withinnormal limits." But one of the reasons that Prentice et al.gave these very large quantities of blood was to do thisvery thing. And surely the fallacy of relying only on theblood-pressure as a measure of circulatory normality isthe reason why blood-loss is so frequently underesti-mated. This recurrent canard is continually being shotdown, and some of the best shots are included in the-references to your editorial. These references point outthat a loss of blood-volume of up to 2 litres can beassociated with a normal blood-pressure. They point outthat such patients are liable to develop alarming andsometimes lethal falls of blood-pressure under anaesthesiaand there is also evidence that they are liable to developacute anuria.The temperature and colour of the nose and extremities

and the size of the subcutaneous veins are far betterclinical indications of the normality of blood-flow thanis the blood-pressure. Prentice and his colleagues wereaware of these facts which is another reason why theygave such large quantities of blood. Finally, the groupwhich they transfused included many suffering frommultiple gunshot wounds which continued to bleed untiland during operation. It is unfair to criticise the quantityof blood (10-20 litres) found necessary in these cases, bycontrasting them with the amounts found to be adequatefor civilian casualties with closed injuries or a singleopen lesion.

CORPORAL PUNISHMENT IN SCHOOL

RONALD W. ANGEL.

SiR,-Dr. Jackson’s letter of May 14 sponsors a

point of view that has been carried to absurd and danger-ous extremes in the United States. Without commentingupon his gestalt theories, I feel compelled to warn Britishreaders that the " permissive " attitude can lead toserious lowering of intellectual and moral standards inthe schools.A Californian teacher has recently been discharged,

not for using corporal punishment, but for teachingschool by " traditional " instead of " progressive "methods. He testified that fourth-grade children donot know the alphabet, and that when he attempted toteach the multiplication tables by drills he was rebukedby a superior. The teacher was not allowed to discipline

a boy who called him obscene names for three months.Another teacher was not allowed to punish a child whoattacked her and broke her nose. The " progressive "school authorities would not listen when these and otherteachers sought disciplinary measures.

Dr. Jackson’s gestalt theories lead him to believe thatpunishment will render children susceptible to illness.Years of experience with "progressive education "convince me that lack of intellectual and moral disciplinecan be a serious danger to children, to the community,and, ultimately, to the survival of all civilised values.

Edinburgh. RONALD W. ANGEL.

1. Drury, A. N., Szent-Györgyi, A. J. Physiol. 1929, 68, 213.2. Green, H. N. Brit. med. Bull. 1945, 3, 102.3. Bielschowsky, M., Green, H. N., Stoner, H. B. J. Physiol. 1946,

104, 239.4. Somló, E. Orv. Lapja, 1947, 3, 1431.5. Somló, E. Pesti Izr. Kórház Évkönyv. 1949.6. Komor, K., Garas, Z. Orv. Hétil. 1954.

ADENOSINE TRIPHOSPHATE IN PAROXYSMALTACHYCARDIA

ERNÖ SOMLÓ.Postgraduate Institute of Medicine,Budapest, Hungary.

SiR,-In 1929 Drury and Szent-Gy6rgyi 1 pointed outthat adenosine triphosphate (A.T.P.), adenosine mono-

phosphate (A.M.P.), and adenosine dilated the coronaryarteries and slowed atrioventricular conduction. Thework of Green,2 Bielschowsky et al.,3 and others made itclear that these substances act by inducing a " shock "comparable to that produced, under certain conditions,by histamine, adrenaline, or insulin. Moreover, it wasfound that the adenyl root is responsible for the vaso-depressor effect, while the pyrophosphate is the shock-inducing factor in A.T.P. ; also, that magnesium phos-phate is the most active shock-inducing member of thisgroup of substances.

Accordingly I have tried, over the past ten years, tobring about the cessation of paroxysmal tachycardia, byproducing a mitigated shock with intravenous adenosinetriphosphate. 18-20 seconds after an intravenous injec-tion (given as rapidly as possible) of 2 ml. (20 mg.) ofA.T.P., complete asystole, lasting 2-4 seconds, usuallyensues. This asystole is sometimes interrupted byventricular extrasystoles originating from various foci,or by isolated auricular contractions : in these circum-stances the patient is asked to swallow once or twice,and subsequently he reports with relief that his gallopingheart action has slowed down. The electrocardiogram(E.C.G.) shows a nodal impulse formation for 3-4 com-plexes or, after a few atypical auricular-ventricular com-plexes, transitional auricle activity without ventricularstoppage. Subsequently regular sinus rhythm is estab-lished, differing from normal rhythm only in that theconduction-time from auricle to ventricle is longer ; butafter 3-4 complexes this too returns to normal.

Judging from the E.C.G. changes during the injection,there seems no doubt that the A.T.P. substances arrestthe heart action and temporarily cause complete asystole.While the impulse formation is slowly recovering theyinhibit impulse conduction and so prevent recurrence ofthe paroxysmal tachycardia.The effective dose is 20 mg. (2 ml.), provided that the vein

is sufficiently wide to allow rapid injection. If the veins arethin and weak-walled, I adminster 30 mg. at the outset. Inno case have I observed any toxic side-effects. Since theeffect is due to the high blood level, intramuscular injection isunsuitable.

In 1947 I reported 96 onsets successfully treated in thisway,4 and in 1949 an additional 118 onsets, Komor andGaras 6 last year reported success in 250 episodes among50 patients.The response of supraventricular paroxysmal tachy-

cardia to adenosine triphosphate is so striking that it

may be taken as one of the chief criteria in the diagnosisof the condition.

Postgraduate Institute of Medicine, E 0.. e ABudapest, Hungary. RN OML.