A QUESTION OF NEGLIGENCE

425 These cases were sible for a non-medical individual to walk into a doses for hypnotic purposes. recorded in detail at a recent meeting of the Royal druggist’s store, as at present, and to buy a bottle Society of Medicine on Dec. 12th, 1933, at which of barbiturate across the counter with no questions Dr. Gillespie read his original paper, but they have asked. Only last week I saw a patient who had thus secured 50 tablets of Sandoptal, a powerful barbiapparently escaped his attention. 2. With regard to suicides, the statistical records turate, with which she attempted suicide-and by the Registrar-General, as quoted by Dr. Gillespie, nearly succeeded. show 12 barbituric suicides out of 5147 in 1931, and I am, Sir, yours faithfully, 20 barbituric suicides out of 5743 in 1932. This J. PURVES-STEWART. looks as if the percentage of barbituric suicides were Feb. 1934. Buckingham-street, S.W., 21st, somewhere between 0-26 and 0-4 per cent. But these figures undoubtedly understate the true condition ADENOID AND TONSIL OPERATIONS of affairs. Some cases of suicide are camouflaged as accidental deaths. Other cases of attempted suicide, To the Editor of THE LANCET where lethal doses of barbiturates have been taken, SiR,—Mr. Denis Browne says that many general are rescued by appropriate energetic treatment. feel disinclined to hand their patients to the Sir William Willcox tells us that during 1933 he surgeons throat surgeon " once it has been decided upon " to has treated 18 cases, whilst I myself have treated It is this decision which is so remove the tonsils. 6 such cases within the last 7 months (3 of them there must be many general whilst and, important, in conjunction with Sir William Willcox). Details of some of these cases have recently been published surgeons who are capable of removing the tonsils in THE LANCET (Jan. 6th, 1934, p. 6). Others are completely and well, it requires considerable experience contained in a joint paper by Sir William Willcox in the examination of the upper air-passages to and myself, which has since been submitted to you. eliminate conditions such as sinusitis. One not infrequently sees patients who have had Apart from personal experiences of this sort, the their tonsils removed, and whose symptoms persist. recent in weeks has a series of daily press published In many of these patients there is present on the cases of suicide by barbiturate drugs. Only to-day (Feb. 21st) two barbiturate suicides are recorded posterior pharyngeal wall bands of lymphoid tissue which show that there is infection present in the nose. on the same day, one at Battersea, the other at Eastbourne. The increasing frequency of barbi- Had this condition been realised before, an unnecessary operation on the throat might have been avoided. turate suicidal attempts, therefore, cannot be denied. It is for this reason that these cases are better in the 3. That the barbiturates sometimes give rise to addiction I stoutly assert. I know many cases in hands of those who are most qualified to make a which the patient has taken a nightly therapeutic complete examination of the nose and throat. dose of a barbiturate for many years and finds himI am, Sir, yours faithfully, self unable to sleep without it. Some of your correT. D. DEIGHTON. Cheltenham, Feb. 16th, 1934. spondents consider this an entirely innocuous habit, to which the stigma of drug-addiction ought not to A QUESTION OF NEGLIGENCE be attached. Much depends upon how drug-addiction is to be To the Editor of THE LANCET defined. To my mind, drug-addiction means a SiR,-In raising the perennial issue of the negligent chronic condition of physical and mental abnormality doctor, Dr. Molloy must be aware that the case panel in which the individual not only habitually consumes he mentioned is probably exceptional, and that a some special drug but also, if his particular drug is amount of good work is going on quietly and large cut off, he hungers for it and finds himself unable under the panel system. The treat. unobtrusively to live his ordinary life (or in a case of a hypnotic of ment domestic servants is a thankless task at best, drug, unable to secure his ordinary sleep) without since, in sickness, the interests of mistress and maid and sometimes even with dangerous grave discomfort A degree of temporary are opposed. In the particular instance, the negligence withdrawal symptoms. was so gross that one cannot help wondering what euphoria or mental exhilaration whilst under the the panel doctor was suffering from : was it overinfluence of the drug occurs in some forms of drugwork, callousness, avarice, or what ? The answer is addiction, but is not invariably present. Some drug; he was suffering from pique. Neither he addicts-e.g., morphinists-do not become euphoric, simple nor the panel system are altogether at fault for this ; but simply acquire a temporary alleviation of their Dr. himself, gives the reason ; " (my friend) misery or drug-hunger, requiring progressively in- thenMolloy, her own doctor." Why had she not sent for creasing doses to attain this condition. done this at first ?-because her own doctor was not are Some drugs such as tea, coffee, tobacco, &c., on the panel. So she sent for another doctor to treat relatively so mild in their symptoms of addiction her cook ; and " he knew, and she knew, and he knew that they rarely call for treatment. Others, such as alcohol and the morphine derivatives, are univer- that she knew, and she knew that he knew that she that she considered him inferior. Hence his sally recognised as a serious menace to the patient’s knew "and his negligence. health. In which category are we to place the pique Why is her family doctor not on the panel1 Do barbiturates’! Sir Maurice Craig and those who agree with him regard them as almost innocuous in thera- not the poor need as good doctors as the rich ? Is he peutic dosage. Sir William Willcox, on the other too clever, or too much of a gentleman1 Is he a snob, hand, regards them so seriously that he does not or does he merely defer to the snobbery of his patients ? prescribe them himself, because of the danger of It matters little ; there lies the rub. Pique is not a their possible abuse. It seems to me that the truth noble sentiment, but it is one from which nobody is lies between these two extremes. The fact that the altogether immune. " Who has a breast so pure, barbiturates are powerful and potentially dangerous but some (unworthy) apprehensions keep leets and drugs need not prevent us from prescribing them law days, and in session sit with meditations with due care in suitable cases, just as we prescribe lawful other powerful drugs. But it ought not to be posWhat is the remedy ?Dr. Molloy is right in thinking s

"

426 that

a

national medical service will not

cure

it:

people cannot be made virtuous by Act of Parliament. Is it possible to raise the social esteem of the panel doctor to that of officers in the Navy, Army, or Air Force, by regarding him as a commissioned officer in the National Insurance Service1 Not yet : the panel doctor has still to show himself worthy of this esteem, and this cannot be done by acts of negligence. Grudging service is bad service, and unless panel doctors are prepared to do more than is required of them by law, they are and will remain inferior doctors. Those panel doctors, and they are not few, who are doing their work conscientiously and with good-will, must for the present content themselves in the knowledge that " some kinds of baseness are nobly underI am, Sir, yours Westgate-on-Sea, Feb. 16th, 1934.

gone."

AN ESSAY IN

faithfully, FREWEN MOOR.

SEX DETERMINATION

To the Editor

of

THE LANCET

SiE,—Some years ago it was suggested that the chemical reaction of the vaginal secretion at the time of coitus might influence the sex of the resulting child.! It is now generally agreed that, in the human species, the spermatozoa are of two kinds-differing in the number of their chromosomes : one variety is believed to be potentially male, the other female. The human female ova are, of themselves, asexual. If an ovum is fertilised by a " male " spermatozoon, the resulting child is a son-if by a " female " spermatozoon it is a daughter. Work done in Germany and elsewhere seems to show that a relatively alkaline secretion favours fertilisation by the male spermatozoa, while an acid secretion favours fertilisation by the female, and this opens up the possibility of prearranging the sex of offspring. In inquiring into this possibility we have collected information from a few women who were examined at frequent intervals over a period of several months, and also from others who were examined two or three times. We were of opinion that the reaction of the vaginal secretion would probably vary during the intermenstrual period-though this has been denied by some workers-and therefore it seemed desirable to make examinations in each case at different stages of the cycle. The details of the patient’s life had to be ascertained-since obviously the use of douches and certain contraceptives will alter the secretion. The material for examination was collected from the vagina on a camel-hair brush and its pH determined by a micro-colorimetric method. Usually the reaction of the cervical secretion was also tested. Tentative conclusions from the observations so far made may be summarised as follows :1. Variations in the pH of the vaginal and cervical secretions do occur, in most cases, during the intermenstrual period. The cervical variations are usually small and do not necessarily run parallel with the vaginal variations, which are often well marked. 2. The vaginal secretion is usually nearly neutral immediately after a period and as a rule becomes progressively more acid until the next period. It is important to note, however, that in some cases the postmenstrual neutrality may be replaced by acidity in a day or two, while in others the secretion is definitely-acid after the period and remains so or becomes more acid. 3. We think it probable that variations in any one person tend to be constant under uniform conditions. 4. The vaginal reaction may be modified by local treatment and, owing to a flow of alkaline secretion from

the cervix,

by sexual relations. 1

See THE LANCET, 1930, i., 475.

5. It is likely, as certain German workers have stated, that the different types of variation in reaction are associated with different vaginal bacterial flora ; but we do not think that, for our purpose, any classification on these lines would be helpful. Rather would we emphasise that each case must be treated individually, since the nature and the amount of secretion present are also of importance and these depend on pathological lesions, sexual life, and hygiene.

If information is sought on the prearrangement of sex, advice may be given on the acid-alkali assumption, but it must be pointed out that results cannot be guaranteed ; and if any useful advice is to be given, preliminary investigations must be made. At least three examinations are required, at various times during an intermenstrual period, and while they are in progress there should be no intercourse and, of course, no douches. In this way it may be discovered when the natural secretion is most advantageous for the sex desired, and appropriate treatment and times of coitus can be arranged accordingly. It seems probable that a medium which is either too acid or too alkaline will cause sterility. If the treatment is given by a douche, the time of the douching in relation to intercourse is important, depending on the nature and amount of natural secretion ; theuse of a douche of any kind shortly before intercourse often seems to prevent pregnancy. Local treatment by means of pessaries is, we consider, undesirable, for they do not always dissolve at the right time or uniformly with the secretion present in the vagina, and the usual bases of pessaries are inappropriate for the purpose. Our work on these lines has not been long in progress and we are still awaiting a number of Two cases already delivered have been results. successful, and in view of the fact that other published results seem to deal exclusively with the production of sons, it may be worth noting that one of these produced a daughter, as desired.

We are, Sir, yours faithfully, HAROLD TAYLOR, KIRWAN-TAYLOR. GORDON KIRWAN-TAYLOR London, W., Feb. 17th

1934.

CARBON DIOXIDE IN GENERAL PRACTICE To the Editor

of THE single hour

LANCET

of general practice SIR,-During one last week the value of carbon-dioxide resuscitation was very strongly brought home to me by three events : (1) a mother with respiratory failure under chloroform during an instrumental labour, (2) the child which required artificial respiration before it breathed, (3) as soon as I had returned to my house, a road accident in which a youth received severe multiple injuries through contact with a motor vehicle. When I arrived on the scene he was unconscious, almost pulseless, and his breathing nearly imperceptible. I applied a diluted carbon-dioxide-air mixture under a facepiece for a few moments while I examined him. His breathing and pulse improved, and he was fully conscious when he was loaded into the ambulance, although his injuries included broken ribs, a fractured shoulder, and a leg which was crushed from the thigh to the ankle. I feel confident that many of our road fatalities are due to respiratory failure within the first few moments after the accident, which carbon dioxide, made available by a portable supply, might do much to

prevent.-I

Hemel

am,

Hempstead,

Sir, yours faithfully,

Feb. 17th.

GILBERT BURNET.