DIABETIC INTERMITTENT CLAUDICATION

595 of this extradural block. I could only say I felt that more speech was expected of me, no other word or comment came to my blank mind ; and having tried the patience of my surgeon and the theatre staff with my chatter throughout, I now had no words to express my sense of satisfaction and gratitude. AURELIA.

thought

"

Excellent " ; for although

URINARY 17-KETOSTEROID ESTIMATION .

SiR,—This estimation is now often made for clinical purposes, but by methods varying in minor ways, so that the results obtained in different laboratories are The committee on clinical not always comparable. of the Medical Research Council has endocrinology therefore prepared an account of a standard method with which other methods can be compared.* It should then be possible to calculate all results in standard terms by using suitable factors when necessary. It is suggested that such results should be reported as "... mg. 17-Ks (M.R.C. method 1951)." A cyclostyled description of this proposed standard method is now available at the offices of the Medical Research Council, 38, Old Queen Street, London, S.W.I, and will be sent to any laboratory on request. Department of Pharmacology, J. H. GADDUM University New Buildings, .

Teviot Place, Edinburgh.

Postgraduate Medical School of London, W.12.

Chairman.

RUSSELL FRASER Hon. Secretary.

A TRAGIC PARADOX

biR,—T-be " tragic paradox to which your

corre-

spondents1

prefer needs further thought. There can be no doubt that the boy wanting to go in for medicine, who was made to give up Greek a year or two before he left school, in order that he might qualify for entry to Oxford or Cambridge, would have done better to forget Oxford and Cambridge, continue his Greek, and then go to one of the younger provincial universities or come up to us in the Metropolis. Not only is it a sad thing for the boy to discontinue his general education prematurely : it is also sad for the profession. We badly need men with general culture. The country has for years been going through a transition in this. Science had begun to storm the citadel of the classics sixty years ago. Unfortunately the defenders, being clergymen, set most store by Latin, which was more closely related to Church affairs, and surrendered Greek-the language we most need. While Rome gave us roads and law, Greece gave us thought ; and for us to lose anyone with some Greek is the greater loss till the transition is past and history has taken the place of the classics in general culture as Trevelyan has prophesied it will. In 1933 a conference on medical education was held by all those examining bodies that had students doing their clinical medicine in London. It was a strong body, with the late Sir Farquhar Buzzard, representing Oxford, in the chair. We examined many witnesses, including the headmasters of the leading London public schools. With these we had a friendly disagreement as to whether the school or the medical school could better teach the preliminary sciences of the first M.B. ; but we were unanimous that if, a year before he had to leave, a boy could get through an examination that would admit him to any of our universities, and if he had a special bent, he should be allowed to follow that bent with a limited amount of routine class-work. If the bent was towards one of the preliminary sciences, then it would be well for him to follow it by reading for the first 1.LB. of the university to which he hoped to go ; ‘

* The committee’s report is set out on p. 585.—ED. L. 1. Lancet, 1951, i, 1367, 1417; Aug. 11, p. 266 ; Sept. 1, p. 400 ;

Sept. 15,

p.

500 ; Sept. 22, p. 545.

but if it lent towards the classics, or history, or literature, or if it took the form of a nature study such as collecting butterflies, studying spiders or beetles, or chipping out fossils from a local chalk-pit, these should be similarly

recognised. In the medical chools of London we particularly looked to the two medieval monastic universities to supply us with this type of man. If it be true that by their regulations these two universities are suppressing the very education for which we looked up to them, it is

much to be London,

regretted.

W.I.

T. B. LAYTON.

DIAMINODIPHENYLSULPHONE IN LEPROSY SiR,—We were most interested to read of Dr. Wheate’s

experiences with diaminodiphenylsulphone (D.A.D.P.S.) in leprosy in Uganda, since it is only from such reports from various countries that a final appreciation of the drug can be made. Dr. Wheate, referring to our article of Aug. 4, says that we did not follow the dosage recommended by Lowe, who increases to 200 mg. daily only after six weeks on 100 mg." We followed the regime recommended by Lowe last year, when he wrote: "The dosage was 100 mg. a day for two weeks, 200 mg. a day for two weeks, and the standard dose of 300 mg. a day from the fifth "

week onwards."1 Because of the known toxic effects we decided not to prescribe more than 200 mg. a day. Dr. Wheate says that on the appearance of toxic manifestations we did not modify the initial dose. We did not do so’ because the toxic signs did not occur in the initial phase but during the second month when the dose was 200 mg. a day, and this we did modify as reported. He also says that we did not take any to desensitise our patients. This is quite true-we preferred to change the treatment to thiosemicarbazone in those who had been sensitised. Our conclusions on the toxicity of the mother sulphone were not based exclusively on our local experiences as suggested, but also on the evidence of the various workers from various parts of the world whom we quoted. Of 657 patients treated with 1-5 g.Sulphetrone subcutaneously biweekly, as recommended by Cochrane, over a period of two years only 1 suffered the sulphone svndrome which we noted in 7 of the 153 cases treated with D.A.D.P.S. J. BARNES. Dublin.

steps

DIABETIC INTERMITTENT CLAUDICATION

SiR,-Relief from the symptoms claudication by plete. For this

non-operative reason

the

of intermittent is rarely comcase is reported.

measures

following

A married woman,

aged 58 years, had been complaining of severe cramp-like pains in the calves for the previous six months, always brought on by exertion and relieved by rest. Because of her increasing incapacity her family doctor had referred her to another hospital, where a course- of vitamin E was prescribed ; but no symptomatic relief resulted. During the subsequent weeks fresh symptoms appeared. She became thirsty, passed a great deal of urine, and began to lose weight ; and on re-examination her family doctor discovered sugar in her urine and referred her again to hospital. At the diabetic clinic of this hospital she admitted to undue lassitude and fatigue and to paraesthesia in the legs, in addition to her symptoms of diabetes. There had been no recent history of sepsis. She told us that she ’was unable to walk for more than 50 yards without experiencing severe cramplike pains in the calves, which disappeared completely after a few minutes rest, and that the administration of vitamin E had afforded no relief from those symptoms. She was a healthy-looking woman, of average build. No abnormalities were noted in the heart or lungs. Ophthalmoscopy revealed no evidence of retinitis, and her blood-pressure was 222/110 nun. Hg. The peripheral arterial pulsation appeared normal to palpation, and the alimentary system 1. Lowe, J.

Lancet, 1950, i, 145.

596 and

central

system were also normal. X-ray legs showed no significant arterial calcifitesting with Benedict’s qualitative solution

nervous

examination of the

cation. Urine gave an orange reaction ;

albumin

was

not detected.

The

glucose-tolerance curve was typical of diabetes mellitus. When all investigations were completed she was instructed in dieting, advised to take 10 black lines from Lawrence’s line-diet scheme with red lines in moderation, and told to discontinue taking vitamin E. Two weeks later she was no longer complaining of thirst and polyuria, and she stated that she was now able to walk two miles without cramps in the legs. We have continued to there has been no recurrence of the leg see her regularly ; symptoms, while the diabetic control, as judged by periodic urine testing and blood-sugar estimations, has been excellent. I have been unable to discover any account of a case. Rundles1 mentioned a calf pain, described as tearing, in subjects with diabetic neuropathy ; this was brought on by mild exertion but not relieved promptly by resting. ’Ve have noted similar cases among It is suggested that in the case our diabetic patients. described here the improved metabolism following careful dieting brought about the disappearance of the intermittent claudication, and that routine urine testing in neurovascular and other outpatient clinics may reveal

similar

similar I

am

cases.

indebted to Dr. M. L. Thomson for

publish this

permission

to

case.

J. C. HERAPATH.

Salford Royal Hospital.

RETENTION OF URINE DURING STREPTOMYCIN THERAPY

find no report of urinary retention comadministration of streptomycin. Within the last year or so I have seen 5 cases of urinary retention developing 1-5 days after the start of streptomycin therapy. The 5 patients were men, aged 40-70 years, who were under treatment for Bact. coli infection of the urinary tract ; 3 were found on rectal examination to have a moderately enlarged prostate gland. In each of the 5 cases the retention proved refractory to the usual remedies, and repeated catheterisation was necessary. Normal flow of urine was not restored in any while streptomycin therapy was continued. In all cases normal flow of urine was restored 1-3 days after

SIR,-I

can

plicating the

streptomycin injections

were

stopped.

I have seen no such complication in a much larger group of tuberculosis patients to whom streptomycin was administered in larger doses and for longer periods. So far I have observed urinary retention only in middleaged and elderly men with urinary infection, with or without Datholosicallv enlarged prostates. RUSTOM JAL VAKIL. Bombay, India. PURULENT PAROTITIS IN THE NEWBORN SiR,-Having read Dr. W. A. B.- Campbe]Ll’s article of Sept. 1, I should like to record a similar case. A female infant, born normally at full term and breastfed, developed in her, fifth week a temperature of 100°F. Examined on Jan. 28, 1951, she had a tender right parotid with no evidence of any buccal infection and no pus from Stensen’s duct. There was no sign of any other system being involved and she continued to take her feeds well. Systemic penicillin was given and hot bathings were undertaken. After three days pus could be expressed from Stensen’s duct, and on- culture the micro-organism proved to be a staphylococcus sensitive to penicillin, By the eighth day (Feb. 8) the discharge had ceased, but two days later the gland became swollen and this time discharged into the external auditory meatus and from the duct into the mouth. On Feb. 20 the baby appeared well but the mother said that the gland became swollen at feeding-time and that pus discharged into the mouth. The gland was palpable and tender. Penicillin therapy was continued. Radiography revealed no evidence of a parotid calculus, though the plates did not justify its complete exclusion. 1. Rundles, R. W.

Medicine, 1945, 24, 111.

On March 1 there was no further discharge and penicillin discontinued. When seen this month, the baby was very fit and gaining weight and there was no sign of any was

glandular enlargement. Hackney Hospital, London, E.9.

R. F. READ.

THE IRON CURTAIN IN HOSPITAL

SIR,-Not only patients get sore heads from bumping into that hospital iron curtain. When I saw her, alone in her flat, the nose of a middle-aged retired nurse, staying with friends, had bled for four hours. Over half an hour’s persuasive therapy failed to stop it ; so I took her in my car to the ex-infirmary-a friend in need for many years. The porter said " Good morning, sir ; we haven’t seen you here for quite a while. You know where to go." So I went to Reception, knocked and entered. I introduced myself and patient to a staff-nurse (not busy) and explained my errand. She cut me short : would I like to see the doctor I would. The resident was at leisure, seated ; he continued his cigarette. I explained myself again ; he indicated that he would see my patient but made no move to do so. He bowed me out and I retired in fair order, passing my patient and the nurses on the way. The patient was admitted and effectively treated, but the pleasant glow I had from the porter’s greeting was gone when I left the gate. Next time the patient was another elderly lady, alone in her house with a newly broken, very painful wrist. I took her to the local ex-voluntary hospital, now a branch of a teaching school. We walked, as bid, down the passage to Casualty, drowsy in the stillness of a summer afternoon. A large, formidable sister sat knitting in the plaster room. I had the effrontery to approach her, hat in hand but unannounced, through the half-open door. Nothing moved but her eyes and lips; she withered me with a look, bade us wait round the corner, and went on knitting. The clang of the falling curtain could have been heard across the street. We found an unoccupied room with a chair and, after a becoming interval, a house-surgeon arrived and took over. Treatment was quite efficient. It takes me back to a day, maybe thirty-four years ago, when I strayed from the warm-hearted hospitable forward area to a c.c.s., to inquire after a soldier patient I had sent down the line. The bruise I got from knocking against the curtain that day-has never quite resolved. With all this shortage of steel isn’t it time it was scrapped NORTH LONDON PRACTITIONER. SiR,—While I agree that patients are not told enough, may I, as a G.P. of eight years’ experience in the London area, pay a tribute to the humane handling of some of my patients at the teaching hospitals ?’? In particular, I should like to mention the Chelsea Hospital for Women, with a record of no complaints from any of my patients over eight years ; St. Thomas’s Hospital, which has given me endless assistance without any " red tape " ; and finally, Barts, which admitted a patient who had gone into premature labour at a time in the war when their maternity unit had been evacuated. I arranged to drive this patient to hospital myself, to save time, and I was delighted, when we drew up, to find a porter waiting, who came forward and greeted my patient by her name. It made all the difference to her, and she went happily away on her trolley, feeling she was in good hands. It is this kindly touch, in the tradition of our teaching hospitals, which I fear may get lost amid the present pressure of work. SOUTH LONDON PRACTITIONER. SiR,-Yo-ur correspondent, in her article of Sept. 15, suggests that in hospital use is made not only of an iron curtain but of a rod of the same element. This criticism is in general less valid today than formerly, but I do- agree with her about the apparent conspiracy