CLINICAL TESTS FOR KETONURIA

1031 same

time

as

explicitly,

if

silently,

in

opposition

ably

like to

see a

clear-cut

rejection

of

Christianity by

dominant opinion and a firm espousal of secular humanism as a means

to mental health. I recommend the

opposite

course.

JOSEPH V. WALKER

Darlington.

Medical Officer of Health.

APPOINTMENT OF REGISTRARS

SIR,—In

your issue of

May 1, six senior registrar posts are advertised by Guy’s Hospital

in various specialties and the South East Metropolitan Regional Hopsital Board. It is stated that preference will be given to applicants who have held a registrar post in the appropriate specialty in a teaching hospital. In your journal, not very many issues ago, the question of junior staffing in peripheral hospitals was discussed and it was agreed that one of the causes of the dearth of applicants for such junior posts was just this tendency to select for the more senior teaching-hospital posts those doctors who were already working in teaching hospitals. Are we now to assume that the South East Metropolitan Regional Hospital Board desire to stimulate this drift from the " country " One wonders how soon it will be before the other regions follow suit, if they have not already done so. It is also demoralising to speculate on the power of the " old school tie " philosophy in the regional boards, which blossoms forth in this type of

prejudice against the non-teaching hospitals. What makes the position more depressing is the present policy of making all senior registrar posts on an exchange basis between the parent teaching hospital and a group of peripheral hospitals. This gives the teaching-hospital boards

greater

power than ever before to influence the of all the senior-registrar posts in their

appointments region. I suggest, Sir, that there is something dubious in this senior-registrar exchange scheme, and that it is made apparent by the prejudice expressed in these advertisements.

REGISTRAR. TEXTBOOK ILLUSTRATIONS SIR,—In his letter of May 8 Mr. Engel really raises two " issues-namely, the supply of opaque " photographs, which lend themselves immediately to textbook illustration ; and sources of transparencies for teaching purposes. In relation to his suggested central library the two problems are slightly different in that the writing of textbooks generally represents individual effort, whereas

these have a common framework : factors must influence the selection of material. Even at the present time it is not difficult to view a reasonable supply of photographic prints of a given subject by contacting a number of photographic depart-

teaching should

copies are generally available. frequently done between departments informally, much to the surprise of medical staff who are unaware of this facility. Arrangements for specialised illustrative techniques may often be arranged on a similar basis. As has been suggested by your correspondent, collections of miniature transparencies would be simple to establish and maintain. This has already been done in America by a commercial firm ; slides being purchased from various departments after which they are duplicated and resold singly or in sets. The resulting turnover is reported to be in the region of 100,000 per yearobviously there is some demand for this service ! ments from which file

This is

Westminster Hospital Medical School. London, S.W.1.

PROLONGED ANURIA

as

when Tertullian contemptuously asked what Athens could expect to find in common with Jerusalem. ’Dr. Comfort, if he remains true to the sentiments expressed in his broadcast talks in 1949, would presum-

PETER HANSELL.

SIR,—We

were

interested in the discussion

on

the

management of prolonged anuria by Prof. Scott Russell and his colleagues in your issue of May 1. We have recently treated 3 similar cases on the same lines and by the infusion of hypertonic dextrose solution into the inferior vena cava via the saphenous vein at the groin. One of us has used this method of intravenous years in all cases where difficulty in has been anticipated—for the infusion maintaining example, while operating with a steep Trendelenburg

infusion for

some

position. In addition to the merits of this method of infusion mentioned in the article, we prefer it because it seems to us technically easier than infusion into the superior vena cava and also because it is appreciably more comfortable for the patient when infusion must be continued for some days. As regards technique, we do not consider it necessary to ligate the main tributaries at the upper end of the saphenous vein; we merely ligate the distal end. Similarly, we find that a gauze pad and ’ Elastoplast ’ gives quite adequate pressure both during infusion and when the catheter is removed. GAVIN SHAW Southern General Hospital, JAMES MAIR. Glasgow. CLINICAL TESTS FOR KETONURIA SIR,—We regret that Dr. Archer and Dr. Lehmann (May 1) were misled into thinking that we wished to decry the method of discovering ketonuria used hitherto. Our comments were directed towards the quantitative interpretation of essentially qualitative clinical tests. Our paper was not intended as a contribution to chemical pathology but rather to the use of these tests in clinical

practice. Dr. Archer and Dr. Lehmann do service to the historical

aspect of the subject in drawing attention to the important papers by Kennaway and Hurtley. One of- the latter’s most important contributions to the Rothera test was his demonstration of the sensitivity of the test to acetoacetic acid, which was unknown to Rothera. Hurtley’s own test, however, is not used in clinical practice. Although the concentrations of aceto-acetic acid and acetone in urine have been well known for many years, the numerous variations in technique in performing the clinical tests have, we believe, prevented a uniform interpretation in clinical practice and have made a standardised procedure desirable. We set out to compare the two classical tests with the tablet test, we made it clear that our sensitivity tests corresponded to those of previous workers, and we referred readers to the review by Friedemann. It is true that Kennaway’s " slow-weak " reaction and similar reactions have been regarded as of no clinical imporWe considered this point and tance by some clinicians. concluded that the significance of such results is still not clear. It is a dangerous assumption to regard them as of no clinical importance until more is known about the problem. A positive test for ketonuria should always be assessed in relation to the clinical state of the patient. Our references to various textbooks were intended not so much as a criticism of the methods described as an illustration of the various descriptions which are current. We agree that when Gerhardt’s test is performed, as described by Harrison, it is usually adequate. We believe, however, that many nurses and clinicians throughout the do not practise thorough boiling in a boiling-tube or open vessel. Indeed, we are certain that many of them possess neither a boiling-tube nor a beaker.

country

’

,

Dr. Archer and Dr. Lehmann conclude that because the tablet test is a " dehydrated," less sensitive Rothera test it has no advantages in the laboratory. We think that they should have more adequate reasons for what seems to us a hasty and illogical condemnation. We

1032 agree that a rapid laboratory method for estimation of ketones is long overdue. We fully agree with Dr. Kay (May 1) that dilution is often a useful procedure, which we have used from time to time. The use of a nitroprusside crystal is also convenient. We were concerned, however, to describe a standardised technique rather than to describe the many variations which can be usefully applied by those who prefer to develop a personal method. JOHN NASH JOHN LISTER Royal Free Hospital, D. H. VOBES. London, W.C.1. -

--

CONGENITAL PYLORIC STENOSIS

SIR,—The influence of heredity in pyloric stenosis is in uniovular and records such as that family published by Dr. Carter and Dr. Powell in their article of April 10. In a pedigree which I described,! the disease appeared in three generations of a family. Two males and two females . were affected, and another female had otosclerosis (see accompanying figure). The diagnosis in all three generations was confirmed by operation. shown

by

those

cases

which

occur

binovular twins, and by

One used to read in textbooks that the disease affected more males than females, in the ratio 9 : 1. Nowadays; it seems that more females are affected, and, Pyloric stenosis in our experience, the ratio is 7 males to 3 females. Otoscierosis In very debilitated patients in whom medical treatment is given a trial, we do not persist with this treatment for more than 3 days. As a rule, we choose operation as the best and quickest means of treatment. We begin feeding the patients 6 hours after operation, and it is usually possible to send them home within 2 weeks.

)

Hilversum, Holland.

D. P. R. KEIZER.

JUVENILE SPRING ERUPTION

juvenile spring eruption affecting children’s reported by Dr. Anderson and her colleagues in your issue of April 10, is not uncommon in that, as they mention, sporadic cases are seen by general practitioners and dermatologists in most years. Most practitioners usually seem to attribute it to a perniosis effect. This " epidemic " in a holiday camp is similar to a minor one which I have just seen in a primary school at Windhill, Shipley. SIR,— The

ears

At this school 25 boys were found to have such lesions on their ears. No girls were affected. The boys’ ages were 8-11 years. All had developed the ear lesions between April 21 and 29, 1954. They were on Easter holiday over this period until April 29. The lesions varied in intensity from moderate (papules and vesicles) in 3 cases (12%) and mild (erythema and papules) in 14 (56%) to slight (erythema and scaling) in 8 (32%). Only 1 boy, aged 9, had had similar lesions on his ears each spring since he was 7 years old. Another boy thought the lesions might be due to his pet budgerigar playfully pecking his ears. None of these boys had lesions on the hands or elsewhere. The weather during this period was cold and dry. Reports ’from the meteorological station at Lister Park, Bradford (2 miles away) showed that the winds were north-easterly from April 21 to 28, varying from light air to gentle breeze (2-9 knots). No rain fell during this time. The maximum thermometer reading was low for the time of year, varying from 45° to 56°F. The number of hours of sunshine per day was also low ; it was zero on two of the days with much cloud, and the highest figure was 8.1 hours on April 28, when 7 (21%) of the cases developed. Being on holiday, these boys had been out of doors most of the time. They had been bird-watching (modern term for bird-nesting), walking on the moors, playing football, cricket, or marbles, or out on bicycles. Many of them said that their mothers made them wear balaclava or leather helmets covering 1.

Keizer, D. P. R.

Pédiatrie, 1952, 7, 1.

the

in cold winter weather, but they had worn no headThe district in which a cap only) during this spell. live is well described by its name-Windhill.

ears

gear

they

(or

I think this is an exposure dermatosis in which cold, in the form of prolonged exposure to cold winds, is a more important factor than the actinic rays suggested by Dr. Anderson and her colleagues. Moreover, apart from the protection afforded the girls by the long hair over their ears, they are more likely to stay indoors helping their mothers or to play in more sheltered places. The reason for the age-inoidence, 8-11 years, remains for conjecture ;it may be that boys of this age have reached a stage of independence when they are more likely to remain outdoors longer than their younger brothers, but their ears are still more prone to perniotic influences than their older brothers. I am indebted to Dr. G. Buckle, school medical officer

Shipley,

for

calling

Royal Infirmary, Bradfcrd.

my attention to this outbreak.

W. E. ALDERSON.

HASHIMOTO’S STRUMA LYMPHOMATOSA SIR,—Dr. Cooke and Dr. Wilder, in their letter of May 8, say : " There is wide agreement about the histological changes in the thyroid-apart perhaps from how much fibrosis to allow before changing the name to Riedel’s disease." This implies, though I doubt if that is what they intended, that the one condition can progress to the other. Clinically the distinction is clear, since Hashimoto’s disease is confined to women of middle to late age and inevitably leads to hypothyroidism, while Riedel’s disease occurs in both sexes, at all ages, and so far as I know never produces hypothyroidism. The degree of fibrosis in a section can do nothing to alter this distinction ; and since in my experience neither condition is rare, I feel it is important to keep the separation clear. Diminution in size of the gland in Hashimoto’s disease with oral thyroid medication does not seem to occur in later cases, presumably because of the increased fibrosis, and in these thyroidectomy in addition is still often

called for. London, W.1.

E. G. SLESINGER.

THE SAD TALE OF MRS. SMITH SIR,—I am grateful to the Widdicombe File (May 1) for introducing me to " Our Rita " and her family. Her doctor says that she is a high-grade mental detective. but, if that is so, I do not think she has done such a bad job. Like Dr. Brewer I deprecate the fleas, the dirt, and the smell, though I doubt if these are directly attributable to the size of her family, for similar conditions may be found in quite small families. But Rita, on her allowance of 14 a week plus family allowances, keeps her family " surprisingly robust "-on the wrong kinds of food, of course. It must also be admitted that they

ragged clothes, that they have no curtains, that garden needs weeding, and that they have a television, but the garments are said to be adequate to keep them warm : nor are they unhappy. True, one of the children in the churchyard lies, but, when all has been said, there are no problem children or juvenile delinquents among the remainder. Perhaps on E7a week Rita and her husband should

wear

their

have had fewer children. As it is Rita leaves the Dutch cap and the spermicidal cream in the cupboard unused, and her husband, not too successfully it seems, still resorts to coitus interruptus. I fear I am like Rita: I cannot see that one method is very much worse than the other, though I repudiate both. At any rate, Rita and her husband do not appear to be heading for the divorce court. And there is still hope for her, because she is not going to be sterilised ! I wonder how many children Rita should have had. Perhaps two. But if you told that to the five additional children who have