- Email: [email protected]
DRINKING SEA-WATER
533 I should like again to emphasise that the acute renal changes in cholera are non-inflammatory and nonproliferative.3 These changes, which are temporary and completely reversible,3 are quite unlike those found in other forms of acute and subacute nephritis.
hazard of cooks. The fundal changes are those of opaque nerve-fibres which almost surround the disc on both sides and make the patient instantly recognisable.
occupational
St. Bartholomew’s Hospital, London, E.C.1.
DRINKING SEA-WATER
Infectious Diseases Ward
Chittaranjan Hospital, HEMENDRA NATH CHATTERJEE. Entally, Calcutta.
DISCREPANCIES IN THE ERYTHROCYTE-SEDIMENTATION TEST SiR,-The explanation quoted by Dr. Groen (Feb. 23) is not applicable to the discrepancies in the E.s.R. test we described (Feb. 2). This is made clear in the last two paragraphs under the subheading " Results." We have now seen discrepancies (arithmetical difference between duplicates) in citrated blood of 40 mm., 26 mm., and 18 mm., in addition to less serious ones. We regret that we did not refer to the valuable paper by Strom.4 Our article, however, was primarily concerned with the frequency and possible clinical significance of the discrepancies in rheumatic fever. Clinical Chemotherapeutic W. D. ALEXANDER Research Unit, M. M. ANDREWS. Western Infirmary, Glasgow, W.1. EFFECT OF UNABSORBED RADIOGRAPHIC CONTRAST MEDIA ON THE CENTRAL NERVOUS SYSTEM
SiR,ŃMr. F. L. Davies
K. W. G. HEATHFIELD.
has detailed the adverse effects of unabsorbed contrast media in the subara.chnoid space. He emphasises the desirability of removing as much of the oil as possible after myelography or during
operation. He is particularly
concerned with " diminishing the chances of the substance entering the cranial cavity." Since this is most likely to occur after cervical myelography, I wish to draw attention to the technique of this examination I have described,6which prevents the flow of oil through the foramen magnum, no matter how extreme the degree of Trendelenburg position employed. The principle consists in the maintenance of hyperextension at the atlanto-occipital joint throughout the examination. Tel-Hashomer, Israel.
F. DALITH.
MUNCHAUSEN’S SYNDROME SiR,-The following case of this condition may be recognised by some of your readers : A red-haired cook or post-office worker, aged 44, appears in the casualty department with a history of’ increasing headaches, vomiting, drowsiness, and rapidly deteriorating vision. The optic discs show changes that, to the uninitiated, appear sometimes to be those of optic atrophy, and at others those of bilateral papillcedema ; the visual fields are grossly constricted. She is very obese and states that she has been gaining weight rapidly, and she is usually somewhat reluctant to come into
hospital. X-rays
of the skull show two round burr-holes in the anterior frontal region : the history she gives to account for these is that she had an accident some years ago, and " a clot of blood " was removed from the brain. She also has a muchscarred abdomen with a discharging sinus, alleged to be due to an old tuberculous peritonitis. When surgical measures to relieve the increased intracranial pressure are suggested, she discharges herself from hospital, but discharge can be achieved more rapidly by confronting her with her previous admissions to hospital. I have seen her twice at this hospital, and also twice at Mile End Hospital, and a casualty officer there recognised her as having attended his old hospital, Charing Cross. She has also been in Hillingdon Hospital. The frontal burr-holes for prefrontal leucotorny were, I believe, made at a hospital near London. Obesity is 3. Chatterjee, H. N. Trans. R. Soc. trop. Med. 4. Ström, J. Acta. med. scand. 1938, 96, 365. 5. Davies, F. L. Lancet, 1956, ii, 747. 6. Dalith, F. Radiol, clin. 1956, 25, 212.
men were
rescued
a
does, however, provide
a
very
convincing " natural --
experiment.")
5
Department of Radiology, Government Hospital,
short time ago after Mediterranean. They " Bombard system " and drunk measured amounts of sea-water, as they had no fresh watery Their story has naturally received considerable publicity, and the inference is usually drawn that they survived because they drank sea-water. I believe they were lucky to survive in spite of it, and, in view of the importance of this question to future castaways, I should like to present the results of some calculations I have made. From the point of view of a castaway the important question is whether drinking sea-water increases or decreases the time he can survive without fresh water. A direct experimental answer to this obviously cannot be obtained for man ; all one can do is to attempt to calculate from experimental data how nearly a lethal point has been approached. (A study of mortality in lifeboats after sinkings during the late war23
SiR,ŃThree
drifting for six days on a raft in the are reported to have followed the
Hyg., 1941, 34, 333.
first that the men had not drunk sea-water. In climate such as that over the Mediterranean, which is a favourable one for survival as it is neither cold enough to cause death from cold nor hot enough to cause sweating, an inactive man without food or water loses about 1-3 litres of body-water a day.4 This comes to 7-8 litres in six days, or I % of an average body-weight. This loss might incapacitate a man, but it is well inside lethal limits. Adolph and his associates 5 considered a loss equal to 20% of the body’s weight, incurred rapidly in the desert, likely to cause death ; more severe dehydration can probably be tolerated if the loss takes place slowly. So far as death from dehydration is concerned, it appears that if the men had not drunk sea-water they should have been able to survive for about twice the time they actually were adrift. Further calculation based on the6 excretion of electrolytes by fasting and dehydrated men shows that in six days the osmolar concentration of their body-fluids would have risen by 10%. The castaways are stated to have drunk 3 tablespoonfuls of sea-water every two hours from 6 A.M. till 8 P.M., which amounts to 12 fluid ounces a day. The salinity of the Mediterranean is 3-7-3-8%,’ and so in six days they would have taken in 2 litres of water and 2600 milliosmols of electrolytes, predominantly sodium chloride. If this had been retained in the body, the overall water balance would have been improved by 2 litres, but the osmolar concentration of the fluids of the body would have risen to 28% above normal. Furthermore, sodium is largely confined to the extracellular space ; and this would be expanded, at the expense of cellwater, which would be depleted by a third of its volume. The available experimental datas8suggest that, after the first day of drinking sea-water, increasing amounts of the ingested salt are excreted, at the cost of body-water. Calculation based on the salt excretion and urine volumes found experimentally suggests that at the end of six days the concentration of the men’s body-fluids would have been 24% Their overall water balance would be about above normal. the same as if they had not drunk sea-water, but their cells would have lost proportionately twice as much water as their extracellular fluids. Death can probably be caused by severe hypertonicity alone, or by severe loss of cell-water, or by
Suppose
a
1. Times, Feb. 5, 1957. 2. McCance, R. A., Crosfill, J. W. L., Ungley, C. C., Widdowson, E. M. Spec. Rep. Ser. med. Res. Coun., Lond. 1956, no. 291. 3. Lancet, 1956, ii, 879. G. R. 4. Hervey, A. Proc. nutr. Soc. 1954, 13, 41. R., MoCance, 5. Adolph, E. F., et al. Physiology of Man in the Desert. New York, 1947. 6. Hervey, G. R., McCance, R. A. Proc. roy. Soc. B, 1952, 139, 527. 7. Harvey, H. W. Recent Advances in the Chemistry and Biology of Sea Water. Cambridge, 1945. 8. Ladell, W. S. S. Lancet, 1943, ii, 441. 9. Whillans, M. G., Smith, G. F. M. Canad. J. Res. (E), 1948, 26, 250.
534 a. combination of lesser degrees of both changes.l0-12
The
combination calculated is probably not far short of a lethal level, and it is certainly worse than if the sea-water had not been drunk. Furthermore, the rate at which water was being lost in the urine would be increasing, and at any later time even the overall balance of water would be worse than if sea-water had not been drunk.
Theory thus suggests that, although survival for six days is not incompatible with the amount of sea-water these men drank, it is unlikely that they could have survived for much more than a day or so longer, as compared with the several days possible if they had not drunk sea-water. Even if drinking sea-water does lead to increased well-being in the early stages, all the evidence is that its late effects are disastrous. Castaways cannot know the duration of the " experiment " in advance, and they should on no account drink sea-water. Medical Research Council Department of Experimental Medicine, Cambridge.
G. R. HERVEY.
that their patients will not suffer as a result of whatever action they may take. The public lias now become used to a service from which it can obtain free medical attention and advice, and drugs at a nominal cost. A return to private practice on the part of their doctor would merely send them along to a neighbouring practitioner remaining in the service. This is especially true in the poorer urban areasin which many dissatisfied doctors practise-where the patients might find it difficult to find the money for consultations and visits and impossible to pay for the new and expensive drugs which have been produced since July 5, 1948. The matter is all economic one ; it is political only in that our pay comes from Treasury sources. Should present conditions continue, the standard of medical nractice can onlv deteriorate.
guaranteed
MERVYN GOODMAN.
NEONATAL COLD INJURY
Si,R,-Dr. J. W. Farquhar mentions (Feb. 16)
some
grave dangers warming by short-wave diathermy. If he wants to warm cold babies, internal warming by the Khalil/Mac Keith intragastric balloon 13-l.i is safe and simple. The logic of the method is supported by the work of Andjus,16 Parkes,!7 and others. of
Keats’ House, Guy’s Hospital, London, S.E.1.
PAUL E. POLANI.
GOVERNMENT AND PROFESSION
"DOCTOR" good reasons for patients using the title of doctor when describing physicians and surgeons who may not hold a university doctorate degree, and at the present time it is well to remember them. Past generations of general practitioners, as well as our surviving elders, have been the only freely accessible men with a higher education and integrity. Because of
SiR,ŁThere
this,
are
patients brought problems, demanding time,
sometimes expense, and always wisdom, that were far SiR,-Your excellent editorial last week suffers from removed from medicine or surgery. They were, and One is a defect of memory : on two main defects. sometimes are still, too uncomfortable in the company previous occasions the threat of mass withdrawal has of the priest, too frightened of the police, and too timid been effective and has not harmed the profession, so to consult their headmasters. Politicians might be hard the argument that it is an alien procedure falls to the to trust ;; the lawyers they could not afford. Their ground. The other is that the idea you put forward in doctors were on their side, and patients found that its place-of individual resignation-is perfect, except doctors would care for them and their problems without for the fact that terms of service and remuneration are thought for themselves. negotiated centrally, and not individually, and that I believe this to be true especially in this country, individual resignations are therefore of no value. and perhaps it is a pity that in this country the What is more serious is the way in which you attempt degree is not a doctorate in medicine. It might remind " and give them justification to rally the " fainthearts us of our heritage and assure patients who might be for not following their colleagues. i disturbed in changing times. I know The Lancet tries to be objective and fair. We need to be reminded that our profession is con. LTnfortunately the profession faces a situation where cerned with an ideal rather than materialistic way of " reason " is not likely to be triumphant. It is the most life. It is a service. However excellent our auxiliarv serious situation the profession has ever had to face. we must preserve our right to attend confinements I Literally it is that we must stand absolutely united and of our patients, to vaccinate and inoculate those whose meet force with force or perish. It grieves me that the parents wish us to do it, and to attend old people and editor of a responsible medical journal should not realise report our own cases to geriatric centres. So to those what the issues are. who say that family doctors will not provide for geriatric Two (or is it three ?) wars ago I sat in the fastness of clinics, clinics for school-children, and infants and G.H.Q. in an administrative post. I set myself two maternity patients unless they are paid extra for doing maxims : (a) my colleague-who is also a doctor-at so, we must reply that all these are being done now the scene of operations knows the right answer and it is without this extra payment. my duty to help him to get what he needs ; (b) the Does the public connect with the title of doctora Those same maxims Government is always wrong. code of ethics and a sense of service beyond which hold true today. might be considered reasonable by a physician and J. L. McCALLUM. surgeon?, This is important, because to disillusion the SiB,ŁYour leading article last week suggests that, public, in this would bring discredit. It behoves the rather than a complete withdrawal from the National public and each of us to have the faith that doctors have Health Service, only those general practitioners who are the standard of service and code of behavior dissatisfied with their lot should resign. To lose this and receive badly needed financial assistance From the press and other reports, it would seem that will be no victory. Doctors do not strike. the majority of doctors are dissatisfied with the present JAMES H. S. MORGAN. scale of remuneration, but, come what may, they have FRACTURES OF FEMUR DURING E.C.T. 10. Elkinton, J. R., Taffel, M. J. clin. Invest. 1942, 21, 787. 11. Winkler, A. W., Elkinton, J. R., Hopper, J. jun., Hoff, II. E. Mr. H. D. W. POWELL (Salford Royal Hospital, Ibid, 1944, 23, 103. Salford 3), writes : 12. Elkinton, J. R., Winkler, A. W. War Med. 1944, 6, 241.
qualifying
/1
help,
I
I
Khalil, H. H., Mac Keith, R. C. Brit. med. J. 1954, ii, 734. 14. Khalil, H. H. Proc. R. Soc. Med. 1957, 50, 78. 15. Khalil, H. H. Lancet, Jan. 26, 1957, p. 185. 16. Andjus, R. Cited by Billingham, R. E. Penguin N ew Biology, 13.
1955, 18, 73. 17. Parkes, A. S. See Billingham, R. E. Loc, cit.
L am interested in the orthopaedic problems of simultaneol1’ hitatera.1 fractures of the femoral neck, sustained during convulsive therapy. I should be grateful if anyone who knows of such cases would kindly let me have details of them.
hazard of cooks. The fundal changes are those of opaque nerve-fibres which almost surround the disc on both sides and make the patient instantly recognisable.
occupational
St. Bartholomew’s Hospital, London, E.C.1.
DRINKING SEA-WATER
Infectious Diseases Ward
Chittaranjan Hospital, HEMENDRA NATH CHATTERJEE. Entally, Calcutta.
DISCREPANCIES IN THE ERYTHROCYTE-SEDIMENTATION TEST SiR,-The explanation quoted by Dr. Groen (Feb. 23) is not applicable to the discrepancies in the E.s.R. test we described (Feb. 2). This is made clear in the last two paragraphs under the subheading " Results." We have now seen discrepancies (arithmetical difference between duplicates) in citrated blood of 40 mm., 26 mm., and 18 mm., in addition to less serious ones. We regret that we did not refer to the valuable paper by Strom.4 Our article, however, was primarily concerned with the frequency and possible clinical significance of the discrepancies in rheumatic fever. Clinical Chemotherapeutic W. D. ALEXANDER Research Unit, M. M. ANDREWS. Western Infirmary, Glasgow, W.1. EFFECT OF UNABSORBED RADIOGRAPHIC CONTRAST MEDIA ON THE CENTRAL NERVOUS SYSTEM
SiR,ŃMr. F. L. Davies
K. W. G. HEATHFIELD.
has detailed the adverse effects of unabsorbed contrast media in the subara.chnoid space. He emphasises the desirability of removing as much of the oil as possible after myelography or during
operation. He is particularly
concerned with " diminishing the chances of the substance entering the cranial cavity." Since this is most likely to occur after cervical myelography, I wish to draw attention to the technique of this examination I have described,6which prevents the flow of oil through the foramen magnum, no matter how extreme the degree of Trendelenburg position employed. The principle consists in the maintenance of hyperextension at the atlanto-occipital joint throughout the examination. Tel-Hashomer, Israel.
F. DALITH.
MUNCHAUSEN’S SYNDROME SiR,-The following case of this condition may be recognised by some of your readers : A red-haired cook or post-office worker, aged 44, appears in the casualty department with a history of’ increasing headaches, vomiting, drowsiness, and rapidly deteriorating vision. The optic discs show changes that, to the uninitiated, appear sometimes to be those of optic atrophy, and at others those of bilateral papillcedema ; the visual fields are grossly constricted. She is very obese and states that she has been gaining weight rapidly, and she is usually somewhat reluctant to come into
hospital. X-rays
of the skull show two round burr-holes in the anterior frontal region : the history she gives to account for these is that she had an accident some years ago, and " a clot of blood " was removed from the brain. She also has a muchscarred abdomen with a discharging sinus, alleged to be due to an old tuberculous peritonitis. When surgical measures to relieve the increased intracranial pressure are suggested, she discharges herself from hospital, but discharge can be achieved more rapidly by confronting her with her previous admissions to hospital. I have seen her twice at this hospital, and also twice at Mile End Hospital, and a casualty officer there recognised her as having attended his old hospital, Charing Cross. She has also been in Hillingdon Hospital. The frontal burr-holes for prefrontal leucotorny were, I believe, made at a hospital near London. Obesity is 3. Chatterjee, H. N. Trans. R. Soc. trop. Med. 4. Ström, J. Acta. med. scand. 1938, 96, 365. 5. Davies, F. L. Lancet, 1956, ii, 747. 6. Dalith, F. Radiol, clin. 1956, 25, 212.
men were
rescued
a
does, however, provide
a
very
convincing " natural --
experiment.")
5
Department of Radiology, Government Hospital,
short time ago after Mediterranean. They " Bombard system " and drunk measured amounts of sea-water, as they had no fresh watery Their story has naturally received considerable publicity, and the inference is usually drawn that they survived because they drank sea-water. I believe they were lucky to survive in spite of it, and, in view of the importance of this question to future castaways, I should like to present the results of some calculations I have made. From the point of view of a castaway the important question is whether drinking sea-water increases or decreases the time he can survive without fresh water. A direct experimental answer to this obviously cannot be obtained for man ; all one can do is to attempt to calculate from experimental data how nearly a lethal point has been approached. (A study of mortality in lifeboats after sinkings during the late war23
SiR,ŃThree
drifting for six days on a raft in the are reported to have followed the
Hyg., 1941, 34, 333.
first that the men had not drunk sea-water. In climate such as that over the Mediterranean, which is a favourable one for survival as it is neither cold enough to cause death from cold nor hot enough to cause sweating, an inactive man without food or water loses about 1-3 litres of body-water a day.4 This comes to 7-8 litres in six days, or I % of an average body-weight. This loss might incapacitate a man, but it is well inside lethal limits. Adolph and his associates 5 considered a loss equal to 20% of the body’s weight, incurred rapidly in the desert, likely to cause death ; more severe dehydration can probably be tolerated if the loss takes place slowly. So far as death from dehydration is concerned, it appears that if the men had not drunk sea-water they should have been able to survive for about twice the time they actually were adrift. Further calculation based on the6 excretion of electrolytes by fasting and dehydrated men shows that in six days the osmolar concentration of their body-fluids would have risen by 10%. The castaways are stated to have drunk 3 tablespoonfuls of sea-water every two hours from 6 A.M. till 8 P.M., which amounts to 12 fluid ounces a day. The salinity of the Mediterranean is 3-7-3-8%,’ and so in six days they would have taken in 2 litres of water and 2600 milliosmols of electrolytes, predominantly sodium chloride. If this had been retained in the body, the overall water balance would have been improved by 2 litres, but the osmolar concentration of the fluids of the body would have risen to 28% above normal. Furthermore, sodium is largely confined to the extracellular space ; and this would be expanded, at the expense of cellwater, which would be depleted by a third of its volume. The available experimental datas8suggest that, after the first day of drinking sea-water, increasing amounts of the ingested salt are excreted, at the cost of body-water. Calculation based on the salt excretion and urine volumes found experimentally suggests that at the end of six days the concentration of the men’s body-fluids would have been 24% Their overall water balance would be about above normal. the same as if they had not drunk sea-water, but their cells would have lost proportionately twice as much water as their extracellular fluids. Death can probably be caused by severe hypertonicity alone, or by severe loss of cell-water, or by
Suppose
a
1. Times, Feb. 5, 1957. 2. McCance, R. A., Crosfill, J. W. L., Ungley, C. C., Widdowson, E. M. Spec. Rep. Ser. med. Res. Coun., Lond. 1956, no. 291. 3. Lancet, 1956, ii, 879. G. R. 4. Hervey, A. Proc. nutr. Soc. 1954, 13, 41. R., MoCance, 5. Adolph, E. F., et al. Physiology of Man in the Desert. New York, 1947. 6. Hervey, G. R., McCance, R. A. Proc. roy. Soc. B, 1952, 139, 527. 7. Harvey, H. W. Recent Advances in the Chemistry and Biology of Sea Water. Cambridge, 1945. 8. Ladell, W. S. S. Lancet, 1943, ii, 441. 9. Whillans, M. G., Smith, G. F. M. Canad. J. Res. (E), 1948, 26, 250.
534 a. combination of lesser degrees of both changes.l0-12
The
combination calculated is probably not far short of a lethal level, and it is certainly worse than if the sea-water had not been drunk. Furthermore, the rate at which water was being lost in the urine would be increasing, and at any later time even the overall balance of water would be worse than if sea-water had not been drunk.
Theory thus suggests that, although survival for six days is not incompatible with the amount of sea-water these men drank, it is unlikely that they could have survived for much more than a day or so longer, as compared with the several days possible if they had not drunk sea-water. Even if drinking sea-water does lead to increased well-being in the early stages, all the evidence is that its late effects are disastrous. Castaways cannot know the duration of the " experiment " in advance, and they should on no account drink sea-water. Medical Research Council Department of Experimental Medicine, Cambridge.
G. R. HERVEY.
that their patients will not suffer as a result of whatever action they may take. The public lias now become used to a service from which it can obtain free medical attention and advice, and drugs at a nominal cost. A return to private practice on the part of their doctor would merely send them along to a neighbouring practitioner remaining in the service. This is especially true in the poorer urban areasin which many dissatisfied doctors practise-where the patients might find it difficult to find the money for consultations and visits and impossible to pay for the new and expensive drugs which have been produced since July 5, 1948. The matter is all economic one ; it is political only in that our pay comes from Treasury sources. Should present conditions continue, the standard of medical nractice can onlv deteriorate.
guaranteed
MERVYN GOODMAN.
NEONATAL COLD INJURY
Si,R,-Dr. J. W. Farquhar mentions (Feb. 16)
some
grave dangers warming by short-wave diathermy. If he wants to warm cold babies, internal warming by the Khalil/Mac Keith intragastric balloon 13-l.i is safe and simple. The logic of the method is supported by the work of Andjus,16 Parkes,!7 and others. of
Keats’ House, Guy’s Hospital, London, S.E.1.
PAUL E. POLANI.
GOVERNMENT AND PROFESSION
"DOCTOR" good reasons for patients using the title of doctor when describing physicians and surgeons who may not hold a university doctorate degree, and at the present time it is well to remember them. Past generations of general practitioners, as well as our surviving elders, have been the only freely accessible men with a higher education and integrity. Because of
SiR,ŁThere
this,
are
patients brought problems, demanding time,
sometimes expense, and always wisdom, that were far SiR,-Your excellent editorial last week suffers from removed from medicine or surgery. They were, and One is a defect of memory : on two main defects. sometimes are still, too uncomfortable in the company previous occasions the threat of mass withdrawal has of the priest, too frightened of the police, and too timid been effective and has not harmed the profession, so to consult their headmasters. Politicians might be hard the argument that it is an alien procedure falls to the to trust ;; the lawyers they could not afford. Their ground. The other is that the idea you put forward in doctors were on their side, and patients found that its place-of individual resignation-is perfect, except doctors would care for them and their problems without for the fact that terms of service and remuneration are thought for themselves. negotiated centrally, and not individually, and that I believe this to be true especially in this country, individual resignations are therefore of no value. and perhaps it is a pity that in this country the What is more serious is the way in which you attempt degree is not a doctorate in medicine. It might remind " and give them justification to rally the " fainthearts us of our heritage and assure patients who might be for not following their colleagues. i disturbed in changing times. I know The Lancet tries to be objective and fair. We need to be reminded that our profession is con. LTnfortunately the profession faces a situation where cerned with an ideal rather than materialistic way of " reason " is not likely to be triumphant. It is the most life. It is a service. However excellent our auxiliarv serious situation the profession has ever had to face. we must preserve our right to attend confinements I Literally it is that we must stand absolutely united and of our patients, to vaccinate and inoculate those whose meet force with force or perish. It grieves me that the parents wish us to do it, and to attend old people and editor of a responsible medical journal should not realise report our own cases to geriatric centres. So to those what the issues are. who say that family doctors will not provide for geriatric Two (or is it three ?) wars ago I sat in the fastness of clinics, clinics for school-children, and infants and G.H.Q. in an administrative post. I set myself two maternity patients unless they are paid extra for doing maxims : (a) my colleague-who is also a doctor-at so, we must reply that all these are being done now the scene of operations knows the right answer and it is without this extra payment. my duty to help him to get what he needs ; (b) the Does the public connect with the title of doctora Those same maxims Government is always wrong. code of ethics and a sense of service beyond which hold true today. might be considered reasonable by a physician and J. L. McCALLUM. surgeon?, This is important, because to disillusion the SiB,ŁYour leading article last week suggests that, public, in this would bring discredit. It behoves the rather than a complete withdrawal from the National public and each of us to have the faith that doctors have Health Service, only those general practitioners who are the standard of service and code of behavior dissatisfied with their lot should resign. To lose this and receive badly needed financial assistance From the press and other reports, it would seem that will be no victory. Doctors do not strike. the majority of doctors are dissatisfied with the present JAMES H. S. MORGAN. scale of remuneration, but, come what may, they have FRACTURES OF FEMUR DURING E.C.T. 10. Elkinton, J. R., Taffel, M. J. clin. Invest. 1942, 21, 787. 11. Winkler, A. W., Elkinton, J. R., Hopper, J. jun., Hoff, II. E. Mr. H. D. W. POWELL (Salford Royal Hospital, Ibid, 1944, 23, 103. Salford 3), writes : 12. Elkinton, J. R., Winkler, A. W. War Med. 1944, 6, 241.
qualifying
/1
help,
I
I
Khalil, H. H., Mac Keith, R. C. Brit. med. J. 1954, ii, 734. 14. Khalil, H. H. Proc. R. Soc. Med. 1957, 50, 78. 15. Khalil, H. H. Lancet, Jan. 26, 1957, p. 185. 16. Andjus, R. Cited by Billingham, R. E. Penguin N ew Biology, 13.
1955, 18, 73. 17. Parkes, A. S. See Billingham, R. E. Loc, cit.
L am interested in the orthopaedic problems of simultaneol1’ hitatera.1 fractures of the femoral neck, sustained during convulsive therapy. I should be grateful if anyone who knows of such cases would kindly let me have details of them.