PHENYLBUTAZONE

139 the dose was collected-a value well within the normal range and much above the value of 4-5% which would be expected for a mild thyrotoxic case with a thyroidrate factor of 0.17. This type of curve for patients who are receiving, or who have recently received, thiouracil has been observed several times and is quite characteristic in leading to a hyperthyroid-rate factor and normal 6-24-hour excretion. Now this is the type of curve that, in varying degree, appears for almost all the urinary excretion results given by McGirr and Hutchinson. It suggests an incomplete thyroid action similar to that obtained with thiouracil, but the secondary release effect appears to be even more distinct in these cases and is probably characteristic of the patients’ condition. The only exception is in case 10 which shows a curve approximately exponential through the whole 24-hour period and corresponding to a thyroid-rate factor of 0.03. Both this and the 6-24-hour excretion of 27-6% are just outside our normal range and would correspond to a slight hypothyroidism. McGirr and Hutchinson do not include this case amongst those showing a large rapid uptake by the thyroid, and it would seem possible that the thyroid function here may be somewhat different and nearer to that of the usual These comments serve to show that examination of the full excretion curve is useful in detecting abnormal patterns of function and helps to avoid misleading conclusions based on single uptake or plasma-iodine estimations. Department of Radiotherapy, R OLIVER R. Churchill Hospital, F. Oxford. F. ELLIS. Oxford.

myxoedema.

experience in a very clear way, and a pregnant woman to read.

is

a

heartening

book

for

F. CHARLOTTE NAISH DOREEN W. STEIN.

York.

SENSITISATION OF NURSING STAFFS TO ANTIBIOTICS

SIR,—There is

practical point I did not see mentioned in the Ministry of Health’s memorandum published in your issue of July 4. Some nurses clean out used syringes by filling them with water, which is then forcibly ejected on to the side of the sink. With a fine needle this procedure gives rise to quite a considerable mist. One nurse was known to be sensitive to streptomycin, and, in spite of rubber gloves, mask, and gown, continued to get one

recurrences after each injection. These recurrences took the form of swelling of the eyelids, forehead, and upper choeks, and erythema of the front of the elbows. Incidentally she wore short sleeves so that an area of both forearms was exposed to the mist. It was only by carefully noting how she worked, and then demonstrating to her the fine mist she produced by her vigorous syringe-cleaning, that it was possible

slight

to

prevent

recurrences.

Possibly

others have had similar

experiences.

G. P. B. WHITWELL.

Chester.

PHENYLBUTAZONE

SIR,—Dr. Hughes (July 4) asks how whether

patient agranulocytosis. He a

counts I do not

see

on

one can

phenylbutazone

will

foretell

develop

states : " short of daily bloodhow the onset of agranulocytosis

be prevented." Unfortunately even with daily blood-counts it is impossible in some cases to predict what will happen ; for fever, sore throat, and malaise may precede changes in the circulating blood by manydays. This is no new thing in therapeutics ; exactly the same fact was noted in the early days of treatment of thyrotoxicosis by antithyroid agents. It was found that the most practical procedure was for patients to report certain symptoms to their practitioners at their first appearance-fever of unexplained origin, sore throat, or skin rashesand to discontinue therapy until such time as they had been seen and their condition assessed by their medical adviser. Exactly the same precaution holds for phenylbutazone. We make it a rule to ask patients on this useful, but all too frequently toxic, drug to report any can

COMFORTABLE CHILDBIRTH SIR,—May we comment on your annotation from a point of view slightly different from that of Dr. Sliila Ransom’s letter ? We deal here with only about 60 cases a year, most of which are domiciliary and the remainder in nursing-homes. One of us (D. W. S.) took a course in antenatal relaxation in the Helen Heardman school before the birth of her first child and has conducted such a class in the practice for the past 21/2 years. The experience leaves us still convinced that analgesia is needed by most mothers, and we entirely agree with Dr. Ransom that it should alwaysbe offered to them. Only once did a mother swear she would refuse it ; and she accepted it gladly (together with our assurance that she had not in any way failed) when labour was advanced. On the other hand we differ a little from Dr. Ransom in We find anteour estimate of antenatal and natal care. natal preparation for the experience essential to a mood of cooperation and exhilaration and a sense of achievement. The atmosphere at the confinement has chiefly negative importance, in that it can easily undo all that has been done beforehand, by whatever means. Our experience also leaves us convinced that the two of your annotation, and gas-and-air subjects " It is not are relaxation," possible totally incompatible. to relax and at the same time make the efforts of inspiration that are needed to draw an effective dose of gas from the machine. Therefore we use other analgesics (mainly pethidine started at half-dilatation) to help our relaxers to gain satisfaction from childbirth. We think it important to appreciate that wherever analgesia is thoughtlessly equated with gas-and-air, a false antithesis between relaxation and analgesia is certain to follow. One of us (F. C. N.) discovered for herself the principles and outlook now called " relaxation " before the birth of her fourth child, and before Dr. Grantly Dick Read published his first book. It is probably true that many thoughtful mothers have acquired this knowledge as a result of the experience of several labours. A medical education may be helpful, but is certainly not necessary. Enid Bagnold’s novel The Squire describes such an "

"

of the above toxic manifestations on their first appearance, and in addition gastric upsets of any sort and oedema of ankles and/or face. As clinical signs of drug intolerance may precede white-cell depression in circulating blood, too much reliance should not be laid on normal haematological findings in the face of symptoms suggestive of drug intolerance. One further point is worth making. Toxic effects may appear as follows : 1. After several weeks or months of therapy. In such reaction is frequently followed by another if therapy is continued, dyspepsia being followed, for instance, by oedema of the face and -ankles, skin rashes, or sometimes bleeding from the stomach, kidney, or elsewhere in the cases one

body. 2. Shortly after re-starting treatment, following a period of withdrawal. This suggests a sensitisation effect. 3. Occasionally with rapid onset after only three or four doses of 200 mg. in patients who have never received this or any similar drug such as amidopyrine previously and who have a completely negative previous history as regards allergic reactions of any sort. One such patient recently under my care-a man with rheumatoid arthritis-derived marked immediate benefit from administration of phenylbutazone, but after receiving only 600 mg. (3 tablets) within a period of thirty-six hours developed a skin rash and pronounced peripheral oedema although he was at the time on a salt intake of only 0-5 g. daily.

140 One cannot, unfortunately, predict how the individual patient will react to phenylbutazone. I have now several patients who have been on regular dosage for periods exceeding nine months with great benefit and no signs of intolerance of any sortII have, unfortunately, many

who have had to discontinue the drug after only few doses. In some cases of rheumatoid disease symptoms have worsened and swelling increased within a few days of starting treatment. We have in phenylbutazone a drug often highly effective in relieving pain in the chronic rheumatic disorders, though all too often this relief is accompanied by toxic effects. Its merits appear to outweigh slightly its demerits, even though on occasion the scales appear to tremble in the balance. F. DUDLEY HART. London, ’%V.1.

more a

SALVAGING OF DRUGS SIR,-Every year an enormous number of drugs have to be discarded because their identity has become unknown or forgotten. Is it not time that every drug dispensed should -have its name, dose, and date of dispensing clearly marked on its container ? Surely in The Pills," these more enlightened days " The Tablets," or The Mixture should be dispensed rarely, and only when especially required by the prescriber. Incidentally it can often be a great help, when one is called to a colleague’s patient in an emergency, to know immediately and unequivocally what the patient is taking, simply by referring to the labels on the containers. SIDNEY G. Gr. HAMILTON. Sa-iider-3tead, Surrey. "

"

"

TRICHOMONAS VAGINITIS

SIR,—May I give my conclusions resulting from reading your leading article of April 4 and the correspondence since then on my letter regarding the gap seat? These conclusions are as follows : 1. The proportion of infection due to venereal disease is a matter of

opinion and guesswork. My figure of 80% nonvenereal is due to seeing many happily married women and many undoubted virgins with the disease. The majority of those affected are parous and 25-40 years old ; their vaginal outlet is larger, more moist, and more likely to rub against the anterior edge of the toilet seat and collect infection. 2. The figures of prevalence-11 % in private cases and 13% in hospital cases-appear large. This is due to every gynaecological patient being examined for this complaint. Several unsuspected cases were thus discovered to be infected, especially among women over 50 with urethral caruncles and among younger women with haemorrhage from incomplete abortions. 3. Cross-infection at gynaecological clinics is a real danger. It is only right, therefore, that fresh gloves be provided for each case examined. 4. Infection may be latent and may flare up after coitus or a vaginal examination. Usually the Trichomonas vaginalis is inactivated by a more acid medium--e.g., pH 4-0-50, such as occurs when monilia or multiple Bacterium, coli are present in the vagina. Local treatment for these infections restores the inert trichomonas to activity, and diagnosis is then easy. 5. Cure can only be declared if no T. vaginalis are discovered in the vagina three months after all treatment has ceased. 6. Infection from the male comes from the presence of T. vaginalis in the urethra ; it occasionally ascends to the seminal vesicles, or it may rest inert but alive under the prepuce ready to reinfect the wife. Sheaths should therefore be worn by the husband until the wife is declared cured. 7. Splash infection from the toilet-basin is an interesting suggestion. I find it not unusual for medical men to fear this possibility as regards bowel infection. They combat it by not only dropping toilet-paper on the water in the pan but flushing out the toilet beforehand. T. vaginalis can live for hours in urine but not for long in plain water, so I think this source of infection is rare. 8. Vaginal infections should not be treated empirically. Unless the microscope is used and vaginal smears taken for report, treatment cannot be efficient and harm can result.

9. There seems general agreement that the lavatory-seat transmit T. vaginalis infection. Action in providing gap seats, especially in hospital inpatient and outpatient departments, is therefore indicated. In addition I believe that all women should be educated to urinate standing erect like the male and thus minimise the danger of infection. can

London, W.I.

McKIM H. MCCULLAGH. W. MCKIM CÆSAREAN SECTION

SIR,—There must be innumerable obstetricians in the Provinces who willjoin with me in deploring the attempt, in your annotation of July 4, to delay the passing of the classical cæsarean operation. Many of us had hoped that after the brilliant exposition of the results of the lower-segment operation given at the 12th Congress of Obstetrics and Gynaecology at Bristol in 1949 the classical section had received a mortal blow.. Although the life-saving properties of the lower-segment operation in cases of gross infection are required less often in this chemotherapeutic decade, it still remains the invariable operation of choice by virtue of the sounder scar and its freedom from adhesions. The less experienced operator may find difficulty with occasional cases of transverse lie or when large dilated veins are present, but the lower segment is still the ideal site for the uterine incision. To suggest that a classical incision should be used when speed is essential is most dangerous teaching. The extra time involved in exposing the lower segment has always been used tenfold in preparing the patient for the operation. To invoke American literature is notoriously misleading, for in the United States a vertical incision in the lower part of the uterus is considered to be a lower-segment operation. I submit, Sir, that our students and graduates should be taught that there are various relative indications for the classical section, depending upon the skill and experience of the operator ; but the only absolute indication remains the performance of the operation post

mortem.

Birmingham.

W. G. MILLS.

JUNIOR MEDICAL STAFFING

SIR,—May we comment further on this subject, with particular reference to Dr. Forrester’s excellent article (June 13) ?’? With most of Dr. Forrester’s observations we are in wholehearted agreement, and he has obviously been to great pains to establish the facts on which his conclusions are based. He refers, however, to a steadily increasing output of doctors from the medical schools of the United Kingdom, whereas the figures cited by him seem to us to show that there has been a more or less steady decline (except perhaps during the war years) in the annual addition to the Medical Register. The lay administrator is almost bound to share Dr. Forrester’s disappointment that " no longer can the young man with his F.R.c.s. settle in general practice and do some surgery." We agree also that the former opportunities of hospital experience as a stepping-stone to more successful general practice seem now to have been completely removed ; and, although in our article (May 23) we were mainly concerned with those on the lowest rungs of the ladder, the time may come when this undervaluation of hospital experience as an asset in all branches of medicine may produce difficulty in the registrar and senior-registrar spheres. Medical men themselves can do much to counter the belief that the ex-registrar is a " failed specialist," and closer liaison of the general practitioner with his local hospitals could do much to help in this direction. We wonder why general practitioners so infrequently visit their patients in hospital, when such a practice should really be encouraged, as is indicated in the recent report by the Central Health