PRESENT AT THE BIRTH

594 any steps he may have taken to exclude other for his unfortunate experience. Might not the saline used have been contaminated ?‘ Was the rubber tubing used above suspicion ?‘l Workers in other fields, for example cardiac catheterisation, well know how difficult it can be even with a most scrupulous technique to avoid occasional toxic reactions to intravenous infusions, due presumably to contamination of the infusion or the not

report

causes

apparatus. Intravenous infusion of A.C.T.H. is a very promising line of treatment and a useful research tool, although it is admittedly still in the experimental stage. I hope that it is in this sense that doctors will continue to use this method for selected patients and that they will not be too discouraged by Dr. Wilson’s adverse report. -

Canadian

Red Cross War Memorial

A. S. DIXON.

Hospital, Taplow, Maidenhead, Berks.

ANTIBIOTICS AND MONILIAL INFECTION

SIR,—in your annotation ot sept. zz you do not mention the urinary tract among the possible sites of monilial infection arising in patients treated with antibiotics. An elderly woman, who had received penicillin as a preliminary to amputation of a gangrenous leg, and streptomycin and chloramphenicol for a coliform cystitis during convalescence from the operation, developed a heavy infection

of the urine with. Candida albicans. With the advent of this infection, coliform organisms disappeared from her urine, only to reappear as the moniliasis receded. There were no urinary symptoms, and the moniliasis subsided without A vaginal swab treatment on stopping the antibiotics. showed a growth of C. albicans, as would be expected.

This

urinary

possibility

further

complicates

infections in similar

West Park Hospital, Macclesfield.

the treatment of

cases.

J. A. SHRIGLEY K. ROWSON.

SMOKERS BEWARE!

SiR,-In his letter last week Dr. Joules has, I think, misconstrued my attitude to the question of smoking and cancer of the lung. My intention was to imply that the evidence so far does not convince me that smoking is responsible for the indisputable annual rise in- deaths from this cause. One cannot expect that any single carcinogenic agent will be found to be the sole cause of such disease. There are many contributory causes-e.g., all bronchial irritants causing chronic hyperaemia and bronchial catarrh (including tobacco smoke), changes in the bronchial mucosa at the male climacteric, and familial predisposition. What we are seeking is an added modern irritant which is causing the alarming increase at the present time. The research being undertaken by Dr. Dunner and Dr. Hicks is important and likely to be productive. I agree entirely with their word of caution, but would urge similar caution in their investigation of the dusts causing pneumoconiosis-i.e., the possibility of these dusts being merely vehicles for other fume-deposited carcinogenic irritants. In docks and other places where the air is often humid and smoky, any dust may carry precipitated vapour-borne substances. A noteworthy comparison is the case of the Cumberland haematiteworkers, in old shafts with rotten wood, escaping pneumoconiosis by the controlling effect of the moist fungus

vapours.l . To Prof. Sidney Russ I am indebted for a personal letter in which, while agreeing that the fumes of crude oil should be incriminated, he suggests that the blackening of the X-ray film in my earliest experiment may have been due to ammonia in the soot scale. The doubtful 1. Fawcitt, R.

Brit. J. Radiol. February, 1951, p. 57.

value of my rather crude experiment is freely admitted. I only ask that this matter be further and fully

investigated. Clifton, Bristol, 8.

HANDLEY B. HOWELL.

PRESENT AT THE BIRTH SiR,-In the spring of this year I had a baby by csesarean section and was conscious throughout the operation. This was the result of earnest consultations between the surgeon, the anaesthetist, and myself; none of us was in favour of a general anaesthetic. I was anxious to avoid unconsciousness because I particularly wished to be present when my baby was born ; and I thought that I should much prefer to know what was happening to me than to come round and find it all over.

Although I had no qualms about the success of the operation, I was apprehensive about the details of it. The birth of my first baby by caesarean had been a most painful experience because the spinal block, though apparently satisfactory from the surgeon’s point of view; was quite unsatisfactory from mine, and after I had heard the child cry and learned her sex, the delivery was completed under general anaesthesia. I wondered whether this would be as painful, and I remember thinking, as I went down to the theatre, that any method of reproduction was more or less unpleasant, and that this after all was what I had asked for. But I reminded myself that it would take little over thirty minutes and that one could bear any discomfort for so short a time as that. Once we reached the anaesthetising room I felt it was too late to ask for any alteration of plan, which was a soothing reflection ; and with the first injection, the slight nausea-which I think must accompany the thought of one’s own body being cut openleft me. The first two (I think) spinal injections felt like any othera sharp prick. After these the others could indeed be felt, but not painfully ; it was almost as though someone were pushing pins into a well-stuffed satin pincushion-not pleasant, but no more than that. There were seemingly long pauses between injections, and my feet, when I was told to raise them against the anaesthetist’s pressure, grew slowly heavier. Then we moved into the theatre itself and I noticed that when Sister raised my legs, in order to disinfect the vagina, they felt quite heavy and numb. The feeling of numbness increased and persisted, extending from the breast-bone downwards. I also felt as though the sere°’en were tickling my nose, though when I complained of this I learned that it was nowhere near me. Towards the end of the operation I was conscious of faint pins-and-needles in my legs, though I had no desire to move them. The removal of the scar of my previous operation was slightly painful-a sharp and continuous prick ; but I was relieved to find, when that was done, that though I could feel pressure and movement in the abdomen well enough to recognise some stages of the operation without watching them, nothing actually hurt except at the lowest inch or so of the wound. The swabbing made me feel very sore, particularly to the left side of the body, but the cuts were not painful; nothing, except the clamping of some large and heavy instrument on to the lower edge of the wound, really hurt. I was glad to be allowed to watch the operation reflected in the mirror above the lights. Apart from being fascinating per se, it gave me something other than myself to think about. In fact I was only recalled unpleasantly to my personal situation twice : once when I heard the anaesthetist read my blood-pressure aloud to the surgeon, and again when the surgeon remarked that the baby was slippery to hold. I admired the rich colours of my abdomen, and was particularly struck with the lavender colour of an organ which after the removal of the baby strayed down towards the wound and was firmly replaced. I should very much have liked a closer view of the baby, but I was more than ever glad to be conscious when I saw him reflected as he lay in my body. My son ; I was there when he was born : I heard his first cry. If one is unable to have a the right way, I am sure that for me at least, and for many like me, this is the next best thing. And vast amount of darning which diow many patients realise the of it? surgeons do-layer upon layer

baby

When it

I felt tired, so that even to think As I was wheeled from the theatre some in and I was asked to tell them what I

was over

was an

effort.

visitors

came

.. a

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.