PRISONS

948

being less characteristic of mongolism than the rest. Almost three-quarters of the mongols have three or more of these characters, but only 6 out of 350 unselected patients have three or more. Any defective with four or more of these characters is almost certainly a mongol." 0ster 22: I have selected ten of the signs, which must-on rough estimate-be regarded as ’characteristic ’ of mongolism, and which are known by experience to be rare in normals, and have called them cardinal signs. These are: (1) four-finger line; (2) short crooked fifth finger; (3) short broad hands; (4) hyperflexibility; (5) oblique palpebral fissures; (6) epicanthus; (7) furrowed tongue; (8) irregular, abnormal sets of teeth; (9) narrow high palate; (10) flat occiput (brachycephaly). Taken "

as a whole we may say, that mental defectives with four or more ’cardinal signs ’ in all probability are mongols, but that also many with fewer signs must be included in this group, owing to the presence of several other stigmata." Thus our patient seems to fulfil the diagnostic criteria stated by Penrose and 0ster; and comparison with the signs tabulated by Levinson et al. 23 also supports this diagnosis. I certainly agree with the suggestion of Hamerton and Polani that patients with Down’s syndrome found to have normal chromosome complement should be fully and extensively documented. The same extensive documentation must, of course, be done in cases of Down’s syndrome with an excess material of chromosome no. 21, so that they may serve as a basis of comparison for the more unusual cases. I am satisfied that the clinical points are against Hamerton and Polani’s first possibility-" that the child described does not, in fact, have Down’s syndrome ". The second possibility (" that the additional chromosome material has been translocated on to another autosome of the set in such a way as not to be immediately visible ") and the third (" that the child described is, in fact, a mosaic for trisomy 21 ") must remain unanswered at present, since the investigation has been carried as far as possible by conventional means without any evidence to suggest either of these. A similar case is being studied by F. Sergovich, of the University of Western Ontario, London, Canada.

My sincere thanks go to Dr. Hamerton and Professor Polani for their keen interest and stimulating questions. I will be very happy to furnish any additional information I can, including the detailed list of the signs present in the series of 0ster and of Levinson et al., which could not be published here because of lack of space. Department of Pædiatrics and Institute of Genetics, BERTIL HALL. University of Lund, Sweden. CYTOLOGY OF THE CERVIX

SIR,-Dr. Osborn is to be congratulated on his letter (April 20). It is indeed a pity to allow a diagnosable and treatable form of cancer to escape. It may cost more to save one life than to let many perish, but this argument leads to the conclusion that there are too many people in the world anyway-so why practise medicine or even

humanity ? He is also right to emphasise that cytology gives much information on matters other than malignant disease. The cytology technician beats his bacteriology colleague every time on the recognition of trichomonas and the various yeasts and moulds that accompany rash antibiotic treatment.

I would amplify his criticism of the I.M.L.T. They do a good job in producing all-round technicians for the smaller laboratories, but the length and complexity of the course is discouraging to those who are not good " all-rounders " and who are not good examinees. The best section-cutters I have ever known might well not have passed the intermediate examination, but they were literally worth their weight in gold. There must be similar people about today, 22. 23.

Øster, J. Mongolism. Copenhagen, 1953. Levinson, A., Friedman, A., Stamps, F. Pediatrics, 1955, 16,

43.

they will never attain senior status because of the insistence upon closed-shop I.M.L.T. standards. A good technician is worth whatever promotion me pathologist thinks fit. Administrators please note!

but

Department of Pathology, Whipps Cross Hospital, London, E.11.

C. RAEBURN.

AN UNUSUAL CASE OF TWINS

SiR,ńThe interesting delivery described by Dr. Logan (April 20) reminds me of a case, almost exactly similar, care about twenty years ago. the mode of delivery to be unique, I discussed Thinking it with Prof. F. J. Browne, who informed me that he had previously known twins "to be born in this manner. The name " geminolisthesia has been suggested to describe this type of labour.

which occurred under my

West Middlesex

Hospital,

Isleworth,

C. W. F. BURNETT.

Middlesex.

PRISONS

SIR,ńII do not think the Wandsworth doctors (March 16) have fully understood the nature of the booklet, Inside Story, which was based on first-hand evidence of prison conditions. The central point in that pamphlet is indeed that, in theory, the prison system is humanely and progressively run, but that practice in many important respects does not sort with profession. For instance, as the doctors point out, the prisoner whose drugs prescribed by his own doctor are taken from him for fear of their misapplication is not supposed to go without his medicine "; in theory he is not to have opportunity for suicide immediately after his conviction, but he is to have adequate substitutes immediately dispensed from the prison pharmacy. In practice the convicted prisoner is shut up for hours in a box by himself and out of sight in receptions, when he arrives at the prison (before he sees the doctor): during this time suicide would probably be possible. More important, by custom he is kept in receptions until after 7 P.M.; by this time no new dispensing is done. But in any case, what is an adequate "

substitute for an asthmatic’s atomiser, except another atomiser? Either keep substitute atomisers in receptions for asthmatics to be given at once, or allow them the use of their own; the second alternative seems simpler. For my part, I remember vividly trying to retain 3 or 4 iron tablets which were taken from me. I had had access to a whole bottle for hours: I did not want an overdose. Our booklet cited evidence from 12 prisons (not including Wandsworth). Evidence of good conditions at Wandsworth, glad as we are to hear it, cannot alter evidence of conditions in the 12 prisons we have experience of. I would venture to suggest two other reasons why the prison medical service calls for particular attention. Firstly, a prisoner’s life is unhealthy in almost every way-as regards exercise, food, hygiene, sanitation, clothing, heating, sexual problems, enforced self-centredness, and nervous strain. Secondly, there is no other class of human being more completely in the power of those in charge of them, except the insane and small children. If someone who has personal experience of deficiencies in the medical service brings forward truthful testimony about it, I do not think such testimony can be dismissed by responsible persons without impartial

investigation. Could I, finally, make a small point in extenuation of the preciousness of our recommending paper handkerchiefs for prisoners. We did so because: (a) one handkerchief per week is inadequate at the best of times; (b) it is usual to supplement it by stealing or borrowing another, by stealing workshop rags, by using lavatory paper, or by wiping on one’s sleeve (all but the last of these solutions renders the prisoner-and accomplice-liable to punishment); (c) the main obstacle to more hankies would be more laundry, and we already recommended

949

grand increase in the laundering of sheets, blankets; nightshirts, &c. (self-laundering is impossible). Paper handkerchiefs seemed a good and hygienic answer. a

OONAGH LAHR.

London, N. 10.

that many pregnant women in this country do their blood examined. Obstetric Hospital, University College Hospital, London, W.C.1.

not

have

G. W. THEOBALD.

PEPTIC ULCER FOLLOWING RECTAL STEROIDS

SIR,-Dr. Lawrence (April 13) is correct in his impliout in columns been cation that in pregnancy total red-cell volume is estimated your recently pointed SIR,-It can absorbed from the bowel be with large that hydrocortisone greater precision with chromium-labelled red cells March and Professor that and than when calculated from the plasma volume by assuming Brooke, 30) (Dr. Sampson of be evidence that the ratio between the body haematocrit and the venous this process may accompanied by pituitaryThe haematocrit is a constant. I have demonstrated,l however, adrenal suppression (Dr. MacDougall, April 13). possibility of other side-effects of steroid therapy in that the haematocrit ratio is as constant in pregnancy as in patients receiving rectal steroids was mentioned, and this the non-pregnant woman, and that the error due to the use of the ratio in calculating total red-cell volume in pregprompts us to record the following history. A young man aged 27 years was referrred to medical outnancy has a standard deviation of 76 ml. This is about 5% with a four months’ of of of the average total red-cell volume in the last trimester. history passage frequent patients loose stools containing blood and mucus and associated with The measurements2 quoted in your leading article of Feb. The has

stools contained no pathogens, and sigmoidoweight loss. scopic appearances were typical of ulcerative colitis. The patient was given once daily ’Predsol’ enemata, each containing 20 mg. of prednisone. After two months’ treatment he developed persistent epigastric pain, and a barium meal revealed an active duodenal ulcer. There was no previous history of indigestion. The plasma-cortisol level, kindly assayed by Dr. D. Mattingly, was found to be nil, indicating complete pituitary suppression. The patient subsequently developed toxic dilatation of the colon, necessitating total colectomy. It is clear that secondary adrenal atrophy in this patient resulted from rectal absorption of prednisone, and it is possible that the duodenal ulcer was precipitated by this form of treatment.

G. R. THOMPSON C. C. BOOTH.

Department of Medicine, Postgraduate Medical School, London, W.12.

PREGNANCY ANÆMIS

SiR,ņThe conclusion in the "second paragraph of your leading article of Feb. 9 that there seems to be good reason for prescribing iron for any pregnant woman whose haemoglobin level falls below 12-0 g. per 100 ml." seems to conflict with your apparent condonation, in your last paragraph, of the present trend of reserving treatment for those whose haemoglobin falls below 10 g. per 100 ml. You note the high incidence of iron deficiency in women. It was shown in one maternity hospital that about 60% of 2000 consecutive women had subnormal hemoglobin levels when they booked at the antenatal clinic (before 16 weeks), that 6-5% had severe anaemia, and that most could be treated successfully with oral iron.I These results have been confirmed by Dr. Fisher (March 16). Most obstetricians think that iron deficiency increases the risk of both antepartum and postpartum hemorrhage and is likely to be carried over into the puerperium and to affect subsequent pregnancies. The haemoglobin level of well-nourished women in social grade I may attain 14 g. per 100 ml., and both prematurity and perinatal mortality are lowest in this group. There is reason for assuming a relationship between perinatal mortality and iron deficiency, but surely none for the assumption that 10 g. hsemoglobin per 100 ml. suffices for the average pregnant woman. Is it not more rational to hand out pills than to assume that there cannot be widespread deficiencies in an " affluent society " ? May I, therefore, hope that your views are more truly reflected in your second than in your last paragraph, and may I

join

with those who

through

your columns have

advocated the routine administration of iron throughout

pregnancy ? It is perhaps 1.

germane to the matter to note

Benstead, N., Theobald, G. W. Brit. med. J. 1952, 1, 407.

9 have

an error

of this order.

Obstetric Medicine Research Unit (M.R.C.),

Maternity Hospital, Foresterhill, Aberdeen.

D. B. PAINTIN.

MISUSE OF SECTION 29 annotation of April 13 is

SiR,ņYour timely, but I think much of the misuse is apparent rather than real. The figures quoted by Paterson and Dabbs are interesting, but their finding that, of the patients admitted under the provisions of section 29, 4.3% were discharged and 28.3% changed to informal can have no real significance unless we know what percentage of patients admitted under the provisions of section 25 were discharged or became informal during the first three days. Misuse of section 29 in the admission of elderly patients arises in situations where a patient has to be admitted to psychiatric hospital but cannot be persuaded to enter informally. The consultant psychiatrist having heard the family doctor’s report on the patient is quite prepared to admit her and recognises that there is no real need for a domiciliary visit, but as the patient is not willing to go into hospital some compulsory procedure is essential. On the other hand, the practitioner realises from his previous experience that many such patients, once they are admitted to hospital and find the situation better than they expected, agree to remain informally. It may be very difficult, particularly in areas where there are no family doctors approved under section 28, to obtain the second certificate before moving such patients, and the only alternative to section 29 would be to ask a consultant to travel anything up to 40 miles in order to complete a certificate. Paterson and Dabbs refer to the emergencies that seem to occur with follow-up patients and which they feel should not arise if there were regular clinics or adequate local-authority services. The fact is that even where there are good follow-up facilities, emergencies do arise, but, in addition to this, section 29 is sometimes used to avert an emergency which is imminent. In such cases the family doctor may have informed the consultant by telephone that he recognises early signs of an exacerbation. The consultant, who probably knows the patient well, may feel that the best way to deal with the problem is to admit the patient to hospital immediately. If, however, the patient is not willing to accept this advice, it would seem reasonable for the family doctor to arrange compulsory admission under section 29, and very often once such a patient is in hospital he realises that he does in fact need treatment and agrees to remain informally. Experience gained in this area during the past two years has shown that section 29 is a very useful provision and is usually applied in the spirit which was intended and is seldom misused. The working of the Mental Health Act depends on the integrity of the family doctors and 1. 2.

Paintin, Paintin,

D. B. J. Obstet. Gynœc. Brit. Commonw. D. B. ibid. 1962, 69, 719.

(in the press).