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life, but till then they do not require supervision.To clutter up out-patient departments or clinics withcases coming up to report must surely be an admissionthat surgeons are getting afraid ever to committhemselves to saying either that they have cured thepatient or that nothing further can be done for hiscondition. A definite pronouncement of this kindhelps the patient in so far as he must either acceptthe particular surgeon’s word or decide to seekconfirmation elsewhere. If statistics of cures are

desired, let these be obtained by means of a writtenquestionnaire. In any case most of us try to gloss overour failures ; they are only seen in true perspectiveby the other man. To have a procession of cured orhopeless cases .coming up to report is useless to thesurgeon and demoralising to the patient or his parents.

I am. Sir. vours faithfullv.Devonshire-street, W., Sept. 14th. G. O. TIPPETT.

SOMNIFAINE NARCOSIS

To the Editor of THE LANCET

SiR,-There are a few points in Dr. Menzies’s letterin your last issue which merit further response. Inthe first place he has not answered my criticism ofhis " starvation " theory. In his series there were19 patients with glycosuria and 5 with ketonuria,alleged to be due to excess of glucose in the diet andto starvation respectively. If that were the casethen alimentary glycosuria would be an exceedinglycommon phenomenon, which of course it is not.The best authorities on carbohydrate metabolism,both clinicians and biochemists, agree that it is verydifficult to induce alimentary glycosuria even after asingle dose of 500 g. of glucose ; in fact, some havebeen unable to induce it at all (vide Taylor andHulton, J. biol. Chem. 1916, 25, 173 ; MacLean,Modern Methods in the Diagnosis and Treatmentof Glycosuria and Diabetes, 1927 ; and Bennett andDodds, Lancet, 1925,1, 429) ; yet Dr. Menzies finds it in19 per cent. of his cases ! As it is the most reasonablecourse to assume that the above-mentioned authoritieson glycosuria are correct, then the obvious lesson tobe learnt from Dr. Menzies’s paper is that his resultssupport the theory of disturbed carbohydrate meta-bolism. No. doubt had Dr. Menzies carried out

systematic tolerance tests on the remaining 76 percent. of cases he would have found a large numberof abnormal responses among them, but this evidenceis lacking. Incidentally quite a large number of myown patients developed glycosuria on 10 units ofinsulin twice or thrice daily, but this disappearedafter increasing the dose to 15 or 20 units.

If Dr. Menzies had read my letter in your issue ofApril 4th, 1936, he would see that my vision is not" obscured," nor am I suffering from a "ketosis

complex " ; he would see that above all I advocatethe most careful clinical observation, apart fromurinary analysis. No doubt ketonuria can be dis-

persed by large amounts of glucose in the majorityof cases, but this does not affect the fundamentaldisturbance. The diminished glucose tolerance andglycosuria during full narcosis shows that the bodycannot deal with the glucose as under normal con-ditions, hence insulin is required. Dr. Menziesmentions the Swiss school in support of his argument.I have recently read abstracts of two of the latestcommunications from this quarter (Zbl. ges. Neurol.Psychiat. 1936, 76, and 1937, 82). In the one theworkers describe just over 200 cases treated withCloetta’s mixture with 3 deaths ; the second comesfrom Berne with a mortality of 5 per cent. in 170schizophrenics. There is nothing to suggest in these

papers that either ketonuria or glycosuria was eventhought of, let alone looked for. Furthermore, thevalidity of the theory of Quastel and-Wheatley basedon careful experiments, and backed’ by clinicalobservation in this country, and at least two well-known hospitals in Scandinavia (Dikemark andBeckomberga) cannot be dismissed with the glibrationalisation that it is only " of general interest,"but requires to be refuted by careful clinical investi-gations combined with laboratory experiments..

Had Dr. Menzies given the insulin modification afair trial instead of juggling with dosage and groupsI am convinced he would have been more favourablyimpressed and have saved himself unnecessary trouble.As it is he is subjecting his patient to the more severestrain of three weeks’ narcosis, with increased risks ofrenal damage, circulatory failure, epileptiform con.vulsions, and unpleasant minor complications, whereasthe course can be shortened to 12-14 days by thesimple addition of insulin.

, T H.m Sir V011r!’B fa/tttifnlv

R. STRÖM-OLSEN.Runwell Hospital, Nr. Wickford, Essex, Sept. 18th.

DIABETIC CLINICS

To the Editor of THE LANCETSiR,-The Diabetic Association would be glad to

publish in its journal particulars of diabetic clinicswhich are held in the provinces. This informationis frequently asked for by diabetics who live outsideLondon and wish to attend a clinic. We should bevery grateful if your readers would send particularsof such clinics to the secretary of the association atthis address.

I am. Sir. vours faithfullv.STELLA CHURCHILL,

Hon. Secretary, Medical Committee.The Diabetic Association, 124, Baker-street,

London, W.1.

EPISIOTOMY

To the Editor of THE LANCETSIR,-I should have liked to have seen Prof.

De Lee’s film demonstrating his method of performinglateral episiotomy, of which you make report in thepresent issue of THE LANCET (Sept. llth, 1937). Noone can observe with any acuity the parturientprocess in a primigravidous woman without becomingperfectly certain that the perineal tissues opposebirth, and in many cases render the process longerthan it need be. And since the simplest of examina-tions suffices to demonstrate that the perineal tissuesconsist mainly of skin, with some-quite unimportantsuperficial muscles (except the ring sphincter of theanus), and, moreover, that very often they are

dreadfully damaged and horribly lacerated by naturalforces, it must be obvious that the correct procedureis to incise them sufficiently early to lighten thelabour and prevent or lessen this damage. Eventhose who advise " protecting " the perineum andaward laurels to those who manage to preserve itfrom laceration must be staggered at the cases ofprolapse occurring in women in whom the perineumhas not been torn. In these cases the perineum haslost all its retractility : it can be stretched as a foldforwards, and backwards almost to cover the anus;and as a visceral support, obviously, it is no goodat all. If an " intact " perineum is desirable, it mustbe preserved from being inordinately stretched:episiotomy, with proper subsequent suture, is justthe way to effect this.But there is another point. Prof. De Lee believes

that episiotomy " protects . : . the pelvic floor."