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772 life, but till then they do not require supervision. To clutter up out-patient departments or clinics with cases coming up to report must surely be an admission that surgeons are getting afraid ever to commit themselves to saying either that they have cured the patient or that nothing further can be done for his condition. A definite pronouncement of this kind helps the patient in so far as he must either accept the particular surgeon’s word or decide to seek confirmation elsewhere. If statistics of cures are desired, let these be obtained by means of a written questionnaire. In any case most of us try to gloss over our failures ; they are only seen in true perspective by the other man. To have a procession of cured or hopeless cases .coming up to report is useless to the surgeon 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 letter in your last issue which merit further response. In the first place he has not answered my criticism of his " starvation " theory. In his series there were 19 patients with glycosuria and 5 with ketonuria, alleged to be due to excess of glucose in the diet and to starvation respectively. If that were the case then alimentary glycosuria would be an exceedingly common phenomenon, which of course it is not. The best authorities on carbohydrate metabolism, both clinicians and biochemists, agree that it is very difficult to induce alimentary glycosuria even after a single dose of 500 g. of glucose ; in fact, some have been unable to induce it at all (vide Taylor and Hulton, J. biol. Chem. 1916, 25, 173 ; MacLean, Modern Methods in the Diagnosis and Treatment of Glycosuria and Diabetes, 1927 ; and Bennett and Dodds, Lancet, 1925,1, 429) ; yet Dr. Menzies finds it in 19 per cent. of his cases ! As it is the most reasonable course to assume that the above-mentioned authorities on glycosuria are correct, then the obvious lesson to be learnt from Dr. Menzies’s paper is that his results support the theory of disturbed carbohydrate meta- bolism. No. doubt had Dr. Menzies carried out systematic tolerance tests on the remaining 76 per cent. of cases he would have found a large number of abnormal responses among them, but this evidence is lacking. Incidentally quite a large number of my own patients developed glycosuria on 10 units of insulin twice or thrice daily, but this disappeared after increasing the dose to 15 or 20 units. If Dr. Menzies had read my letter in your issue of April 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 advocate the most careful clinical observation, apart from urinary analysis. No doubt ketonuria can be dis- persed by large amounts of glucose in the majority of cases, but this does not affect the fundamental disturbance. The diminished glucose tolerance and glycosuria during full narcosis shows that the body cannot deal with the glucose as under normal con- ditions, hence insulin is required. Dr. Menzies mentions the Swiss school in support of his argument. I have recently read abstracts of two of the latest communications from this quarter (Zbl. ges. Neurol. Psychiat. 1936, 76, and 1937, 82). In the one the workers describe just over 200 cases treated with Cloetta’s mixture with 3 deaths ; the second comes from Berne with a mortality of 5 per cent. in 170 schizophrenics. There is nothing to suggest in these papers that either ketonuria or glycosuria was even thought of, let alone looked for. Furthermore, the validity of the theory of Quastel and-Wheatley based on careful experiments, and backed’ by clinical observation in this country, and at least two well- known hospitals in Scandinavia (Dikemark and Beckomberga) cannot be dismissed with the glib rationalisation 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 a fair trial instead of juggling with dosage and groups I am convinced he would have been more favourably impressed and have saved himself unnecessary trouble. As it is he is subjecting his patient to the more severe strain of three weeks’ narcosis, with increased risks of renal damage, circulatory failure, epileptiform con. vulsions, and unpleasant minor complications, whereas the course can be shortened to 12-14 days by the simple 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 LANCET SiR,-The Diabetic Association would be glad to publish in its journal particulars of diabetic clinics which are held in the provinces. This information is frequently asked for by diabetics who live outside London and wish to attend a clinic. We should be very grateful if your readers would send particulars of such clinics to the secretary of the association at this 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 LANCET SIR,-I should have liked to have seen Prof. De Lee’s film demonstrating his method of performing lateral episiotomy, of which you make report in the present issue of THE LANCET (Sept. llth, 1937). No one can observe with any acuity the parturient process in a primigravidous woman without becoming perfectly certain that the perineal tissues oppose birth, and in many cases render the process longer than it need be. And since the simplest of examina- tions suffices to demonstrate that the perineal tissues consist mainly of skin, with some-quite unimportant superficial muscles (except the ring sphincter of the anus), and, moreover, that very often they are dreadfully damaged and horribly lacerated by natural forces, it must be obvious that the correct procedure is to incise them sufficiently early to lighten the labour and prevent or lessen this damage. Even those who advise " protecting " the perineum and award laurels to those who manage to preserve it from laceration must be staggered at the cases of prolapse occurring in women in whom the perineum has not been torn. In these cases the perineum has lost all its retractility : it can be stretched as a fold forwards, and backwards almost to cover the anus; and as a visceral support, obviously, it is no good at all. If an " intact " perineum is desirable, it must be preserved from being inordinately stretched: episiotomy, with proper subsequent suture, is just the way to effect this. But there is another point. Prof. De Lee believes that episiotomy " protects . : . the pelvic floor."
Transcript of SOMNIFAINE NARCOSIS
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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."
