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evidence that these white-Negro differences are presentin the foetus two weeks before birth, as are the well-knownmale-female differences in maturity. 4

Thus, Dr. Cicely Williams’s question can be tentativelyanswered for at least one characteristic of African child-ren : their advancement in respect of skeletal maturityeither depends on "intrinsic differences" or else ondifferences in prenatal environment, and the former iscertainly the more probable. It is, I think, likely thatmuch of the advancement in behavioural tests describedby Dr. Geber and Dr. Dean is intrinsic too, and dependson the degree of maturity of bones, muscles, and brain.

J. M. TANNER.Institute of Child Health,

London, W.C.1.

4. Amer. J. Obstet. Gynec. 1950, 60, 133.

EUSTACHIAN SELF-INSTILLATION

DAVID JACKSON.

SIR,-As Dr. Niosi pointed out last week, yawningopens the eustachian tubes. Air-travellers have beenadvised to open their tubes by swallowing, chewing, orshouting ; but yawning is, in my experience, much moreeffective. It is surprisingly easy to yawn at will as theaeroplane descends, thus avoiding earache and perhapseven barotrauma.

DOWN AMONG THE ARCHIVES

C. D. NEEDHAM.

SIR,-I am not certain whether, in your annotation ofJuly 6, you mean that the Ministry of Health has alreadygiven permission for hospital case-notes to be destroyedafter six years, or is considering doing so. If the former,then it would be important to know what prior con-sultation had taken place with the profession on a

matter of such great clinical interest.Even apart from research considerations, previous

hospital case-records are frequently, not just occasionally,most helpful in dealing with problems which arise in

diagnosis and treatment. Examples in plenty will cometo the mind of anyone who has worked in hospitalpractice for several years.Can it really be supposed that after six years a careful

record of a patient’s health and disease ceases to berelevant to the further handling of his health problems ?Do not the body and mind at any age reflect in somedegree all that has happened to the individual throughoutthe whole of life ? Are we then to destroy this docu-ment concerning the evolution of his health 1

It should be remembered that the prime function ofa hospital is care for the welfare of patients, and notadministrative convenience. If this ideal is still acceptedthen it must follow that the destruction of case-records

during a patient’s life-time is to be deplored : indeed,it is arguable whether case-notes should ever be destroyed.They would, with keeping, become of as much historicalinterest to our descendants of 2110 as are the pre-1800ones now spared destruction, and for that same reason.Adequately indexed storage of the records of a large

hospital costs a lot of money, but then so does any othermajor department or item of service for that hospital.If the notes were destroyed, the great expense of modernhospitals would be money wasted to the extent that thepatient’s welfare was so lightly disregarded and effortnot made to benefit from the hard lessons of the past.

* * The National Health Service Act made the Ministerof Health responsible for hospital records. By the eighthschedule (Public Records : Ministry of Health : NationalHealth Service) he classified clinical notes (except thosein mental or mental-deficiency hospitals) as documentsnot of sufficient public value to justify their preservationin the Public Record Office. They may be destroyedsix years after the end of treatment or three years afterdeath if the patient dies in hospital.-ED. L.

ST. LUKE’S TIDE SERVICES

J. B. GURNEY SMITHHon. Treasurer, Union of St. Luke.

Royal Earlswood InstitutionRedhill. Surrey.

SiR,-I have read with interest the letter by theBishop of Lichfield (July 6). I should like to make one

very important observation and to draw attention toanother matter.The observation refers to the panel of doctors quoted in

the letter as being able to fulfil preaching functions atSt. Luke’s Tide. As far as the Anglican Church is concerned.it is usually an understood fact, of which the Bishop of Lichfieldhimself seems unaware, that only men licensed by bishopse.g., lay readers, of whom many are medical men-areallowed the hospitality of church pulpits. Most bishops arevery strict on this matter. It is possible that the panel mightcontain men quite spiritually inadequate for the ministrationsdesired of them. A note of warning is therefore needed.The other matter to which I wish to draw attention concerns

a body known as the Union of St. Luke, which was foundedin 1948 to deepen the spiritual lives of communicant Anglicandoctors, and to foster a strong link between the Church andMedicine. Growth in membership is much to be desired andall Anglican doctors are warmly invited to become members.I will gladly forward particulars of membership to anyoneinterested.

1. Foster, C. A. Lancet, 1957, i, 11442. Johnstone, M. Ibid, p. 1196.

HYPOTENSION DURING HALOTHANEANÆSTHESIA

SIR,-After reading Dr. Foster’s letter 1 on cardiacarrest with halothane (’ Fluothane ’), we feel that it maybe of value to record 2 similar cases, neither of whichended fatally but in which the same profound drop inblood-pressure was seen.

After using halothane with very satisfactory results,vaporised from the trichlorethylene bottle of a Boyle’sapparatus, and basing our technique on the scaledescribed by Johnstone,2 we decided on grounds ofcost to try using a closed-circuit technique once the

patient had been stabilised on halothane. Using thebottle as before, we induced anaesthesia using a con.

centration of up to 3-3.5%. The gas flow was thenturned down to 300-500 c.cm. per min., and the halothaneturned either off or just on.The results of this technique proved satisfactory

except in the following cases.CASE I.-A fit muscular man, aged 57, was undergoing

repair of a recurrent right inguinal hernia. As premedicationhe was given pethidine 100 mg., chlorpromazine 50 mg., andatropine 0-65 mg. Anaesthesia was induced with thiopentone250 mg. and continued with halothane. After two to threeminutes, the halothane was turned off, the gas-flow reducedto oxygen 400 c.cm. a minute, and the circuit closed. Afterabout five minutes the pulse could not be felt and the blood-pressure was unrecordable. The patient’s colour remainedgood and spontaneous respiration was maintained at a verysatisfactory volume. The foot of the table was raised, andafter a few minutes the blood-pressure was recorded as

60/50 mm. Hg. The operation was satisfactorily completed.Carbon dioxide with oxygen was then given. The feet werestill further raised, and methylamphetamine, in two dosesof 6 mg. intravenously, brought the systolic pressure up to100. Thirty minutes later the patient asked for a drink ofwater and said he felt " fine."

CASE 2.-A man, aged 78, with acute upper abdominalpain, was admitted for laparotomy. Premedication was

pethidine 75 mg., chlorpromazine 25 mg., and atropine0-65 mg. After induction with thiopentone 250 mg. followedby gallamine 80 mg., the patient resisted intubation. Aftera further 20 mg. of gallamine a cuffed tube was passed.Halothane was given in an initial concentration of 3-3’a%using controlled respiration. In five minutes the systolicpressure fell from 140 mm. Hg to 50. Raising the foot of thetable caused a transient rise to 75. After methylamphetamine12 mg. intravenously and 6 mg. intramuscularly, the systohcpressure was maintained at around 90. The operation wascompleted in twenty-five minutes. Thirty minutes later thepatient regained consciousness and made a satisfactoryrecovery. During the latter part of the operation, numerous

191

extrasystoles were felt. Postoperative electrocardiogram wasnormal.

It is obvious that, until some method is devised of

estimating the concentration of halothane in a closedcircuit, this technique must be used with the greatestcaution.. I would agree with Dr. Johnstone 2 that mostof the unpleasant reactions to halothane have beenRRRocÎated with errors in technique.

R. M. S. KEIRR. B. S. Ross.Dumfries and Galloway Royal Infirmary,

Dumfries.

DOSAGE OF TOLBUTAMIDE

FREDERICK WOLFF.Postgraduate Medical School

of London and theWellcome Foundation.

SIR,-I note in your report of the Banting memorialmeeting (July 20, p. 125) that you quote me as sayingthat the optimal daily dose of tolbutamide in man wasabout 3 g. In fact, what I did say was that in a series ofacute dose-response tests 3 g. of tolbutamide was moreeffective than 1 g. in producing hypoglycaemia, but whenthat dose was pushed to 6 g. the hypoglycsemic responsebecame diminished. This finding implied that in man aswell as in the laboratory animal, as shown by Mr. G. A.Stewart during the same meeting, tolbutamide appearedto possess a biphasic action depending upon its dose.The results of this acute dose-response test bear little

relation to what one might consider the optimal dailydose therapeutically and in our experience it is of no usein the majority of patients to increase this beyond1112 g. per day.

Certain arteriovenous studies reported at the meetingcompared the lack of response to insulin and glucose ininsulin-dependent diabetics with the response under thesame conditions in diabetics controlled with tolbutamide.The results suggested insulin antagonism in the first2IOUT).

THE BACILLUS OF PFEIFFER

DAVID HARLEY

Sir,-During the past few weeks I have noticed amarked increase of Hcemophilus influenzœ in throat-swab cultures. The patients concerned are allergicsubjects in whom a routine bacteriological overhaul ofthe upper respiratory tract is carried out, and with oneexception none of them gave a history of any recentacute pyrexial respiratory illness.

Direct and " pathogen-selective " cultures are made fromthroat, post-nasal, and nasal swabs. The pathogen-selectivetechnique (Solis-Cohen) utilises the in-vitro bactericidalpower of the patient’s fresh whole blood to kill off anyorganisms to which he is immune and to allow the growth ofpotentially pathogenic organisms, thus assisting in thedifferentiation of the setiologically important organisms froma mixed direct culture, in allergic cases with chronic or focalinfection.

Though careful examination of direct blood-agar platecultures from the throat and post-nasal space of suchpatients will often reveal a few colonies of H. influenzaein a mixed growth, in my experience it is uncommon tofind that organism prominant or predominating. Whenit does so occur-usually during the winter months-it comes up more in the post-nasal than in the throatculture, and rarely grows out in the pathogen-selectiveculture.In the recent cases I refer to, H. influenzce was pro-

minant in the direct throat culture (as well as in thepost-nasal) and came through in heavy growth as thepredominating or the only organism in the pathogen-selective culture.Through the courtesy of your columns, I would be

grateful for leave to inquire whether other clinicalbacteriologists have had a similar experience, or whetherthis is just a chance happening.

It is of interest, if only one of coincidence, that inThe Lancet exactly 39 years ago to the month the lateDr. John Matthews reported finding H. influencein cultures-just prior to the major outbreaks of the1918 influenza epidemic.Though long universally agreed that it plays no

symbiotic setiological r6le with human influenza virus-as does H. influenzae suis with swine influenza virus-why does the Bacillus of Pfeiffer still persist in croppingup so regularly in association with human influenza ?

1. Lancet, 1918, ii, 91.2. Edholm, P., Seldinger, S. I. Acta radiol. Stockh. 1956, 45, 15.3. Odman, P. Ibid, p. 1.

RENAL FAILURE FOLLOWING AORTOGRAPHY

DUNCAN GREGG.Addenbrooke’s Hospital,

Cambridge.

SIR,-The excellent accounts by Mr. Roy, Dr.Dormandy, and others in your issue of July 6 are buttwo examples of complications possibly arising fromerrors of technique for the cases in question.The well-established translumbar method of aorto-

graphy has many disadvantages and dangers, not theleast of which is the maldirection of too high a concentra-tion and often too large a volume of contrast mediuminto the aorta at or near the origin of the renal arteries.Often only 15-20 ml. of a 30-35% strength of contrastmedium will give very adequate results and 15-20 ml.of a 60% strength of contrast medium invariably givesexcellent films of good diagnostic quality.

If it is known, from a previous intravenous pyelogram,that one kidney functions poorly or not at all, still furthercaution is demanded during aortography and only asmall volume, not more than 15 ml.-of one of the lesstoxic media such as ’Urografin’ 60%-should be usedto protect the normal kidney from damage.The Seldinger method of aortography is now widely

practised but caution is needed here also because the

tip of the catheter may, under the influence of the

injection pressure, point towards the mouth of a mainrenal or accessory renal artery and a large volume of themedium may be injected into the artery. At Adden-brooke’s Hospital, we have demonstrated this catheter-tip movement on occasions by means of cineradiology ;moreover, maldirection of the catheter tip is more likelyto occur and should be guarded against in a tortuousaorta. It has, therefore, been our practice to place thecatheter tip at an estimated point some 11/2-2 in. belowthe hila of the kidneys for non-selective renal arterio-graphy and to allow free mixing of contrast mediumwith the aortic blood-stream, allowing the injectionpressure to fill the segment of aorta adjacent to therenal arteries. The same caution with regard to theamount and concentration of contrast medium (15-20 ml.,60% urografin) should be observed as with the trans-lumbar route. We consider the injection of a 75%medium quite unnecessary and we have long sinceabandoned it for arteriography.

Cognisant of the possible dangers of kidney damagefollowing injection of an uncontrolled amount of contrastmedium into the renal arteries, we at Addenbrooke’sHospital have for the past 15 months adopted the methodof selective catheterisation of the renal arteries, as

advocated by Edholm and Seldinger and Odman,3and have injected small amounts (4-5 ml.) of contrastmedium of only an approximately 30% solution of uro-grafin and have obtained renal arteriograms of excellentquality and detail. We have experienced no untowardeffects using this technique and no renal complicationshave ensued. This method also avoids the other risksmentioned in your annotation of July 6. A detailed

report of this work is to be published in the August issueof the British Journal of Radiology.