138

do nothing to improve unhealthy working conditionsbecause the worker is free to refuse the job. The worstsocial abuses of the Industrial Revolution were justifiedby this fiction. In fact, of course, the worker’s freedomwas an illusion. The awakening of public opinion andthe rise of the trade-union movement forced legislationto remove these and similar fictitious " rights of theindividual," substituting for them some very solidbenefits.

Thus, although Dr. Todd wisely qualifies the supposedright of the individual to accept a job which will endangerhis health, the general acceptance of the principle headvocates would put back the clock a hundred years.I cannot believe this to be his intention.

Port Sunlight, Cheshire. F. H. TYRER.

SiR,-We have read with considerable misgivingDr. Todd’s article, in which he states : " We maytherefore conclude that there is no real place for a

medical examination as a part of the selection of adultsfor jobs." He writes of injustice towards employeesand infringements of their liberties as results of pre-employment examination. We consider that theseremarks are incorrect and misleading.No experienced industrial medical officer doubts the

desirability and value of pre-employment medicalexamination. The duties of, and ethical rules for,industrial medical officers drawn up and published bythe British Medical Association support this contention.The incidence of illness, the loss of working hours, andthe risks to other employees-to say nothing of loss ofefficiency due to faulty job allocation, which is moreliable to occur where there is no pre-employment medicalexamination-are alone sufficient to justify such a

procedure.Would Dr. Todd suggest, as he certainly implies, that

there should be no inquiry and investigation into suchconditions as pyorrhoea, septic tonsils, chronic aural

discharge, previous intestinal disturbance, or pyogenicconditions of the hands of persons whom it is pro-posed to employ in the preparation and handling offood 1

It has been estimated within recent years that forevery day lost to industry by industrial disputes 270 daysare lost by illness ; and surely nothing that wouldreduce this figure should be neglected. No industrialmedical officer is able, or wishes, to forbid any prospectiveemployee taking a job. His function is purely advisoryto executive management and is analogous to thefunction of a medical officer in the Services towards the

commanding officer.It is our experience that employees or prospective

employees are grateful for kindly and sympatheticadvice concerning the work for which they are bestsuited and the types of occupation which they shouldavoid. For example, a man with monocular vision

working as a crane-driver would constitute a considerablepotential danger to his workmates, whereas he wouldbe in no way handicapped working as a fitter. Theworker himself may be safeguarded as a result of theexamination-for example, if he has hyperpiesia and isprevented from lifting heavy weights continuously andover long periods.

Dr. Todd’s statements are absolutely contradicted bythe experience of large numbers of industrial medicalofficers over many years. To dispense with pre-employ-ment examination in industry and with the industrialmedical officer in his role as a member of the teamnerformins iob allocation would be retrograde.

R. A. GORDON SMITHMedical Officer, Carreras Limited.

R. FRANK GUYMERLate Chief Medical Officer,

J. Sainsbury Ltd.

INFLUENZA COSMO

SIR,-I believe-open to correction and, I hope,sufficiently humbly-that I am about to describe, inthis letter, a hitherto undifferentiated but quite definiteclinical entity. For several years now, in spite of aver-agely good health considering advancing age, I havesuffered, perhaps twice in eighteen months, perhapstwice in a year, from what apparently begins as a" common cold." It is not a severe cold. It does not

interfere with appetite, physical vigour, or the taste ofa cigarette. It is apyrexial. It seldom requires the useof more than two pocket-handkerchiefs in twenty-fourhours. But it is a cold. People notice it. It affects thevoice by modifying nasal resonance, and after three daysit disappears. " Thank God," I used to say, " that’sover." But I was wrong, and now I don’t say it. Aftera day of relief and relative bien-etre, the second phaseinvariably begins. Several times a day, a tracheal irri-tation provokes a spasmodic and not very productivecough. But worse than that, a feeling of general malaisesets in. Cigarettes taste quite differently. Appetitelessens. Flatus travels north instead of south. An houror so after luncheon, an hour or so after tea, and anhour or so after dinner, there is a rise of temperatureto about 100, 101, or 102°F. This has generally dis-

appeared before the next meal-time and before going tobed. But however light the meal, or even if it has beenentirely foregone, this is the behaviour of the tempera-ture, accompanied by introspection of a dismal type anda strong tendency to profane or even obscene language.Sometimes I have reluctantly spent a day in bed. Itmakes no difference. All this goes on for not less thanseven and sometimes eight or nine or ten drab andmelancholy days, when the attack is over.During the first " cold in the head " period, I have e

often tried lavage with various substances, alleged bytheir sponsors to do good. But in vain. Nothing modifiesor alters the pattern or duration of the complaint. Otherpeople in my house, or my neighbours, may "catch acold " at the same time. The first stage of theirs maybe longer and much more nasally uncomfortable. But

they do not have a second stage. Theirs are one-volumecolds. Mine are two-volume somethings. Now, what isthe explanation ? Does the agent or virus of volume one,having been carried into the alimentary canal, perhapsby involuntarily swallowed mucus, produce volume two 1Or is volume two due to some other agent, normallyinnocuous but roused into activity by agent one ? ’f I amnot a bacteriologist. I am far from libraries and learnedsocieties. I don’t possess a microscope. I don’t know.But here, at any rate, is an exact picture of what hasregularly happened to at least one person-and possiblyto many thousands more-for several years. Perhaps itmay provoke a fruitful idea in the mind of somebodyporing over the problem of the " common cold," thevarious types of

" influenza," and the amorphous massof complaints, sometimes labelled one, sometimes theother, and sometimes " chill," " catarrh," " feverishchill," or " pyrexial catarrh," according to the certifyingdoctor’s whim, his erudition, or the time at his

disposal.But by now, I hope, the deeper significance of this

letter has begun to dawn. For it was out of a similarchaos, known as continuous fever-and with no aid frombacteriology-that typhoid and typhus were ultimatelydisentangled. By whom ? Q By patient and exact clinicaldiarists. And may it not be true that this chaos also-so huge in its aggregate of discomfort and sick absence-really consists of several disorders just, in their way, asdistinct And that being so, is any real progress likelyto be made until they have received, in respect of exacthistories, very much more clinical attention than has asyet been bestowed upon them ’? It may be argued thatthe majority of sufferers seldom come under medical

139

notice and that, when they do, it is only too easy for abusy doctor lightly to dismiss them with one or otherof the above scraps of terminology. But there are, inthese islands, in the shape of these very doctors, at least50,000 trained observers, who must themselves beoccasional victims. Surely these are enough for an

adequate beginning. But why call this particular entityInfluenza Cosmo ? Well, I have my private reasons ; and,in the present state of our knowledge, why not ?

Easton Royal, Wilts. H. H. BASHFORD.

STERILISATION OF POLYTHENE TUBING

SiR,—Dr. Galley’s letter of Jan. 7, in connexion withmy note published on Dec. 24, is fair comment on thefragility of fine Polythene ’ catheters after sterilisationby boiling. I am aware of the mishap he reports, andwithin the last three months have seen four cases wherethe tubing has broken at the skin margin-one in thesacral canal and the other three in the lumbar region.In three of our cases, the break occurred after the tubinghad been in position for 12 hours, and in the otherafter 48 hours. In many dozens of cases, however, wehave had no trouble with this technique in prolongedsurgical operations of 2-4 hours’ duration. There isa real risk of breakage in prolonged cases, and untiltubing of more resilient material is available, its useshould be restricted to gravely ill patients in whomcontinuous extradural block offers the only reasonablehope of survival-e.g., the eclamptic woman in whom theblood-pressure cannot be controlled by more conservativemeasures.

Should the catheter break, the results are of no greatconsequence. In three of our cases a small incisionunder a local anaesthetic was made within 12 hours offracture and the piece easily found and withdrawn.In the fourth case, no attempt was made to recover thecatheter for three weeks. It could not be found, and itwas reassuring to note that experimental findings wereconfirmed in that there was no evidence of tissue reaction.Nuffield Department of Anæsthetics,

University of Oxford.R. BRYCE-SMITH.

PEMPHIGUS VULGARIS TREATED WITHAUREOMYCIN

SIR,-Dr. Bettley’s account last week of a successfultrial of Aureomycin ’ in a case of pemphigus vulgaris,prompts me to record my own experience of thistreatment in a case under my care.He was a well-preserved man, aged 89, who was admitted

to Addenbrooke’s Hospital, Cambridge, on Dec. 6, 1949,with the typical clinical picture of severe pemphigus vulgarisof two weeks’ standing. He had numerous blisters on thearms and legs, and circinate patches of dusky erythema onthe trunk. The eruption began on the feet.The progress of the eruption was rapid, and uninfluenced

by sulphapyridine ; the bulle increased daily in number andin size, reaching 4 cm. in diameter. He remained apyrexialand in fair general condition until Dec. 20 when erosions

appeared on the palate ; his general condition was obviouslydeteriorating, his appetite began to fail, and almost thewhole skin surface was involved-blistering, ulcerated, or

erythematous.I started aureomycin on this day with 250 mg. 6-hourly

by mouth, and increased it to 500 mg. 6-hourly next day,continuing it at this level without toxic effects. After 48 hoursthe patient’s general condition improved, and the few freshblisters were small. On the third day no fresh blistersappeared, for the first time since his admission. He feltbetter and could move in bed without much pain ; theulcerations were drying and the erythematous plaques fading.This striking improvement lasted six days, during which the

healing areas of skin began to pigment. But on Dec. 25fresh small blisters appeared on his abdomen and legs. Theygradually increased in size and extent, his. general conditiondeteriorated, and he died on Jan. 7. The aureomycin hadbeen discontinued a week previously, since it was no longerproducing any response.

Pemphigus vulgaris is characterised by remissions andrelapses, but the improvement in the patient’s conditionand the cessation of blistering during the administrationof aureomycin parallel Dr. Bettley’s observations.A similar case has been reported by Philip,l whose patientalso died after an initial improvement in the skin onthe third day.Many dermatologists have already started using

aureomycin for pemphigus vulgaris, and assessment ofresults at this stage is likely to be premature, especiallysince the condition is notoriously capricious in its responseto a variety of agents. But the hope engendered by thesethree cases warrants at least further trial of the drugearly in the course of a disease which usually proves fatal.Addenbrooke’s Hospital, Cambridge. C. H. WHITTLE.

TUBERCULOUS ABSCESS AT SITE OFPENICILLIN INJECTIONS

SiR,-I would like to reinforce the plea by Dr. Douglas,on Jan. 14, for better syringe sterilisation and user

technique. I feel sure that contamination of the injectionmaterial by dust-laden air or failure in aseptic techniqueis the cause of the accidents, as I have stated before.2I know from experience that (1) exclusion of ward dustfrom solutions, and (2) conscientious and good aseptictechnique will prevent these unpleasant consequencesof exogenous infection. Training in bacteriology for alllllJrP,R iR atsn mfHcat.ed-

St. Margaret’s Hospital, Epping, Essex. FRANK MARSH.

EPILEPSY AND ORGANIC DISEASE

SiR,—I am grateful to Dr. Dalton (Jan. 14, p. 94)for his reference to my address on epilepsy to the Man-chester Medical Society (Lancet, 1949, ii, 994) ; and heis right in saying that I drew attention to organic diseaseas a cause of epilepsy, especially in later life. His partialquotation of my figures is, however, somewhat misleading.It is true that of 25 deaths in patients who had their firstfit after the age of forty, the cause of death in 10 wasa cerebral tumour. But the 25 deaths occurred in 100patients with the same age of onset of epilepsy, and theremaining 75 showed, when re-examined not less thanthree years later, no sign of cerebral tumour. In thisseries, therefore, of people over forty developing epilepsy,only 10% were subsequently proved to have a tumour.This does not diminish the importance of bearing thispossibility in mind and of re-examining periodically allcases of enilensv.

Newcastle upon Tyne. F. J. NATTRASS.

HEAT CRAMPS

SiR,-I am most gratified that, in his letter of Nov. 19,Dr. Marsh, who has had wide practical experience in thefield, expressed interest in my article of Nov. 5.

I agree with Dr. Marsh that the development and reliefof cramp may involve more than simple osmotic factors.In the first draft of my article I did go so far as to suggestthat the speed with which cramps were relieved by theinjection of strong sodium-chloride solution was greaterthan might be expected with a simple osmotic mechanism;a certain natural caution, however, and the feeling thatpossibly a biologically minded physical chemist mightmake the attempt to calculate the actual time requiredfor an osmotic transfer and show me wrong, caused meto withdraw this remark-I think in proof. But I didgo so far, in my paper as printed, as to suggest thatsodium chloride, by which I meant either the whole saltor one of its ions, might possibly have a specific function.The best evidence against a simple osmotic theory ofheat cramp is provided by those tests in which osmoticallyeverything was in favour of cramp developing, but in

1. Philip, A. J. Urol. cutan. Rev. 1949, 53, 417.2. Lancet, 1946, ii, 508 ; Ibid, 1949, i, 800.