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(5) A primigravida, at 34 weeks, has had a surgical inductionfor toxœmia ten days ago, but is still not in labour ; she isdraining offensive liquor. her temperature is 100°F, and the

fœtal heart-sounds are still audible : what should be done ?-Mr. Arthure said he would have already used further effortsto get labour under way ; he might even have used a hydro-static bag, or he might already have done a csesarean section.As things now are the only course was to operate after pre-liminary chemotherapy in order to save the baby. ProfessorNixon said this was surely a case for extraperitoneal csesareansection. He agreed that the case could not be left and thethreat of eclampsia still hung over the patient. Mr. Stall-worthy thought that at 34 weeks there was a fair chance thatthe head would be high anyway and this would make caesareansection the wiser course, but if the head was deep in the pelvisa bag could be used. He did not care for the extraperitonealoperation because he trusted the peritoneum more than thepelvic cellular tissue to cope with infection ; the technicaldifficulties of the operation often led to accidental openingof the peritoneum. This brought a retort from ProfessorNixon that opening the peritoneum mattered little providedthat it was recognised before the infected uterus was opened ;it could then be simply closed. He quoted the remarkablecase-mortality of 0.8% in Whittaker’s series of about 300cases.

(6) Can ovulation occur before puberty and can conceptionoccur before ovulation ?-Miss Barnes answered " Yes " tothe first part and " No

" to the second.

(7) What is the best method of emptying the uterus in a caseof hydatidiform mole ?-Mr. Arthure thought that if spon-taneous abortion had already begun it should be allowed tocontinue ; but otherwise he favoured abdominal hysterotomy,because one could then be more certain of removing the molecompletely, the risk of subsequent chorion epithelioma wasreduced, and the perforating type of mole could be recognisedat operation. The large uterus should certainly be emptiedby the abdominal route. Professor Nixon favouredevacuation from below, and Miss Barnes agreed provideduterine activity had first been stimulated by medical induction.Sir William Gilliatt recommended laminaria tents for 12-24hours followed by evacuation from below. The tents wouldensure better uterine tone and so reduce haemorrhage duringevacuation ; this alone was reason enough for not relegatingthem to the museum. For the elderly, hysterectomy wasthe safest course.

(8) What is the treatment of imperforate hymen with hcemato-colpos, kœmatometra, and hœmatosalpinx ?-Professor Nixon :" Incise the hymen." Miss Barnes : " Excise the hymen."All agreed that there was no case for laparotomy and that theneed for rigid asepsis was paramount. Sir William Gilliattadded that one would not know at the time of operationthat the tubes were in fact distended with blood, and thereckless folly of trying to find out by bimanual examinationwas at least implied.

(9) What is the treatment of genital tuberculosis, and isdilatation and curettage ever justified ?-Mr. Stallworthy saidone must distinguish between the cases without physicalsigns, which were discovered during investigations for sterilityby routine endometrial biopsy, and those with obviousclinical pelvic disease ; he had yet to see a case of thelatter that had been cured without radical surgery or hadsubsequently become pregnant. Streptomycin might alterthis outlook and initial results seemed encouraging. Curettage,though it involved a risk of spreading infection, might benecessary before the pelvic tuberculosis could be diagnosedin the first place, and endometrial biopsy could easily missthe tubercle. Miss Barnes had treated a few cases with

streptomycin. Such cases must be very carefully controlledand patients with associated pulmonary or renal lesionsshould be excluded. Results were not likely to be con-

clusive for many years. Cases without large masses in thepelvis did best. Professor Nixon said that X-ray therapyshould be considered.

(10) What method induction is safe to prevent a case

booked for trial labour-from becoming postmature ?--Mr. Arthureeschewed surgical induction if trial labour was contemplatedbut had no objection to medical induction. Miss Barneswould not even use pituitary extracts in such an inductionbecause of the risk of uterine rupture-in fact, she did not useinduction in trial labour at all and preferred to stand by heroriginal decision. Sir William Qilliatt said that trial labourmust be spontaneous and not induced labour, and -that theuse of pituitary extracts increased’the fœtal mortality.

(11) When should it be considered that trial labour has failed ?-Miss Barnes thought a decision should be reached whetherto allow labour to continue by examining the patient after24 hours of real labour or after the membranes had been

ruptured for 4 hours. The question of failure could not beconsidered, however, while the membranes remained intact.Mr. Arthure disliked the setting of arbitrary time-limits;a trial labour had failed only if progress ceased, and progresshad to be estimated by vaginal examination. ProfessorNixon said that failure often occurred long before full dilata-tion ; foetal distress was in itself an indication for intervening.Mr. Stallworthy pointed out that progress was not onlyindicated by descent of the presenting part but also byprogressive dilatation of the cervix.

Sir William Gilliatt’s closing remark, that further

meetings of this sort were likely to be as profitable andas entertaining, was applauded.

DRINK

RATS, pigs, monkeys, and other animals readily developa taste for alcohol; about the only exception is thecat, which, given the choice of milk or milk and brandy,will take the latter only when its hair is standing onend. Dr. J. Y. Dent told this to the Hunterian Societylast Monday in speaking for a motion " that alcohol hascontributed more to the happiness than the misery ofmankind " ; and he went on to advise that man shoulddrink like the cat. He divided mankind into four

groups : alcohol addicts, those who drink to excess, thetemperate, and abstainers. Addicts (who in the U.S.A.number about 6% of drinkers) can never hope to takealcohol temperately : for them the only way is life-

long abstinence. Often these are intelligent and ablepeople, eager to be cured ; and they should not beconfused with the self-indulgent drunkard of the sortthat " insists on going to the dogs," and for whom theonly cure is penury. Paragons are sometimes uncom-fortable people to live with ; and those who drink toexcess at least have a prpper humility. To the temperate,alcohol makes friends seem more friendly and enemiesless hostile. Even the abstainer may derive satisfactionfrom alcohol through a sense of superiority-a

" soul’sunction " denied to those who drink.As a psychiatrist Dr. Desmond Curran was able to

show that alcohol is an increasingly rare cause of mentalbreakdown. He enjoys seeing alcoholics ; they are

engagingly shameless and their condition is oftenamenable to treatment. In drink they get what theydeserve ; he has seen a man with a robustly cheerfulpersonality laugh at the snakes in his bath. Manyarticles, he said, have been written on alcohol as a

cause of mental illness. Can it also prevent it ? Hebelieves that it can. He observed during his war--

time experience in the Navy that mental breakdownwas much less common under the stress of service atsea than on shore. By analogy, might alcohol nothave a place in ensuring a smooth transition from thetrials of a day’s work to the comparative calm of thehome ’?The motion was opposed with skilled advocacy by

Dr. Henry Yellowlees and Mr. Archibald Crawford, x.c.Dr. Yellowlees conceded that the expectation of lifefor moderate drinkers was greater than for abstainers ;that it could afford dutch courage ; enable the shy tospeak ; possibly assist the creative worker ; and pro-mote conviviality. But how many " jolly good fellows " were needed to balance the suffering caused through onechild being run over by a drunken motorist ? The motionbefore the meeting could not be answered in terms oflogic and should therefore be rejected. To the questionwhether alcohol had greater potentialities for good orfor evil, intelligent people could give only one answer.The discussion revealed general recognition that

alcohol is no longer the pressing social problem that itwas. More than one speaker spoke, perhaps a little

wistfully, of the days when gin was 3d. a glass ; but the

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waning of alcoholism was ascribed not only to the grow-ing cost but to improved social conditions, the restrictivelicensing laws, the advent of cinemas and radio, and thechanged attitude to heavy drinking. From a large gather-ing not a single convinced teetotaller emerged to expresshis viewpoint. Nevertheless the motion was rejected.

DENTAL DRILL OR HIGH-PRESSURE JET ?

THE faint purr of the electric motor on the dentaldrill is enough to make cowards of most of us, and whenthat faint purr is transmuted into a shattering vibrationin our mouths our terror is complete. Why this shouldbe so it is hard to say. The vibration and the noise areadmittedly unpleasant, but in skilled hands and withmodern technique drilling is not invariably, or even

necessarily, painful. It is perhaps more the feeling ofhelplessness and the fear of that little something extrawhich may at any moment spring on us that bringsweat to the brows of the strongest. Local anaesthetics areused to a considerable extent to allay these fears. Theiruse is, however, somewhat dangerous in the. hands ofthe unwary, since too much live tissue can easily be cutaway, giving rise to later irritation of the pulp with thepossibility of further unpleasant sequelae. Their use tooinvolves some pain, since even when the needle is insertedthrough an area of locally cocainised gum its entry isat least unpleasant. The numbing of pain by cold hasbeen utilised in various techniques, such as allowing afine jet of cold water, ethyl chloride, or other chillingagent to impinge on the tooth while the drilling is in

progress. None of these manoeuvres has proved whollysuccessful. Now from the United States, home of inven-tions both credible and incredible, comes news of a newdevice in which a jet of carbon dioxide carrying fineparticles of abrasive aluminium oxide is directed at thetooth and the abrasive dusts are sucked up by a vacuumpipe. The nozzle of the jet is only 1/18,000th of an inchin diameter but the pressure behind the jet is 75 lb. persquare inch. For long we have been brought up tobelieve that pain in the dentine is caused, among otherthings, by pressure, and certain it is that the pressureeven of a probe on sensitive dentine is decidedly unplea-sant. What happens when particles launched with 75 lb.per square inch behind them hit this sensitive dentinewe are not told. We can only hope that this inventionproves less fearsome in practice than it sounds.

CHLOROMYCETIN IN TYPHOID FEVER

UNTIL the introduction of chloramphenicol (’ Chloro-mycetin ’) there was no satisfactory chemotherapeuticagent for typhoid fever. Some of the sulphonamideswere reported to protect mice infected with lethal dosesof S. typhi ; and the less soluble sulphonamides, such assulphaguanidine and succinylsulphathiazole, are reputedto relieve the abdominal symptoms, though the evidencehas never been very convincing. In high concentrationspenicillin and streptomycin inhibit S. typhi, but they donot clearly alter the course of the disease.Initial studies on the antibiotic, chloramphenicol,

showed that it had a wide antibacterial spectrum andwas particulary active against rickettsial and gram-negative bacterial infections, including those producedby members of the salmonella group. The originalreport of Smadel and his co-workers on the beneficialeffect of chloramphenicol on typhoid fever in Malaya wasfollowed by that of Woodward and his colleagues. 2Favourable reports have been published in this countryby Murgatroyd,3 Bradley,4 Lomax,5 Douglas,6 and

1. Smadel, J. E., Woodward, T. E., Ley, H. L. jun., Philip, C. B.,Traub, R., Lewthwaite, R., Savoor, S. R. Science, 1948,108, 160.

2. Woodward, T. E., Smadel, J. E., Ley, H. L. jun., Green, R.,Mankikar, D. S. Ann. intern. Med. 1918, 29, 131.

3. Murgatroyd, F. Brit. med. J. 1949, i, 851.4. Bradley, W. H. Lancet, 1949, i, 869.5. Lomax, W. Brit. med. J. Oct. 22, p. 911.6. Douglas, A. D. M. Lancet, July 16, p. 105.

Patel et al 7; in the U.S.A. by Foster and Concloii.8These reports deal, however, only with isolated cases orsmall noncontrolled groups ; and so the results, thoughusually impressive, have had to be interpreted cautiously.The virulence of strains of S. typhi varies widely ;in some outbreaks the illness is severe and the mortalityhigh, while in others it is mild and runs a relativelybenign course. Moreover, in assessing results the effectof previous inoculation has also to be borne in mind.With the synthesis’ of chloramphenicol early this yearin the Detroit laboratories of Parke, Davis & Co. andthe consequent improvement in supplies, it has beenpossible to treat larger groups. Woodward,9 of Balti-more, has now treated 21 cases in which the diagnosiswas confirmed by blood-culture. The patients were

treated in the active phase of the disease, the course ofwhich was followed by observations on the clinical condi-tion, the duration of fever, and repeated blood, stool,and urine cultures. By the 3rd day clinical improvementwas apparent, with relief of headache, -cough, anddelirium, and disappearance of rose spots ; the averageduration of fever from the start of treatment was 31/2days. Nevertheless, some patients continued to harbourthe typhoid organism and relapses ensued if the drugwas given for less than 8 days.

‘

- In this issue Cook and Marmion describe the resultsobtained with chloramphenicol in 14 cases treatedin the British Military Hospital at Fayid, Egypt.Fever began to abate within 24 hours, and had

usually disappeared within 5 days ; the mental statecleared, toxic symptoms began to disappear, and theappetite returned within 4-6 days. At whatever stageit was given, chloramphenicol ’seemed to arrest thedisease; but Cook and Marmion, like Woodward,remark that intestinal - hæmorrhage and perforationmay still occur. There were no deaths in the 14 treatedcases, and 1 death among the 11 untreated ; but theresults are actually better than this suggests, because allthe seriously ill patients received chloramphenicol.Confirmation of these observations comes from Contiand his colleagues, 1 in Italy. In their series of 63cases there were 4 deaths, 3 of which were attributed totreatment being started too late ; and there were 9 relapses.

’ , ,

Chloramphenicol is undoubtedly the best chemo-

therapeutic agent that we have for typhoid. - Very fewtoxic effects have been observed, and it does not appearto produce resistant strains. The one drawback is that itdoes not always sterilise the gut, so that relapse mayfollow and carriers may still transmit the disease ; butthis may be a question of dosage Further trials areneeded with larger doses given over longer periods, butshortage of the drug is still a limiting factor.

THE MINISTRY OF HEALTHSir WILSON JAMESON, G.B.E., F.R.C.F., K.H.P., chief

medical officer of the Ministry of Health ’and of theMinistry of Education, is retiring from the public serviceon reaching the age limit on May 11, 1950. He hasbeen chief medical officer since Nov. 12, 1940. TheMinister of Health and the Minister of Education have

appointed Dr. JOHN ALEXANDER CHARLES, F.R.C.P.,K.H.P., a deputy chief medical officer in the Ministry ofHealth, to the joint post thus to be vacated next May.Dr. GEORGE EDWARD GODBER, F.R.C.P., will be deputyto the chief medical officer in succession to Dr. Charles.

THE Royal College of Obstetricians and Gynaecologistshas launched an appeal for 400,000, of which £350,000is required for research, building, and general funds and50,000 for a travelling professorship. Since 1929fellows and members have contributed £70,000.7. Patel, J. C., Banker, D. D., Modi, C. J. Brit. med. J. Oct. 22,

p. 908.8. Foster, W. D., Condon, R. J. J. Amer. med. Ass. 1949, 141, 131.9. Woodward, T. E. Ann. intern. Med. 1949, 31, 53.

10. Conti, F., Cassano, A., Monaco, R. Rif. med. 1949, 63, 901.