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tion with oliguria in - a pre-existing nephritic or evennephrotic syndrome. In one instance of renal-vein

thrombosis, malignant hypertension supervened.The clinical recognition of these syndromes is a matter

of the greatest interest, which throws new light on variousmanifestations of renal disease. The diagnosis can oftenbe clinched by retrograde venography of the renal veins- technique described by Harrison et al. Renal veno-graphy is indicated when there are collateral abdominalveins with upward blood-flow ; and also when unex-

plained oedema, of the legs or lower trunk is associatedwith proteinuria of too mild a degree to produce a typicalnephrotic syndrome. Recent pulmonary infarction mayalso suggest the use of renal venography if the source ofembolus is not clinically obvious. Recent thrombi inthe renal veins or the inferior vena cava are extremelyliable to give rise to showers of emboli and recurrentpulmonary infarction. - Unexplained proteinuria in

patients known to be suffering from malignant diseasealso raises the suspicion of renal-vein obstruction.Obstruction may be caused by direct pressure of thegrowth on the upper cava, or it may be secondary tovenous thrombosis, which is a familiar complication ofmalignant disease. Renal-vein thrombosis withoutinvolvement of the cava is more likely to be clinicallysignificant in patients with a single kidney ; coincidentbilateral thrombosis of the renal veins is obviously lesslikely than thrombosis of a single renal vein. The

nephrotic syndrome appearing for the first time in

elderly patients may be another indication for renal

venography: unnecessary operations may be avoided

by the demonstration of caval obstruction from secondarydeposits.

1. Manchester Regional Hospital Board : Abstract of Statisticsfor 1955.

INVESTIGATIONS FOR PRACTITIONERS

NOT long ago misgivings were expressed at the pro-posal that general practitioners be given direct access tothe pathological laboratories and X-ray departments ofthe hospitals. These departments, it was said, wouldsoon be swamped by requests for investigations andfilms. The wrong tests would be asked for, samples wouldbe wrongly collected, and reports on them would be

misinterpreted by doctors who had become far removedfrom " real " clinical medicine. Gloom spread throughthese departments, and the barricades were raised

reluctantly.How far have those fears been realised ? "? Dr. F. N.

MarshalI,1 senior administrative medical officer of theManchester Regional Hospital Board, cites figures forthe use of these departments in his area by generalpractitioners and compares these with those of otherusers. The unit of measurement is the " standard unit "

introduced by the Minister of Health in 1953. By thissystem routine laboratory tests are evaluated in terms oftime, one " unit " equalling 10 minutes. The radio-logical "unit" takes into account the time of theradiologist and the radiographer as well as the cost ofmaterials.

In terms of standard units the total work of thelaboratories increased by 19% during 1955, but thegeneral practitioners made no contribution to this. Infact the work done on behalf of general practitionersdecreased from 3.6% in 1954 to 2.9% in 1955. Theunits of work carried out for general practitionersrepresented only about a twenty-fifth of that requestedby the hospitals in which the departments were situated.In Manchester one or more X-ray departments are

open " to general practitioners in every hospital centre,and in these the storv is similar. On average the volumeof work carried out on behalf of family doctors wasbetween 10 and 11 % of the total work of the departments.

Opportunity is seldom taken to measure the value ofdiagnostic procedures to those who request them and theextent to which they do or do not confirm diagnosesmade on clinical grounds alone. In the annual reportof the Darbishire House Health Centre, Manchester,Dr. H. W. Ashworth compares the number of testsrequested with the number reported as abnormal. Thetests conducted in the laboratory at Darbishire Houseare not complex, but are of undoubted value in diagnosis.The proportion in which abnormal findings were reportedapproached one in three. The centre’s X-ray apparatus,a general diagnostic model, is used discriminately butfreely by the four doctors at the centre. The 1507examinations made during the year yielded 301 positivereports.The proportion of investigations that yield positive

results is no certain guide to either economy or efficiency ;but in Manchester the opportunity for a comparativestudy might be taken by investigating a comparablerange of laboratory and X-ray investigations, ordered inthe outpatient and casualty departments themselves,with regard to the proportion found positive.

1. Gowers, W. R. Epilepsy and Other Chronic Convulsive Diseases.London, 1881.

2. Efron, R. Brain, 1956, 79, 267.

COUNTER-IRRITATION IN EPILEPSY

IT has long been known that an epileptic fit can

occasionally be aborted by the application of some

strong sensory stimulus as soon as the aura of the attackappears. The stimulus is more effective if it is strong andunpleasant and applied to the site involved in the aura.Thus, a focal motor attack in the hand may be alteredor abolished by applying a tourniquet to one finger,by gripping the hand hard, or by forcibly moving itagainst the movement of the spasm. Smelling salts,burning feathers, or other strong and unpleasant odoursmay also, though rarely, prevent a grand-mal attack,if applied early. Gowers believed that they were mosteffective when the aura was epigastric or of uncinatetype ; but he was led away from the sensory aspectsof the stimulus by finding that amyl nitrite, with itsvasodilator action, was very effective. - Thereafter thepossibilities of cerebral I vasodilatation occupied hisattention. Efron 2 has lately had the opportunity tostudy the way in which an olfactory stimulus modifiesgrand mal with a long and stereotyped aura. The auraconsisted of -a march of psychic events, involving afeeling of depersonalisation, the expectation of an odour,then the sudden bursting through of an intense,unpleasant, sweet, penetrating smell as an immediateprelude to loss of consciousness and a grand-mal attack.Efron found that a strong unpleasant odour appliedduring the period of depersonalisation would modifyor prevent the subsequent course of the attack. He

proceeded initially on -the assumption that competition.in cortical pathways accounted for the effect-that theextraneous odour occupied the olfactory sensory cortexand thus prevented the physiological march - of the

spontaneous attack. Indeed, it was this view that ledhim to try this method of preventing an attack, sincehe was at first unaware of Gowers’s work on the subject.He found, however, that simple pathway competitionsuch as Gowers had suggested would not explain hisfindings. He noted, for instance, that the externalstimulus was more effective if applied early in the

depersonalisation aura, and was in fact ineffective if

applied just before the spontaneous smell developed.By the pathway-competition view, this should havebeen the best timing, since it would be the moment whenthe cortical march was about to debouch into the olfactorycortical areas. Abnormal spiking in the electro-encephalo-gram of the uncinate area had already been noted on one

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occasion (suggesting that olfactory mechanisms werethen occupied by the discharge), when the externalstimulus was still able to modify the attack. Moreover,the feeling of depersonalisation was rapidly reversedby the olfactory stimulus, sometimes before even the"

expectation of a smell " had appeared. These observa-tions led Efron to explain the action of the stimulusby some active inhibitory mechanism at cortical level.But the fact that the counter-stimulus must be strongand unpleasant may well point to some action at centren-cephalic rather than cortical level. Whatever the inter-

pretation of these findings, they are useful observationsmade by applying simple physiological principles toclinical investigation in a way that Gowers would certainlyhave appreciated. Their therapeutic implications willalso require consideration.

1. Gibson, J. P. J. Pediat. 1956, 49, 256.2. Code of Surgical Operations. H.M. Stationery Office. 1956.

Pp. 276. 15s.

IN BED OR OUT ?

SHOULD feverish children always be put to bed? ’lGenerally the question is superfluous, since most of themask to go there, and quickly fall asleep before passinginto the restless miserable stage. In rheumatic fever,diphtheria, and nephritis it would be bold, if not reckless,to try any other course ; but it is questionable whetherthe principle should be extended to all pyrexias, whatevertheir cause. Gibson often heard mothers say, " WhenI keep him in his bed he jumps and cries continually.It seems to me he would exert himself less if I let him

play in the house " ; so he decided to investigate. Of1082 feverish children, most had respiratory infections,but 14 had scarlatina. All were treated at home, and471 were kept in bed for three days, while 611 werenot put to bed at all, but kept indoors. The resultsin the two groups were identical and there were no

complications.What conclusion can be drawn from such work ? ’l

Certainly not the abandonment of bed rest in the treat-ment of pyrexia ; but a reminder that insistence on

periods of bed rest for all feverish children may not bein the best interests of mother or child. As a matter offact, any doctor who pays unexpected visits to his

patients’ homes knows that many mothers proved thispoint to their own satisfaction years ago.

CODING FOR CASE-NOTES

THE surest foundation for the publication of clinicalresults is an efficient system for filing and indexinginformation obtained from the clinical case-notes. This

inevitably calls for coding and translation of facts to

punch cards. Until this is undertaken for the basic facts,such as age, sex, diagnosis, and treatment, large seriesof cases are almost impossible to study with any accuracyfrom one hospital alone and certainly not on a nationalscale. The International Claskifteation of Diseases, Injuriesand Causes of Death, published in 1948, started the bal.].rolling. A comprehensive index of treatment is moredifficult to compile ; nevertheless the task has now beenachieved for surgery and the allied subjects of radio-

therapy and anaesthesia. The Code of Surgical Operations 2is a welcome addition to the Olassification of Diseases.But how long will it be before it is widely used *? Thisis only the beginning of a much harder task : theeducation of doctors to appreciate the need to adoptthis statistical method ; and the education of regionalboards and boards of governors to realise the importanceof adequate clerical assistance and access to a Hollerithmachine. For who is to do the coding ? ’1 The registraror house-surgeon, burning the midnight oil, or a clerk ? ’1

Though the code is a model of clarity, its use by a doctorstrange to such tools entails concentration and labour,and is an uneconomic use of his specialised skill. It

would be better for each hospital to employ a secretaryfor the sole purpose of coding, who would soon learnand remember the common code numbers and so savetime otherwise spent in continual reference to the code-book. The publication of this valuable code shouldtherefore be a stimulus to both doctors and administrators,for it may well remain useless on the shelf until it i3decided who can and who shall do the coding.

1. Fry, J. Brit. med. J. 1954, i, 190.2. Cotes, J. E., Higgins, I. T. T., Thomas, A. J. Ibid, 1956, i, 601.3. Palmer, K. N. V. Ibid, 1954, i, 1473.4. Leese, W. L. B. Lancet, Oct. 13, 1956, p. 762.5. Oswald, N. C., Medvei, V. C. Ibid, 1955, ii, 843.6. Lowell, F. C., Franklin, W., Michelson, A. L., Schiller, I. W.

Ann. intern. Med. 1956, 45, 268.7. Cloodman, N., Lane, R. E., Rampling, S. B. Brit. med. J. 1953,

ii, 237.8. Oswald, N. C., Harold, J. T., Martin, W. J. Lancet, 1953. ii, 639.

SMOKING AND BRONCHITIS

HEREDITARY disposition, bacterial infection, allergy,atmospheric pollution, exposure to cold and damp, andcigarettes are some of the things that are thought tocontribute to the development of chronic bronchitis.In recent years more attention has been directed to

cigarette smoking because it has been linked also withlung cancer and because it is an influence which mightbe eliminated if proved evil. With few exceptions 12 thefindings have indicated that a significant relationshipdoes exist between smoking (especially heavy smoking)and chronic bronchitis.3-6 As smoking is probablyonly one of many contributory causes, it is important,in assessing the effects of differences in smoking habits,to ensure that as far as possible the individuals studiedare similar in other respects. For this reason, Oswaldand Medvei 5 examined the smoking habits and theincidence of chronic bronchitis in London Civil Servants-people living and working in much the same conditions-and their finding that chronic bronchitis was morefrequent in smokers than in non-smokers seems particu.larly significant. Goodman et al.’ noted that in thiscountry, the death-rate from chronic bronchitis in malesis much greater than in females ; but they suggestedthat this might be due to differences in working condi.tions and smoking habits rather than to a specific sexdifference in susceptibility. This surmise is supportedby Oswald and Medvei’s finding that the incidence ofchronic bronchitis in male and female Civil Servantswith similar smoking habits was much the same.

Carefully controlled inquiries into the relationshipbetween cigarette smoking and chronic bronchitis are

valuable and necessary ; for, although common sensesuggests that not everyone will be able to draw smokeover the lining of his bronchial tubes with impunityfor years, many,people are uneasy nowadays until eventhe most reasonable hypothesis receives statistical

support. Chronic bronchities addicted to smoking arenot so inhibited : in one group 8 the majority consideredthat smoking had caused or aggravated their bronchitisand a proportion of them had abandoned the habit ontheir own initiative. More should be encouraged to -ofollow this example, but those who are not deterredfrom heavy smoking by the cost of tobacco are unlikelyto be swayed by mere exhortation. A more promisingcourse is to take every opportunity to impress on olderschool-children and young men and women the potentialdangers of smoking ; in this way we might counter tosome extent the powerful propaganda in favour of tobaccowhich continues to face them on all sides. And it cannotbe denied that the most persuasive contribution thedoctor can make to an anti-smoking campaign is notto smoke himself.

WE have to record the death on Oct. 30 of Dr. J. C.CRUICKSHANK, professor of bacteriology as applied tohygiene at the London School of Hygiene and TropicalMedicine. He was 57 years of age.