814

No nappy returns

Ultra-absorbent nappies make urine recovery not just unreliable(see Lancet Sept 14, p 675) but sometimes impossible-and maylead to a mistaken impression of anuria. A letter in the New EnglandJournal of Medicine’ describes a 12-month-old girl who underwentsurgery for vesicoureteric reflux. During the second week aftersurgery the mother reported that her child had not passed urine for24 h, but the results of ultrasound examination were unremarkable.A recent change to a superabsorbent brand of nappy was thennoted; although urine could not be expressed by wringing, thenappy was found to be heavy. The author notes that therecommendation for parents to count wet nappies after urinarysurgery needs to take account of the fact that ultra-absorbent brands

may feel wet only if they contain more than 300 ml urine.

1. Barada JH. Pseudoanuria due to superabsorbent diapers. N Engl J Med 1991; 325:892-93.

In England Now

I hope the 68-year-old gentleman with lepromatous leprosy in aresidential home in Sussex (Lancet Sept 21, p 739) didn’t cause asmuch of a hoo-ha as my patient did in the London Blitz when I was asenior resident. He was first seen in our teaching hospital by one ofthe casualty officers, who sent his notes to me for advice and action. Iwas having tea with my consultant after the afternoon ward round insister’s sitting-room-macaroons on Royal Worcester china. Iscanned the notes and read the diagnosis.

"These new casualty officers! Diagnosing leprosy now!" I said,not altogether kindly.The consultant, an eminent cardiologist, had seen leprosy in

Mesopotamia as a young doctor in the 1914-18 war. He

accompanied me (typical of the great man) to the casualtydepartment. Clinically the 25-year-old Cypriot waiter from Sohocertainly had leprosy; and under a microscope the casualty officerhad a nasal smear showing plenty of Hansen’s bacilli. I admitted thepatient for the night and, to make room for more blitz casualties,moved him next morning in an ambulance (a converted Green Linebus) to a Surrey hospital.The medical superintendent telephoned at noon. "What the hell

do you think you’re doing? ... Twenty-four other patients in thatambulance-all infected, and I’ve admitted them to the wards here.I’ve no facilities for isolating your damn’d patient." He was almostincoherent with rage. I tried to explain, but he shouted me down."Good God, man, haven’t you read the Bible? Ringing bells and allthat? I’m reporting you to the Minister now." He slammed downthe ’phone.An hour later the Minister of Health’s benign scholarly adviser on

leprosy rang me. He had placated Surrey; of course it was all right,he said. I never doubted it, but after all these years it is nice to knowthat he wasn’t just being kind.

* * *

During- these-fearful days of AIDS and heated debates about thepros and cons of routine HIV testing it is uncommon to meetsomeone eager for a test. A 30-year-old married Nigerian came foran HIV test, discussed the issues with a counsellor, and returned 2weeks later for the negative result. Relief, and then the request,"Could I have a letter saying I’ve been here and the results?"

"Certainly, but who’s it for?" (Who asked him for this? Was hepressurised into undergoing the test? Does he not know that HIVtesting can be used in discriminatory ways?)"My wife, and my friends."So I wrote one of those "to whom it may concern" letters, putting

all my qualifications and even finding him an official stamp.He whooped with delight, saying that he and his friends had often

discussed testing but they had all chickened out. They were toofrightened. Now he was going to show them this letter, prove hisbravery, and encourage them to attend by shaming them.

Even though I want people tested so that they can make theirlife-plans, try treatments, and perhaps limit spread, I am not surethat macho competitive "testing roulette" is really the best way. Butwho knows.

* * *

I was recently consulted about a French infant whose mother is apsychiatrist. Exasperated at having to obtain a consultant referralthrough a general practitioner (and offering a Napoleonic view that1992 would sweep away such cartels) she told me: "if you are mad inFrance you may make a direct appointment with a psychiatrist". Ibanished unworthy recollections of, I think, Catch 22 (if one iscapable of recognising one’s madness and making an appointmentto see a psychiatrist, is one really mad?), cooed over her child, andmurmured "vive la difference".

Serendipity is a word much beloved of researchers, especially inthe drug industry, and its use in print is almost invariably followedby an explanation of its origin. I am sure you already know, so I shallmerely pause to wonder for a moment just how many people arethen actually prompted to go on and read some Walpole. Preciousfew, I would suspect.However, serendipity is the act itself and doesn’t really describe

the innocent pleasure one gets from stumbling upon an unexpectedevent: like the first time I saw a camel walking through the snow onewinter in Azerbaijan. Yet surprise or astonishment hardly seemsadequate.

I had always assumed these two words were interchangeable untilI came across a story that nicely illustrates the difference. It seemsthat the wife of the early 19th-century American lexicographer,Noah Webster, discovered her husband one day sitting in theirkitchen with one of the servant girls on his knee. "Noah", sheexclaimed, "I’m surprised!". "No, my dear", he is supposed to havereplied. "I am surprised, you are astonished." Mercifully history issilent on what happened next.

This joy that accompanies chance discovery was brought back tome recently when I witnessed a trapeze artist wearing spectacles.When I first saw the girl I assumed that she was on the platform fordecoration only. But I was wrong. Up she went on her toes, seizedthe bar, and swung out to perform the classic salto mortale, whichinvolves a tricky back flip. I do not know how the spectacles werefixed to her head, but her skilful antics suggested nothing less than asilver bolt through her skull.

International Diary

International conference entitled Advances in Molecular Research-New Strategies for Immuno-, Tumour, and Neuro-Therapy will takeplace in Germany on Oct 9-12: Georgina Mason, IBC Technical ServicesLimited, Bath House, 56 Holborn Viaduct, London EC1A 2EX, UK(071-236 4080).

A meeting entitled Medicine and Human Rights will be held in Londonon Saturday, Oct 26: Secretariat, Physicians for Human Rights (UK), c/oUniversity Department of Forensic Medicine, Royal Infirmary, DundeeDD1 9ND, UK (0382 200794).

A meeting on Viral Infections in AIDS and their Treatment will takeplace in London on Thursday, Oct 31: Julia Davies, Coordinator, NationalAIDS Neuropathology Database, Department of Neuropathology, Instituteof Psychiatry, De Crespigny Park, London SE5 8AF, UK (071-703 5411 ext3287).

2nd meeting of the Genetic Interest Group entitled Choices-Transition to Adult Life for People with Genetic Disorders is to beheld in London on Friday, Nov 15: Mrs Ann Hunt, Genetic Interest Group,Church Farm House, Church Road, North Leigh, Oxon OX8 6TX, UK(0993 881238).

An international conference on Gastroenterology will be held in HongKong on Oct 30-Nov 3 and in Beijing on Nov 3-6: Conference Secretariat,12/F Kaiseng Commercial Centre, 4-6 Hankow Road, Kowloon, HongKong (851-3679372).