106 BRITISH MEDICAL JOURNAL 12 OCTOBER 1974 would like to add one more consideration. To avoid the accusation that "eagerness to with methyldopa for essential hypertension I have recently observed two cases of post- declare" my discovery might shamefuly were seen in our medical outpatient clinic anaesthetic jaundice in which halothane was distort [my] historical judgement" I looked at the Veterans Administration Hospital, employed. On careful investigation these up Lister's original commnunication2 in which Northport, New York, in the month of July Br Med J: first published as 10.1136/bmj.4.5936.106 on 12 October 1974. Downloaded from were proved to be due to Gilbert's disease hie stated that "in the course of the year 1974. These Patients were taking 500-2,000 (congenital hyperbilirubinaemia). Starvation 1864 I was much struck with the account of mig a day in divided oral doses and were precipitates icterus in these cases, causing a the remarkable effects produced by carbolic aged 43-64 years. Close interrogation re- raised plasma unconjugated bilirubin level, acid upon the Eewage of Carlisle . . . vealed that seven were experiencing some usually within 48 hours. The incidence of and the applicability of carbolic acid disorder of sexual function which had started Gilbert's disease may be as high as 5% and for the treatment of compound frac- within a few days of commencing therapy. it should therefore be a consideration in the tures naturally oocurred to me." Six months These included a decrease in libido, an differential diagnosis of cases of post- later, in a leading article, the Lancet3 re- inability to maintain an erection, and diffi- anaesthetic jaundice.-I am, etc., vealed that Dr. Lemain of Paris had already culty in ejaculation. Within two weeks of published a book on the use of carbolic acid discontinuing the drug and instituting a J. E. G. WALKER in medical and surgical diseases but credited regimen of propranolol and hydralazine Department of Oral Surgery, Lister with having made the agent these undesirable side effects had dis- Eastman Dental Hospital, exten- London W.C.1 sively known in this country. This provoked appeared. Sexual dysfunction was not noted a spirited reply from Lister4 who, to quote in a comparable group of 22 hypertensive Professor Hubble "introduced some explana- males treated with a thiazide diiuretic alone. tion, which, in his own view at least, In view of the fact that alberrations of Gonorrhoea in Obstetrics and Gynaecology diminished the fault." He admnitted that he sexual function were not related to age or SIR,-Dr. R. S. Morton's letter (27 July, did not claim the introduoion of carbolic daily dose of the drug we would urge p. 253) raises some very interesting and acid to surgery but claimed originality "for physicians to inquire specifically about the important points. its employment with the view of protecting side effects expe-rienced by patients being The a,pproval by the Royal College of the reparatory processes from disturbance treated with methyldopa.-We are, etc., Obstetricians and Gynaecology of a by external agency." A broadside was then post in delivered by Sir James Young Simpson in R. J. NEWMAN venereology during the elective year preced- the School of Medicine, ing the M.R.C.O.G. examination is most form of an article5 giving very detailed University of Leeds, welcome, as it would enlighten the holders evidence that "Mr. Lister has been most Leeds of such a that venereology is a much undoubtedly preceded by other authors in HUGO R. SALERNO jpost all his leading theories and uses in more complex sufbject than is generally connex- State University of New York at Stony Brook, thought. However, I fail to follow Dr. ion with this subject." The earliest use of New York carbolic acid that he ouoted was as a dress- Morton's reasoning t;hat "the emphasis in to Wilson, G. M., Practitioner, 1965, 194, 51. the Epecialty of venereology is nowadays ing wounds by Cruveilhier, Follet, and 2 Bock, K. D., von., Zeitschrift fur Allgemein- very much on what might be called medical Rigault in 1859, followed by the treatment medizin, 1970, 46, 1287. of oompound fractures by MM. Darrican 3 Evans, B., Practitioner, 1963, 191, 96. gynaecology" and that the "future lies with 4 Johnson, P., et al., British Medical 7ournal, 1966, holders of the M.R.C.O.G." If this were true and Petit in 1860. After this Lister retired 1, 133. as gracefully as possible "having already 5 Bauer, G. E., et al., Medical 7ournal of Australia, it would have a disastrous effect on the re- 1973, 1, 930. cruitment of junior medical staff. While endeavoured to place the matter in its true 6 Bulpitt, C. J., and Dollery, C. T., British Medical solving an immediate situation, it would in light without doing injustice to anyone."6 Yournal, 1973, 3, 485. the long term aggravate a condition which The fact remains that Lister had claimed is becoming more and more acute. In my to have introduced carbolic acid to "protect opinion the specialty of venereology is in the reparatory processes from external Swelling of Arm in Patients with danger of collapse unless we sell the image agency" in 1864, while in 1863 Bert was of Arteriovenous Fistula of the specialty as it really is-one of im- the opinion that acide phWnique was essen- http://www.bmj.com/ tial to arrest putrid transformation. I think SIR,-We were most interested in the recent portance and not one to be ignored, as is E. shown by the increasing nuntber of patients we may safely say with Sir Walter Langdon- case reiport 'by Drs. J. G6thlin and Brown that "while there was no real claim Lindstedt (7 September, p. 629) and have and the nore complex diagnostic tests. studies of hand A major factor in the deterioration of re- to priority, there was no wilful plagiarism recently completed formal with intent to deceive."-I am, etc., volume in patients on intermittent dialysis cruitment to tLhe specialty is outlined in the using an arteriovenous fistula. We found letter from Dr. S. Mehta and others (14 hand was p. did not DAVID PERRINS that the volume of the dominant September, 690). Though they Churchill Hospital, 5-1% greater than that of the non-dominant name it, venereology is in the very worst Oxford

but on 30 September 2021 by guest. Protected copyright. position in that few if any consultants re- hand (P < 0001) in 28 normal subjects ceive more than the basic salary. If this Bert, P., De la greffe animale. Paris, Bailliere, that the volume of the non-dominant 1863. (fistula) hand was greater in age- and sex- cause were removed it would obviate the 2 Lister, J., Lancet, 1867, 1, 326. P < and necessity for back-door recruitment.-I am, 3 Lancet, 1867, 2, 412. matched male (18%, n = 23, 0001) 4 Lister, J., Lancet, 1867, 2, 444. female (21%0o, n = 5, P < 001) dialysis etc., 5 Simpson, J. Y., Lancet, 1867, 2, 546. F. M. LANIGAN-0'KEEFFE 6 Lister, J., Lancet, 1867, 2, 595. patients. We found that 23 out of 36 patients de- Venereal Diseases Department, veloped pain, numbness, or paraesthesiae on General Hospital, to Birmingham Sexual Dysfunction Due to Methyldopa dialysis, these symptoms being confined the distribution of the median nerve in the SIR,-It is now widely held that methyldopa fistula hand. In six patients with severe Plagiarsm in Medicine is a drug which can oontrol systemic hyper- symptoms the volume of the fistula hand tension with relatively few unwanted side increased by 150% on dialysis (P < 0 05), SIR,--Profeor Douglas Huibble's Personal effects. Disorders of sexual function are whereas the volume of the non-fistula hand View (7 Septentber, p. 623) has proved too known to occur, but apart from reports increased by 4% (P > 010). Predialysis great a temptation for .me to resist confess- saying that they are "rare"' or met with venous pressure in the dorsum of the fistula ing the "rare excitement" I felt when I "seldomn"2 or "infrequently"3 their exact in- hand was 21 ± 4 cm H20 higher than in thought I was the first to find that Lord cidence has been poorly documented. Papers the non-fistula hand. Because of severe Lister had not introduced antilseptic surgery. reporting a 2% incidence of methyldopa- symiptoms two patients have required carpal While preparing my M.D. thesis I read that induced impotence have been published4 as tunnel decompression. of the French physiologist Paul Bent, which well as others which report no significant We conclude that oedema of the fistula wtas published in 1863. While considering change in libido, potency, or ejaculation.56 hand is common in dialysis patients, though the influence of various agents on the swr- We are of the opinion that disorders of it may be undetectable on physical examina- vival of skin grafts he wondered if "la sexual function oocur in approximately one- tion. The oedema is probably a conse- presence d'acide phenique si propre a arriwer third of males so treated and append the quence of high venous pressure and les trasformations putride" offered, an ad- following information. exacerbated by immobility during dialysis. vantage or disadvantage.- Twenty-seven male patients being treated Construction of an end-to-side anastomosis