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Stewart 3 showed that cholesterol crystals, injectedinto the tissues, act as irritant foreign bodies leading tothe formation of a foreign-body granuloma. Such forma-tions were described in the ear by Manasse in 1917,4whose report seems to have attracted little attention.Singer 5 rediscovered these formations, but more recentaccounts have paid little attention to them. Simpson 6has revived interest in the rôle of cholesterol in choles-teatoma. Birrell included, in a paper entitled BlackCellular Cholesteatosis in Children, beautiful illustrationsof cholesterol granulomata which, however, he interpretedas cholesteatomata or " black cholesteatomata."On histopathological grounds I have suggested the

adoption of the term cholesterol granuloma for thesestructures.2

ConclusionsThe two lesions-epidermoid cholesteatoma and chol-

esterol granuloma-may cause similar clinical features,but their microscopic appearances are fundamentallydifferent. The epidermoid cholesteatoma is an epithelialstructure ; it is an epidermoid cyst in a particularlyimportant and vulnerable part of the skull. Cholesterolcrystals produce a foreign-body-type granuloma whichshould be called cholesterol granuloma.

I. FRIEDMANN.Department of Pathology,

Institute of Laryngology andOtology, London, W.C.1.

3. Stewart, M. J. J. Path. Bact. 1915, 19, 305.4. Manasse, P. Ohrenheilk. Gegenw. 1917, p. 9.5. Singer, L. Z. Hals- Nase- u. Ohrenheilk. 1933, 32, 110, 130.6. Simpson, R. R. Proc. R. Soc. Med. 1954, 42, 205.7. Birrell, J. F. J. Laryng. 1956, 70, 260.

OBSTETRIC FLYING-SQUADSSIR,—Many progressive obstetricians will be surprised

to read that Professor Nixon (March 16) supports theprinciple of routine interference with physiological par-turition by administering ergometrine in all cases ofnormal labour.

The better understanding of the phenomena of normallabour has resulted in the exclusion of empiricism which,in turn, has disclosed that the natural and healthyperformance of the total mechanism of human reproduc-tion incurs less risk and trouble to all concerned thanthe applied science of interference.The vast majority of serious postpartum haemorrhages

are the result of faulty midwifery, and true pathologicalhaemorrhage after a well-conducted physiological labourrarely occurs. This is demonstrated by the almost entireabsence of postpartum haemorrhage in uncomplicatedlabour amongst unurbanised tribal Africans. They donot sever the cord until the placenta is born, and in onlya few tribes is the birth of the placenta assisted in

any way.When there is a clinical indication for antepartumergometrine, it should be given intravenously as theanterior shoulder is delivered. To give it " with thecrowning of the head " in primipara predisposes to

unnecessary pain, episiotomy, and laceration.In 1934, I first taught the students at University

College Hospital that " the most effective postpartumstyptic is a screaming newborn baby in the arms of ahealthy, happy mother." This should be the objectiveof all who attend women in childbirth. The emergencywork of the flying squad would become less onerous

as the quality of obstetric teaching and practiceimproves.

All midwives should be fully equipped to treat thisalarming complication immediately it occurs. The con-duct and the dangers of the third stage of labour shouldbe drilled into all students and midwives. The evils ofroutine interference in normal labour should be overcomeby understanding.

GRANTLY DICK-READ.

TOWARDS PREVENTING SUICIDE

1. The Health of the School Child. Report of the Chief MedicalOfficer of the Ministry of Education for the years 1954 and1955. H.M. Stationery Office; p. 24.

2. Busvine, J. R., Burn, J. L., Gamlin, R. Med. Offr, 1948,79, 121.

SIR,—We should, I feel, all like to congi’atulate Mr.Chad Varah (March 16) on the excellent scheme forwhich he is responsible and for his work in preventingsuicide and referring patients to psychiatrists. This isclearly a field in which the minister and the doctor cancooperate more closely ; and perhaps one in which mostof us need additional training. The elderly depressedpatient is clearly better with a transference or dependenceupon the Church than upon a movable person such asthe psychiatrist. If the psychiatrist or therapist movesto another post or goes on holiday, the depression withits suicide risk returns. This is but one example of ahost of problems.The Church now recognises that its training in pastoral

care does not meet the need of this highly specialisedfield ; and there are hopes that changes will soon bemade in theological training.

J. H. PRICE.Hill End Hospital,

St. Albans.

PEDICULOSIS CAPITIS: MASS CONTROL

SIR,-Over a quarter of a million school-children in1955 had evidence of verminous infestation of the hair.lThe chief medical officer of the Ministry of Education inreporting this says : ’’ there is no cause for complacency.In some areas infestation has ceased to be a problem;in others, almost 20 per cent of the children are affected."In Salford-despite the determined use of modern insec-ticides successfully applied to the hair of individualchildren-there was an obvious failure to eradicateinfestation in the community ; the infestation-rate inschool-children reported monthly was often 17%. Thesefacts are a grave reproach to public health. Especiallygalling in comparison is the negligible or nil infestation-rate in certain European cities.

I decided, therefore, to have an all-out attack oninfested school-children and their family contacts at oneand the same time. I am compiling a full report forpublication, but for the present it is sufficient to saythat over 25,000 children attending all the schools inSalford, apart from the grammar and technical schools,were examined by members of the public-health nursingstaff on the re-opening of the schools after the summerholidays in 1956. Over 17% showed signs of infestation.All such children, however slight the infestation, receivedtubes of a gamma benzene hexachloride shampoo(’Lorexane’ no. 3), and sufficient tubes were providedfor every member of the family to be treated. Some10,000 tubes were distributed.

At the end of the survey, of over 25,000 childrenexamined, less than 2% showed signs of infestation;although some months have elapsed since the shampoowas applied on a large scale the infestation-rate appearsstill to be under 3%. A small control group using theshampoo, without the insecticide, did not show the samedecisive reduction in the infestation-rate.

Busvine et a1.2 showed in 1948 that in Salford gammabenzene hexachloride (’ Gammexane ’) appeared to givebetter results than dicophane (D.D.T.). Since then,experience here has shown that gamma benzene hexa-chloride is a safe remedy even when used on impetiginousscalps ; hence it was suggested that this be incorporatedin a first-class shampoo.

Success in disinfestation lies in the "acceptability" "

of the remedy by the child and his contacts, includingof course every member of the family-for infestationis a family disease. The shampoo described is safe to use;

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no ill effect has been observed, and the hair is left in

good condition, with no sign or stigma of treatment.The use of an attractive shampoo overcomes the reluct-ance of the adolescent and the mother. A first-class

shampoo is necessary so that all members of the

family will not only tolerate the remedy, but like it andwant it.

There is great need for industrial areas, irrespective oflocal-government boundaries, to attack the problem ofinfestation together and at the same time. I have tried

many insecticides during the past twenty years, and thenew lorexane no. 3 appears to be the best remedy.Acknowledgment is warmly made to those who did all the

work: the Salford public-health nursing service (superin-tendent health visitor, Miss B. M. Langton), and I.C.I.Pharmaceuticals Division for supplies of ’ Lorexane ’ no. 3

shampoo.

J. L. BURN.Public Health Department,

Salford.

1. Wilson, G. S., Miles, A. A. Topley and Wilson’s Principles ofBacteriology and Immunity. London, 1948.

2. Zinsser, H. Textbook of Bacteriology. New York, 1948.

DYSENTERY DURING ADMINISTRATION OFANTIBIOTICS

SiR,-The use of antibiotics is usually followed by theappearance of a new microbial flora in the intestine ; andwhen the host is debilitated the new micro-organismsmay give rise to a secondary disease-e.g., candidiasis orstaphylococcal enterocolitis. Recently we have seen acase of dysentery apparently caused by Proteus morganiwhich arose during administration of tetracycline andpenicillin after an operation on the intestine.A man, aged 30, had for several years had pain in his right

lower abdomen. A diagnosis of mobile caecum was made.At operation, severe chronic inflammation of the caecum andascending colon were found. The ileocaecal region, caecum,and ascending colon were resected and an ileocolostomy wascreated. Since abdominal distension and high fever continuedafter the operation, food and water were not given orally fora week; blood and Ringer’s solution were infused andvitamins injected ; tetracycline 500 mg. daily was adminis-tered intravenously with 500 ml. of 5% glucose solution,and penicillin 300,000 units daily was given intramuscularly.On the 7th day after operation, the patient had severe

dysenteric symptoms. From the faeces bacteria of the proteusgroup were isolated in almost pure culture ; they were

identified as Proteus morgani biologically and serologically.Among the biological properties of the organism was a markedactivity of histidine decarboxylase, but the significance of theactive production of histamine in this case was not known.The organism was highly resistant to penicillin, erythromycin,tetracycline, chlortetracycline, oxytetracycline, and strepto-mycin, and only moderately sensitive to chloramphenicol.After oral administration of chloramphenicol 1 g. daily for3 days, the dysenteric symptoms abated, the faeces becamenormal, and the organism disappeared from the faeces.

Proteus morgani seems to be mainly commensal butpotentially pathogenic.l 2 It has been cultured from thefseces in sporadic dysentery, enteritis, and diarrhoea, butits pathogenicity is doubtful. Under suitable conditionsit seems able to multiply in the intestine, but it canhardly be ranked with the organisms of the shigellagroup.

In our patient, active growth of Proteus morgani inthe intestine, resulting from the depression of the normalintestinal microbial flora, may have caused dysentericlesions-at a time when he was undernourished after theoperation on the intestine. In most reported cases,staphylococcal enterocolitis has followed nutritionaldeficiencies or severe cachectic states. We must thereforepay much more attention to the nutritional state ofpatients when antimicrobial therapy is being given.

NOBUO KATOYOSINORI NARITA.

Nagoya University Schoolof Medicine,

Nagoya, Japan.

UNMARRIED PARENTHOOD

SIR,—This letter is intended to be an olive-branch.Both Dr. Tuthill and Miss Steel want to see more andmore happy marriages, with more and more childrengrowing up in confidence and security because thesexual life of their parents is harmonious and free frommorbid associations of guilt. It is a little hard of MissSteel to call the notions which seem to underlie the letterfrom Dr. Tuthill, who after all is only out to help thosecouples whose sex life has gone adrift (often because theyhave been indoctrinated with " guilt "), " very barbaricand sub-human." To call sex an appetite does not seemto be contradicted by experience, nor indeed by the out-spoken phrases of the Book of Common Prayer. Arethere not perhaps some couples who are such idealistswith regard to sex that they are permanently dis-appointed, and permanently feeling guilty ? While

no-one wants children to be born of illegitimate parents,there are other kinds of sexual tragedies-e.g., the con-scientious couple, both brought up to regard sex as strictly" sacred," who are never free from scruple and inhibitionwith each other. If things go seriously adrift, such

couples need help from outside, and it is possible that theonly person who can help them is one who can persuadethem to be less solemn and idealistic, more playful andlusty, in their sexual life. We all want to help and to behelped, and I feel we must not get too hot under thecollar over the unorthodox opinions and methods ofsome of the helpers.

EDWARD MANSFIELD.Bowers Gifford Rectory,Basildon, Essex.

1. Brown, A. S. Anœsthesia, 1954, 9, 19.2. Brown, A. S. Ibid, 1955, 10, 351.

REFLECTIONS ON CIRCULATORY CONTROL

SiR; Dr. Cecil Gray suggests (Feb. 23) that " hypo-tension should be reserved for those cases in which it isclearly imperative because of the nature of the surgery ;this would limit it to neurosurgical and perhaps someotolaryngological and plastic operations ... " Yet thereare probably more contra-indications to hypotensionin cerebral disorders than in those elsewhere in thebody.For example, Brown 1 pointed out the danger of using

hypotension and surgical retraction in the acute phase ofsubarachnoid haemorrhage, with its concurrent arterial spasmin the vicinity of the aneurysm. He also mentioned the

danger of using hypotension in the presence of stretch ordistension of major vessels from tumour or other causes.

Brown 2 has since pointed out the importance of preventinga fall of blood-pressure in seriously ill patients with spasm ofthe anterior basal perforating arteries.

Access within the skull is considerably aided by goodanaesthesia with attention to posture, venous drainagefrom the head and neck, adequate respiratory exchange,the substitution of barbiturate drugs for opiates in pre-medication, and the use of aids such as ventricular orspinal drainage of cerebrospinal fluid during operationand intravenous infusion of hypertonic salt solution if

required. Certainly by these methods operating condi-tions can be as satisfactory as when hypotension andhypothermia are used. Mortality and morbidity rates,however, are definitely lower, and the patient recoversconsciousness more rapidly.Where major cerebral vessels are not involved by

spasm or are not stretched by tumours or other causes,hypotension may be of considerable value. For example,I would regard hypotension as an invaluable aid to thesurgical removal of a cerebral arteriovenous malformation,contributing materially to the excellent surgical resultsin this condition.

ALLAN S. BROWN.Department of Surgical Neurology,Royal Infirmary, Edinburgh.