BRITISH MEDICAL JOURNAL
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and the deposits of organic material on all metallic IUDs are of significance in relation to their contraceptive efficacy. A recent publication by Johnson et all shows that in 200% of patients the device is completely free of organic deposition when it is removed between six and 27 months of use, though deposition of organic material increases with time. There is no way yet of determining which patients are to be free of this deposited material. However, recent work from orthopaedic surgery indicates that metallic implants in joint prostheses are also covered with similar deposits of organic and inorganic material, though the metal used is not copper. Metallic ions do diffuse through this deposited material. It may therefore be safe to assume that copper ions will diffuse through the calcium carbonate and organic material that is deposited on some IUDs. JOHN R NEWTON Department of Obstetrics and Gynaecology, King's College Hospital Medical School, London SE5 I
Johnson, A B, et al, Contraception, 1976, 14, 507.
Entry to medicine SIR,-It has profoundly depressed me at the end of my first year studying medicine to realise how relieved I am to be finished with it for three months. I did not drift into medicine. Like Susan Bewley (16 July, p 184) I have a medical background and the required (excessively) high A level grades to secure entry to medical school. But I did not embark on the course motivated by ambition or out of indifference. I was entirely convinced that I wanted to enter what I saw as an admirable and worthwhile profession. At the end of a year I found myself bored and dissatisfied-eager to escape from the round of lectures and practicals and uncertain as to whether I wanted to return. I was well warned before I began what a dull grind the first two years could be. But with 0 levels and A levels I have coped with boredom and hard work before. It is only when you lose faith in their object that they become a burden. After a year at medical school any sense of vocation I started with had been almost entirely lost. My enthusiasm returned only when I returned to working medicine-in a vacation job as a clerk in a local hospital. The fault in the doctors of the future will result not so much from the means of their selection as from the aims of their selectors. Academic merit is the criterion for entry to medical school and throughout the course the emphasis is on professional and academic achievement. Vocation is a bad joke-the province of dreamers and hypocrites. But doctors without commitment and compassion are like priests without faith-corrupt charlatans. Apart from a new part of our course involving social medicine and contact with patients from the outset-a course that is publicly praised but privately slanged and ridiculed by the medical faculty-medical education in Newcastle seems to be about everything but caring. It is absurd that in future members of a caring profession a memory for biochemistry is more highly honoured than a capacity to care. More compassion is evident in the cytology lab I now work in than in any part of the medical school.
6 AUGUST 1977
This is a plea: bring back caring people to diagnosis is often missed, and clinicians would medical schools before they drive away the be well advised to consider this condition very people the profession most needs. before referring their patients to a surgical colleague. Treatment (without drug therapy) CHARLOTTE WRIGHT of the chronic hyperventilation which accomMedical student, panies this syndrome is most rewarding for University of Newcastle both patient and doctor. Rickmansworth, Herts ANITA E DAVIES London SW3
SIR,-The questioning mood of the young lady from BNC (16 July, p 184) prompts me to reply, assuring her that hers is by no means an isolated experience. Some 64 years ago I was encouraged by the staff of my London high school to go up to Oxford to take Honour Moderations and "Greats," presumably with a view to becoming a classics mistress at a similar seat of learning. This was settled for me by the headmistress on the grounds that I was "good at classics" (a trait for which I have never ceased to be thankful in that the nomenclature of diseases and medical terms generally become instantly clear to one with a background of Latin and Greek). Having circumvented the examiners for Honour Mods in the shortest possible time I realised that another 24 years spent in the study of so-called dead languages and philosophies was not for me, especially as it was a time of war. With the co-operation of my parents I approached the principal of my college with the information that I wished to take up medicine and would take my preliminary science subjects (they were known as "'groups"). Her only reply was, "Very well Miss Vaughan, I will make all arrangements for chaperons as you will be the only student from this college requiring a scientific tutor." Accordingly I set off for the labs and various tutors' rooms with one elderly lady who spent her time knitting endless pairs of socks, presumably for the Navy. I recall this experience because I think it is worth while to put on record the extraordinary change in circumstances that has taken place since 1915. In 1917 I descended to the anatomy room in the basement of King's College, Strand, in the company of several other women (none from Oxford). Early in 1918 I was sent for by the dean, who told me that as so many RAMC officers had been killed some half-dozen students were to be released from active service to resume their medical studies at King's. With a twinkle he said that he hoped for a welcome for them from us. The ensuing result for me was marriage. Can I claim to be the first woman medical student to become engaged in an anatomy room ?
Hill, 0 W, and Blendis, L, Gut, 1967, 8, 221. 3Lum, L C, in Modern Trends in Psychosomatic Medicine, vol 3, p 196. London, Butterworths, 1976.
Genital yeast infections SIR,-I hope that Dr R N Thin and his colleagues (9 July, p 93) will forgive me if I point out that the conclusion to be drawn from his paper is not as stated but that any sexually active patient with a genital yeast infection who attends a VD clinic should be screened for sexually transmitted disease-but is this not already so ? To extend this conclusion to general practice would be as wrong as to label all the scabies and molluscum we see there as sexually transmitted. LESLIE OLDERSHAW London SE23
Cryoglobulinaemia in Henoch-Schonlein purpura SIR,-We read with interest the article by Dr Miguel *Garcia-Fuentes and others (16 July, p 163). A recent case lends support to their concept of an immune-complex pathogenesis for this condition. A 50-year-old man was admitted for investigation of acromegaly. On four occasions since 1974 he had had a purpuric rash following a flu-like illness. Cryoglobulins had been detected during the last two episodes and a renal biopsy in mid-1975 showed proliferative glomerulonephritis. Immunofluorescence tests were not done. He had been treated with steroids and had received two courses of cyclophosphamide. Abdominal pain accompanied one episode. On this occasion cryoglobulins were initially not detected. However, he contracted flu while in hospital and a purpuric rash developed on his buttocks and lower limbs. At this time mixed cryoglobulins of the IgG-IgM variety were detected, serum C3 and C4 being normal. The cryoglobulins were not tested for complement activation. There was proteinuria of 5-9 g/day and urine microscopy showed 600 red and 200 white cells/ mm.3 Granular but no lipoid casts were detected. Serum proteins, immunoglobulins, and creatinine clearance were normal. The test for antinuclear factor was weakly positive but DNA antibodies were absent. A renal biopsy showed membranoproliferative glomerulonephritis with IgG, IgM, and C3 deposited on the membranes.
That the coeducational colleges at our universities will provide equally happy solutions to their members' queries is the fervent hope of one nearing her diamond wedding day. Henoch-Schonlein purpura is recognised in GWENDOLEN FORTESCUE-FOULKES adults, although as abdominal pain was an inconsistent feature and joint disease absent Exeter this patient does not meet the criteria of Garcia-Fuentes. However, this clinical condition may represent a spectrum of immune"Non-organic" abdominal pain complex response to infection. The pathogenic implication of IgG-IgM cryoglobulins in SIR,-In your leading article on "Diagnostic this case may represent a variation in infecting laparotomy" (16 July, p 144), quoting Hill and organism or of response in an older host. Blendis,' you have described as typical of "nonorganic" abdominal pain the classical sympG A FITZGERALD toms of chronic hypocapnia-epigastric pain C CROWE associated with distension, belching, and M I DRURY nausea-without mentioning the crucial in- Mater Misericordiae Hospital, vestigation of determination of the PCo2. This Dublin
388
and the deposits of organic material on all metallic IUDs are of significance in relation to their contraceptive efficacy. A recent publication by Johnson et all shows that in 200% of patients the device is completely free of organic deposition when it is removed between six and 27 months of use, though deposition of organic material increases with time. There is no way yet of determining which patients are to be free of this deposited material. However, recent work from orthopaedic surgery indicates that metallic implants in joint prostheses are also covered with similar deposits of organic and inorganic material, though the metal used is not copper. Metallic ions do diffuse through this deposited material. It may therefore be safe to assume that copper ions will diffuse through the calcium carbonate and organic material that is deposited on some IUDs. JOHN R NEWTON Department of Obstetrics and Gynaecology, King's College Hospital Medical School, London SE5 I
Johnson, A B, et al, Contraception, 1976, 14, 507.
Entry to medicine SIR,-It has profoundly depressed me at the end of my first year studying medicine to realise how relieved I am to be finished with it for three months. I did not drift into medicine. Like Susan Bewley (16 July, p 184) I have a medical background and the required (excessively) high A level grades to secure entry to medical school. But I did not embark on the course motivated by ambition or out of indifference. I was entirely convinced that I wanted to enter what I saw as an admirable and worthwhile profession. At the end of a year I found myself bored and dissatisfied-eager to escape from the round of lectures and practicals and uncertain as to whether I wanted to return. I was well warned before I began what a dull grind the first two years could be. But with 0 levels and A levels I have coped with boredom and hard work before. It is only when you lose faith in their object that they become a burden. After a year at medical school any sense of vocation I started with had been almost entirely lost. My enthusiasm returned only when I returned to working medicine-in a vacation job as a clerk in a local hospital. The fault in the doctors of the future will result not so much from the means of their selection as from the aims of their selectors. Academic merit is the criterion for entry to medical school and throughout the course the emphasis is on professional and academic achievement. Vocation is a bad joke-the province of dreamers and hypocrites. But doctors without commitment and compassion are like priests without faith-corrupt charlatans. Apart from a new part of our course involving social medicine and contact with patients from the outset-a course that is publicly praised but privately slanged and ridiculed by the medical faculty-medical education in Newcastle seems to be about everything but caring. It is absurd that in future members of a caring profession a memory for biochemistry is more highly honoured than a capacity to care. More compassion is evident in the cytology lab I now work in than in any part of the medical school.
6 AUGUST 1977
This is a plea: bring back caring people to diagnosis is often missed, and clinicians would medical schools before they drive away the be well advised to consider this condition very people the profession most needs. before referring their patients to a surgical colleague. Treatment (without drug therapy) CHARLOTTE WRIGHT of the chronic hyperventilation which accomMedical student, panies this syndrome is most rewarding for University of Newcastle both patient and doctor. Rickmansworth, Herts ANITA E DAVIES London SW3
SIR,-The questioning mood of the young lady from BNC (16 July, p 184) prompts me to reply, assuring her that hers is by no means an isolated experience. Some 64 years ago I was encouraged by the staff of my London high school to go up to Oxford to take Honour Moderations and "Greats," presumably with a view to becoming a classics mistress at a similar seat of learning. This was settled for me by the headmistress on the grounds that I was "good at classics" (a trait for which I have never ceased to be thankful in that the nomenclature of diseases and medical terms generally become instantly clear to one with a background of Latin and Greek). Having circumvented the examiners for Honour Mods in the shortest possible time I realised that another 24 years spent in the study of so-called dead languages and philosophies was not for me, especially as it was a time of war. With the co-operation of my parents I approached the principal of my college with the information that I wished to take up medicine and would take my preliminary science subjects (they were known as "'groups"). Her only reply was, "Very well Miss Vaughan, I will make all arrangements for chaperons as you will be the only student from this college requiring a scientific tutor." Accordingly I set off for the labs and various tutors' rooms with one elderly lady who spent her time knitting endless pairs of socks, presumably for the Navy. I recall this experience because I think it is worth while to put on record the extraordinary change in circumstances that has taken place since 1915. In 1917 I descended to the anatomy room in the basement of King's College, Strand, in the company of several other women (none from Oxford). Early in 1918 I was sent for by the dean, who told me that as so many RAMC officers had been killed some half-dozen students were to be released from active service to resume their medical studies at King's. With a twinkle he said that he hoped for a welcome for them from us. The ensuing result for me was marriage. Can I claim to be the first woman medical student to become engaged in an anatomy room ?
Hill, 0 W, and Blendis, L, Gut, 1967, 8, 221. 3Lum, L C, in Modern Trends in Psychosomatic Medicine, vol 3, p 196. London, Butterworths, 1976.
Genital yeast infections SIR,-I hope that Dr R N Thin and his colleagues (9 July, p 93) will forgive me if I point out that the conclusion to be drawn from his paper is not as stated but that any sexually active patient with a genital yeast infection who attends a VD clinic should be screened for sexually transmitted disease-but is this not already so ? To extend this conclusion to general practice would be as wrong as to label all the scabies and molluscum we see there as sexually transmitted. LESLIE OLDERSHAW London SE23
Cryoglobulinaemia in Henoch-Schonlein purpura SIR,-We read with interest the article by Dr Miguel *Garcia-Fuentes and others (16 July, p 163). A recent case lends support to their concept of an immune-complex pathogenesis for this condition. A 50-year-old man was admitted for investigation of acromegaly. On four occasions since 1974 he had had a purpuric rash following a flu-like illness. Cryoglobulins had been detected during the last two episodes and a renal biopsy in mid-1975 showed proliferative glomerulonephritis. Immunofluorescence tests were not done. He had been treated with steroids and had received two courses of cyclophosphamide. Abdominal pain accompanied one episode. On this occasion cryoglobulins were initially not detected. However, he contracted flu while in hospital and a purpuric rash developed on his buttocks and lower limbs. At this time mixed cryoglobulins of the IgG-IgM variety were detected, serum C3 and C4 being normal. The cryoglobulins were not tested for complement activation. There was proteinuria of 5-9 g/day and urine microscopy showed 600 red and 200 white cells/ mm.3 Granular but no lipoid casts were detected. Serum proteins, immunoglobulins, and creatinine clearance were normal. The test for antinuclear factor was weakly positive but DNA antibodies were absent. A renal biopsy showed membranoproliferative glomerulonephritis with IgG, IgM, and C3 deposited on the membranes.
That the coeducational colleges at our universities will provide equally happy solutions to their members' queries is the fervent hope of one nearing her diamond wedding day. Henoch-Schonlein purpura is recognised in GWENDOLEN FORTESCUE-FOULKES adults, although as abdominal pain was an inconsistent feature and joint disease absent Exeter this patient does not meet the criteria of Garcia-Fuentes. However, this clinical condition may represent a spectrum of immune"Non-organic" abdominal pain complex response to infection. The pathogenic implication of IgG-IgM cryoglobulins in SIR,-In your leading article on "Diagnostic this case may represent a variation in infecting laparotomy" (16 July, p 144), quoting Hill and organism or of response in an older host. Blendis,' you have described as typical of "nonorganic" abdominal pain the classical sympG A FITZGERALD toms of chronic hypocapnia-epigastric pain C CROWE associated with distension, belching, and M I DRURY nausea-without mentioning the crucial in- Mater Misericordiae Hospital, vestigation of determination of the PCo2. This Dublin
