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Discussion of absence from industry nearly alwaysstarts from the point of view of employers, whetherprivate or public, or of society as a whole ; and strong

pressure may be put on individual workers to stay at their

jobs unless circumstances are exceptional. Dr. D. H.

Stott 3 finds that this pressure is likely to increase:" We have to recognise that the static, self-indulgent pattern

of living is out of place in the modern world. If one of a gangof roadworkers stayed at home to tend his pigeons the losswould be just that of his day’s labour. But now excavating isdone by mechanical monsters ; if the trained man working onetakes a day off the whole job is held up."At present, absence from work is especially common, andespecially deprecated, in coalmining-which, as has beenlately pointed out,4 is one of the few remaining industrieswhere a man can earn enough to afford an occasionalunpaid day’s leisure if the fancy takes him; and whichtherefore attracts men to whom this freedom appeals.The anxiety felt about absence from work stems largelyfrom society’s overwhelming need to increase productionin a competitive or warring world. But from the indivi-dual’s point of view, it will be a poor world if we becamerich in the goods produced by industry at the expense ofbeing tied rigidly to our work. That, rather than conquestby " universal robots ", might be the way in whichmachines could come to dominate us-not only themechanical devices for production but the mechanicalorganisation of society.

3. Stott, D. H. Present Needs in Our Work Among Youth. London,1958. See Lancet, Feb. 8, 1958, p. 305.

4. See Observer, Jan. 5, 1958.5. Sirota, J. H., Narins, L. New Engl. J. Med. 1957, 257, 1111.

REFLEX ANURIA

SUPPRESSION of renal function occasionally followsinstrumental procedures on the renal tract, or the suddenrelief of chronic urinary retention; it may arise in an

apparently healthy kidney when the contralateral organbecomes acutely obstructed, as by a calculus; and rarelyit follows certain gynxcological and obstetric operationsin which the urinary tract has not apparently been pri-marily involved. To this condition, with such diversecauses, the name " reflex anuria " has been given; and ithas generally been assumed to be caused by excessivestimulation of the sympathetic nervous system, whichinduces either reflex renal ischsemia or overproductionof pituitary antidiuretic hormone. The possibility thatsome cases may be due to postrenal obstructive causes hastended to become overlooked; and, since the oliguriais often transient, the need to inquire further seldomarises.

Sirota and Narins 5 report three cases in which anobstructive lesion was evident, in the form of grossbullous oedema at the ureteric orifices. In two of thesecases both ureters had previously been catheterised inthe normal way; in the third case nephrectomy had beencarried out shortly after catheterisation of the oppositeside. In all three cases severe oliguria and progressiveazotsmia and hypertension had followed the ureteric

manipulation. A second cystoscopy confirmed the pre-sence of obstruction due to oedema at the orifices, withabsence of normal effluxes; and in each case the con-dition was relieved by the reinsertion of indwellingureteric catheters. Since there was no apparent technicaldifficulty at the time of the initial investigation, Sirotaand Narins conclude that the oedema may have beeninduced by an idiosyncratic response to trauma, to the

formaldehyde used for catheter sterilisation, or to thecontrast medium used for retrograde pyelography.Such sensitivity can be assumed to be rare; but these

cases are a reminder of the need for preliminary inquiryand for careful washing of all the instruments before

making this commonplace examination.

1. Publ. Serv. February, 1958, p. 38.2. See Lancet, 1957, ii, 1104.

SALARIES OF HOSPITAL EMPLOYEES

THE National and Local Government Officers Associa-tion (NALGO) 1 have surveyed the salaries and work ofmore than a quarter of all administrative and clericalworkers in the National Health Service to find that 36%earn less than E400 a year, 46% earn E400-E600, 10%earn E600-E800, 5% earn B800-B1200, and 3% over

E1200. More than 80% are thus earning less than theweekly E12 Is. 6d. earned by a male manual worker.The modest rises which these workers have receivedover the past ten years have not been enough to keeppace with inflation. Thus though a man who was earningE385 in 1948 is now earning E515 the cash value of hisearnings would have been only about E325 in 1948.

Compared with his colleagues on the same salary in otherservices he has had a poor deal. His effective salary hasfallen by 15% compared with 1% in the Civil Service.The Guillebaud and the Hall Committees, both

valuable outside opinions, have confirmed the inside

opinion of hospital administrators that the presentrates of pay are threatening efficiency and injuringrecruitment, yet NALGo’s survey shows that few officesare " seriously below establishment ". This may perhapsmask some of the dangers of the situation. The postsare apparently only being filled after repeated, and

expensive, advertisements. Too many of the staff aredrawn from elderly retired men and married women.These workers are often skilled and conscientious and their

help is valued, but they are not " promotion material "The few young people who join the service do not stayand are often unsuitable. Older men and women whofind the work satisfying and who have pension rightsare understandably less likely to leave, though even inthis group there have been some reluctant defaulters.At present they are overworked and spend too muchof their time training the constantly changing juniorstaff, and checking and supervising their work. NALGO’ssurvey gives as examples of this overbrisk turnover asouth-eastern hospital group that has replaced a third ofits staff in two years, a London group that has replacedtwo-thirds in the same period, and a west country groupthat has replaced the whole of its finance departmentsince January, 1955.The present economy in salaries seems to be causing

not only inefficiency but also extravagance. Advertisingover the whole country must, it is estimated, cost aboutE500,000 a year. Agency typists are often employed asstop-gaps and earn more money and work shorter hoursthan the permanent staff.

The recommendations of the Hall report,2 which areat present being considered by a joint sub-committee of theWhitley Council, would do much to right the situation.It is important that the hospital service should be ableto attract and retain its fair share of competent youngmen and women who will be willing and able to takeadvantage of the opportunities for training and promotionwhich it should offer. But we live in a century, to look

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no further, in which there are likely to be more and moreold people and fewer young people. The health servicewould be sensible to remember the help that pensionersand married women have given in these difficult times.Even in easier times they could offer valuable supportto the recruits whom we all hope the service will get,and for themselves have the healthy satisfaction of doinga worth-while job.

1. J. Obstet. Gynœc., Brit. Emp. 1957, 64, 815.

THE SECOND STAGE

IN these days of strict training for natural childbirth itis widely held that the first stage of labour should nor-mally be a time of rest and relaxation in an atmosphere ofquiet efficiency. The time for hard physical effort comeslater, in the second stage. A first labour is seldom con-cluded naturally without at least a short period of push-ing by the mother to assist the uterine action. But it is

perhaps not always remembered that much of the secondstage needs no help from the mother, the uterus aloneadvancing the presenting part down to the perineum. Apatient who is urged to push too early in the secondstage may achieve little which could not be done as well

by the unaided uterus, her exertions leaving her exhaustedtowards the end of her labour when her efforts are re-

quired. Constance Beynon 1 believes that there are otherdisadvantages both to too early and to too vigorouspushing. She points out that the secondary powersapplied while the presenting part is still gripped by thecervix or the upper vagina-broadly the site of insertionof the transverse cervical ligaments-will produce onthese important supporting structures a downward thrustwhich may well be a significant factor in the causation ofvault prolapse. Similarly, straining efforts made while

part of the anterior vaginal wall is below the head mayresult in this part of the wall being rolled down beneaththe head with potential damage to the underlying struc-tures around the bladder base, perhaps leading to stressincontinence. Mrs. Beynon believes that these ten-

dencies will be slighter in the absence of straining efforts,since the early part of each contraction pulls the vaginataut and prevents it and the structures deep to it beingpushed down in front of the presenting part. She likensthe process to a sleeve with a loose lining : the slower thearm is passed down the sleeve the less the tendency forthe lining to roll out at the wrist, especially if the liningis held firmly at the top.

Theoretical considerations apart, Mrs. Beynon’s methodof allowing the patients to follow their own inclinations inthe second stage of labour, forbidding any mention ofpushing by those in attendance, seems to prove its worthin practice. In a clinical trial a much shorter period ofpushing and a lower forceps and perineal-laceration rateswere found in patients managed in this way than in asecond group more actively encouraged to push the childout. Although, because of variable factors, this was notstrictly a controlled trial, the method seems to have muchto commend it. Thus, the atmosphere of tranquillity whichshe describes in the second stage contrasts sharply withthe scenes of violent muscular effort when the " labouringwoman is persistently urged to take an active part.

For the normal case this policy of non-interventionseems reasonable. There are circumstances, however, inwhich the vigorous cooperation of the patient can con-tribute significantly to the safe delivery of her child.Breech delivery, for instance, achieved by the patient’sefforts with minimal interference by the attendants is

greatly to be preferred to breech extraction under generalanaesthesia. Rarely in the multipara the pains will almostdisappear in the second stage, leaving the head stationaryin the middle or lower part of the pelvis; and here, aswith the breech which the patient cannot quite push overthe perineum, brief adoption of the squatting positionmay have dramatic effects.

1. See Manchester Guardian, Feb. 5 and 6, 1958.2. See Suffern, C. Lancet, 1957, ii, 1174.

ARMY MEDICAL HISTORY ON SHOW

IT seems that in this country few museums, apart fromthe famous national ones, can be said to prosper 1; and ifmany of the rest are ill attended it may be because theyare ill tended. But no such accusation can be laid againstthe R.A.M.C. Historical Museum, at Crookham. Built

up in the past five years by Major-General R. E. Barnsley,who remains the curator, this collection sparkles; and itsexistence should be more widely known.The collection is mainly for the non-specialist: the

muniments section is held elsewhere (at the R.A.M.College, Millbank); and no effort has been made to dupli-cate the purely technical collections that were already inbeing. But, without entering into technicalities, thisgroup of apparatus, models, plaques, letters, drawings,photographs, standards, medals, and so on illustrates bril-liantly the development of the Army medical servicesfrom the time of the Peninsular War, in which the Dukeof Wellington had miserably small medical resources athis command, down to and beyond the war of 1939-45,with Field-Marshal Montgomery writing soon after itstermination of a Corps "whose contribution to victoryhas been beyond all calculation ".The medical relics include "Dr. Wilde’s electric alarum

indicator with insulated explorer and forceps," which putsfar back into the 19th century the date when metallic foreignbodies-in this case bullets-were first localised electrically.2There is a wealth of paramedical objects-including a letterfrom the indefatigable Miss Nightingale, who took time off atScutari to communicate at some length with a young admirerin England. Also on view is a quilt knitted by Queen Victoriafor patients at Netley Hospital. (There is an old story, pro-bably apocryphal, that this was applied only to fortify thedying, but, as this became widely known, its single purposemay not have been wholly achieved.) Inevitably, too, themuseum shows something of our military history proper.(Who knows the origin of

" Thomas Atkins " ?) And for theunwarlike it provides welcome evidence of evolution from thedays, not so long ago, of the cat-o’-nine-tails, of brandingdeserters, and of " crime-and-punishment " books whose everypage is filled with charges of drunkenness.The collection reveals doctors, in war and in peace,

as incorrigible magpies: the trophies range from a Russiandrum won at Sebastopol to a Coptic cross collected by asurgeon in Lord Napier’s Abyssinian Campaign of 1868.Perhaps the keenest medical collector of all is GeneralBarnsley himself, who (ignoring the adage that good wineneeds no bush) is at present bent on discovering a pre-1914 horse-drawn heavy ambulance-wagon to place out-side the museum-perhaps hoping thus to distinguish it,for the benefit of visitors, from the commandant’s officenearby. Any reader lighting on a disused horse-drawnheavy ambulance-wagon in his garage is invited to offerit to the museum.The museum is open to the public on Mondays to Fridays from

10 A.M. till noon and from 5 till 7 P.M., and on Saturdays from10 A.M. till noon. Visitors are welcome at other times, includingSundays, but are asked to write in advance to the Curator, R.A.M.C.Historical Museum, Queen Elizabeth Barracks, Crookham, Hants.