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Vacuum Extractor-Chalmers MBICARJOURNAL anterior position. The more experienced practitioner may wish to extend the range of his intervention, but this should be limited to institutional conditions. There are many general practitioners in this country, including several of our former house-surgeons, who are using the instrument successfully. Further extension of this trend would help to reduce the dangers of forceps in unpractised hands and lead to improved figures for infant survival in the home, as we believe it has in the hospital. SummaryThe Malmstr6m vacuum extractor has been employed for 400 deliveries at the Obstetric Unit, Ronkswood Hospital, Worcester, during 1948-63. In this time the incidence of vacuum extraction has increased progressively, while that of forceps delivery has fallen.Foetal mortality has fallen progressively, and recently there has been a fall in the incidence of caesarean section. It is suggested that both of these are due in part to the use of the vacuum extractor.Indications are described for the use of the instrument in both the first and the second stage of labour, and the results are detailed.The method has proved effective in cases of malrotation of the foetal head and of foetal distress, and results for both mother and foetus have been satisfactory. I am grateful to my colleague Mr. A. T. Marshall for permission to quote many of his cases included in the above series.

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Summary: The synthetic polypeptide depot-tetracosactrin (Synacthen-Depot) was given to nine steroidtreated asthmatic patients hypersensitive to animal corticotrophin. Eight had a satisfactory increase in plasma and urinary 17-hydroxycorticosteroids (17-OHCS). The remaining patient had been shown previously to have adrenal suppression. None of the patients developed allergic reactions to depot-tetracosactrin, and seven have been receiving regular injections of the polypeptide twice weekly for the past eight months.In 13 normal subjects intramuscular injections of 1 mg. and 0.5 mg. of depot-tetracosactrin and 40 units of corticotrophin-gel were equally potent in raising the plasma 17-OHCS, but depot-tetracosactrin had a significandy longer action than corticotrophin-gel.

1. About half of our asthmatic patients on long-term treatment with prednisone developed nocturia.2. This is due to reversal of the normal circadian rhythm of water and electrolyte excretion and is partially corrected within 48 hr of stopping treatment.3. The disturbance in water and electrolyte excretion appeared to be due to a decrease in proximal tubular reabsorption of sodium at night. This was not directly related to a change in the secretion of cortisol, aldosterone or antidiuretic hormone.Nocturia is known to occur in Cushing's syndrome and in Addison's disease (Doe, Vennes & Flink, 1960) and is a recognized feature of Conn's syndrome (Lennon, Ruetz &Engstrom, 1961) but has not been described in patients on long-term treatment with steroids. Few complain spontaneously of nocturia yet enquiry has revealed that it is a common symptom. Of eightyseven patients receiving maintenance doses of 5 or 10 mg of prednisone for asthma, forty-one (47%) stated that they passed more urine by night than by day. These patients had been accustomed to routine collection of 24 hr urine specimens for tests of pituitary and adrenal function. The symptom is not confined to patients with asthma; patients with rheumatoid arthritis given steroids also develop nocturia but the incidence has not been established in this disease.The onset is variable. Some patients notice nocturia on starting steroids while in others it appears after a period of treatment. To elucidate the mechanism of this phenomenon, detailed studies were carried out on a few patients receiving prednisone. PATIENTS A N D METHODSFive patients with well-controlled asthma and without hypertension or evidence of renal disease were admitted to hospital for study. They were not confined to bed but were given a