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In Reply. —Dr Pincus raises some important points concerning thrombolytic therapy in acute ischemic stroke. The first of these is the precision with which patients can be certain of the time of onset. The current indications for the use of t-PA in the United States are based on the NINDS trial and stipulate administration of the drug within 3 hours of onset. Clearly, it will not always be possible for patients to be absolutely certain of the time of ictus, although our experience in the ASK trial 1 would suggest that the majority of people are reasonably certain within this relatively short time frame. If uncertainty does exist, then it would be unreasonable to administer thrombolytic therapy, particularly if the time after stroke onset was approaching 3 hours. The issue concerning variability of infarct size and location influencing disability scores, such as the Barthel Index, is an interesting one. To our knowledge

To the Editor. —I was pleased to read your introduction to the new series on clinical examination. I thought the initial article 1 and Editorial 2 were both excellent. I would like to present the following case to pose a question: Four weeks ago, an 82-year-old woman came into my office with a 1-month history of right leg swelling. During this month, she had three separate episodes of pleuritic chest pain, the first two of which resolved spontaneously. She came to the office after the third episode of pain. On examination, she was found to have râles medial to her left scapula without audible rub. Her right leg was swollen and tender with a circumference of 40 cm compared with a left leg circumference of 35 cm. I felt absolutely certain that she had a deep-vein thrombosis with recurrent pulmonary emboli. I admitted her to the hospital where a venous

The great scientific advances and the increased ability to deal with disease raise social problems undreamed of a half century ago. The relations of medicine to society—the socalled sociology of medicine—is now recognized as a major challenge in medical education and practice. Sociology of medicine is a poorly defined concept, for it merges with numerous other fields—economics, political philosophy, "practical politics" (a very different thing); it relates to humanistic subjects like ethics and history, literature and art, and the nature and development of culture. These subjects are not merely abstract topics, for the economic, cultural, and ethical problems to which they give rise are becoming more and more intrusive and are demanding answers. We can be absolutely certain that answers will be forthcoming, hammered out by irresistible pressures. There is growing realization that physicians must be equipped to play a part in the process that will eventually find suitable answers.

To the Editor.— Medical knowledge increases yearly. Our medical schools train better doctors and postgraduate training constantly improves. Yet, in spite of great increases in knowledge and training, even the finest doctor is not immune from occasional error. Often a decision has to be made in an apparently hopeless case whether or not to submit the patient to exploratory surgery or to dangerous and uncomfortable additional tests and procedures. Sometimes this may involve considerable added expense for the family, as well as additional suffering for the patient. In objection to this, there now arises a great outcry to allow the patient to "die with dignity." There can be merit in withholding further procedures and care only if the physician can be absolutely certain of the hopeless nature of the case, but there is a real danger that an error may be made in assessing hopelessness. Such an error may cost

To the Editor: —Recently, attention has been called to carelessness on the part of some physicians in not examining patients thoroughly. The following two cases well illustrate need of a thorough examination even though the diagnosis seems absolutely certain from a casual inspection: A boy, aged 9 years, was taken sick with sneezing, fever, watering of the eyes and a slight sore throat, January 21. The following day an eruption had appeared. A physician was called and diagnosed the case as measles. However, as the physician is a competent pediatrician, he examined farther and found an inflamed throat with a small patch on one tonsil. He diagnosed it as diphtheria and gave antitoxin. Cultures proved the correctness of his diagnosis. With the prompt administration of antitoxin the child made a nice recovery, even if two serious diseases were present at the same time. A boy, aged 5 years, had an

To the Editor:— I should like to take issue with statements made by Samuel Katz, MD, in his answer to a question ( 209 :1911, 1969) regarding the intradermal method of administering influenza virus vaccine. Dr. Katz suggests that such administration is warranted only "under special situations," such as booster doses, in times of critical shortage, to immunize infants and children under 5 years of age, or older people who fall in the "high risk" category in whom an ensuing reaction to the vaccine would be undesirable. He correctly emphasizes the necessity that in administering the vaccine intradermally, it must be absolutely certain that the injection is given into and not beneath the skin in order for it to be effective immunologically. But although, as Dr. Katz points out, individuals receiving two 1-ml doses of the vaccine subcutaneously have a somewhat higher hemagglutinin titer than those getting the vaccine intradermally in two

The diphtheria culture test, valuable as it is in clinical diagnosis, is not infallible. Indeed it would be strange to find it an absolutely certain method, dealing as it does with forms of life confessedly prone to sudden, and at present, inexplicable variations. The following examples are cited because they illustrate some puzzling occurrences in routine bacteriologic work, and because they impress us with the necessity of due scientific conservatism in even so apparently simple an operation as the culture test for diphtheria. The first case came to notice in Chicago, in February, 1894. A Prudden swab was kindly brought to the laboratory by Dr. J. B. Loring, of Valparaiso, Ind. The swab was obtained from a case which had all the clinical features of true faucial diphtheria, and the provisional diagnosis of diphtheria was strengthened by the fact that diphtheria was endemic at the time in Valparaiso, and that