CARE FOR THE OLD

371 STUDIES IN INERTIA

SIR,-May we congratulate you on your leading article (Jan. 22). As representatives of one of the hospitals and institutes most concerned, we welcome the airing of opinions that are widely discussed in private gatherings. We have two units, one in Central London and the other in the East End, separated by seven miles, and each unit houses a part of the hospital and institute. This separation makes cooperation very difficult and expansion even more so. Your follow-up leading article, entitled Towards a University Hospital (Jan. 29), deserves very careful consideration, and could produce a better grouping of specialties than that envisaged in the Chelsea plan. As it is likely to be many years before

moved to a permanent site, some interim arrangerelieve our dichotomv is ursentiv reouired. R. H. MEARA Chairman, Medical Committee, St. John’s Hospital for

we are

ment to

Diseases of the Skin

P. D. SAMMAN Dean, Institute of Dermatology.

FIBROSIS IN GUINEAPIG HEART SIR,-We have read with interest the preliminary communication by Dr. McKinney and Dr. Crawford (Oct. 30) on the experimental production of fibrosis in the guineapig heart. Since interest in endomyocardial fibrosis (E.M.F.) is almost world-wide, we feel that workers in this field should bear in mind that the term E.M.F. is used to describe a specific disorder. In their communication Dr. McKinney and Dr. Crawford cite work by Miller et a1.l and Selye2 as examples of the experimental production of E.M.F. This is rather misleading. Miller et al. found, in their dogs, subendocardial hoemorrhages and endocardial lesions consisting of elastic and fibrous tissue. Neither of these features occur in E.M.F. Selye produced subendocardial muscle degeneration which was later replaced by fibrous tissue incorporating the endocardium; in contrast, the descriptions of the pathological findings in E.M.F. suggest that fibrosis probably results predominantly from organisation of mural thrombi.34 An attempt is made by Dr. McKinney and Dr. Crawford to indicate a pathogenetic relation between E.M.F. and defective metabolism or increased intake of 5-hydroxytryptamine (5-H.T.). Work by Spatz5 is cited to support this hypothesis. But there is some doubt about the astiological relation of 5-H.T. to the carcinoid heart.Spatz only produced endocardial lesions in guineapigs when 5-H.T. was given together with a hepatotoxic agent and a tryptophan-deficient diet. The lesions produced were not entirely similar to those of the disease in man, and it is uncertain which of the above factors was responsible for the cardiac lesions. The differences between the pathological findings in E.M.F. and in carcinoid heart-disease have been described ’-the more important ones are that, in the carcinoid heart, both inflow and outflow valves are involved in the fibrotic process, and the left side of the heart is rarely affected. Descriptions of experimental results should therefore pay particular attention to these differences. Any worker who seeks to establish a valid claim that E.M.F. has been produced experimentally should indicate which cardiac chamber is involved by the fibrosis, and whether the valves are also involved or not. Fibrous thickening of the endocardium is not necessarily E.M.F., for this lesion has also been observed in other forms of primary myocardial disease. 8-10 1. 2. 3. 4. 5. 6. 7. 8. 9.

Miller, A. J., Pick, R., Katz, L. M. Br. Heart J. 1963, 25, 182. Selye, H. Lancet, 1958, i, 1351. Davies, J. N. P., Ball, J. D. Br. Heart J. 1955, 17, 337. Nwokolo, C. W. Afr. med. J. 1962, 21, 51. Spatz, M. Lab. Invest. 1965, 13, 288. Roberts, W. C., Sjoerdsma, A. Am. J. Med. 1964, 36, 5. Thorson, A. H. Acta med. scand. 1958, 161, suppl. 334. Eddington, G. M., Jackson, J. G. J. Path. Bact. 1963, 86, 333. Becker, B. J. P., Chazgidakis, C. B., van Lingen, B. Circulation, 7, 345. 10. Stuart, K. L., Hayes, J. A. Q. Jl Med. 1963, 32, 99.

1953

Indiscriminate use of the term E.M.F. will lead to confusion in the search for its Etiology. We agree that cardiomyopathy, and even endocardial thickening, may be produced experimentally in various ways including a plantain diet. The recognition of the pathological anatomy of endomyocardial fibrosis, however, is based on the application of certain specific criteria, and we suggest that the term be used in the experimental field only when these criteria are fulfilled. Departments of Medicine and Paediatrics, University College Hospital, Ibadan, Nigeria.

A. C. IKEME ASUQUO U. ANTIA.

THE WORKING-WIFE SYNDROME SIR,-Dr. Hanratty last week described a typical day for Mrs. Overtired, a two-job wife. Surely hers was a home with a lost father " and she was a two-job widow ". When parents agree that the mother should exercise her right to earn outside the home, most modern fathers accept the position and enjoy sharing in family responsibilities. Nurseries should certainly be set up to help parents, but the responsibility of providing these should not fall only on firms which employ women. Both men and women workers would benefit by shifts being more flexible and part-time work more available, and by the abolition of the present restrictions on hours of work for women. With such improvements there need be no lost fathers and no over-tired wives. A. M. FLEMING. "

"

LONDON’S SKID ROW SIR,-Iwas interested in the special article by Dr. Edwards and his colleagues (Jan. 29), but was surprised to see no mention made of blindness. Cecil and Loeb’s Textbook of Medicine (p. 1794, 1963 edition) mentions the " terrible toxic properties " of methyl alcohol, and the highly specific action of its metabolites on the neurones of the retina. Perhaps, as Cecil and Loeb says, the toxic effects of methyl alcohol may be lessened or even prevented by the concurrent administration of ethyl alcohol-this may have unwittingly played a part in the prevention of the serious toxic effects in the Skid Row men, or there may be some acquired tolerance in these chronic alcoholics. In the average psychiatric practice the methylated-spirit drinker is somewhat rare, and it seems that the further investigation of this group from all aspects, including the biochemical, could be rewarding.

ROBIN GEORGE.

CARE FOR THE OLD SiR,—There is much that I would agree with in your annotation (Jan. 29). May I be permitted, however, to make one observation about welfare accommodation from experience in a London Borough. I am firmly convinced that, to get the most out of our meagre resources of welfare beds, there should be a vetting, by the local geriatrician, of doubtful cases referred for welfare accommodation. On the other hand the geriatrician should be in a position to referee cases which he feels are socially urgent and from his assessment fit for " Part III " accommodation, as is done for medical cases by the Emergency Bed Service. Secondly, a certain proportion of welfare beds should be used for social therapy by which is meant food, shelter, accommodation, building up, treatment of minor ailments, and-last but not least-tender loving care. While the aged person is being built up, the living accommodation at home could be cleaned and prepared to go back to, with the social props available. It is only by using some welfare accommodation in this way that the increasing need of a proportion of old

people

can

be

met.

372 A lot of

good work is done at present in welfare homes, but dichotomy of authority should not stand in the way of a broader coordination between the hospital geriatric service and welfare homes. Various skills and team-work are needed to put frail elderly people on their feet, and I suggest that in a minor way a continued projection of some of these should follow the patient when she goes into a welfare home to help her almost to the last. Geriatric

Unit,

St. Francis’

Hospital, London, S.E.22.

MOHAN S. KATARIA.

" DOES THE GRASS GROW GREENER ... ?" SIR,-I greatly enjoyed Dr. Goodall’s Point of View (Jan. 1) on hospital life in the United States, and would agree with most of her observations as they apply to a large university centre. Having worked in New York for several years as a consultant, I think it is important to stress that other types of hospitals are less favoured. Above all, the nursing provided suffers from a lack of participation in the clinical observation and treatment of patients, so that many nursing duties are performed by interns and junior residents. Wound’ dressings are not usually carried out by the nursing staff, and their absence from ward rounds confirms the schism referred to by Dr. Goodall. Excellent though the idea and sometimes the execution of the postgraduate residency training programme may be, there is too much talk and not enough action. Large numbers of house staff are required so that justice can be done to both patient-care and educational activities, confirming that these positions are really intended to be training posts. Unfortunately this leads to a considerable reduction of personal experience for residents when compared with that of doctors of equal years of training in the National Health Service. It also encourages an unduly academic approach to the patient, which would be quite out of place in the Health Service. I believe that the Royal Commission on Medical Educationmust take note of this problem in formulating its plans for similar programmes in the United Kingdom. Finally, although research is important, it is grossly overemphasised in the U.S. The magnitude of one’s grant has become an important factor in professional advancement, and the scramble for finding an exciting new " project " is sad to watch. This emphasis also engenders the idea among many residents that using the most recently published method of therapy is equivalent to keeping abreast of medical progress. Quite apart from considerations of schooling for one’s children, the high cost of living, and different social and moral concepts, the idea of being able to return to the more measured, clinical atmosphere of the N.H.S. still seems attractive to many of us medical emigres. Because of this I hope you will allow me to

sign myself F.R.C.S.

DEFICIENCY OF LINOLEIC ACID SIR,-In their preliminary communication2 on a malignant hepatoma in an eight-year-old girl, Dr. Collins and Dr. Connelly state that they unexpectedly found A 5, 8, 11eicosotrienoic acid upon analysis of plasma and hepatic lipids. This fatty acid is believed to be one of the earliest biochemical manifestations of essential-fatty-acid deficiency. Contrary to their statement that this fatty acid has not been found in human tissue, it has been identified3 in early studies of human adipose-tissue composition. In this report this unusual fatty acid was found in increasing amounts in foetal adipose tissue during pregnancy, decreasing to trace but readily identifiable amounts during childhood and adult life. The last trimester of pregnancy is

normally

1. See Lancet, 1965, ii, 71. 2. Collins, F. D., Connelly, J. F. Lancet, 1965, 3. Farquhar, J. W., Ahrens, E. H., Peterson, M. Am. J. clin. Nutr. 1960, 8, 499.

characterised

by

ii, 883. L., Stoffel, W., Hirsch, J.

twelve-fold increase in adipose tissue, and it was suggested3 that this period of active lipogenesis may be accompanied by an a

essential-fatty-acid deficiency, comparable to the experimental situations cited by Dr. Collins and Dr. Connelly. The close relation of lipogenesis to this possible deficiency state is emphasised by the finding of progressively increasing amounts of A 5, 8, 11-eicosotrienoic acid in the adipose tissue of larger, obese, full-term infants.4 One could speculate that analysis of hepatic lipids of the normal unfed full-term infant would yield a substantial amount of this fatty acid-perhaps in amounts in excess of that recorded in the case of hepatoma reported by Dr. Collins and Dr. Connellv. Department of Medicine, University of Washington, Veterans Administration Hospital, J. D. BAGDADE. Seattle, Washington 98108.

more

TEST FOR PITUITARY FUNCTION

SIR,-Dr. Gwinup has published a preliminary communication entitled Test for Pituitary Function Using Vasopressin.5 We should like to draw your attention to the fact that in 1956 McDonald et al. showed that vasopressin stimulates the secretion of hydrocortisone in man.6 In view of the ample experimental evidence that vasopressin is a powerful corticotrophin releaser,’ we undertook clinical studies to investigate the effect of this peptide on corticotrophin release in children. These studies on the evaluation of the pituitary-adrenal system demonstrated that vasopressin causes a reproducible and rapid stimulation of the secretion of cortisol and corticosterone in peripheral blood. From the results obtainedthe use of vasopressin in a relatively simple test for the evaluation of the corticotrophic function of the anterior pituitary was advocated.9a Department of Pharmacology, Faculty of Medicine, University of Utrecht, The Netherlands.

D. B.

DE

WIED

VAN DER

WAL.

TONSILLECTOMY AND MULTIPLE SCLEROSIS SIR,-In his subjoined reply to my letter (Jan. 15), Dr. Poskanzer makes the good point that the significance test used in his article 10 is likely to be conservative. I fully agree that his x2 will be smaller than the correct x2 when the association between members of a pair is positive. His reference to the procedure I propose as a marginal x2 test is a little strange, since I emphasised that the ordinary x2 test for a 2 x 2 table such as that in his letter is irrelevant, and that what is required is a diagonal X2 or diagonal binomial test. It is of course pleasing to have Dr. Poskanzer’s reassurance that his associations were positive and that a change of statistical test does not alter the conclusions of his article. One would not expect any assertions of significance to be affected, but there was the possibility that a more sensitive test would show as significant, differences previously regarded as attributable to sampling variation. I part company with Dr. Poskanzer, however, in his statement that his 420 persons were independent, and in his implied assumption that the choice of statistical test is a matter of personal preference. Each of the 210 siblings entered the records solely because of his relationship to a patient; information may have been obtained from the siblings by independent procedures, but a classificatory and statistical dependence is" implicit in the investigation (as it still would be if " siblins D. Unpublished. Gwinup, G. Lancet, 1965, ii, 572. McDonald, R. K., Weise, V. K., Patrick, R. W. Proc. Soc. exp. Biol. Med. 1956, 93, 348. 7. de Wied, D., Smelik, P. G., Moll, J., Bouman, P. R. in Major Problems in Neuroendocrinology (edited by E. Bajusz and G. Jasmin); p. 156. Basle and New York, 1964. 8. van der Wal, B., Israëls, A. L. M., Janssen, J. F., de Wied, D. Acta endocr., Copenh. 1961, 38, 392. 9. van der Wal, B., Wiegman, T., Janssen, J. F., Delver, A., de Wied, D. ibid. 1965, 48, 81. 10. Poskanzer, D. C. Lancet, 1965, ii, 1264. 4. 5. 6.

Bagdade, J.