- Email: [email protected]
LONG-TERM HEPATIC SUPPORT
769 comes from some who have vention in medical matters.
hotly opposed Federal
inter-
Letters
to
the Editor
SUBURBAN PROBLEMS
The preliminary results of the 1970 census are being released. It is, of course, proclaimed as the most accurate ever taken here, though this is disputed by those towns and cities that have not attained the expected population rise, Since Federal and or had a drop greater than expected. State aid is often given on a population basis, a drop, or a failure to rise to a new aid-level can be a serious matter to hard-pressed areas. But, barring unpleasant local surprises of this sort, nothing unusual or unexpected has emerged. The overall total is about 209 million, with California the most populous State. The farms, the big cities, and the South have declined in population, relatively in some regions, absolutely in others, and the pattern of migration, from the centre outwards to the oceans and from the south to the north, has continued. But now the suburbanites outnumber both the rural dwellers and the city dwellers. An answer to many of the big-city problems would be to incorporate the suburban areas, as has been done in other countries, and in our friendly neighbour to the north, but just imagine the outcry that this would create. Yet it may come to it, for the suburban areas are now beginning to face the same problems that have led to the decline of the city centres-for example, lack of open space. Moreover, as the largest section of the population, the suburbanites will be the largest body of taxpayers, and if an inordinate share of their taxes goes to meet the needs of the cities an old slogan " no taxation without representation " may again be heard, and they may well feel that to exert adequate influence over taxation and expenditure they have to throw in their lot with the cities. PORNOGRAPHY CONTROVERSY
A very jolly and typically American row is now going on about the report of the Federal Commission on Obscenity and Pornography (subjects not easily defined), which the A.M.A. regards as " neither helpful nor elevating ". A series of legal decisions, some smart young lawyers, and court challenges have thrown the existing laws into confusion and allowed the wide dissemination, at least to adults, of much material hitherto regarded as pornographic and obscene. This caused so much perturbation in various quarters that Mr. Johnson set up the commission, and Mr. Nixon, without obvious enthusiasm, added to it a single member, an Ohio lawyer. The commission’s report was expected to be published without much delay. In the event, there has, as usual, been a series of leaks, calculated or not. It seems that the large majority approved a report which says that there is no experimental evidence that dissemination of pornographic material has any antisocial effect, that any increased sexuality is slight, limited, and soon declines, to perhaps even less than normal levels, and that repeated exposure soon induces boredom. These members therefore took a fairly liberal attitude to the dissemination of such material. This has aroused violent dissent from Mr. Nixon’s lone appointee, and under his loudly expressed criticisms some of the other members have weakened. Determined that the report should not appear without clear expressions of minority dissent, a court order to hold up publication has been obtained to give the dissenters time to hammer out a draft. This order is of course also being challenged in the courts. Meanwhile, accusations are flying around, and criticisms have been voiced by persons who can have had no access to the report. The usual guilt-by-association accusations are being made. The upshot is, of course, to give maximum prepublication publicity to, and possibly to make a bestseller of, a report which might otherwise have gone rapidly into the oblivion which seems to be the usual destiny for the reports of commissions.
24-HOUR PATHOLOGY SERVICE
SIR,-Ibelieve that the time has come to reorganise pathology services within the N.H.S. These services originated in the old clinical laboratories when " aids to diagnosis were added to vital investigations such as the identification of pathogenic bacteria and the diagnosis of histological sections. All these tests were done during "office hours ". With the advent of blood-transfusion, grouping was done by laboratory staff during the day and clinical staff during the night. The discovery of blood"
group systems in addition to the ABO system necessitated more
sophisticated methods of grouping and matching, and
this need an " on-call " system of trained technicians was started. With intensive-care units, toxicology units, and accident centres, the haematology and biochemistry departments of large hospitals are almost as busy during the night as they are during the day, but the old voluntary on-call system still persists. To sum up, laboratory services are geared to the efficient organisation of routine work, while the urgent work-usually much more vital-is left to volunteers. I believe that we must break with history and reorganise our laboratory services. The ideal would be to give a guaranteed emergency service throughout the 24 hours, 7 days a weekand fit in the routine work at leisure. To do this, the appropriate Whitley Council will need to work out a new Other Englishagreement for laboratory technicians. speaking countries have already adopted the extended-day system, why should this country lag behind ? to meet
Department of Pathology, Whipps Cross Hospital,
W. W. WALTHER.
London E.11.
LONG-TERM HEPATIC SUPPORT
SIR,-There have always been pessimists in our profesreadily protest when any of their colleagues employ anything more than the common stethoscope and the prescription pad for the management of dying patients. One often hears these same voices objecting to the use by the medical profession of scientific and technical devices like dialysis machines, breathing machines, and cardiac pacemakers in an effort to support the life of patients dying from failing essential organs. It is often forgotten that, by the use of technological aids, new and important knowledge for the treatment of human disease is brought to medicine. More important, it was by the use of such technical advances that many patients have been saved from certain death. Several sion who
hundred
patients
who would have otherwise died from
kidney failure have now been restored to a useful place in society by maintenance dialysis followed by kidney transplantation. Although such a fortunate outcome has not yet been possible for patients dying from liver failure, there is little doubt that, in the near future, many young patients will be saved from death and restored to health by suitable supportive techniques followed by timely hepatic transplantation. We want to assure Dr. Cotterill (Sept. 26, p. 661) that the patient we supported by intermittent liver perfusions while he was awaiting liver transplantation was accorded the best and the highest medical management ever given to any patient, in humane as well as in technological terms. It may be unfair to expect Dr. Cotterill to imagine that, as a result of those " extraordinary treatments we gave our patient, he recovered sufficiently not only to take food "
770 and drink but also to enjoy the company of his friends and family (who for humanitarian reasons were given free accommodation in the hospital). It may be of further comfort to know that during this patient’s support with extracorporeal human liver, which was maintained without interruption for 1’2 days, he recovered full consciousness and was able to take lunch with his parents while still connected to the " liver machine ". It seems to us that Dr. Cotterill has missed the essential point of our report. Although we showed that it is possible to treat a patient with fatal liver failure by the intelligent
(and humane) application of modern scientific techniques, my colleagues and I did this while our patient was waiting for liver transplantation; we were deeply disappointed by his unfortunate outcome, since neither his own liver regenerated nor was he fortunate enough to receive the benefits of liver transplantation. It is the easiest thing in the world for the medical practitioner faced with the treatment of a patient whose life is imperilled by a grave and difficult illness to despair and take the easiest course. Thank God there are still many doctors who are prepared to strive, using every technical and scientific aid, to save the lives of their fellow men, and will refuse to accept what is merely difficult as insoluble, and what is only unknown as inevitable. They may fail most of the time, but they will succeed some of the time. It is this positive attitude that we need to cultivate in our medical students and our juniors, for this is healthy and productive as well as humane.
possible
Department of Surgery, Medical College of Virginia,
continuing education, seminars, conferences, specialised libraries-and, most important, a warm welcome and a home-away-from-home for its overseas members and Fellows. recall we all gave a pledge to support our in every way possible, when we were admitted. If the Fellows and Members do not, who will? Mr. Editor, the signature " Old Fellow " is surely a misprint. Is it really " Odd Fellow "? I
seem to
Colleges
Parsi General Hospital, Karachi-3, Pakistan.
ROEINTON B. KHAMBATTA.
PARKINSONISM WITH ALKAPTONURIA: A NEW SYNDROME ?
SIR,-Arras and Bailey1 claimed G. M. ABOUNA.
Richmond, Virginia.
RECORD OF THE ROYAL COLLEGES SiR,-The anonymous correspondent in " Intercepted Letter " (Sept. 12, p. 563) has made certain comments which cannot remain unanswered. He terms the record of the Royal College of Physicians of Edinburgh as " shabby ... in lifting money from overseas graduates attracted to this country by the cachet of a College diploma ". I happen to be one of the many overseas graduates who came to Britain to be trained in advanced medicine. Like other British trainees, I was one of those admitted to the Membership, in 1950, and then proceeded to further training in my chosen specialty. We returned to our own countries, and helped to train many more young men and women in the highest traditions and qualities of British medicine-which, in our view, still remain unexcelled. Today, our students are training a third generation to serve their countries all around the world. I feel certain that this may be considered as a proud achievement " rather than a shabby record " by the Royal Colleges in Britain. One also totally fails to understand the reasoning behind your correspondent’s plea to " exclude overseas visitors from the Membership examination ". Many distinguished past-Presidents, Fellows, and Members of the Royal Colleges have eagerly spent time and energy in developing countries-not as " an act of penance " on behalf of their Colleges, but because of the friendships and associations developed with overseas graduates who studied under them. One thinks of the dedicated service given to Pakistan medicine by the late Sir James Cameron, past-President of the Royal College of Physicians of Edinburgh in helping to establish an Institute of Postgraduate Medicine, and also acting as a friend and counsellor to our own fledgling College. There I are many others who serve in Baroda and elsewhere. have met physicians from India, Pakistan, Ceylon, Nigeria, and the West Indies who praise the inspiration provided "
by the frequent visits of Lord Rosenheim-President of the Royal College of Physicians of London-despite his I am afraid the multifarious engagements at home. correspondent’s views regarding overseas relations of the Royal Colleges cannot be shared by those who live overseas. Finally, he points out that the possession of the M.D. does not call for any annual fees to the university. As a Fellow, he has direct responsibility and rights-if he wishes to exercise them-in the government and management of his Royal College. In the university, the M.D. gives no such rights. His Royal College receives no annual grants from the Exchequer. The Royal Colleges provide
"
excretion of
homogentisic acid in
find a high urinary parkinsonian patient
to a
during dopa treatment, but we were unable to confirm this observation in our own series.2 One possible explanation we considered was that their patient might coincidentally have been alkaptonuric. The publication of two isolated reports in which the association of alkaptonuria and parkinsonism was noted 3,4prompts us to suggest that all three patients may have been examples of a new syndrome -striato-nigral ochronosis, perhaps ? A familial element, which should be sought if future cases of the association are observed, is suggested by the fact that the father of one of these patients 4 also had parkinsonism. Queen Charlotte’s Maternity Hospital, London W.6.
M. SANDLER F. KAROUM C. R. J. RUTHVEN.
TRIMETHYLAMINURIA: THE FISH-ODOUR SYNDROME SIR,-We have studied a 6-year-old girl who had multiple pulmonary infections since the neonatal period. Her mother related that the child had intermittently had a peculiar " fishy " odour. The child had the clinical stigof Turner’s syndrome and splenomegaly. Laboratory studies revealed a mild anaemia (packed-cell volume 34%) and neutropenia (800-1500 neutrophils per c.mm.). Platelet count was normal. While neutrophils performed adequately in phagocytic and bactericidal tests, they did not adhere normally to glass beads. Platelet functions were abnormal, as evidenced by a prolonged bleeding-time, decreased adhesiveness to glass beads, and decreased aggregation to collagen. Decreased deformability of the patient’s red cells was demonstrated by an increased resistance to red-cell filtration through a 3 I-’ pore filter. abmata
These
Arras, M. J., Bailey, G. W. H. New Engl. J. Med. 1968, 278, 280. Sandier, M., Karoum, F., Ruthven, C. R. J. ibid. 1969, 281, 1429. Weeth, J. B., Shealy, C. N., Mercier, D. A. Wisconsin med. J. 1969, 68, 325. 4. Siekert, R. G., Gibilisco, J. A. Oral Surg. 1970, 29, 197. 1. 2. 3.
hotly opposed Federal
inter-
Letters
to
the Editor
SUBURBAN PROBLEMS
The preliminary results of the 1970 census are being released. It is, of course, proclaimed as the most accurate ever taken here, though this is disputed by those towns and cities that have not attained the expected population rise, Since Federal and or had a drop greater than expected. State aid is often given on a population basis, a drop, or a failure to rise to a new aid-level can be a serious matter to hard-pressed areas. But, barring unpleasant local surprises of this sort, nothing unusual or unexpected has emerged. The overall total is about 209 million, with California the most populous State. The farms, the big cities, and the South have declined in population, relatively in some regions, absolutely in others, and the pattern of migration, from the centre outwards to the oceans and from the south to the north, has continued. But now the suburbanites outnumber both the rural dwellers and the city dwellers. An answer to many of the big-city problems would be to incorporate the suburban areas, as has been done in other countries, and in our friendly neighbour to the north, but just imagine the outcry that this would create. Yet it may come to it, for the suburban areas are now beginning to face the same problems that have led to the decline of the city centres-for example, lack of open space. Moreover, as the largest section of the population, the suburbanites will be the largest body of taxpayers, and if an inordinate share of their taxes goes to meet the needs of the cities an old slogan " no taxation without representation " may again be heard, and they may well feel that to exert adequate influence over taxation and expenditure they have to throw in their lot with the cities. PORNOGRAPHY CONTROVERSY
A very jolly and typically American row is now going on about the report of the Federal Commission on Obscenity and Pornography (subjects not easily defined), which the A.M.A. regards as " neither helpful nor elevating ". A series of legal decisions, some smart young lawyers, and court challenges have thrown the existing laws into confusion and allowed the wide dissemination, at least to adults, of much material hitherto regarded as pornographic and obscene. This caused so much perturbation in various quarters that Mr. Johnson set up the commission, and Mr. Nixon, without obvious enthusiasm, added to it a single member, an Ohio lawyer. The commission’s report was expected to be published without much delay. In the event, there has, as usual, been a series of leaks, calculated or not. It seems that the large majority approved a report which says that there is no experimental evidence that dissemination of pornographic material has any antisocial effect, that any increased sexuality is slight, limited, and soon declines, to perhaps even less than normal levels, and that repeated exposure soon induces boredom. These members therefore took a fairly liberal attitude to the dissemination of such material. This has aroused violent dissent from Mr. Nixon’s lone appointee, and under his loudly expressed criticisms some of the other members have weakened. Determined that the report should not appear without clear expressions of minority dissent, a court order to hold up publication has been obtained to give the dissenters time to hammer out a draft. This order is of course also being challenged in the courts. Meanwhile, accusations are flying around, and criticisms have been voiced by persons who can have had no access to the report. The usual guilt-by-association accusations are being made. The upshot is, of course, to give maximum prepublication publicity to, and possibly to make a bestseller of, a report which might otherwise have gone rapidly into the oblivion which seems to be the usual destiny for the reports of commissions.
24-HOUR PATHOLOGY SERVICE
SIR,-Ibelieve that the time has come to reorganise pathology services within the N.H.S. These services originated in the old clinical laboratories when " aids to diagnosis were added to vital investigations such as the identification of pathogenic bacteria and the diagnosis of histological sections. All these tests were done during "office hours ". With the advent of blood-transfusion, grouping was done by laboratory staff during the day and clinical staff during the night. The discovery of blood"
group systems in addition to the ABO system necessitated more
sophisticated methods of grouping and matching, and
this need an " on-call " system of trained technicians was started. With intensive-care units, toxicology units, and accident centres, the haematology and biochemistry departments of large hospitals are almost as busy during the night as they are during the day, but the old voluntary on-call system still persists. To sum up, laboratory services are geared to the efficient organisation of routine work, while the urgent work-usually much more vital-is left to volunteers. I believe that we must break with history and reorganise our laboratory services. The ideal would be to give a guaranteed emergency service throughout the 24 hours, 7 days a weekand fit in the routine work at leisure. To do this, the appropriate Whitley Council will need to work out a new Other Englishagreement for laboratory technicians. speaking countries have already adopted the extended-day system, why should this country lag behind ? to meet
Department of Pathology, Whipps Cross Hospital,
W. W. WALTHER.
London E.11.
LONG-TERM HEPATIC SUPPORT
SIR,-There have always been pessimists in our profesreadily protest when any of their colleagues employ anything more than the common stethoscope and the prescription pad for the management of dying patients. One often hears these same voices objecting to the use by the medical profession of scientific and technical devices like dialysis machines, breathing machines, and cardiac pacemakers in an effort to support the life of patients dying from failing essential organs. It is often forgotten that, by the use of technological aids, new and important knowledge for the treatment of human disease is brought to medicine. More important, it was by the use of such technical advances that many patients have been saved from certain death. Several sion who
hundred
patients
who would have otherwise died from
kidney failure have now been restored to a useful place in society by maintenance dialysis followed by kidney transplantation. Although such a fortunate outcome has not yet been possible for patients dying from liver failure, there is little doubt that, in the near future, many young patients will be saved from death and restored to health by suitable supportive techniques followed by timely hepatic transplantation. We want to assure Dr. Cotterill (Sept. 26, p. 661) that the patient we supported by intermittent liver perfusions while he was awaiting liver transplantation was accorded the best and the highest medical management ever given to any patient, in humane as well as in technological terms. It may be unfair to expect Dr. Cotterill to imagine that, as a result of those " extraordinary treatments we gave our patient, he recovered sufficiently not only to take food "
770 and drink but also to enjoy the company of his friends and family (who for humanitarian reasons were given free accommodation in the hospital). It may be of further comfort to know that during this patient’s support with extracorporeal human liver, which was maintained without interruption for 1’2 days, he recovered full consciousness and was able to take lunch with his parents while still connected to the " liver machine ". It seems to us that Dr. Cotterill has missed the essential point of our report. Although we showed that it is possible to treat a patient with fatal liver failure by the intelligent
(and humane) application of modern scientific techniques, my colleagues and I did this while our patient was waiting for liver transplantation; we were deeply disappointed by his unfortunate outcome, since neither his own liver regenerated nor was he fortunate enough to receive the benefits of liver transplantation. It is the easiest thing in the world for the medical practitioner faced with the treatment of a patient whose life is imperilled by a grave and difficult illness to despair and take the easiest course. Thank God there are still many doctors who are prepared to strive, using every technical and scientific aid, to save the lives of their fellow men, and will refuse to accept what is merely difficult as insoluble, and what is only unknown as inevitable. They may fail most of the time, but they will succeed some of the time. It is this positive attitude that we need to cultivate in our medical students and our juniors, for this is healthy and productive as well as humane.
possible
Department of Surgery, Medical College of Virginia,
continuing education, seminars, conferences, specialised libraries-and, most important, a warm welcome and a home-away-from-home for its overseas members and Fellows. recall we all gave a pledge to support our in every way possible, when we were admitted. If the Fellows and Members do not, who will? Mr. Editor, the signature " Old Fellow " is surely a misprint. Is it really " Odd Fellow "? I
seem to
Colleges
Parsi General Hospital, Karachi-3, Pakistan.
ROEINTON B. KHAMBATTA.
PARKINSONISM WITH ALKAPTONURIA: A NEW SYNDROME ?
SIR,-Arras and Bailey1 claimed G. M. ABOUNA.
Richmond, Virginia.
RECORD OF THE ROYAL COLLEGES SiR,-The anonymous correspondent in " Intercepted Letter " (Sept. 12, p. 563) has made certain comments which cannot remain unanswered. He terms the record of the Royal College of Physicians of Edinburgh as " shabby ... in lifting money from overseas graduates attracted to this country by the cachet of a College diploma ". I happen to be one of the many overseas graduates who came to Britain to be trained in advanced medicine. Like other British trainees, I was one of those admitted to the Membership, in 1950, and then proceeded to further training in my chosen specialty. We returned to our own countries, and helped to train many more young men and women in the highest traditions and qualities of British medicine-which, in our view, still remain unexcelled. Today, our students are training a third generation to serve their countries all around the world. I feel certain that this may be considered as a proud achievement " rather than a shabby record " by the Royal Colleges in Britain. One also totally fails to understand the reasoning behind your correspondent’s plea to " exclude overseas visitors from the Membership examination ". Many distinguished past-Presidents, Fellows, and Members of the Royal Colleges have eagerly spent time and energy in developing countries-not as " an act of penance " on behalf of their Colleges, but because of the friendships and associations developed with overseas graduates who studied under them. One thinks of the dedicated service given to Pakistan medicine by the late Sir James Cameron, past-President of the Royal College of Physicians of Edinburgh in helping to establish an Institute of Postgraduate Medicine, and also acting as a friend and counsellor to our own fledgling College. There I are many others who serve in Baroda and elsewhere. have met physicians from India, Pakistan, Ceylon, Nigeria, and the West Indies who praise the inspiration provided "
by the frequent visits of Lord Rosenheim-President of the Royal College of Physicians of London-despite his I am afraid the multifarious engagements at home. correspondent’s views regarding overseas relations of the Royal Colleges cannot be shared by those who live overseas. Finally, he points out that the possession of the M.D. does not call for any annual fees to the university. As a Fellow, he has direct responsibility and rights-if he wishes to exercise them-in the government and management of his Royal College. In the university, the M.D. gives no such rights. His Royal College receives no annual grants from the Exchequer. The Royal Colleges provide
"
excretion of
homogentisic acid in
find a high urinary parkinsonian patient
to a
during dopa treatment, but we were unable to confirm this observation in our own series.2 One possible explanation we considered was that their patient might coincidentally have been alkaptonuric. The publication of two isolated reports in which the association of alkaptonuria and parkinsonism was noted 3,4prompts us to suggest that all three patients may have been examples of a new syndrome -striato-nigral ochronosis, perhaps ? A familial element, which should be sought if future cases of the association are observed, is suggested by the fact that the father of one of these patients 4 also had parkinsonism. Queen Charlotte’s Maternity Hospital, London W.6.
M. SANDLER F. KAROUM C. R. J. RUTHVEN.
TRIMETHYLAMINURIA: THE FISH-ODOUR SYNDROME SIR,-We have studied a 6-year-old girl who had multiple pulmonary infections since the neonatal period. Her mother related that the child had intermittently had a peculiar " fishy " odour. The child had the clinical stigof Turner’s syndrome and splenomegaly. Laboratory studies revealed a mild anaemia (packed-cell volume 34%) and neutropenia (800-1500 neutrophils per c.mm.). Platelet count was normal. While neutrophils performed adequately in phagocytic and bactericidal tests, they did not adhere normally to glass beads. Platelet functions were abnormal, as evidenced by a prolonged bleeding-time, decreased adhesiveness to glass beads, and decreased aggregation to collagen. Decreased deformability of the patient’s red cells was demonstrated by an increased resistance to red-cell filtration through a 3 I-’ pore filter. abmata
These
Arras, M. J., Bailey, G. W. H. New Engl. J. Med. 1968, 278, 280. Sandier, M., Karoum, F., Ruthven, C. R. J. ibid. 1969, 281, 1429. Weeth, J. B., Shealy, C. N., Mercier, D. A. Wisconsin med. J. 1969, 68, 325. 4. Siekert, R. G., Gibilisco, J. A. Oral Surg. 1970, 29, 197. 1. 2. 3.