THE FUTURE OF COMMUNITY MEDICINE

262

perpendicular strip of

any chosen material. If there

is

any

adhesion between the chosen material and the clot, the amount of clot builds up with time. If the forces of adhesion are not very great the clot soon becomes heavy enough to part from the substratum. Thus by weighing the strip with the attached clot at intervals until the clot falls off, an idea of the forces of adhesion can be gained. Some examples will indicate the kind of results which may be obtained. When the perpendicular strip was coated with cholesterol the clot did not fall off during an experiment lasting 2.5 h by which time the weight of curd had reached 9 g (on a strip 25 x1 cm). When the coating was of lecithin some curd fell away after 25min when the weight was 0-55 g and all the curd fell away between 60 and 70 min just after the weight had reached 1.5g. When the surface was covered with dialysis membrane (’Viscose’, regenerated cellulose) the weight of adhering clot was negligible until 100 min when it reached 1.00 g and then some fell away. When the surface was a strip of beef aorta the clot built up rapidly but it was then found to be adhering to the cut edges only. A deep-frozen and thawed aorta turned inside-out also showed strong adhesion and experiments need to be done with uncut fresh material, but they will not be undertaken in this laboratory. Results with a number of other surfaces suggested, although they were insufficient to prove, that adhesion was minimal if not zero when the surface was very hydrophilic and a compound of carbon, hydrogen, and oxygen only. Even then adhesion occurred eventually unless calcium ions could be continuously removed (e.g., by irrigation of dialysis membrane from the other sideB National Institute for Research

in

Dairying,

Shinfield, Reading,

N.

Berkshire RG2 9AT

J.

BERRIDGE

EAR, JANEU, AND HEART SiR,—1 read with interest the letter

by

Saxena et al. I

recently had occasion serendipitously to abort an attack of paroxysmal atrial tachycardia while performing routine otoscopy. The clue was the sudden bout of coughing occasioned by both speculum insertion and retraction of the pinna. The "batting" tachycardia 240-280/min settled over the ensuing 20 min whereupon the staccato cough that had persisted after removal of the speculum also ceased. There have been other methods of increasing vagal tone (e.g., the diving reflex2 and wearing of an ice-collar3 but I think none simpler. The infant-a boy aged 3 months-has had no further attacks or evidence of any other cardiac anomaly. Cardioversion or digitalis was not required. Children’s Dublin 1, Ireland

Hospital,

J. DAVID O’KANE

BROMOCRIPTINE AND SECONDARY

AMENORRHŒA

SIR,-In reply out

that there

to

were

the letter by Jacobs et a1.4 we would point 5 of 18 and not 9 of 18 patients with nor-

moprolactinaemic amenorrhoea in whom we found evidence for ovulation during bromocriptine treatment.5 Like Jacobs et al. we also were surprised by the result, which became evident only after we measured the prolactin levels which were not known when treatment began. Now that the question has been Saxena, S. R., Solanki, D., Kataria, M. S. Lancet, 1976, i, 1415. Wildenthal, K., Leshin, S. J., Atkins, J. M., Skelton, C. L. ibid. 1975, i, 12. 3. Murphy, R. J. Am. med. Ass. 1960, 172, 555. 4. Jacobs, H. S., Franks, S., Hull, M. G. R., Steele, S. J., Nabarro, J D. N. Lancet, 1976, i, 1402. 5. Seppälä, M., Hirvonen, E., Ranta, T. ibid. 1976, i, 1154.

1. 2.

raised as to whether bromocriptine has anything to do with the transient recovery of some patients with normoprolactinaemic amenorrhcea we fully agree that a double-blind controlled trial is needed. I and II of Obstetrics and Gynæcology, University Central Hospital, and Department of Serology and Bacteriology, University of Helsinki, Finland

Departments

M. SEPPÄLÄ E. HIRVONEN T. RANTA

THE FUTURE OF COMMUNITY MEDICINE

SIR,-While I appreciate the honour of having my name a Lancet editorial, your use of my statement’ on the

cited in

importance of epidemiology

to

public-health planning

occurs

part of your argument that epidemiology is a useful management tool for improving health services.:2 My statement referred to the way in which an epidemiological perspective applied to today’s health techniques would have warned us about a new rising tide of disease and disability produced by the well-intentioned health services you wish to see

as

applied more efficiently. I pointed out that society’s efforts to reduce the prevalence of disease and disability should take account of the fact that our health techniques have developed in such a way that the more efficiently they are applied the higher will rise the prevalence of such conditions as Down syndrome and its associated disabilities. Antimicrobial drugs and other advances in health technology have assembled an array of devices for averting death in the presence of chronic conditions, while we continue to lack means for either preventing or curing these conditions: the newer means for "extending life" are in fact too often means for extending disease and disability. Consequently, from a public health point of view, more systematic application of such techniques will still further raise the prevalence of disease and disability and thus heighten the need for even more medical care and social services. Epidemiology is needed to recognise these new patterns (a service it too rarely performs) and it is also needed to find the preventable causes of conditions such as Down syndrome, senile brain disease, diabetes, Alzheimer disease, pernicious anaemia, and other chronic, incurable conditions whose fatal complications today’s techniques are so successful at thwarting. The resulting rising prevalence-rates call for new priorities, not just for health and social services but for epidemiological research especially, which must be directed toward finding modifiable precursors of such growing conditions. That is the burden of the statement you cited in support of using epidemiology as a health service management tool. It can be so used. But I hope that more epidemiologists would prefer to use their skills in spotting the hazards created by new health techniques and discovering means to prevent the new diseases of medical progress. On which problems epidemiologists deploy their skills will depend in part on where society offers most in financial and professional status rewards. Department of Mental Hygiene, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland 21205, U.S.A.

ERNEST M. GRUENBERG

S:R,—The article by Dr Heath and Dr Parry (July 10, p. 82) filled me with foreboding. I am a community physician who is on the brink of a career in community medicine. I use the word brink rather than beginning, after much thought. When I entered public health five years ago, medical administration was something done at regional level. I was not sure then what it involved, and am still not sure, although that is E. M. in Higher Education for Public Health: Milbank Memorial Fund Commission. New York, 1976.

1.

Gruenberg,

2.

Lancet, 1976, i, 78.

a

report of the

263

probably my deficiency. In the local authorities, the work in preventive medicine-especially preventing infectious

was

dis-

ease—and in the provision of care for people with long-term handicaps. The medical officer of health was accountable to the local health committee, and accountability meant something when administered by a good committee chairman.

However, it

seems

that

we are

be found outside the health service. This drift into administration will be perpetuated and ingrained by the proposals for training, which looks with tunnel vision at the activities of the National Health Service. Trainees in community medicine should be placed in local authority environmental health, housing, social services, and education authorities, and if they wish to gain any insight into the activities of the Health Service they should be placed in other countries, instead of pursuing a myopic course at region, area, and district level of the N.H.S. Has community medicine a future? In my opinion the future will see the development of epidemiology as a specialist skill, leaving medical administration as the mainstream of community medicine. But what worries me is that administration can be done by administrators, and decision-making by clinto

°

receiving the expert advice of epidemiologists. Perhaps you will consider publishing a selection of one-word answers to the question which was the title of the article, which was presumably posed as a rhetorical question.

icians

(Teaching),

J. A. MUIR GRAY

A MEDICAL SCHOOL IN HULL

SiR,—There is an error in your geography (July 24, p. 186) when you describe Leeds and Newcastle as being "nearest neighbours". This is true for Leeds, but the old-established medical schools of Manchester and Sheffield and the recent additions of Leicester and Nottingham are all nearer to Hull than is Newcastle. General Infirmary Leeds LS1 3EX

at

204 Bertrand Drive, Princeton, New Jersey

JOHN WERTH

08540, U.S.A.

all administrators now, and

increasing proportion of our time is to be spent tackling health service problems rather than health problems, although solutions to the great epidemics of non-infectious diseases are an

Oxford Area Health Authority Headington, Oxford OX3 9DZ

the study could be of great importance in comparing lead and cadmium as possible causes of hypertension.

Leeds,

MICHAEL WAUGH

BLOOD-LEAD AND HYPERTENSION

SiR,—Iread with interest the article by Dr Beevers and his colleagues (July 3, p. 1) reporting an association between blood-lead and hypertension. While the authors discuss several

hypotheses for this correlation, I believe that at least one other possible mechanism

warrants attention. Beevers et al. state that "the acidic nature of soft water leads to increased plumbosolvency." Soft water also tends to dissolve cadmium from the surface of galvanised steel, and cadmium induces hypertension in laboratory animals.’-’ Furthermore, Glauser et al. found a strong positive correlation between blood-cadmium and hypertension.6 Beevers et al. mention that many of the storage tanks in Renfrew are lead-lined. It would be interesting to examine the relative prevalence in that town of galvanised tanks and pipes, both of which are common in older buildings. Also, an analysis of the blood-cadmium in both the male and female subjects of 1. Schroeder, H. A., Vinton, W. H. Am. J. Physiol. 1962, 202, 515. 2 Schroeder, H. A. J. chron. Dis. 1965, 18, 647. 3. Schroeder, H. A. Kroll, S. S., Little, J. W., Livingston, P. O., Myers, M. Archs envir Hlth, 1966, 13, 788. 4 Schroeder, H. A , Buckman, J. ibid. 1967, 14, 693. 5 Fassett, D. W. in Metallic Contaminants and Human Health (edited by D. H K Lee , chap. 4, p. 97. New York, 1972. 6 Glauser, S C., Bello, C. T., Glauser, E. M. Lancet, 1976, i, 717.

USE OF PLASMA-PROTEIN FUNCTION IN PLASMA EXCHANGE

SIR,-Human plasma-protein fraction (P.P.F.) has certain properties which render it especially useful for the purpose of plasma exchange. However, analysis of P.P.F. (Blood Products Laboratory, Lister Institute, Elstree, Herts) shows it to have a low content of both K+ and Ca++ as compared with normal human plasma. These deficits can be easily remedied by the addition of 1.5mmol of K+ (0-75 ml potassium chloride containing 2 mmol/ml) and 0.45 mmol of Ca++ (2 ml of 10% calcium gluconate, not 2 g as previously statedl) to each 400 ml bottle of P.P.F. This approach has resulted in maintenance of normal serum K+ and Ca++ levels during plasma exchange and has virtually eliminated the hypotensive episodes which used to be such an unpleasant side-effect of the procedure. M.R.C. Lipid Metabolism Hammersmith Hospital, London W12 0HS

Unit,

GILBERT THOMPSON

TERMINAL CARE

SIR,-In your issue of July 24, it is salutory article

to

compare Dr

planning for terminal care and your note on N.H.S. expenditure. It would indeed be possible to make political capital out of such a comparison but I am more concerned here with dying patients. There is much to agree with in Dr Simpson’s article and much to abhor in the approach of many clinicians to the "dying patient for whom nothing can be done". Some of us, however, would like to continue our total care of the terminally ill patient beyond the point of using anti-cancer therapy, but the simple logistics of so doing would demand more money than is presently available. Dr Simpson must have experience of the work-load of active treatment units in surgical, radiotherapeutic, and medical oncology. Even if the beds could be made available, and knowing that many patients die at home with less than optimal medical and nursing attention despite the goodwill of all concerned, the "dying art of death" requires not only motivation but also careful training of the extra personnel involved. Geographical barriers are not the only factors to militate against the useful Simpson’s

on

centralisation of terminal care, but at least in some instances the provision of hospital beds for dying patients would allow the motivated cancer physician to provide continuing care on the basis of an established doctor/patient relationship. Should this be too much to ask for? Department of Medical Oncology, Christie Hospital and Holt Radium Institute, HAYDN BUSH

Manchester M20 98X

SIR,-Dr Simpson’s sympathetic approach

to

terminal

care

persistent "blind spot" characteristic of almost all thought on this subject. He briefly refers to the possibility of "death on demand" only to dismiss it out of hand. One is entitled to ask why. To open up the availability of voluntary dying to terminal patients by legalising voluntary euthanasia would introduce a breath of fresh air into terminal care comparable with the enormous improvement which occurred with regard to abortion on the passing of the 1967 Act. The decision "where to die" as between hospital and home is acknowledged to be reveals

1.

once

again

the

Thompson, G. R., Lowenthal, R., Myant,

N. B. Lancet, 1975, i, 1208.