- Email: [email protected]
CHRONIC OBSTRUCTIVE LUNG DISEASE
1294 You remark that
might be said about
rare but memorandum it is enough to state that " special consideration should be given to outbreaks in which cases of rheumatic fever and nephritis occur ". " Children for whom recurrent streptococcal infection constitutes a special risk (such as those who have had rheumatic fever) should be advised to stay away in the event of an outbreak of streptococcal infection in a school; they should be referred to their own doctor for prophylactic chemotherapy unless this has already been more
lamentable epidemics, but surely in
a
prescribed." Influenza may cause havoc, but winter vomiting disease and glandular fever perhaps may cause mild dislocation. The Control of Communicable Diseases in Man is excellent, but for schools I recommend the handbook of the Medical Officers of Schools’ Association. Warwickshire Postgraduate Medical Centre,
R. E. SMITH.
Coventry.
Sm,—Your editorial (June 5, p. 1171) states that school is a good place to study the natural history of infectious disease ", and goes on to infer that this property is largely due to the monastic seclusion of the boardingschool ". Twenty years ago there might have been some truth in these statements, but they can hardly be credible "
a
"
now.
Infectious diseases in any significant number rarely in boarding-schools today, and the boarders in most schools now can and do mix freely with the local community, be it rural for pleasure or urban for shopping and the cinema. Furthermore, many of the domestic staff come daily from the surrounding areas and can easily carry " fresh parasites " as well as their domestic equipment. On the credit side of the memorandum you quote is the " failure to mention " influenza". Influenza " is an umbrella term and if influenza ", in its commonest designation, is handled aright it does not " play havoc with the curriculum ", and neither does glandular fever. School medicine is the same as any other medicine. There is still unfortunately a special stigma about it and these special memoranda seem to encourage all the old adages. It is a pity, for the execution of normal medical thought in schools thus remains impaired by this out-ofdate official guidance. occur
significant finding in this reanalysis which is inconsistent with the hypothesis of a negative paternal-age effect, is the suggestion of a positive paternal-age effect when maternal age has been controlled at birth orders 5+ (see their table III). I would like to offer an interpretation of this point. controlled for race or social class: and lower-class births seem to births moreover, Negro have a lower sex ratio than White births4 and upper-class births,5 respectively. So, as Teitelbaum et al. acknowledge in their discussion, this particular result may be the consequence of " different patterns of family formation between whites and Negroes ". It could also be due to similar social-class differences. In particular, when maternal age is held constant at birth orders 5+ one might expect a disproportionate number of Negro births and lower-class births to young fathers as contrasted with old fathers. So the above-cited result may stem from a failure to control for race and class. Moreover, one might wonder whether the same sort of artefact may have operated at birth-ranks 2, 3, and 4 (thus masking a true negative paternal-age effect at those ranks too). Indeed, it still seems possible that sex ratio is subject to a real negative paternal-age effect. At any rate, I think it would be unwise to accept Teitelbaum’s conclusion until results are presented on data which are controlled for race and social class in addition to parental ages and birth order. The data
I
D. W. S. SHELDON.
COITAL RATE, SEX RATIO, AND PARENTAL AGE
SiR,-Dr. Teitelbaum suggests (April 17, p. 800) that when birth order is controlled, neither maternal age nor paternal age bears a consistent relationship with sex ratio. I have hypothesised that coital rate depends more on husbands than on wives, and that therefore the decline in coital rate with the wife’s age is largely secondary to a decline caused by the husband’s age.2 If this hypothesis is true, then Teitelbaum’s claim constitutes prima-facie evidence against my theory that sex ratio is partially dependent on coital rate. Teitelbaum’s argument is based on data originally presented by Novitski and Kimball3 as reanalysed by Teitelbaum et al. It is worth considering whether the results of this reanalysis may be the consequence of failure to control relevant variables. As far as I can see, the only statistically 1.
Sheldon, D. W. S. Compendium of Emergencies; p. 380. London, 1971.
2. 3. 4.
James, W. H. Lancet, Jan. 16, 1971, p. 112. Novitski, E., Kimball, A. W. Am. J. hum. Genet. 1958, 10, 268. Teitelbaum, M. S., Mantel, N., Stark, C. R. ibid. (in the press).
grateful
to
Prof. C. A. B.
London, for advice. I
am
Smith, of University College supported by the Population Council
of New York. In furtherance of my research, I should like to hear from any married person (doctor or patient) who has kept a record for a considerable period (say at least a year) of the exact dates on which they had coitus. Galton Laboratory, Department of Human Genetics and Biometry, University College London,
London N.W.1.
"
Repton, Derbyshire.
am
were not
WILLIAM H. JAMES.
CHRONIC OBSTRUCTIVE LUNG DISEASE SiR,—The study of Thurlbeck and his colleaguesin Montreal, which is discussed in your editorial (June 5, p. 1172), suggests that the majority of their patients with chronic (non-allergic) obstructive lung disease have emphysematous as well as bronchitic changes in the lung. These workers found a reduction in the single-breath carbonmonoxide-transfer factor (D.L.CO) to be the pulmonaryfunction test that correlated best with the extent of emphysema at necropsy, and we find the D.L.co in general to be low in patients with chronic obstructive lung disease in Aberdeen’-in 45 such patients the mean was 44’3 (s.D.j: 23-7) of the % predicted normal value-so it seems likely that our patients, like theirs, commonly have emphysema. We regard the D.L.co as a useful test in patients with airway obstruction to differentiate between allergic and non-allergic types (in 72 patients with allergic airways obstruction the mean was 78-2 (S.D. :1:23.5) of the % predicted normal value). This separation is not merely of academic interest, since patients with persistent allergic airways obstruction often improve dramatically with corticosteroids, whereas in our experience those with nonallergic airways obstruction do not. Another test which we find helpful in separating these two groups of patients is the increase in airways obstruction after the aerosol inhalation of histamine. Normal subjects show little or no increase, but those with allergic airways obstruction show a 4. 5. 6. 7.
Teitelbaum, M. S., J. biosoc. Sci. 1970, 2, suppl. p. 61. Teitelbaum, M. S., Mantel, N. ibid. 1971, 3, 23. Thurlbeck, W. M., Henderson, J. A., Fraser, R. G., Bates, D. V. Medicine, Baltimore, 1970, 49, 81. Palmer, K. N. V., Diament, M. L Thorax, 1970, 25, 101.
1295 those with non-allergic airways obstruction show increases greater than normal, but less than that seen in the allergic type.
pronounced increase; University Department of Medicine,
K. N. V. PALMER.
Aberdeen.
SIR,-What is the purpose of the word " disease " in the phrase " chronic obstructive lung disease " in your editorial ? Presumably this phrase is intended to refer to a group of patients with a specified disorder of function in the respiratory system, chronic airways obstruction. We have become accustomed to the use of phrases indicative of disorders of function in other systems (e.g., systemic hypertension, intestinal obstruction, raised intracranial pressure, congestive heart-failure), or even on the vascular side of the lungs themselves (pulmonary hypertension), without thinking it necessary to add " disease ". Why is it so generally thought necessary to add this word in referring to abnormally high resistance to gas-flow in the lungs ? To my mind, in this context it is worse than useless: its presence distracts attention from the main purpose of the use of this sort of term-namely, to refer to groups of patients characterised by a common disorder of function, without commitment to implications about aetiology, structural changes, or other characteristics. Institute of Diseases of the Chest, London S.W.3.
J. G. SCADDING.
MEDICAL SERVICES OF ISRAEL
SIR,-As a former deputy director of regional health services of the Ministry of Health in Israel, I feel it my duty to try and correct some of the impressions which may have been left in your readers’ minds by Dr. Gilliland’s article (March 13, p. 537). In describing our medical services, the article nearly omits altogether our preventive health services, provided almost exclusively by the Ministry of Health, such as mother and child health services, the care of chronically ill and elderly, health education, and others. Dr. Gilliland does refer to Prof. T. Grushka’s report of 1959, The Health Services of Israel, which contains a wealth of information on the subject which was not included in his article. But a new report by Professor Grushka, published in 1968, has seemingly not come to his attention, which is a pity indeed, since he was using scientific material published by the Workers’ Sick Fund (Kupath Holim) up to the year 1970. Thus, I would suggest that a better heading for our distinguished colleague’s article would be " The Health Services provided by the General Workers’ Sick Fund in Israel ". Although our Medical Association and the institutions of medical education were also consulted by Dr. Gilliland, they, like the Sick Fund physicians, may have omitted to put in proper focus the services rendered by the Ministry of Health in Israel. Thus, the whole picture appears somewhat unbalanced, as most of our health problems today are certainly to be found on the preventive side. Unit for the Prevention of Infections
Ministry
** * We
in Hospitals, of Health, Jerusalem, Israel.
showed this letter
K. RABINOWITZ.
British Postgraduate Medical Federation, London W.C.1.
SIR,-We thank Dr. Fowler and his colleagues (May 29, p. 1126) for their interest in our paper (May 8, p. 934). Two tests for thyroid antibodies were in fact carried out in 23 of our 26 patients (see tableI of our article); the tests were those recommended by Doniach and Roitt 1 as being a most sensitive combination. In our patients, who all had their plasma-lipoprotein abnormalities characterised, thyroid-antibody tests did not enable us to predict responsiveness to D-thyroxine. Most of our responders had not only normal serum-protein-bound-iodine (P.B.I.) levels but also negative tests for thyroid antibodies. Only 3 responders were positive to one or both antibody tests. By these of 20 of did not have evidence criteria, 17 thyroid responders disease; D-thyroxine thus appeared to be acting pharmacologically and not as replacement therapy. While the association between hypercholesterolaemia and the presence of circulating thyroid antibodies 2,3 is of great interest, these reports did not include characterisation of the lipoprotein pattern. Some hyperlipoproteinxmias can result from thyroid insufficiency, which should then be demonstrable by low plasma-thyroxine or high thyroidstimulating-hormone levels or, less sensitively, by low P.B.I. levels. A study using the newer techniques would be of value, and it remains to be seen what proportion of patients presenting with hyperlipoproteinxmias prove to be thyroid-insufficient. If a major proportion of our D-thyroxine-responsive patients had thyroid insufficiency it might be expected that their P.B.I. levels would show some tendency to be low. However, their mean serum-P.B.i. concentration was 6-3± 1.2 µg. per 100 ml. (laboratory mean 6-5 µg. per 100 ml.). Yet several were likely to have been hyperlipidaemic for many years, as judged by atherosclerosis, corneal arcus, or xanthomata. In at least 5 the disorder was present from early life, for studies on relatives showed it to be familial. Concerning the mechanism of hypercholesteroleemia, thyroid hormone increases fsecal neutral-steroid excretion in man4 and fxcal bile-acid excretion at least in the rat.i> (Bile-acids are a major end-product of cholesterol metabolism.) The hypercholesterolsemia of thyroid insufficiency probably results from decreased elimination of cholesterol by these pathways. In most studies of familial hyperbetalipoproteineemia, fsecal bile-acid and sterol excretion have 1.
grateful for the opportunity to reply to Dr. Rabinowitz. My article says: " The Government Services supply still other hospitals and most of the pre-
2. 3.
follows.-ED. L.
SIR,-I
Doniach, D., Roitt, I. M. in Clinical Aspects of Immunology (edited by P. G. H. Gell and R. R. A. Coombs); p. 933. Oxford, 1968.
am
ventivehealth measures, and make certain there
I. C. GILLILAND.
THYROID FUNCTION IN CORONARY-ARTERY DISEASE
Gilliland, whose reply
to
Dr.
other gaps in the service ". I think the impression this gives to an unbiased reader needs no correction. Dr. Rabinowitz is correct in stressing the health problems on the preventive side in a community containing social The groups of widely differing cultural backgrounds. health education programme which I witnessed in the Lachish region was being carried out by both doctors and nurses in a singularly patient and understanding way. At the health centre organised by the department of social medicine in Jerusalem, the service provided health education, maternity and child welfare, &c., in a very impressive way. I wished to draw attention to the degree of selfless devotion and the sense of social obligation of the many individuals concerned, without which no central policy could succeed.
are no
Fowler, P. B. S., Swale, J. Lancet, 1967, i, 1077. Bastenie, P. A., Vanhaelst, L., Bonnyns, M., Neve, P., Staquet, M. ibid. Jan. 30, 1971, p. 203. 4. Miettinen, T. A. J. Lab. clin. Med. 1968, 71, 537. 5. Eriksson, S. Proc. Soc. exp. Biol. Med. 1957, 94, 582.
might be said about
rare but memorandum it is enough to state that " special consideration should be given to outbreaks in which cases of rheumatic fever and nephritis occur ". " Children for whom recurrent streptococcal infection constitutes a special risk (such as those who have had rheumatic fever) should be advised to stay away in the event of an outbreak of streptococcal infection in a school; they should be referred to their own doctor for prophylactic chemotherapy unless this has already been more
lamentable epidemics, but surely in
a
prescribed." Influenza may cause havoc, but winter vomiting disease and glandular fever perhaps may cause mild dislocation. The Control of Communicable Diseases in Man is excellent, but for schools I recommend the handbook of the Medical Officers of Schools’ Association. Warwickshire Postgraduate Medical Centre,
R. E. SMITH.
Coventry.
Sm,—Your editorial (June 5, p. 1171) states that school is a good place to study the natural history of infectious disease ", and goes on to infer that this property is largely due to the monastic seclusion of the boardingschool ". Twenty years ago there might have been some truth in these statements, but they can hardly be credible "
a
"
now.
Infectious diseases in any significant number rarely in boarding-schools today, and the boarders in most schools now can and do mix freely with the local community, be it rural for pleasure or urban for shopping and the cinema. Furthermore, many of the domestic staff come daily from the surrounding areas and can easily carry " fresh parasites " as well as their domestic equipment. On the credit side of the memorandum you quote is the " failure to mention " influenza". Influenza " is an umbrella term and if influenza ", in its commonest designation, is handled aright it does not " play havoc with the curriculum ", and neither does glandular fever. School medicine is the same as any other medicine. There is still unfortunately a special stigma about it and these special memoranda seem to encourage all the old adages. It is a pity, for the execution of normal medical thought in schools thus remains impaired by this out-ofdate official guidance. occur
significant finding in this reanalysis which is inconsistent with the hypothesis of a negative paternal-age effect, is the suggestion of a positive paternal-age effect when maternal age has been controlled at birth orders 5+ (see their table III). I would like to offer an interpretation of this point. controlled for race or social class: and lower-class births seem to births moreover, Negro have a lower sex ratio than White births4 and upper-class births,5 respectively. So, as Teitelbaum et al. acknowledge in their discussion, this particular result may be the consequence of " different patterns of family formation between whites and Negroes ". It could also be due to similar social-class differences. In particular, when maternal age is held constant at birth orders 5+ one might expect a disproportionate number of Negro births and lower-class births to young fathers as contrasted with old fathers. So the above-cited result may stem from a failure to control for race and class. Moreover, one might wonder whether the same sort of artefact may have operated at birth-ranks 2, 3, and 4 (thus masking a true negative paternal-age effect at those ranks too). Indeed, it still seems possible that sex ratio is subject to a real negative paternal-age effect. At any rate, I think it would be unwise to accept Teitelbaum’s conclusion until results are presented on data which are controlled for race and social class in addition to parental ages and birth order. The data
I
D. W. S. SHELDON.
COITAL RATE, SEX RATIO, AND PARENTAL AGE
SiR,-Dr. Teitelbaum suggests (April 17, p. 800) that when birth order is controlled, neither maternal age nor paternal age bears a consistent relationship with sex ratio. I have hypothesised that coital rate depends more on husbands than on wives, and that therefore the decline in coital rate with the wife’s age is largely secondary to a decline caused by the husband’s age.2 If this hypothesis is true, then Teitelbaum’s claim constitutes prima-facie evidence against my theory that sex ratio is partially dependent on coital rate. Teitelbaum’s argument is based on data originally presented by Novitski and Kimball3 as reanalysed by Teitelbaum et al. It is worth considering whether the results of this reanalysis may be the consequence of failure to control relevant variables. As far as I can see, the only statistically 1.
Sheldon, D. W. S. Compendium of Emergencies; p. 380. London, 1971.
2. 3. 4.
James, W. H. Lancet, Jan. 16, 1971, p. 112. Novitski, E., Kimball, A. W. Am. J. hum. Genet. 1958, 10, 268. Teitelbaum, M. S., Mantel, N., Stark, C. R. ibid. (in the press).
grateful
to
Prof. C. A. B.
London, for advice. I
am
Smith, of University College supported by the Population Council
of New York. In furtherance of my research, I should like to hear from any married person (doctor or patient) who has kept a record for a considerable period (say at least a year) of the exact dates on which they had coitus. Galton Laboratory, Department of Human Genetics and Biometry, University College London,
London N.W.1.
"
Repton, Derbyshire.
am
were not
WILLIAM H. JAMES.
CHRONIC OBSTRUCTIVE LUNG DISEASE SiR,—The study of Thurlbeck and his colleaguesin Montreal, which is discussed in your editorial (June 5, p. 1172), suggests that the majority of their patients with chronic (non-allergic) obstructive lung disease have emphysematous as well as bronchitic changes in the lung. These workers found a reduction in the single-breath carbonmonoxide-transfer factor (D.L.CO) to be the pulmonaryfunction test that correlated best with the extent of emphysema at necropsy, and we find the D.L.co in general to be low in patients with chronic obstructive lung disease in Aberdeen’-in 45 such patients the mean was 44’3 (s.D.j: 23-7) of the % predicted normal value-so it seems likely that our patients, like theirs, commonly have emphysema. We regard the D.L.co as a useful test in patients with airway obstruction to differentiate between allergic and non-allergic types (in 72 patients with allergic airways obstruction the mean was 78-2 (S.D. :1:23.5) of the % predicted normal value). This separation is not merely of academic interest, since patients with persistent allergic airways obstruction often improve dramatically with corticosteroids, whereas in our experience those with nonallergic airways obstruction do not. Another test which we find helpful in separating these two groups of patients is the increase in airways obstruction after the aerosol inhalation of histamine. Normal subjects show little or no increase, but those with allergic airways obstruction show a 4. 5. 6. 7.
Teitelbaum, M. S., J. biosoc. Sci. 1970, 2, suppl. p. 61. Teitelbaum, M. S., Mantel, N. ibid. 1971, 3, 23. Thurlbeck, W. M., Henderson, J. A., Fraser, R. G., Bates, D. V. Medicine, Baltimore, 1970, 49, 81. Palmer, K. N. V., Diament, M. L Thorax, 1970, 25, 101.
1295 those with non-allergic airways obstruction show increases greater than normal, but less than that seen in the allergic type.
pronounced increase; University Department of Medicine,
K. N. V. PALMER.
Aberdeen.
SIR,-What is the purpose of the word " disease " in the phrase " chronic obstructive lung disease " in your editorial ? Presumably this phrase is intended to refer to a group of patients with a specified disorder of function in the respiratory system, chronic airways obstruction. We have become accustomed to the use of phrases indicative of disorders of function in other systems (e.g., systemic hypertension, intestinal obstruction, raised intracranial pressure, congestive heart-failure), or even on the vascular side of the lungs themselves (pulmonary hypertension), without thinking it necessary to add " disease ". Why is it so generally thought necessary to add this word in referring to abnormally high resistance to gas-flow in the lungs ? To my mind, in this context it is worse than useless: its presence distracts attention from the main purpose of the use of this sort of term-namely, to refer to groups of patients characterised by a common disorder of function, without commitment to implications about aetiology, structural changes, or other characteristics. Institute of Diseases of the Chest, London S.W.3.
J. G. SCADDING.
MEDICAL SERVICES OF ISRAEL
SIR,-As a former deputy director of regional health services of the Ministry of Health in Israel, I feel it my duty to try and correct some of the impressions which may have been left in your readers’ minds by Dr. Gilliland’s article (March 13, p. 537). In describing our medical services, the article nearly omits altogether our preventive health services, provided almost exclusively by the Ministry of Health, such as mother and child health services, the care of chronically ill and elderly, health education, and others. Dr. Gilliland does refer to Prof. T. Grushka’s report of 1959, The Health Services of Israel, which contains a wealth of information on the subject which was not included in his article. But a new report by Professor Grushka, published in 1968, has seemingly not come to his attention, which is a pity indeed, since he was using scientific material published by the Workers’ Sick Fund (Kupath Holim) up to the year 1970. Thus, I would suggest that a better heading for our distinguished colleague’s article would be " The Health Services provided by the General Workers’ Sick Fund in Israel ". Although our Medical Association and the institutions of medical education were also consulted by Dr. Gilliland, they, like the Sick Fund physicians, may have omitted to put in proper focus the services rendered by the Ministry of Health in Israel. Thus, the whole picture appears somewhat unbalanced, as most of our health problems today are certainly to be found on the preventive side. Unit for the Prevention of Infections
Ministry
** * We
in Hospitals, of Health, Jerusalem, Israel.
showed this letter
K. RABINOWITZ.
British Postgraduate Medical Federation, London W.C.1.
SIR,-We thank Dr. Fowler and his colleagues (May 29, p. 1126) for their interest in our paper (May 8, p. 934). Two tests for thyroid antibodies were in fact carried out in 23 of our 26 patients (see tableI of our article); the tests were those recommended by Doniach and Roitt 1 as being a most sensitive combination. In our patients, who all had their plasma-lipoprotein abnormalities characterised, thyroid-antibody tests did not enable us to predict responsiveness to D-thyroxine. Most of our responders had not only normal serum-protein-bound-iodine (P.B.I.) levels but also negative tests for thyroid antibodies. Only 3 responders were positive to one or both antibody tests. By these of 20 of did not have evidence criteria, 17 thyroid responders disease; D-thyroxine thus appeared to be acting pharmacologically and not as replacement therapy. While the association between hypercholesterolaemia and the presence of circulating thyroid antibodies 2,3 is of great interest, these reports did not include characterisation of the lipoprotein pattern. Some hyperlipoproteinxmias can result from thyroid insufficiency, which should then be demonstrable by low plasma-thyroxine or high thyroidstimulating-hormone levels or, less sensitively, by low P.B.I. levels. A study using the newer techniques would be of value, and it remains to be seen what proportion of patients presenting with hyperlipoproteinxmias prove to be thyroid-insufficient. If a major proportion of our D-thyroxine-responsive patients had thyroid insufficiency it might be expected that their P.B.I. levels would show some tendency to be low. However, their mean serum-P.B.i. concentration was 6-3± 1.2 µg. per 100 ml. (laboratory mean 6-5 µg. per 100 ml.). Yet several were likely to have been hyperlipidaemic for many years, as judged by atherosclerosis, corneal arcus, or xanthomata. In at least 5 the disorder was present from early life, for studies on relatives showed it to be familial. Concerning the mechanism of hypercholesteroleemia, thyroid hormone increases fsecal neutral-steroid excretion in man4 and fxcal bile-acid excretion at least in the rat.i> (Bile-acids are a major end-product of cholesterol metabolism.) The hypercholesterolsemia of thyroid insufficiency probably results from decreased elimination of cholesterol by these pathways. In most studies of familial hyperbetalipoproteineemia, fsecal bile-acid and sterol excretion have 1.
grateful for the opportunity to reply to Dr. Rabinowitz. My article says: " The Government Services supply still other hospitals and most of the pre-
2. 3.
follows.-ED. L.
SIR,-I
Doniach, D., Roitt, I. M. in Clinical Aspects of Immunology (edited by P. G. H. Gell and R. R. A. Coombs); p. 933. Oxford, 1968.
am
ventivehealth measures, and make certain there
I. C. GILLILAND.
THYROID FUNCTION IN CORONARY-ARTERY DISEASE
Gilliland, whose reply
to
Dr.
other gaps in the service ". I think the impression this gives to an unbiased reader needs no correction. Dr. Rabinowitz is correct in stressing the health problems on the preventive side in a community containing social The groups of widely differing cultural backgrounds. health education programme which I witnessed in the Lachish region was being carried out by both doctors and nurses in a singularly patient and understanding way. At the health centre organised by the department of social medicine in Jerusalem, the service provided health education, maternity and child welfare, &c., in a very impressive way. I wished to draw attention to the degree of selfless devotion and the sense of social obligation of the many individuals concerned, without which no central policy could succeed.
are no
Fowler, P. B. S., Swale, J. Lancet, 1967, i, 1077. Bastenie, P. A., Vanhaelst, L., Bonnyns, M., Neve, P., Staquet, M. ibid. Jan. 30, 1971, p. 203. 4. Miettinen, T. A. J. Lab. clin. Med. 1968, 71, 537. 5. Eriksson, S. Proc. Soc. exp. Biol. Med. 1957, 94, 582.