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CIGARETTE SMOKING AT SCHOOL
685 tion. The provision of a medical dossier for all patients be a proper and valuable feature of the National Health Service. Perhaps a National Medical Archive Office storing microfilm copies of records is not an
might
of keeping patients’ the of around revolves records question the space required for their storage. The ideal way of keeping records is probably in their original and complete form. Less satisfactory is to employ some selection of types of records to be conserved. Microfilm records obviously save an enormous amount of space, but the initial cost of the apparatus, as well as the continual employment of extra staff to operate it, represents a formidable financial burden, and such a solution might be more suitable to a Central Medical Archive Office than to smaller units such
hospital
groups. In my view, it is better that case-papers be kept intact and indefinitely and in their original form until some further consideration be given to this problem on a national scale. It seems unsatisfactory that the fate of patients’ records should be decided at the level of local hospital management committees whose practice will
certainlv
varv.
Lewisham Hospital, London, S.E.13.
M. 0. SKELTON.
INSULIN TREATMENT OF SCHIZOPHRENIA SIR,—I should like to congratulate Dr. Ackner, Dr. Harris, and Dr. Oldham on their controlled study, a masterpiece of planning and execution, described in your last issue (p. 607). Whether we like it or not, we shall have to accept their conclusion that insulin is not the therapeutic agent of the coma regime. However, this need not sadden the old hands ; it simply confirms that for getting there’in medicine there is nothing like the prescription : Sweat makes good mortar. H. PULLAR-STRECKER HEBERDEN SOCIETY SIR,—Your report of March 16 (p. 565) of the papers read at the meeting of the Heberden Society on Feb. 22 contains a number of inaccuracies which we would be grateful if you would correct. First, with regard to the electrodiagnostic changes in polymyositis, no evidence of spontaneous lower-motorneurone activity was found and it was the association of a high rheobase with an intensity-duration curve characteristic of denervated muscle that was of significance. The characteristic electromyographic change was a predominance on volition of the short duration and polyphasic motor unit potentials typical of a myopathy with, in half the cases, the coexisting features of a neuropathic lesion-i.e., long duration polyphasic motor unit potentials with occasional fibrillation potentials and positive
potentials. the electrophoresis of serumyou report, to glycoproteins," but to mucoproteins," the fractions wrl and M2 of which forma part only of the &agr;1 and &agr;2 glycoproteins respectively. Therefore, mucoprotein wrl or M2 should be read for &agr;1 or &agr;2 glycoproteins throughout your report. While the shapes indicative of fraction micro-heterogeneity were obtained after two dimensional electrophoresis, semi-quantitative estimation of the two mucoprotein fractions were, in fact, based on a single electrophoretic analysis at pH 4.5. Finally, in the paper on sheep-cell agglutination tests, the figures you report-e.g., positive results in 48% of cases of lupus erythematosus—relate to those quoted from the world literature and were not the results obtained at this hospital upon which the paper was based. More important, however, is the fact that not all of our lupus cases with positive agglutination with the super-
Second, the paper referred not,
proteins
"
spot
on
as
a
Finally,
impracticable suggestion. Meanwhile, the practical problem
as
a positive result with the precipitate and as method of distinguishing between rheumatoid arthritis and lupus erythematosus, it was apparently reliable in the event of a positive agglutination with the supernatant.
natant had
"
it
was
the
cases
of
systemic lupus erythematosus
without joint involvement that appeared to have a higher incidence of false positive Wassermann tests (especially the cardiolipin test) and it was in two cases, not one, of systemic lupus with positive agglutination tests that the activity lay in the &bgr;-globulin zone. A. T. RICHARDSON J. H. JACOBS Department of Physical Medicine and Rheumatology, R. L. MARKHAM Royal Free Hospital, E. V. HESS. London, W.C.1. CIGARETTE SMOKING AT SCHOOL SIR,—I was most interested in the article by Dr. Parry Jones in your issue of March 23. I notice that he thinks his results might be abnormally high. I am at present conducting an investigation into the smoking habits of school-children in this county. This is being carried out by means of an anonymous questionnaire, following an explanatory talk to the pupils. The eventual total number involved will be in the region of 9500 children between the ages of 11and 16 and attending all types of school. Several months will elapse before the survey has been completed and analysed, but preliminary results indicate that Dr. Parry Jones’s findings are not in any way abnormal, and, in fact, some of my earlier findings show that the incidence of smoking is higher than he has quoted. Health Department, Oxfordshire County Council, Oxford.
P. W. BOTHWELL Deputy County Medical Officer.
RHEUMATOID ARTHRITIS WITH CHRONIC LEG ULCERATION
SIR,—It was not at all our intention, in our article of Feb. 9, to suggest that varicose ulceration may not coexist with rheumatoid arthritis. It would indeed be significant if two such common disorders were not often seen in the same patient. We are naturally familiar with cases like the one Dr. Rivlin mentions (March 9) in which, as he says, the ulcer obviously results from venous stasis. Our point is that in the cases we described we could decide that the ulcers did not so originate. We need hardly detail the bed rest and ancillary treatment we gave for these ulcers except to emphasise that the methods we used were those by which we regularly heal stasis ulcers and that failure of these cases to heal was striking and at first unexpected. We agree with Dr. Laine and Dr. Vainio (March 23) that the L.E.-cell phenomenon is not specific, but we had Because of the clinical simimore evidence than this. skin ulceration with of the all cases, showing larity rheumatoid arthritis in the absence of vascular stasis, we thought it right to group them together, and it then is seen that among six patients four had shown drug sensitivity, all had serum abnormalities, four showed the L.E.-cell phenomenon, and there were many other features which taken together can all be covered by the diagnosis of disseminated lupus erythematosus and by no other ,
single diagnosis. In describing these cases as " rheumatoid arthritis with chronic leg ulceration " we were careful to avoid calling them " disseminated lupus erythematosus with leg ulceration," and in our discussion we indicated the contrast between these cases and the more acute case in which the diagnosis of disseminated lupus erythematosus is more acceptable. In general the diagnostic criteria of disseminated lupus erythematosus cannot be precisely laid down. If, therefore, we put these cases into the category of disseminated
might
of keeping patients’ the of around revolves records question the space required for their storage. The ideal way of keeping records is probably in their original and complete form. Less satisfactory is to employ some selection of types of records to be conserved. Microfilm records obviously save an enormous amount of space, but the initial cost of the apparatus, as well as the continual employment of extra staff to operate it, represents a formidable financial burden, and such a solution might be more suitable to a Central Medical Archive Office than to smaller units such
hospital
groups. In my view, it is better that case-papers be kept intact and indefinitely and in their original form until some further consideration be given to this problem on a national scale. It seems unsatisfactory that the fate of patients’ records should be decided at the level of local hospital management committees whose practice will
certainlv
varv.
Lewisham Hospital, London, S.E.13.
M. 0. SKELTON.
INSULIN TREATMENT OF SCHIZOPHRENIA SIR,—I should like to congratulate Dr. Ackner, Dr. Harris, and Dr. Oldham on their controlled study, a masterpiece of planning and execution, described in your last issue (p. 607). Whether we like it or not, we shall have to accept their conclusion that insulin is not the therapeutic agent of the coma regime. However, this need not sadden the old hands ; it simply confirms that for getting there’in medicine there is nothing like the prescription : Sweat makes good mortar. H. PULLAR-STRECKER HEBERDEN SOCIETY SIR,—Your report of March 16 (p. 565) of the papers read at the meeting of the Heberden Society on Feb. 22 contains a number of inaccuracies which we would be grateful if you would correct. First, with regard to the electrodiagnostic changes in polymyositis, no evidence of spontaneous lower-motorneurone activity was found and it was the association of a high rheobase with an intensity-duration curve characteristic of denervated muscle that was of significance. The characteristic electromyographic change was a predominance on volition of the short duration and polyphasic motor unit potentials typical of a myopathy with, in half the cases, the coexisting features of a neuropathic lesion-i.e., long duration polyphasic motor unit potentials with occasional fibrillation potentials and positive
potentials. the electrophoresis of serumyou report, to glycoproteins," but to mucoproteins," the fractions wrl and M2 of which forma part only of the &agr;1 and &agr;2 glycoproteins respectively. Therefore, mucoprotein wrl or M2 should be read for &agr;1 or &agr;2 glycoproteins throughout your report. While the shapes indicative of fraction micro-heterogeneity were obtained after two dimensional electrophoresis, semi-quantitative estimation of the two mucoprotein fractions were, in fact, based on a single electrophoretic analysis at pH 4.5. Finally, in the paper on sheep-cell agglutination tests, the figures you report-e.g., positive results in 48% of cases of lupus erythematosus—relate to those quoted from the world literature and were not the results obtained at this hospital upon which the paper was based. More important, however, is the fact that not all of our lupus cases with positive agglutination with the super-
Second, the paper referred not,
proteins
"
spot
on
as
a
Finally,
impracticable suggestion. Meanwhile, the practical problem
as
a positive result with the precipitate and as method of distinguishing between rheumatoid arthritis and lupus erythematosus, it was apparently reliable in the event of a positive agglutination with the supernatant.
natant had
"
it
was
the
cases
of
systemic lupus erythematosus
without joint involvement that appeared to have a higher incidence of false positive Wassermann tests (especially the cardiolipin test) and it was in two cases, not one, of systemic lupus with positive agglutination tests that the activity lay in the &bgr;-globulin zone. A. T. RICHARDSON J. H. JACOBS Department of Physical Medicine and Rheumatology, R. L. MARKHAM Royal Free Hospital, E. V. HESS. London, W.C.1. CIGARETTE SMOKING AT SCHOOL SIR,—I was most interested in the article by Dr. Parry Jones in your issue of March 23. I notice that he thinks his results might be abnormally high. I am at present conducting an investigation into the smoking habits of school-children in this county. This is being carried out by means of an anonymous questionnaire, following an explanatory talk to the pupils. The eventual total number involved will be in the region of 9500 children between the ages of 11and 16 and attending all types of school. Several months will elapse before the survey has been completed and analysed, but preliminary results indicate that Dr. Parry Jones’s findings are not in any way abnormal, and, in fact, some of my earlier findings show that the incidence of smoking is higher than he has quoted. Health Department, Oxfordshire County Council, Oxford.
P. W. BOTHWELL Deputy County Medical Officer.
RHEUMATOID ARTHRITIS WITH CHRONIC LEG ULCERATION
SIR,—It was not at all our intention, in our article of Feb. 9, to suggest that varicose ulceration may not coexist with rheumatoid arthritis. It would indeed be significant if two such common disorders were not often seen in the same patient. We are naturally familiar with cases like the one Dr. Rivlin mentions (March 9) in which, as he says, the ulcer obviously results from venous stasis. Our point is that in the cases we described we could decide that the ulcers did not so originate. We need hardly detail the bed rest and ancillary treatment we gave for these ulcers except to emphasise that the methods we used were those by which we regularly heal stasis ulcers and that failure of these cases to heal was striking and at first unexpected. We agree with Dr. Laine and Dr. Vainio (March 23) that the L.E.-cell phenomenon is not specific, but we had Because of the clinical simimore evidence than this. skin ulceration with of the all cases, showing larity rheumatoid arthritis in the absence of vascular stasis, we thought it right to group them together, and it then is seen that among six patients four had shown drug sensitivity, all had serum abnormalities, four showed the L.E.-cell phenomenon, and there were many other features which taken together can all be covered by the diagnosis of disseminated lupus erythematosus and by no other ,
single diagnosis. In describing these cases as " rheumatoid arthritis with chronic leg ulceration " we were careful to avoid calling them " disseminated lupus erythematosus with leg ulceration," and in our discussion we indicated the contrast between these cases and the more acute case in which the diagnosis of disseminated lupus erythematosus is more acceptable. In general the diagnostic criteria of disseminated lupus erythematosus cannot be precisely laid down. If, therefore, we put these cases into the category of disseminated