DOG BITES AND PASTEURELLA

469 SUMMER DEATHS IN GREATER LONDON AND THE SOUTH-EAST

PREDICTED EFFECT OF RELAXING LICENSING LAWS

participants were also asked if they thought the Clayson report would increase, diminish, or cause no change in the problem of alcoholism. The results (see table) do not suggest that psychiatrists in the Glasgow area consider that alcoholism would increase; indeed, nearly a third of the consultants the

decrease if licensrelaxed. However, alcoholism was regarded sigmficantly less favourably than any other organic or psychiatric illness with the exception of self-poisoning and drug dependence.

thought that alcohol-related problems might ing laws

were

Medical Department, National Coal Board, Doncaster DN1 2JS

EWAN B. MACDONALD

Accident and Emergency

Department,

Western Infirmary, Glasgow

A. R. PATEL temperatures rise above about 20 °C and that mortality is lowest when the temperature is about 17-18°C. The table sets out the mean temperature at Kew Observatory during the relevant weeks of 1975 and 1976 and also the weekly registrations of deaths in Greater London and the rest of the South-East Region. The South-East has an estimated population of nearly 17 millions, mostly living in a fairly narrow belt encircling Greater London, which has an estimated population of 7-11 millions. The peak of deaths during both heatwaves was quickly followed by an exceptionally low trough. Those rises and falls will tend to cancel each other out when the numbers of deaths are considered monthly instead of weekly. The two troughs seem to indicate that the number of persons at imminent risk of death in summertime is fairly precise. If a heatwave suddenly kills most of them off, fewer will die in the immediately succeeding weeks. Weekly deaths in Greater London correlate well with weekly deaths in the remainder of the South-East Region. During the 25 weeks up to Dec. 19, 1975, the correlation coefficient was found to be 0.9359 (P<0001). mean

ABORTION DEATHS AND SOCIAL CLASS

SIR,-The report on Confidential Inquiries into Maternal Deaths’ shows the numbers of "true maternal deaths" by social class and birth-rates per million total births. In my opinion, deaths due to abortion should not be computed per million births because women who give birth cannot die from abortion. A more appropriate denominator is the number of women, 15-44 years of age. The 10% sample tabulations of the 1971 census2 permit the identification of 83% of all women by social class, unmarried women being assigned by their own occupation and married women by the occupation of husband. On the basis of these sources the following table has been prepared.

Institute of Obstetrics and

Gynæcology,

Hammersmith Hospital, None of the differences in death-rates from abortion between adjacent social classes is statistically significant, but the difference between the rate for classes 1-3 combined (8.6 per million) and classes 4-5 combined (15-00 per million) is significant at the 5% level. Population Council, New York, N Y. 10017, U.S.A.

CHRISTOPHER TIETZE

DEATH IN SUMMER

S;R,—The monthly distribution of deaths from all

causes

in

England usually has its lowest point in August but ’xcMonaity in July or September. The heatwaves of late June :n3 early 1976, and August, 1975, let us see that the and Wales

July,

pattern of deaths, as reported in OPCS Monitor,4 is Tijre complex than the monthly pattern. We now have evi..r,ce that, in England and Wales, mortality increases when on Confidential Inquiries into Maternal Deaths in England and Wales 1970-72, p. 126. Census 1971 Economic Activity, part IV, table 29. H.M. Stationery Office. 3 Registrar General of England and Wales, Statistical Review of England and Part I various issues), H.M Stationery Office, London. 4 OPCS Monitor, issues of 1975 and 1976 Office of Population Censuses and Survey St Catherine’s House, Kingsway, London. 1 Report

2

Wales,

London W12 0HS

W. R. LYSTER

DOG BITES AND PASTEURELLA

SiR,—The following brief

account is given to remind colof the association between dog bites and Pasteurella. A wound swab was submitted to this laboratory from the casualty department and the only relevant details on the request form were that the swab was from a female, aged 45. As is our routine, the specimen was inoculated onto blood agar incubated aerobically and anaerobically, and also onto McConkey agar. After a 24h incubation an organism was isolated, resembling a small coliform, but exhibiting a slight greenish tinge, especially on the confluent growth; it was sensitive to penicillin and ampicillin but resistant to kanamycin. Gram staining revealed a tiny gram-negative coccobacillus. We suspected that the isolate might be a Pasteurella, and a telephone inquiry revealed that the patient had indeed been bitten by a dog. Further investigations of the isolate gave the following reactions : growth on nutrient agar, no growth on McConkey agar, non-motile at 22°C or 37°C, acid (no gas) in maltose and sucrose, indole positive, urease positive, oxidase positive, catalase positive. These characteristics allowed us to classify the isolate

leagues

470 P. pneumotropica; freeze-dried cultures those who are interested. as

are

available

to

SIR,-Dr McIntosh (Aug. 7, p. 300) raises

problem

Bacteriology Deaprtment, Royal Victoria Hospital,

C. RUSSELL

Belfast BT12 6BA

HANDBAG PARÆSTHESIA

SiR,—I examined recently a physician who had attended a conference and returned with a slowly resolving paraesthesia of the right forearm. She had been carrying her camera equipment in a bag draped over her right antecubital fossa. After 3-4 days her symptoms developed. Examination disclosed an area of decreased sensation to pain and light touch over the radial aspect of her right forearm extending from the posterior aspect of the thenar region to the antecubital fossa. The rest of her examination was normal. The region of paresthesia corresponded to the area supplied by the lateral cutaneous nerve, a distal branch of the musculocutaneous nerve which emerges from between the brachialis and biceps muscles just above the lateral humeral epicondyle. It is relatively superficial in the antecubital fossa and subject to various injuries. Injury to the nerve from venepuncture has been reported.’1 I feel that the partesthesia in this patient was secondary to nerve compression by the strap of a heavy bag, but I can find no reference to a similar disorder. This mononeuropathy should be fairly common and will undoubtedly be seen by others in practice. Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana 46202, U.S.A.

BRADFORD R. HALE

A.L.G. AND RENAL TRANSPLANTATION

SIR,-You have lately reviewed’ the position of anti-lymphocyte globulin (A.L.G.) in immunosuppressive treatment of kidney-transplanted patients. We agree that controlled investigations using A.L.G. in reasonably long periods of treatment are needed, and you report that such a clinical trial is under way in Britain. A controlled clinical investigation of the immunosuppressive effect of A.L.G. (Behringwerke) in kidney transplantation has been in progress at two transplantation centres in Denmark for the past six months. The project is being carried out in cooperation with the Danish State Medical Research Council. Treatments are given intravenously: 20 mg/kg/day for 14 days, 10 mg/kg every other day for the following 14 days, 10 mg/kg twice weekly in the subsequent month, and finally 10 mg/week in the third month. The final period of treatment is

given to ambulatory patients. A sequential test of the Wilcoxon type (A. M. Gehan) has been chosen for the statistical analysis. Of the tests available, this one provides best use of the data and thus permits the most rapid completion of the project. Improvement of 1-year graft survival by 20% has been chosen for the alternative hypothesis. Limits of significance are fixed so that the probability of error does not exceed 30% if the null hypothesis, no effect, is true, and does not exceed 15% if the alternative hypothesis is true. These limits accord with the fact that an acceptance of the null hypothesis makes A.L.G. acceptance of the alternative makes a of hypothesis repetition the project attractive. On the basis of programme simulations optimal randomisation between treated and control patients has been fixed at 1/5, and the number of A.L.G.-treated patients needed to obtain a significant result has been calculated to be 30-40. The project is expected to be completed within about two years.

.treatment

irrelevant and

an

Klevervaenget 26C, UK.3000, Odense, Denmark

1.

COMMUNICATION AND THE CANCER PATIENT

S. A. BIRKELAND

Sunderland, S. Nerves and Nerve Injuries; pp. 708, 803. Edinburgh, 1968.

of communication with the

cancer to

many

patients is

cancer

once

again the

patient. The word

synonymous with

a

death sentence,

By and large the general public is still misinformed about

malignant disease. This is a result of a number of factors: fear of the disease (and dying), inaccurate information about malignant disease (usually acquired from other patients and friends equally ignorant about cancer), and the refusal of so many doctors to talk honestly and frankly to patients about the problems of cancer. In my experience, very few patients collapse and lose hope when told the diagnosis of cancer. If patients are acclimatised gradually to the diagnosis most accept it remarkably well. This spares them that terrible uncertainty of whether or not they are suffering from cancer. For example, a man with a mass on chest X-ray is told at the first interview that he has a shadow on the lung which could represent a growth. After admission to hospital for histological confirmation of the diagnosis (during which time the patient has time to accept the fact that he may have cancer) he is told the diagnosis. At this stage it is important to conduct the interview with the spouse. This method of communication defuses the atmosphere of uncertainty which surrounds the subject of cancer. It helps to develop that personal relationship between the doctor and patient which is so vital in planning a course of treatment and aftercare, likely to be prolonged. It enables the patient at the earliest opportunity in the doctor-patient relationship to talk about his anxieties and worries. Dr McIntosh found that many patients preferred the anxiety arising from uncertainty as to whether or not they had malignant disease to knowing the true diagnosis. I am sure that this is in no small part due to the ignorance and fear of malignant disease in the general public. Perhaps if doctors adopted a policy of honest, frank, but sympathetic communication with patients who have malignant disease, much of the terror and anxiety surrounding the problem of cancer would disappear. 8 coombs

Lodge,

Warren Walk, London SE7

JOHN PRIOR

HIGH-DENSITY LIPOPROTEIN IN DIABETICS

SIR,—We are analysing data on the metabolism of a group of Sunderland diabetics who have a high prevalence of microangiopathy and yet have, on the whole, low fasting serum lipids. Our results should be compared with those from Carolina.1

It will be noted that the serum-cholesterol levels are higher in the diabetics and yet their absolute H.D.L.-cholesterol and apo-A lipoprotein levels do not differ from normal. Indee4 among the diabetics the L.D.L. and V.L.D.L. cholesterol value. were higher than normal. The same patients clearly hare : low-grade coagulopathy, as shown by their lower a2-andthrombin values. Thus in Sunderland diabetics H.D.L. is no relevant to microangiopathy and the data do not suggesta’ important relation to atherosclerotic disease. E. N. WARDLE Royal Infirmary, P. TRINDER Sunderland 1.

Lopes-Virella, M. F., Colewell, J. A. Lancet, 1976, i, 1291.