- Email: [email protected]
FAIR
875
hospital. In Dr. Cargill’s view hospital consultants should tighten up this procedure, for neglect to send information to the family doctor could be as serious as neglect to order a clinical test. But Dr. Cargill thought that the family doctor also often failed in communication, especially when his advice was sought by the patient in the no man’s land of human relations. Here the doctor often could and should offer valuable help; but his authority was based not on scientific fact, but on education and experience, and he should offer his dvice-not as cut-and-dried assertion but as personal opinion. Dr. Cargill rated smoking as a painful boomerang to this technique of overconfident assertion. In the past, many doctors had disapproved of smoking without scientific evidence: today, when we had the evidence, their advice was dangerously ignored. It was a warning to doctors that before assuming the necromancer’s wand they should put aside the little black bag. Miss June Neill, who is a member of the team at the Caversham centre in North London, believed that a social worker might succeed in persuading a patient to admit his, or her, real worries, which were often presented to the doctor only under the cloak of physical symptoms. The patient regarded difficulties in human relations as a failure which he was reluctant to admit to the doctor, and sometimes he found it easier to explain them to a stranger. But she insisted that it must be clear that the social worker was offering an extra service and that contact with her did not mean dismissal from the doctor’s attention. Dr. Charles Fletcher suggested that the first thing for a doctor to find out was what the patient was afraid of. The patient was always anxious to know what was the diagnosis of his illness, what was its treatment, what would be the outcome, and how long the disorder was likely to last. The good doctor must learn to answer all these questions and where necessary to overcome the patient’s reluctance to ask them. The doctor’s replies might be guarded by tact and sympathy, but he should offer intelligible and satisfying information. Doctors must be educated to answer questions, and patients must be educated to ask them.
HYDROGEN PEROXIDE AND GAS EMBOLISM
peroxide has been put to surgical uses on grounds. Because the liberated oxygen was believed to inhibit the growth of sporing organisms, wounds were irrigated with a solution of hydrogen peroxide, and in Hirschsprung’s disease peroxide enemas HYDROGEN
tenuous
believed
break up the accumulation of hard of the risk of perforation of the scybala. now bowel, peroxide is seldom, if ever, used in this way, though some surgeons still use peroxide wash-outs at operation to remove the adherent meconium from the bowel in intestinal obstruction caused by mucoviscidosis. Danis et al.1 reported oxygen embolisation in a child with rectal atresia and rectoperineal fistula after irrigation of the distal colon beyond the colostomy with dilute hydrogen peroxide to remove barium and meconium. The legs and the lower half of the trunk suddenly became cyanosed and swollen, and on radiological examination gas was seen in the portal venous system. This child recovered, but Shaw et al. were not so fortunate. They used 1% hydrogen peroxide to wash out inspissated were
On
1. 2.
to
account
Danis, R. K., Brodeur, A. E., Shields, J. J. pediat. Surg. 1967, 2, 131. Shaw, A., Cooperman, A., Fusco, J. New Engl.J. Med. 1967, 277, 238.
meconium in a neonate with mucoviscidosis. They saw gas bubbles spread widely in the vessels of the ileum, but later blood-flow was resumed and appeared normal. Because of increasing abdominal distension, the abdomen was reopened on the fifth day of life, and gangrene with perforation of the distal ileum was disclosed. In subsequent experiments, Shaw et al. showed that bubbles of gas appeared in the veins of the small intestine in dogs only when 0-75% or stronger solutions of peroxide were used, but they were unable to reproduce the gangrene of the intestine. Danis et al. produced gas embolisation in dogs with a steep rise in portal venous pressure and filling of the portal system with gas. Clearly, hydrogen peroxide is dangerous for washing out the bowel. Moreover, the practice is no longer necessary in mucoviscidosis. An end-to-side ileostomy,3 combined with a pancreatic extract given by mouth and instilled into the ileostomy, usually results in the rapid liquefaction of the inspissated meconium.
FAIR
THE handiest instrument for pulling facts quickly out of store is still the human brain. Unfortunately, for scientists and many others, the explosion of new data has left even their best brains far behind; and they have for many years been looking to the computer and other little gadgets to help them catch up. FAIR (fast access information retrieval) is an experiment which began in Hampstead two years ago, in the division of biomedical engineering of the National Institute for Medical Research, and which holds promise for research-workers whose desk or back garden is too small to hold a computer. The emphasis in FAIR is not on the " where can I get some references for my " paper ? inquiry but on rapid follow-up of an idea or a question 4-in an effort to cut losses down the " ideas drain " by providing prompt answers from a large collection of literature on a fairly small subject. FAIR’S method of constructing an economical on-desk library is by feature-card index and microfiche file. Like any information retrieval system it depends very largely for efficiency on the use of a good language. and Pickford4 and his colleagues believe there is a way of compiling, by computer or electronic data processing, an information retrieval language regardless of subject without performing the intuitive tasks that have hitherto had to suffice. For a ’start, from September, 1965, to November, 1966, they made a collection of literature on biomedical engineering ; and they found they had 1488 articles from 220 different journals (the literature is certainly " scattered " here). The collection was then circulated (in batches of four reprints at a time) to collaborators from the Biological Engineering Society, the Hospital Physicists Association, and elsewhere, who allocated keywords (descriptors), up to a total of 15 descriptors in order of importance, which defined the scope of the paper. Each reprint was sent to two collaborators so that the two sets of descriptors and the retrieval languages derived from both circulations could be compared. The descriptors having been punched on cards, they were presented to a computer programmed to select those which best satisfied certain criteria based on frequency of occurrence of a particular word or phrase and on the importance attached to descriptors in each list. This part of the research has been completed; and an 3. 4.
Bishop, H. C., Koop, C. E. Ann. Surg. 1957, 145, Pickford, A. G. A. Aslib Proc. 1967, 19, 79.
410.
876
experimental language for biomedical engineering is now available. By phrasing his inquiry in these terms, the searcher can operate the retrieval mechanism to identify the documents meeting the selection criteria. He then extracts the full texts from a microfiche file, and if he wishes, he can make a photocopy to take away. A working library on these lines is being constructed at Hampstead; and further investigations are assessing whether a large group of collaborators (such as the members of a scientific society) can be used to code new articles (that is, allocate descriptors from some form of thesaurus) if the coding process is made easy enough.
acquired experiences which are loosely called culture and which, in practical terms, have equipped him with a repertoire of behaviour patterns that are unique in their diversity. Animal studies are useful in interpreting human behaviour, but no ethologist would suggest that direct comparisons are valid. There is no reason to believe, for example, that human aggressive behaviour was any less destructive in its primitive than its present form: unlike subhuman apes, men do not wage war solely to defend or establish territorial rights-in fact, agonistic behaviour in apes seldom leads to full-scale conflict. With intelligence at our command we might be wiser to forget that we were once apes, and concentrate, instead, on becoming successful human beings.
WHICH WAY TO SALVATION?
ZOOLOGISTS are an irreverent lot: to them man is just another species of animal, and language, art, and culture are some of his species characteristics. Dr. Desmond Morris is a zoologist, and he regards man-along with snakes, apes, and pandas-as fair game for his pen.1 But Homo sapiens is a puzzle, even to zoologists. He does not look much like his anthropoid relatives: he stands and walks upright, his arms are short and his legs long, he has a large brain, and he is virtually hairless. Of all human characteristics, hairlessness is the one that most fascinates Dr. Morris. Hair loss, he suggests, was encouraged by the transition from a quiet fruit-gathering existence in tropical forests to a hunting life in hot, open country-a long hairy coat would lead to overheating during a sudden sprint after prey. (This explanation is plausible enough, but loss of hair could just as well have been a sideeffect of the neoteny that gave-man his upright stance and large brain.) Adoption of a diet that was largely carnivorous also led to important changes in behaviour. Being none too fleet of foot, the hunting ape had to work in packs. The males had to cooperate on the hunt, leaving the females behind to look after the young during the prolonged childhood imposed by the need to develop a big brain. The development of pair-bonding, which was supposed to ensure that a female remained faithful to her absent husband, also met the protective needs of the female and her offspring, and to keep a male to herself she became sexually receptive all year round. The naked skin, by its sensitivity, gave greater emphasis to precopulatory behaviour, thereby reinforcing the bond. Thus, sexual activity became much more intense in man than in any other primate.
Dr. Morris’s analysis of man is incisive and sometimes slightly disquieting. Unfortunately, it is presented with an air of authority that is not always justified. Headaches and minor infections may attract a little sympathy, but can they really be called " grooming invitation ailments " ? Are pathogens deliberately acquired a as comfort-seeking mechanism? A more serious criticism can be levelled against the whole raison d’etre of this book-a warning from Dr. Morris that we should remember our anthropoid past, and, for the salvation of our paranoid and anxiety-prone species, give rein to some of our earthy primate impulses. But, in presenting man as a biological species, he has surely overlooked one important fact: man is a naked ape, but he is also an intelligent ape. Man can think and communicate, and these two processes have given him a set of historically 1. The Naked 1967. Pp.
Ape. 252.
By DESMOND MORRIS. 30s.
London: Jonathan
Cape.
GENETIC FACTORS IN OTOSCLEROSIS
IN otosclerosis abnormal deposits of spongy bone arise in and around the otic capsule, causing ankylosis of the stapes. This condition is the commonest single cause It has been of deafness in Caucasian adults. recognised for over a century but, despite intensive study with increasingly elaborate equipment, much remains to be discovered about aetiology and pathology. The importance of heredity in otosclerosis was also noted as long ago as 1861, but much later work was invalidated by inadequate diagnosis and unwarranted genetic conclusions. Morrisonhas now presented a survey of 150 patients with otosclerosis and their families. The incidence in East London was 3 per 1000 population, and histological frequency was 7 per 1000. The disease has an autosomal dominant inheritance and is manifest in about 40% of individuals carrying the abnormal gene. Contrary to common otological experience, the incidence is probably the same in both sexes, though in many females hormonal influences cause the deafness to advance more rapidly. The age of onset is the same for males and females, the main risk age being 15-44 years. In any given sibship the age of onset tends to be similar, while with succeeding generations the disease appears earlier. About 30% of cases are isolated instances, which could arise by another mode of inheritance, but they are more likely to result from failure of the disease to manifest itself in other members of the family. Some sporadic cases will be the result of new mutations, and there is evidence to suggest that, among these isolated cases, later births are more likely to be affected. Further work is needed to clarify this point. No evidence exists of either association or linkage between otosclerosis and the ABO, MN, and rhesus blood-groups, the secretor states, or the haptoglobin genotypes. But there is a statistically significant association with the ability to taste phenylthiocarbamide ; and this link cannot be explained in biochemical language. Chromosome studies and analyses in otosclerosis and in osteogenesis imperfecta have produced normal karyotypes.
Otosclerosis, like osteogenesis imperfecta, is one of a group of hereditary disorders of collagen, with a similar mode of inheritance, incomplete manifestation, varying degrees of expressivity, and possibly a common abnormal The deafness found in osteogenesis enzyme system. imperfecta is not otosclerosis, but a genocopy of it. 1.
Morrison, A. W. Ann.
R. Coll.
Surg. 1967, 41,
202.
hospital. In Dr. Cargill’s view hospital consultants should tighten up this procedure, for neglect to send information to the family doctor could be as serious as neglect to order a clinical test. But Dr. Cargill thought that the family doctor also often failed in communication, especially when his advice was sought by the patient in the no man’s land of human relations. Here the doctor often could and should offer valuable help; but his authority was based not on scientific fact, but on education and experience, and he should offer his dvice-not as cut-and-dried assertion but as personal opinion. Dr. Cargill rated smoking as a painful boomerang to this technique of overconfident assertion. In the past, many doctors had disapproved of smoking without scientific evidence: today, when we had the evidence, their advice was dangerously ignored. It was a warning to doctors that before assuming the necromancer’s wand they should put aside the little black bag. Miss June Neill, who is a member of the team at the Caversham centre in North London, believed that a social worker might succeed in persuading a patient to admit his, or her, real worries, which were often presented to the doctor only under the cloak of physical symptoms. The patient regarded difficulties in human relations as a failure which he was reluctant to admit to the doctor, and sometimes he found it easier to explain them to a stranger. But she insisted that it must be clear that the social worker was offering an extra service and that contact with her did not mean dismissal from the doctor’s attention. Dr. Charles Fletcher suggested that the first thing for a doctor to find out was what the patient was afraid of. The patient was always anxious to know what was the diagnosis of his illness, what was its treatment, what would be the outcome, and how long the disorder was likely to last. The good doctor must learn to answer all these questions and where necessary to overcome the patient’s reluctance to ask them. The doctor’s replies might be guarded by tact and sympathy, but he should offer intelligible and satisfying information. Doctors must be educated to answer questions, and patients must be educated to ask them.
HYDROGEN PEROXIDE AND GAS EMBOLISM
peroxide has been put to surgical uses on grounds. Because the liberated oxygen was believed to inhibit the growth of sporing organisms, wounds were irrigated with a solution of hydrogen peroxide, and in Hirschsprung’s disease peroxide enemas HYDROGEN
tenuous
believed
break up the accumulation of hard of the risk of perforation of the scybala. now bowel, peroxide is seldom, if ever, used in this way, though some surgeons still use peroxide wash-outs at operation to remove the adherent meconium from the bowel in intestinal obstruction caused by mucoviscidosis. Danis et al.1 reported oxygen embolisation in a child with rectal atresia and rectoperineal fistula after irrigation of the distal colon beyond the colostomy with dilute hydrogen peroxide to remove barium and meconium. The legs and the lower half of the trunk suddenly became cyanosed and swollen, and on radiological examination gas was seen in the portal venous system. This child recovered, but Shaw et al. were not so fortunate. They used 1% hydrogen peroxide to wash out inspissated were
On
1. 2.
to
account
Danis, R. K., Brodeur, A. E., Shields, J. J. pediat. Surg. 1967, 2, 131. Shaw, A., Cooperman, A., Fusco, J. New Engl.J. Med. 1967, 277, 238.
meconium in a neonate with mucoviscidosis. They saw gas bubbles spread widely in the vessels of the ileum, but later blood-flow was resumed and appeared normal. Because of increasing abdominal distension, the abdomen was reopened on the fifth day of life, and gangrene with perforation of the distal ileum was disclosed. In subsequent experiments, Shaw et al. showed that bubbles of gas appeared in the veins of the small intestine in dogs only when 0-75% or stronger solutions of peroxide were used, but they were unable to reproduce the gangrene of the intestine. Danis et al. produced gas embolisation in dogs with a steep rise in portal venous pressure and filling of the portal system with gas. Clearly, hydrogen peroxide is dangerous for washing out the bowel. Moreover, the practice is no longer necessary in mucoviscidosis. An end-to-side ileostomy,3 combined with a pancreatic extract given by mouth and instilled into the ileostomy, usually results in the rapid liquefaction of the inspissated meconium.
FAIR
THE handiest instrument for pulling facts quickly out of store is still the human brain. Unfortunately, for scientists and many others, the explosion of new data has left even their best brains far behind; and they have for many years been looking to the computer and other little gadgets to help them catch up. FAIR (fast access information retrieval) is an experiment which began in Hampstead two years ago, in the division of biomedical engineering of the National Institute for Medical Research, and which holds promise for research-workers whose desk or back garden is too small to hold a computer. The emphasis in FAIR is not on the " where can I get some references for my " paper ? inquiry but on rapid follow-up of an idea or a question 4-in an effort to cut losses down the " ideas drain " by providing prompt answers from a large collection of literature on a fairly small subject. FAIR’S method of constructing an economical on-desk library is by feature-card index and microfiche file. Like any information retrieval system it depends very largely for efficiency on the use of a good language. and Pickford4 and his colleagues believe there is a way of compiling, by computer or electronic data processing, an information retrieval language regardless of subject without performing the intuitive tasks that have hitherto had to suffice. For a ’start, from September, 1965, to November, 1966, they made a collection of literature on biomedical engineering ; and they found they had 1488 articles from 220 different journals (the literature is certainly " scattered " here). The collection was then circulated (in batches of four reprints at a time) to collaborators from the Biological Engineering Society, the Hospital Physicists Association, and elsewhere, who allocated keywords (descriptors), up to a total of 15 descriptors in order of importance, which defined the scope of the paper. Each reprint was sent to two collaborators so that the two sets of descriptors and the retrieval languages derived from both circulations could be compared. The descriptors having been punched on cards, they were presented to a computer programmed to select those which best satisfied certain criteria based on frequency of occurrence of a particular word or phrase and on the importance attached to descriptors in each list. This part of the research has been completed; and an 3. 4.
Bishop, H. C., Koop, C. E. Ann. Surg. 1957, 145, Pickford, A. G. A. Aslib Proc. 1967, 19, 79.
410.
876
experimental language for biomedical engineering is now available. By phrasing his inquiry in these terms, the searcher can operate the retrieval mechanism to identify the documents meeting the selection criteria. He then extracts the full texts from a microfiche file, and if he wishes, he can make a photocopy to take away. A working library on these lines is being constructed at Hampstead; and further investigations are assessing whether a large group of collaborators (such as the members of a scientific society) can be used to code new articles (that is, allocate descriptors from some form of thesaurus) if the coding process is made easy enough.
acquired experiences which are loosely called culture and which, in practical terms, have equipped him with a repertoire of behaviour patterns that are unique in their diversity. Animal studies are useful in interpreting human behaviour, but no ethologist would suggest that direct comparisons are valid. There is no reason to believe, for example, that human aggressive behaviour was any less destructive in its primitive than its present form: unlike subhuman apes, men do not wage war solely to defend or establish territorial rights-in fact, agonistic behaviour in apes seldom leads to full-scale conflict. With intelligence at our command we might be wiser to forget that we were once apes, and concentrate, instead, on becoming successful human beings.
WHICH WAY TO SALVATION?
ZOOLOGISTS are an irreverent lot: to them man is just another species of animal, and language, art, and culture are some of his species characteristics. Dr. Desmond Morris is a zoologist, and he regards man-along with snakes, apes, and pandas-as fair game for his pen.1 But Homo sapiens is a puzzle, even to zoologists. He does not look much like his anthropoid relatives: he stands and walks upright, his arms are short and his legs long, he has a large brain, and he is virtually hairless. Of all human characteristics, hairlessness is the one that most fascinates Dr. Morris. Hair loss, he suggests, was encouraged by the transition from a quiet fruit-gathering existence in tropical forests to a hunting life in hot, open country-a long hairy coat would lead to overheating during a sudden sprint after prey. (This explanation is plausible enough, but loss of hair could just as well have been a sideeffect of the neoteny that gave-man his upright stance and large brain.) Adoption of a diet that was largely carnivorous also led to important changes in behaviour. Being none too fleet of foot, the hunting ape had to work in packs. The males had to cooperate on the hunt, leaving the females behind to look after the young during the prolonged childhood imposed by the need to develop a big brain. The development of pair-bonding, which was supposed to ensure that a female remained faithful to her absent husband, also met the protective needs of the female and her offspring, and to keep a male to herself she became sexually receptive all year round. The naked skin, by its sensitivity, gave greater emphasis to precopulatory behaviour, thereby reinforcing the bond. Thus, sexual activity became much more intense in man than in any other primate.
Dr. Morris’s analysis of man is incisive and sometimes slightly disquieting. Unfortunately, it is presented with an air of authority that is not always justified. Headaches and minor infections may attract a little sympathy, but can they really be called " grooming invitation ailments " ? Are pathogens deliberately acquired a as comfort-seeking mechanism? A more serious criticism can be levelled against the whole raison d’etre of this book-a warning from Dr. Morris that we should remember our anthropoid past, and, for the salvation of our paranoid and anxiety-prone species, give rein to some of our earthy primate impulses. But, in presenting man as a biological species, he has surely overlooked one important fact: man is a naked ape, but he is also an intelligent ape. Man can think and communicate, and these two processes have given him a set of historically 1. The Naked 1967. Pp.
Ape. 252.
By DESMOND MORRIS. 30s.
London: Jonathan
Cape.
GENETIC FACTORS IN OTOSCLEROSIS
IN otosclerosis abnormal deposits of spongy bone arise in and around the otic capsule, causing ankylosis of the stapes. This condition is the commonest single cause It has been of deafness in Caucasian adults. recognised for over a century but, despite intensive study with increasingly elaborate equipment, much remains to be discovered about aetiology and pathology. The importance of heredity in otosclerosis was also noted as long ago as 1861, but much later work was invalidated by inadequate diagnosis and unwarranted genetic conclusions. Morrisonhas now presented a survey of 150 patients with otosclerosis and their families. The incidence in East London was 3 per 1000 population, and histological frequency was 7 per 1000. The disease has an autosomal dominant inheritance and is manifest in about 40% of individuals carrying the abnormal gene. Contrary to common otological experience, the incidence is probably the same in both sexes, though in many females hormonal influences cause the deafness to advance more rapidly. The age of onset is the same for males and females, the main risk age being 15-44 years. In any given sibship the age of onset tends to be similar, while with succeeding generations the disease appears earlier. About 30% of cases are isolated instances, which could arise by another mode of inheritance, but they are more likely to result from failure of the disease to manifest itself in other members of the family. Some sporadic cases will be the result of new mutations, and there is evidence to suggest that, among these isolated cases, later births are more likely to be affected. Further work is needed to clarify this point. No evidence exists of either association or linkage between otosclerosis and the ABO, MN, and rhesus blood-groups, the secretor states, or the haptoglobin genotypes. But there is a statistically significant association with the ability to taste phenylthiocarbamide ; and this link cannot be explained in biochemical language. Chromosome studies and analyses in otosclerosis and in osteogenesis imperfecta have produced normal karyotypes.
Otosclerosis, like osteogenesis imperfecta, is one of a group of hereditary disorders of collagen, with a similar mode of inheritance, incomplete manifestation, varying degrees of expressivity, and possibly a common abnormal The deafness found in osteogenesis enzyme system. imperfecta is not otosclerosis, but a genocopy of it. 1.
Morrison, A. W. Ann.
R. Coll.
Surg. 1967, 41,
202.