- Email: [email protected]
HEALTH AND SOCIAL SERVICES
774
In A
England Now
Running Commentary by Peripatetic Correspondents
WHEN we came down on Sunday morning the water was in fairly briskly under the front door, down a step into the hall and into the floor-coverings of the eating and sitting rooms. A daughter’s family arrived suitably equipped, and with dustpans, pails, shovels, and a draw-hoe the water was dammed off, coaxed away or dumped in the orchard, but sodden carpets and felts remained. A store of old Lancets shared, with an Esteemed Contemporary and all the old newspapers we had, a night’s bed between felt and carpet, and next day " a wonder came to light". The newspapers, of course, lap it all up; so, surprisingly, does your E.C.-but not you. Your pages have a duck’s back quality resistant to watery stuff. So should Thames rise, submerge the region of the immortal Brothers and threaten the Strand, when he returns to his bed your archives will emerge little the worse. But should " the cataract of the cliff of Heaven " fall on the Vale of Health while a great occluding embolus forms beneath New Bridge Street, and should the swollen, thwarted Fleet burst his pipes in mid course and, erupting, inundate W.C.I, then, when mopping up is over, only Journal pulp, I fear, will be found in the files. But when it’s drying out carpets your E.C. has you beat.
flowing
*
*
*
We first met our badgers of the garden as a
early this year soon after they chose lavatory. Every morning we found one or two freshly dug pits, each containing a little pile of excrement, and an increasingly obvious badger-path led us to the set 200 yards away. But ours were a suburban pair, and a corner
Letters
to
the Editor
SOCIAL WORK IN GENERAL PRACTICE SIR,-In view of the findings of the Seebohm Committee, attention should be paid to the important interim report from the National Institute for Social Work Training and the Caversham Centre (Sept. 7, p. 552). The Seebohm Committee’s recommendation that social workers should be attached to large health centres and group practices is enlightened and welcome; but the dominant position of general practice as a contact-point for social problems has been missed. The committee noted that only a minority of referrals to social-work agencies come from medical sources; but no serious attempt seems to have been made to assess the volume of major social and psychological problems presenting in general practice, of which only a minute proportion are, for various reasons, referred to social-work agencies. Perhaps the most significant sentence of the Caversham Centre report is, " Although most of the patients referred to the [attached] social worker had serious and often prolonged social and psychological difficulties, most (70%) had not been in touch with any other social-work agency." This reflects experience in a similar series of 409 referrals from a Devonshire group practice to an attached medical social worker in 1963-66.1 Reports from Nijmegen in Holland 2 repeat the picture.2 Some of these problems are facets of medical problems, some are purely social or psychological; the majority are mixed. But they all present to general practitioners, and often at the best moment for contact by a social worker-when the need is
greatest. While the future structure of the social services and family medicine are still malleable, much more attention should be paid to the development of an integrated medical/social casework service at ground level. Much remains to be learned, but there are now sufficient blueprints for such a system to warrant its wide extension. SHOLTO FORMAN. Barnstaple, Devon.
HEALTH AND SOCIAL SERVICES
SIR,-Dr. Lycett writes, in the last paragraph of his letter (Aug. 3, p. 286): " It is becoming too common to regard doctors merely as skilled technicians diagnosing and treating illness in the narrow sense of the word and advising more broadly based lay administrators or social workers, instead of as members of a liberal profession concerned with the whole individual and his environment. Here is the, real malady."
This is a profound statement. But can we entirely blame people for taking this view ?Young doctors for years now have been turned out of large metropolitan teaching centres with
Oak tree with badger.
each night they crossed the fields to the metropolis in the woods a mile away. There, on a bare patch of earth surrounded by a dozen sets, they met their cousins and played for a while before setting off in search of food. Sometimes you could see as many as seven badgers rolling about, scratching, grunting, and cuffing each other. They often climbed trees, and when we left peanuts on the lower branches they soon learned to look there every night. After an hour or so of frolicking they would suddenly stop, plunge into the bracken, and disappear noisily down the hillside.
half
their heads so crammed with detailed but " narrow " scientific facts that their cri-de-coeur, " This case should not have died: the electrolytes were normal ", is no longer funny. Then there is the tragic remark of the young house-officer: " I would like to discharge this case; it is not very interesting "-meaning, of " course, scientifically interesting ". This is the sort of response one can expect only from intelligent young people who are " subjected to the intellectual diet of a narrow "scientific" training with a minimum of the biological, sociological, and ecological sciences. Too many consultants have retired into their marble palaces to practise the minutiae of their biochemical and narrowly academic sciences without too much interruption from or reference to the community way of life of their patients. Their medical young have absorbed their interests. At a recent conference on the management of handicapped infants and children and their families, I asked a mother, who had given birth to a severely handicapped child in a large 1. 2.
Forman, J. A. S., Fairbairn, E. M. Social Casework in General Practice. London, 1968. Vlamings, H. L. A. Samenwerking van Huisarts en Maatschappelijk Werkster (with English summary) Nijmegen, 1967.
775
London hospital, what the obstetric resident doctor had said to " her about her child. Her reply was incredible. She said: When he came to sew up my tear, at about forty minutes after the birth, he just swore about the gloves not being right, did the job at the other end, and went away without addressing a single word to me." Can we wonder if there are those who look elsewhere for social insight or even good manners ? General Hospital, R. WIGGLESWORTH. Kettering, Northants.
FOLIC-ACID ABSORPTION IN MAN SIR,-Opinions differ as to whether folic acid is passively1 Dr. Hepner and his or actively absorbed by the intestine. 10, colleagues (Aug. p. 302) investigated intestinal absorption in man by comparing the amounts of folic acid absorbed over a small constant length of the intestine after the infusion of widely different ranges in the concentration of the vitamin. Part of their analysis was done with a modification of the method of Lineweaver and Burk.3 Instead of plotting the reciprocal of the uptake against the reciprocal of folic-acid concentration infused, they used the logarithms of these values. As Dr. Sladen (Aug. 24, p. 459) pointed out, one cannot simply log the original kinetic equation, since it contains an additive term. Even though the use of logarithms seems to be more practical, as Dr. Hepner and his co-workers suggest (Sept. 14, p. 637), it is still incorrect, and no information can be obtained from such a plot. An alternative to plotting the results is to use the computer program of Cleland.4 However, two special considerations have to be taken into account because of the nature of the data. Firstly, if each point is given equal weight the higher concentrations have undue emphasis on the shape of the curve; this is because the concentrations chosen by Hepner et al. were spaced geometrically at 10, 100, 1000, and 10,000 mg. per ml. To overcome this it is more accurate to use a weighted analysis, the appropriate weights in this case being the reciprocal of the squares of the dependent variables.5 Secondly, since the variation within each point is so great, the use of mean values alone is misleading from a statistical point of view. For example, using the mean values, the points fit a Michaelis-Menten curve with a variation of approximately ±2% even though the points have a variation range from 20% to more than 100%-i.e., the fit is too good to be true. An alternative to a Michaelis-Menten type curve (active transport) is a straight line (passive diffusion). We have thus analysed the data to see if they give a better fit to a straight line or a weighted straight line than they do to the Michaelis-Menten equation. To determine the goodness of fit, we used an analysis of variance (F) test. When the data were fitted by a computer to 1. Turner, J. B., Hughes, D. E. Q. Jl exp. Physiol. 1962, 47, 107. 2. 3. 4. 5.
Herbert, V. Archs intern. Med. 1962, 110, 649. Lineweaver, H., Burk, D. J. Am. chem. Soc. 1934, 56, 658. Cleland, W. W. Adv. Enzymol. 1967, 29, 1. Anderson, K. P., Snow, R. L. J. chem. Educ. 1967, 44, 756.
the Michaelis-Menten equation the F ratio was so large as to indicate that the data and the fitted line were very different (see table). For the unweighted fit to a straight line, the F ratio was much smaller, but was still significant. Only with weighted fit to a straight line, when the undue emphasis of the high point had been removed, was the F ratio small enough to suggest good agreement. We thus conclude that the best fit obtainable with this data is to a weighted straight line. Dr. Hepner and his co-workers also suggest that they have shown that the absorption of folic acid was active because they can demonstrate the absorption of the vitamin from the intestine when the blood was loaded with 30 times the infusion concentration. However, there is good evidence that, while folic acid given intravenously circulates as suchfolic acid which has passed through the intestinal wall is converted to 5-methyltetrahydrofolic acid .6This, we feel, invalidates the suggestion that transport has taken place against the concentration
gradient. In summary, we feel that the absorption of folic acid over this concentration range is passive, showing a linear relationship between uptake and concentration. We suggest that in cases of coeliac disease the surface area capable of absorbing folic acid by diffusion is simply reduced. Folic acid might be actively absorbed at small concentrations, but at higher concentrations a passive system is operative. Department of Biochemistry, JOHN M. SCOTT Trinity College, BRUNO A. ORSI. Dublin 2.
SiR,—The article by Dr. Hepner and his colleagues is interesting but, I believe, draws conclusions not warranted from the data. They state that the uptake of folic acid by the gastrointestinal tract is an active process. The basis for this assertion is the demonstration of a concentration-dependent uptake compatible with saturation kinetics and data taken as evidence of absorption against a concentration gradient. There are several fallacies in this argument. While it is true that demonstration of$aturation kinetics is one criterion for the existence of carrier-mediated transport,8 it should be pointed out that these same results can be observed in a system in which the studied molecule is, above a given concentration, complexed and absorption is thereby prevented. An interesting example of this is seen in the uptake of calcium from the gastrointestinal tract in the presence of phosphate. When the calcium activity exceeds the solubility product of CaxPp precipitation occurs. If one were then to plot the uptake of calcium against the total concentration of calcium one would find a curve very similar to that seen with enzyme substrate saturation. The data presented to demonstrate active transport not only fail to do so, but also fail to substantiate the claim of carriermediated transport. The authors, by infusing a large amount 6. 7. 8.
Baker, H., Frank, O., Feingold, S., Ziffer, H., Gellene, R. A., Leevy, C. M., Sobotka, H. Am. J. clin. Nutr. 1965, 17, 88. Cohen, N. Clin. Res. 1965, 13, 252. Stein, W. D. The Movement of Molecules Across Cell Membranes. New York, 1967.
GOODNESS OF FIT FOR DATA GIVEN BY HEPNER ET AL.
The internal variance for " normal " was 1-94 x 10’’ and for " coeliacs " was 1-20 x 105. The F ratio was calculated from the ratio internal/residual variance. The table for the distribution of F was entered at F (75,3) for controls and F (25,3) for coeliac cases. Not significant at P<0’01.
In A
England Now
Running Commentary by Peripatetic Correspondents
WHEN we came down on Sunday morning the water was in fairly briskly under the front door, down a step into the hall and into the floor-coverings of the eating and sitting rooms. A daughter’s family arrived suitably equipped, and with dustpans, pails, shovels, and a draw-hoe the water was dammed off, coaxed away or dumped in the orchard, but sodden carpets and felts remained. A store of old Lancets shared, with an Esteemed Contemporary and all the old newspapers we had, a night’s bed between felt and carpet, and next day " a wonder came to light". The newspapers, of course, lap it all up; so, surprisingly, does your E.C.-but not you. Your pages have a duck’s back quality resistant to watery stuff. So should Thames rise, submerge the region of the immortal Brothers and threaten the Strand, when he returns to his bed your archives will emerge little the worse. But should " the cataract of the cliff of Heaven " fall on the Vale of Health while a great occluding embolus forms beneath New Bridge Street, and should the swollen, thwarted Fleet burst his pipes in mid course and, erupting, inundate W.C.I, then, when mopping up is over, only Journal pulp, I fear, will be found in the files. But when it’s drying out carpets your E.C. has you beat.
flowing
*
*
*
We first met our badgers of the garden as a
early this year soon after they chose lavatory. Every morning we found one or two freshly dug pits, each containing a little pile of excrement, and an increasingly obvious badger-path led us to the set 200 yards away. But ours were a suburban pair, and a corner
Letters
to
the Editor
SOCIAL WORK IN GENERAL PRACTICE SIR,-In view of the findings of the Seebohm Committee, attention should be paid to the important interim report from the National Institute for Social Work Training and the Caversham Centre (Sept. 7, p. 552). The Seebohm Committee’s recommendation that social workers should be attached to large health centres and group practices is enlightened and welcome; but the dominant position of general practice as a contact-point for social problems has been missed. The committee noted that only a minority of referrals to social-work agencies come from medical sources; but no serious attempt seems to have been made to assess the volume of major social and psychological problems presenting in general practice, of which only a minute proportion are, for various reasons, referred to social-work agencies. Perhaps the most significant sentence of the Caversham Centre report is, " Although most of the patients referred to the [attached] social worker had serious and often prolonged social and psychological difficulties, most (70%) had not been in touch with any other social-work agency." This reflects experience in a similar series of 409 referrals from a Devonshire group practice to an attached medical social worker in 1963-66.1 Reports from Nijmegen in Holland 2 repeat the picture.2 Some of these problems are facets of medical problems, some are purely social or psychological; the majority are mixed. But they all present to general practitioners, and often at the best moment for contact by a social worker-when the need is
greatest. While the future structure of the social services and family medicine are still malleable, much more attention should be paid to the development of an integrated medical/social casework service at ground level. Much remains to be learned, but there are now sufficient blueprints for such a system to warrant its wide extension. SHOLTO FORMAN. Barnstaple, Devon.
HEALTH AND SOCIAL SERVICES
SIR,-Dr. Lycett writes, in the last paragraph of his letter (Aug. 3, p. 286): " It is becoming too common to regard doctors merely as skilled technicians diagnosing and treating illness in the narrow sense of the word and advising more broadly based lay administrators or social workers, instead of as members of a liberal profession concerned with the whole individual and his environment. Here is the, real malady."
This is a profound statement. But can we entirely blame people for taking this view ?Young doctors for years now have been turned out of large metropolitan teaching centres with
Oak tree with badger.
each night they crossed the fields to the metropolis in the woods a mile away. There, on a bare patch of earth surrounded by a dozen sets, they met their cousins and played for a while before setting off in search of food. Sometimes you could see as many as seven badgers rolling about, scratching, grunting, and cuffing each other. They often climbed trees, and when we left peanuts on the lower branches they soon learned to look there every night. After an hour or so of frolicking they would suddenly stop, plunge into the bracken, and disappear noisily down the hillside.
half
their heads so crammed with detailed but " narrow " scientific facts that their cri-de-coeur, " This case should not have died: the electrolytes were normal ", is no longer funny. Then there is the tragic remark of the young house-officer: " I would like to discharge this case; it is not very interesting "-meaning, of " course, scientifically interesting ". This is the sort of response one can expect only from intelligent young people who are " subjected to the intellectual diet of a narrow "scientific" training with a minimum of the biological, sociological, and ecological sciences. Too many consultants have retired into their marble palaces to practise the minutiae of their biochemical and narrowly academic sciences without too much interruption from or reference to the community way of life of their patients. Their medical young have absorbed their interests. At a recent conference on the management of handicapped infants and children and their families, I asked a mother, who had given birth to a severely handicapped child in a large 1. 2.
Forman, J. A. S., Fairbairn, E. M. Social Casework in General Practice. London, 1968. Vlamings, H. L. A. Samenwerking van Huisarts en Maatschappelijk Werkster (with English summary) Nijmegen, 1967.
775
London hospital, what the obstetric resident doctor had said to " her about her child. Her reply was incredible. She said: When he came to sew up my tear, at about forty minutes after the birth, he just swore about the gloves not being right, did the job at the other end, and went away without addressing a single word to me." Can we wonder if there are those who look elsewhere for social insight or even good manners ? General Hospital, R. WIGGLESWORTH. Kettering, Northants.
FOLIC-ACID ABSORPTION IN MAN SIR,-Opinions differ as to whether folic acid is passively1 Dr. Hepner and his or actively absorbed by the intestine. 10, colleagues (Aug. p. 302) investigated intestinal absorption in man by comparing the amounts of folic acid absorbed over a small constant length of the intestine after the infusion of widely different ranges in the concentration of the vitamin. Part of their analysis was done with a modification of the method of Lineweaver and Burk.3 Instead of plotting the reciprocal of the uptake against the reciprocal of folic-acid concentration infused, they used the logarithms of these values. As Dr. Sladen (Aug. 24, p. 459) pointed out, one cannot simply log the original kinetic equation, since it contains an additive term. Even though the use of logarithms seems to be more practical, as Dr. Hepner and his co-workers suggest (Sept. 14, p. 637), it is still incorrect, and no information can be obtained from such a plot. An alternative to plotting the results is to use the computer program of Cleland.4 However, two special considerations have to be taken into account because of the nature of the data. Firstly, if each point is given equal weight the higher concentrations have undue emphasis on the shape of the curve; this is because the concentrations chosen by Hepner et al. were spaced geometrically at 10, 100, 1000, and 10,000 mg. per ml. To overcome this it is more accurate to use a weighted analysis, the appropriate weights in this case being the reciprocal of the squares of the dependent variables.5 Secondly, since the variation within each point is so great, the use of mean values alone is misleading from a statistical point of view. For example, using the mean values, the points fit a Michaelis-Menten curve with a variation of approximately ±2% even though the points have a variation range from 20% to more than 100%-i.e., the fit is too good to be true. An alternative to a Michaelis-Menten type curve (active transport) is a straight line (passive diffusion). We have thus analysed the data to see if they give a better fit to a straight line or a weighted straight line than they do to the Michaelis-Menten equation. To determine the goodness of fit, we used an analysis of variance (F) test. When the data were fitted by a computer to 1. Turner, J. B., Hughes, D. E. Q. Jl exp. Physiol. 1962, 47, 107. 2. 3. 4. 5.
Herbert, V. Archs intern. Med. 1962, 110, 649. Lineweaver, H., Burk, D. J. Am. chem. Soc. 1934, 56, 658. Cleland, W. W. Adv. Enzymol. 1967, 29, 1. Anderson, K. P., Snow, R. L. J. chem. Educ. 1967, 44, 756.
the Michaelis-Menten equation the F ratio was so large as to indicate that the data and the fitted line were very different (see table). For the unweighted fit to a straight line, the F ratio was much smaller, but was still significant. Only with weighted fit to a straight line, when the undue emphasis of the high point had been removed, was the F ratio small enough to suggest good agreement. We thus conclude that the best fit obtainable with this data is to a weighted straight line. Dr. Hepner and his co-workers also suggest that they have shown that the absorption of folic acid was active because they can demonstrate the absorption of the vitamin from the intestine when the blood was loaded with 30 times the infusion concentration. However, there is good evidence that, while folic acid given intravenously circulates as suchfolic acid which has passed through the intestinal wall is converted to 5-methyltetrahydrofolic acid .6This, we feel, invalidates the suggestion that transport has taken place against the concentration
gradient. In summary, we feel that the absorption of folic acid over this concentration range is passive, showing a linear relationship between uptake and concentration. We suggest that in cases of coeliac disease the surface area capable of absorbing folic acid by diffusion is simply reduced. Folic acid might be actively absorbed at small concentrations, but at higher concentrations a passive system is operative. Department of Biochemistry, JOHN M. SCOTT Trinity College, BRUNO A. ORSI. Dublin 2.
SiR,—The article by Dr. Hepner and his colleagues is interesting but, I believe, draws conclusions not warranted from the data. They state that the uptake of folic acid by the gastrointestinal tract is an active process. The basis for this assertion is the demonstration of a concentration-dependent uptake compatible with saturation kinetics and data taken as evidence of absorption against a concentration gradient. There are several fallacies in this argument. While it is true that demonstration of$aturation kinetics is one criterion for the existence of carrier-mediated transport,8 it should be pointed out that these same results can be observed in a system in which the studied molecule is, above a given concentration, complexed and absorption is thereby prevented. An interesting example of this is seen in the uptake of calcium from the gastrointestinal tract in the presence of phosphate. When the calcium activity exceeds the solubility product of CaxPp precipitation occurs. If one were then to plot the uptake of calcium against the total concentration of calcium one would find a curve very similar to that seen with enzyme substrate saturation. The data presented to demonstrate active transport not only fail to do so, but also fail to substantiate the claim of carriermediated transport. The authors, by infusing a large amount 6. 7. 8.
Baker, H., Frank, O., Feingold, S., Ziffer, H., Gellene, R. A., Leevy, C. M., Sobotka, H. Am. J. clin. Nutr. 1965, 17, 88. Cohen, N. Clin. Res. 1965, 13, 252. Stein, W. D. The Movement of Molecules Across Cell Membranes. New York, 1967.
GOODNESS OF FIT FOR DATA GIVEN BY HEPNER ET AL.
The internal variance for " normal " was 1-94 x 10’’ and for " coeliacs " was 1-20 x 105. The F ratio was calculated from the ratio internal/residual variance. The table for the distribution of F was entered at F (75,3) for controls and F (25,3) for coeliac cases. Not significant at P<0’01.