LEAD IN DRINKING WATER

1207 RELIABILITY OF TITLES SIR,-The problems of the proliferation of medical literature have been aired many times in many places. Some of the solutions offered deal with techniques of information storage and retrieval. One method that has been recommended1 finds a counterpart in the solution to the hospital record storage problem proposed by Dr. Mitchell and his colleagues (Oct. 28, p. 932). Those who become interested in the techniques of information storage and retrieval soon find themselves involved, inter alia, with such matters as subject headings, key terms, and descriptors, and with the question of adequate, conceptually relevant titles for scientific reports. A title like a bikini should reveal abundantly and accurately. A case in point is the title of the article by Dr. Jordanov and Dr. Ruben, Reliability of Pupillary Changes as a Clinical Sign of Hypoxia, in the same issue (p. 915). An important conclusion of the article is: " It seems doubtful whether dilatation of the pupils is a reliable clinical sign of anoxia ". " in the title This being so, surely the word " unreliability would have been much more pertinent than " reliability ". Catholic Hospitals Medical Education Foundation, GEORGE X. TRIMBLE. Kansas City, Missouri 64108.

fessionally qualified staff. The wider integration of psychiatry with society, discussed by both Dr. Dicks and Professor Rees, can be said to have already found expression in mental-health

SIR -" Barbiturate Fits " can suggest only one thing to the ordinary user and reader of English-namely, fits caused by taking a barbiturate. Having seen your table of contents last week and hoping to learn about a subject new to me I turned to p. 1148 and found a letter about its well-known opposite. Space may be valuable, but " Barbiturate-withdrawal Fits " could have been printed on one line. Surely this is abbreviation carried beyond reason, and to a point at which the intended

potential lead poisoning has not yet been eliminated. I record here an experience which clearly illustrates the plumbosolvency problem in rural areas. In August, 1963, two occupants of a bungalow at Pickmere, Cheshire, were found to have abnormal amounts of lead in their urine. The husband, aged 49 years, had been employed for 14 years by a local firm of lead/additive manufacturers. On Aug. 19, 1963, a concentration of 150 mg. of lead per litre was found in his urine, although he had been restricted from possible exposure to lead for the previous 31/2 months. On the same day 97 mg. of lead per litre was found in the urine of his wife, aged 45 years, who was employed at a nearby wireworks. There was no known lead hazard in her occupation,

meaning vanishes.

JOHN PENMAN.

PSYCHIATRY RAMPANT SIR,-Your annotation (Nov. 4, p. 976) on the meeting of the Society of Clinical Psychiatrists records that Dr. Denis Williams chided the psychiatrist for not withdrawing " when Does the neurologist stop a patient could not be helped ". seeing patients in whom he has diagnosed multiple sclerosis ? Humanitarian and scientific reasons provide as good an argument for the management of the one as of the other. That psychiatry is to be acknowledged structurally as a discipline, though functionally (like the electrolytes of physiology) it enters into all aspects of medicine, must be reckoned All disciplines, schools, or even fragments are an advance. artefacts and matters of convenience. I believe it was Pascal who said that men made divisions and were surprised that Nature did not take account of them. In purist terms child psychiatry is an even more debatable specialty. Creak2 has discussed the relation of child health to child psychiatry, and the debate in the child psychiatry section of the Royal MedicoPsychological Association is active. In practical terms, even though child psychiatrists see only a small proportion of emotionally disturbed children,3 there seems to be a good case for extending their influence in the provision of child-care.4 With the approaching publication of the report of the Seebohm committee on the social services, still greater emphasis will be given to the emotional well-being of families in an attempt to provide an effective family service. Despite the great advances in training of social workers, much of their practice is based on theory which is outpaced by psychiatric advances. In this area of medicosocial work decisions are made about children and families which, in my experience, exceed in seriousness many of the problems grappled with in child-guidance and adult psychiatric clinics bv more Dro1. Fox, T. Am. J. Orthopsychiat. 1967, 2. Creak, M. Lancet, 1959, i, 481. 3. Br. med. J. 1967, ii, 585. 4. Barnett, B. ibid. 1967, iii, 238.

37, 507.

consultation.55

Such services must be much more widely available than at present. It is not only to the old asylums, mental hospitals, and the newer " therapeutic communities " that psychiatrists must turn their attention-close cooperation in the wider community will help these agencies, and psychiatry will thereby extend its contribution. B. BARNETT.

FLUORIDATION

SIR,-In view of the extensive dental decay in the islanders of Tristan da Cunha, referred to by Dr. Shibli in his letter (Nov. 4, p. 992), it would be interesting to know the percentage of fluoride in their drinking-water supplies. MARJORIE M. DOBSON. LEAD IN DRINKING WATER

SiR,ňThe interesting and important leading article (Nov. 18, p. 1077) and analyses reported by Dr. Crawford and Professor Morris (p. 1087) emphasise that every danger of

but 4 weeks later the lead concentration in her urine had risen to 110 mg. per litre. Both gave a past history of " rheumatism ", together with occasional attacks of abdominal colic, constipation and loss in weight and appetite over a number of years. Both were easily tired. Further inquiries revealed that a previous married couple in the bungalow had had similar vague stomach disturbances, and that the wife had developed nephritis-the reason for their leaving the area in 1958. Since departing, their general health had improved. Lead estimations carried out on tap-water from the bungalow and nearby wire-works on Aug. 23, 1963, gave the following results:

Control samples from tap-water at a site 2 miles away and at sites 500 yards either way from the junction pipes to the bungalow and wire-works showed lead readings of 0-007, 0-004, and 0-005 p.p.m. respectively. The wire-works employed 6 women from 9 A.M. to 5.30 to Friday, and 9 A.M. to 12.30 P.M. Saturday. used for drinking and tea-making during these periods. Apart from the first housewife referred to, all gave no history suggestive of lead absorption, and they had less than the normal mean average of 0-03 mg. lead per litre of urine (Sept. 19, 1963). It was decided to replace the entire length of lead piping with copper piping from the watermain in the road to both bungalow and wire-works. In the meantime the two occupants of the bungalow left, and in October, 1963, a young married couple (aged 29 and 25 years) made known their intention of buying the bungalow. They were informed of the recent finding of lead in the drinking water, but insisted that the risk, over the short period

Monday

P.M.

Water

5.

was

Caplan, G. Concepts of Mental Health and Consultation. Children’s Bureau Publication, U.S. Department of Health, Education and Welfare, 1959.

1208 before the

pipe replacement would be negligible. They did,

have urine-lead estimations carried out both before they moved into the bungalow and at monthly intervals both before and after replacement of the lead pipes, which was done in February/March, 1964. The results were as follows:

however, agree

to

temporal arteritis " with " reactive specific blood tests for syphilis." I suggest that, while this report need in no sense invalidate the role of stress, further investigation of these findings could well yield useful information not inconsistent with known facets of the disease, including the arterial involvement and the raised erythrocyte-sedimentation rate. Bearing in mind the widespread incidence of subspirochaetocidal courses of penicillin in the population at large, are we here again faced with an iatrogen ? proven

Sussex Eye Hospital,

Brighton

*

living in bungalow. the urine-lead levels of this couple increased conAlthough the 4-month siderably during period before the copper piping replaced the lead, they did not reach abnormal levels, and by the beginning of May, 1964, they were approaching the levels determined in October, 1963. At the same time, there was no clinical evidence of lead absorption. However, the increase in their urine-lead levels seems to indicate a probability of abnormal absorption should they have remained exposed for a long time. Public Health Department, WILFRID H. PARRY. Town Hall Chambers, Sheffield 1. Before

CRANIAL ARTERITIS AND POLYMYALGIA RHEUMATICA Sir-In your leading article (Oct. 28, p. 926) you are vague in your use of expressions such as confirmation by biopsy, and findings of abnormal arteries in diagnosing cranial arteritis. This unclearness is explained by the fact that some workers clearly differentiate between giant-cell arteritis on the one hand and granulomatous arteritis without giant cells or non-specific arteritis on the other, while other workers do not describe their histological examinations in detail. For instance you write: " Hamrin et al.1 discovered 12 abnormal temporal arteries among 21 cases ". Actually it is clear from table 11 in our report1 that, histologically, 16 of the 21 cases had abnormal arteries-i.e., an arteritis. From table i in the same report it is also evident that in our patient no. 18, who clinically had a temporal arteritis, we could not find any giant cells in the temporal arteries, which were excised at different times on both sides. However, both vessels showed a striking granulomatous inflammatory reaction. Later we found about the same proportion between abnormal arteries with and without giant cells. Obviously this result too depends on whether the right artery or the right segment is excised, and whether the time when the biopsy is done is suitable. Central Hospital, BENGT HAMRIN. Växjö, Sweden. most strongly to endorse Dr. Paulley’s cranial arteritis. The evidence from a personal series of some 75 cases leaves me no reasonable doubt that this is, par excellence, a typical stress-mediated disease of later life. I suggest that those who would contest this statement have not so much asked questions as asked the wrong questions. The " tag of euphoria " which has been given to the mental state so characteristic of these patients, particularly those who have become blind, has been at least in part responsible for this failure of understanding. For how much longer is the main stream of medicine going to ignore the strong probability that an important element in the xtiology of systemic diseases in which steroids play a significant therapeutic role is governed by what one must call, for lack of a better term, the " cephalic

SIR,-I should like

comments on

system " ? Smith 1. 2.

et

al .2 have

reported four

out

of

ten cases

of

"

biopsy

Hamrin, B., Jonsson, N., Landberg, T. Lancet, 1964, i, 397. Smith, J. L., Israel, C. W., Harner, R. E. Archs Ophthal. 1967, 78, 284.

M. J. GILKES.

7.

M.C.Q. AND THE MEMBERSHIP SIR,-Iagree with Dr. Towers (Nov. 18, p. 1088)-the priorities are wrong. The overwrought M.R.C.P. examiners might take comfort in the knowledge that they are peripherally involved in the design of medical practice as they would wish it to be ten years hence, rather than perpetuating the sterile atmosphere of incontestible dogma which fills our medical schools, wards, and now examination papers. Granted that a candidate may wish to comply, and learn data until he is blue in the face-can anyone inform me where he will find out which information is incorrect ? A book on Common Misconceptions in Clinical Medicine might fill such a role, but it would be a bigger volume than Cecil-Loeb. It is encouraging that the system seems to work, like giant blocks of council flats and paper-towels. However, it is just conceivable that those who dissent and opt out may have had something to offer. M.R.C. Experimental Hæmatology Research Unit, St. Mary’s Hospital Medical School, MICHAEL S. ROSE. London W.2.

THE E.S.R.

SIR,-Your annotation

(Oct. 14,

p.

817) provokes this

comment.

The immediate cause for a raised erythrocyte-sedimentation (E.S.R.) is rouleaux formation, which is brought about by changes in the plasma-proteins, chiefly elevation of fibrinogen and globulin and lowering of albumin. It is my contention that rouleaux act as a normal mechanical protective device against thrombosis by improving the sweeping action of the bloodstream (and single red cells) in removing platelet clumps from injured vascular endothelium (particularly arteries) and by denying platelets access to injured endothelium. Further, it is my belief that rouleaux should lessen the dissolution of red cells, with consequent lessening of the release of procoagulant substances from erythrocytes because of decrease of the total exposed red-cell surface. This belief is born out by the finding of a raised E.S.R. in a number of medical conditions and normal situations in which coronary thrombosis and/or pulmonary embolism are relatively rare. These include premenopausal women, pregnancy in the second and third trimesters (notably excluding the stages of delivery and the puerperium), tuberculosis, leprosy, rheumatoid arthritis, multiple myeloma, pulmonary emphysema, subacute bacterial endocarditis (with associated non-septic pulmonary embolism), cirrhosis of the liver, and certain " normal " populations in primitive countries where the problem has been studied. Conversely, in patients with sickle-cell anaemia, in whom the E.S.R. is abnormally decreased owing to the shape of the erythrocytes, thrombotic events are frequent and the common mode of death. As you say, " the erythrocyte-sedimentation rate (E.S.R.) seems to measure the response of the body to injury ". An integral part of almost any injury is injury to blood-vessels and vascular endothelium, and it is difficult to believe that Nature would not provide some protective device against this fundamental initiator of thrombosis.1 Holy Name of Jesus Hospital, J. H. ROGERS. Gadsden, Alabama.

rate

1.

Rogers, J. H. J. med. Ass. St. Ala. 1967, 37, 269.