NOCTURNAL WHEEZE AND MITE SENSITIVITY

480 focal cirrhosis, focal nodular hyperplasia .22-27 The variable terminology reflects the diversity of the authors’ opinions on the nature of the lesion; but the main gross and microscopical features of all these nodules corresponded with those observed in women who had been on oral contraceptives for several months or years. Benz and Baggenstoss 12 encountered 34 such liver nodules in the necropsy material of the Mayo Clinic over the period 1922-51. It is interesting that the majority of the nodules were small and, not causing any symptoms, remained unnoticed throughout life. Nearly half of them were found in males. Against this, the majority of cases reported since 1951 have been in young women, and the nodules were larger and usually caused symptoms;23 25-27 whether or not these patients had been on the pill was not pursued. These findings support the suggestion that oral contraceptives might stimulate the growth of pre-existing isolated liver nodules, upon which may follow secondary lesions and symptoms. The true nature of the isolated liver nodules needs to be clarified and the nomenclature reviewed before the precise role of oral contraceptives in the development or progression of hepatic tumours can be determined. Department of Pathology Radioisotope Laboratory

ISTVÁN BARTÓK SUZAN GARAS

Department of Surgery, Péterfy Hospital, 1441 Budapest, P.O. Box

76,

LÁSZLÓ SZABÓ

Hungary

ARMS AND THE BRONCHI

SIR,-We agree28 with you (Feb. 7, p. 287) about the need for a continued search for biochemical mediators in exerciseinduced asthma, but we feel that the emphasis placed on differences between different types of exercise might be misleading. Is running really more likely to provoke asthma than cycling? You indicate, and we have said it ourselves,29 that in comparisons of this type the important measure of work to control and report is total oxygen consumption. We are told that the rate of exercise is unimportant, but examination of the literature purporting to show a greater bronchial response to running reveals that it is this, and not total oxygen consumption, which has been reported.3O-33 When we measured total oxygen consumption 29 we found no difference in the bronchial response to treadmill-running and ergometer-pedalling. You suggest that the limit of bronchial response to work is reached at a total oxygen consumption of approximately 200 ml/kg body-weight, and imply that this is more or less independent of the type of subject and form of exercise. We find the evidence used in support of this figure" to be unsatisfactory. Surely there must be considerable biological variation in what represents "maximal stimulation". Our view is that there is no substitute for actual measurement of total oxygen consumption, and until more such studies are reported the relative effects of different types of exercise in asthma must remain un7 certain. We might add that we find the cycle ergometer per22. 23. 24. 25.

Benz, E. J., Baggenstoss, A. H. Cancer, 1953, 6, 743. Begg, C. F., Berry, W. H. Am. J. clin. Path. 1953, 23, 447. Edmondson, H. A. Am. J. Dis. Child. 1956, 91, 168. Palubinskas, A. J., Baldwin, J., McCormack, K. R. Radiology, 1967, 89, 444.

26. 27. 28.

Whelan, T. J., Baugh, J. H., Chandor, S. Ann. Surg. 1973, 177, 150. McLoughlin, M. J., Colapinto, R. F., Gilday, D. L., Hobbs, B. B., Korobkin, M. T., McDonald, P., Phillips, J. Radiology, 1973, 107, 257. Seaton, A., Davies, G., Gaziano, D., Hughes, R. O. Br. med. J. 1969, iii, 556.

29. 30. 31. 32. 33.

Miller, G. J., Davies, B. H., Cole, T. J., Seaton, A. Thorax, 1975, 30, 306. Fitch, K. D., Morton, A. R. Br. med. J. 1971, iv. 577. Anderson, S. D., Connolly, N. M., Godfrey, S. Thorax, 1971, 26, 396. Silverman, M., Anderson, S. D. Archs Dis. Childh. 1972, 47, 882. Anderson, S. D., Silverman, M., König, P., Godfrey, S. Br. J. Dis. Chest, 1975, 69, 1.

fectly satisfactory for the study of exercise-induced asthma in the clinical laboratory. .

Medical Research Council Pneumoconiosis Unit,

Llandough Hospital, Penarth, South Wales

G. J. MILLER

Sully Hospital, Sully, Glamorgan

A. SEATON B. H. DAVIES

NOCTURNAL WHEEZE AND MITE SENSITIVITY

SIR,—Dr Burr and his colleagues (Feb. 14, p. 333) describe Dermatophagoides pteronyssinus as causing nocturnal asthma in sensitive subjects. Nocturnal wheezing is a very common complaint in asthmatics, whether their asthma is extrinsic or intrinsic. A questionnaire completed by 40 of our asthmatic patients showed that 75% of the intrinsics were troubled with nocturnal wheeze compared with 93% of the extrinsic patients; the difference is rather small if allergy to the mite is a major cause of nocturnal wheezing. Asthmatics also seem to complain of nocturnal wheezing during exacerbation due to seasonal pollen asthma and when psychological factors (e.g., examinations) are operative. If type-I allergy is involved it is strange that the patients often wake in the early hours of the morning, i.e., after several hours of exposure. More than 80% of extrinsic asthmatics demonstrate positive skin tests to the house-dust mite.’ It is difficult to prove that sensitivity to the mite is a major cause of nocturnal wheeze, so anti-mite measure may not be as successful as anticipated. Chest

Clinic,

G. J. ARCHER S. K. U. MALIK

Stepping Hill Hospital, Stockport SK2 7UE

SIR The asthmatic patients studied by Dr Burr and his

colleagues had positive skin tests to D. pteronyssinus, but there is no indication that their symptoms were precipitated or exacerbated by dust contact. Many adults with asthma are atopic and may have positive skin tests to D. pteronyssimus and,other common allergens. A positive skin test does not necessarily mean that the allergen is relevant to the patient’s symptoms. I hope the conclusions of Dr Burr and his colleagues will not dissuade physicians from advising measures to reduce the mite population in the homes of patients whose symptoms are clearly related to house-dust exposure. Department of General Medicine, Frenchay Hospital, Bristol BS16 1LE

R. J. WHITE

SIR,—I have studied 200 patients at this allergy clinic and have had many patients with mite-sensitive asthma who have been given inadequate advice from other allergy clinics about reduction of exposure to house-dust mite. Many of these patients had failed to benefit because the advice given still allowed exposure to this mite. There is a very significant aerosol from the base of the bed which should also be covered with ’Polythene’, and, in our experience, the house-dust-mite antigen cannot be removed from pillows containing any potential air space. I advise the patient to cover the mattress and base wi6 polythene; the pillow should also be covered with polythene, and a pillow-slip with a towel under it may be used for greater comfort. The blankets should be washed every two or three months, and any quilt is discarded unless it is of very light material and easily washed. It is also advisable (especially with children) to treat any other bed in the room. 1.

Hendrick, II.

D.

J., Davies,

R.

J., D’Souza, M. F., Pepys, J. Thorax, 1975, 30,

481 Should this be effective we then advise them to get a goodquality solid foam-rubber pillow. It is not advisable to use pillows with small pieces of foam because the mite could easily lodge in the air spaces in this type of pillow. Using this technique there is a very significant improvement in the symptoms, both in adults and children. Glasgow Homœopathic Hospital, 1000 Great Western 0NR

Road,

R. G. GIBSON

Glasgow G12

HANDICAPPED SCHOOL LEAVERS

SIR,-Your editorial (Jan. 10, p. 77) highlights a problem which has concerned school medical officers for many years. The report on the Handicapped School Leaver published by the British Council for Rehabilitation of the Disabled in 1963 recommended that the Education Act 1944 be amended "so as to require the School Health Service to provide continuity of medical care and supervision for handicapped young people up to at least the age of 18". Despite strong representations from the School Health Group Council of the Society of Medical Officers of Health this was never implemented. The recommendation was an attempt to bridge some of the gaps in the services outlined in your columns. Adolescents who receive their education in residential schools are especially vulnerable. They may be under supervision of consultants away from home, they are no longer on the lists of the home family doctor, and often the only local contact is with the school medical officer who reviewed the individual periodically during holidays. On leaving school this support is withdrawn. From the educational aspect unless the person embarks on some form of further education the education authority cannot provide support after school-leaving. The social-services departments have a statutory duty to provide for all handicapped children, but in many areas staffing permits little more than emergency services, and the young physically handicapped adult often receives little help other than the provision of home adaptations and appliances. The county careers officers do valuable work in attempting to obtain employment for the handicapped, supported by the Employment Medical Advisory Service, but suitable work is becoming more difficult to obtain and more are being left to vegetate at home, often with few outside contacts.

I suggest that one of the roles of the area community physician responsible to the social-services department could be to act as coordinator for further developments to fill the gaps. There would no longer appear to be any legal reason why experienced clinical medical officers could not continue some oversight of individuals since they are now employed by area health authorities, not local authorities. Detailed studies are required to assess local needs and deficiencies as the pattern varies throughout the country. Once the needs have been assessed schemes for further education could be developed in consultation with the education authorities, at least until the age of 19 years. Attention needs to be given to the mental as well as the physical health of these deprived handicapped adolescents. Many of the recommendations of the 1963 report have never been brought to fruition and all concerned would be well advised to look at the report again. 57

Kingsway Close, C. SIMPSON SMITH

Ossett WF5 8DZ

HEALTH: A DEMYSTIFICATION OF MEDICAL TECHNOLOGY

SIR,-Dr Moore suggests (Jan. 10, p. 83) that Dr Mahler’s argument (Nov. 1, p. 829) against high-technology medical care’ disregards "the needs of the sick, disabled, or elderly, for 1.

Mahler, H. Lancet, 1975, ii, 829.

On the contrary, I believe that the in regard to those groups of resources maldistribution present in the United States entirely supports Dr Mahler’s argument. Let me give three illustrations. (1.) In an emergency, the disabled elderly in Connecticut will find little or no barrier to intensive care at$200 per day; highly trained nurses and technicians will attend them (with their machinery) and physicians and specialists may visit several times a day. But as soon as they reach the barely crawling stage, the Medicare fiscal intermediary will insist on their discharge to "skilled nursing facilities", where there is minimal rehabilitative staffing, nursing by untrained aides, and where doctors visit once a month. If they fall sick again, reentry to the high-technology area is relatively easy, and it is often easier to readmit the patient than have him get slightly better and go home. (2.) Dr Moore writes that the older patient "wants, needs, and in our society will insist on receiving help." I infer, with some surprise, that in his part of New England the elderly disabled may have a real choice from among a variety of resourthe

helpful healing hand."

ces-a

friendly cooking/cleaning

woman

three times

a

week,

for life if necessary, with a home-visiting physician? Or once or twice on the round a bout of hospital intensive care? In my, less fortunate, part of New England, the choice appears to have been made by high-technology providers and a compliant fiscal system. Connecticut has hardly a voluntary hospital, small or large, that does not boast of a coronary or intensive care unit, and we may even have allowed one or two openheart teams to develop in excess of need. But rehabilitation units for the spinally damaged or the elderly are few and struggling ; day hospitals are a rarity; meals-on-wheels and home makers are fractionally available in regard to the size of community needs; and home-visiting by physicians to the disabled has almost ceased.

(3.) A man attended a medical clinic for low-income elderly. He had been admitted twice to one of our teaching hospitals for weight loss and nondescript gastrointestinal symptoms. What with two jejunal biopsies and the rest, I reckon his hospital care cost at least$6000. He was sent home to take a glutenfree diet. It took a nurse-practitioner an hour on a home visit to verify by systematic history taking and a look at his mouth that he was severely depressed, in financial distress, in semisqualor, living in an alienated relationship with a similarily affected brother, and that he lacked teeth and had a broken upper denture. I observed some petechiae and Hess’s test was positive. But it has proved awfully hard to get him meals-onwheels at$10 per week; I can get him an endoscopy or a hospital work-up any time. Unlike Dr Moore, I did not infer from Dr Mahler that the choice is between a humane caring for the chronically ill and disabled on the one hand and public-health interventions on the other. Neither are doing well at present (in the United States 18 million children are not protected from poliomyelitis) and there is no need to worsen their case by implying that they are competitive. The voracious competitor to them both is

high-cost technology, centred on the doctor-hospital complex. Even in developed countries, it is losing touch with the real biology of need. By reason of its intramural psychology, its control on education, and its autonomous costing, it curbs the invention and development of the medium and low cost technology services which are required to support the well-being of communities and the personal care of their large, needy minorities, whether they be rural villagers or urban elderly. Given infinite time and money, the doctor-hospital complex will never of its own extend outwards towards them. For it is a kind of black hole in the medicosocial sky: more resources only make it denser. Its limited but valuable potential needs, rather, to function within the strict exactions and conditions of a public and its agents who know what to expect and who will operate as brutally as Henry Ford would to factories who "volunteered" to produce front halves of Rolls-Royces but