- Email: [email protected]
PLANS FOR NEW PSYCHIATRIC UNITS
94 whole of medical education. Even the specialist confined in a laboratory needs an understanding of the social impact of his work on the patient. The logistics of time, stage, and who shall teach must be discussed. It is essential that a knowledge of the behavioural sciences should be included in the curriculum. I do not think many of the present medical teachers are capable of this task. G.P.s have the widest field experience, but few are sited where they would be available for formal undergraduate teaching. Professional students of behaviour need re-educating in the relevant to medicine, but I application of their knowledge abhor the idea of a " specialist in medical sociology ". Selection of teachers is difficult, and good ones appear more by accident than design. Educational theorists have not had much practical success in the application of their techniques to the selection of medical teachers. Paradoxically, it is in the field of postgraduate training for general practice that selection and training of teachers, as opposed to appointment on purely academic grounds, is making most progress. The undergraduate is thrown to the wolves, while the trainee G.P. has his teachers selected, and taught how to do it. 114 Newport Road, Cardiff CF2 1YT.
H. CAIRNS.
TRANSMISSIBILITY OF HUMAN MYELOMATOSIS
SiR,—The article by Dr. Mitchell and colleagues (Nov. 6, 1971) concluded that multiple myeloma is possibly a transmissible disease, based on data obtained from brokencell filtrates. The cells featured in figs. 1 and 3, labelled as plasma cells, look identical to me, and I doubt whether they are of different origin. Chromosomal study probably would solve the mystery; such a study should be performed to identify whether the cells in question are of human or murine origin.1 Department of Medicine B, Roswell Park Memorial Institute. Buffalo, New York 14203, U.S.A.
by the Hoechst immunodiffusion technique 6) was serum. One possibility might be that during the initial period in which the injected human myeloma cells persist, an infection of mouse hasmopoietic stem cells takes place and that a proportion of the primitive malignant cells of mouse origin which arise thereafter are enabled to produce human immunoglobulin. found in the
M.R.C. Tuberculosis and Chest Diseases Unit,
Brompton Hospital, Road, London S.W.3.
Fulham
SIR,-We completely agree with Dr. Chang that the cells seen in mouse spleens (figs. 2 and 3) appear identical to those from the human donor (fig. 1). We are undertaking cytogenetic studies (chromosome cultures, histocompatibility tests, tests for the presence of cytoplasmic antibodies, and electron-microscope studies) of affected mouse tissues. However, with regard to the chromosomal study proposed by Dr. Chang it is recognised that definitive results might not be obtained in an experimental hybrid situation and studies to detect human chromatin material by a quinacrine fluorescence3 or similar method4 are also required. Moreover, the presence of human chromatin in cells harvested from mice only a short period after injection of human donor cells would be no certain indication of the growth of human cells in the mouse. Conversely, it seems unlikely that cells harvested from mice receiving broken-cell filtrates could be of human origin, as suggested by Dr. Chang. The cells featured in figs. 2 and 3 of our paper5 (plasma and large primitive myeloma-like cells with mitotic figures) were harvested from the spleens of mice receiving intact human marrow cells and broken mouse marrow and spleen cells, respectively, and in each case human IgG (as deterSandberg, A. A., Hosfeld, D. Ann. Rev. Med. 1970, 21, 379. Harris, H., Klein, G. Nature, 1969, 224, 1315. Borgaonkar, D. S., Hollander, D. H. ibid. 1971, 230, 52. Drets, M. E., Shaw, M. W. Proc. natn. Acad. Sci. 1971, 68, 2073. Mitchell, D. N., Rees, R. J. W., Salsbury, A. J. Lancet, 1971, ii, 1009
D. N. MITCHELL R. J. W. REES A. J. SALSBURY.
TREATMENT OF THE CHILD AT HOME
SIR,-Your review (Dec. 25, p. 1405) of my book is unfair in three of its five specific criticisms. Firstly, it makes the common mistake of taking a sentence out of its context and then attacking it. You criticise " " me for saying that overfeeding is a myth without saying I that was referring to breast-fed babies only. How many examples of overfeeding have you seen in fully breast-fed babies in well-baby clinics in the past year, and how do you treat them ? In my experience it is very rare for a young breast-fed baby to be overfed. " Secondly, you criticise me for treating evening colic with a symptomatic drug instead of treating the cause ". As no-one knows the cause of evening colic, it is impossible for anyone knowingly to treat the cause. Long experience and a blind trial has indicated that the anti-cholinergic drug recommended is highly successful if the diagnosis is correct.
Thirdly, the criticism that I advise that children with an anal fissure, without proper medical treatment, should be referred to a surgeon, is incorrect, as you will see if you read what I wrote. I am grateful to you for drawing my attention to my failure to discuss the treatment of wheezing due to causes other than asthma. Department of Child Health, University of Sheffield,
TSE-CHIANG CHANG.
** * We showed Dr. Tse-Chiang Chang’s letter to Dr. Mitchell and his colleagues and their reply follows.-ED. L.
1. 2. 3. 4. 5.
mined
The Children’s Hospital, Western Bank, Sheffield S10 2TH.
R. S. ILLINGWORTH.
*** The review of Professor Illingworth’s book ended: Though a few rarities and lists might have been omitted, this small book is a distillation of sensible, practical, and "
balanced advice."-ED. L.
PLANS FOR NEW PSYCHIATRIC UNITS
SiR,—I write in support of Dr. Crocket (Dec. 18,
1373) and his plea to reconsider serious defects in plans for new psychiatric units being built in association with district general hospitals. No-one is likely to build a surgical ward without an associated operating-theatre, or an accident unit without X-ray facilities, but it is not generally
p.
realised that rooms for individual and group interviews are just as essential in psychiatric treatment. I have had the fortune to be able to visit a number of new psychiatric units under the auspices of the Walter Dixon research award of the British Medical Association, and hope to publish observations on these units in the near future. In brief, there are obvious deficiencies in terms of those facilities which Dr. Crocket mentions, and also a great lack of adequate space for various types of occupational
therapy. His second point concerns the division of clinic:’ responsibility between inpatients and day-patients. In my opinion the concept of the separate day hospital is 6. Hoechst: Pamphlet entitled " Partigen immunodiffusion plates for the Quantitative Determination of the Immunoglobulins, IgG. IgA and IgM ". 1971.
95 outmoded treatment and an
one.
In any hospital, there should be a area for patients, consisting of day-
living dining-room, occupational-therapy rooms, interview-rooms, &c., in which patients spend all their time from 8 A.M. to 10 or 11 P.M. Some patients will then retire to bed in dormitory accommodation within the hospital, while others will return to their own homes. Furthermore, certain patients may go home at 5 P.M., while other patients will come into the hospital from -5 P.M. for the evening or may require to stay overnight. Thus, there would be complete flexibility in the use of accommodation according to needs of individual patients. Overall care would be the responsibility of a single psychiatric team responsible for the catchment area in which the patient lives, and there would be no need for transfer from outpatient to inpatient to day-patient under separate doctors and nurses when there were changes in the patient’s condition.
rooms,
University Department of Psychiatry, Whiteley Wood Clinic, Woofindin Road, Sheffield 10.
C. P. SEAGER.
SIR,-There have been reports 1-3 suggesting that the concept that the mixed lymphocyte reaction (M.L.R.) expresses solely differences at the HL-A locus may have to be modified. Your editorial implied that the hypothesis of an independent M.L.R. locus (on the same chromosome as the HL-A locus) would be strengthened if HL-A non-identical, non-reacting pairs could be found. During the study of the M.L.R. using lymphocytes from normal people and from patients with chronic lymphocytic leukaemia,5 the cells of two normal unrelated people failed to react in spite of being HL-A non-identical: HL-A8, W5
belonged to group A and their lymphocytes responded normally to phytohaemagglutinin. The results of the M.L.R. were assessed both in terms of uptake of tritiated thymidine and morphological transformation. To exclude a technical error the test was repeated and the lymphocytes were again found to be non-reactive. Further details will be published in due course. Both donors
Department of Clinical Research, The Royal Marsden Hospital and The Institute of Cancer Research, Fulham Road, London S.W.3.
C. R. PENTYCROSS P. T. KLOUDA SYLVIA D. LAWLER.
SIR,-Dr. Koch and colleagues, (Dec. 18, quote their
p.
1334)
and other findings relating to a mixed lymphocyte culture (M.L.C.) locus separate from that for HL-A. In particular, it is thought that stimulation in M.L.C. between identical siblings supports the existence of such a locus. We have been studying HL-A influences in human pregnancy. In genetically identical HL-A mother x cord pairs, M.L.R.s have shown positive responses. One would expect less difference in the HL-A molecules in these combinations, and these findings at present are better explained by a separate M.L.C. locus. own
Department of Obstetrics and Gynæcology, University of Leeds, 17 Springfield Mount, Leeds LS2 9NG.
DAVID M.
JENKINS.
Johnston, J. M., Bashir, H. V. Br. med. J. 1971, iv, 581. Koch, C. T., Eysvoogel, V. P., Frederiks, E., Van Rood, J. J. Lancet, 1971, ii, 1334. 3. Dupont, B., Staub Nielson, L., Svejgaard, A. ibid. p. 1336. 4. ibid. p. 1362. 5. Pentycross, C. R. Unpublished. 1. 2.
logical disturbances in a proper manner. With rare exceptions, the direct estimation of hormones in this country is performed only when research funds are available. The only outstanding exception is the estimation of plasmacortisol. Otherwise, renin, angiotensin, adrenaline, noradrenaline, insulin, parathormone, thyroxine, secretin, aldosterone, testosterone, A.D.H., growth hormone, corticotrophin (A.C.T.H.), F.S.H., T.S.H., L.H., oxytocin, oestriol cestradiol, oestrone, progesterone, and pregnantriol can be performed only if the particular research worker has the time to fit in an estimation between his requirements for research. The gap therefore between what is possible and what is available as regards endocrinology is discouragingly wide. One enormous field where this is particularly relevant is hypertension. We would suggest that the Department of Health should convene a meeting of clinicians and pathologists to delineate the need and decide how this deficiency could be remedied. Department of Medicine, King’s College Hospital Medical School, Denmark Hill, London S.E.5.
THE HL-A SYSTEM AND THE MIXED LYMPHOCYTE REACTION
Donor 1: HL-A1, HL-A9, Donor 2: W19, HL-A12
INVESTIGATION AND TREATMENT OF ENDOCRINOLOGICAL DISORDERS SIR,-Many of us are increasingly worried that we cannot investigate and treat patients who suffer from endocrino-
Fulham Hospital, St. Dunstan’s Road, London W.6.
Department of Medicine, Manchester Royal Infirmary, Manchester.
JOHN ANDERSON. K. D. BAGSHAWE.
D. A. K. BLACK.
Department of Medicine, St. Thomas’s Hospital Medical School, London S.E.1.
Charing Cross Hospital, London W.C.2. Unit, The London Hospital, Whitechapel, London E1 1BB.
W. I. CRANSTON. P. B. S. FOWLER.
Medical
J.
M. LEDINGHAM.
Department of Physiology, Charing Cross Hospital Medical School, 62 Chandos Place, London W.C.2.
J. LEE.
Department of Obstetrics and Gynæcology, Charing Cross Hospital Medical School,
N. MORRIS.
London W.C.2. Westminster Hospital Medical School, London S.W.1.
Department of Medicine, Charing Cross Hospital Medical School, Fulham Hospital, London W.6. H. E.
M. D. MILNE.
DE
WARDENER.
Department of Medicine, University of Dundee, Dundee.
O. M. WRONG.
Fulham Hospital, St. Dunstan’s Road, London W.6.
A. L. WYMAN.
INTRACATH IN SUPRAPUBIC CYSTOSTOMY
SiR,—Ishould like to comment on the views of Professor Tinckler (Dec. 25, p. 1422) in response to my letter of Nov. 20 (p. 1160). I do not dispute the value of his self-retaining catheter with trocar and split cannula, but I feel that the whole procedure would be no different from the conventional suprapubic cystostomy with trocar, cannula, and indwelling catheter apart from the fact that those are disposable. This method is certainly an advantage for longstanding suprapubic drainage where there are indications for retaining the catheter for more than 48 ’ Intracath ’, however, is convenient and hours or so. useful in conditions requiring drainage for a short period or emergency release after unsuccessful transurethral catheterisation in order to minimise trauma to the urethra and avoid introducing infection into the bladder. So far
H. CAIRNS.
TRANSMISSIBILITY OF HUMAN MYELOMATOSIS
SiR,—The article by Dr. Mitchell and colleagues (Nov. 6, 1971) concluded that multiple myeloma is possibly a transmissible disease, based on data obtained from brokencell filtrates. The cells featured in figs. 1 and 3, labelled as plasma cells, look identical to me, and I doubt whether they are of different origin. Chromosomal study probably would solve the mystery; such a study should be performed to identify whether the cells in question are of human or murine origin.1 Department of Medicine B, Roswell Park Memorial Institute. Buffalo, New York 14203, U.S.A.
by the Hoechst immunodiffusion technique 6) was serum. One possibility might be that during the initial period in which the injected human myeloma cells persist, an infection of mouse hasmopoietic stem cells takes place and that a proportion of the primitive malignant cells of mouse origin which arise thereafter are enabled to produce human immunoglobulin. found in the
M.R.C. Tuberculosis and Chest Diseases Unit,
Brompton Hospital, Road, London S.W.3.
Fulham
SIR,-We completely agree with Dr. Chang that the cells seen in mouse spleens (figs. 2 and 3) appear identical to those from the human donor (fig. 1). We are undertaking cytogenetic studies (chromosome cultures, histocompatibility tests, tests for the presence of cytoplasmic antibodies, and electron-microscope studies) of affected mouse tissues. However, with regard to the chromosomal study proposed by Dr. Chang it is recognised that definitive results might not be obtained in an experimental hybrid situation and studies to detect human chromatin material by a quinacrine fluorescence3 or similar method4 are also required. Moreover, the presence of human chromatin in cells harvested from mice only a short period after injection of human donor cells would be no certain indication of the growth of human cells in the mouse. Conversely, it seems unlikely that cells harvested from mice receiving broken-cell filtrates could be of human origin, as suggested by Dr. Chang. The cells featured in figs. 2 and 3 of our paper5 (plasma and large primitive myeloma-like cells with mitotic figures) were harvested from the spleens of mice receiving intact human marrow cells and broken mouse marrow and spleen cells, respectively, and in each case human IgG (as deterSandberg, A. A., Hosfeld, D. Ann. Rev. Med. 1970, 21, 379. Harris, H., Klein, G. Nature, 1969, 224, 1315. Borgaonkar, D. S., Hollander, D. H. ibid. 1971, 230, 52. Drets, M. E., Shaw, M. W. Proc. natn. Acad. Sci. 1971, 68, 2073. Mitchell, D. N., Rees, R. J. W., Salsbury, A. J. Lancet, 1971, ii, 1009
D. N. MITCHELL R. J. W. REES A. J. SALSBURY.
TREATMENT OF THE CHILD AT HOME
SIR,-Your review (Dec. 25, p. 1405) of my book is unfair in three of its five specific criticisms. Firstly, it makes the common mistake of taking a sentence out of its context and then attacking it. You criticise " " me for saying that overfeeding is a myth without saying I that was referring to breast-fed babies only. How many examples of overfeeding have you seen in fully breast-fed babies in well-baby clinics in the past year, and how do you treat them ? In my experience it is very rare for a young breast-fed baby to be overfed. " Secondly, you criticise me for treating evening colic with a symptomatic drug instead of treating the cause ". As no-one knows the cause of evening colic, it is impossible for anyone knowingly to treat the cause. Long experience and a blind trial has indicated that the anti-cholinergic drug recommended is highly successful if the diagnosis is correct.
Thirdly, the criticism that I advise that children with an anal fissure, without proper medical treatment, should be referred to a surgeon, is incorrect, as you will see if you read what I wrote. I am grateful to you for drawing my attention to my failure to discuss the treatment of wheezing due to causes other than asthma. Department of Child Health, University of Sheffield,
TSE-CHIANG CHANG.
** * We showed Dr. Tse-Chiang Chang’s letter to Dr. Mitchell and his colleagues and their reply follows.-ED. L.
1. 2. 3. 4. 5.
mined
The Children’s Hospital, Western Bank, Sheffield S10 2TH.
R. S. ILLINGWORTH.
*** The review of Professor Illingworth’s book ended: Though a few rarities and lists might have been omitted, this small book is a distillation of sensible, practical, and "
balanced advice."-ED. L.
PLANS FOR NEW PSYCHIATRIC UNITS
SiR,—I write in support of Dr. Crocket (Dec. 18,
1373) and his plea to reconsider serious defects in plans for new psychiatric units being built in association with district general hospitals. No-one is likely to build a surgical ward without an associated operating-theatre, or an accident unit without X-ray facilities, but it is not generally
p.
realised that rooms for individual and group interviews are just as essential in psychiatric treatment. I have had the fortune to be able to visit a number of new psychiatric units under the auspices of the Walter Dixon research award of the British Medical Association, and hope to publish observations on these units in the near future. In brief, there are obvious deficiencies in terms of those facilities which Dr. Crocket mentions, and also a great lack of adequate space for various types of occupational
therapy. His second point concerns the division of clinic:’ responsibility between inpatients and day-patients. In my opinion the concept of the separate day hospital is 6. Hoechst: Pamphlet entitled " Partigen immunodiffusion plates for the Quantitative Determination of the Immunoglobulins, IgG. IgA and IgM ". 1971.
95 outmoded treatment and an
one.
In any hospital, there should be a area for patients, consisting of day-
living dining-room, occupational-therapy rooms, interview-rooms, &c., in which patients spend all their time from 8 A.M. to 10 or 11 P.M. Some patients will then retire to bed in dormitory accommodation within the hospital, while others will return to their own homes. Furthermore, certain patients may go home at 5 P.M., while other patients will come into the hospital from -5 P.M. for the evening or may require to stay overnight. Thus, there would be complete flexibility in the use of accommodation according to needs of individual patients. Overall care would be the responsibility of a single psychiatric team responsible for the catchment area in which the patient lives, and there would be no need for transfer from outpatient to inpatient to day-patient under separate doctors and nurses when there were changes in the patient’s condition.
rooms,
University Department of Psychiatry, Whiteley Wood Clinic, Woofindin Road, Sheffield 10.
C. P. SEAGER.
SIR,-There have been reports 1-3 suggesting that the concept that the mixed lymphocyte reaction (M.L.R.) expresses solely differences at the HL-A locus may have to be modified. Your editorial implied that the hypothesis of an independent M.L.R. locus (on the same chromosome as the HL-A locus) would be strengthened if HL-A non-identical, non-reacting pairs could be found. During the study of the M.L.R. using lymphocytes from normal people and from patients with chronic lymphocytic leukaemia,5 the cells of two normal unrelated people failed to react in spite of being HL-A non-identical: HL-A8, W5
belonged to group A and their lymphocytes responded normally to phytohaemagglutinin. The results of the M.L.R. were assessed both in terms of uptake of tritiated thymidine and morphological transformation. To exclude a technical error the test was repeated and the lymphocytes were again found to be non-reactive. Further details will be published in due course. Both donors
Department of Clinical Research, The Royal Marsden Hospital and The Institute of Cancer Research, Fulham Road, London S.W.3.
C. R. PENTYCROSS P. T. KLOUDA SYLVIA D. LAWLER.
SIR,-Dr. Koch and colleagues, (Dec. 18, quote their
p.
1334)
and other findings relating to a mixed lymphocyte culture (M.L.C.) locus separate from that for HL-A. In particular, it is thought that stimulation in M.L.C. between identical siblings supports the existence of such a locus. We have been studying HL-A influences in human pregnancy. In genetically identical HL-A mother x cord pairs, M.L.R.s have shown positive responses. One would expect less difference in the HL-A molecules in these combinations, and these findings at present are better explained by a separate M.L.C. locus. own
Department of Obstetrics and Gynæcology, University of Leeds, 17 Springfield Mount, Leeds LS2 9NG.
DAVID M.
JENKINS.
Johnston, J. M., Bashir, H. V. Br. med. J. 1971, iv, 581. Koch, C. T., Eysvoogel, V. P., Frederiks, E., Van Rood, J. J. Lancet, 1971, ii, 1334. 3. Dupont, B., Staub Nielson, L., Svejgaard, A. ibid. p. 1336. 4. ibid. p. 1362. 5. Pentycross, C. R. Unpublished. 1. 2.
logical disturbances in a proper manner. With rare exceptions, the direct estimation of hormones in this country is performed only when research funds are available. The only outstanding exception is the estimation of plasmacortisol. Otherwise, renin, angiotensin, adrenaline, noradrenaline, insulin, parathormone, thyroxine, secretin, aldosterone, testosterone, A.D.H., growth hormone, corticotrophin (A.C.T.H.), F.S.H., T.S.H., L.H., oxytocin, oestriol cestradiol, oestrone, progesterone, and pregnantriol can be performed only if the particular research worker has the time to fit in an estimation between his requirements for research. The gap therefore between what is possible and what is available as regards endocrinology is discouragingly wide. One enormous field where this is particularly relevant is hypertension. We would suggest that the Department of Health should convene a meeting of clinicians and pathologists to delineate the need and decide how this deficiency could be remedied. Department of Medicine, King’s College Hospital Medical School, Denmark Hill, London S.E.5.
THE HL-A SYSTEM AND THE MIXED LYMPHOCYTE REACTION
Donor 1: HL-A1, HL-A9, Donor 2: W19, HL-A12
INVESTIGATION AND TREATMENT OF ENDOCRINOLOGICAL DISORDERS SIR,-Many of us are increasingly worried that we cannot investigate and treat patients who suffer from endocrino-
Fulham Hospital, St. Dunstan’s Road, London W.6.
Department of Medicine, Manchester Royal Infirmary, Manchester.
JOHN ANDERSON. K. D. BAGSHAWE.
D. A. K. BLACK.
Department of Medicine, St. Thomas’s Hospital Medical School, London S.E.1.
Charing Cross Hospital, London W.C.2. Unit, The London Hospital, Whitechapel, London E1 1BB.
W. I. CRANSTON. P. B. S. FOWLER.
Medical
J.
M. LEDINGHAM.
Department of Physiology, Charing Cross Hospital Medical School, 62 Chandos Place, London W.C.2.
J. LEE.
Department of Obstetrics and Gynæcology, Charing Cross Hospital Medical School,
N. MORRIS.
London W.C.2. Westminster Hospital Medical School, London S.W.1.
Department of Medicine, Charing Cross Hospital Medical School, Fulham Hospital, London W.6. H. E.
M. D. MILNE.
DE
WARDENER.
Department of Medicine, University of Dundee, Dundee.
O. M. WRONG.
Fulham Hospital, St. Dunstan’s Road, London W.6.
A. L. WYMAN.
INTRACATH IN SUPRAPUBIC CYSTOSTOMY
SiR,—Ishould like to comment on the views of Professor Tinckler (Dec. 25, p. 1422) in response to my letter of Nov. 20 (p. 1160). I do not dispute the value of his self-retaining catheter with trocar and split cannula, but I feel that the whole procedure would be no different from the conventional suprapubic cystostomy with trocar, cannula, and indwelling catheter apart from the fact that those are disposable. This method is certainly an advantage for longstanding suprapubic drainage where there are indications for retaining the catheter for more than 48 ’ Intracath ’, however, is convenient and hours or so. useful in conditions requiring drainage for a short period or emergency release after unsuccessful transurethral catheterisation in order to minimise trauma to the urethra and avoid introducing infection into the bladder. So far