- Email: [email protected]
REHABILITATION MEDICINE ?
1207
patients with myeloma, though with the small amount of available material and the long natural history of the disease it might be hard
to
arrive
at any
valid statistical results.
Westminster Hospital Teaching Group,
Department of Pathology, Queen Mary’s Hospital, Roehampton, London S.W.15.
J. KOHN.
ANGIOTENSIN II AND RENAL FAILURE Sm,ŇDr. Gavras and his colleagues (Oct. 2, p. 764) have misinterpreted my letter, and thus I must conclude that my thoughts were poorly expressed. I, like them, would like to incriminate the renin-angiotensin system in the pathogenesis of acute renal failure, but believe that the evidence is largely circumstantial. I have not yet had access to their papers detailing their findings, since they are still in the press. I am pleased to find, however, that they agree that .diuretics (frusemide and mannitol) are not contraindicated .and may be beneficial. I also agree that sodium depletion needs to be avoided since sodium status is an important -controller of renin release, but likewise sodium overload must be avoided as this may cause the patient to die. Thus sodium intake in human beings usually needs to be restricted, since in man the common form of renal failure is an
-oliguric one. The " protective action " of mannitol, frusemide, and sodium loading can be explained by a model in which the -stimulus for renin release is a low sodium concentration or -flux at the macula densa, and it should be emphasised that there is no direct evidence that a high sodium concen-tration or flux at that site is the stimulus as they suggest.1 The majority of the evidence suggests that renin secretion varies inversely with sodium concentration,2particularly as
.cause
1. Brown, J. J., et al. Br. med. J. 1970, i, 253. 2. Vander, A. J. Physiol. Rev. 1967, 47, 359. 3. Thurau, K., Schnermann, J. Klin. Wschr. 1965, 43, 410. 4. Gottschalk, C. W., Leysacc, P. P. Acta physiol. scand. 1968, 74, 453. 5. Morgan, T. Am. J. Physiol. 1971, 220, 186. 6. Morgan, T., Berliner, R. W. Nephron, 1969, 388. 7. Schnermann, J., et al. Pflügers Arch. ges. Physiol. 1970, 318, 147. 8. Schnermann, J., Nagel, W., Thurau, K. ibid. 1966, 287, 296. 9. Thurau, K., Dahlheim, H., Granger, P. Proc. IV int. Congr. Nephrol. 1969, 2, 24. 10. Johnston, C. I., Mendelsohn, F. A., Doyle, A. E. Unpublished. 11. Mendelsohn, F. A., Johnston, C. I. Personal communication.
fallen. The exact amount of sodium flowing to the distal nephron will depend on the interaction of the physical forces controlling proximal tubule reabsorption 12 and their effect on the percentage reabsorption of sodium by the proximal tubule. In this situation most of these forces tend to increase the percentage reabsorption from the proximal tubule and thus reduce further the delivery of sodium to the distal nephron. If a low sodium concentration or flux at the macula densa is the stimulus for renin release, a vicious cycle will be set up. Saline infusion and diuretics that depress proximal tubule reabsorption (mannitol, frusemide) interrupt this sequence of events and, provided the initial stimulus producing renal failure and renin release is no longer acting, the progression of renal failure may be aborted.
This sequence of events is as likely as that suggested by Brown et al.,l but experimental evidence is required to verify critical aspects of both hypotheses. Department of Medicine, Austin
Hospital, Heidelburg, Victoria 3084, Australia.
T. MORGAN.
REHABILITATION MEDICINE ? of the skills involved in rehabilitation of the disabled was the underlying theme in the Fourth International Seminar of the British Council for Rehabilitation of the Disabled earlier this year. More than 1200 participants from some 40 different countries sought to present their papers and orientate their discussions to the idea of rehabilitation as a unified concept, and this was emphasised by the two Ministers of the Crown who gave the opening and closing addresses. In 1967, the General Medical Council for the first time recommended that there should be a place for rehabilitation in the medical curriculum. To the best of my knowledge very little, if anything, has been done to implement that recommendation. A few years ago the University of New York announced that, because of the medical, psychological, educational, and sociological content of rehabilitation, they would no longer use the term " physical medicine " in the context of rehabilitation but would replace it with the term " rehabilitation medicine ". They offered bursaries to doctors from other countries who might wish to spend up to three years studying in Now rehabilitation medicine is receiving New York. world-wide acceptance, while in the United Kingdom, where modern rehabilitation concepts and techniques very largely originated, there is apparently a good deal of confused thinking. The onward march in world affairs is reflected in the following, which relates to a World Congress to be held in Sydney, Australia, in August, 1972:
SiR,ŇThe coordination
"
Rehabilitation Medicine is a special area of medical practice with the problems of the severely disabled and with the task of restoring them to a place of independence and dignity in society. As it becomes more established as a discipline, it is focusing attention on the need for comprehensive management in medical care, generally, and on the contribution to such care of many allied health disciplines."
traditionally concerned
12. Brenner, B.
M., Troy, J. L. J. clin. Invest. 1971, 50, 336.
1208 What steps are possible to bring the U.K. at least into line with world trends; to bring some order into thinking and practice; to establish training and education in such a way as will ensure that the disciplines have a unified concept; and to restore initiative to the medical and allied disciplines and to the associated sociological skills ? Is the answer in the establishment of a chair of rehabilitation (? medicine) in the universities-the setting up of an Institute of Rehabilitation (? medicine) ? Can we produce the sort of superman who will be at least conversant with the implications of orthopaedics, paediatrics, neurology, physical medicine and rheumatology, psychology, education and science, sociology, vocational training, &c., as to a the is rehabilitative This question applied process ? to be solved by the leaders of the Royal Colleges and Societies, and by the authorities in the seats of learning, with a willingness on the part of some to waive vested interest and to communicate freely. In the Welfare State this includes Government bodies. Few nowadays will question the desirability of promoting the economic viability of the disabled person, if only to lessen the burden on the State. Despite our shortcomings in the U.K., the world is still willing to beat a path to our door, as our last seminar revealed. How long can we expect this to continue ? Much will depend upon a coordinated policy backed by an educational programme designed to produce and place strategically those who can ensure progress in rehabilitation. IAN R. HENDERSON, Secretary General, British Council for Rehabilitation of the Disabled.
Tavistock House, London WC1H 9LB.
CLASSIFICATION OF PROTEIN-CALORIE MALNUTRITION
SIR,-Some time ago you reported a meeting at which it proposed that forms of severe protein-calorie malnutrition (P.-c.M.) should be differentiated according to weight deficit and presence or absence of cedema.1 A similar classification is proposed in the Eighth Report of the Joint was
F.A.O./W.H.O. Expert Committee on Nutrition (1971), and it is intended that it be used in the next (1975) revision of the International Classification of Diseases. The proposed classification is as follows:
several snags in this proposed method. as a reference poses problems-including of unavailability accurate age. This can be overcome by the use of an age-independent ratio, such as mid-arm/head circumference.2 More seriously, weight is affected not only by growth retardation but also by changes in body composition especially marked in kwashiorkor. There is general agreement that the severity of malnutrition 4s proportional to the weight deficit. This method confuses classification according to type (in the middle column) and severity (in the third column). It has kwashiorkor appearing to be less severe than marasmic kwashiorkor. The latter group is often referred to as intermediate forms ", and it has been shown that these cases have not only clinical features of both marasmus and kwashiorkor but also intermediate status in biochemical terms.33 The spectral concept of P.-C.M. is not reflected in the proposed classifiThere
are
Weight-for-age
"
3.
VIOLENT PARENTS SIR,-Your leader of Nov. 6 (p. 1017) again draws attention to this distressing and perplexing medicosocial problem discussed in these columns last year.7-9 Violent parents " seems to have more to commend it than " battered-baby syndrome " (the syndrome was originally focused on the multiple injuries). The baby is certainly the presenting symptom and symptomatic treatment is not enough. " Battered baby ", as you note, is useful in raising the index of suspicion, but the most difficult aspect is not that of case-finding. As a general practitioner, I am at present concerned in a situation where the baby, a dissimilar twin, her brother being male, was born to a family with three other female children. The paediatrician noted that the baby was likely to be neglected for her brother in the maternity hospital. At three months there were two admissions for vomiting, diarrhoea, and dehydration to one hospital, and then three admissions to the hospital where the total picture was by then well known. The infant is now being fostered. Though there had been previous meetings between medical and social-service departments, both kindly agreed to a further meeting with me. My concern was to review the contacts between the various agencies and individuals involved and to clarify what further contribution might have been possible from the family-doctor angle. Explicitly or implicitly, psychopathological theory pervades all such discussions, yet it seems more useful to deal with those aspects of the situation which are in the hands of those in contact with the family. In other words, what are the possibilities and limitations for the family doctor ? Might the hospital be used in more than a curative role for the infant ? In retrospect it is easy to see what might have been -done by oneself or others, but there is no obvious drill. Certainly when a situation deteriorates a reappraisal is essential-with the formulation of possible interim goals. The matter of " case conferences " is yet another issue for both doctors and social workers. Conferences are apt to be uneconomical in time and must have well-defined aims for different occasions. Are they decision making, information passing, professional exchange and training ? More attention to simple management and administration might "
make 4.
proposed,2
6.
Lancet, 1970, ii, 302. Kanawati, A. A., McLaren, D. S. Nature, 1970, 228, 573. McLaren, D. S., Pellett, P. L., Read, W. W. C. Lancet, 1967, i, 533.
7. 8. 9.
Simple Scoring System
which
we
subsequent discussion of the
Schendel,
H.
more
speculative prob-
E., Hansen, J. D. L., Brock, J. F. S. Afr. J. Lab. clin.
Med. 1962, 8, 23. 5. Whitehead, R. G., Frood,
2
cation. The 1. 2.
based on 4 clinical signs and plasma-albumin, does not correlate at all with the classification related to weight. In our series there was no significant difference in % weightfor-age in the three groups (marasmus 52-5%, marasmic kwashiorkor 54-7%, and kwashiorkor 51-6%). Although a number of workers have reported the value of our system, we would like to see its trial sponsored internationally. It is the most objective, simple means of distinguishing the severe forms of P.-c.M. Other workers have also emphasised the value of plasma-albumin.4,5 Simple micromethods are available for direct estimation of albumin without involving electrophoresis and total protein. 5,6Is it too much to expect that plasma-albumin standards be accepted internationally in the classification of P.-C.M., in the same way as haemoglobin standards are for anxmia ? American University of Beirut, D. S. MCLAREN. Lebanon.
J. D. L., Poskitt, E. M. E. Lancet, Aug. 7, 1971, p. 287. Doumas, B. T., Watson, W. A., Briggs, H. G. Clinica chim. Acta, 1971, 31, 87. Gans, B. Lancet, 1970, i, 1286. Pugh, R. J. ibid. 1970, ii, 466. Barnett, B. ibid. p. 567.
patients with myeloma, though with the small amount of available material and the long natural history of the disease it might be hard
to
arrive
at any
valid statistical results.
Westminster Hospital Teaching Group,
Department of Pathology, Queen Mary’s Hospital, Roehampton, London S.W.15.
J. KOHN.
ANGIOTENSIN II AND RENAL FAILURE Sm,ŇDr. Gavras and his colleagues (Oct. 2, p. 764) have misinterpreted my letter, and thus I must conclude that my thoughts were poorly expressed. I, like them, would like to incriminate the renin-angiotensin system in the pathogenesis of acute renal failure, but believe that the evidence is largely circumstantial. I have not yet had access to their papers detailing their findings, since they are still in the press. I am pleased to find, however, that they agree that .diuretics (frusemide and mannitol) are not contraindicated .and may be beneficial. I also agree that sodium depletion needs to be avoided since sodium status is an important -controller of renin release, but likewise sodium overload must be avoided as this may cause the patient to die. Thus sodium intake in human beings usually needs to be restricted, since in man the common form of renal failure is an
-oliguric one. The " protective action " of mannitol, frusemide, and sodium loading can be explained by a model in which the -stimulus for renin release is a low sodium concentration or -flux at the macula densa, and it should be emphasised that there is no direct evidence that a high sodium concen-tration or flux at that site is the stimulus as they suggest.1 The majority of the evidence suggests that renin secretion varies inversely with sodium concentration,2particularly as
.cause
1. Brown, J. J., et al. Br. med. J. 1970, i, 253. 2. Vander, A. J. Physiol. Rev. 1967, 47, 359. 3. Thurau, K., Schnermann, J. Klin. Wschr. 1965, 43, 410. 4. Gottschalk, C. W., Leysacc, P. P. Acta physiol. scand. 1968, 74, 453. 5. Morgan, T. Am. J. Physiol. 1971, 220, 186. 6. Morgan, T., Berliner, R. W. Nephron, 1969, 388. 7. Schnermann, J., et al. Pflügers Arch. ges. Physiol. 1970, 318, 147. 8. Schnermann, J., Nagel, W., Thurau, K. ibid. 1966, 287, 296. 9. Thurau, K., Dahlheim, H., Granger, P. Proc. IV int. Congr. Nephrol. 1969, 2, 24. 10. Johnston, C. I., Mendelsohn, F. A., Doyle, A. E. Unpublished. 11. Mendelsohn, F. A., Johnston, C. I. Personal communication.
fallen. The exact amount of sodium flowing to the distal nephron will depend on the interaction of the physical forces controlling proximal tubule reabsorption 12 and their effect on the percentage reabsorption of sodium by the proximal tubule. In this situation most of these forces tend to increase the percentage reabsorption from the proximal tubule and thus reduce further the delivery of sodium to the distal nephron. If a low sodium concentration or flux at the macula densa is the stimulus for renin release, a vicious cycle will be set up. Saline infusion and diuretics that depress proximal tubule reabsorption (mannitol, frusemide) interrupt this sequence of events and, provided the initial stimulus producing renal failure and renin release is no longer acting, the progression of renal failure may be aborted.
This sequence of events is as likely as that suggested by Brown et al.,l but experimental evidence is required to verify critical aspects of both hypotheses. Department of Medicine, Austin
Hospital, Heidelburg, Victoria 3084, Australia.
T. MORGAN.
REHABILITATION MEDICINE ? of the skills involved in rehabilitation of the disabled was the underlying theme in the Fourth International Seminar of the British Council for Rehabilitation of the Disabled earlier this year. More than 1200 participants from some 40 different countries sought to present their papers and orientate their discussions to the idea of rehabilitation as a unified concept, and this was emphasised by the two Ministers of the Crown who gave the opening and closing addresses. In 1967, the General Medical Council for the first time recommended that there should be a place for rehabilitation in the medical curriculum. To the best of my knowledge very little, if anything, has been done to implement that recommendation. A few years ago the University of New York announced that, because of the medical, psychological, educational, and sociological content of rehabilitation, they would no longer use the term " physical medicine " in the context of rehabilitation but would replace it with the term " rehabilitation medicine ". They offered bursaries to doctors from other countries who might wish to spend up to three years studying in Now rehabilitation medicine is receiving New York. world-wide acceptance, while in the United Kingdom, where modern rehabilitation concepts and techniques very largely originated, there is apparently a good deal of confused thinking. The onward march in world affairs is reflected in the following, which relates to a World Congress to be held in Sydney, Australia, in August, 1972:
SiR,ŇThe coordination
"
Rehabilitation Medicine is a special area of medical practice with the problems of the severely disabled and with the task of restoring them to a place of independence and dignity in society. As it becomes more established as a discipline, it is focusing attention on the need for comprehensive management in medical care, generally, and on the contribution to such care of many allied health disciplines."
traditionally concerned
12. Brenner, B.
M., Troy, J. L. J. clin. Invest. 1971, 50, 336.
1208 What steps are possible to bring the U.K. at least into line with world trends; to bring some order into thinking and practice; to establish training and education in such a way as will ensure that the disciplines have a unified concept; and to restore initiative to the medical and allied disciplines and to the associated sociological skills ? Is the answer in the establishment of a chair of rehabilitation (? medicine) in the universities-the setting up of an Institute of Rehabilitation (? medicine) ? Can we produce the sort of superman who will be at least conversant with the implications of orthopaedics, paediatrics, neurology, physical medicine and rheumatology, psychology, education and science, sociology, vocational training, &c., as to a the is rehabilitative This question applied process ? to be solved by the leaders of the Royal Colleges and Societies, and by the authorities in the seats of learning, with a willingness on the part of some to waive vested interest and to communicate freely. In the Welfare State this includes Government bodies. Few nowadays will question the desirability of promoting the economic viability of the disabled person, if only to lessen the burden on the State. Despite our shortcomings in the U.K., the world is still willing to beat a path to our door, as our last seminar revealed. How long can we expect this to continue ? Much will depend upon a coordinated policy backed by an educational programme designed to produce and place strategically those who can ensure progress in rehabilitation. IAN R. HENDERSON, Secretary General, British Council for Rehabilitation of the Disabled.
Tavistock House, London WC1H 9LB.
CLASSIFICATION OF PROTEIN-CALORIE MALNUTRITION
SIR,-Some time ago you reported a meeting at which it proposed that forms of severe protein-calorie malnutrition (P.-c.M.) should be differentiated according to weight deficit and presence or absence of cedema.1 A similar classification is proposed in the Eighth Report of the Joint was
F.A.O./W.H.O. Expert Committee on Nutrition (1971), and it is intended that it be used in the next (1975) revision of the International Classification of Diseases. The proposed classification is as follows:
several snags in this proposed method. as a reference poses problems-including of unavailability accurate age. This can be overcome by the use of an age-independent ratio, such as mid-arm/head circumference.2 More seriously, weight is affected not only by growth retardation but also by changes in body composition especially marked in kwashiorkor. There is general agreement that the severity of malnutrition 4s proportional to the weight deficit. This method confuses classification according to type (in the middle column) and severity (in the third column). It has kwashiorkor appearing to be less severe than marasmic kwashiorkor. The latter group is often referred to as intermediate forms ", and it has been shown that these cases have not only clinical features of both marasmus and kwashiorkor but also intermediate status in biochemical terms.33 The spectral concept of P.-C.M. is not reflected in the proposed classifiThere
are
Weight-for-age
"
3.
VIOLENT PARENTS SIR,-Your leader of Nov. 6 (p. 1017) again draws attention to this distressing and perplexing medicosocial problem discussed in these columns last year.7-9 Violent parents " seems to have more to commend it than " battered-baby syndrome " (the syndrome was originally focused on the multiple injuries). The baby is certainly the presenting symptom and symptomatic treatment is not enough. " Battered baby ", as you note, is useful in raising the index of suspicion, but the most difficult aspect is not that of case-finding. As a general practitioner, I am at present concerned in a situation where the baby, a dissimilar twin, her brother being male, was born to a family with three other female children. The paediatrician noted that the baby was likely to be neglected for her brother in the maternity hospital. At three months there were two admissions for vomiting, diarrhoea, and dehydration to one hospital, and then three admissions to the hospital where the total picture was by then well known. The infant is now being fostered. Though there had been previous meetings between medical and social-service departments, both kindly agreed to a further meeting with me. My concern was to review the contacts between the various agencies and individuals involved and to clarify what further contribution might have been possible from the family-doctor angle. Explicitly or implicitly, psychopathological theory pervades all such discussions, yet it seems more useful to deal with those aspects of the situation which are in the hands of those in contact with the family. In other words, what are the possibilities and limitations for the family doctor ? Might the hospital be used in more than a curative role for the infant ? In retrospect it is easy to see what might have been -done by oneself or others, but there is no obvious drill. Certainly when a situation deteriorates a reappraisal is essential-with the formulation of possible interim goals. The matter of " case conferences " is yet another issue for both doctors and social workers. Conferences are apt to be uneconomical in time and must have well-defined aims for different occasions. Are they decision making, information passing, professional exchange and training ? More attention to simple management and administration might "
make 4.
proposed,2
6.
Lancet, 1970, ii, 302. Kanawati, A. A., McLaren, D. S. Nature, 1970, 228, 573. McLaren, D. S., Pellett, P. L., Read, W. W. C. Lancet, 1967, i, 533.
7. 8. 9.
Simple Scoring System
which
we
subsequent discussion of the
Schendel,
H.
more
speculative prob-
E., Hansen, J. D. L., Brock, J. F. S. Afr. J. Lab. clin.
Med. 1962, 8, 23. 5. Whitehead, R. G., Frood,
2
cation. The 1. 2.
based on 4 clinical signs and plasma-albumin, does not correlate at all with the classification related to weight. In our series there was no significant difference in % weightfor-age in the three groups (marasmus 52-5%, marasmic kwashiorkor 54-7%, and kwashiorkor 51-6%). Although a number of workers have reported the value of our system, we would like to see its trial sponsored internationally. It is the most objective, simple means of distinguishing the severe forms of P.-c.M. Other workers have also emphasised the value of plasma-albumin.4,5 Simple micromethods are available for direct estimation of albumin without involving electrophoresis and total protein. 5,6Is it too much to expect that plasma-albumin standards be accepted internationally in the classification of P.-C.M., in the same way as haemoglobin standards are for anxmia ? American University of Beirut, D. S. MCLAREN. Lebanon.
J. D. L., Poskitt, E. M. E. Lancet, Aug. 7, 1971, p. 287. Doumas, B. T., Watson, W. A., Briggs, H. G. Clinica chim. Acta, 1971, 31, 87. Gans, B. Lancet, 1970, i, 1286. Pugh, R. J. ibid. 1970, ii, 466. Barnett, B. ibid. p. 567.