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STRIÆ GRAVIDARUM
924 STRIÆ GRAVIDARUM
Letters
to
the Editor
CYTOMEGALOVIRUS INFECTION IN UTERO
SiR,—Idisagree with some of the comments of my distinguished friend, Dr Joseph Pagano, and his colleague, Dr Huang (Feb. 23, p. 316), concerning the cytomegalovirus (c.M.v.) inoculations performed by Professor Elek and Professor Stern (Jan. 5, p. 1). The technical caveats raised by them are well taken and I am sure that Professor Elek and Professor Stern will use cell-free virus and better methods of antibody measurement in the future. Their results are not less interesting because of these limitations in their methodology. Nor does the possibility that there are better antigens than strain AD-169 render the results of Elek and Stern invalid, for at some point we must find out directly whether C.M.v. strains cross-protect. Development of several strains for use in man will provide the answer to this
SIR,-Although more specific methods of measuring strix1 may prove to be helpful in elucidating their cause, I believe that more attention should be paid to the composition of skin itself. Most approaches to the study of stride 2-4 have examined certain endocrine and physical stresses upon the skin without commenting on the individual variations in skin composition. Even gross inspection reveals considerable differences in thickness, laxity, elasticity, and texture of the skin among individuals and in different parts of the body in the It is my clinical impression that strix same person. more are frequent and more extensive in women gravidarum with fine skin. There is probably a significant hereditary component to stria:. Saint Francis Hospital, 2260 Liliha Street,
Honolulu, Hawaii 96817, U.S.A.
GERIATRICS IS MEDICINE
question. Dr Pagano and Dr Huang raise three substantive considerations concerning c.Nt.v, inoculation: persistence, oncogenicity, and attenuation. They ask for the evidence that reactivation of attenuated virus would not be more serious than reactivation of wild virus. I would ask, on the contrary, why should one believe that reactivation of attenuated virus would be more serious, and how are we to find out without doing vaccine inoculation ? They wish the question of oncogenic potential of C.M.v. to be settled first, but since there are no epidemiological data that suggest c.M.v. is oncogenic and the interpretation of in-vitro tests is open to doubt, it would appear that the question is not going to be settled for some time. Meanwhile 4000 to 10,000 c.M.v.-damaged babies are being born each year in the United States alone. They say that there is no evidence that in-vitro passage of c.M.v. leads to attenuation and that studies in normal volunteers should be precluded. This would seem to be an ethical point, since Professor Elek and Professor Stern in fact show that their strain is attenuated. There being no alternative host for human c.M.v., it is difficult to think of an acceptable test group other than informed normal volunteers. Finally, Dr Pagano and Dr Huang mention that the subcutaneous route is not the normal one for C.M.v. They forget that thousands of people receive c.M.v. each year in the form of blood-transfusion. According to estimates, 6% of fresh donor blood units (and perhaps stored blood also) carry infectious wild C.M.V.1-6 Thus parenteral inoculation of c.M.v. is daily being practised under uncontrolled conditions. All vaccines at this stage of development have had legitimate objections raised against them. Nevertheless, there is often ultimate success in plucking the flower from the nettles. Wistar Institute of Anatomy and Biology, 36th and Spruce Streets, Philadelphia, Pennsylvania 19104, U.S.A. 1. 2.
3.
4.
5.
STANLEY A. PLOTKIN.
Diosi, P., Moldovan, E., Tomescu, N. Br. med. J. 1969, iv, 660. Stevens, D. P., Barker, L. F., Ketcham, A. S., Meyer, H. F., Jr. J. Am. med. Ass. 1970, 211, 1341. Henle, W., Henle, G., Scriba, M., Joyner, C. R., Harrison, F. S., Jr., Essen, R. V., Paloheimo, J., Klemola, E. New Engl. J. Med. 1970, 282, 1068. Prince, A. M., Szmuness, W., Millian, S. J., David, D. S. ibid. 1971, 284, 1125. Perham, T. G. M., Caul, E. O., Conway, P. J., Mott, M. Br. J. Hœmatol. 1971, 20, 307.
6.
Armstrong, D., Ely, M., Steger, L. Infect. Immun. 1971, 3, 159.
CHARLES K. TASHIMA.
a
SIR,-Dr Crockett (April 27, p. 804) eloquently expresses number of entirely valid points. Geriatrics is in many
a phoney specialty "-perhaps it is more a state of mind. It is, however, difficult to share his conviction that we have " a new generation of physicians who will take on the responsibility of continuing care " and even more the management functions that this entails. It has been said that the most crucial function of a geriatrician is to be the final common pathway to long-stay hospital beds, and this implies that no patient must be admitted to such a bed until all possible avenues of rehabilitation and discharge have been explored. Would most general physicians really be prepared to soldier on with the rehabilitation of a hemiplegic perhaps over a period of months, or might the temptation to transfer such a patient out of one of his acute beds after a week or two prove too strong ? If these beds were given to the general physicians, or to general practitioners in the new community hospitals, it is only too likely that they might become blocked within a week or two with patients who did not really need them but who proved to be undischargeable. Furthermore, geriatricians are charged with the responsibility of meeting the total demands of an area, which does not always endear them to general practitioners but at least it forces them to attempt the usual N.H.S. exercise of making bricks without
ways "
straw! It is equally entirely true that in many geriatric patients the medical problem is quickly solved and that sophisticated doctors will encounter " an immense amount of work ... extremely mundane and lacking the intellectual stimulation he would find in acute medicine in younger age-groups." This argues that we are training too many doctors to this degree of sophistication and motivated purely towards intellectual stimulation. The taxpayer pays heavily for the education and the subsequent salary of our doctors. It is in his interest that only a minority of them should expect to spend their lives contemplating the minutix of superspecialist medicine while the majority are prepared to shoulder the medical burdens afflicting the community, which are predominantly within the fields of general practice, psychiatry, and care of the aged. If this demands endless discussions with relatives and local-authority officials, so be it. The British consultant is meagrely rewarded compared with his colleagues in other affluent nations. However, in most countries the doctor is paid 1. 2. 3. 4.
Williams, B. Lancet, Feb. 23, 1974, p. 307. Carr, R. D., Hamilton, J. F. Archs Derm. 1969, 99, Elton, R. F. ibid. 1966, 94, 33. J. Am. med. Ass. 1966, 197, 140.
26.
Letters
to
the Editor
CYTOMEGALOVIRUS INFECTION IN UTERO
SiR,—Idisagree with some of the comments of my distinguished friend, Dr Joseph Pagano, and his colleague, Dr Huang (Feb. 23, p. 316), concerning the cytomegalovirus (c.M.v.) inoculations performed by Professor Elek and Professor Stern (Jan. 5, p. 1). The technical caveats raised by them are well taken and I am sure that Professor Elek and Professor Stern will use cell-free virus and better methods of antibody measurement in the future. Their results are not less interesting because of these limitations in their methodology. Nor does the possibility that there are better antigens than strain AD-169 render the results of Elek and Stern invalid, for at some point we must find out directly whether C.M.v. strains cross-protect. Development of several strains for use in man will provide the answer to this
SIR,-Although more specific methods of measuring strix1 may prove to be helpful in elucidating their cause, I believe that more attention should be paid to the composition of skin itself. Most approaches to the study of stride 2-4 have examined certain endocrine and physical stresses upon the skin without commenting on the individual variations in skin composition. Even gross inspection reveals considerable differences in thickness, laxity, elasticity, and texture of the skin among individuals and in different parts of the body in the It is my clinical impression that strix same person. more are frequent and more extensive in women gravidarum with fine skin. There is probably a significant hereditary component to stria:. Saint Francis Hospital, 2260 Liliha Street,
Honolulu, Hawaii 96817, U.S.A.
GERIATRICS IS MEDICINE
question. Dr Pagano and Dr Huang raise three substantive considerations concerning c.Nt.v, inoculation: persistence, oncogenicity, and attenuation. They ask for the evidence that reactivation of attenuated virus would not be more serious than reactivation of wild virus. I would ask, on the contrary, why should one believe that reactivation of attenuated virus would be more serious, and how are we to find out without doing vaccine inoculation ? They wish the question of oncogenic potential of C.M.v. to be settled first, but since there are no epidemiological data that suggest c.M.v. is oncogenic and the interpretation of in-vitro tests is open to doubt, it would appear that the question is not going to be settled for some time. Meanwhile 4000 to 10,000 c.M.v.-damaged babies are being born each year in the United States alone. They say that there is no evidence that in-vitro passage of c.M.v. leads to attenuation and that studies in normal volunteers should be precluded. This would seem to be an ethical point, since Professor Elek and Professor Stern in fact show that their strain is attenuated. There being no alternative host for human c.M.v., it is difficult to think of an acceptable test group other than informed normal volunteers. Finally, Dr Pagano and Dr Huang mention that the subcutaneous route is not the normal one for C.M.v. They forget that thousands of people receive c.M.v. each year in the form of blood-transfusion. According to estimates, 6% of fresh donor blood units (and perhaps stored blood also) carry infectious wild C.M.V.1-6 Thus parenteral inoculation of c.M.v. is daily being practised under uncontrolled conditions. All vaccines at this stage of development have had legitimate objections raised against them. Nevertheless, there is often ultimate success in plucking the flower from the nettles. Wistar Institute of Anatomy and Biology, 36th and Spruce Streets, Philadelphia, Pennsylvania 19104, U.S.A. 1. 2.
3.
4.
5.
STANLEY A. PLOTKIN.
Diosi, P., Moldovan, E., Tomescu, N. Br. med. J. 1969, iv, 660. Stevens, D. P., Barker, L. F., Ketcham, A. S., Meyer, H. F., Jr. J. Am. med. Ass. 1970, 211, 1341. Henle, W., Henle, G., Scriba, M., Joyner, C. R., Harrison, F. S., Jr., Essen, R. V., Paloheimo, J., Klemola, E. New Engl. J. Med. 1970, 282, 1068. Prince, A. M., Szmuness, W., Millian, S. J., David, D. S. ibid. 1971, 284, 1125. Perham, T. G. M., Caul, E. O., Conway, P. J., Mott, M. Br. J. Hœmatol. 1971, 20, 307.
6.
Armstrong, D., Ely, M., Steger, L. Infect. Immun. 1971, 3, 159.
CHARLES K. TASHIMA.
a
SIR,-Dr Crockett (April 27, p. 804) eloquently expresses number of entirely valid points. Geriatrics is in many
a phoney specialty "-perhaps it is more a state of mind. It is, however, difficult to share his conviction that we have " a new generation of physicians who will take on the responsibility of continuing care " and even more the management functions that this entails. It has been said that the most crucial function of a geriatrician is to be the final common pathway to long-stay hospital beds, and this implies that no patient must be admitted to such a bed until all possible avenues of rehabilitation and discharge have been explored. Would most general physicians really be prepared to soldier on with the rehabilitation of a hemiplegic perhaps over a period of months, or might the temptation to transfer such a patient out of one of his acute beds after a week or two prove too strong ? If these beds were given to the general physicians, or to general practitioners in the new community hospitals, it is only too likely that they might become blocked within a week or two with patients who did not really need them but who proved to be undischargeable. Furthermore, geriatricians are charged with the responsibility of meeting the total demands of an area, which does not always endear them to general practitioners but at least it forces them to attempt the usual N.H.S. exercise of making bricks without
ways "
straw! It is equally entirely true that in many geriatric patients the medical problem is quickly solved and that sophisticated doctors will encounter " an immense amount of work ... extremely mundane and lacking the intellectual stimulation he would find in acute medicine in younger age-groups." This argues that we are training too many doctors to this degree of sophistication and motivated purely towards intellectual stimulation. The taxpayer pays heavily for the education and the subsequent salary of our doctors. It is in his interest that only a minority of them should expect to spend their lives contemplating the minutix of superspecialist medicine while the majority are prepared to shoulder the medical burdens afflicting the community, which are predominantly within the fields of general practice, psychiatry, and care of the aged. If this demands endless discussions with relatives and local-authority officials, so be it. The British consultant is meagrely rewarded compared with his colleagues in other affluent nations. However, in most countries the doctor is paid 1. 2. 3. 4.
Williams, B. Lancet, Feb. 23, 1974, p. 307. Carr, R. D., Hamilton, J. F. Archs Derm. 1969, 99, Elton, R. F. ibid. 1966, 94, 33. J. Am. med. Ass. 1966, 197, 140.
26.