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STUDIES IN INERTIA
371 STUDIES IN INERTIA
SIR,-May we congratulate you on your leading article (Jan. 22). As representatives of one of the hospitals and institutes most concerned, we welcome the airing of opinions that are widely discussed in private gatherings. We have two units, one in Central London and the other in the East End, separated by seven miles, and each unit houses a part of the hospital and institute. This separation makes cooperation very difficult and expansion even more so. Your follow-up leading article, entitled Towards a University Hospital (Jan. 29), deserves very careful consideration, and could produce a better grouping of specialties than that envisaged in the Chelsea plan. As it is likely to be many years before
moved to a permanent site, some interim arrangerelieve our dichotomv is ursentiv reouired. R. H. MEARA Chairman, Medical Committee, St. John’s Hospital for
we are
ment to
Diseases of the Skin
P. D. SAMMAN Dean, Institute of Dermatology.
FIBROSIS IN GUINEAPIG HEART SIR,-We have read with interest the preliminary communication by Dr. McKinney and Dr. Crawford (Oct. 30) on the experimental production of fibrosis in the guineapig heart. Since interest in endomyocardial fibrosis (E.M.F.) is almost world-wide, we feel that workers in this field should bear in mind that the term E.M.F. is used to describe a specific disorder. In their communication Dr. McKinney and Dr. Crawford cite work by Miller et a1.l and Selye2 as examples of the experimental production of E.M.F. This is rather misleading. Miller et al. found, in their dogs, subendocardial hoemorrhages and endocardial lesions consisting of elastic and fibrous tissue. Neither of these features occur in E.M.F. Selye produced subendocardial muscle degeneration which was later replaced by fibrous tissue incorporating the endocardium; in contrast, the descriptions of the pathological findings in E.M.F. suggest that fibrosis probably results predominantly from organisation of mural thrombi.34 An attempt is made by Dr. McKinney and Dr. Crawford to indicate a pathogenetic relation between E.M.F. and defective metabolism or increased intake of 5-hydroxytryptamine (5-H.T.). Work by Spatz5 is cited to support this hypothesis. But there is some doubt about the astiological relation of 5-H.T. to the carcinoid heart.Spatz only produced endocardial lesions in guineapigs when 5-H.T. was given together with a hepatotoxic agent and a tryptophan-deficient diet. The lesions produced were not entirely similar to those of the disease in man, and it is uncertain which of the above factors was responsible for the cardiac lesions. The differences between the pathological findings in E.M.F. and in carcinoid heart-disease have been described ’-the more important ones are that, in the carcinoid heart, both inflow and outflow valves are involved in the fibrotic process, and the left side of the heart is rarely affected. Descriptions of experimental results should therefore pay particular attention to these differences. Any worker who seeks to establish a valid claim that E.M.F. has been produced experimentally should indicate which cardiac chamber is involved by the fibrosis, and whether the valves are also involved or not. Fibrous thickening of the endocardium is not necessarily E.M.F., for this lesion has also been observed in other forms of primary myocardial disease. 8-10 1. 2. 3. 4. 5. 6. 7. 8. 9.
Miller, A. J., Pick, R., Katz, L. M. Br. Heart J. 1963, 25, 182. Selye, H. Lancet, 1958, i, 1351. Davies, J. N. P., Ball, J. D. Br. Heart J. 1955, 17, 337. Nwokolo, C. W. Afr. med. J. 1962, 21, 51. Spatz, M. Lab. Invest. 1965, 13, 288. Roberts, W. C., Sjoerdsma, A. Am. J. Med. 1964, 36, 5. Thorson, A. H. Acta med. scand. 1958, 161, suppl. 334. Eddington, G. M., Jackson, J. G. J. Path. Bact. 1963, 86, 333. Becker, B. J. P., Chazgidakis, C. B., van Lingen, B. Circulation, 7, 345. 10. Stuart, K. L., Hayes, J. A. Q. Jl Med. 1963, 32, 99.
1953
Indiscriminate use of the term E.M.F. will lead to confusion in the search for its Etiology. We agree that cardiomyopathy, and even endocardial thickening, may be produced experimentally in various ways including a plantain diet. The recognition of the pathological anatomy of endomyocardial fibrosis, however, is based on the application of certain specific criteria, and we suggest that the term be used in the experimental field only when these criteria are fulfilled. Departments of Medicine and Paediatrics, University College Hospital, Ibadan, Nigeria.
A. C. IKEME ASUQUO U. ANTIA.
THE WORKING-WIFE SYNDROME SIR,-Dr. Hanratty last week described a typical day for Mrs. Overtired, a two-job wife. Surely hers was a home with a lost father " and she was a two-job widow ". When parents agree that the mother should exercise her right to earn outside the home, most modern fathers accept the position and enjoy sharing in family responsibilities. Nurseries should certainly be set up to help parents, but the responsibility of providing these should not fall only on firms which employ women. Both men and women workers would benefit by shifts being more flexible and part-time work more available, and by the abolition of the present restrictions on hours of work for women. With such improvements there need be no lost fathers and no over-tired wives. A. M. FLEMING. "
"
LONDON’S SKID ROW SIR,-Iwas interested in the special article by Dr. Edwards and his colleagues (Jan. 29), but was surprised to see no mention made of blindness. Cecil and Loeb’s Textbook of Medicine (p. 1794, 1963 edition) mentions the " terrible toxic properties " of methyl alcohol, and the highly specific action of its metabolites on the neurones of the retina. Perhaps, as Cecil and Loeb says, the toxic effects of methyl alcohol may be lessened or even prevented by the concurrent administration of ethyl alcohol-this may have unwittingly played a part in the prevention of the serious toxic effects in the Skid Row men, or there may be some acquired tolerance in these chronic alcoholics. In the average psychiatric practice the methylated-spirit drinker is somewhat rare, and it seems that the further investigation of this group from all aspects, including the biochemical, could be rewarding.
ROBIN GEORGE.
CARE FOR THE OLD SiR,—There is much that I would agree with in your annotation (Jan. 29). May I be permitted, however, to make one observation about welfare accommodation from experience in a London Borough. I am firmly convinced that, to get the most out of our meagre resources of welfare beds, there should be a vetting, by the local geriatrician, of doubtful cases referred for welfare accommodation. On the other hand the geriatrician should be in a position to referee cases which he feels are socially urgent and from his assessment fit for " Part III " accommodation, as is done for medical cases by the Emergency Bed Service. Secondly, a certain proportion of welfare beds should be used for social therapy by which is meant food, shelter, accommodation, building up, treatment of minor ailments, and-last but not least-tender loving care. While the aged person is being built up, the living accommodation at home could be cleaned and prepared to go back to, with the social props available. It is only by using some welfare accommodation in this way that the increasing need of a proportion of old
people
can
be
met.
SIR,-May we congratulate you on your leading article (Jan. 22). As representatives of one of the hospitals and institutes most concerned, we welcome the airing of opinions that are widely discussed in private gatherings. We have two units, one in Central London and the other in the East End, separated by seven miles, and each unit houses a part of the hospital and institute. This separation makes cooperation very difficult and expansion even more so. Your follow-up leading article, entitled Towards a University Hospital (Jan. 29), deserves very careful consideration, and could produce a better grouping of specialties than that envisaged in the Chelsea plan. As it is likely to be many years before
moved to a permanent site, some interim arrangerelieve our dichotomv is ursentiv reouired. R. H. MEARA Chairman, Medical Committee, St. John’s Hospital for
we are
ment to
Diseases of the Skin
P. D. SAMMAN Dean, Institute of Dermatology.
FIBROSIS IN GUINEAPIG HEART SIR,-We have read with interest the preliminary communication by Dr. McKinney and Dr. Crawford (Oct. 30) on the experimental production of fibrosis in the guineapig heart. Since interest in endomyocardial fibrosis (E.M.F.) is almost world-wide, we feel that workers in this field should bear in mind that the term E.M.F. is used to describe a specific disorder. In their communication Dr. McKinney and Dr. Crawford cite work by Miller et a1.l and Selye2 as examples of the experimental production of E.M.F. This is rather misleading. Miller et al. found, in their dogs, subendocardial hoemorrhages and endocardial lesions consisting of elastic and fibrous tissue. Neither of these features occur in E.M.F. Selye produced subendocardial muscle degeneration which was later replaced by fibrous tissue incorporating the endocardium; in contrast, the descriptions of the pathological findings in E.M.F. suggest that fibrosis probably results predominantly from organisation of mural thrombi.34 An attempt is made by Dr. McKinney and Dr. Crawford to indicate a pathogenetic relation between E.M.F. and defective metabolism or increased intake of 5-hydroxytryptamine (5-H.T.). Work by Spatz5 is cited to support this hypothesis. But there is some doubt about the astiological relation of 5-H.T. to the carcinoid heart.Spatz only produced endocardial lesions in guineapigs when 5-H.T. was given together with a hepatotoxic agent and a tryptophan-deficient diet. The lesions produced were not entirely similar to those of the disease in man, and it is uncertain which of the above factors was responsible for the cardiac lesions. The differences between the pathological findings in E.M.F. and in carcinoid heart-disease have been described ’-the more important ones are that, in the carcinoid heart, both inflow and outflow valves are involved in the fibrotic process, and the left side of the heart is rarely affected. Descriptions of experimental results should therefore pay particular attention to these differences. Any worker who seeks to establish a valid claim that E.M.F. has been produced experimentally should indicate which cardiac chamber is involved by the fibrosis, and whether the valves are also involved or not. Fibrous thickening of the endocardium is not necessarily E.M.F., for this lesion has also been observed in other forms of primary myocardial disease. 8-10 1. 2. 3. 4. 5. 6. 7. 8. 9.
Miller, A. J., Pick, R., Katz, L. M. Br. Heart J. 1963, 25, 182. Selye, H. Lancet, 1958, i, 1351. Davies, J. N. P., Ball, J. D. Br. Heart J. 1955, 17, 337. Nwokolo, C. W. Afr. med. J. 1962, 21, 51. Spatz, M. Lab. Invest. 1965, 13, 288. Roberts, W. C., Sjoerdsma, A. Am. J. Med. 1964, 36, 5. Thorson, A. H. Acta med. scand. 1958, 161, suppl. 334. Eddington, G. M., Jackson, J. G. J. Path. Bact. 1963, 86, 333. Becker, B. J. P., Chazgidakis, C. B., van Lingen, B. Circulation, 7, 345. 10. Stuart, K. L., Hayes, J. A. Q. Jl Med. 1963, 32, 99.
1953
Indiscriminate use of the term E.M.F. will lead to confusion in the search for its Etiology. We agree that cardiomyopathy, and even endocardial thickening, may be produced experimentally in various ways including a plantain diet. The recognition of the pathological anatomy of endomyocardial fibrosis, however, is based on the application of certain specific criteria, and we suggest that the term be used in the experimental field only when these criteria are fulfilled. Departments of Medicine and Paediatrics, University College Hospital, Ibadan, Nigeria.
A. C. IKEME ASUQUO U. ANTIA.
THE WORKING-WIFE SYNDROME SIR,-Dr. Hanratty last week described a typical day for Mrs. Overtired, a two-job wife. Surely hers was a home with a lost father " and she was a two-job widow ". When parents agree that the mother should exercise her right to earn outside the home, most modern fathers accept the position and enjoy sharing in family responsibilities. Nurseries should certainly be set up to help parents, but the responsibility of providing these should not fall only on firms which employ women. Both men and women workers would benefit by shifts being more flexible and part-time work more available, and by the abolition of the present restrictions on hours of work for women. With such improvements there need be no lost fathers and no over-tired wives. A. M. FLEMING. "
"
LONDON’S SKID ROW SIR,-Iwas interested in the special article by Dr. Edwards and his colleagues (Jan. 29), but was surprised to see no mention made of blindness. Cecil and Loeb’s Textbook of Medicine (p. 1794, 1963 edition) mentions the " terrible toxic properties " of methyl alcohol, and the highly specific action of its metabolites on the neurones of the retina. Perhaps, as Cecil and Loeb says, the toxic effects of methyl alcohol may be lessened or even prevented by the concurrent administration of ethyl alcohol-this may have unwittingly played a part in the prevention of the serious toxic effects in the Skid Row men, or there may be some acquired tolerance in these chronic alcoholics. In the average psychiatric practice the methylated-spirit drinker is somewhat rare, and it seems that the further investigation of this group from all aspects, including the biochemical, could be rewarding.
ROBIN GEORGE.
CARE FOR THE OLD SiR,—There is much that I would agree with in your annotation (Jan. 29). May I be permitted, however, to make one observation about welfare accommodation from experience in a London Borough. I am firmly convinced that, to get the most out of our meagre resources of welfare beds, there should be a vetting, by the local geriatrician, of doubtful cases referred for welfare accommodation. On the other hand the geriatrician should be in a position to referee cases which he feels are socially urgent and from his assessment fit for " Part III " accommodation, as is done for medical cases by the Emergency Bed Service. Secondly, a certain proportion of welfare beds should be used for social therapy by which is meant food, shelter, accommodation, building up, treatment of minor ailments, and-last but not least-tender loving care. While the aged person is being built up, the living accommodation at home could be cleaned and prepared to go back to, with the social props available. It is only by using some welfare accommodation in this way that the increasing need of a proportion of old
people
can
be
met.