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STUDIES IN INERTIA

R. H. MEARAChairman, Medical Committee,

St. John’s Hospital forDiseases of the Skin

P. D. SAMMANDean,

Institute of Dermatology.

SIR,-May we congratulate you on your leading article

(Jan. 22). As representatives of one of the hospitals andinstitutes most concerned, we welcome the airing of opinionsthat are widely discussed in private gatherings. We have twounits, one in Central London and the other in the East End,separated by seven miles, and each unit houses a part of thehospital and institute. This separation makes cooperation verydifficult and expansion even more so.Your follow-up leading article, entitled Towards a Uni-

versity Hospital (Jan. 29), deserves very careful consideration,and could produce a better grouping of specialties than thatenvisaged in the Chelsea plan. As it is likely to be many yearsbefore we are moved to a permanent site, some interim arrange-ment to relieve our dichotomv is ursentiv reouired.

FIBROSIS IN GUINEAPIG HEART

SIR,-We have read with interest the preliminary communi-cation by Dr. McKinney and Dr. Crawford (Oct. 30) on theexperimental 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 inmind that the term E.M.F. is used to describe a specific disorder.

In their communication Dr. McKinney and Dr. Crawfordcite work by Miller et a1.l and Selye 2 as examples of theexperimental production of E.M.F. This is rather misleading.Miller et al. found, in their dogs, subendocardial hoemorrhagesand endocardial lesions consisting of elastic and fibrous tissue.Neither of these features occur in E.M.F. Selye produced sub-endocardial muscle degeneration which was later replaced byfibrous tissue incorporating the endocardium; in contrast, thedescriptions of the pathological findings in E.M.F. suggest thatfibrosis probably results predominantly from organisation ofmural thrombi.3 4

An attempt is made by Dr. McKinney and Dr. Crawford toindicate a pathogenetic relation between E.M.F. and defectivemetabolism or increased intake of 5-hydroxytryptamine (5-H.T.).Work by Spatz 5 is cited to support this hypothesis. But there issome doubt about the astiological relation of 5-H.T. to thecarcinoid heart. Spatz only produced endocardial lesions inguineapigs when 5-H.T. was given together with a hepatotoxicagent and a tryptophan-deficient diet. The lesions producedwere not entirely similar to those of the disease in man, and it isuncertain which of the above factors was responsible for thecardiac 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 andoutflow valves are involved in the fibrotic process, and the leftside of the heart is rarely affected. Descriptions of experimentalresults should therefore pay particular attention to thesedifferences.

Any worker who seeks to establish a valid claim that E.M.F.has been produced experimentally should indicate whichcardiac chamber is involved by the fibrosis, and whether thevalves are also involved or not. Fibrous thickening of theendocardium is not necessarily E.M.F., for this lesion has alsobeen observed in other forms of primary myocardial disease. 8-10

1. Miller, A. J., Pick, R., Katz, L. M. Br. Heart J. 1963, 25, 182.2. Selye, H. Lancet, 1958, i, 1351.3. Davies, J. N. P., Ball, J. D. Br. Heart J. 1955, 17, 337.4. Nwokolo, C. W. Afr. med. J. 1962, 21, 51.5. Spatz, M. Lab. Invest. 1965, 13, 288.6. Roberts, W. C., Sjoerdsma, A. Am. J. Med. 1964, 36, 5.7. Thorson, A. H. Acta med. scand. 1958, 161, suppl. 334.8. Eddington, G. M., Jackson, J. G. J. Path. Bact. 1963, 86, 333.9. Becker, B. J. P., Chazgidakis, C. B., van Lingen, B. Circulation, 1953

7, 345.10. Stuart, K. L., Hayes, J. A. Q. Jl Med. 1963, 32, 99.

Indiscriminate use of the term E.M.F. will lead to confusion inthe search for its Etiology. We agree that cardiomyopathy, andeven endocardial thickening, may be produced experimentallyin various ways including a plantain diet. The recognition ofthe pathological anatomy of endomyocardial fibrosis, however,is based on the application of certain specific criteria, and wesuggest that the term be used in the experimental field onlywhen these criteria are fulfilled.

A. C. IKEME

ASUQUO U. ANTIA.

Departments of Medicineand Paediatrics,

University College Hospital,Ibadan, Nigeria.

THE WORKING-WIFE SYNDROME

A. M. FLEMING.

SIR,-Dr. Hanratty last week described a typical day forMrs. Overtired, a two-job wife. Surely hers was a home witha " 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 theposition and enjoy sharing in family responsibilities. Nurseriesshould certainly be set up to help parents, but the responsibilityof providing these should not fall only on firms which employwomen. Both men and women workers would benefit by shiftsbeing more flexible and part-time work more available, and bythe abolition of the present restrictions on hours of work forwomen. With such improvements there need be no lostfathers and no over-tired wives.

LONDON’S SKID ROW

ROBIN GEORGE.

SIR,-I was interested in the special article by Dr. Edwardsand his colleagues (Jan. 29), but was surprised to see no

mention made of blindness. Cecil and Loeb’s Textbook ofMedicine (p. 1794, 1963 edition) mentions the " terrible toxicproperties " of methyl alcohol, and the highly specific actionof its metabolites on the neurones of the retina. Perhaps, asCecil and Loeb says, the toxic effects of methyl alcohol may belessened or even prevented by the concurrent administrationof ethyl alcohol-this may have unwittingly played a part inthe prevention of the serious toxic effects in the Skid Row

men, or there may be some acquired tolerance in these chronicalcoholics.

In the average psychiatric practice the methylated-spiritdrinker is somewhat rare, and it seems that the further investiga-tion of this group from all aspects, including the biochemical,could be rewarding.

CARE FOR THE OLD

SiR,—There is much that I would agree with in your annota-tion (Jan. 29). May I be permitted, however, to make oneobservation about welfare accommodation from experience ina London Borough.

I am firmly convinced that, to get the most out of our meagreresources of welfare beds, there should be a vetting, by thelocal geriatrician, of doubtful cases referred for welfare accom-modation. On the other hand the geriatrician should be in aposition to referee cases which he feels are socially urgent andfrom his assessment fit for " Part III " accommodation, as isdone for medical cases by the Emergency Bed Service.

Secondly, a certain proportion of welfare beds should beused 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 agedperson is being built up, the living accommodation at homecould be cleaned and prepared to go back to, with the socialprops available. It is only by using some welfare accommoda-tion in this way that the increasing need of a proportion of oldpeople can be met.

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A lot of good work is done at present in welfare homes, butdichotomy of authority should not stand in the way of abroader coordination between the hospital geriatric service andwelfare homes.

Various skills and team-work are needed to put frail elderlypeople on their feet, and I suggest that in a minor way a con-tinued projection of some of these should follow the patientwhen she goes into a welfare home to help her almost to the last.

MOHAN S. KATARIA.

Geriatric Unit,St. Francis’ Hospital,

London, S.E.22.

" DOES THE GRASS GROW GREENER ... ?"

SIR,-I greatly enjoyed Dr. Goodall’s Point of View (Jan. 1)on hospital life in the United States, and would agree withmost of her observations as they apply to a large universitycentre. Having worked in New York for several years as aconsultant, I think it is important to stress that other types ofhospitals are less favoured. Above all, the nursing providedsuffers from a lack of participation in the clinical observationand treatment of patients, so that many nursing duties areperformed by interns and junior residents. Wound’ dressingsare not usually carried out by the nursing staff, and theirabsence from ward rounds confirms the schism referred to byDr. Goodall.

Excellent though the idea and sometimes the execution ofthe postgraduate residency training programme may be, thereis too much talk and not enough action. Large numbers ofhouse staff are required so that justice can be done to bothpatient-care and educational activities, confirming that thesepositions are really intended to be training posts. Unfortunatelythis leads to a considerable reduction of personal experience forresidents when compared with that of doctors of equal years oftraining in the National Health Service. It also encourages an

unduly academic approach to the patient, which would bequite out of place in the Health Service. I believe that the

Royal Commission on Medical Education must take note ofthis problem in formulating its plans for similar programmesin the United Kingdom.

Finally, although research is important, it is grossly over-emphasised in the U.S. The magnitude of one’s grant hasbecome an important factor in professional advancement, andthe scramble for finding an exciting new " project " is sad towatch. This emphasis also engenders the idea among manyresidents that using the most recently published method oftherapy is equivalent to keeping abreast of medical progress.

Quite apart from considerations of schooling for one’schildren, the high cost of living, and different social and moralconcepts, the idea of being able to return to the more measured,clinical atmosphere of the N.H.S. still seems attractive to manyof us medical emigres. Because of this I hope you will allowme to sign myself

F.R.C.S.

DEFICIENCY OF LINOLEIC ACID

SIR,-In their preliminary communication 2 on a malignanthepatoma in an eight-year-old girl, Dr. Collins and Dr.

Connelly state that they unexpectedly found A 5, 8, 11-eicosotrienoic acid upon analysis of plasma and hepatic lipids.This fatty acid is believed to be one of the earliest biochemicalmanifestations of essential-fatty-acid deficiency. Contrary totheir statement that this fatty acid has not been found in humantissue, it has been identified 3 in early studies of human

adipose-tissue composition. In this report this unusual fattyacid was found in increasing amounts in foetal adipose tissueduring pregnancy, decreasing to trace but readily identifiableamounts during childhood and adult life.The last trimester of pregnancy is normally characterised by

1. See Lancet, 1965, ii, 71.2. Collins, F. D., Connelly, J. F. Lancet, 1965, ii, 883.3. Farquhar, J. W., Ahrens, E. H., Peterson, M. L., Stoffel, W., Hirsch, J.

Am. J. clin. Nutr. 1960, 8, 499.

a twelve-fold increase in adipose tissue, and it was suggested 3that this period of active lipogenesis may be accompanied by anessential-fatty-acid deficiency, comparable to the experimentalsituations cited by Dr. Collins and Dr. Connelly. The closerelation of lipogenesis to this possible deficiency state isemphasised by the finding of progressively increasing amountsof A 5, 8, 11-eicosotrienoic acid in the adipose tissue of larger,more obese, full-term infants.4One could speculate that analysis of hepatic lipids of the

normal unfed full-term infant would yield a substantial amountof this fatty acid-perhaps in amounts in excess of thatrecorded in the case of hepatoma reported by Dr. Collins andDr. Connellv.

J. D. BAGDADE.

Department of Medicine,University of Washington,

Veterans Administration Hospital,Seattle, Washington 98108.

TEST FOR PITUITARY FUNCTION

D. DE WIEDB. VAN DER WAL.

Department of Pharmacology,Faculty of Medicine,University of Utrecht,The Netherlands.

SIR,-Dr. Gwinup has published a preliminary communica-tion entitled Test for Pituitary Function Using Vasopressin.5We should like to draw your attention to the fact that in 1956McDonald et al. showed that vasopressin stimulates thesecretion of hydrocortisone in man. 6

In view of the ample experimental evidence that vasopressinis a powerful corticotrophin releaser,’ we undertook clinicalstudies to investigate the effect of this peptide on corticotrophinrelease in children. These studies on the evaluation of the

pituitary-adrenal system demonstrated that vasopressin causesa reproducible and rapid stimulation of the secretion of cortisoland corticosterone in peripheral blood. From the results

obtained the use of vasopressin in a relatively simple test forthe evaluation of the corticotrophic function of the anteriorpituitary was advocated. 9 a

TONSILLECTOMY AND MULTIPLE SCLEROSIS

SIR,-In his subjoined reply to my letter (Jan. 15), Dr.Poskanzer makes the good point that the significance test usedin his article 10 is likely to be conservative. I fully agree thathis x2 will be smaller than the correct x2 when the associationbetween members of a pair is positive. His reference to the

procedure I propose as a marginal x2 test is a little strange,since I emphasised that the ordinary x2 test for a 2 x 2 tablesuch as that in his letter is irrelevant, and that what is requiredis a diagonal X2 or diagonal binomial test.

It is of course pleasing to have Dr. Poskanzer’s reassurancethat his associations were positive and that a change of statisticaltest does not alter the conclusions of his article. One would not

expect any assertions of significance to be affected, but there wasthe possibility that a more sensitive test would show as signifi-cant, differences previously regarded as attributable to samplingvariation. I part company with Dr. Poskanzer, however, in hisstatement that his 420 persons were independent, and in hisimplied assumption that the choice of statistical test is a matterof personal preference. Each of the 210 siblings entered therecords solely because of his relationship to a patient; informa-tion may have been obtained from the siblings by independentprocedures, but a classificatory and statistical dependence isimplicit in the investigation (as it still would be if " siblins "

4. Bagdade, J. D. Unpublished.5. Gwinup, G. Lancet, 1965, ii, 572.6. McDonald, R. K., Weise, V. K., Patrick, R. W. Proc. Soc. exp. Biol.

Med. 1956, 93, 348.7. de Wied, D., Smelik, P. G., Moll, J., Bouman, P. R. in Major Problems

in Neuroendocrinology (edited by E. Bajusz and G. Jasmin); p. 156.Basle and New York, 1964.

8. van der Wal, B., Israëls, A. L. M., Janssen, J. F., de Wied, D. Actaendocr., Copenh. 1961, 38, 392.

9. van der Wal, B., Wiegman, T., Janssen, J. F., Delver, A., de Wied, D.ibid. 1965, 48, 81.

10. Poskanzer, D. C. Lancet, 1965, ii, 1264.