a high cellular turnover might be swamped by postnatal environmental factors. The birth dates of sufferers from two tumours, one of each type-namely, astrocytoma of the cere-
brum and bronchial carcinoma-are being investigated. Tables i and 11 summarise the incidence of these two tumours according to season of birth. TableI shows that patients with astrocytoma of the cerebrum are more likely to be born in the months November to April than in the months May to October. Table 11 (carcinoma of the bronchus) shows no clear-cut seasonal incidence of birth dates, though it does appear that more are born from July to October than during the other twothirds of the year. My observations do not confirm Dijkstra’s finding that persons born in winter are more susceptible to carcinoma of the bronchus than those born in the summer. There is a possible explanation. The factor may not be primarily a seasonal one but one of maternal epidemic illness. Thus, by analogy, if the birth dates of patients with the congenital malformations of maternal rubella were recorded they might show a seasonal incidence secondary to epidemics of German measles. The difficulty is that epidemics have two dimensions-time and space-and these may be different in different countries. It is interesting to note that Dr. Dijkstra was set off on his inquiry by noticing that more cases of lung cancer were born in some years than others. But he did not feel satisfied about the epidemic nature of the observation. There is also some evidence in my data for epidemic distribution. For instance, 16 cases of bronchial carcinoma were born in the first quarter of 1893; 6’6 would have been expected; then again in the third quarter of 1895 17 cases were born and only 6’2 were expected. The incidence of lung cancer and cigarette consumption are both less in the Netherlands than in England and Wales. So it may be presumed that any congenital factor is more likely to be swamped by postnatal environmental factors in England than in Holland. It is hoped later, when more figures have been collected, to give the full results. I should wish then to thank my colleagues who have so generously allowed me access to their records. In the meantime I should like to thank Dr. Richard Doll and Mr. P. M. Payne, of the South Metropolitan Cancer Registry, for supplying me with some birth dates of patients with astrocytoma.
GEOFFREY E. LOXTON. NEONATAL HEPATITIS
SIR,-In his letter of Nov. 23, commenting on your annotation of Oct. 26, Dr. Dunn suggests foeto-maternal incompatibility as the cause of the genetically determined cases of " neonatal hepatitis " described by the late Dr. Bodian and myself.! Our evidence (parentalconsanguinity) can only be interpreted, however, as meaning that affected individuals are homozygous for a rare gene. The mother must be a heterozygote for the same gene, and so would not be capable of reacting antigenically to the product of this gene, which would, in fact, be present in her own body. In hasmolytic disease of the newborn, the fcetus is always heterozygous for the gene concerned, and the mother always lacks this gene. Some mechanisms by which a recessive genotype could cause a foetal disease which may be fatal or may subside
(i) The polypeptide, whose function is deranged because of the abnormal genes, normally has an effect which is needed only by the foetus. Location of this substance in the placenta could explain this, but the many changes in chemical environment of the foetus which occur at the time of birth, must also render some functions, which are essential to the foetus, no
longer necessary. (ii) The polypeptide
concerned may be made only in the fcetus. The two-gene control of the structure of lactic dehydrogenase, proposed by Markert2 two explain the isozyme patterns 1. Danks, D. M., Bodian, M. Arch. Dis. Childh. 1963, 38, 425. 2.
Science, 1963, 140,
found on electrophoretic study, provides an appropriate model. In most tissues, the changes in the isozyme patterns of this enzyme could fit with one gene mainly controlling its formation in the fcetus and the other being mainly responsible in the adult. Were the defect in the former gene, maturation might result in spontaneous return of function.
reject Dr. Dunn’s explanation of the recessively inherited cases, I agree that liver damage, and even the clinical and histological pattern of " neonatal giant-cell hepatitis ", occur in cases of haemolytic disease of the newborn, and may be caused by it. This is one of many reasons for believing that our present crude criteria lead this
the inclusion of several title.
Clinical Research Unit, Royal Children’s Hospital, Melbourne, Victoria.
many diseases under
DAVID M. DANKS.
AN EXPERIMENT IN HOSPITAL SOCIAL WORK
SiR,—The experiment in hospital social work reported
by Dr. McFarland and Dr. Ramage (Dec. 14) is a practical expression of the idea1 of cooperation which has been mainly an ideal.2 Sometimes the advice of the general practitioner with a keen appreciation of the social background and needs of his patient may be appropriate. His knowledge of patient and family may allow him to decide directly from facts within his own experience. The domiciliary consultation allows the general practitioner to take specialist advice. A similar procedure in reverse would call the general practitioner to the hospital to give his special advice on discharge and rehabilitation. This happens to a very limited degree at present at resettlement conferences. To be of real value special training is necessary with experience of resettlement problems at work. Ferguson and MacPhail,3 in a study of 705 men discharged after treatment in acute medical wards of four hospitals in the West of Scotland, found that 25% had died, been readmitted, or clearly deteriorated within three months of leaving hospital. A fifth of 307 who had returned to work were in unsuitable jobs. Two years after discharge a third of the survivors had worked for less than one of the two years; many had done no work. A more recent and wider study4 gave similar results and suggested the "need for a more effective bridge" between hospital and community. The Scottish figures show the need for help and are a measure of the successes of hospital treatment. Surgeons measure results by five-year survival-rates. A five-year work record would be a more useful and revealing measure of therapeutic success.
hospital social service can work in many ways which supplement one another and are not mutually exclusive. The active participation of medical officer of health and general practitioner in this work at the district general A
J. J. MCMULLAN. DRUG ADDICTION Baker’s SIR,-Dr. plea (Nov. 2) for an official register of drug addicts is unlikely to receive the attention it merits because, numerically, we have no serious addiction problem in Great Britain. But surely it is just at this juncture that measures should be introduced to make the abuse of the Dangerous Drugs Regulations more difficult. All addicts should be registered and provided with identity cards on which the date and amount of drug supplied or 1. Brackenbury, Sir H. Patient and Doctor. London, 1935. 2. McMullan, J. J. Postgrad. med. J. 1963, 39, 382. 3. Ferguson, T., MacPhail, A. N. Hospital and Community: Oxford, 1954. 4. McKenzie, M., Weir, R. D., Richardson, I. M., Mair, A., Harnett, R. W. F., Curran, A. P., Ferguson, T. Further Studies in Hospital and Community. London, 1962.
prescribed should be stated. Addicts not previously under medical supervision and those arriving in this country from overseas should be referred to special clinics where it would be the responsibility of the medical officer in charge to satisfy himself that the patient was a drug addict and to decide, after a period of observation, the appropriate amount of drug the patient would require. The medical officer would issue an identity card and notify the case to the dangerous drugs department of the Home Office where an official list of addicts could be compiled. The clinics could be situated at ports which cater for passenger services and in a number of principle cities throughout the country and would be part of a general hospital. Such regulations would prevent self-styled addicts from obtaining drugs from general practitioners in amounts which can only be a compromise estimate between what the patient insists he requires and what the practitioner decides to supply. If practitioners were under the obligation to notify the dangerous drugs department of the Home Office whenever they prescribed for a new patient, the movements of the latter could be readily checked and this would be a more practical measure than the periodic inspection of dangerous drugs registers often carried out many months in arrear, if at all. There is no attempt in these suggestions to deprive the practitioner of his personal discretion in the matter of prescribing and treating an addict patient, provided the latter is not NDtDfnnf nut
of the hlue.
ELLIS STUNGO Honorary Medical Secretary, Society for the Study of Addiction
each year during the last three years. This saving of life is considerably more than the possible occasional unfortunate incident in which an increase in titre might have an adverse affect. R. F. JENNISON Department of Pathology, Whitworth Park, A. H. C. WALKER. Manchester, 13. BIOCHEMICAL DEFIBRILLATION was interested to read the letter by Dr. Beveridge SiR,łI and Dr. Rollason (Dec. 14). A suitable poster indicating a similar method of biochemical defibrillation under emergency conditions is available from Imperial Chemical Industries, provided as a service to the medical profession. I found it of great value in treating a case of ventricular fibrillation when no electrical defibrillater was available.’ Orthopædic Department, Western Infirmary, Glasgow.
J. C. GRIFFITHS.
CHILD VICTIMS OF SEX OFFENCES
SIR,-Dr. Elizabeth Tylden (Dec. 14) has outlined a position which is causing increasing anxiety to doctors concerned with severe behaviour disorders in children about 12 years of age, and those who are approaching
school-leaving age. While lip service is being paid to the concept of preventing, far as it can be prevented, mental ill health in the community, residential accommodation for disturbed children is increasingly difficult to find. Behaviour disorders can frequently be improved by residential-school discipline. It is quite ridiculous to speak in terms of prevention of mental sickness when one disabled child can react so violently in home surroundings as to produce illness in the whole family-father, mother, brothers, and sisters. In adult psychiatric hospitals, child patients are neither catered for nor welcomed. Such hospitals, while willing to take young persons for a short period to relieve conditions which have built up to a point beyond endurance at home, are not geared to these patients. as
AMNIOCENTESIS SIR,- The paper by Mr. Fairweather and his colleagues (Dec. 7) calls for some comment. They conclude that there is no evidence as yet that amniocentesis often causes the stimulation of antibody formation. Amniocentesis has been carried out in the Saint Mary’s Hospitals, Manchester, for seven years and, although, as might be expected, there are occasional instances where it would appear that the amniocentesis caused a rise in titre, these
are very uncommon. In the last series that we published1 we showed that in only 41 % of our cases was there a rise in titre following amniocentesis and that this 41 % included even minimal rises of one tube-i.e., twofold-whereas other workers (for instance, Kelsall et a1.2) report increases in titre in 50% of their patients
when amniocentesis was not performed. Fairweather et al. similarly report an increase in titre in a little over 50% of cases.
Adolescent wards in
desperately needed now. JOHN MILLS.
Lest amniocentesis comes to be regarded as a dangerous operation as far as the fcetus is concerned, it is important that this lack of evidence of rises in titres following the operation should be emphasised. Zipursky et awl. showed that 3 out of 4 bloodstained taps produced a rise in titre; the 4th did not because the foetus was Rh-negative. But Zipursky does not make it clear that in his small series there were nine other taps in which there was no evidence of blood-staining or presumably a rise in titre. This is an unusually high proportion of bloodstained specimens. We have found after nearly one thousand taps that complete failure occurs in about 5% of cases and blood-staining even microscopically occurs only in a further 5%, if due care is paid to technique. Thus in 9 out of 10 mothers this valuable technique is completely without danger to the fcetus. We have recently examined maternal blood for foetal cells and we have never found foetal cells in the maternal circulation after amniocentesis unless there is obvious blood in the liquor.
By assessing the severity of hsemolytic disease of the newborn antenatally and practising induction of labour when indicated, the survival-rate of infants affected with hsemolytic disease in this hospital has risen approximately one-third, representing the further survival of 30 babies 1. Walker, A. H. C., Jennison, R. F. Brit. med. J. 1962, ii, 1152. 2. Kelsall G. A., Vos, G. H., Kirk, R. L. Med. J. Aust. 1959, i, 488. 3. Zipursky, A., Pollock, J., Chown, B., Israels, L. G. Lancet, Sept. 7, 1963
MOVEMENT OF DOCTORS BETWEEN COUNTRIES SIR,-Your comments of Oct. 26 were read with interest,
the article by Dr. Whitfield in the same issue. Apparently no-one is yet convinced that medical immigration-emigration represents a major problem. Everyone probably agrees that it some day may. If so, in the best traditions of British Medicine, we should search as was
for and examine the causes of such movement and try to remedy them. You refer to this approach in last sentence, but you give more consideration to the your " of question the necessity for a policy for controlling ... emigration of doctors "-i.e., legislation to prevent free movement of citizens. This, I understand is a policy which has not worked well, even in East Germany. This, I believe, is Police State " thinking, Sir, and is beneath the dignity and tradition of British Medicine as exemplified remove or
by The Lancet. Manitoba Clinic,
A. B. HOUSTON.
*** Doctors provide an essential social service; and, if their number became severely depleted, the Government of the day might argue that, with due notice, medical 1.
Griffiths, J. C. Scot. med. J. 1962, 7,