BRITISH MEDICAL JOURNAL
5 AUGUST 1978
and will be fewer in number than those at present receiving limited-period oxygen. We would take issue with the conclusions of Dr Jones and his colleagues. Current domiciliary oxygen supply is costly, inefficient, and uses outdated equipment. Changes will have to be made, but only on the basis of a clearer knowledge of the type of patient likely to benefit, the duration and quantity of daily therapy required for clinical benefit, and a thorough evaluation of new techniques of delivery, "G" size cylinders, oxygen concentrators, or portable liquid oxygen systems. P HOWARD H C MIDDLETON Lodge Moor Hospital,
Sheffield 2
Neff, T A, and Petty, T L, Annals of Internal Medicine, 1970, 72, 621. Stark, R D, Finnegan, P, and Bishop, J M, British Medical fournal, 1972, 3, 724.
Maintenance treatment of duodenal ulcer with cimetidine
433
of reulceration and of non-ulcer dyspepsia as well as other gastrointestinal disturbances and, very rarely, mortality. Further experience of the long-term treatment of duodenal ulcer disease with cimetidine and of contemporary surgery are required before any firm conclusions can be made for the relative merits of these alternatives. W L BURLAND B HAWKINS R J HORTON
of operation is considerably better defined than that of cimetidine and our original letter was intended to give a temporal assessment on current evidence while the clinical use of cimetidine is being extended. C G CLARK J H WYLLIE Surgical Unit, University College Hospital Medical School, London WC1
Smith, Kline, and French Laboratories Ltd,
Welwyn Garden City, Herts 1 Burland, W L, et al, in Proceedings of Westminster Hospital Symposium on Cimetidine. Edinburgh, Churchill Livingstone. In press. 2 Bodemar, G, and Walan, A, Lancet, 1978, 1, 403. 3Wormsley, K G, Symposium on Management of Peptic Ulceration, Royal College of Surgeons of Edinburgh, April 1978.
***The authors sent a copy of this letter to Professors Clark and Wyllie, whose reply is printed below.-ED, BM7.
Efficacy of rubella vaccination SIR,-In the staff health unit of this hospital from 31 May 1977 to 1 June 1978 we examined the serum of 112 women and 22 men aged 18-50 + for the presence of rubella antibodies. This test is routine. Personnel when asked direct questions concerning vaccinations cannot give complete answers; we have therefore not asked about rubella immunisation to date. Fourteen women and two men were found by this test to be susceptible. It is our policy to offer rubella vaccine to all women of childbearing age. Of the 14 susceptible women, 12 accepted the vaccine, of whom nine were aged 18-25. The follow-up rubella haemagglutination inhibition (HAI) test in four of the 12 vaccinated showed evidence of susceptibility at periods ranging from 3 to 6 weeks. In one of these four the test became positive after three months, but in three it remained negative 3-8 months later. The hospital pharmacist has written to the makers, who have no explanation. The vaccine was stored in the recommended manner and was in date. Three different batch numbers were used as well as different makes at differing times. There is no historical or clinical evidence that any of the women who responded negatively to immunisation have abnormal immunological functions. Blood was sent through the normal hospital channels to a public laboratory for testing. These results clearly raise a number of issues concerning: (1) the efficacy of the vaccines; (2) the immunological integrity of the individuals; and (3) the integrity of the HAI test. There are also wider implications. If the findings were to be confirmed, then there are certain mandatory steps the profession should take before women of childbearing age can be assured of immunity as offered by immunisation. These must include follow-up studies of allegedly immunised women and a policy of revaccination should this be considered necessary. W J C ROBERTS
SIR,-If we made an error of interpretation of the data of Dr Burland and his colleagues SIR,-In making their case for surgical treat- others may do the same. From the table, if ment of chronic duodenal ulcer disease in 2 1 patients on 400 mg cimetidine at bedtime preference to cimetidine Professors C G relapsed per 100 patient months, then Clark and J H Wyllie (8 July, p 123) appear recurrence would appear to be at a rate of to have made an error in reference to our 2522% per annum (not 1340%) and we conreview of data for recurrence of duodenal ulcer clude that the average length of follow-up of during longer-term treatment with cimetidine.1 the 179 patients was 6 4 months. In 184 These data are given in the table below and are patients treated with cimetidine 400mg not dissimilar from those also referred to by twice daily the follow-up was 7 2 months Professors Clark and Wyllie which were with a symptomatic relapse rate of 21 60%. reported by Bodemar and Walan2 and Dr E In addition there are a further 7%/ of patients Gudmand-Hoyer and others (29 April, p 1095). with asymptomatic reulceration. Their data Professors Clark and Wyllie are also concerned are therefore not comparable with those of about the frequency of symptomless recur- Bodeman and Walan or Dr Gudmand-Hoyer rence associated with cimetidine treatment and his colleagues, who followed patients for a as reported by Wormsley.3 Data for this whole year. Our reference to a relapse rate of 40%O we association from our review are also presented in the table and suggest that longer-term regarded as understating what was found in treatment with cimetidine will protect against Dr Burland's data at one year-namely, 23 symptomless reulceration and that short-term of 47 patients (490o with 95%0 confidence courses of treatment with cimetidine are not limits 35-630o). If this is not correct then more likely to be associated with subsequent clarification is necessary. Symptomless recurrence was seen this symptomless reulceration. Professors Clark and Wyllie do not discuss week in one of our patients, a man aged 39 the merits of additional courses of treatment treated on maintenance therapy for just over with cimetidine. Should duodenal ulcers recur one year. He presented with severe haemduring longer-term treatment or when that orrhage necessitating emergency surgery, a treatment is discontinued, then a second situation which carries an appreciable mortality course of treatment and indeed a third may in elderly patients. We do not dispute that second or third therapeutic courses of be as successful as the first.2 They also refer to some of the best results cimetidine may be given to those who relapse available from proximal gastric vagotomy. on maintenance therapy. Nor do we dispute While this is becoming the operation of choice, that recurrent ulceration is seen after proximal Bronglais General Hospital, it is fair to say that its long-term efficacy and gastric vagotomy. Indeed, comparing silent Aberystwyth, Dyfed safety are no more well defined than for recurrence with cimetidine and recurrence cimetidine. Results are likely to improve with after surgery, the incidence is about the same, increased operator experience, but at present and it may well be that the risks involved are it is an irreversible procedure (unlike medica- no different though for different reasons. Children who cannot read tion) associated with a small but real incidence However, we do think the long-term efficacy SIR,-I was disappointed by your leading article on this subject (1 July, p 3). Ten years as school medical officer have given me a special Recurrence of ulceration during longer-term cimetidine treatment interest in this problem and I thought your strong psychological bias left a very important Asymptomatic reulceration Symptomatic reulceration group of children too much out of account. seen at routine endoscopy confirmed at endoscopy Treatment (No) These children are far from being negligible (Patients entered studies with No No 100 No (%°') per with endoscopically proved in numbers and often have high intellectual reulceration examined patient-months No (%) healed ulcers) treatment ability. As a rule they are psychologically stable, although considerable mental stress 4 (5 3) 75 21 24 (13-4) Cimetidine 400 mg at bedtime (179) 7 (9 3) 75 1-8 may be caused by their disability. They 24 (13-0) Cimetidine 400 mg twice daily (184) 0) (30 22 75* 9.9 158 (47 4) . Placebo (333) . suffer-I use the word literally and purposean inherited neurological defect fully-from *13 previously treated with placebo and 5 (38%) ulcerated; 60 previously treated with cimetidine and 17 (28%) which makes interpretation of written symbols ulcerated. none and or cimetidine than placebo other with drugs treated 2 previously ulcerated;
434
BRITISH MEDICAL JOURNAL
a difficult problem. This, it should be noted, is an isolated cognitive defect. Few qualified doctors find the concept of acquired dyslexia, as for example the result of a cerebral vascular accident, difficult to accept, but strangely an inherited defect causing difficulty in learning to read in an otherwise normal child appears to be almost unbelievable. Were this not the case the term dyslexia would not be held in such suspicion and the powerful negating control that many educational psychologists hold over the whole problem of reading difficulties would never have eventuated. One must sadly come to the conclusion that many doctors have abrogated their responsibilities for this important aspect of the school medical service. This has led to greater hardships for this group of children, who with their parents are in an impossible position to conduct their own defence. This is the chief cause for the shortage of specialised remedial teachers of which you make mention, whereas many other countries which recognise the true nature of the problem have no such deficit. For a more balanced view of the whole subject of the problem of children who cannot read I recommend a small book by MacDonald
Critchley.' It is, of course, recognised that this group of children with a neurological defect are suffering from only one of a number of causes of reading difficulties. They are, however, quite separate from the continuum usually recognised by the educational psychologists, which range from intellectual inadequacy at one end of the scale to neurosis at the other. They are nevertheless all too often incorporated into this, and as a result spend their secondary school careers in the general remedial section undergoing the usual group therapy. It is generally recognised by experts that they respond poorly to this and need much greater specialised teaching.2 They need, and are worthy of, special consideration, and as a working rule it is most misleading to qualify the degree of their disability as "particularly likely to express the behaviour-poor reading-in an adverse environment (for example, a large family or a poor school)." Most of them come from good caring and loving homes with two or three children, and it has not been my experience that any school shows particular poorness by demonstrating a greater number than others. R D HARLAND Seething, Norfolk
2
Critchley, M, The Dyslexic Child, 2nd edn. London, Heinemann. 1970. Department of Education and Science, Children with Specific Reading Difficulties, Report of the Advisory Committee on Handicapped Children, p 4, para 15. London, HMSO, 1972.
SIR,-With regard to your leading article (1 July, p 3), it should also be mentioned that those who study the physiology of education will mostly agree that a dedicated mother or other adult will prevent all chance of future reading difficulty if she arouses a very early interest by the infant in all aspects of wordstalking, reading, singing, drawing, writing, etc.1-3 In support for this early start it is obviously very desirable that all television programmes for children should illustrate some enjoyable aspects ofall the language skills. The current failure of our TV children's programmes to help adequately in this way is, I think, quite deplorable and positively
damaging to our national standards of education. W RITCHIE RUSSELL Oxford
lBrierley, J, Growing and Learning. London, Ward Lock Educational, 1978. 2 Ibuka, M, Kindergarten is Too Late. London, Souvenir Press, 1977. 3Russell, W R, Explaining the Brain. London, Oxford University Press, 1975.
Hypostatic ulceration and male sex chromosomal anomalies SIR,-Dr R Howell (8 July, p 95) recently reported six cases of Klinefelter's syndrome suffering from ulceration of legs and collected from the literature 14 other cases of the same disorder. In this hospital we have, among 343 male mentally handicapped patients, the following sex chromosomal abnormalities: two with Klinefelter's syndrome, one with XXXXY syndrome,1 and another with XXYY syndrome.2 In 1968 we admitted a patient for assessment who had an XXXY/XXY sex chromosomal anomaly. All these patients suffer from varicose veins of various degrees and two (one with XXXXY and one with XXYY syndrome) from hypostatic ulceration of the legs. As we have observed hypostatic ulceration in other clinical conditions and younger patients-for example, Prader-Willi syndrome3 at 12 years of age-we are planning to investigate all the hospital population for hypostatic ulceration and varicose veins and we would be grateful for any relevant observations on this subject from workers in mental handicap and, for comparison, from workers with the normal population. J JANCAR Purdown Hospital, Stapleton, Bristol
Jancar, J, Proceedings of the
International Copenhagen Congress for SSMR, 1964, vol 1, p 179. Jancar, J, Lancet, 1968, 2, 970. 3Jancar, J, Journal of Mental Deficiency Research, 1971, 15, 20.
'
3
SIR,-The article by Dr R Howell (8 July, p 95) provides evidence that chronic leg ulcers appear more often than expected in men with Klinefelter's syndrome. Dr Howell suggests that this chromosomal anomaly should be considered in men presenting with hypostatic ulceration. We wish to draw attention to the fact that not only supernumerary X chromosomes in men but also additional Y chromosomes seem to have this effect. Court Brown et all found varicose ulcerations in two YY men in a series of 15. We have systematically examined 24 men with double Y chromosomes, cared for in mental hospitals, with respect to the tendency to varicose veins.2 We recognised two grades, a severe and a milder. Subjects were assigned to the severe grade who, in addition to varicose veins, had complications in the form of attacks of thrombophlebitis or leg ulcers, either currently or in the medical history. Such a condition of severe varices with complications was present in five of our index cases (210%). By comparison with the prevalence figures given in the literature we considered it justified to assert that our figure shows that the chromosomal constitution 47,XYY carries with it an increased risk of varicose veins and hypostatic ulceration. It is interesting that the two gonosomal
5 AUGUST 1978
aberrations in males should have this effect in common. HANS FORSSMAN LEIF WALLIN University of Goteborg, Psychiatric Research Centre, St Jorgen's Hospital, Hisings Backa, Sweden. Brown, W M C, Price, W H, and Jacobs, P A, British Medical journal, 1968, 2, 325.
2Forssman, H, et al, Males with Double Y-chromosomes. Grroteborg, Akademiforlaget, 1975.
Depot fluphenazine and tardive dyskinesia SIR,-The view expressed in Any Questions ? (8 July, p 114) that the risk of causing longterm dyskinesia with depot fluphenazine is small is probably optimistic. Although different workers have described greatly differing figures for the incidence of tardive dyskinesia (TD) in different studies, their criteria for diagnosis must have differed, and recent investigations suggest a high incidence of the condition in patients who have received neuroleptic drugs for many years. For instance Bell and Smith,' looking at the population in nine mental hospitals in Illinois and rating signs of all severity, found that 400 of patients exhibited probable evidence of TD and 260% showed undoubted signs. Most of these patients were on oral neuroleptics, but there is no reason to suppose that patients receiving fluphenazine by injection would be less likely to develop dyskinesia. Not only do they have less chance to be non-adherers to a treatment schedule, but the injection bypasses the vagaries of absorption of oral preparations.2 In this area we have nearly 400 patients on depot fluphenazine and fluphenthixol and since 1973 63 of them have developed TD, though it is fortunately mild in the majority. All had had other neuroleptics before. Nevertheless, depot injections have allowed thousands of people to lead reasonably normal lives outside hospital and it is surely better to have involuntary movements of the lower face and tongue than to suffer the disturbing perceptions of uncontrolled schizophrenia; if we psychiatrists would use neuroleptics in the smallest effective therapeutic dose (half my patients on fluphenazine need 12 5 mg monthly) and eschew the use of the routine anticholinergic drugs the next generation of schizophrenics might have less trouble with TD than the present. ALAN C GIBSON St Ann's Hospital,
Poole, Dorset
Bell, R C H, and Smith, R C, J7ournal of Clinical Psychiatry, 1978, 39, 39 and 46. 2Adamson, L, et al, Diseases of the Nervous System, 1973, 34, 181.
Prostaglandin F2, and tumours of the female genital tract SIR,-Williams et all first reported elevated levels of prostaglandins (PG) in tumour tissues and in the plasma of patients with medullary carcinoma of the thyroid. Subsequently, raised blood PGE2 and PGF2, levels have been reported in association with a variety of human tumours, including phaeochromocytoma, carcinoid tumours, rectal carcinoma, Kaposi's sarcoma, neuroblastoma, bronchial carcinoma, islet cell tumours, and carcinoma of the breast.
5 AUGUST 1978
and will be fewer in number than those at present receiving limited-period oxygen. We would take issue with the conclusions of Dr Jones and his colleagues. Current domiciliary oxygen supply is costly, inefficient, and uses outdated equipment. Changes will have to be made, but only on the basis of a clearer knowledge of the type of patient likely to benefit, the duration and quantity of daily therapy required for clinical benefit, and a thorough evaluation of new techniques of delivery, "G" size cylinders, oxygen concentrators, or portable liquid oxygen systems. P HOWARD H C MIDDLETON Lodge Moor Hospital,
Sheffield 2
Neff, T A, and Petty, T L, Annals of Internal Medicine, 1970, 72, 621. Stark, R D, Finnegan, P, and Bishop, J M, British Medical fournal, 1972, 3, 724.
Maintenance treatment of duodenal ulcer with cimetidine
433
of reulceration and of non-ulcer dyspepsia as well as other gastrointestinal disturbances and, very rarely, mortality. Further experience of the long-term treatment of duodenal ulcer disease with cimetidine and of contemporary surgery are required before any firm conclusions can be made for the relative merits of these alternatives. W L BURLAND B HAWKINS R J HORTON
of operation is considerably better defined than that of cimetidine and our original letter was intended to give a temporal assessment on current evidence while the clinical use of cimetidine is being extended. C G CLARK J H WYLLIE Surgical Unit, University College Hospital Medical School, London WC1
Smith, Kline, and French Laboratories Ltd,
Welwyn Garden City, Herts 1 Burland, W L, et al, in Proceedings of Westminster Hospital Symposium on Cimetidine. Edinburgh, Churchill Livingstone. In press. 2 Bodemar, G, and Walan, A, Lancet, 1978, 1, 403. 3Wormsley, K G, Symposium on Management of Peptic Ulceration, Royal College of Surgeons of Edinburgh, April 1978.
***The authors sent a copy of this letter to Professors Clark and Wyllie, whose reply is printed below.-ED, BM7.
Efficacy of rubella vaccination SIR,-In the staff health unit of this hospital from 31 May 1977 to 1 June 1978 we examined the serum of 112 women and 22 men aged 18-50 + for the presence of rubella antibodies. This test is routine. Personnel when asked direct questions concerning vaccinations cannot give complete answers; we have therefore not asked about rubella immunisation to date. Fourteen women and two men were found by this test to be susceptible. It is our policy to offer rubella vaccine to all women of childbearing age. Of the 14 susceptible women, 12 accepted the vaccine, of whom nine were aged 18-25. The follow-up rubella haemagglutination inhibition (HAI) test in four of the 12 vaccinated showed evidence of susceptibility at periods ranging from 3 to 6 weeks. In one of these four the test became positive after three months, but in three it remained negative 3-8 months later. The hospital pharmacist has written to the makers, who have no explanation. The vaccine was stored in the recommended manner and was in date. Three different batch numbers were used as well as different makes at differing times. There is no historical or clinical evidence that any of the women who responded negatively to immunisation have abnormal immunological functions. Blood was sent through the normal hospital channels to a public laboratory for testing. These results clearly raise a number of issues concerning: (1) the efficacy of the vaccines; (2) the immunological integrity of the individuals; and (3) the integrity of the HAI test. There are also wider implications. If the findings were to be confirmed, then there are certain mandatory steps the profession should take before women of childbearing age can be assured of immunity as offered by immunisation. These must include follow-up studies of allegedly immunised women and a policy of revaccination should this be considered necessary. W J C ROBERTS
SIR,-If we made an error of interpretation of the data of Dr Burland and his colleagues SIR,-In making their case for surgical treat- others may do the same. From the table, if ment of chronic duodenal ulcer disease in 2 1 patients on 400 mg cimetidine at bedtime preference to cimetidine Professors C G relapsed per 100 patient months, then Clark and J H Wyllie (8 July, p 123) appear recurrence would appear to be at a rate of to have made an error in reference to our 2522% per annum (not 1340%) and we conreview of data for recurrence of duodenal ulcer clude that the average length of follow-up of during longer-term treatment with cimetidine.1 the 179 patients was 6 4 months. In 184 These data are given in the table below and are patients treated with cimetidine 400mg not dissimilar from those also referred to by twice daily the follow-up was 7 2 months Professors Clark and Wyllie which were with a symptomatic relapse rate of 21 60%. reported by Bodemar and Walan2 and Dr E In addition there are a further 7%/ of patients Gudmand-Hoyer and others (29 April, p 1095). with asymptomatic reulceration. Their data Professors Clark and Wyllie are also concerned are therefore not comparable with those of about the frequency of symptomless recur- Bodeman and Walan or Dr Gudmand-Hoyer rence associated with cimetidine treatment and his colleagues, who followed patients for a as reported by Wormsley.3 Data for this whole year. Our reference to a relapse rate of 40%O we association from our review are also presented in the table and suggest that longer-term regarded as understating what was found in treatment with cimetidine will protect against Dr Burland's data at one year-namely, 23 symptomless reulceration and that short-term of 47 patients (490o with 95%0 confidence courses of treatment with cimetidine are not limits 35-630o). If this is not correct then more likely to be associated with subsequent clarification is necessary. Symptomless recurrence was seen this symptomless reulceration. Professors Clark and Wyllie do not discuss week in one of our patients, a man aged 39 the merits of additional courses of treatment treated on maintenance therapy for just over with cimetidine. Should duodenal ulcers recur one year. He presented with severe haemduring longer-term treatment or when that orrhage necessitating emergency surgery, a treatment is discontinued, then a second situation which carries an appreciable mortality course of treatment and indeed a third may in elderly patients. We do not dispute that second or third therapeutic courses of be as successful as the first.2 They also refer to some of the best results cimetidine may be given to those who relapse available from proximal gastric vagotomy. on maintenance therapy. Nor do we dispute While this is becoming the operation of choice, that recurrent ulceration is seen after proximal Bronglais General Hospital, it is fair to say that its long-term efficacy and gastric vagotomy. Indeed, comparing silent Aberystwyth, Dyfed safety are no more well defined than for recurrence with cimetidine and recurrence cimetidine. Results are likely to improve with after surgery, the incidence is about the same, increased operator experience, but at present and it may well be that the risks involved are it is an irreversible procedure (unlike medica- no different though for different reasons. Children who cannot read tion) associated with a small but real incidence However, we do think the long-term efficacy SIR,-I was disappointed by your leading article on this subject (1 July, p 3). Ten years as school medical officer have given me a special Recurrence of ulceration during longer-term cimetidine treatment interest in this problem and I thought your strong psychological bias left a very important Asymptomatic reulceration Symptomatic reulceration group of children too much out of account. seen at routine endoscopy confirmed at endoscopy Treatment (No) These children are far from being negligible (Patients entered studies with No No 100 No (%°') per with endoscopically proved in numbers and often have high intellectual reulceration examined patient-months No (%) healed ulcers) treatment ability. As a rule they are psychologically stable, although considerable mental stress 4 (5 3) 75 21 24 (13-4) Cimetidine 400 mg at bedtime (179) 7 (9 3) 75 1-8 may be caused by their disability. They 24 (13-0) Cimetidine 400 mg twice daily (184) 0) (30 22 75* 9.9 158 (47 4) . Placebo (333) . suffer-I use the word literally and purposean inherited neurological defect fully-from *13 previously treated with placebo and 5 (38%) ulcerated; 60 previously treated with cimetidine and 17 (28%) which makes interpretation of written symbols ulcerated. none and or cimetidine than placebo other with drugs treated 2 previously ulcerated;
434
BRITISH MEDICAL JOURNAL
a difficult problem. This, it should be noted, is an isolated cognitive defect. Few qualified doctors find the concept of acquired dyslexia, as for example the result of a cerebral vascular accident, difficult to accept, but strangely an inherited defect causing difficulty in learning to read in an otherwise normal child appears to be almost unbelievable. Were this not the case the term dyslexia would not be held in such suspicion and the powerful negating control that many educational psychologists hold over the whole problem of reading difficulties would never have eventuated. One must sadly come to the conclusion that many doctors have abrogated their responsibilities for this important aspect of the school medical service. This has led to greater hardships for this group of children, who with their parents are in an impossible position to conduct their own defence. This is the chief cause for the shortage of specialised remedial teachers of which you make mention, whereas many other countries which recognise the true nature of the problem have no such deficit. For a more balanced view of the whole subject of the problem of children who cannot read I recommend a small book by MacDonald
Critchley.' It is, of course, recognised that this group of children with a neurological defect are suffering from only one of a number of causes of reading difficulties. They are, however, quite separate from the continuum usually recognised by the educational psychologists, which range from intellectual inadequacy at one end of the scale to neurosis at the other. They are nevertheless all too often incorporated into this, and as a result spend their secondary school careers in the general remedial section undergoing the usual group therapy. It is generally recognised by experts that they respond poorly to this and need much greater specialised teaching.2 They need, and are worthy of, special consideration, and as a working rule it is most misleading to qualify the degree of their disability as "particularly likely to express the behaviour-poor reading-in an adverse environment (for example, a large family or a poor school)." Most of them come from good caring and loving homes with two or three children, and it has not been my experience that any school shows particular poorness by demonstrating a greater number than others. R D HARLAND Seething, Norfolk
2
Critchley, M, The Dyslexic Child, 2nd edn. London, Heinemann. 1970. Department of Education and Science, Children with Specific Reading Difficulties, Report of the Advisory Committee on Handicapped Children, p 4, para 15. London, HMSO, 1972.
SIR,-With regard to your leading article (1 July, p 3), it should also be mentioned that those who study the physiology of education will mostly agree that a dedicated mother or other adult will prevent all chance of future reading difficulty if she arouses a very early interest by the infant in all aspects of wordstalking, reading, singing, drawing, writing, etc.1-3 In support for this early start it is obviously very desirable that all television programmes for children should illustrate some enjoyable aspects ofall the language skills. The current failure of our TV children's programmes to help adequately in this way is, I think, quite deplorable and positively
damaging to our national standards of education. W RITCHIE RUSSELL Oxford
lBrierley, J, Growing and Learning. London, Ward Lock Educational, 1978. 2 Ibuka, M, Kindergarten is Too Late. London, Souvenir Press, 1977. 3Russell, W R, Explaining the Brain. London, Oxford University Press, 1975.
Hypostatic ulceration and male sex chromosomal anomalies SIR,-Dr R Howell (8 July, p 95) recently reported six cases of Klinefelter's syndrome suffering from ulceration of legs and collected from the literature 14 other cases of the same disorder. In this hospital we have, among 343 male mentally handicapped patients, the following sex chromosomal abnormalities: two with Klinefelter's syndrome, one with XXXXY syndrome,1 and another with XXYY syndrome.2 In 1968 we admitted a patient for assessment who had an XXXY/XXY sex chromosomal anomaly. All these patients suffer from varicose veins of various degrees and two (one with XXXXY and one with XXYY syndrome) from hypostatic ulceration of the legs. As we have observed hypostatic ulceration in other clinical conditions and younger patients-for example, Prader-Willi syndrome3 at 12 years of age-we are planning to investigate all the hospital population for hypostatic ulceration and varicose veins and we would be grateful for any relevant observations on this subject from workers in mental handicap and, for comparison, from workers with the normal population. J JANCAR Purdown Hospital, Stapleton, Bristol
Jancar, J, Proceedings of the
International Copenhagen Congress for SSMR, 1964, vol 1, p 179. Jancar, J, Lancet, 1968, 2, 970. 3Jancar, J, Journal of Mental Deficiency Research, 1971, 15, 20.
'
3
SIR,-The article by Dr R Howell (8 July, p 95) provides evidence that chronic leg ulcers appear more often than expected in men with Klinefelter's syndrome. Dr Howell suggests that this chromosomal anomaly should be considered in men presenting with hypostatic ulceration. We wish to draw attention to the fact that not only supernumerary X chromosomes in men but also additional Y chromosomes seem to have this effect. Court Brown et all found varicose ulcerations in two YY men in a series of 15. We have systematically examined 24 men with double Y chromosomes, cared for in mental hospitals, with respect to the tendency to varicose veins.2 We recognised two grades, a severe and a milder. Subjects were assigned to the severe grade who, in addition to varicose veins, had complications in the form of attacks of thrombophlebitis or leg ulcers, either currently or in the medical history. Such a condition of severe varices with complications was present in five of our index cases (210%). By comparison with the prevalence figures given in the literature we considered it justified to assert that our figure shows that the chromosomal constitution 47,XYY carries with it an increased risk of varicose veins and hypostatic ulceration. It is interesting that the two gonosomal
5 AUGUST 1978
aberrations in males should have this effect in common. HANS FORSSMAN LEIF WALLIN University of Goteborg, Psychiatric Research Centre, St Jorgen's Hospital, Hisings Backa, Sweden. Brown, W M C, Price, W H, and Jacobs, P A, British Medical journal, 1968, 2, 325.
2Forssman, H, et al, Males with Double Y-chromosomes. Grroteborg, Akademiforlaget, 1975.
Depot fluphenazine and tardive dyskinesia SIR,-The view expressed in Any Questions ? (8 July, p 114) that the risk of causing longterm dyskinesia with depot fluphenazine is small is probably optimistic. Although different workers have described greatly differing figures for the incidence of tardive dyskinesia (TD) in different studies, their criteria for diagnosis must have differed, and recent investigations suggest a high incidence of the condition in patients who have received neuroleptic drugs for many years. For instance Bell and Smith,' looking at the population in nine mental hospitals in Illinois and rating signs of all severity, found that 400 of patients exhibited probable evidence of TD and 260% showed undoubted signs. Most of these patients were on oral neuroleptics, but there is no reason to suppose that patients receiving fluphenazine by injection would be less likely to develop dyskinesia. Not only do they have less chance to be non-adherers to a treatment schedule, but the injection bypasses the vagaries of absorption of oral preparations.2 In this area we have nearly 400 patients on depot fluphenazine and fluphenthixol and since 1973 63 of them have developed TD, though it is fortunately mild in the majority. All had had other neuroleptics before. Nevertheless, depot injections have allowed thousands of people to lead reasonably normal lives outside hospital and it is surely better to have involuntary movements of the lower face and tongue than to suffer the disturbing perceptions of uncontrolled schizophrenia; if we psychiatrists would use neuroleptics in the smallest effective therapeutic dose (half my patients on fluphenazine need 12 5 mg monthly) and eschew the use of the routine anticholinergic drugs the next generation of schizophrenics might have less trouble with TD than the present. ALAN C GIBSON St Ann's Hospital,
Poole, Dorset
Bell, R C H, and Smith, R C, J7ournal of Clinical Psychiatry, 1978, 39, 39 and 46. 2Adamson, L, et al, Diseases of the Nervous System, 1973, 34, 181.
Prostaglandin F2, and tumours of the female genital tract SIR,-Williams et all first reported elevated levels of prostaglandins (PG) in tumour tissues and in the plasma of patients with medullary carcinoma of the thyroid. Subsequently, raised blood PGE2 and PGF2, levels have been reported in association with a variety of human tumours, including phaeochromocytoma, carcinoid tumours, rectal carcinoma, Kaposi's sarcoma, neuroblastoma, bronchial carcinoma, islet cell tumours, and carcinoma of the breast.
