1326 abnormalities of sodium intake or metabolism play in the genesis of essential hypertension. The years have, however, brought us some knowledge of when and how to control sodium intake in the hypertensive patient. The first important distinction to make is between the patient with essential or renovascular hypertension associated with good renal function, and the patient with advanced renal failure and clear evidence of sodium retention. The academic niceties of the balance between renin and sodium have previously been reviewed here. 74 suffice it to say that those patients who are either on dialysis or approaching dialysis require sodium restriction to prevent overload. 75 In nonspecialist clinical practice these are extremely rare. Almost all patients who attend a hypertensive clinic or general practice will have renal function which is either normal or (in the most severe cases) only slightly
impaired. Since the classic studies of Ambard and Beaujard 76e at the turn of the century, it has been known that salt restriction will lower blood-pressure. Clinical application of this discovery naturally followed." Salt restriction was widely advocated after the 1939-45 war’$with the development of the Kempner rice-fruit diet.’" This went into abeyance in the treatment of essential hypertension for three reasons. Firstly, drugs with more potent hypotensive action became available. Secondly, it was shown that a profound degree of salt restriction was required to obtain a significant effect. (In one study, for instance, substantial benefit was obtained only when dietary sodium intake was reduced to 10 mmol a day or less.110 Whilst some renal-failure patients may require this, the individual with essential
hypertension will, quite reasonably, object to lifelong sodium restriction of this degree.) The third reason for doubts about salt restriction in hypertension is that patients with impaired renal function often showed a further degree of impairment with salt depletion, and this could even prove life-threatening.81 Even in normal individuals, salt depletion causes a fall in glomerular filtration, but this is not clinically important. 82 The minority of patients with pre-existing diminution in glomerular filtration cannot afford such a loss.
Current practice allows no place for salt restriction in the management of hypertension. The doctor who tells his hypertensive patient with normal renal function to avoid salt is wrong on two grounds. Firstly, the reduction in salt intake with such advice falls far short of that required to produce a significant effect upon blood-pressure. Secondly, existing drugs are potent enough to render the misery of effective lifelong salt restriction unnecessary. Our Australian colleagues will have to produce substantial evidence before current thought upon this topic is altered. 74. 75. 76. 77. 78.
79. 80. 81. 82.
Lancet, April 5, 1975, p. 783. Ulvila, J. M., Kennedy, J. A., Lamberg, J. D., Scribner, B. H. J. Am. med. Ass. 1972, 220, 233. Ambard, L., Beaujard, E. Arch. gén. Méd. 1904, 1, 520. Allen, F. M., Sherrill, J. W. J. Metab. Res. 1922, 2, 429. Grollman, A., Harrison, T. R., Mason, M. F., Baxter, J., Crampton, J., Reichsman, F. J. Am. med. Ass. 1945, 129, 533. Kempner, W. Am. J. Med. 1948, 4, 545. Corcoran, A. C., Taylor, R. D., Page, I. H. Circulation, 1951, 3, 1. Chasis, H., Goldring, W., Breed, E., Bolomey, A., Smith, H. W. J. clin. Invest. 1949, 28, 775 (abstr.). Nickel, J. F., Lowrance, P. B., Leifer, E., Bradley, S. E. ibid. 1953, 32, 68.
NO CHILDHOOD
OVER 8000
mentally and physically handicapped
children in Britain at present live in long-stay hospitals, many of them having been abandoned by their families. Yet they are denied the high standards of care that children who are similarly deprived but not handicapped enjoy in local-authority children’s homes. This discrepancy in the standards of care of handicapped and non-handicapped deprived children in the 1970s is taken up in the pamphlet No Childhood1 from the Council for Children’s Welfare. Despite the emphasis of the reorganised Health Service on community care, the report notes that an increasing number of hospitals are now assuming the role of substitute homes for handicapped children, their staff acting as substitute parents. Most of these children are not acutely ill; they do not require elaborate nursing procedures but, rather, good child-care practices; and yet they spend their childhood years in hospitals ill-equipped to cope with their situation. Long-stay hospitals have never been the subject of legislation to prevent bad child-care practices. Under the Children and Young Persons’ Act a child living in a community home is guaranteed certain basic
rights as regards privacy, mothering, clothing, education, and holidays. His deprived handicapped sibling, on the other hand, has to live in hospital where these fundamental rights are denied. For years he will have to endure mass bathing and toileting, constant changes in staff, communal clothing, absence of community links, and limited educational opportunities. No Childhood recommends that responsibility for the everyday care of handicapped children should be transferred from the health authorities to the localauthorities’ social-services departments. Implicit in such a move would be an acknowledgment that hospitals cannot provide for these children proper standards of care or recognition of their psychological needs. As a short-term measure, the localauthority social-services department might take over the wards of the long-stay hospital and run them on a children’s home basis. The longer-term objective would be to close the wards and 3 return the children to family or community care in their place of origin. This would involve the local authority in accepting its obligation to provide small community homes as part of the local services. It should also encourage fostering, thedesirability and feasibility of which is shown in a report, based on North American experience, from the Campaign for the Mentally
Handicapped.2 Until lately, adoption
of mentally handicapped children was not even countenanced, principally because it was thought inconceivable that suitable parents could be found. The Parent to Parent Information on Adoption Services3 group, however, have received an increasing number of requests from 1. No Childhood: The Handicapped Child at Home and in Hospital in the 1970s. Council for Children’s Welfare, 183/189 Finchley Road, London NW3. 2. More Foster Care Needed for Mentally Handicapped Children. Campaign for the Mentally Handicapped, 96 Portland Place, London W1N 4EX. 3. Parent to Parent Information on Adoption Services, 26 Belsize Grove, London NW3.
1327
couples interested in adopting these children. Moreover, a considerable number of mentally handicapped children who are placed with families progress mentally to a degree previously thought impossible. No Childhood suggests that small inpatient units providing intensive rehabilitation programmes could be established for the most severely handicapped and disturbed children, who can now benefit from modem techniques of therapy and communication aids. In addition it advocates improvement of staff training and attitudes, with emphasis on child-care training and experience at all levels. Much of what is required is simple mothering. A group that seems particularly well suited to this work, by both situation and temperament, is the elderly. If selected carefully they might be grateful for the opportunity to engage in a worthwhile occupation of this sort. Parents of handicapped children have not received the medical and social support they needed to keep their children at home. When the family unit breaks down, the handicapped child must make his home elsewhere. The report’s main contention is the need to accept the right of these children to long-term home care. STREPTOZOTOCIN FOR PANCREATIC CHOLERA THE syndrome of watery diarrhoea, hypokalaemia, and absence of gastric-acid hypersecretion associated with non-beta islet-cell tumour was first reported in 1958 and is now often called pancreatic cholera. 1,s About half the tumours are malignant with distant metastases by the time of surgical exploration, and in these cases, although resection of part of the tumour mass, corticosteroid therapy, or radiotherapy may be of temporary help, the clinical course is usually inexorably downhill.3 The pathophysiology of the condition is still uncertain, and various peptide hormones which may be secreted by the tumour have been suggested.In at least some cases vasoactive intestinal peptide may be implicated. The presence of an isletcell tumour suggests that the cytotoxic drug streptozotocin might be useful in clinical practice. This drug has been found useful in malignant insulinomas 5 and and it may also be of value in non-beta islet-cell tumours secreting various other hormones.B,? Kahn and his colleagues 8 now report two patients with pancreatic cholera who obtained remarkable and prolonged symptomatic relief on streptozotocin. Both patients had extensive hepatic metastases, and the drug was given by infusion into the hepatic artery. This resulted in lower systemic blood-levels and less renal excretion than when the same dose was given into a peripheral vein. In addition to delivering the drug in high concentration directly to the site where it is required, which should increase its effectiveness, this method of treatment may also reduce the high inci1. Verner, J. V., Morrison, A. B. Am. J. Med. 1958, 25, 374. 2. Verner, J. V., Morrison, A. B. Archs intern. Med. 1974, 133, 492. 3. Schein, P. S., et al. Ann. intern. Med. 1973, 79, 239. 4. Bloom, S. R., Polak, J. M., Pearce, A. G. E. Lancet, 1973, ii, 14. 5. ibid. p. 1063. 6. Murray-Lyon, I. M., Eddleston, A. L. W. F., Williams, R., Brown, M., Hogbin, B. M., Bennett, A., Edwards, J. C., Taylor, K. W. ibid. 1968, ii, 895. 7. De Wys, W. D., et al. Am. J. Med. 1973, 55, 671. 8. Kahn, C. R., Levy, A. G., Gardner, J. D., Miller, J. V., Gorden, P., Schein, P. S. New Engl. J. Med. 1975, 292, 941.
dence of renal toxicity which is encountered with intravenous therapy. CHEMICAL PATHOLOGY—ANY FUTURE ? WHY is chemical pathology failing to recruit medical graduates ? Will the specialty disappear ? Should it disappear ? These questions will be familiar to Lancet readers. 1, The image of a specialty is founded on the work done in hospital and on the publications which issue from the academic side. On both counts chemical pathology seems heavily preoccupied with methodology, with in-vitro biochemistry, with automation, and with data processing. Though clinical biochemistry is ubiquitous in the medical journals,a most of the published work seems to come from physicians and full-time research-workers-and very little from chemical pathologists.4 So what is there in chemical pathology to attract the medical graduate who, though interested in biochemistry, still wants to deal with patients and to treat disease ? Today’s typical efficient and comprehensive biochemistrylaboratory service, say the doubters, might just as well be run by a non-medical; and the low recruitment to chemical pathology shows how medical graduates feel about working as laboratory managers. So, if chemical pathology were to slide gently from medical control, there might be few tears shed. In the United States, non-medical encroachment on the whole of clinical pathology is far advanced. Only in morphology is the medically trained pathologist still dominant.5 But a few chemical pathologists are doing something different. They are seen on the wards; they collaborate in clinical, biochemical, and metabolic investigations; and some of them care directly for patients with special problems. Could the future of the specialty lie this way ?6,7 If so, the chemical pathologist of the future will need postgraduate experience of medicine (perhaps to M.R.C.P. level) as well as of biochemistrya training far removed from the tedious years now spent in methodology, laboratory management, data processing, and report-signing. His laboratory facilities would be specialised rather than routine; so he could work in harmony with the non-medical biochemists. while avoiding the charge of being a mere dabbler in matters biochemical .4 The Royal College of Pathologists already favours a wide range of clinical experience for would-be haematologists; and, as Calvert points out, the Australians go further, with a combined scheme run by their colleges of Physicians and Pathologists. The choice for chemical pathology seems to lie between Yet heads of chemicalextinction and change. pathology units, from their laboratories and offices, continue to mould trainees in their own images. Salvation may be round the corner, but it will not be won without a change of direction. It is surely time for the Physicians and the Pathologists to have a serious talk. Lancet, 1974, i, 300. ibid. p. 1204. Wills, E. D. ibid. 1974, ii, 217. Calvert, G. D. ibid. p. 473. Stein, A. Bull. Coll. Am. Path. 1975, 29, 167. Carter, P. M., Davison, A. J., Wickings, H. I., Zilva, J. F. Lancet, p. 1555. 7. Cheng, B., Lockey, E. ibid. April 19, 1975, p. 920.
1. 2. 3. 4. 5. 6.
impaired. Since the classic studies of Ambard and Beaujard 76e at the turn of the century, it has been known that salt restriction will lower blood-pressure. Clinical application of this discovery naturally followed." Salt restriction was widely advocated after the 1939-45 war’$with the development of the Kempner rice-fruit diet.’" This went into abeyance in the treatment of essential hypertension for three reasons. Firstly, drugs with more potent hypotensive action became available. Secondly, it was shown that a profound degree of salt restriction was required to obtain a significant effect. (In one study, for instance, substantial benefit was obtained only when dietary sodium intake was reduced to 10 mmol a day or less.110 Whilst some renal-failure patients may require this, the individual with essential
hypertension will, quite reasonably, object to lifelong sodium restriction of this degree.) The third reason for doubts about salt restriction in hypertension is that patients with impaired renal function often showed a further degree of impairment with salt depletion, and this could even prove life-threatening.81 Even in normal individuals, salt depletion causes a fall in glomerular filtration, but this is not clinically important. 82 The minority of patients with pre-existing diminution in glomerular filtration cannot afford such a loss.
Current practice allows no place for salt restriction in the management of hypertension. The doctor who tells his hypertensive patient with normal renal function to avoid salt is wrong on two grounds. Firstly, the reduction in salt intake with such advice falls far short of that required to produce a significant effect upon blood-pressure. Secondly, existing drugs are potent enough to render the misery of effective lifelong salt restriction unnecessary. Our Australian colleagues will have to produce substantial evidence before current thought upon this topic is altered. 74. 75. 76. 77. 78.
79. 80. 81. 82.
Lancet, April 5, 1975, p. 783. Ulvila, J. M., Kennedy, J. A., Lamberg, J. D., Scribner, B. H. J. Am. med. Ass. 1972, 220, 233. Ambard, L., Beaujard, E. Arch. gén. Méd. 1904, 1, 520. Allen, F. M., Sherrill, J. W. J. Metab. Res. 1922, 2, 429. Grollman, A., Harrison, T. R., Mason, M. F., Baxter, J., Crampton, J., Reichsman, F. J. Am. med. Ass. 1945, 129, 533. Kempner, W. Am. J. Med. 1948, 4, 545. Corcoran, A. C., Taylor, R. D., Page, I. H. Circulation, 1951, 3, 1. Chasis, H., Goldring, W., Breed, E., Bolomey, A., Smith, H. W. J. clin. Invest. 1949, 28, 775 (abstr.). Nickel, J. F., Lowrance, P. B., Leifer, E., Bradley, S. E. ibid. 1953, 32, 68.
NO CHILDHOOD
OVER 8000
mentally and physically handicapped
children in Britain at present live in long-stay hospitals, many of them having been abandoned by their families. Yet they are denied the high standards of care that children who are similarly deprived but not handicapped enjoy in local-authority children’s homes. This discrepancy in the standards of care of handicapped and non-handicapped deprived children in the 1970s is taken up in the pamphlet No Childhood1 from the Council for Children’s Welfare. Despite the emphasis of the reorganised Health Service on community care, the report notes that an increasing number of hospitals are now assuming the role of substitute homes for handicapped children, their staff acting as substitute parents. Most of these children are not acutely ill; they do not require elaborate nursing procedures but, rather, good child-care practices; and yet they spend their childhood years in hospitals ill-equipped to cope with their situation. Long-stay hospitals have never been the subject of legislation to prevent bad child-care practices. Under the Children and Young Persons’ Act a child living in a community home is guaranteed certain basic
rights as regards privacy, mothering, clothing, education, and holidays. His deprived handicapped sibling, on the other hand, has to live in hospital where these fundamental rights are denied. For years he will have to endure mass bathing and toileting, constant changes in staff, communal clothing, absence of community links, and limited educational opportunities. No Childhood recommends that responsibility for the everyday care of handicapped children should be transferred from the health authorities to the localauthorities’ social-services departments. Implicit in such a move would be an acknowledgment that hospitals cannot provide for these children proper standards of care or recognition of their psychological needs. As a short-term measure, the localauthority social-services department might take over the wards of the long-stay hospital and run them on a children’s home basis. The longer-term objective would be to close the wards and 3 return the children to family or community care in their place of origin. This would involve the local authority in accepting its obligation to provide small community homes as part of the local services. It should also encourage fostering, thedesirability and feasibility of which is shown in a report, based on North American experience, from the Campaign for the Mentally
Handicapped.2 Until lately, adoption
of mentally handicapped children was not even countenanced, principally because it was thought inconceivable that suitable parents could be found. The Parent to Parent Information on Adoption Services3 group, however, have received an increasing number of requests from 1. No Childhood: The Handicapped Child at Home and in Hospital in the 1970s. Council for Children’s Welfare, 183/189 Finchley Road, London NW3. 2. More Foster Care Needed for Mentally Handicapped Children. Campaign for the Mentally Handicapped, 96 Portland Place, London W1N 4EX. 3. Parent to Parent Information on Adoption Services, 26 Belsize Grove, London NW3.
1327
couples interested in adopting these children. Moreover, a considerable number of mentally handicapped children who are placed with families progress mentally to a degree previously thought impossible. No Childhood suggests that small inpatient units providing intensive rehabilitation programmes could be established for the most severely handicapped and disturbed children, who can now benefit from modem techniques of therapy and communication aids. In addition it advocates improvement of staff training and attitudes, with emphasis on child-care training and experience at all levels. Much of what is required is simple mothering. A group that seems particularly well suited to this work, by both situation and temperament, is the elderly. If selected carefully they might be grateful for the opportunity to engage in a worthwhile occupation of this sort. Parents of handicapped children have not received the medical and social support they needed to keep their children at home. When the family unit breaks down, the handicapped child must make his home elsewhere. The report’s main contention is the need to accept the right of these children to long-term home care. STREPTOZOTOCIN FOR PANCREATIC CHOLERA THE syndrome of watery diarrhoea, hypokalaemia, and absence of gastric-acid hypersecretion associated with non-beta islet-cell tumour was first reported in 1958 and is now often called pancreatic cholera. 1,s About half the tumours are malignant with distant metastases by the time of surgical exploration, and in these cases, although resection of part of the tumour mass, corticosteroid therapy, or radiotherapy may be of temporary help, the clinical course is usually inexorably downhill.3 The pathophysiology of the condition is still uncertain, and various peptide hormones which may be secreted by the tumour have been suggested.In at least some cases vasoactive intestinal peptide may be implicated. The presence of an isletcell tumour suggests that the cytotoxic drug streptozotocin might be useful in clinical practice. This drug has been found useful in malignant insulinomas 5 and and it may also be of value in non-beta islet-cell tumours secreting various other hormones.B,? Kahn and his colleagues 8 now report two patients with pancreatic cholera who obtained remarkable and prolonged symptomatic relief on streptozotocin. Both patients had extensive hepatic metastases, and the drug was given by infusion into the hepatic artery. This resulted in lower systemic blood-levels and less renal excretion than when the same dose was given into a peripheral vein. In addition to delivering the drug in high concentration directly to the site where it is required, which should increase its effectiveness, this method of treatment may also reduce the high inci1. Verner, J. V., Morrison, A. B. Am. J. Med. 1958, 25, 374. 2. Verner, J. V., Morrison, A. B. Archs intern. Med. 1974, 133, 492. 3. Schein, P. S., et al. Ann. intern. Med. 1973, 79, 239. 4. Bloom, S. R., Polak, J. M., Pearce, A. G. E. Lancet, 1973, ii, 14. 5. ibid. p. 1063. 6. Murray-Lyon, I. M., Eddleston, A. L. W. F., Williams, R., Brown, M., Hogbin, B. M., Bennett, A., Edwards, J. C., Taylor, K. W. ibid. 1968, ii, 895. 7. De Wys, W. D., et al. Am. J. Med. 1973, 55, 671. 8. Kahn, C. R., Levy, A. G., Gardner, J. D., Miller, J. V., Gorden, P., Schein, P. S. New Engl. J. Med. 1975, 292, 941.
dence of renal toxicity which is encountered with intravenous therapy. CHEMICAL PATHOLOGY—ANY FUTURE ? WHY is chemical pathology failing to recruit medical graduates ? Will the specialty disappear ? Should it disappear ? These questions will be familiar to Lancet readers. 1, The image of a specialty is founded on the work done in hospital and on the publications which issue from the academic side. On both counts chemical pathology seems heavily preoccupied with methodology, with in-vitro biochemistry, with automation, and with data processing. Though clinical biochemistry is ubiquitous in the medical journals,a most of the published work seems to come from physicians and full-time research-workers-and very little from chemical pathologists.4 So what is there in chemical pathology to attract the medical graduate who, though interested in biochemistry, still wants to deal with patients and to treat disease ? Today’s typical efficient and comprehensive biochemistrylaboratory service, say the doubters, might just as well be run by a non-medical; and the low recruitment to chemical pathology shows how medical graduates feel about working as laboratory managers. So, if chemical pathology were to slide gently from medical control, there might be few tears shed. In the United States, non-medical encroachment on the whole of clinical pathology is far advanced. Only in morphology is the medically trained pathologist still dominant.5 But a few chemical pathologists are doing something different. They are seen on the wards; they collaborate in clinical, biochemical, and metabolic investigations; and some of them care directly for patients with special problems. Could the future of the specialty lie this way ?6,7 If so, the chemical pathologist of the future will need postgraduate experience of medicine (perhaps to M.R.C.P. level) as well as of biochemistrya training far removed from the tedious years now spent in methodology, laboratory management, data processing, and report-signing. His laboratory facilities would be specialised rather than routine; so he could work in harmony with the non-medical biochemists. while avoiding the charge of being a mere dabbler in matters biochemical .4 The Royal College of Pathologists already favours a wide range of clinical experience for would-be haematologists; and, as Calvert points out, the Australians go further, with a combined scheme run by their colleges of Physicians and Pathologists. The choice for chemical pathology seems to lie between Yet heads of chemicalextinction and change. pathology units, from their laboratories and offices, continue to mould trainees in their own images. Salvation may be round the corner, but it will not be won without a change of direction. It is surely time for the Physicians and the Pathologists to have a serious talk. Lancet, 1974, i, 300. ibid. p. 1204. Wills, E. D. ibid. 1974, ii, 217. Calvert, G. D. ibid. p. 473. Stein, A. Bull. Coll. Am. Path. 1975, 29, 167. Carter, P. M., Davison, A. J., Wickings, H. I., Zilva, J. F. Lancet, p. 1555. 7. Cheng, B., Lockey, E. ibid. April 19, 1975, p. 920.
1. 2. 3. 4. 5. 6.
