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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.
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.
