40

understand immunity to erytshocytic malaria, and it is far from simple. What we just do not know is how to identify and produce in bulk the appropriate antigen(s) of experimental malarias, let alone of P. falciparum and other human parasites. Nor do we know -how to present these antigens in a way which stimulates the inmnune system to best advantage without using Draconian adjuvants like F.CA. When we have solved these fomidable problems a practical vaccine incorprating blood stage antigens might become feasible.-I am, etc., K. N. BROWN

perience of the American centres, where in fact the opposite has bappened and more frequent isotope brain scanning has emerged as a consequence of the use of the E.M.I. scanner. The second point which needs clarification is related to the method of comparison implicit in t-he article. Since one should compare only "like with like," digital scanning based on x-Tay technology should be compared only with digital scanning based on radlionuclide technology. Indeed, computer-Wrocessed isotope brain scans produce images of high resolution and sensitivity. Data presemed at a recent postgraduate symposium at ColumNational Institute for Medical ReEearch, bia University, New York, by Kuhl comparLondon N.W.7 ing the E.M.I. scanner and his computer1 Freund, J., et al., American Yournal of Tropical assisted tomographic brain scanner (isotope Medicine, 1948, 28, 1. 2 Targett, C. A. T., and Fulton , J. D., Experi- scanner) proves this point very well. So if one wants to evaluate EM.I. scanner results mental Parasitology, 1965, 17, 180. 3 Brown, K. N., and Brown, I. N., Nature, 1965, one should avoid looking at the analogue 208, 1286. brain-scanning techniques. 4 Brown, I. N., et al., Immunology, 1968, 14, 127. 5Brown, K. N., et al., Experimental Parasitology, In spite of these 'Sbad days" for nuclear 1970, 28, 304. 6 Brown, K. N., and Hills, L. A., Transactions of medicine the accuracy of analogue brain the Royal Society of Tropical Medicine and scanning i's generally estimated at 85%. So Hygiene, 1972, 66, 668. far as we can foresee now, this figure will 7 Mitchell, G. H., et al., Nature, 1974, 252, 311. 8 Brown, K. N., and Tanaka, A., Transactions of improve with computer-assisted isotope the Royal Society of Tropical Medicine and scanning. This is a considerable asset for a Hygiene. In press. 9 Brown, K. N., Nature, 1974, 230, 163. technology which at the moment has not 10 Brown, K. N., Ciba Symposium. No. 25, p. 35. only passed the test of tinme but also offers Edinburgh, Churchill Livingstone, 1974. the advante of not employing a singlepurpose machine.-We are, etc., PETER ELL Withdrawal Symptoms in Newborn Infants M. MEIXNER of Epileptic Mothers K. H. LoTRrrscH SIR,-It is a well-known fact that infants Landes-UnfaUlkrankenhaus, Institut fuir Strahlenmedizin, born to narcotic addicts may show with- Feldkirch, Austria drawal symptoms, including vomiting, though it is less well-publicized that withdrawal of other drugs may produce vomiting Fluorinated Corticosteroids and in the neonate. We have noticed that infants Dermatophytosis born to epileptic mothers often show drug withdrawal effects, including hypotonia, SiR,-I wish to comment on your epidemioiritability, and vomiting. The vomiting logical report on an outbreak of dermatotends to occur during the first two or three phytosis (29 March, p. 745). It is stated that days following delivery and is usually con- "Epidermophyton floccosum usually causes fined to babies whose mothers have been tinea pedis or tinea cruris" and "where there having barbiturates (phenobarbitone) as their is an obvious reservoir of infection, the articonulsant medication. The last few speies is quite frequently found as a cause cases we have seen here have usually settled of small outbreaks" of these conditions. It is down rpidly after a single intramuscular also stated that E. floccosum "rarely causes dose of amylobarbitone, though one infant, ithe tinea corporis described" in the report whose mnther had uncontrolled epilepsy and it is suggested that the infection throughnecessitating large doses of many anti- out a geriatric ward came after the admission convulsants, took several days to recover. of a simpleuon who was scratching vigorAs epilepsy is a common disorder, we find ously. that this cause of vomiting is one of the Over the past few montihs I have seen more likely in the differential diagnosis of several cases of infection wih E. floccosum in neonatal vomiting.-I am, etc., tew submammary area, a site only occaM. J. ERrrH sionally infected by this organismn. All the General Hospital, women were using a fluorinated corticoNorthampton isteroid ointment or cream and all had husbands who complained of iscdlng feet. I have also seen a 3-year-old girl with widespread tinea corporis from E. floccosum who was Non-invasive Investigations of the Brain under treatment for infantile eczema with a SIR,-We read with considerable interest fluorinated corticosteroid cream and whose your leading article on this subject (10 May, father suffered from tinea pedis. "Tinea inP. 295). We would like to comment on some cognito," 2 which results from unosup of the points made in that article since we pression caused by fluorinated corticosteroid feel they need clarification. applications, is increasing in dermatological A comparison of non-invasive investiga- practice in Soutlh Austraia. Though there tions of the brain is implicit in the article, seemed to be an obvious reservoir of infecwhich follows the current trend of empla- tion in the outbreak of dermatophytosis sizing the potential of the E.M.I. scanner. which you report, I wonder whethr the reHowever, it is misleading to say that the servoir might not have ibeen increased by the advent of E.M.I. scanning has reduced the application of a fluorinated corticosteroid number of isotope brain scans carried out. cream or ointment. I wonder whether the So far this is not the experience in ssome simpleton who had been scratcing was European centres and certainly not the ex- treated with one of these preparations and

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5 juLy 1975

whether this was the ultimate explanation for the outbreak of the infection. Fluorinated corticosteroid creams and ointments are in constant use and readily available to nursing staff. Was the simpleton.'s itching treated with one of these? Could inquiries be made?-I am, etc., JOHN N. BURRY St. Peters, South Australia 1 Ive, A. F., and Marks, R., British Medical

7ournal,

1968, 3, 149. 2 Burry, J. N., Medical 7ournal of Austra!ia, 1973, 1, 393.

*** A correspondent in the Epidemiological Research Laboratory writes: "We, have made further iquiries of the bospital where this outbreak oocurred and find that fluorinated corticosteroid creams were indeed prescribed for the index case on several occasions during the months before the fungal infection was diagnosed. Tese preparations were used to alleviate his scratching but were not given to the other infected patients. Clearly the use of these creams may have been a factor in the spread of the infection, and we are grateful to Dr. Burry for ibringing this to our attention."-ED., B.M.7. Improving the Service SIR,-It is clear that, in part at least, 1975 will be remembered for the confrontation between the various branches of the profession and the Government. However justified our several disputes have been, at the end of the day it is still our responsibility (and for most of us our earest desire) to provide the best possible service for our patients. Realistic remunertion and iterms of semioe will make the profession more content, but much more than this will be required to counteract the erosion of medical standards and the constant deteriortion in facilities for patient care in the foreseeable future as the N.H.S. purse-strings, in common with all others, get progressively .ghter. Tbe simple fact, but one ghat successive levels of N.H.S. administration 'have failed 'to correct, is that the NH.S. is grossly inefficient. There is far too much duplication of services, due largely to the haphazard nature in which the service has proliferated. The numerous cardiothoracic and renal transplant units within the London area illustrate this, as does the situation in Birmingham, where two major accident and emergency departments exist at separate hospitals, within 2 miles of each other- with full duplication of manpower and equipment. In many large cities (and Liverpool is a prime example) there may ibe any number of hospitals within a 10-nile radius worling far below true capacity (though most may appear "busy") but each professing to provide full emergency servies 24 hours a day for a wide range of medical, isurgical, and gynaecological conditions. If the premise of inefficiency is accepted, it is then easy to appreciate that proper use of medical man, power might well reveal that, contrary ito popular bele, there is no true shortge of hospital doctors in this country. As it is, our ratio of doctors to patients is higher than virtually every other country. Though the service at present is wasteful of money and manpower, it is readily ava,ilable and convenient for the vast majority of patients and itheir relatives, for in most areas

BRITISH MEDICAL JOURNAL

5 JULY 1975

an acute admitting hospital is selom far away. But in the coming years of financial stringency the population must dhoose between this luxury of convenience and rather opt for a streamlined, rationalized, and efficient service. For example, for every 5 acute hospitals at present open 24 hours a day, in the future one ihospital only in that district should be adequately staffed and equipped to deal with all emergencies. At present ithere is great variation in work load between hospitals of comparable staffing and beds. Such a scheme would give junior staff no less exnperience but a more concentrated training and indeed would assist in reducing the present very long periods of postgraduate medical training which have long distinguished Bri'tain from comparable nations. If you are on duty in the hospital, at whatever grade, you might as well ibe

busy! I am not advocating wholesale treduction in the hours worked by junior hospital staff, though some cuts could be achieved, fbut rathe,r suggesting that nothing but good would stem from bringing planning and order to what in some areas resembles nothing less than chaos. Wiithin the next 5 years it is probable that less rather than more doctors will be available to staff our hospitals, with an increase in the proportion of women trained who then either 'take part-time appointments or leave medicine for a large part of their life and with the prospect of significant reductions in the nunibers of foreign medical graduates entering the country. Consideration of these further reasons for likely diminishing skilled medical manpower adds substantial weight to a plea for enihanced efficiency. Surely it should be ipossible for medical staff through their local medical executive committees and district management teams to put such proposals as outlined aibove to the relevant higher area and/or regional health authorities and refuse to take "no" for an answer. While I am not so naive as to ignore all the vested interests and petty little enpires that over the years 'have grown up within the N.H.S., surely the time has come for those 'whose eyes are open to let a "wind of change" blast all the muddled and ineffective thinking fTom all those areas where they can influence affairs. After all, it only needs common sense and resolution -alas, rare qualities indeed, especiary in combination, in 1975.-I am, ec.,

RICHARD W. GRIFFITHS Broadgreen Hospital, Liverpool

Randomization SIR,-In the controlled clinical trial reported 'by Mr. I. L. Rosenberg and other.s (22 March, p. 649) randomization to the three treatnwnt groups was by month of birth, those born in the first four months of the year being allocated to one treatment, etc. The resulting group sizes weire 73, 79, and 121 respectively, with 22 withrawals. Prior to withdrawal the group sizes were 88, 85, and 122 respectively (Pollock A.V., personal commnunication) and this poor distribution of group sizes deviates significantly fron ewectation (P=0015, x2 test). Assuming ithat one aim of this method of randomization was the reasonable one of achieving roughly equal group sizes (though

41

this is not necessarily the statistical optimum) it has clearly not proved satisfactory in this respect. One is therefore also led to question whether this method can (be trusted to ensure that on average the treatment groups are similar with respect to patient dharacteri,stics correlated with the trial end-points, a necessary condition for unbiased comparison. In view of the ready availability of eminently satisfactory randomizing techniques using random numbers,1 which can be constrained to give equal group sizes if required, it is unnecessary to rely on other techniques of possible dubiety sudh as ones based on dates of birth. The unbalanced distribution of group sizes is in itself interesting. After allowing for differing lengths of the months and seasonality of birth rate the significance of the observed deviations increases, so the explanation does not lie here. An explanation in terms of admission procedure or simple bad luck must initially be preferred to the possilbility of a real correlation between morbidity and month of birth. I am currently collecting examples of isuch correlations and should be interested to hear from anyone with relevant data in narrowly defined disease areas rather than in a heterogeneous situation.-I am, etc., J. A. LEWIS Imperial Chemical Industries Ltd., Pharmaceutical Division, Macclesfield, Cheshire I Armitage, P., Statistical Methods in Medical Re-

search, Oxford, Blackwell, 1971.

reduced the smoker comipensates 'bY taking more smoke into his lungs; and if the nrcotine yield is lowered so, much '(