73

Letters to the Editor CHEMICAL FACTORS IN ÆTIOLOGY OF DUODENAL ULCER

chemicals. Only whether chemicals ulcer in man.

epidemiological studies can indicate related to the xtiology of duodenal

are

Department of Pathology, Peter Bent Brigham Hospital, Harvard Medical School, Boston, Massachusetts 02115, U.S.A.

SANDOR SZABO EDWARD S. REYNOLDS MARY TREINEN MOSLEN.

SIR Your editorial (May 10, p. 1074) prompts us to a public plea for epidemiological inquiry into the relationship between exposure and/or consumption of make

chemicals and the incidence of duodenal ulcer.

Many compounds widely used in industry, agriculture, and medicine produce duodenal ulcer in laboratory animals. a Propionitrile (ethyl cyanide, CH3.CH2.CN) induces solitary perforating duodenal ulcer in the rat.1 Cysteamine, 1-4 3,4-toluenediamine5 and 3,4-toluenedithiol6 also found to have a similar action. When the initial reports appeared, similarities in structure or pharmacological properties of the compounds were not recognised. The ability of drugs to produce duodenal ulcer in the rat now seems to be related to an ethane backbone (2-carbon moiety) bearing cyano, sulphydryl, amino, or chloro groups on one or both ends of the chain.6,7 Branching of the chain or insertion of a hydroxyl diminishes ulcerogenesis.’ Unsaturated homologues, such as acrylonitrile 8,9 (vinyl cyanide, CH2.CH.CN) and numerous allyl compounds, have adrenocortiolytic activity.6,7,10 To date, we have identified 26 chemicals (e.g., butyronitrile, ethylamine, allyl mercaptan, homologues of pyridimine and toluidine) which produce duodenal ulcer, and 30 compounds which induce adrenocortical necrosis in the rat.6,7,10 Many of the chemicals affect both the duodenum and the adrenal gland. Some of these results were presented at a conference on public-health implications of components of plastics manufacture, organised by the National Institutes of Hea Ith.10 We wonder whether those who manufacture or use such chemicals might have a higher incidence of peptic-ulcer disease than the rest of the population. Only the relationship between aspirin and peptic ulcer is generally accepted in man.11 Could the geographical distribution of gastroduodenal ulcer disease be related to the presence of other chemicals in the environment (e.g., as pollutants) ? Propionitrile is an industrial intermediate and solvent. Propionic acid and other propionates are widely used as mould inhibitors of grain, and fungicides in general, and have been noted to stimulate appetite in swine. Propionitrileinduced duodenal ulcers are also associated with enhanced gastric secretion 12 and are prevented by antacids and antisecretory agents.13 Cysteamine is given for radiation sickness and as an antidote for acetaminophen (paracetamol) poisoning. Butyronitrile is used in poultry. Allyl mercaptan is a common flavouring agent (garlic). Are these chemicals natural or artificial constituents of our food ? We hope that the association of hepatic angiosarcoma with occupational exposure to vinyl chloride has heightened awareness of the potential hazards of synthetic were

1. 2. 3.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Szabo, S., Selye, H. Archs Path. 1972, 93, 389. Selye, H., Szabo, S. Nature, 1973, 244, 458. Groves, W. G., Schlosser, J. H., Mead, F. D. Res. Comm. chem. Path. Pharmac. 1974, 9, 523. Robert, A., Nezamis, J. E., Lancaster, C., Badalamenti, J. N. Digestion, 1974, 11, 199. Selye, H. Proc. Soc. exp. Biol. Med. 1973, 142, 1192. Szabo, S. Proc. Vth Wld Congr. Gastroenterol. 1974, p. 169. Szabo, S., Feldman, D., Reynolds, E. S. Fedn Proc. 1975, 34, 227. Szabo, S., Selye, H. Endokrinologie, 1971, 57, 405. Szabo, S., Selye, H. Endocr. exp. 1972, 6, 141. Szabo, S., Reynolds, E. S. Environ. Hlth Persp. (in the press). Grossman, M. I. in Textbook of Medicine (edited by P. B. Beeson). Philadelphia, 1975. Szabo, S., Dzau, V. J., Feldman, D., Reynolds, E. S. Clin. Res. 1974, 22, 370A. Robert, A., Nezamis, J. E., Lancaster, C. Toxicol. appl. Pharmac. 1975, 31, 201.

THE TEACHING OF ANATOMY

SIR,-As an anatomist who has advocated a much greater involvement of radiology in the teaching of anatomy,1 I was most disappointed to read Dr Bull’s criticism (June 7, p. 1290). His accusation is far too generalised and he is not familiar with the situation in some provincial medical schools. In Manchester the radiologists make a valuable and very popular contribution to a course in applied anatomy for the second-year students. Moreover, Dr Bull is less than fair to Professor Coupland (May 3, p. 1028). At the Nottingham Medical School a very determined effort has been made to involve radiologists in the teaching of the basic medical sciences and especially to forge close ties with the department of human morphology. In fact, it was proposed that the recently established readership in radiology should be attached to the department of human morphology.

Traditionally, anatomy departments have relied heavily teaching of topographical anatomy on demonstrators preparing for a career in surgery. For them, dissecting for the

the cadaver is still considered a very effective way of learning anatomy. It is almost inevitable that the demonstrators, who have " front-line " contact with students, will tend to emphasise cadaveric anatomy. It does not help the present situation to compare the expertise of the radiologist with that of the anatomist. The knowledge of both groups should be complementary in the teaching of medical students. Moreover, Dr Bull’s implied " take-over " bid is completely impracticable. Radiologists are far. too busy with clinical work to engage in a heavy teaching The impending establishment of more programme. academic departments of radiology surely points the way towards very fruitful cooperation between anatomists and radiologists. Now that the Royal College of Radiologists has been established it would be of enormous value if the College would, as part of their training, make it mandatory for trainee radiologists to spend part of their time teaching in anatomy departments as demonstrators, just as primary In this way F.R.C.S. candidates have for so many years. emphasis on cadaveric anatomy would diminish whilst the anatomy of the living subject would receive much greater emphasis. Also it would be helpful if joint permanent appointments could be established between anatomy and radiology departments. This might attract more medical graduates into anatomy departments and career anatomists trained in the essentials of radiology might, by assisting in the more routine investigations, spare the expert radiologist for the highly specialised techniques. In the field of research, especially with the advent of the various scanning techniques, students reading for an intercalated B.SC. could be involved in radiological projects. After qualifying, such students could fortify the staffing of radiology and anatomy departments, particularly if they held joint appointments.

Finally, the reason a student may not know the position of the spleen (which will surely have been taught) is that anatomy teaching time has been so curtailed (to be replaced by more fashionable subjects) and the general congestion of the whole curriculum is so great that the student has 1. Br. med.

J. 1968, ii,

48.

74 little time to assimilate and evaluate the mass of information with which he is currently inundated. Anatomy Department, The Medical School, University of Manchester, Manchester M13 9PT.

PHILIP HARRIS.

social facilities which the hospital provides and are members of the staff. The idea behind this arrangement was to bring about the sort of integration with the community and the hospital which Professor Fendall describes, because as he says, any general hospital in a town or city is in fact the community

hospital. THE DOCTOR IN THE HOSPITAL LABORATORY

SIR,-Professor Griffiths and Dr Mitchell (July 5, p. 27) rightly ask that the non-medical scientists in clinical chemistry are not forgotten in the current concern for chemical pathologists. They ask: " If clinicians with specialised laboratories take over all the interesting biochemical work, where will people good enough to ensure proper standards for the day-to-day routine be found ?" But they miss the point of other letters on the subject.1-a Many of the clinicians referred to should be chemical pathologists, with routine laboratory commitments. Likewise, the staff of these specialised laboratories should have commitments in the general laboratory. Clinically competent chemical pathologists should provide opportunities for non-medical scientists to work on clinical problems. At present, in many departments, such opportunities are absent, and trained scientists too often find themselves frustrated, working as technicians. Only by bringing the scientist in on the cooperative investigation of patients can his expertise in clinical chemistry be fully used. This, in practice, can only be done through clinicians, preferably working alongside him. This is not a plea for an entire volte-face in the profession ; the routine tests must continue to be performed on request, and work on methodology must go on. This is a plea for the profession to broaden its horizons, to seek out clinical problems, to direct the investigation of biochemical aspects of disease rather than passively to await direction. A clinical chemistry department should be more than just an efficient factory. In my opinion a start can be made by encouraging some trainee pathologists to become clinicians. Many clinicians are good scientists; why should not the reverse be true ? At present there is little encouragement to gain a dual qualification, and, for that matter, little encouragement to gain confidence in clinical research for most trainees. And if such experience is not gained during training, all too often the qualified pathologist then finds himself a prisoner of his laboratory, a laboratory manager unable to use what medical skills he has. If he cannot involve the non-medical graduate in challenging biochemical work bearing directly on clinical problems, it is

unlikely

anyone can. Department of Clinical Chemistry, Queen Elizabeth Hospital, Birmingham B15 2TH.

G. D. CALVERT.

AN ASSISTANT IN THE HOUSE ? SIR,-In his letter (June 7, p. 1291), Professor Fendall wrote of the general practitioner becoming the primary-care physician with responsibility for the family " whether at home or in the hospital". We have had here at the Radcliffe Infirmary what we call associate general practitioners who have an honorary contract with the hospital, attend ward rounds, and are encouraged (though they rarely do so) to admit their own patients direct into the hospital’s beds. They have all the Calvert, G. D. Lancet, 1974, ii, 473. Carter, P. M., Davison, A. J., Wickings, H. I., Zilva, J. F. ibid. p. 1555. 3. Cheng, B., Lockey, E. ibid. 1975, i, 920.

1. 2.

The associate G.P.S were welcomed by the consultant staff and by the registrars and the " house ". There is with them an interchange of learning and teaching, and the students also benefit. It is, however, a very small prototype of what Professor Fendall was proposing and one of the major barriers to its expansion is lack of money. Under present regulations it is impossible to make any payment to the G.P.S or even make a contribution to their practice expenses (which increase because of their association). I have been unable to persuade the Department of Health or any Trust to put money into the experiment, and it may die because of that. Now is no time to expect a subsidy but a time to re-deploy existing resources. The problem is to find what resources to deploy. It would be sad if the thing falls apart, because obviously it is fundamental to a proper and natural integration. Ours is a fragile plant much in need of the compost of finance. For four years it has been nurtured only by enthusiasm and good will. Radcliffe Infirmary, E. J. R. BURROUGH. Oxford OX2 6HE.

COST OF TRAVELLING TO SPECIALIST CENTRES with chronically sick adults and children SIR,-Working in a London teaching hospital, I have become aware of the financial burden placed on adults or the parents of young children being treated as outpatients or inpatients at some highly specialised units. Many physicians are ignorant of the scarce statutory allowances available to help with travelling expensespatients and their relatives are also either unaware of the costs that may be involved, or unwilling to admit that their resources may not meet the demands. The regulations under which assistance may be given to people towards their travelling expenses requires that a person or family must be receiving supplementary benefit or family income supplement. Many families’ incomes fall just above this category, and, under the Department of, Health and Social Security’s regulations, they are not entitled to financial assistance. Social services departments both within and outside the hospital are often fully aware of this problem and do all in their power to help, using Samaritan (hospital voluntary) funds and other monies from trusts and charities; however, these funds are often limited and moreover rarely do they see their function as being one of supplementing outpatient or other essential

hospital travelling expenses. The Department of Health should recognise that specialist centres provide a service not only for their own health-care district, and that patients may travel substantial distances for treatment (200 miles is not uncommon). The National Association for the Welfare of Children in Hospital believe that the visiting of children in hospital by parents must almost always be seen as being part of essential treatment. The Department of Health and Social Security and the professions should consider the possibility of changing the regulations to provide financial assistance for travelling arrangements to cover all those patients and relatives who have to travel outside their health-care districts for treatment. Guy’s Hospital, ANDREW BEHR, St. Thomas Street, London SE1 9RT. Senior Social Worker.

Letter: The teaching of anatomy.

73 Letters to the Editor CHEMICAL FACTORS IN ÆTIOLOGY OF DUODENAL ULCER chemicals. Only whether chemicals ulcer in man. epidemiological studi...
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