263
probably my deficiency. In the local authorities, the work in preventive medicine-especially preventing infectious
was
dis-
ease—and in the provision of care for people with long-term handicaps. The medical officer of health was accountable to the local health committee, and accountability meant something when administered by a good committee chairman.
However, it
seems
that
we are
be found outside the health service. This drift into administration will be perpetuated and ingrained by the proposals for training, which looks with tunnel vision at the activities of the National Health Service. Trainees in community medicine should be placed in local authority environmental health, housing, social services, and education authorities, and if they wish to gain any insight into the activities of the Health Service they should be placed in other countries, instead of pursuing a myopic course at region, area, and district level of the N.H.S. Has community medicine a future? In my opinion the future will see the development of epidemiology as a specialist skill, leaving medical administration as the mainstream of community medicine. But what worries me is that administration can be done by administrators, and decision-making by clinto
°
receiving the expert advice of epidemiologists. Perhaps you will consider publishing a selection of one-word answers to the question which was the title of the article, which was presumably posed as a rhetorical question.
icians
(Teaching),
J. A. MUIR GRAY
A MEDICAL SCHOOL IN HULL
SiR,—There is an error in your geography (July 24, p. 186) when you describe Leeds and Newcastle as being "nearest neighbours". This is true for Leeds, but the old-established medical schools of Manchester and Sheffield and the recent additions of Leicester and Nottingham are all nearer to Hull than is Newcastle. General Infirmary Leeds LS1 3EX
at
204 Bertrand Drive, Princeton, New Jersey
JOHN WERTH
08540, U.S.A.
all administrators now, and
increasing proportion of our time is to be spent tackling health service problems rather than health problems, although solutions to the great epidemics of non-infectious diseases are an
Oxford Area Health Authority Headington, Oxford OX3 9DZ
the study could be of great importance in comparing lead and cadmium as possible causes of hypertension.
Leeds,
MICHAEL WAUGH
BLOOD-LEAD AND HYPERTENSION
SiR,—Iread with interest the article by Dr Beevers and his colleagues (July 3, p. 1) reporting an association between blood-lead and hypertension. While the authors discuss several
hypotheses for this correlation, I believe that at least one other possible mechanism
warrants attention. Beevers et al. state that "the acidic nature of soft water leads to increased plumbosolvency." Soft water also tends to dissolve cadmium from the surface of galvanised steel, and cadmium induces hypertension in laboratory animals.’-’ Furthermore, Glauser et al. found a strong positive correlation between blood-cadmium and hypertension.6 Beevers et al. mention that many of the storage tanks in Renfrew are lead-lined. It would be interesting to examine the relative prevalence in that town of galvanised tanks and pipes, both of which are common in older buildings. Also, an analysis of the blood-cadmium in both the male and female subjects of 1. Schroeder, H. A., Vinton, W. H. Am. J. Physiol. 1962, 202, 515. 2 Schroeder, H. A. J. chron. Dis. 1965, 18, 647. 3. Schroeder, H. A. Kroll, S. S., Little, J. W., Livingston, P. O., Myers, M. Archs envir Hlth, 1966, 13, 788. 4 Schroeder, H. A , Buckman, J. ibid. 1967, 14, 693. 5 Fassett, D. W. in Metallic Contaminants and Human Health (edited by D. H K Lee , chap. 4, p. 97. New York, 1972. 6 Glauser, S C., Bello, C. T., Glauser, E. M. Lancet, 1976, i, 717.
USE OF PLASMA-PROTEIN FUNCTION IN PLASMA EXCHANGE
SIR,-Human plasma-protein fraction (P.P.F.) has certain properties which render it especially useful for the purpose of plasma exchange. However, analysis of P.P.F. (Blood Products Laboratory, Lister Institute, Elstree, Herts) shows it to have a low content of both K+ and Ca++ as compared with normal human plasma. These deficits can be easily remedied by the addition of 1.5mmol of K+ (0-75 ml potassium chloride containing 2 mmol/ml) and 0.45 mmol of Ca++ (2 ml of 10% calcium gluconate, not 2 g as previously statedl) to each 400 ml bottle of P.P.F. This approach has resulted in maintenance of normal serum K+ and Ca++ levels during plasma exchange and has virtually eliminated the hypotensive episodes which used to be such an unpleasant side-effect of the procedure. M.R.C. Lipid Metabolism Hammersmith Hospital, London W12 0HS
Unit,
GILBERT THOMPSON
TERMINAL CARE
SIR,-In your issue of July 24, it is salutory article
to
compare Dr
planning for terminal care and your note on N.H.S. expenditure. It would indeed be possible to make political capital out of such a comparison but I am more concerned here with dying patients. There is much to agree with in Dr Simpson’s article and much to abhor in the approach of many clinicians to the "dying patient for whom nothing can be done". Some of us, however, would like to continue our total care of the terminally ill patient beyond the point of using anti-cancer therapy, but the simple logistics of so doing would demand more money than is presently available. Dr Simpson must have experience of the work-load of active treatment units in surgical, radiotherapeutic, and medical oncology. Even if the beds could be made available, and knowing that many patients die at home with less than optimal medical and nursing attention despite the goodwill of all concerned, the "dying art of death" requires not only motivation but also careful training of the extra personnel involved. Geographical barriers are not the only factors to militate against the useful Simpson’s
on
centralisation of terminal care, but at least in some instances the provision of hospital beds for dying patients would allow the motivated cancer physician to provide continuing care on the basis of an established doctor/patient relationship. Should this be too much to ask for? Department of Medical Oncology, Christie Hospital and Holt Radium Institute, HAYDN BUSH
Manchester M20 98X
SIR,-Dr Simpson’s sympathetic approach
to
terminal
care
persistent "blind spot" characteristic of almost all thought on this subject. He briefly refers to the possibility of "death on demand" only to dismiss it out of hand. One is entitled to ask why. To open up the availability of voluntary dying to terminal patients by legalising voluntary euthanasia would introduce a breath of fresh air into terminal care comparable with the enormous improvement which occurred with regard to abortion on the passing of the 1967 Act. The decision "where to die" as between hospital and home is acknowledged to be reveals
1.
once
again
the
Thompson, G. R., Lowenthal, R., Myant,
N. B. Lancet, 1975, i, 1208.
probably my deficiency. In the local authorities, the work in preventive medicine-especially preventing infectious
was
dis-
ease—and in the provision of care for people with long-term handicaps. The medical officer of health was accountable to the local health committee, and accountability meant something when administered by a good committee chairman.
However, it
seems
that
we are
be found outside the health service. This drift into administration will be perpetuated and ingrained by the proposals for training, which looks with tunnel vision at the activities of the National Health Service. Trainees in community medicine should be placed in local authority environmental health, housing, social services, and education authorities, and if they wish to gain any insight into the activities of the Health Service they should be placed in other countries, instead of pursuing a myopic course at region, area, and district level of the N.H.S. Has community medicine a future? In my opinion the future will see the development of epidemiology as a specialist skill, leaving medical administration as the mainstream of community medicine. But what worries me is that administration can be done by administrators, and decision-making by clinto
°
receiving the expert advice of epidemiologists. Perhaps you will consider publishing a selection of one-word answers to the question which was the title of the article, which was presumably posed as a rhetorical question.
icians
(Teaching),
J. A. MUIR GRAY
A MEDICAL SCHOOL IN HULL
SiR,—There is an error in your geography (July 24, p. 186) when you describe Leeds and Newcastle as being "nearest neighbours". This is true for Leeds, but the old-established medical schools of Manchester and Sheffield and the recent additions of Leicester and Nottingham are all nearer to Hull than is Newcastle. General Infirmary Leeds LS1 3EX
at
204 Bertrand Drive, Princeton, New Jersey
JOHN WERTH
08540, U.S.A.
all administrators now, and
increasing proportion of our time is to be spent tackling health service problems rather than health problems, although solutions to the great epidemics of non-infectious diseases are an
Oxford Area Health Authority Headington, Oxford OX3 9DZ
the study could be of great importance in comparing lead and cadmium as possible causes of hypertension.
Leeds,
MICHAEL WAUGH
BLOOD-LEAD AND HYPERTENSION
SiR,—Iread with interest the article by Dr Beevers and his colleagues (July 3, p. 1) reporting an association between blood-lead and hypertension. While the authors discuss several
hypotheses for this correlation, I believe that at least one other possible mechanism
warrants attention. Beevers et al. state that "the acidic nature of soft water leads to increased plumbosolvency." Soft water also tends to dissolve cadmium from the surface of galvanised steel, and cadmium induces hypertension in laboratory animals.’-’ Furthermore, Glauser et al. found a strong positive correlation between blood-cadmium and hypertension.6 Beevers et al. mention that many of the storage tanks in Renfrew are lead-lined. It would be interesting to examine the relative prevalence in that town of galvanised tanks and pipes, both of which are common in older buildings. Also, an analysis of the blood-cadmium in both the male and female subjects of 1. Schroeder, H. A., Vinton, W. H. Am. J. Physiol. 1962, 202, 515. 2 Schroeder, H. A. J. chron. Dis. 1965, 18, 647. 3. Schroeder, H. A. Kroll, S. S., Little, J. W., Livingston, P. O., Myers, M. Archs envir Hlth, 1966, 13, 788. 4 Schroeder, H. A , Buckman, J. ibid. 1967, 14, 693. 5 Fassett, D. W. in Metallic Contaminants and Human Health (edited by D. H K Lee , chap. 4, p. 97. New York, 1972. 6 Glauser, S C., Bello, C. T., Glauser, E. M. Lancet, 1976, i, 717.
USE OF PLASMA-PROTEIN FUNCTION IN PLASMA EXCHANGE
SIR,-Human plasma-protein fraction (P.P.F.) has certain properties which render it especially useful for the purpose of plasma exchange. However, analysis of P.P.F. (Blood Products Laboratory, Lister Institute, Elstree, Herts) shows it to have a low content of both K+ and Ca++ as compared with normal human plasma. These deficits can be easily remedied by the addition of 1.5mmol of K+ (0-75 ml potassium chloride containing 2 mmol/ml) and 0.45 mmol of Ca++ (2 ml of 10% calcium gluconate, not 2 g as previously statedl) to each 400 ml bottle of P.P.F. This approach has resulted in maintenance of normal serum K+ and Ca++ levels during plasma exchange and has virtually eliminated the hypotensive episodes which used to be such an unpleasant side-effect of the procedure. M.R.C. Lipid Metabolism Hammersmith Hospital, London W12 0HS
Unit,
GILBERT THOMPSON
TERMINAL CARE
SIR,-In your issue of July 24, it is salutory article
to
compare Dr
planning for terminal care and your note on N.H.S. expenditure. It would indeed be possible to make political capital out of such a comparison but I am more concerned here with dying patients. There is much to agree with in Dr Simpson’s article and much to abhor in the approach of many clinicians to the "dying patient for whom nothing can be done". Some of us, however, would like to continue our total care of the terminally ill patient beyond the point of using anti-cancer therapy, but the simple logistics of so doing would demand more money than is presently available. Dr Simpson must have experience of the work-load of active treatment units in surgical, radiotherapeutic, and medical oncology. Even if the beds could be made available, and knowing that many patients die at home with less than optimal medical and nursing attention despite the goodwill of all concerned, the "dying art of death" requires not only motivation but also careful training of the extra personnel involved. Geographical barriers are not the only factors to militate against the useful Simpson’s
on
centralisation of terminal care, but at least in some instances the provision of hospital beds for dying patients would allow the motivated cancer physician to provide continuing care on the basis of an established doctor/patient relationship. Should this be too much to ask for? Department of Medical Oncology, Christie Hospital and Holt Radium Institute, HAYDN BUSH
Manchester M20 98X
SIR,-Dr Simpson’s sympathetic approach
to
terminal
care
persistent "blind spot" characteristic of almost all thought on this subject. He briefly refers to the possibility of "death on demand" only to dismiss it out of hand. One is entitled to ask why. To open up the availability of voluntary dying to terminal patients by legalising voluntary euthanasia would introduce a breath of fresh air into terminal care comparable with the enormous improvement which occurred with regard to abortion on the passing of the 1967 Act. The decision "where to die" as between hospital and home is acknowledged to be reveals
1.
once
again
the
Thompson, G. R., Lowenthal, R., Myant,
N. B. Lancet, 1975, i, 1208.
