56
BRITISH MEDICAL JOURNAL
Nissen (20 May, p 1354) taxes us with not considering an affection of the median nerve, but this suggestion is contraverted completely by the clinical information available and therefore not worth discussion. After localisation, we proceeded in classical neurological fashion to consider possible causes of the lesion. Professor Walker scorns the idea that piano playing might be the cause of a hand injury producing chronic partial paralysis; he does not pause to consider our argument, based on personal anatomical and surgical observation, that if piano playing was related to the hand disability, then there must have been an associated anatomical variation. This caveat was an essential point in our discussion because of the absence of other reported cases among professional pianists. Incidentally, we know many rowing men and only one has developed a posterior interosseous palsy in relation to this pastime. Lastly, Professor Walker takes us to task for our direct, acknowledged, quotation from Dr Sams, to whom we refer him, on the subject of Schumann and the finger strengthener he is said to have ordered. As a final blow, Professor Walker implies that we entertained the idea that the unproved use of such a machine was the cause of a condition present for seven previous years. Nothing we wrote supported this ridiculous interpretation. It might be helpful if Professor Walker were to discuss the neurological problems of this tragic but interesting case with our colleagues in the department of neurology in the Medical School of McMaster University. Alternatively, we would be pleased to pursue the matter when he is next in London. R A HENSON Neurological Department, London Hospital, London El
***This correspondence
is now closed.-ED,
BM7. Kidney failure in liver disease
1 JULY 1978
liver disease4 may imply an inability to inactivate endotoxin that has shunted past the normally active Kupffer (ells of the cirrhotic liver. 'rhirdly, bile acid retention in cirrhotic plasma may mean that endotoxin is dissociated into subunits that are poorly antigenic and that react in a biologically different manner. Fourthly, for this previous reason, the true antitoxic antilipid A titres may actually be low in cirrhosis.
purified insulins and has persisted despite using different insulin regimens. That it was due to the insulin treatment was demonstrated by the absence of urticaria during insulin withdrawal. The possibility exists that the urticarial reaction reflects a delayed-type hypersensitivity, but immediate reactions could be demonstrated following intradermal skin tests. The occurrence of urticaria appeared to be triggered by the change to highly purified porcine insulins and it is speculated E N WARDLE that a particular component of one of the preparations ( ? Nordisk "medium") acted as 1 Wardle, E N, Clinical Science and Molecular Medicine, an adjuvant in this particular case. Fortunately, 1974, 46, 17P. 2 Wardle, E N, Archives of Surgery, 1974, this patient's symptoms are reasonably 109, 741. 3Coleman, M, et al, Annals of Internal Medicine, 1975, controlled by chlorpheniramine tablets, and 83, 79. despite these difficulties his diabetic control 4Waterlow, J, Lancet, 1950, 1, 908. has improved. Such reactions are rare complications of insulin treatment but both this report and that of Leslie' indicate that they Generalised urticaria precipitated by may occur in response to porcine insulins, change to highly purified porcine and in both cases there was a strong history of insulin allergy or hay fever.
SIR,-Allergic reactions to unpurified insulins are well recognised.' 2 Recently an allergic reaction to a porcine monocomponent insulin (Actrapid MC) has been reported.3 We wish to describe another case in which generalised urticaria developed after changing to highly purified porcine insulins and which has persisted despite the subsequent use of monocomponent preparations. A 54-year-old man who has had diabetes for 18 years was restabilised on porcine insulin. He had received continuous treatment with bovine insulins from the onset of his diabetes and for many years had been taking a twice-daily admixture of soluble and isophane insulins (Weddel). Diabetic control had been far from adequate despite increasing doses of insulin (120 U daily) and following discussion it was felt that he might benefit from a more purified insulin preparation. Leo Neutral and Leo Retard insulins (Nordisk) were started and good diabetic control was achieved with a total of 84 U daily. Five days after starting the new regimen he began to develop intermittent generalised urticarial reactions throughout the day and night which gradually increased in severity. No other drugs had been introduced during this period and he was admitted for further assessment. Systematic investigation failed to reveal any other underlying cause for the urticaria; the peripheral blood eosinophil count was normal. It is of interest that he gave a history of hay fever, but he has had no other particular allergies. Insulin treatment was withdrawn and no new urticarial reactions developed during a 25-h period of observation. Treatment was recommenced with Actrapid MC and Semitard MC insulins (Novo), with a prompt return of urticaria, which has persisted despite trying different regimens, including a return to the original bovine preparations. Intradermal skin tests were performed using 2 U (0 05 ml) of the following insulins: bovine soluble and isophane (Weddel); highly purified porcine Leo Neutral and Retard (Nordisk), and monocomponent porcine Actrapid and Semitard (Novo). In addition, 0-1 ml of Nordisk protamine and "medium" and of Novo methylparaben and "carrier" was injected. Equal volumes of saline were used for controls. At 30 min a 17-mm weal had developed in response to the Nordisk "medium." In addition, 8-mm weals occurred at the sites of the Nordisk Neutral and Retard insulins, protamine, and the bovine insulins. Minimal reactions to Novo carrier, methylparaben, Actrapid MC, and Semitard MC were observed, but these were not significantly different from the controls. All reactions, with the exception of the Nordisk "medium" and bovine isophane insulin, had faded within 4 h.
SIR,-With reference to your leading article (27 May, p 1375), since I was the first in this country' to emphasise the finding of endotoxin in the plasma of patients with hepatorenal failure and the larger series that have followed have simply confirmed this fact, may I be allowed to observe that it is time that further discriminatory work be done? The original observation followed the introduction of the limulus assay but stemmed from radiofibrinogen studies which showed continuing fibrinogen catabolism in such patients.2 This particular type of renal failure does not have the features of a Shwartzman reaction (glomerular and peritubular thrombosis) that is the standard response to endotoxin. In part this may be due to the very active fibrinolysis that is found in cirrhosis. That there is true disseminated intravascular clotting is shown by the improvement with heparin. Another anomaly is that these patients have high antibody titres to 0 antigens of Gramnegative organisms. Thus the endotoxin is likely to be present in plasma as endotoxinantibody complexes. Yet there is no nephritis. Four factors that require exploration come to mind. Firstly, the antibodies may be of broad specificity and low affinity: such complexes are not easily precipitated by This patient's urticaria developed within ammonium sulphate in the Farr test. Secondly, the low level of serum esterases in chronic five days of changing from conventional to
We thank Mr F A P Henesey for his kind co-operation in providing the Nordisk protamine and "medium," and Dr D Leslie for providing the Novo methylparaben and "carrier."
C REISNER D J MOUL A G CUDWORTH Diabetic Department, St Bartholomew's Hospital, London EC1 E P, Gray, H, and Root, A F, Jrournal of Metabolic Research, 1922, 2, 651. Hanauer, L, and Batson, J M, Diabetes, 1961, 10, 105. 3 Leslie, D, British Medical Journal, 1977, 2, 736.
l
Joslin,
2
Legalisation of cannabis SIR,-I am gravely disturbed by a further attempt to legalise the use of cannabis in Britain. Whatever argument is put forward by those interested in or merely indifferent to such a measure, there is universal agreement among the comparatively few pot smokers (both habitual and occasional) I have encountered as individuals that a person under the influence of cannabis is disinclined to go to work or look after his or her children and more than likely to fail to do this or any other useful work. Even more important, none of them would care to be driven in a car by such a person. These views are amply confirmed by such examinations as I have been able to make on persons so affected; they were certainly unfit to drive. Have we not enough misery on these scores caused by alcohol that we must now be invited to add to it? The legalisation of cannabis cannot do good. It can only do harm. I look for a unanimous reiteration of this view from the profession. A LEWIS London Wl
Confidentiality of medical records
SIR,-I was recently informed by a patient that, while attending a school medical examination with her son, she noticed that the school medical officer had in his possession copies of letters sent to me by a paediatrician at a local hospital. I made further inquiries and discovered that copies of letters from paediatricians concerning schoolchildren are sent automatically to area specialists in child health
1 JULY 1978
57
and then to school medical officers without the prior knowledge and consent of the referring general practitioner. I further understand that this practice is not peculiar to my district. This raises considerable ethical problems, as I am sure that in certain circumstances the information may be considered to be of a highly confidential nature. There is no guarantee of security of records kept by school medical officers and I am sure that the parents are not aware of the dissemination of information about their children. An important point is the fact that it is no longer obligatory for children to be examined by school medical officers so that information about these children is being distributed to people with whom they may never have any professional relationship. We are living at a time in which there is increasing concern about personal liberties and privacy and I would like to have the response of other practitioners about what I feel is a rather sinister procedure.
Of course reflecting on the controversy in your pages some 10 years ago-if porphyria is endemic in the family to which Dr Fisher refers, then I would concede a strong presumption for a Hanoverian descent, though not from George III. IAN R CHRISTIE
BRITISH MEDICAL JOURNAL
Edgware, Middx
with these organisms when incubated at 42°C for 6-8 h. Incubation for longer than 8 h results in overgrowth of other intestinal flora. However, when this medium was used for patients' stool specimens isolation of C lejuni was not as good as with the other media described. As a holding medium, especially useful for transporting swabs, we use thioglycollate broth containing 016% agar and the same antibiotics as in Skirrow's medium plus amphotericin B. After inoculation this medium is refrigerated overnight and then plated. We have also found that C jejuni stains poorly with safranin as the counterstain in the Gram method. The substitution of 0O0600 carbol fuchsin for safranin has overcome this difficulty. Using these methods we have recently isolated C jejuni from five patients with diarrhoea. Further discussion will be forthcoming. W L WANG A B DAVID MARTIN BLASER JAMES CRAVENS
Aortography in infantile coarctation SIR,-I wish to confirm Dr B R Denham's finding on the usefulness of the balloon angiocatheter in producing retrograde flow of contrast in children with congenital heart disease (13 May, p 1282). The use of balloondirected angiography in patients with congenital heart disease was reported from this unit to a recent meeting of the British Cardiac Society. The technique is applicable not only when the descending aorta can be entered through a ductus as in severe coarctation or atresia of the arch, but also in cyanotic heart disease. If the catheter is passed through the aortic valve and the balloon inflated in the descending aorta, it will cause obstruction to forward flow, and balloon-directed flow of contrast will fill any major aortopulmonary anastomoses which are present. The technique has now been used in over 20 patients ranging in weight from 2 to 20 kg. No adverse effects have occurred. H C MULHOLLAND Cardiac Unit, Royal Victoria Hospital, Belfast
Isolation of campylobacter
SIR,-The discussion in your pages of campylobacter enteritis has been most interesting. We have been comparing the methods of Butzler et all and Skirrow2 for the culture of Campylobacter jejuni and have found no notable differences in selectivity and sensitivity between the media. Overgrowth with yeast was a problem, but addition of amphotericin B (2 mg/l has resolved this. We now use Skirrow's medium plus amphotericin B. Filtration, while it eliminates other bacteria, also decreases the recovery of campylobacter. We do not use filtration except when culturing the faeces of animals. This has been necessary owing to growth of spreading proteus despite the presence of antibiotics in the medium. Alkaline peptone water, as suggested by Tanner,3 has proved to be useful to recover C jejuni from faecal suspensions inoculated
Croxley Green, Herts
The consultation and the therapeutic illusion
SIR,-Dr K B Thomas is to be congratulated on his brief but important and profound paper (20 May, p 1327). He finds that in general practice undiagnosed patients who receive no treatment do as well as those who are given a symptomatic diagnosis and
medication. This principle can, and arguably should, be extended to no treatment for self-curing conditions. To take but one example from orthopaedic practice, if the patient with a frozen shoulder is told the good news that it is Microbiology Department, Denver Veterans Administration Hospital not arthritis or cancer, that no other joint and School of Medicine, than the shoulder is ever affected, and that the University of Colorado Denver, Colorado pain will inevitably go and the movement be restored completely or almost completely he I Butzler, J P, et al, Pediatrics, 1973, 82, 493. 2 Skirrow, M B, British MedicalgJournal, 1977, 2, 9. usually receives with equanimity the bad 3 Tanner, E L, and Bullin, C H, British Medical_Journal, news that recovery will take a long time and 1977, 2, 579. that no treatment hastens it. E SHEPHARD George III's offspring West Kent General Hospital, Maidstone, Kent
SIR,-My attention has been drawn to Dr Shirley Fisher's assertion (3 June, p 1479) that George III had descendants by an illegitimate line. This suggestion would have been more possible if made about almost any other member of the Hanoverian royal family, including brothers of George III, but it is totally at variance with all the very considerable evidence available to historians about the king's character and personality. He was a man of strong moral principles and sincere religious convictions. Again, under the conventions of the time there would have been no reason for secrecy about the existence of a royal bastard, had one been born, but in 30 years of studying this period I have never come across a fragment of social gossip hinting at the presence of one in the circumstances posited by Dr Fisher. Letters offering patronage and support are no evidence of such a liaison. Indeed, they suggest the opposite; for had there been a liaison ample provision would have been made at the time and occasions for promises later would have been unlikely. The temptation to make pretensions to royal descent is not uncommon. These pretensions may sometimes begin with a deliberate fabrication, or perhaps more often with a wild guess based on inadequate evidence which hardens a generation later into firm belief. Except in those cases which have been publicly known and acknowledged from the beginning, such claims are in my judgment likely to prove empty if exposed to the rigours of historical investigation. If Dr Fisher will refer to Patricia Storrar's book, George Rex: Death of a Legend (Johannesburg, 1974), in which I had some share, she will see how this was demonstrated in the most famous case of an attempt to foist an illegitimate brood upon George III. Some of the crucial evidence in that case was also discussed by me in Notes and Queries for January 1975.
Cough mixtures SIR,-Dr D Adler (3 June, p 1489) has clearly never suffered from a nocturnal cough and perhaps never had children who did. Neither investigations nor antibiotics will give immediate alleviation of what can be a distressing and disturbing symptom in the common cold, bronchitis, bronchial carcinoma, etc. But the despised symptomatic remedies he mentions (Actifed compound linctus, Benylin) do provide exactly this relief and allow a therapeutically beneficial night's rest in such conditions. They were never intended to do more than this. We should remember that good doctors treat symptoms at the same time as effecting cures and consider the patient's comfort as well as his diagnosis. BARBARA COMAISH Newcastle upon Tyne
Housing and violence to children
SIR,-The report issued by the Department of Health and Social Security entitled "Violence to Children,"' which was recently presented to Parliament, merits discussion. I would like to comment upon one of the issues raised in this document-namely, housing (paras 29-32). The first part of the recommendation on housing stresses that young people have to be housed in the area in which they have grown up so that they can have the support of their extended families. This is in keeping with current research, since most of the studies show that violent parents are socially isolated2 and detached from their roots,4 and have very little contact with their extended families.5 But the report then proceeds to suggest that better housing conditions and
BRITISH MEDICAL JOURNAL
Nissen (20 May, p 1354) taxes us with not considering an affection of the median nerve, but this suggestion is contraverted completely by the clinical information available and therefore not worth discussion. After localisation, we proceeded in classical neurological fashion to consider possible causes of the lesion. Professor Walker scorns the idea that piano playing might be the cause of a hand injury producing chronic partial paralysis; he does not pause to consider our argument, based on personal anatomical and surgical observation, that if piano playing was related to the hand disability, then there must have been an associated anatomical variation. This caveat was an essential point in our discussion because of the absence of other reported cases among professional pianists. Incidentally, we know many rowing men and only one has developed a posterior interosseous palsy in relation to this pastime. Lastly, Professor Walker takes us to task for our direct, acknowledged, quotation from Dr Sams, to whom we refer him, on the subject of Schumann and the finger strengthener he is said to have ordered. As a final blow, Professor Walker implies that we entertained the idea that the unproved use of such a machine was the cause of a condition present for seven previous years. Nothing we wrote supported this ridiculous interpretation. It might be helpful if Professor Walker were to discuss the neurological problems of this tragic but interesting case with our colleagues in the department of neurology in the Medical School of McMaster University. Alternatively, we would be pleased to pursue the matter when he is next in London. R A HENSON Neurological Department, London Hospital, London El
***This correspondence
is now closed.-ED,
BM7. Kidney failure in liver disease
1 JULY 1978
liver disease4 may imply an inability to inactivate endotoxin that has shunted past the normally active Kupffer (ells of the cirrhotic liver. 'rhirdly, bile acid retention in cirrhotic plasma may mean that endotoxin is dissociated into subunits that are poorly antigenic and that react in a biologically different manner. Fourthly, for this previous reason, the true antitoxic antilipid A titres may actually be low in cirrhosis.
purified insulins and has persisted despite using different insulin regimens. That it was due to the insulin treatment was demonstrated by the absence of urticaria during insulin withdrawal. The possibility exists that the urticarial reaction reflects a delayed-type hypersensitivity, but immediate reactions could be demonstrated following intradermal skin tests. The occurrence of urticaria appeared to be triggered by the change to highly purified porcine insulins and it is speculated E N WARDLE that a particular component of one of the preparations ( ? Nordisk "medium") acted as 1 Wardle, E N, Clinical Science and Molecular Medicine, an adjuvant in this particular case. Fortunately, 1974, 46, 17P. 2 Wardle, E N, Archives of Surgery, 1974, this patient's symptoms are reasonably 109, 741. 3Coleman, M, et al, Annals of Internal Medicine, 1975, controlled by chlorpheniramine tablets, and 83, 79. despite these difficulties his diabetic control 4Waterlow, J, Lancet, 1950, 1, 908. has improved. Such reactions are rare complications of insulin treatment but both this report and that of Leslie' indicate that they Generalised urticaria precipitated by may occur in response to porcine insulins, change to highly purified porcine and in both cases there was a strong history of insulin allergy or hay fever.
SIR,-Allergic reactions to unpurified insulins are well recognised.' 2 Recently an allergic reaction to a porcine monocomponent insulin (Actrapid MC) has been reported.3 We wish to describe another case in which generalised urticaria developed after changing to highly purified porcine insulins and which has persisted despite the subsequent use of monocomponent preparations. A 54-year-old man who has had diabetes for 18 years was restabilised on porcine insulin. He had received continuous treatment with bovine insulins from the onset of his diabetes and for many years had been taking a twice-daily admixture of soluble and isophane insulins (Weddel). Diabetic control had been far from adequate despite increasing doses of insulin (120 U daily) and following discussion it was felt that he might benefit from a more purified insulin preparation. Leo Neutral and Leo Retard insulins (Nordisk) were started and good diabetic control was achieved with a total of 84 U daily. Five days after starting the new regimen he began to develop intermittent generalised urticarial reactions throughout the day and night which gradually increased in severity. No other drugs had been introduced during this period and he was admitted for further assessment. Systematic investigation failed to reveal any other underlying cause for the urticaria; the peripheral blood eosinophil count was normal. It is of interest that he gave a history of hay fever, but he has had no other particular allergies. Insulin treatment was withdrawn and no new urticarial reactions developed during a 25-h period of observation. Treatment was recommenced with Actrapid MC and Semitard MC insulins (Novo), with a prompt return of urticaria, which has persisted despite trying different regimens, including a return to the original bovine preparations. Intradermal skin tests were performed using 2 U (0 05 ml) of the following insulins: bovine soluble and isophane (Weddel); highly purified porcine Leo Neutral and Retard (Nordisk), and monocomponent porcine Actrapid and Semitard (Novo). In addition, 0-1 ml of Nordisk protamine and "medium" and of Novo methylparaben and "carrier" was injected. Equal volumes of saline were used for controls. At 30 min a 17-mm weal had developed in response to the Nordisk "medium." In addition, 8-mm weals occurred at the sites of the Nordisk Neutral and Retard insulins, protamine, and the bovine insulins. Minimal reactions to Novo carrier, methylparaben, Actrapid MC, and Semitard MC were observed, but these were not significantly different from the controls. All reactions, with the exception of the Nordisk "medium" and bovine isophane insulin, had faded within 4 h.
SIR,-With reference to your leading article (27 May, p 1375), since I was the first in this country' to emphasise the finding of endotoxin in the plasma of patients with hepatorenal failure and the larger series that have followed have simply confirmed this fact, may I be allowed to observe that it is time that further discriminatory work be done? The original observation followed the introduction of the limulus assay but stemmed from radiofibrinogen studies which showed continuing fibrinogen catabolism in such patients.2 This particular type of renal failure does not have the features of a Shwartzman reaction (glomerular and peritubular thrombosis) that is the standard response to endotoxin. In part this may be due to the very active fibrinolysis that is found in cirrhosis. That there is true disseminated intravascular clotting is shown by the improvement with heparin. Another anomaly is that these patients have high antibody titres to 0 antigens of Gramnegative organisms. Thus the endotoxin is likely to be present in plasma as endotoxinantibody complexes. Yet there is no nephritis. Four factors that require exploration come to mind. Firstly, the antibodies may be of broad specificity and low affinity: such complexes are not easily precipitated by This patient's urticaria developed within ammonium sulphate in the Farr test. Secondly, the low level of serum esterases in chronic five days of changing from conventional to
We thank Mr F A P Henesey for his kind co-operation in providing the Nordisk protamine and "medium," and Dr D Leslie for providing the Novo methylparaben and "carrier."
C REISNER D J MOUL A G CUDWORTH Diabetic Department, St Bartholomew's Hospital, London EC1 E P, Gray, H, and Root, A F, Jrournal of Metabolic Research, 1922, 2, 651. Hanauer, L, and Batson, J M, Diabetes, 1961, 10, 105. 3 Leslie, D, British Medical Journal, 1977, 2, 736.
l
Joslin,
2
Legalisation of cannabis SIR,-I am gravely disturbed by a further attempt to legalise the use of cannabis in Britain. Whatever argument is put forward by those interested in or merely indifferent to such a measure, there is universal agreement among the comparatively few pot smokers (both habitual and occasional) I have encountered as individuals that a person under the influence of cannabis is disinclined to go to work or look after his or her children and more than likely to fail to do this or any other useful work. Even more important, none of them would care to be driven in a car by such a person. These views are amply confirmed by such examinations as I have been able to make on persons so affected; they were certainly unfit to drive. Have we not enough misery on these scores caused by alcohol that we must now be invited to add to it? The legalisation of cannabis cannot do good. It can only do harm. I look for a unanimous reiteration of this view from the profession. A LEWIS London Wl
Confidentiality of medical records
SIR,-I was recently informed by a patient that, while attending a school medical examination with her son, she noticed that the school medical officer had in his possession copies of letters sent to me by a paediatrician at a local hospital. I made further inquiries and discovered that copies of letters from paediatricians concerning schoolchildren are sent automatically to area specialists in child health
1 JULY 1978
57
and then to school medical officers without the prior knowledge and consent of the referring general practitioner. I further understand that this practice is not peculiar to my district. This raises considerable ethical problems, as I am sure that in certain circumstances the information may be considered to be of a highly confidential nature. There is no guarantee of security of records kept by school medical officers and I am sure that the parents are not aware of the dissemination of information about their children. An important point is the fact that it is no longer obligatory for children to be examined by school medical officers so that information about these children is being distributed to people with whom they may never have any professional relationship. We are living at a time in which there is increasing concern about personal liberties and privacy and I would like to have the response of other practitioners about what I feel is a rather sinister procedure.
Of course reflecting on the controversy in your pages some 10 years ago-if porphyria is endemic in the family to which Dr Fisher refers, then I would concede a strong presumption for a Hanoverian descent, though not from George III. IAN R CHRISTIE
BRITISH MEDICAL JOURNAL
Edgware, Middx
with these organisms when incubated at 42°C for 6-8 h. Incubation for longer than 8 h results in overgrowth of other intestinal flora. However, when this medium was used for patients' stool specimens isolation of C lejuni was not as good as with the other media described. As a holding medium, especially useful for transporting swabs, we use thioglycollate broth containing 016% agar and the same antibiotics as in Skirrow's medium plus amphotericin B. After inoculation this medium is refrigerated overnight and then plated. We have also found that C jejuni stains poorly with safranin as the counterstain in the Gram method. The substitution of 0O0600 carbol fuchsin for safranin has overcome this difficulty. Using these methods we have recently isolated C jejuni from five patients with diarrhoea. Further discussion will be forthcoming. W L WANG A B DAVID MARTIN BLASER JAMES CRAVENS
Aortography in infantile coarctation SIR,-I wish to confirm Dr B R Denham's finding on the usefulness of the balloon angiocatheter in producing retrograde flow of contrast in children with congenital heart disease (13 May, p 1282). The use of balloondirected angiography in patients with congenital heart disease was reported from this unit to a recent meeting of the British Cardiac Society. The technique is applicable not only when the descending aorta can be entered through a ductus as in severe coarctation or atresia of the arch, but also in cyanotic heart disease. If the catheter is passed through the aortic valve and the balloon inflated in the descending aorta, it will cause obstruction to forward flow, and balloon-directed flow of contrast will fill any major aortopulmonary anastomoses which are present. The technique has now been used in over 20 patients ranging in weight from 2 to 20 kg. No adverse effects have occurred. H C MULHOLLAND Cardiac Unit, Royal Victoria Hospital, Belfast
Isolation of campylobacter
SIR,-The discussion in your pages of campylobacter enteritis has been most interesting. We have been comparing the methods of Butzler et all and Skirrow2 for the culture of Campylobacter jejuni and have found no notable differences in selectivity and sensitivity between the media. Overgrowth with yeast was a problem, but addition of amphotericin B (2 mg/l has resolved this. We now use Skirrow's medium plus amphotericin B. Filtration, while it eliminates other bacteria, also decreases the recovery of campylobacter. We do not use filtration except when culturing the faeces of animals. This has been necessary owing to growth of spreading proteus despite the presence of antibiotics in the medium. Alkaline peptone water, as suggested by Tanner,3 has proved to be useful to recover C jejuni from faecal suspensions inoculated
Croxley Green, Herts
The consultation and the therapeutic illusion
SIR,-Dr K B Thomas is to be congratulated on his brief but important and profound paper (20 May, p 1327). He finds that in general practice undiagnosed patients who receive no treatment do as well as those who are given a symptomatic diagnosis and
medication. This principle can, and arguably should, be extended to no treatment for self-curing conditions. To take but one example from orthopaedic practice, if the patient with a frozen shoulder is told the good news that it is Microbiology Department, Denver Veterans Administration Hospital not arthritis or cancer, that no other joint and School of Medicine, than the shoulder is ever affected, and that the University of Colorado Denver, Colorado pain will inevitably go and the movement be restored completely or almost completely he I Butzler, J P, et al, Pediatrics, 1973, 82, 493. 2 Skirrow, M B, British MedicalgJournal, 1977, 2, 9. usually receives with equanimity the bad 3 Tanner, E L, and Bullin, C H, British Medical_Journal, news that recovery will take a long time and 1977, 2, 579. that no treatment hastens it. E SHEPHARD George III's offspring West Kent General Hospital, Maidstone, Kent
SIR,-My attention has been drawn to Dr Shirley Fisher's assertion (3 June, p 1479) that George III had descendants by an illegitimate line. This suggestion would have been more possible if made about almost any other member of the Hanoverian royal family, including brothers of George III, but it is totally at variance with all the very considerable evidence available to historians about the king's character and personality. He was a man of strong moral principles and sincere religious convictions. Again, under the conventions of the time there would have been no reason for secrecy about the existence of a royal bastard, had one been born, but in 30 years of studying this period I have never come across a fragment of social gossip hinting at the presence of one in the circumstances posited by Dr Fisher. Letters offering patronage and support are no evidence of such a liaison. Indeed, they suggest the opposite; for had there been a liaison ample provision would have been made at the time and occasions for promises later would have been unlikely. The temptation to make pretensions to royal descent is not uncommon. These pretensions may sometimes begin with a deliberate fabrication, or perhaps more often with a wild guess based on inadequate evidence which hardens a generation later into firm belief. Except in those cases which have been publicly known and acknowledged from the beginning, such claims are in my judgment likely to prove empty if exposed to the rigours of historical investigation. If Dr Fisher will refer to Patricia Storrar's book, George Rex: Death of a Legend (Johannesburg, 1974), in which I had some share, she will see how this was demonstrated in the most famous case of an attempt to foist an illegitimate brood upon George III. Some of the crucial evidence in that case was also discussed by me in Notes and Queries for January 1975.
Cough mixtures SIR,-Dr D Adler (3 June, p 1489) has clearly never suffered from a nocturnal cough and perhaps never had children who did. Neither investigations nor antibiotics will give immediate alleviation of what can be a distressing and disturbing symptom in the common cold, bronchitis, bronchial carcinoma, etc. But the despised symptomatic remedies he mentions (Actifed compound linctus, Benylin) do provide exactly this relief and allow a therapeutically beneficial night's rest in such conditions. They were never intended to do more than this. We should remember that good doctors treat symptoms at the same time as effecting cures and consider the patient's comfort as well as his diagnosis. BARBARA COMAISH Newcastle upon Tyne
Housing and violence to children
SIR,-The report issued by the Department of Health and Social Security entitled "Violence to Children,"' which was recently presented to Parliament, merits discussion. I would like to comment upon one of the issues raised in this document-namely, housing (paras 29-32). The first part of the recommendation on housing stresses that young people have to be housed in the area in which they have grown up so that they can have the support of their extended families. This is in keeping with current research, since most of the studies show that violent parents are socially isolated2 and detached from their roots,4 and have very little contact with their extended families.5 But the report then proceeds to suggest that better housing conditions and
