of stress-induced anxiety of this sort factor in the pathogenesis of perforating

SiR,—I read with interest Dr Karetzky’s article (April 12, 828) and the subsequent exchange of letters (May 17,

1139). I










pneumothorax in an asthmatic patient who was being operated on for removal of a retrosternal goitre. Increasing resistance to controlled respiration, combined with controlled hypotension, almost certainly obscured the fact that cardiac arrest had occurred. The right pleura was decompressed and the heart re-started with external massage, but tragically, though a satisfactory circulation was soon restored, irreversible brain damage had occurred. Recognition of this complication during operation is made doubly difficult by the concealment of the patient under drapes. Post-mortem examination showed the cause to be a ruptured bulla. There was no connection between the and the pneumothorax operative site in the neck. 4

Upper Harley Street, London NW1 4PN.


PEPTIC ULCER AND CIVIL DISTURBANCES stress in the xtiology of ulcer was first perforated peptic reported in your columns during the second world war by Stewart and Winserl who demonstrated an increase in admissions to London hospitals for this condition at the same time as the heavy air-raids of the 1940 blitz. The civil disturbances in Northern Ireland during the past six years have produced a considerable amount of anxiety in the population 2 and, if perforated peptic ulcer were related to this sort of stress, we might have expected an increase in cases. We spent

SIR,—The role of civilian



as an setiologicat peptic ulcer.

We thank Prof. John Pemberton for encouragement, Mr G. MacKenzie and Mrs I. Hay of the department of social and preventive medicine for statistical advice, and the heads of the medical records departments of the Royal Victoria, Belfast City, Musgrave Park, Mater Infirmorum, and Ulster Hospitals, Belfast, for allowing us access to the case-notes. Department of Social and Preventive Medicine, Institute of Clinical Science, Queen’s University of Belfast, Belfast BT12 6BJ.



SiR,—It has been suggested that multiple sclerosis (M.s.) develops against a background of some genetically determined mishandling of unsaturated fatty acids, though the disease itself has not purely genetical pathogenesis.2 Whilst a deficiency of unsaturated fatty acids seems to be essential to this condition, findings by Love et al. suggest a decreased serum level of linoleic acid (L.A.) not only in M.s. but also in acute illness. Departures from normal in the size4 and osmotic fragility5 of red cells have been reported in M.s., which might be associated with abnormal unsaturated phospholipid constitution. It seemed probable that the surface membrane of M.s. lymphocytes (already known to behave unusually to L.A. 6) might also show unusual properties. We therefore studied the effect of L.A.

upon the electrophoretic mobility (E.P.M.) of 10 nt.s. patients, 7 patients with other neurological diseases (O.N.D.), and 3 normal subjects. The electrophoretic mobility of the lymphocytes in a Zeiss cytopherometer was used as a measure of surface charge. It was supposed that L.A. might bind to the surface of the cells (specially in M.s. cases) and so induce a different charge and altered speed of E.P.M. The migration time distance of 16 m. was estimated before and after exposure to 0.16 mg. per ml. L.A. at room temperature (20°C) for half an hour. The electric field strength was 6’5 V per cm. At least 50 cells were studied in each specimen. A histogram was constructed to show the frequency of different cell-migration times. In each case the percentage of the total cells at a particular speed was calculated. The difference in the percentage before and after the L.A. treatment was tabulated for each time at intervals of 0.1 sec., beginning at a migration time of 1.9 sec. and ending at 3.1 sec., so that 10 categories were obtained. Discriminant analysis by computershowed a clear difference in the behaviour of the 10 M.s. lymphocytes as compared with the 10 O.N.D. and normal lymphocytes significant at the 0-05 level. r2.s. lymphocytes were slowed much more by L.A. than the others. Thus they appear to have a greater reactivity to L.A. than do normal. These data, with previous reports,8,9 give further support to the hypothesis of M.s. having a metabolic component, which might also involve secondary autoimmune processes. A possible connection between these two factors may result from L.A.-deficient T lymphoctyes of M.S. patients over a

Figures in italic type show rates

per million.

part of our fifth-year social-medicine clerkship examining the case-records of all patients with a discharge diagnosis of perforated peptic ulcer (I.C.D. 531-533), resident in Belfast and admitted to any of Belfast’s five general hospitals which dealt with emergencies in the years 1967-74. Serious civil disturbances started in the summer of 1969. There were 527 cases admitted to the above hospitals in the period under study, 1967-74 (11% gastric, 87% duodenal, 2% peptic, and 81% male and 19% female). There was no perceptible trend in admissions over the whole period (see table). In the worst affected districts of the city (Falls and Shankill) the number of perforations during the troubles did not exceed the pre-1969 figure. We found no significant difference in the distribution of cases among Catholics and non-Catholics over the eight years. 34% of the Belfast population and 30-3% of the 402 patients whose religion could be ascertained were Catholic. We conclude that communal violence in Belfast has not been associated with an increased frequency of admissions to hospital for perforated peptic ulcer. Even in two of the most troubled areas of the city there has been no evidence of an increase. These results call into question the potency 1. 2.

Stewart, D. N., Winser, D. M. de R. Lancet, 1942, i, 259. Lyons, H. A. in Recent Advances in Surgery, p. 344. Edinburgh, 1973.

1. 2. 3. 4.

Thompson, R. H. S. Proc. R. Soc. Med. 1966, 59, 269. Meyer-Rienecker, H., Field, E. J., Jenssen, H. L., Shenton, B. K., Köhler, H., Günther, J. Lancet, 1974, ii, 1445. Love, W. C., Cashell, A., Reynolds, M., Callaghan, N. Br. med. J. 1974, iii, 18. Plum, C. M., Fog, T. Acta psychiat. neurol. scand. 1959, 34, suppl. 128, p. 13.

5. Caspary, E. A., Sewell, F., Field, E. J. Br. med. J. 1967, ii, 610. 6. Field, E. J., Shenton, B. K., Joyce, G. ibid. 1974, i, 412. 7. Ahrens, H., Läuter, J. Mehrdimensionale Varianzanalyse; p. 125. Berlin, 1974. 8. Jenssen, H. L., Köhler, H., Günther, J., Meyer-Rienecker, H. 9.

Lancet, 1974, ii, 1327. Field, E. J. ibid. 1973, ii, 1080.


showing a striking susceptibility to immunisation either by autologous or heterologous antigenic stimulation. Detailed investigations of the at-risk groups 6,9-e.g., near (female) relatives of M.S. patients-must be regarded as necessary to give an answer about the inheritance of the metabolic component of


Medical Section, University of Rostock, Immunological Research Division, Departments of Physiological Chemistry and Neurology, Lenin-Allee 70, 25 Rostock, German Democratic Republic.



SIR,-Our reference laboratory lately investigated a sample of blood from a haemophiliac patient from a local hospital who had received 561 bottles of commercial factor-vm concentrate in one month. He also received 17 units of group-specific blood during this time. The patient was group A, Rho(D) positive. His red cells had a positive direct antiglobulin test and anti-A was eluted. His treatment included A.H.F. from two manufacturers and six different lots were used. One of the manufacturers provided their titre results for three lots of A.H.F. Their results ranged from 16 to 64 by anti-human-globulin techniques. One of these lots was available to us, and we found the antiglobulin titre with group-A cells to be 256.l One lot of the other manufacturers’ A.H.F. concentrate had an antiglobulin titre of 512. When large amounts of factor vill are needed in a short time, the ABO group of the patient should be considered (Rosati et al.2). In these instances perhaps group-compatible cryoprecipitate (human) may be used for treatment rather than commercial A.H.F. concentrates that contain anti-A and anti-B. Missouri-Illinois Regional Red Cross Blood Program, 4050 Lindell Boulevard, St. Louis, Missouri 63108, U.S.A.

CECILIA A. CRONIN, Director of Technical Services.


SiR,—The example of Topley and Wilson’s Principles of -Bacteriology, Virology, and Immunity increasing in price from S3 in 1946 to E65 with the present edition (Feb. 1, p. 272) should make us realise that we must adapt the way we write, read, and publish to rising prices, or scholarship will suffer. Costs can be reduced at most of the steps between the writer and his readers, and we must make the best use of all of them. The most radical solution, and one which is particularly suitable for Topley and Wilson, is to publish only in one of the more advanced miniature versions, such as microfiche, and to produce it directly from the author’s manuscript without setting up type. If we wanted particular pages in paper form, we could always get a photocopy. The resulting savings in composing, printing, storing, paper, postage, and capital might even bring Topley and Wilson back to its 1946 price. By reducing publishing delays it might also be available a year earlier. However, if we are to read such a miniature version at home we shall have to own our own viewers, but it is surely time we did. We should have an additional incentive if we could use one in an armchair, or prop it up on a pillow while reading in bed. The same shortcut from manuscript to miniature version could also reduce the cost of specialist journals. A less radical economy is for the author to save all composing costs by sending his manuscript to his publisher 1. A.A.B.B. Technical Methods and 2. Transfusion, 1974, 10, 139.


p. 121. 1974.



ready ", so that it can be used directly for printing

books lithographically. Both these solutions demand that we accept what a good typewriter can produce for us and are prepared to forgo proportionate spacing, and a straight right-hand margin. They also demand that the author and his secretary produce exactly what they intend their readers to see without any further attention from the publisher. This has fortunately been made easier by such recent developments as the self-erasing typewriter, white correcting fluid, and the dry transfer (’ Letraset’). It is also a great opportunity for the specialist secretary working at home. Further solutions are for the author to forgo his royalties, as Morley1 has done, to obtain a subsidy to cover composing costs, or to cut out the retail bookseller by publishing through a non-profit mail-order service, such as TALC.* We must also be more prepared to publish in the form of slides and tapes. All this is to deny the author some of the most delicious moments 6f his life-opening the first copy of his new book with its glossy paper, superb typography, handsome binding, elegant jacket, and the intoxicating aroma of new print, but alas so expensive that none of his intended readers can buy it. Would Topley and Wilson have obtained the same satisfaction from a little packet of microfiches ? More seriously, can we standardise the miniature system we are going to use, and make viewers which are really suitable for domestic use ? Is there a publisher prepared to move with the times and produce miniature versions, or to print a new series of cheap textbooks straight from his author’s manuscripts ? Lembaga Kesehatan Nasional, Jalan Indrapura, MAURICE KING. Surabaya, Indonesia.


SIR,—Your editorial, " Copper and Steely Hair " (April 19, p. 902), underlines the many metabolic consequences of copper

deficiency. In a patient with steely-hair syndrome (S.H.S.) we have lately found evidence of impaired T-cell function; others have reported increased susceptibility to infection in S.H.S.2-5 Our patient was first seen at the age of 10 months; the history and clinical picture were characteristic of the S.H.S.3 Serum-copper ranged between 37 and 44 tg. per 100 ml. (normal 65-165 g.) and caeruloplasmin between 6 and 10 mg. per 100 ml. (normal 20-60 mg.). During the hospital stay the child had repeated episodes of bronchopneumonia, pyelonephritis, and enteritis, and a single Serum episode of Staphylococcus aureus septicaemia. immunoglobulin and complement (C3, C4) levels, isohasmagglutinin and antistreptolysin-0 titres, antibody response to the H and 0 antigens of Salmonella typhi, and the number of circulating B lymphocytes (700-1200 per c.mm.) were all in the normal range for our laboratory values. Candidin, P.P.D., and S.K.-S.D. (’Varidase’, Lederle) skin tests were negative; furthermore, dinitrochlorobenzene failed to sensitise the child on repeated challenges. The number of circulating T lymphocytes (E rosettes) was in the low normal range on repeated testing (1700-3100 per c.mm.), and the lymphocyte response to stimulation with mitogens (phytohasmagglutinin, concanavalin A, and pokeweed mitogen) and allogeneic cells (mixed culture) * Teaching Aids at Low Cost, Institute of Child Health, 30 Guilford Street, London WC1N 1EH. 1. Morley, D. C. Pædiatric Priorities in the Developing World. London, 1973. 2. Danks, D. M., Cartwright, E., Campbell, P. E., Mayne, V. Lancet, 1971, ii, 1089. 3. Danks, D. M., Campbell, P. E., Stevens, B. J., Mayne, V., Cartwright, E. Pediatrics, Springfield, 1972, 50, 188. 4. Singh, S., Bresman, M. J. Am. J. Dis. Child. 1973, 125, 572. 5. Walker-Smith, J. A., Turner, B., Blomfield, J., Wise, G. Archs Dis. Childh. 1973, 48, 958.

Letter: Pathogenesis of multiple sclerosis.

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