BRITISH MEDICAL JOURNAL
18
JUNE
1977
motions do not return completely to normal on a sucrose-free diet may be offered starch restriction. Sucrose malabsorption may not be as rare as has been assumed, even outside Greenland. A large paediatric gastroenterology clinic may expect to identify three to four new families every year.9 Certainly the diagnosis has been overlooked in children with chronic diarrhoea. In 1973 the delay in diagnosis in six children varied from one to eight years,7 and in 1977 another study found delays of up to four years with as many as six inconclusive hospital admissions in one patient.8 In view of the modern tendency to give sucrose to very young babies, who are the least able to tolerate it, early diagnosis is important, for treatment leads to an increase in weight and height8 that is vital for the child's development in the long run. The condition should not be left for the child to "grow out of." In adults the syndrome does not rate the same importance, but it should be remembered as a possible cause of refractory diarrhoea which may even appear for the first time after puberty."' 1' Weijers, H A, et al, Acta Paediatrica, 1961, 50, 55. Prader, A, Auricchio, S, and Murset, G, Schzweizerische medizinische Wochenschrift, 1961, 91, 465. 3 Anderson, C M, et al, Pediatrics, 1963, 31, 1003. 4 Burgess, E A, et al, Archives of Disease in Childhood, 1964, 39, 431. 5 Kerry, K R, and Townley, R R W, Australian Paediatric Journal, 1965, 1, 223. 6 McNair, A, et al, British Medical Journal, 1972, 2, 19. Ament, M E, Perera, D R, and Esther, L J, Journal of Pediatrics, 1973, 83, 721. 8 Gudmand-Hoyer, E, Krasilnikoff, P A, Scandinavian Journal of Gastroenterology, 1977, 12, 103. 9 Anderson, C M, and Burke, V, Paediatric Gastroenterology, p 205. Oxford, Blackwell, 1975. " Sonntag, W M, et al, Gastroenterology, 1964, 47, 18. t' Neale, G, Clark, M, and Levin, B, British Medical Journal, 1965, 2, 1223. 2
Thymus hormones We now have convincing experimental evidence that the thymus secretes hormones'3 elaborated by its epithelial cells.4 Thymus grafts restore the immunological function of thymectomised mice even when transplanted in millipore chambers that allow the passage of soluble factors but not intact cells.3 Similarly, thymus grafting in immunodeficient children is often succeeded by so rapid an appearance of immunological competence that it is logical to invoke a hormonal effect.5 Yet, despite extensive efforts to extract material from the thymus or the blood of various animals, it has proved difficult to isolate and characterise any thymus hormones. The thymus has multiple functions. Thymus-derived T lymphocytes initiate both antibody production and cellmediated immunity, and many experiments have aimed to show that thymus extracts restore the reactivity in vivo of immunologically deprived recipients-commonly thymectomised mice or other species.3 6 One example is the ability of thymus extracts to promote host resistance to virus-induced neoplasms,7 while such extracts also appear to limit the development of amyloid in mice repeatedly injected with casein,8 a process related to impaired T lymphocyte function in susceptible strains. Moreover, extracts of thymus increase such responses as the graft versus host9 and the mixed lymphocyte reaction.'0 By contrast, other lymphocytes constituting one variety of "suppressor cell"" limit the duration and intensity of immune responses. Possibly thymus extracts
1559
may overcome the regulatory action of these cells with the net result that immune reactions are stimulated12; but equally probably some crude thymus extracts preferentially stimulate such suppressor cells. The relation between the thymus and autoimmune disease has long been debated. In mice multiple thymus grafts have been claimed to impair neuromuscular transmission in a manner resembling myasthenia gravis,13 suggesting that this disease is caused by the release of thymus hormones in toxic amounts from a thymus damaged by autoimmune inflammation. When secreted in normal amounts these hormones could have a protective function. Two kinds of studies have been carried out in New Zealand mice and other strains which develop autoimmune disease to investigate this suggestion. Firstly, the serum content of thymus hormone has been shown to be deficient in autoimmune mouse strains compared with that of normal strains.14 15 Secondly, when thymus hormone has been given directly to New Zealand mice16 or provided by thymus grafting,'7 the onset of autoimmune disorders has been delayed or suppressed. Similarly, autoreactivity in nude mice (which congenitally lack a thymus) is suppressed by such manoeuvres.18 It is unlikely that such diverse functions are performed by a single hormone, and crude thymus extracts probably contain a variety of active principles. The concept that "thymus hormone" acts as a single stage in the differentiation of the T lymphocyte is certainly too simple. A further problem has concerned the bioassays3 14 19 available for measuring thymus hormones (since these hormones cannot yet be measured routinely by direct techniques such as radioimmunoassay). These techniques are difficult to standardise, and may give non-specific results. Moreover, purification of the hormone preparations is difficult. Many investigators have used a fraction of crude thymus extract which contains at least 12 major heat-stable polypeptides with molecular weights ranging from 1200 to 14000.20 Such preparations probably contain material which will alter the lymphocyte surface entirely non-specifically.2' 22 Furthermore, since these preparations are certainly immunogenic the neutralising effect of the recipient animals' antibody response makes the interpretation of long-term experiments extremely difficult. So it is encouraging that a nonapeptide of molecular weight about 900, recently isolated from normal pig blood, has the properties in vitro and in vivo of thymus hormone.23 This material has been characterised, and the information should provide the basis for an acceptable assay; and, as it can also be synthesised,23 the lengthy and expensive process for isolating the naturally occurring factor may no longer be necessary. Thymus extracts have been used to treat patients with immune deficiency24 and to correct postulated T lymphocyte defects in such disorders as malignant disease2527 and uraemia.28 T lymphocyte deficiency in patients with virus infections such as influenza has also been said to be corrected in vitro.29 Such claims should not be accepted uncritically: they recall the similar enthusiasm for transfer factor, most of which has evaporated in the wake of properly controlled trials. Even the beneficial effects of thymus hormones in New Zealand mice are not universally accepted.30 The thymus plays an important part in regulating immune responses, and elucidating possible hormonal factors is highly relevant to clarifying the underlying mechanisms. Nevertheless, we must understand these better before we introduce thymus hormones into widespread clinical use. The risks attached to such treatment, including the possible activation of retroviruses (oncogenic RNA tumour viruses),31 must also be evaluated.
1560
1 Goldstein, A L, Slater, F D, and White, A, Proceedings of the National Academy of Sciences of the United States of America, 1966, 56, 1010. 2 Bach, J F, et al, Proceedings of the National Academy of Sciences of the
United States of America, 1971, 68, 2734. 3Bach, J F, and Carnaud, C, Progress in Allergy, 1976, 21, 342. 4Dardenne, M, et al, Immunology, 1974, 27, 299. 5 August, C S, et al, Lancet, 1968, 2, 1210. 6 Collins, F M, and Morrison, N E, Infection and Immunity, 1976, 13, 564. 7Zisblatt, M A, et al, Proceedings of the National Academy of Sciences of the United States of America, 1970, 66, 1170. 8 Scheinberg, M A, Goldstein, A L, and Cathcart, E S, J7ournal of Immunology, 1976, 116, 156. 9 Trainin, N, Small, M, and Globerson, N,Journal of Experimental Medicine, 1969, 130, 765. 10 Umiel, T, and Trainin, N, European Journal of Immunology, 1975, 5, 85. "I Allison, A C, Annals of the Rheumatic Diseases, 1973, 32, 283. 12 Bash, J A, et al, Cellular Immunology, 1976, 26, 308. 13 Goldstein, G, and Hofman, W W, Clinical and Experimental Immunology, 1969, 4, 181. 14 Bach, J F, Dardenne, M, and Salomon, J C, Clinical and Experimental Immunology, 1973, 14, 247. 16 Dardenne, M, et al, Clinical and Experimental Immunology, 1974, 17, 339. 16 Gershwin, M E, et al,,Journal of Immunology, 1974, 113, 1068. 17 Niaudet, P, and Bach, M A, Clinical and Experimental Immunology, 1976, 23, 328. 18 Charreire, J, and Bach, J F, Proceedings of the National Academy of Sciences of the United States of America, 1975, 72, 3201. 19 Touraine, J L, et al, Clinical and Experimental Immunology, 1974, 17, 151. 20 Goldstein, A L, et al, Medical Clinics of North America, 1976, 60, 591. 21 Gershwin, M E, et al, Journal of Immunology, 1975, 115, 1444. 22 Plescia, 0 J, et al, Annals of the New York Academy of Sciences, 1976, 274, 519. 23 Bach, J F, et al, Nature, 1977, 266, 55. 24 Incefy, G S, et al, Clinical Immunology and Immunopathology, 1975, 4, 258. 25 Sakai, H, et al, Cancer, 1975, 36, 974. 26 Hardy, M A, Freund, M, and Friedmann, N, Surgery, 1976, 80, 238. 27 Schafer, L A, et al, Annals of the New York Academy of Sciences, 1976, 277, 609. 28 Harris, J, et al, Transplantation, 1975, 20, 176. 29 Scheinberg, M A, et al, New England3Journal of Medicine, 1976, 294, 1208. 30 Gershwin, M E, et al, Arthritis and Rheumatism, 1976, 19, 862. 31 Forger, J M, and Cerny, M, Cancer Research, 1976, 36, 2048.
Reviving the hospital necropsy Six years ago we drew attention' to a deterioration in the effectiveness of the post-mortem services, both as a quality control in the National Health Service and as an instrument of medical education. A study from Scotland (p 1577) on the trends in necropsy rates there suggests that the decline in the use of the necropsy has not been halted. The same trend has been reported in Birmingham2 and in London.3 The extent of the decline is evident from the observations recorded in the Goodenough Report4 in 1944 that two teaching hospitals in London and one in the provinces had rates of 90%0. Today hospital necropsy rates in Britain average around 20-25%, though the range is wide. Decreasing necropsy rates do not necessarily imply a corresponding fall in the absolute number of necropsies done in hospitals, for the proportion of deaths occurring in hospitals has steadily risen-from 41% of all deaths in 1957 to nearly 53% in 1973.3 Furthermore, where the coroner system operates there has been a steady rise in the number of deaths reported to the coroner, on almost all of which necropsies are ordered. Possibly, then, the absolute number of necropsies may have
BRITISH MEDICAL JOURNAL
18 JUNE 1977
declined little, if at all, in England and Wales, though in Scotland (where there are fewer medicolegal necropsies on deaths from natural causes) there may have been some fall-off. The fact remains that throughout Britain an increasing proportion of deaths occurring in hospitals escape the "benefit" of having a necropsy. Few would deny the past gains from the careful correlation of necropsy studies with observations made during life, in the era when techniques of clinical investigation developed from palpation, percussion, and auscultation up to the elaborate technological procedures of today. Surely this role for the necropsy must continue. Again, the post-mortem services have a valuable function of quality control. Now that performance monitoring is the order of the day for all the investigative services, is it not right that the clinician should still have this check on the accuracy of his diagnosis and the appropriateness of his treatment? Sometimes, too, important original discoveries stem directly from what have seemed to be requests for routine necropsies-as instanced by postpartum pituitary necrosis5 and hypertrophic obstructive cardiomyopathy.6 A final, vital function of a necropsy service is to maintain a high standard of accuracy in health records and statistics: thus in the Birmingham study there was a 2000 disagreement between clinical and post-mortem diagnoses.2 There can be little point, however, in necropsies if they are not well done; or if, as is now so often the case, clinicians do not attend to benefit from what is disclosed; or if, as the Scottish survey suggests, the necropsy findings make no impact on the recorded diagnoses even when there have been gross discrepancies. The decline in hospital necropsy rates can be reversed if both clinicians and pathologists have the will to do it. District laboratory services are mostly overstretched, and in these hard times the necropsy service is unlikely to attract funds for upgrading facilities-though much could be done at little cost. As Robertson7 has said, post-mortem room technology needs to be updated so that the pathologist is relieved of detailed dissection and his time used for more specialist work. Regrettably the Institute ofMedical Laboratory Sciences (formerly Technology) turned its back on the postmortem room technicians, who, despite some notable exceptions, remain members of a self-perpetuating inferior branch of the technological profession. Their pay-scales have been kept at a level that gives little incentive for a move from hospital porter grades. There is much to be said for post-mortem room technology to be closely linked-as it used to be-with technology in histopathology and museum display. It is the teaching hospitals, where staffing is usually rather more generous, that should lead the way in pushing the necropsy rates back over 500o and in improving the quality of the work so as to regain clinicians' interest-which implies some agreement between clinicians and pathologists on case selection.3 1
Medical_Journal,
1971, 2, 181. British Waldron, H A, and Vickerstaff, L, British Medical J'ournal, 1975, 2, 326. 3 McMahan, C A, Hammett, L K, and Robertson, W B, Health Trends, 1977, in press. 4Ministry of Health. Department of Health for Scotland. Report of InterDepartmental Committee on Medical Schools. London, HMSO, 1944. 5Sheehan, H L, Journ,al of Pathology and Bacteriology, 1937, 45, 189. 6 Teare, R D, British Heart Journal, 1958, 20, 1. 7 Robertson, W B, Lancet, 1972, 1, 152. 2
18
JUNE
1977
motions do not return completely to normal on a sucrose-free diet may be offered starch restriction. Sucrose malabsorption may not be as rare as has been assumed, even outside Greenland. A large paediatric gastroenterology clinic may expect to identify three to four new families every year.9 Certainly the diagnosis has been overlooked in children with chronic diarrhoea. In 1973 the delay in diagnosis in six children varied from one to eight years,7 and in 1977 another study found delays of up to four years with as many as six inconclusive hospital admissions in one patient.8 In view of the modern tendency to give sucrose to very young babies, who are the least able to tolerate it, early diagnosis is important, for treatment leads to an increase in weight and height8 that is vital for the child's development in the long run. The condition should not be left for the child to "grow out of." In adults the syndrome does not rate the same importance, but it should be remembered as a possible cause of refractory diarrhoea which may even appear for the first time after puberty."' 1' Weijers, H A, et al, Acta Paediatrica, 1961, 50, 55. Prader, A, Auricchio, S, and Murset, G, Schzweizerische medizinische Wochenschrift, 1961, 91, 465. 3 Anderson, C M, et al, Pediatrics, 1963, 31, 1003. 4 Burgess, E A, et al, Archives of Disease in Childhood, 1964, 39, 431. 5 Kerry, K R, and Townley, R R W, Australian Paediatric Journal, 1965, 1, 223. 6 McNair, A, et al, British Medical Journal, 1972, 2, 19. Ament, M E, Perera, D R, and Esther, L J, Journal of Pediatrics, 1973, 83, 721. 8 Gudmand-Hoyer, E, Krasilnikoff, P A, Scandinavian Journal of Gastroenterology, 1977, 12, 103. 9 Anderson, C M, and Burke, V, Paediatric Gastroenterology, p 205. Oxford, Blackwell, 1975. " Sonntag, W M, et al, Gastroenterology, 1964, 47, 18. t' Neale, G, Clark, M, and Levin, B, British Medical Journal, 1965, 2, 1223. 2
Thymus hormones We now have convincing experimental evidence that the thymus secretes hormones'3 elaborated by its epithelial cells.4 Thymus grafts restore the immunological function of thymectomised mice even when transplanted in millipore chambers that allow the passage of soluble factors but not intact cells.3 Similarly, thymus grafting in immunodeficient children is often succeeded by so rapid an appearance of immunological competence that it is logical to invoke a hormonal effect.5 Yet, despite extensive efforts to extract material from the thymus or the blood of various animals, it has proved difficult to isolate and characterise any thymus hormones. The thymus has multiple functions. Thymus-derived T lymphocytes initiate both antibody production and cellmediated immunity, and many experiments have aimed to show that thymus extracts restore the reactivity in vivo of immunologically deprived recipients-commonly thymectomised mice or other species.3 6 One example is the ability of thymus extracts to promote host resistance to virus-induced neoplasms,7 while such extracts also appear to limit the development of amyloid in mice repeatedly injected with casein,8 a process related to impaired T lymphocyte function in susceptible strains. Moreover, extracts of thymus increase such responses as the graft versus host9 and the mixed lymphocyte reaction.'0 By contrast, other lymphocytes constituting one variety of "suppressor cell"" limit the duration and intensity of immune responses. Possibly thymus extracts
1559
may overcome the regulatory action of these cells with the net result that immune reactions are stimulated12; but equally probably some crude thymus extracts preferentially stimulate such suppressor cells. The relation between the thymus and autoimmune disease has long been debated. In mice multiple thymus grafts have been claimed to impair neuromuscular transmission in a manner resembling myasthenia gravis,13 suggesting that this disease is caused by the release of thymus hormones in toxic amounts from a thymus damaged by autoimmune inflammation. When secreted in normal amounts these hormones could have a protective function. Two kinds of studies have been carried out in New Zealand mice and other strains which develop autoimmune disease to investigate this suggestion. Firstly, the serum content of thymus hormone has been shown to be deficient in autoimmune mouse strains compared with that of normal strains.14 15 Secondly, when thymus hormone has been given directly to New Zealand mice16 or provided by thymus grafting,'7 the onset of autoimmune disorders has been delayed or suppressed. Similarly, autoreactivity in nude mice (which congenitally lack a thymus) is suppressed by such manoeuvres.18 It is unlikely that such diverse functions are performed by a single hormone, and crude thymus extracts probably contain a variety of active principles. The concept that "thymus hormone" acts as a single stage in the differentiation of the T lymphocyte is certainly too simple. A further problem has concerned the bioassays3 14 19 available for measuring thymus hormones (since these hormones cannot yet be measured routinely by direct techniques such as radioimmunoassay). These techniques are difficult to standardise, and may give non-specific results. Moreover, purification of the hormone preparations is difficult. Many investigators have used a fraction of crude thymus extract which contains at least 12 major heat-stable polypeptides with molecular weights ranging from 1200 to 14000.20 Such preparations probably contain material which will alter the lymphocyte surface entirely non-specifically.2' 22 Furthermore, since these preparations are certainly immunogenic the neutralising effect of the recipient animals' antibody response makes the interpretation of long-term experiments extremely difficult. So it is encouraging that a nonapeptide of molecular weight about 900, recently isolated from normal pig blood, has the properties in vitro and in vivo of thymus hormone.23 This material has been characterised, and the information should provide the basis for an acceptable assay; and, as it can also be synthesised,23 the lengthy and expensive process for isolating the naturally occurring factor may no longer be necessary. Thymus extracts have been used to treat patients with immune deficiency24 and to correct postulated T lymphocyte defects in such disorders as malignant disease2527 and uraemia.28 T lymphocyte deficiency in patients with virus infections such as influenza has also been said to be corrected in vitro.29 Such claims should not be accepted uncritically: they recall the similar enthusiasm for transfer factor, most of which has evaporated in the wake of properly controlled trials. Even the beneficial effects of thymus hormones in New Zealand mice are not universally accepted.30 The thymus plays an important part in regulating immune responses, and elucidating possible hormonal factors is highly relevant to clarifying the underlying mechanisms. Nevertheless, we must understand these better before we introduce thymus hormones into widespread clinical use. The risks attached to such treatment, including the possible activation of retroviruses (oncogenic RNA tumour viruses),31 must also be evaluated.
1560
1 Goldstein, A L, Slater, F D, and White, A, Proceedings of the National Academy of Sciences of the United States of America, 1966, 56, 1010. 2 Bach, J F, et al, Proceedings of the National Academy of Sciences of the
United States of America, 1971, 68, 2734. 3Bach, J F, and Carnaud, C, Progress in Allergy, 1976, 21, 342. 4Dardenne, M, et al, Immunology, 1974, 27, 299. 5 August, C S, et al, Lancet, 1968, 2, 1210. 6 Collins, F M, and Morrison, N E, Infection and Immunity, 1976, 13, 564. 7Zisblatt, M A, et al, Proceedings of the National Academy of Sciences of the United States of America, 1970, 66, 1170. 8 Scheinberg, M A, Goldstein, A L, and Cathcart, E S, J7ournal of Immunology, 1976, 116, 156. 9 Trainin, N, Small, M, and Globerson, N,Journal of Experimental Medicine, 1969, 130, 765. 10 Umiel, T, and Trainin, N, European Journal of Immunology, 1975, 5, 85. "I Allison, A C, Annals of the Rheumatic Diseases, 1973, 32, 283. 12 Bash, J A, et al, Cellular Immunology, 1976, 26, 308. 13 Goldstein, G, and Hofman, W W, Clinical and Experimental Immunology, 1969, 4, 181. 14 Bach, J F, Dardenne, M, and Salomon, J C, Clinical and Experimental Immunology, 1973, 14, 247. 16 Dardenne, M, et al, Clinical and Experimental Immunology, 1974, 17, 339. 16 Gershwin, M E, et al,,Journal of Immunology, 1974, 113, 1068. 17 Niaudet, P, and Bach, M A, Clinical and Experimental Immunology, 1976, 23, 328. 18 Charreire, J, and Bach, J F, Proceedings of the National Academy of Sciences of the United States of America, 1975, 72, 3201. 19 Touraine, J L, et al, Clinical and Experimental Immunology, 1974, 17, 151. 20 Goldstein, A L, et al, Medical Clinics of North America, 1976, 60, 591. 21 Gershwin, M E, et al, Journal of Immunology, 1975, 115, 1444. 22 Plescia, 0 J, et al, Annals of the New York Academy of Sciences, 1976, 274, 519. 23 Bach, J F, et al, Nature, 1977, 266, 55. 24 Incefy, G S, et al, Clinical Immunology and Immunopathology, 1975, 4, 258. 25 Sakai, H, et al, Cancer, 1975, 36, 974. 26 Hardy, M A, Freund, M, and Friedmann, N, Surgery, 1976, 80, 238. 27 Schafer, L A, et al, Annals of the New York Academy of Sciences, 1976, 277, 609. 28 Harris, J, et al, Transplantation, 1975, 20, 176. 29 Scheinberg, M A, et al, New England3Journal of Medicine, 1976, 294, 1208. 30 Gershwin, M E, et al, Arthritis and Rheumatism, 1976, 19, 862. 31 Forger, J M, and Cerny, M, Cancer Research, 1976, 36, 2048.
Reviving the hospital necropsy Six years ago we drew attention' to a deterioration in the effectiveness of the post-mortem services, both as a quality control in the National Health Service and as an instrument of medical education. A study from Scotland (p 1577) on the trends in necropsy rates there suggests that the decline in the use of the necropsy has not been halted. The same trend has been reported in Birmingham2 and in London.3 The extent of the decline is evident from the observations recorded in the Goodenough Report4 in 1944 that two teaching hospitals in London and one in the provinces had rates of 90%0. Today hospital necropsy rates in Britain average around 20-25%, though the range is wide. Decreasing necropsy rates do not necessarily imply a corresponding fall in the absolute number of necropsies done in hospitals, for the proportion of deaths occurring in hospitals has steadily risen-from 41% of all deaths in 1957 to nearly 53% in 1973.3 Furthermore, where the coroner system operates there has been a steady rise in the number of deaths reported to the coroner, on almost all of which necropsies are ordered. Possibly, then, the absolute number of necropsies may have
BRITISH MEDICAL JOURNAL
18 JUNE 1977
declined little, if at all, in England and Wales, though in Scotland (where there are fewer medicolegal necropsies on deaths from natural causes) there may have been some fall-off. The fact remains that throughout Britain an increasing proportion of deaths occurring in hospitals escape the "benefit" of having a necropsy. Few would deny the past gains from the careful correlation of necropsy studies with observations made during life, in the era when techniques of clinical investigation developed from palpation, percussion, and auscultation up to the elaborate technological procedures of today. Surely this role for the necropsy must continue. Again, the post-mortem services have a valuable function of quality control. Now that performance monitoring is the order of the day for all the investigative services, is it not right that the clinician should still have this check on the accuracy of his diagnosis and the appropriateness of his treatment? Sometimes, too, important original discoveries stem directly from what have seemed to be requests for routine necropsies-as instanced by postpartum pituitary necrosis5 and hypertrophic obstructive cardiomyopathy.6 A final, vital function of a necropsy service is to maintain a high standard of accuracy in health records and statistics: thus in the Birmingham study there was a 2000 disagreement between clinical and post-mortem diagnoses.2 There can be little point, however, in necropsies if they are not well done; or if, as is now so often the case, clinicians do not attend to benefit from what is disclosed; or if, as the Scottish survey suggests, the necropsy findings make no impact on the recorded diagnoses even when there have been gross discrepancies. The decline in hospital necropsy rates can be reversed if both clinicians and pathologists have the will to do it. District laboratory services are mostly overstretched, and in these hard times the necropsy service is unlikely to attract funds for upgrading facilities-though much could be done at little cost. As Robertson7 has said, post-mortem room technology needs to be updated so that the pathologist is relieved of detailed dissection and his time used for more specialist work. Regrettably the Institute ofMedical Laboratory Sciences (formerly Technology) turned its back on the postmortem room technicians, who, despite some notable exceptions, remain members of a self-perpetuating inferior branch of the technological profession. Their pay-scales have been kept at a level that gives little incentive for a move from hospital porter grades. There is much to be said for post-mortem room technology to be closely linked-as it used to be-with technology in histopathology and museum display. It is the teaching hospitals, where staffing is usually rather more generous, that should lead the way in pushing the necropsy rates back over 500o and in improving the quality of the work so as to regain clinicians' interest-which implies some agreement between clinicians and pathologists on case selection.3 1
Medical_Journal,
1971, 2, 181. British Waldron, H A, and Vickerstaff, L, British Medical J'ournal, 1975, 2, 326. 3 McMahan, C A, Hammett, L K, and Robertson, W B, Health Trends, 1977, in press. 4Ministry of Health. Department of Health for Scotland. Report of InterDepartmental Committee on Medical Schools. London, HMSO, 1944. 5Sheehan, H L, Journ,al of Pathology and Bacteriology, 1937, 45, 189. 6 Teare, R D, British Heart Journal, 1958, 20, 1. 7 Robertson, W B, Lancet, 1972, 1, 152. 2
