subnormality at the crossroads

353

INTRAVENOUS FEEDING

SIR,-The letters from Newcastle 1,2 reflect an increasingconcern with iatrogenic disease. However, no mention ismade of the previous reports of hyperammonxmia in

both children and adults on hyperalimentation. Thebest discussion I believe is the one by Samuel Bessman.3This hyperaliminentation problem has occurred with boththe protein-hydrolysate solution and the crystalline amino-acid solutions. Dr Bessman’s figures suggest that 5% ormore of otherwise normal individuals are in fact hetero-

zygotes for disease in aminoacid metabolism and may reactto the load presented by hyperalimentation with systemictoxicity and hyperammonsmia. The protein-hydrolysatesolutions themselves contain large amounts of free ammonia(up to 50,000 ig. per 100 ml.), which, in a marginal patient,could induce ammonia intoxication. This would be

extremely important where Aminosol’ is used as an

intravenous-feeding component, and blood-ammonia levelsshould be measured routinely in individuals receiving suchtherapy.

816 Headley Drive,London, Ontario N6H 3V8, Canada. FRANK A. WALKER.

1. Wright, P. D. Lancet, 1973, ii, 1335.2. Tweedle, D. E. F., Johnston, D. A. ibid.3. Bessman, S. J. Pediat. 1972, 81, 834.

SUBNORMALITY AT THE CROSSROADS

SIR,-Workers in all professions concerned with thementally handicapped will surely echo the call for a numberof well-endowed academic units so as to establish highstandards of practice in mental handicap. Not everyonewill agree with the methods proposed in your leadingarticle (Feb. 2, p. 156).Mental handicap, as you say, presents a medico-socio-

logical challenge: one might add that it presents an equallygreat educational challenge. What is needed is a networkof units or institutes which will, by training, education, anddemonstration in a service setting, improve our presentmethods for delivering service: these institutes are neededfor qualified people in many professions-education, childcare, psychiatry, social work, educational psychology,nursing, genetics, social psychology, and a growing numberof therapies. Each has a distinctive contribution in hisown right.That such units, or institutes, need a university base or

link goes without saying: but would they be rightly basedon psychiatry, as you seem to suggest ? One of the mostsuccessful such institutes in the U.S.A., at Ann Arbor, isan Institute of Mental Retardation and Related Dis-abilities, headed by a psychologist and accountable directto the University Council. Doctors are involved heavilyin its work, but it is not part of the medical faculty.Any attempt to regard this medico-socio-educational

venture as being a primarily medical effort with socio-educational appendages is likely to halt progress and todeter some of the best of the non-medical contributors.Your description of the knowledge and skills needed bythe new-look subnormality specialist leaves one gasping.Where will we find these erudite beings who are to possessnot only a deep knowledge of general medicine, psychiatry,child development, and paediatric neurology, but also,learning theories, cultural behaviour, psychological assess-ment and special education-and much more besides ?Just when mental handicap workers throughout the worldare beginning to benefit from the work of non-medicalpeople like Professor Mittler on learning processes, DrGunzburg on social education, and Professor Tizard oneducation, you seem to be advocating a return to the medicaljack-of-all-trades.The task is not to develop a small elite of doctors who

will know it all, but to develop an army of people who willbe able to work together, always seeking higher standards,in a venture of which medicine forms only a part, thoughan extremely important one.A gloomy account of the present state of medical educa-

tion for the medical component of mental handicap wasgiven recently by Holt and Huntley showing the greatneed for better medical training both at undergraduate andpostgraduate level. But in addition to this medical training,we need broadly-based multidisciplinary institutes on thelines beginning to be developed at the Institute of MentalSubnormality at Kidderminster, headed by Dr G. B.Simon, which has close links with the University of

Birmingham.It could well be that there is room for a pluralistic

approach, and that some units might be based withinmedicine, and others not. The important thing is to

recognise the urgent need for .centres where the bestmethods can be demonstrated. We have a lot to learnabout such units, and there is plenty of room for experiment.The King’s Fund Centre is proposing a meeting in the

autumn at which ideas on institutes and training, medicaland otherwise, may be discussed. I would be glad to hearfrom doctors and others who would be interested in

attending.I congratulate you on bringing this important matter to

public attention.King’s Fund Centre,24 Nutford Place,London W1H 6AN.

JAMES ELLIOTT,Associate Director.

1. Holt, K. S., Huntley, R. M. C. Br. J. med. Educ. 1973, 7, 197.

SIR,-We welcome your very sensible leader. Onecannot overemphasise the importance to the mentallyhandicapped and to society of doctors committed to workingwith the under-privileged and accepting responsibility ontheir behalf.

It is in the natural order of things that the handicappedand those who work with them tend to be at the lower endof priorities. One way to obviate this is to enhance thestatus of the specialty and those who work in it. Thecreation of one or more university chairs, as proposed,would help to do this, whilst at the same time it wouldcoordinate the teaching of the trainees and stimulateresearch into the causes and treatment of mental deficiency.

Royal Scottish NationalHospital,

Larbert, Stirlingshire.

D. A. PRIMROSE,Secretary,

Western Regional Division ofMental Deficiency.

SIR,-Your leader is almost worthy of the Old Thundereritself, and not all will agree with its dogma. However, Iam sure there is a large measure of support for the proposalthat much better academic recognition be made of theproblems in mental handicap. My experience in teachingthe subject to medical undergraduates during the past7 years is that it can be introduced just as effectively withinthe paediatric or community-medicine courses as in psy-chiatry, and certainly in Edinburgh the knowledge andconcern for the problems shown by recent final-yearstudents contrasts markedly with their hard cynicism whichI remember so vividly in 1967 when their total exposurewas a fragment of the psychiatry programme. In myopinion it is essential that any academic units in this fieldbe multidisciplinary (medical and non-medical), to whichpsychiatry should make an important contribution.

University Department ofSocial Medicine,Usher Institute,

Warrender Park Road,Edinburgh EH9 1DW. T. L. PILKINGTON.