1382

PhI-positive erythropoietic cells in a case of chronic myeloidleukxmia, but this case had been treated with cyclophospha-mide, busulfan, and 6-mercaptopurine. If their findings shouldbe confirmed, it could, for example, mean that, even aftercells had become granulocyte precursors, drugs might yetmake them acquire some characteristics of the erythropoieticline. It would not mean that PhI-positive erythrocyte pre-cursors-if such cells exist at all-occur in untreated chronic

myeloid leukaemia. It would, anyhow, be hard to see why, incase of simultaneous presence of Phl-positive erythrocyte andgranulocyte precursors, the erythropoietic and leucopoieticsystems should behave in different manners.We may not be able to distinguish between young precursor

cells of granulocytes and erythrocytes, but that does not meanthat they are identical. In my opinion they will differ at leastin one respect: the genes through which the reproduction ofboth types of cells is controlled will be different ones.The loss of " leucopoietic " genes in the 21st chromosome

in chronic myeloid leukaemia seems to me to be pathognomonicfor this disease; in polycythaemia vera, chronic lymphaticleukxmia, myelomatosis, &c., other genes will probably beaffected, different ones in each disease and probably located invarious chromosomes.

If (this is a matter for genetics and for biochemistry)disintegration in one or more genes in a D.N.A. spiral werepropagated to adjacent nucleotides and so lead to permanentloss of its helical configuration, this might offer an explanationfor the changing of the 21st chromosome into a PhI chromo-some. Similar events in large chromosomes will be moredifficult to detect.

It might be worth considering whether alterations in onechromosome could have consequences for other ones.

N. H. D. SCHÖYER.Gorinchem,The Netherlands.

MEASUREMENT OF PROTEIN LOSSINTO THE INTESTINE

SIR,-In protein-loosing enteropathy the methods

employed for the measurement of protein loss are notstandardised, and different methods give different results.Jeejeebhoy and Coghill introduced the method of

feeding ion-exchange resin to patients given 131I-labelledalbumin, in order to bind any free 1311 in the intestine.They suggested that the fsecal 1311 excretion was" quantitatively representative " of protein loss into theintestine. Jones and Morgan, 2 however, using this

technique, found a relation between the faecal and urinaryexcretion of 1311, and suggested that the amount of 1311excreted in the fxces was more closely related to thelevel of free 1311 in the plasma resulting from endogenouscatabolism of the 1311-labelled albumin, than to the

passage of intact albumin into the intestine. On these

grounds they criticised the validity of the resin method.In a preliminary study of tropical sprue,3 using the resin

technique, we found an increased loss of 1311 into the intestine.Recently in a more detailed study in 10 normal subjects and19 patients with tropical sprue, using the same-technique, wehave again found a considerably increased fxcal excretion of1311 in the sprue group as compared with the controls.4 In thecontrol group there was no correlation between the urinaryand fsecal excretion, but in the patient group there was astatistically significant correlation between the urinary andfxcal excretion of radioactivity. However, since there was nosignificant difference between the mean urinary excretion of131 in the patient and control groups, the increased feecalexcretion in the patients could not be explained on the basisof increased endogenous catabolism, and therefore must

presumably represent an increased passage of protein into the1. Jeejeebhoy, K. N., Coghill, N. F. Gut, 1961, 2, 123.2. Jones, H. J., Morgan, D. B. Lancet, 1963, i, 626.3. Vaish, S. K., Baker, S. J. Communication to Association of Physicians

of India, 1962.4. Vaish, S. K., Ignatius, M., Baker, S. J. To be published.

gut. It would appear that the resin technique is still the bestavailable for obtaining simultaneously an indication of theamounts of protein breakdown occurring in the intestine andin other sites. Nevertheless, the technique is not perfect,because the precise amount of 1 entering the gastrointestinaltract not bound to protein cannot be quantitated.

S. K. VAISHM. IGNATIUSS. J. BAKER.

Wellcome Research Unit,Christian Medical College Hospital,

Vellore, South India.

" MULTIPLE-CHOICE " EXAMINATION

JEFFREY BOSS.Department of Physiology,University of Bristol.

SIR,-Sir Charles Illingworth (Dec. 14) finds that thereis a good case for replacing written examinations of theconventional kind by multiple-choice papers. Without

disputing that grading by multiple-choice papers tells usas much about the candidate as do the marks of con-ventional papers, it remains to be asked whether theanswers to conventional papers, and the marks given, dothemselves tell us what we need to know.

STRESS AND OCCLUSIVE CORONARY-ARTERYDISEASE

SiR,—The value of Dr. Pearson and Miss Joseph’scareful comparison 1 of the prevalence of emotional stressamong patients with myocardial infarct and amongmatched patients with gastrointestinal disorders could beenhanced by a discussion of two questions which bear onthe validity of their results and the duplication of theirprocedure.

First, in what proportion of cases could the interviewer guesscorrectly whether a subject was in the study group or in thecontrol group ? It seems unlikely that small clues that suggestthe correct category never arose in the interview, despite theinvestigator’s best efforts to avoid guessing. Such clues mightinclude breathlessness, cyanosis, slowness of bodily motion,and references to cardiovascular or gastrointestinal sensationswhen relating stressful experiences. A case in point is thequotation from patient no. 22: " There’s one chap there thatmakes me mad ... terrific arguments ... my heart begins tobeat and I go all hot." The correct identification of the diagnos-tic category in a substantial number of cases could systematicallyaffect, quite unconsciously, the kind of material elicited duringthe interview and the interviewer’s assessments of stress basedupon these data.2

Secondly, to what extent can the interviewer’s assessment ofthe frequency and severity of stresses be reproduced by otherpersons working solely from the transcripts and acting withoutknowledge of the original judgments or the diagnostic cate-gories ? Particularly when dealing with such an intangiblefactor as emotional stress, the investigator should demonstratethat his measurements can be made reliably, both by himselfand others.

Given satisfactory answers to these questions, a persistentcritic could still argue that the results of the inquiry by Dr.Pearson and Miss Joseph do not necessarily reflect a realdifference between the two groups in exposure to stressfulsituations. A spurious relationship would result, for example,if the recall of stresses was influenced by the severity of theillness. The procedures for collecting data can always bereasonably under suspicion in case-history studies of thisproblem regardless of the extent to which they may be con-trolled, and persons opposed to the idea that emotional stressis important in the xtiology of ischxniic heart-disease willremain unconvinced by the results of such studies.We think it is now time to put the matter to a more

rigorous test. Blood-pressure, blood-lipids, and cigarettesmoking have been definitely linked with ischasmic heart-

1. Lancet, 1963, i, 415.2. Rosenthal, R. Amer. Sci. 1963, 51, 268.

1383

disease ; exercise, diet, and obesity are suspected. On theother hand, Morris 3 maintains that these factors by them-selves are insufficient to explain the geographical distribu-tion of this disease, and he suggests that mental andemotional factors also may be important. The work ofDr. Pearson and Miss Joseph, and of others in this field,offers sufficient support for this hypothesis to warrant thetrouble and expense of a cohort study which could directlyestimate the risk associated with emotional stress andevaluate its importance relative to that of known factors.

RICHARD B. SHEKELLEADRIAN M. OSTFELD.

Departments of Psychiatry andPreventive Medicine,University of Illinois,

Chicago, Illinois, U.S.A.

LANGUAGE AND PSYCHIATRY

T. B. MADDEN.

SIR,-I am in agreement with Dr. Enoch’s letter ofNov. 30.

.

When inducing anaesthesia with sodium thiopentone inWelsh-speaking patients I have noticed that if one asksthem to count out loud in English they will oftenrevert to their native Welsh after they reach " four orfive ". This demonstration that the brain will revert toits primary language when " confused " with sodiumthiopentone may also have some bearing when dealingwith mental illness in the Welsh-speaking.

HYPERBARIC OXYGEN IN RESUSCITATION OFTHE NEWBORN

SIR,-Dr. Herbert Barrie’s disparaging letter (Dec. 7)concerning the Glasgow use of hyperbaric oxygen inresuscitation of the newborn does not do justice to thework which those of us, who are on the spot, have seenat first hand.The experience in emergency techniques in the large

Glasgow maternity units is massive, and the value ofmethods of pulmonary inflation is well recognised. This,however, is no reason for excluding other approaches.More important than methods of resuscitation are the

reasons for a baby’s inability to initiate or maintain res-piration. These are very much the concern of the obste-trician who often presents the paediatrician with a hopelesstask. The differential diagnosis which underlies this

emergency is a formidable matter, and time is on the sideof neither doctor nor baby. Of the babies that are in

respiratory trouble at birth, some are so overwhelmed byunderlying abnormalities that they will die in any case, orsurvive as neurological casualties; some will recover inspite of almost any treatment which is not too grosslyunsound, and some, the marginal group, will reward

prompt and intelligent resuscitation. It is seldom possibleto segregate these groups with accuracy except in retro-spect, and to compare recovery figures between differentworkers may be misleading.

Dr. Barrie’s claim to have revived 95% of babies inSt. Thomas’s Hospital (number not stated) who weretreated with intubation would hardly apply to the 46%mortality of the Glasgow babies treated with hyperbaricoxygen, in most of whom abundant lesions were demon-strated at necropsy. It is neither scientific nor reasonableto compare like with unlike. Dr. Barrie has referred to

Glasgow’s enviable record, although he overrates mycontribution to the subject of lung inflation. I can onlyclaim to have learned that the truth in this matter isneither plain nor simple, and I am more than ready tocooperate with Professor Hutchison and Dr. Margaret

3. Morris, J. N. Yale J. Biol. Med. 1961-62, 34, 359.

Kerr, with whom I have worked for so long, in exploringfresh methods.

My interest in pulmonary inflation techniques assistedby patient-triggered electronic respirators, on the principleof " augmented respiration ", does not blind me to thepossible advantages of a new approach to an old problem.

IAN DONALD.

A DESIGN FOR GENERAL PRACTICE

M. J. F. COURTENAY.

SIR,-How much I agree with Dr. Evans (Dec. 7) inhis letter from his consulting-room. He has read myletter exactly as I intended, and has dealt kindly with myover-simplifications. Of course, organisation will improvethe efficiency of a practice provided it is not so rigid as toimpair the doctor’s flexibility; and tools are part of thedefinition of " man ".

As he includes psychoanalysis as a tool, it is here that Ishould like to add a word. For me, general practice in thefuture lies in developing the skill of the doctor in the field ofpsychological medicine to parity with his skill in somatic

medicine, so that such an artificial division no longer has anymeaning when dealing with a patient. I contend that the G.P.needs insight more than prostheses.

This revolution in thinking for general practice was initiatedby Dr. Michael Balint at the Tavistock Clinic, and I have nodoubt that trying to apply it has been rewarding to me andmy patients.The kind of re-approach that follows this change of stand-

point can be well illustrated by Dr. Franklin’s letter, whichfollows that of Dr. Evans.

Dr. Franklin encourages us to respond to the feelingsaroused in us by psychopathic aggression rather than inter-preting it to the patient by word and deed. I can only thinkthat this will reinforce the patients’ pattern of behaviour,though I am not suggesting it is easy to stand it. I

Much has been said this year about the need for thedoctor to be a man of outstanding character, but thedescription couched in moral terms seems to excludethose of us who are not saints; so that I think it is impera-tive that we become as scientific in our approach to thedoctor-patient relationship as we try to be in the rest ofour work.

THE GENERAL PRACTICE ADVISORY SERVICE

SIR,-Following resolutions passed by the annual

representative meeting of the British Medical Associationand the Conference of Local Medical Committees, andwith the active support of the B.M.A., the MedicalPractitioners’ Union, and the College of General Practi-tioners, the General Practice Advisory Service Ltd. hasnow been incorporated and the first meeting of its manage-ment committee held.

It is one thing, however, formally to bring into beingan organisation and quite another to give it flesh and blood.At the moment we have no money, no staff, and noinformation to supply. These deficiencies will be cor-rected with all possible speed, but however successful weare, many months must elapse before any help can beoffered. I would guess that by September or Octobernext practical advice will start to flow. The purpose ofthis letter, therefore, is to beg doctors not to write to theService asking for advice. As soon as we are in a positionto offer help we shall announce the fact.But I must not end on this depressing note. All those

associated with the Service, which is an imaginativeventure uniting all those who have the good of generalpractice at heart, are determined to make it a great success