leukaemia associated with phenylbutazone treatment (21March, p. 744). Wehave re- cently been reviewing cases of motor neurone disease in an attempt to ...
2
was found that the average number of E.C.T.s given in the course of a year following admission and the number of days in hospital in that year were both reduced in 1961. The figures are shown in the table. While other factors may have been operating, I think that a major one in accounting for the change is that 22 of the 28 patients in 1961 were treated with imipramine.-I am, etc., Bexley Hospital, Bexley, Kent.
MEDICAL JORNAL
Correspondence
May 1964
ANDREW C. SMITH.
Pathogenesis of Atherosclerosis Sir,-Dr. A. C. Mayer (18 April, p. 1045) asks whether sudden coronary deaths occur in patients with a calcified left anterior descending coronary artery, and whether those patients whom we see and treat either do not develop calcification or have not done so when first seen. We have recently published' our observations from 250 patients with ischaemic heart disease and 250 age-matched controls in whom fluoroscopy with an image intensifier was used to detect coronary-artery calcification during life. This study confirms that the main left coronary artery and the proximal part of the left anterior descending branch are the commonest sites of calcification, but indicates that there is no relationship between either the mode of presentation of ischaemic heart disease or the length of history and the incidence of calcification. In other words, a man who had his first myocardial infarct last night is as liable to show coronary-artery calcification as the patient who had an infarct several years ago and the patient who has had angina for up to 10 years. Further, calcified coronary arteries were detected in 54 % of living patients with ischaemic heart disease and in 24 % of apparently healthy controls. Dr. J. L. Edwards (7 March, p. 629) usually finds calcification in four out of five fatal myocardial infarcts, and this is consistent with our findings that during life the incidence of calcification, which rises with age, is 74% in patients over 55 years. As a pathologist, Dr. Edwards has naturally assumed that there is a positive relationship between calcification and fatality. While the calcification is intimal in site and may be more common at points of stenosis and obstruction,2 we have no evidence that it is "frequently lethal" and prefer to regard it as a sign of advanced intimal disease.-We are, etc., Departments of Cardiology M. F. OLIVER. ERIC SAMUEL. and Radiology, Royal Infirmary,
Edinburgh 3.
REFERENCES Oliver, M. F., Samuel, E., Morley, P., Young, G. P., and Kapur, P. L., Lancet, 1964, 1, 891. Crawford, T., Dexter, D., and Teare, R. D., ibid., 1961, 1, 181.
N.H.S. Prescriptions for Contraceptives SIR,-The Ministry of Health has issued a statement to the effect that oral contraceptive tablets could not be prescribed under the National Health Service to patients who did not require them on medical grounds, but
that practitioners were free to issue a private prescription provided no charge was made. This appears to be an attempt by the Minister both to have the cake and eat it, or, at least, to present the doctor from eating it, and ought not to go unchallenged. Under the N.H.S. Act a practitioner is required to give all proper and necessary treatment to a patient on his list, to make no charge for it, and to prescribe such treatment on Form E.C.10. If there are no medical contraindications to pregnancy it seems he is precluded from prescribing these tablets on the official form. It follows, therefore, that provision of contraceptive tablets under these circumstances does not constitute medical treatment within the meaning of the N.H.S. Act, and that the practitioner in prescribing these tablets is fulfilling some function that is not covered by this Act. There seems to be no reason why he should not charge a fee for this if he is so inclined, just as he is entitled to charge for other services outside the scope of the Act-for example, the provision of private certificates or reports.-I am, etc., R. W. NEWMARK. Cleadon, Co. Durham.
important is the consistency of the paste. Briefly it can be stated that the stiffer the paste the better the result, provided, of course, the patient or nurse can apply the preparation accurately and liberally to the lesions. It has also been shown that the paste must be milled ; this provides great difficulties for dermatologists in remote country districts or practitioners trying to obtain suitable pastes from their chemists. Messrs. Reynolds and Bransons, of Leeds, have been persuaded to mill a "Hard Lassar's Paste" with i% (or 2%) dithranol, keeping the stiffness to the optimum degree obtained by clinical experiment (2 grains per oz.= 0.42%). It is thought that this preliminary information may be of considerable help until full details of the work are completed and published at a later date. The length of periods of absolute freedom from psoriasis is the primary concern of patient, practitioner, and dermatologist. Accurate statistics from various treatments are not yet available, but I agree with F. R. Bettley's clinical impression that the older therapies give longer periods of freedom than the latest steroid occlusion ones.2 He also states that in most cases the best local results are obtained with dithranol.-I am, etc., Lancaster.
SIR,-There was an announcement in the press last week stating that the Minister of Health had given his dispensation to the use of oral contraception under the N.H.S. in cases where further pregnancies would be harmful to the mother. This introduces a new concept of the scope of the N.H.S. However, dealing with the contraceptive aspect, this announcement needs further clarification. Basically there is now an official statement that in certain cases contraceptives are prescribable under the N.H.S. Now although only oral means have been specifically mentioned, to be restricted to this new method would amount to dictation of therapy, so that officially one can take a tablet per os but not per vaginam. Of those qualifying for N.H.S. contraceptives there will be some with mammary carcinomas or thrombophlebitis in which these oral tablets are contraindicated. There are some couples who have strong objections to the use of oral methods, and among doctors there is some misgiving as to the long-term effect of these tablets. My conclusions are therefore these. It has been publicly announced that in certain cases contraceptives are prescribable under the N.H.S. Now for the reasons already mentioned, and for the preservation of the freedom of clinical judgment, I contend that it must be left to the doctor to prescribe what is most suitable for any particular case, whether it is one of the occlusive types or spermicidal. If the Minister of Health does not intend the whole gamut of contraceptives to be available, how can it be justified to the patients ?-I am, etc., P. Q. M. SPAIGHT. King's Lynn,
1
R. H. SEVILLE, REFERENCES
1 Ingram, J. T., Brit. med. 7., 1953, 2, 591. Bettley, F. R., Prescribers' 7ournal, 1963, 3, 85.
2
Listeria Meningitis SIR,-One of your "pointers" in the B.M.7. of 18 April (p. 995) reads "Fungal Meningitis: Listeria monocytogenes meninw gitis . . ." At the present time Listeria is regarded as a bacterium, being classified as a genus of the family Corynebacteriaceae of the order Eubacteriales of the class Schizomycetes. It is not a fungus as inferred in your editorial heading. One can only assume that this error arose from a misunderstanding of Dr. P. Richards's statement on p. 1028: " Although fungal meningitis is particularly associated with debilitation . . . no such association has been demonstrated with . . . L. monocytogenes."-I am, etc., J. R. PHILP. Department of Materia Medica and Therapeutics, Aberdeen.
*** We are grateful to Dr. Philp for thia correction.-ED., B.M.7. Phenylbutazone and Motor Neurone Disease
SIR,-I was interested in the paper by Drs. H. J. Woodliff and L. Dougan on acute leukaemia associated with phenylbutazone treatment (21 March, p. 744). We have recently been reviewing cases of motor neurone disease in an attempt to elucidate the aetioNorfolk. logical factors, and in 6 out of 130 cases there has been an association with the taking of phenylbutazone before the onset of the motor neurone disease. Treatment of Psoriasis This may in fact be coincidental, but in SIR,-Professor J. T. Ingram gives, among view of the toxicity of phenylbutazone to the other essential details, physical data for the leucocytes in certain cases and the production consistency of the dithranol paste in his treat- of bone-marrow depression by this drug it ment for psoriasis.' Clinical research was may well be that in certain cases it can also started here in 1961 which has confirmed how affect the motor neurone.
