You are on page 1of 5

366

DIOGENES SYNDROME* order and squalor, is not uncommon, yet has attracted
A CLINICAL STUDY OF GROSS NEGLECT little study.2,3 Such people pose serious problems in
terms of community care and sometimes need urgent
IN OLD AGE
hospital admission. We describe here the back-
A. N. G. CLARK G. D. MANKIKAR ground, presentation, psychiatric factors, and out-
IAN GRAY come in thirty such cases and investigate the sugges-

Department of Geriatric Medicine, Brighton General tionthat this social and clinical picture might repre-
Hospital, Brighton BN2 3EW sent a syndrome.
Patients and Methods
Summary
study of elderly patients (fourteen
A
men, sixteen women) who were ad- Thirty patients (foutteen male, sixteen female) aged
mitted to hospital with acute illness and extreme self- 66-92 (average 79) were seen. All lived in a desperate
state of domestic disorder, squalor, and self-neglect, and
neglect revealed common features which might be they were referred for urgent admission to the geriatric
called Diogenes syndrome. All had dirty, untidy unit between October, 1972, and July, 1973. The social
homes and a filthy personal appearance about which and environmental background was examined in every
they showed no shame. Hoarding of rubbish (syllo- case, together with conventional medical examination and
gomania) was sometimes seen. All except two lived investigations on admission. Comprehensive intelligence
alone, but poverty and poor housing standards were and psychometric testing were assessed by the intellectual
not a serious problem. All were known to the social- rating scale (I.R.S.), intelligence quotient by Wechsler
services departments and a third had persistently adult intelligence scale,4 and by Cattell’s methodfor
refused offers of help. An acute presentation with personality.
falls or collapse was common, and several physical Results
diagnoses could be made. Multiple deficiency states Social and Environmental Factors
were found—including iron, folate, vitamin B12, vita-
min C, calcium and vitamin D, serum proteins and All patients lived in
a state of domestic squalor, dis-

albumin, water, and potassium. The mortality, order, and self-neglect. Their homes were
extreme

especially for women, was high (46%); most of the filthy on the outside-peeling paintwork and dirty,
survivors responded well and were discharged. Half often broken, windows with dingy net curtains serv-
ing as external markersto conditions within. Inside
showed no evidence of psychiatric disorder and
there characteristic strong, stale, and slightly
was a
possessed higher than average intelligence. Many
had led successful professional and business lives, suffocating smell. The patients were usually dressed
with good family backgrounds and upbringing. Per- in’layers of dirty clothing sometimes covered by an
old raincoat or overcoat, and, when confined to bed,
sonality characteristics showed them to tend to be
aloof, suspicious, emotionally labile, aggressive, they lay beneath a pile of ragged blankets, clothing,
group-dependent, and reality-distorting individuals. or newspapers. They never appeared to undress or
It is suggested that this syndrome may be a reaction wash, the hair being long and unkempt, with exposed
late in life to stress in a certain type of personality. surfaces of skin deeply engrained with dirt. Only
two patients apologised about their personal or domes-

Introduction tic state. Several hoarded useless rubbish (syllogo-

THE acutely ill old person with a dirty and neg-


mania)-newspapers, tins, bottles, and rags, often in
bundles and stacks-and in six instances the size of
lected appearance, in a setting of gross domestic dis- the collection seriously reduced living space.

*
DIOGENES (4th century B.C.). Greek philosopher, the first of
Family and Home Support
the cynics. Supplied his needs in food and clothing, which Twenty-eight lived alone-one man lived with a
he kept to the minimum, by begging.... His ideals were son and grandson, and one lived with his unmarried
" "
" life according to nature ", self-sufficiency ", freedom
from emotion ", " lack of shame ", "
daughter; seventeen had relatives (eight in the Brigh-
outspokenness ", and ton area) while thirteen had none. Every patient had
" contempt for social organisation ".1
been known to the community authorities for several
weeks to years, and the domestic predicament was
well recognised. Twelve had home services (home
19. Estrada-Parra, S., Olguin-Palacios, E. in Nucleic Acids in Immuno- help, nursing, and meals) while ten repeatedly de-
logy (edited by O. J. Plescia and W. Braun); p. 96, New York, clined offers of help, sometimes refusing to open the
1968.
Acad. Sci. U.S.A. 1969,
door to callers.
20. Schur, P. H., Monroe, M. Proc. natn. 63,
1108.
21. Talal, N., Steinberg, A. D., Daley, G. G. J. clin. Invest. 1971, 50, Nutrition
1248. Little food was to be found in the house, and old
22. Epstein, W. V., Tan, M., Easterbrook, M. New Engl. J. Med.
1971, 285, 1502. dishes and mouldy scraps were often seen. Tea,
23. Koffler, D., Carr, R., Agnello, V., Thoburn, R., Kunkel, H. G. bread, biscuits, cakes, and tinned food seemed to be
J. exp. Med. 1971, 134, 294.
24. Stollar, D., Levine, L. Archs Biochem. Biophys. 1963, 101, 417. the staple diet.
25. Stollar, D., Levine, L., Lehrer, H. I., Van Vunakis, H. Proc. natn.
Acad. Sci. U.S.A. 1962, 48, 874. Finance
26. Arana, R., Seligmann, M. J. clin. Invest. 1967, 46, 1867. All the patients received the old-age pension and
27. Erickson, E., Braun, W., Plescia, O. J., Kwiatokowski, Z. in Nucleic
Acids in Immunology (edited by O. J. Plescia and W. Braun); six had supplementary pension; two had savings of
p. 201. New York, 1968. E2600 and E5000, and seven owned their homes. No-
28. Tanenbaum, S. W., Karol, M. H. ibid. p. 222.
29. Leroy, E. C. J. clin. Invest. 1974, 54, 880. one complained of shortage of money, and poverty
367

did not seem to be a feature. Food and clothing were No gross deviation of personality was found when
sometimes accepted from sympathetic neighbours. the personality-testing scores were compared with
general population norms ’despite striking age differ-
Professions ences, and the patients showed a closer correspondence
Three men had held Service commissions; two had with normal than abnormal personality. However,
been journalists; one had been a dentist, and one a they seemed more aloof, detached, shrewd, suspicious,
professional violinist. Three women had been school- and less well integrated. Other less significant traits
teachers, one a West-End fashion designer, one a showed them to be less stable emotionally, more
music teacher, one an opera singer (Covent Garden), serious, aggressive, and group-dependent, with a
and one a teacher of needlework. Their careers tendency to distort reality.
seemed to have been successful and they had enjoyed
sound family backgrounds, education, and social Progress and Aftercare
standing in earlier life. Four men (average age 85) and ten women (aver-
Admission and Presentation age age 81) died. The death-rate for women is striking
and significantly greater (P<0-05) than that seen in
Two were compulsorily admitted (under Section 47 our unit 8; the death-rate for men is in keeping with
of the Mental Health Act), the rest voluntarily; eight routine experience. The patients either responded
had previously refused until the point where illness well or died shortly after admission.’
became critical. A fall or collapse (seventeen) was the Thirteen were discharged: home (one man, four
most common presentation. women), welfare home (six men, one woman), private
Diagnosis home (one man). Only three were placed in long-
All were acutely ill, and the principal diagnoses stay wards. Follow-up visiting showed that those at
were congestive heart-failure (eight), cerebrovascular
home were in a reasonable, yet untidy, state; those in
welfare homes settled well and voiced no regrets.
disease (seven), bronchopneumonia (four), malignant
disease (two), Parkinson’s disease (two), osteoarthritis
Discussion
(two), and leukaemia, gangrene, cervical spondylosis,
pulmonary embolism, and renal failure were present This study reveals sufficient common features to
in single cases. confirm the suggestion that severe self-neglect in old
age is a syndrome.’ Common features include domes-
Pathological Investigations tic and personal dirt and squalor,2 poor housing stan-
These revealed the presence of anaemia and multiple dards not seeming to be important. They were all
deficiencies including sideropenia, changes in the known to authority, and a third caused problems by
serum-proteins, low folate and vitamin-B]2 levels, refusing help.9 All required urgent hospital admis-
deficiencies of vitamins C and D, and water deprivation sion, and a presentation with falls and collapse was
(see table). common. A variety of diseases and deficiency states
were diagnosed, and anxmia, sideropenia, and folate,
Intelligence and Personality Assessment
vitamin-C, and vitamin-Bl2 deficiencies were more
This was studied in fifteen patients,- several weeks common than in routine admissions.’&deg;&deg;" Dietary
after admission, to allow treatment to take effect and vitamin-D deficiency was present, and is well recog-
for them to settle in new surroundings. The striking nised in old age.12,13 The plasma-protein changes were
finding was the high l.Q., ranging from 97 to 134, probably due to nutritional inadequacy, and we found
the mean (115) being in the top quarter of the popula- four examples of hypokalxmia, which has been
tion at this age. A mean I.R.S. of 14 (range 10-5-17) ascribed to poor nutrition."
indicated a high level of intellectual preservation
Psychological assessment (on those patients who
(maximum possible score 17). could be tested) revealed good intellectual preserva-
LABORATORY FINDINGS tion and higher than average intelligence. Several
isolated themselves in the ward, others avoided group
activities, and some displayed outbursts of temper
when discussing future care. The tendency to dis-
tort reality might explain the lack of concern about
living standards. Poverty was not a serious factor;
several owned their own homes and two had capital
assets. Two previous examples, living as paupers,
were of a man with E’2 million and a woman with
30,000 accepting food and clothing from neighbours.
This may be a delusion of inability to afford necessi-
ties 15 or the result of a long tendency to save rather
than to spend.
The syllogomania may have been a distortion of
an instinctive drive to collect things.16 Some have
a compulsive habit to hoard objects which might be

useful; others lack the initiative to sort and throw


away useless items. The significance of this useless
hoarding is obscure, but it could provide a feeling of
security, and it can be seen in normal individualsY
368

There are two possible explanations why intelligent


educated individuals descend to such .debased stan- Preliminary Communication
dards of living. One might be a lifelong proclivity
to give personal and domestic care a low priority-
ABNORMAL ORGANIC ACIDURIAS IN
a disorganised style of life becoming exaggerated by
MENTALLY RETARDED PATIENTS
ageing and physical infirmity-or it might be a
reaction to stress in an elderly person with certain R. W. E. WATTS R. A. CHALMERS
personality characteristics. Sometimes previously Division of Inherited Metabolic Diseases,
stable old people develop neurotic breakdown with- Medical Research Council Clinical Research Centre,
out previous history,17 due to social, economic, and Harrow, Middlesex HA1 3UJ
declining health factors with predisposing features A. M. LAWSON
in the personality (e.g., being aloof, moody, and
Division of Clinical Chemistry, M.R.C. Clinical
anxious). A vicious circle of increasing anxiety, help- Research Centre
lessness, and anger is accentuated by inadequacy to
master everyday problems, producing a further ineffici- Urine specimens from 1778 mentally
ency.18 Social, psychological, and economic stress Summary retarded patients and 420 age and sex
produce mental illness in old age 19 and invoke defence matched non-retarded controls selected from a general
mechanisms of withdrawal and denial of need." Our
practice have been analysed for non-amino organic
patients seem to need social contact which earlier may acids by a quantitative extraction and gas chromato-
have been found within their profession and family.
graphic method. The compounds were identified by
Enforced isolation by bereavement,3 with loss of sup- combined gas chromatography and mass spectro-
port, or retirement could result in reactive rejection metry. Approximately 5% of the patients had an
of contemporary standards and social contacts. abnormal organic aciduria. The frequency of abnor-
What can be done to help these people? If accep- malities was slightly higher (about 7%) in a group
ted, a home help is often unable to make any impres- of 248 severely subnormal children, but not in cases
sion on the dirt and untidiness and finds the work with a family history of mental retardation, retarded
distasteful. On the other hand, compulsory removal
sibs, or whose parents were consanguineous. The
to a welfare home or to hospital should never be most frequently observed abnormalities were phenyl-
applied merely to ensure cleanliness and conformity. alanine metabolites in cases of phenylketonuria (about
Community-service agencies have no right to enter 1%), increased excretion of benzoic acid (about 1%),
a home without consent, and if, after offers of care
and increased excretion of 2-oxoglutaric acid with or
have been refused, a sane person suffers or dies alone, without raised urinary citric-acid levels (about 1%).
then no criminal negligence is involved.21 Society The biochemical and clinical significance of these
may protest at the standards of these people and neigh- findings is being further investigated.
bours may complain, but compulsory powers are rarely
used and care by consent should be the principle in INTRODUCTION

management. If they recover, their freedom to decide ABOUT 3 % of the general population are mentally
their future should be respected. retarded, with i.Q. values below 70, and in about
We thank Dr N. I. Condon, Dr W. S. Parker, and Dr J. A. 0-4% of the population the i.Q. is less than 50 when
Whitehead, and the health visitors and social workers for their measured at the age of seven years.1,2 If the mental
interest and help in this study. Prof. J. F. Scott gave statisti- retardation can be shown to be linked with a specific
cal advice. biochemical abnormality, it may be possible to improve
Requests for reprints should be addressed to A. N. G. C. the situation by specific treatment or by developing
methods of prenatal diagnosis upon which to base
REFERENCES appropriate genetic counselling, with the option of
1. Chambers Encyclop&aelig;dia; vol. IV, p. 533. Oxford, 1966. aborting an affected fetus.
2. Stevens, R. S. Br. J. geriat. Pract. 1963, 2, 88.
3. MacMillan, D., Shaw, P. Br. med. J. 1966, ii, 1032.
Many inherited metabolic diseases that manifest as
4. Britton, P. G., Savage, R. D. Br. J. Psychiat. 1966, 112, 417. an organic aciduria include mental retardation among
5. Cattell, R. B., Stice, G. F. Handbook of the Sixteen Personality their symptoms. Previous work has concentrated on
Factor Questionnaire; and handbook supplement for form C.
Institute for Personality and Ability Testing, Illinois, 1957. aminoacidopathies and certain other disorders for
6. Payne, R. B., Little, A. J., Williams, R. B., Milner, J. T. Br. med. J. which relatively simple screening methods are avail-
1973, iv, 643. able. Although isolated examples of organic acid-
7. Harris, L. J., Abbasy, M. A. Lancet, 1937, ii, 1429.
8. Clark, A. N. G. Publ. Hlth, Lond. 1973, 88, 11. urias associated with mental retardation are known,3
9. Rudd, T. N. Br. J. clin. Pract. 1960, 14, 345. there are no previous reports of comprehensive meta-
10. Powell, D. E. R., Thomas, J. H., Mills, P. Geront. clin. 1968, 10,
21. bolic screening for abnormal non-amino organic
11. Hurdle, A. D. F., Picton Williams, T. C. Br. med. J. 1966, ii, 202. acidurias. New quantitative methods H have now
12. Anderson, I., Campbell, A. E., Dunn, A. Scott. med. J. 1966, 11, 429.
13. Chalmers, J. Jl R. Coll. Surg. Edinb. 1968, 13, 225.
enabled this to be undertaken, and we describe here
14. Judge, T. G. Geront. clin. 1968, 10, 102. a study of the incidence of metabolic disorders associ-
15. Beatson, A. W. Br. med. J. 1960, ii, 468. ated with an organic aciduria in mentally defective
16. James, W. Principles of Psychology. London, 1901.
17. Slater, E., Rother, M. Clinical Psychiatry; p. 117. London, 1969. adults and children.
18. Freedman, A. M., Kaplan, M. D. Comprehensive Textbook of The analytical methods used permit the quantitative
Psychiatry. Baltimore, 1967.
19. Padmore, F. B. in Mental Illness in Later Life (edited by E. Pfeiffer analysis of one approximately 5 ml. urine sample
and E. W. Busse); p. 46. American Psychiatric Association, 1973.
20. Pfeiffer, E., Busse, E. W. (editors). Mental Illness in Later Life;
(equivalent to 3 mg. creatinine) for any acidic com-
p. 110. American Psychiatric Association, 1973. pound with a pKa value less than about 5-5. Prior
21. Kinsey, E. W. Times, Jan. 9, 1973. knowledge of the likely acidic metabolites is not
515

SIR,-It is likely that the name Diogenes syndrome


Letters to the Editor will become common currency, and it is refreshing to read
for the first time a study of this by no means rare condition.
The authors are undoubtedly right in urging that insistence
RECOGNITION OF DIPHTHERIA
on conventional standards of cleanliness and behaviour
SiR,&mdash;We read with interest the report of diphtheria
never justifies the compulsory removal of a person from
in the Manchester area by Dr Butterworth and colleagues his or her home. There is, however, an important omission
(Dec. 28, p. 1558). They clearly imply that there is a in the article-namely, fire risk. The combination of a frail,
need to investigate routinely every case of sore throat for
the presence of diphtheria bacilli. This is an assertion
unsupported old person and masses of hoarded rubbish
often adds up to a danger of fire, not only to the person
with which we cannot agree. On the contrary, we believe concerned but to neighbours as well, if there are other
that routine examination for Corynebacterium diphtheria, at houses nearby. In my experience, it is this that causes the
present, is wasteful and may be counter-productive. In most worry when trying to deal with these difficult old
support of this view we would quote from Sir James people.
Howie’s summing-up of a symposium on diphtheria 1:
Warwickshire Area Health Authority,
" Obviously the disease has now reached such clinical Rugby District, 17 Warwick Street,
levels that to look for diphtheria in all throat swabs routinely Rugby, Warwicks. J. TWOMEY.
as we did in the 1930s would not be practical politics-the
cost would scarcely be justified. We really must beg our
clinical colleagues to raise their index of suspicion and SiR,&mdash;That some independently minded old people
make a clear approach to us, either a personal approach or resist the pressure of society to conform (Feb. 15, p. 366)
a definite note on the request form ’ diphtheria suspected’ should be a source of satisfaction to those who care for the
and that ought to put the staff of any reasonable laboratory freedom of the human spirit. One wonders whether self-
on its toes."
neglect in such cases is not a manifestation of the death-
During 1973, the isolation of 5 toxigenic and 45 non- wish, as in some cases of hypothermia. If so are we neces-
toxigenic strains of C. diphtheriae was reported to the sarily justified in interference as long as the person’s habits
Communicable Disease Report of the Public Health and behaviour are not a nuisance to others ?
Laboratory Service. The figures for 1974 (still provisional) Perhaps the existence of such cases supports the con-
were 3 and 73 respectively (Mrs E. Vernon, personal tention that the option of an arranged voluntary dying should
communication). A routine test for an organism with be available to the elderly in a civilised society. It should
such a low prevalence may breed carelessness and inatten- not be left to the individual to have to take steps himself
tion in the use of that test. either by forcible or more protracted means to terminate
When a strain of C. diphtherice is isolated from a patient his existence.
without clinical features of diphtheria, its significance To rescue such persons from their self-imposed exile
must be carefully assessed. It is not unknown for wards from society presupposes that our ideas of conventional
to be closed and the management of sick patients seriously behaviour are correct. Whether we are ever justified in
disrupted before evidence "of the toxigenic
"
status of an doing so is debatable. The application of pressure in such
organism isolated from a routine specimen has been cases is all too frequent and is excused by a devotion to the
determined, even though it is most likely that such a strain theory of " the sanctity of life " which overrides respect
will be non-toxigenic. for individual self-determination.
We make these observations because we believe that the Portland House,
detection of diphtheria at an early stage will best be Lindley,
achieved by urging clinicians to voice their suspicions to the Huddersfield. S. L. HENDERSON SMITH.
laboratory, and also to alert practitioners to the fact that not
all laboratories routinely examine specimens forC. diphtheria.
We are indebted to Prof. M. G. McEntegart for the proceed- GASTRIC ACID AND DUODENOGASTRIC
ings of the symposium on diphtheria. REFLUX
Public Health Laboratory and
Department of Microbiology, SiR,-Dr Kallner (Feb. 8, p. 338) rightly emphasises the
Central Middlesex Hospital, D. A. MCSWIGGAN importance of duodenogastric reflux, which, as he states,
Park Royal, London NW10 7NS. C. E. D. TAYLOR. is often overlooked. This error, although of greatest
importance during the basal period, will also distort
results during stimulated secretlon.1
DIOGENES SYNDROME The effect of reflux on hydrogen-ion concentration is
SIR,&mdash;The article by Dr Clark and his colleagues (Feb. even more striking than the effect on basal acid output,
15, p. 366) is important in so far as it draws attention to a since not only neutralisation but also dilution is involved.
characteristic picture by no means rare in clinical prac- This undoubtedly accounts for the large spontaneous
tice, but which as far as I know has never been clearly variations in basal hydrogen-ion concentration2 and is a
described before. I should, however, like to point out that major factor in the difficulties of interpretation of the
this syndrome is not restricted to the elderly. From my own insulin test. It is for this reason that we have ignored
unpublished observations on a series of recluses a similar basal collections in our investigations of postvagotomy
picture is found in much younger persons and betokens a insulin status,3 and our criteria have allowed us to give the
variety of psychiatric anomalies, including certain person- insulin test predictive accuracy in the individual cast for
ality disorders, frank psychosis, or dementia, and these need the first time.4,6
not necessarily be associated with physical handicap. It is a
pity that Dr Clark and his colleagues did not include a 1. Faber, R. G., Russell, R. C. G., Royston, C. M. S., Whitfield, P.,
psychiatric evaluation of their patients. We have not yet Hobsley, M. Gut, 1974, 15, 880.
reached the stage when psychometric testing can replace 2. Gillespie, G., Elder, J. B., Smith, J. S., Kennedy, F., Gillespie,
I. R., Kay, A. W., Campbell, E. H. G. Gastroenterology, 1972, 62,
clinical examination by a psychiatrist. 903.
Oldham and District Hospital, 3. Faber, R. G., Parkin, J. V., Russell, R. C. G., Whitfield, P.,
Rochdale Road, Oldham OL1 2JH. N. BERLYNE. Hobsley, M. Br. J. Surg. 1974, 61, 911.
4. Weinstein, V. A., Hollander, F. Gastroenterology, 1950, 14, 586.
1. Unpublished Proceedings of Symposium on Diphtheria, Sheffield, 5. Faber, R. G., Russell, R. C. G., Parkin, J. V., Whitfield, P.,
1970. Hobsley, M. Gut (in the press).
750

However, the cells display a growth pattern characteristic DIOGENES SYNDROME


of cultured human B lymphoid cells: they grow in large
SIR,-I should like to agree with some of the points
clumps. The cultured lymphoid cells have extremely long made in this correspondence (March 1, p. 515, March 15,
surface projections and produce mature virions of a herpes-
p. 627). Fire hazards to the patient and to neighbours
type virus, probably those of the Epstein-Barr virus (see can be very real, and can often ultimately tip the scales
accompanying figure). It is known that this virus selectively towards compulsory removal. One must also add the
transforms only B but not T human llmphocytes.10 Thus,
the cells obtained in permanent culture from the spleen
danger of gassing and explosions if the house has gas
of a patient with L.R.E. appear and behave like B lympho-
appliances.
I cannot, however, agree that one must always respect
cytes but display unusually long surface villi. the wish of the individual to neglect himself even unto
University of Texas System death. I have seen some patients who did not do well in a
Cancer Center,
M. D. Anderson Hospital, JOSEPH G. SINKOVICS geriatric unit or eventide home, but I have also seen many
Houston, Texas 77025, U.S.A. CHIU-HWA WANG. take on a new and happy life after admission to such units,
Veterans Administration Hospital particularly if the units are stimulating and well run.
and Baylor College of Medicine, In Scotland, such cases are rarely handled by compulsory
Houston, Texas 77025, U.S.A. FERENC GY&Ouml;RKEY. admission powers under the Mental Health (Scotland)
Act 1960. More appropriate (and .effective) is Section 47
of the National Assistance Act 1948 (" unable to devote to
THE CONSULTANTS’ CONTRACT themselves proper care and attention, and not receiving it
from others... " &c.) or the National Assistance (Amend-
SiR,&mdash;The proposals put forward by the Secretary of
State on Dec. 2011 seem on the surface to be good for the ment) Act 1951.
N.H. S. However, even if consultants were able to give more Non-conformity in itself is never a sure sign of psychiatric
time to the N.H.S. as a result of this reshaped contract, disorder and whether or not one invokescompulsory powers
there is not money available to provide the operating may well depend on as accurate a psychiatric assessment
suites and outpatient consulting-rooms necessary. as possible. Personality inventories and psychometric
The situation is, however, more serious than this because I
assessments, fear, have no place in helping the clinician
to make up his mind in the patient’s home. Repeated
by the Secretary of State’s proposals the scene would be set visits are nearly always necessary before an accurate
for changes of pattern of consultant activity that would
worsen both the short and long term manpower situation assessment can be made.
so far as service and postgraduate education is concerned. The decision on the correct course of action will always
How could the profession’s negotiators have accepted this be difficult, but I feel that if the physician approaches each
at a time when there is insufficient money to maintain even case with an open mind and weighs all the clinical, social,

the agreed 4% annual increase in consultant establishment and domestic factors carefully, he will usually take the
and when, because of the continued effect of the Willink action which is in the patient’s best interests.
recommendation, the hospital service is more dependent Department of Community
on overseas doctors than at any time in its history ? The Medicine,
Ruchill Hospital,
principles behind the Secretary of State’s proposals Glasgow G20 9NB. H. MACANESPIE.
remain and it is for this reason that impasse has been
reached.
Editorial pens move people. Perhaps yours can be LEVAMISOLE
instrumental in urging the Government and profession
to jointly seek a judicial definition of what the consultant
SIR,&mdash;Your editorial (Jan. 18, p. 151) calls for controlled
clinical trials of levamisole, and at least two centres are
contract really means.
already using it in the treatment of human malignancies.I,2
Hellingly Hospital, We wish to support the caution sounded by Dr Hopper and
Hailsham, RONALD MAGGS,
Sussex BN27 4ER. Whole-time consultant. others,3 regarding the experimental evidence for tumour
inhibition by levamisole.
In our experience with levamisole (L-tetramisole), and
SiR,-In view of the escalating and irresponsible sanctions with the racemic mixture (D-L-tetramisole) to which greater
by some N.H.S. consultants, I call upon my fellow retired activity has been attributed,4the drug did not stimulate
consultants to report for unpaid part-time duty, either at
humoral or cellular immune responsiveness. We found no
their former place of work or at the nearest hospital that
evidence of altered humoral antibody response to sheep
needs them. In this way we may hope to salvage what is
left of our reputation at home and abroad and to break the erythrocytes injected in groups of mice receiving 1-25 mg.
per kg. body-weight intraperitoneally of levamisole over
stranglehold that threatens our patients. various time schedules.- We did not observe either immuno-
llA Acol Road,
London NW6 3AA. L. S. MICHAELIS. suppression associated with drug therapy before antigen
challenge, or immunostimulation associated with drug
administration with or soon after antigen challenge, as
SIR,-It is with interest that we read Mr Robinson’s reported by others.4 Similarly, we found no evidence of
letter (March 15, p. 626). Do you, Sir, regard The Lancet accelerated rejection of tail skin grafts in mice treated by
"
as essentially a consultants’ journal "? similar schedules, which also failed to inhibit growth of a
M. G. BAMBER transplanted fat tumour. In this last experiment, rats
H. R. L. BISHOP-CORNET immunised with irradiated Walker 256 tumour cells or
Medical Students’ Residence, A. F. MANLEY inoculated with viable tumour received the drug (2-5 mg.
Alder Hey Hospital,
West Derby, SUSAN M. MURRAY per kg. body-weight) intraperitoneally. In-vitro assays
Liverpool 12. M. WARMINGER. showed no increase in serum-antibody potency or spleen-
cell cytotoxicity at different times following tumour
"
** *No: we do not look upon this journal as being
essentially " for (or against, for that matter !) any parti- 1. Webster, D. J. T., Hughes, L. E. Lancet, Feb. 15, 1975, p. 389.
cular group of readers.-ED. L. 2. Amery, W. ibid.
3. Hopper, D. G., Pimm, M. V., Baldwin, R. W. ibid. March 8, 1975,
10. Pattengale, P. K., Smith, R. W., Gerber, P. Lancet, 1973, ii, 93. p. 574.
11. See Lancet, Jan. 11, 1975, p. 92. 4. Renoux, G., Renoux, M. J. Immun. 1974, 113, 779.