798 23 September 1967
notoriously difficult to find in any quantity.
I presume, therefore, that the vast majority
would be housed in hostels, and, as the
Ministry of Health's standard sets a maxi-
mum of 25 beds per hostel, and there is no
mention of any existing hostel accommoda-
tion in Birmingham, approximately 30
hostels will have to be found or built. When
applied on a national basis it is in my opinion
quite. unrealistic to contemplate money, let
alone staff, becoming available on this kind
of scale. This is not to say that much more
money is not required for the service ; I
agree completely with the authors that an
inadequate service should not be disguised as
desirable because it is economical.
One way of obtaining improvement in the
service is to avoid multi-authority respon-
sibility and duplication of effort; we should
close our ranks, pool our resources, and inte-
grate. A single responsible authority derived
from health and welfare, education, and hos-
pital authorities could wellibe the basic essen-
tial ingredient of such a concept. The best
use is thereby, I suggest, more likely to be
made of the available finances, staff, and
accommodation, and the controlling authority
would have a sense of unified responsibility
and purpose.-I am, etc.,
Broomfield, M. E. YORK-MOORE.
Chelmsford, Essex.
SIR,-I noted with some surprise in a
leading article dealing with this subject
(2 September, p. 567) the dogmatic statement
that "clearly no special search should be
made to 'ascertain' the large number [of
persons with intelligence quotients of 70 or
lessl or to make special provision for them."
If this is correct then much of the work
of school medical officers and educational
psychologists is indeed being misdirected.
The ascertainment of mental subnormality
is essential to the assessment of the educa-
tional needs of the individual and his work
potentials. It is equally important in the
exclusion of emotional disturbance or physical
handicap as a cause for apparent backward-
ness. Recognition of mental subnormality
also makes it possible to avoid the placement
of children in social or educational situations
which they are intellectually incapable of
surmounting, and which can give rise to
severe psychic trauma to the individual
concerned.
Finally, the lack of adequate provision
for mentally subnormal persons may in part
be due to past failures to ascertain the true
extent of the problem of mental subnormality,
and to plan suitably for the special educa-
tional, communal, and hosnital care for all
those in need of these facilities.-I am, etc.,
Rayleigh. Essex. R. BEAVER
S.T.P. and Alcohol
SIR.-Your leading article (2 Sep-ember,
p. 570) ends with the slmirable sentence,
" Society has a responsibility to protect its
members from drugs that can make them
frankly insane or indeed kill them, as it has
to stop the spread of communicable
diseases." This certainly applies to
marihuana.
However, the opposition of at least some
psychiatrists to the prohibition of marihuana
Correspondence
was intended to emphasize that the antics of
a few hundred hippies was of trifling
importance compared with the enormous
damage to the health and happiness of the
community caused by the current misuse of
alcohol, which, after all, does in fact drive
many people "insane or indeed kill them."
In Scotland 200% of admissions to mental
hospitals are now due to alcoholism, while
W.H.O. lists alcoholism as the fourth most
important cause of premature death. The
number of chronic alcoholics in Great Britain
is estimated at about 400,000.
Yet, so far from society feeling any respon-
sibility for this, it allows the licensed trade
to spend £23m. a year on advertisements de-
signed to persuade families, especially teen-
agers and women, to drink not only more
beer and wine but gin, whisky, and vodka;
and the bizarre situation arises that the same
newspaper might report a nine-month sen-
tence on a purple-heart vendor and the eleva-
tion of a whisky vendor to the peerage. Yet
it is known that the increase of alcohol con-
sumed correlates with an increase of many
social evils, including murders, suicides,
divorces, road accidents, venereal diseases,
and many other diseases such as. tuberculosis,
diabetes, and heart disease.
Reforms have been prevented to some ex-
tent because many believe that the only solu-
tion is prohibition, but that, as this is
impossible. nothing more can he done. Recent
studies, however, have indicated that social
attitudes to drink are proportional to the
degree of alcoholism in the community, and
that much denends on the example of the
medical profession.
Perhaps, therefore, we should reassess
whether garish American bars are not out of
place in medical premises, and whether
young doctors, many of whom dislike drink,
should not be offered soft drinks as well
when offered alcohol. Also, are cocktails and
liqueurs really necessary before and after
medical dinners respectively ? Or the
announcement at 9.30 that the " bqr is still
onen" ? Is the argument that the sale of
drinks is a gold mine for tbp societv eth1icilv
sound, or should societies, like some Govern-
ments, refuse to benefit from such profits ?
Is there justification for the claim freauen-1v
made by the alcoholic that it is impossible
to Pet on in England if you are a non-
drinker ? And is the propasanda image of
the non-drinker as a dull, unsociable fellow
really justified ?-I am, etc.,
London W.I. A. SPENCER PATERSON.
Sodium Uptake in Peritoneal Dialysis
STR.-I wonder if Dr. J. D. Swales
(5 August, p. 345) is doing himself an
inius;tice in his apparent asqumption that he
failed to remove sodium from his natients bv
using hvyertonic (6.36 g. dextrose/l0() ml.)
peritoneal dialvyis fluid. The fall in sodium
concentration which he ohberved when using
this occurs always. even when the plasma
sodium concentration equals or exceeds the
initial level in the fluid, provided the ohserva-
tion is made during the first hour of the
exchange. This is simply a reflection of
the disnaritv of the osmotic and sodiium
gradients across the membrane. Dr. Swsles
did not mention the volume of fluird removed
when the dialvsate sodium concentration
MMM
dropped. to 123 and 122 mEq/l. (final Table),
but if, as is likely, this corresponded to the
volumes given in Fig. 4 (300-450 ml. for
exchange) then the sodium balance referable
to the patient would lie between + 1.4 and
- 19.4 mEq per exchange. ([Vol. out x [Na]
out]-[Vol. inx [NaI in].) That the postu-
lated negative balance is the one that most
likely obtains is apparent from the results
shown in Fig. 4.
The significance of sodium balance during
dehydrating peritoneal dialysis is of further
importance when this form of treatment is
applied to patients with fluid overload but
relatively normal initial plasma sodium con-
centrations. We have observed' that the
sodium concentration in the excess fluid
removed (the above balance figure divided by
the volume difference) ranges from 70 to 110
mEq/l. This means that even though the
patients were in negative sodium balance they
became hypernatraemic. Under these con-
ditions we have observed plasma sodium
concentrations as high as 168 mEq/l.
Like Dr. Swales, we have toyed with the
idea of reducing the amount of sodium in
the dialysate fluid, and Messrs. Allen &
Hanbury have provided basic solutions for
us with sodium concentrations as low as 115
mEq/l., with a corresponding adjustment of
osmolality. This does make things com-
plicated, and a satisfactory alternative is
occasionally to substitute a litre of 5 g./100
ml. dextrose for one of the two units of
peritoneal dialysis fluid. With a 45-minute
equilibration period this will usually remove
about 50 mEq of sodium, and is well tolerated
by the patient. I cannot imagine, however,
that even this would hove benefited the
patient who first drew the attention of Dr.
Swales to the problem.-T am, etc.,
M. V. MORIARTY.
Department of Medicine,
University of British Columbia.
Vancouver, Canada.
REFERENCE
Moriarty. M. V., and Parsons, F. M., in Proc.
Symposium European Dialysis and Transplant
Association. 1967 3. p. 359 Amsterdam
Peripheral Gangrene in Infancv and
Childhood
SIR,-Referring to the corresnondence
"Peripheral Gangrene in Infancv and Child-
hood " (10 June, p. 700'). T would like to add
a few points to the diwcussinn Perinheral
ancnqrene is also one of the intriguine prob-
lems in Kenva. Work on this condition
has been done hv J R M Miller' and more
recentlv bv memberq of whe (-lasgLnw team
of the Niirohi Medical School
T had the opportunity to stildv the histo-
pathological sections of tiss;ue, rernoved from
a few of these patients. Invariablv there
was in these cases an infectious. condition
(pneumonia. gastroenteritis) ;nedaneinc the
onset of the usual symmetrical gangrene.
The histopathological findings were con-
troversial
rn a ne-ropsv case no vascular lesions could
he funid in the arteries of the affected areas;
vascular lesinns were, siso exclided in another
case. The histol eical sections -4 the other
(*rqans in the necr prv ca~e res'enled the
presence of a "virus-inferti'n." t nfortunately
we could n t identify the causative virus on the
baqis of the histopathol' gi.al findings only