50 BRITISH MEDICAL JOURNAL 6 OCTOBER 1973 were fewer late and more early developers tors suggested by Dr. Gonco contribute little is made on clinical grounds alone it does because at the chronological age of 15 girls to it. While Africans may have a higher indeed critically depend on a correct inter- are on the whole biologically more mature pain threshold than whites I pretation of the and the doctor Indians or carn- symptoms, Br Med J: first published as 10.1136/bmj.4.5883.50-b on 6 October 1973. Downloaded from than boys. By late developers I mean that at not believe that this is an important reason in a developing country may have very real 15 the child would pass for 14 or 13 cr- for the failure to diagnose I.HD. If they problems. But in Dr. Conco's own words even 12 chronologically. The medical neglect reach hospital in large numbers with other any assessment of the prevalence of coronary of this problem is evident in one of the heart disease (hypertensive, rheumatic pul- heart disease can only be based on "informed fallacies of the educational system, where monary, and myopathic) and feel and de- conjectures" if there is no E.C.G. evidence raising the school leaving age regards only scribe the pains of pleurisy, pneumonia, peri- to back up the clinical impression, and if the chronological age and not the immensely carditis, rheumatic fever, mnmingitis, and no necropsy material is available. At the important biological age, which has such a acute abdominal conditions, why should they Makerere Medical School there is now a vital influence on attitudes at the watershed not do so with I.H.D? A proDortion of pat- very great deal of E.C.G. and necropsy of puberty. Detention in unsuitable schools ients might die from I.H.D. before reaching material, and this material prov,des incontro- is particularly hard on the early developer, hospital, but what of the 70 or 80 % who vertible evidence for the infrequency of and leads to asocial behaviour. should survive the first attack? Why should coronary heart disease. It is not claimed that There appears to be a strong genetic link they, unlike other cardiac cases, selectively it is totally absent; the claim is that it is in the stages of development. In the great avoid hospital? Why should I.H.D. con- much rarer than in European and Asian majority of cases inquiry confirms that the sistently escape detection in African post- communities in the same countries. More- early developing boy has a father who de- mortem material? I.H.D. accounts for mor- over, in the indigenous peoples the ones at veloped early, and the late developer like- bidity among white and Indian hospital staff, risk are those who have tended to adout our wise father and brother who developed late. yet is not observed among the African staff. mode of life and especially those wuho are It is an axiom of paediatrics that if you This rarity of I.H.D. among Africans is members of our own profession. have a disturbed child you treat the parents. universal and not confined to the rural Knowledge about the prevalence of coron- If parents of "short boys" were more en- people who make up a large proportion of ary heart disease in any country in the lightened about their own development and the patients of this hospital.' It may be that world can only be obtained by analysing the .-roblems involved there would be even with increasing urbanization the incidence objective data. No doubt there are some fewer emotional difficulties, thus further of I.H.D. will increase2 but this trend is sudden deaths in Africa due to coronary reducing the need for any medication of the not evident in this population yet. If Dr. heart disease, just as there are in Britain. unfortunate child. The problem of the early Conco's postulates are valid, we should find But the knowledge of the prevalence of developer who then stands still and is over- niore I.H.D. among the urbanized, sophisti- coronary heart disease in Britain is based taken by boys he could previously master at cated, English-speaking African population. on sound objective criteria, and exactly the games would -be similarly helped. The water- This is not yet sig.ificantly apDarent here. same criteria must be applied in the African shed period of adolescence is often parti- Regarding communication, the language of continent. When such criteria are applied, aularly vulnerable, and requires much rnore a community will develop according to the the very striking differences in the pre- careful study.-I am, etc., needs it serves. If they have no words to valence of the disease are clearly seen and express cardiac pain, it is reasonable to infer objectively acceptable, and do not deLpend M. E. M. HERFORD that such pain is a rare exper ence in that on conjectures, nor do they derend on any Farnham Royal, more selection than is unavoidable.-I am, Bucks community. Lack of terminology does not seriously impede the diagnosis of countless etc., 1 Widdowson. F. M., Lancet, 1951, 1, 1316. other painful conditions. I agree that scien- J. R. BILLINGHURST Romford Group of Hospitals, tific terminology is lacking in Zulu, but this Essex is not relevant to symptoms. The fact that Diseases in the Tropics a patient's language has no words for menin- gococcal meningitis does not prevent him http://www.bmj.com/ SIR,-The suggestion by Dr. W. Z. Conco Social Workers in Hospitals (11 August, p. 331) that the rarity of ap- from complaining of headache. Even in pearance of ischaemic heart disease (I.H.D.) sophisticated European practice it would be SIR,-Dr. P. E. Baldry (15 September, p. among Africans is a consequence of high most unusual for patients to proffer the 589) is a lucky man to possess the in.tuitive pain threshold and failure of conmmuication complaints listed in Dr. Conco's taible IV, skills necessary to appreciate and handle the demands comment. In the interests of epi- the significance of which escapes me. unspoken problems of hospital inpatients, demiological accuracy I must submit that To my mind the evidence of true rarity but for the less fortunate may we support these factors cannot explain the huge dis- of I.H.D. in the African is overwhelming. Mrs. Carole Smith's plea (25 August, p. 443) between the incidence of I.H.D. My concern is that epidemiological en- for more effective deployment of hospital crepancy on 30 September 2021 by guest. Protected copyright. in Af,ricans and those of Eurooean or Asian thusiasm will be dampened by Dr. Conco's social workers? Though basic personality is stock. The 1,6004bedded general hospital specious explanation and the opportunity undoubtedly an essential prerequisite, we frTom which I write is fortunate in being for investigation of this important pheno- would suggest that the skills necessary to able to treat, and compare the incidence of, menon will be reduced. Also, if it can be understand and help anxious or disturbed disease in Indians and Africans (both rural shown that his African practice produces a patients who may ha,ve added difficulties of and urban). Electrocardiograms and chest significant number of cases of I.H.D., then cominunication are learned and not innate x-rays are done in all cardiac cases, at no this community should be an important fi!ld (psychiatrists are made and not born). A cost to the patients. Necromsies are per- for research, for that is an unusual pattern graduate degree in sociology or psychology formed in all cases of unexplained death in Africans at present.-We are, etc., may not equip a social worker entirely for when consent is available. Indian and African such a task, but we believe it to be of are the same J. E. COSNETT greater value in this respect than the average patients managed by group of Edendale Hospital, physicians. It was in this setting that a Pietermaritzburg, medical student's education, which considers survey of consecutive cardiac patients was Natal, South Africa the patient's persona to ibe of negligible im- made.' One of the conclusions reached was I Cosnett, J. E., British Heart Yournal, 1962, 24, portance compared with his lump or his was at 76. diabetes. Add to this the content of a hos- that "myocardial infarction least 15 2 Seftel, H. C., Kew, M. C., and Bersohn, I., times more common in the Indian than in South African Medical Yournal, 1970, 44, 8. pital doctor's work which is-necessarily- the Zulu." An extract of relevant statistics unlikely either to leave him time or to make gleaned from some 51,000 general admissions i.t a priority to stop and listen for half an during 1971 and 1972 yields a corrected Coronary Heart Disease in Africa hour to a querulous patient. If the social ratio of about 40 Indians to 1 African in worker can provide such a service, then the cases classified as "arteriosclerotic heart SIR,-I would like to make some conments medical profession should be grateful, not disease including coronary disease." on Dr. W. Z. Conco's paper "Diseases in jealous, for not only does it free them to I do not wish to minimize the well-known the Tropics; a Confrontation in African treat the illness (which is why most of them fallacies of hospital admnission statistics, but Rural Practice" (11 August, p. 331), having are in the business) but would encourage I am convinced, froom some 15 years' full- recently returned from the Makerere quicker rehabilitation of the patient. time experience in this field, that these figures Medical School in Uganda. Unless or until the medical school indicate a real discrepancy and that the fac- If the diagnosis of coronary heart disease curriculuem includes within its terms of BRITISH MEDICAL JOURNAL 6 OCTOBER 1973 51 reference care of worried and "difficult" rupted by the kind of arguments used in their office bearers who are coloured as well as patients and the handling of particular prob- letter.-We are, etc., white; and (3) that the M,unicialivt of lems such as the social and psychological EuAN M. Ross Johannesburg has this year decided that it Br Med J: first published as 10.1136/bmj.4.5883.50-b on 6 October 1973. Downloaded from management of terminal cases, we need the N. R. BUTLER will no longer continue the differentiation services of trained social workers whose jdb Department of Child Health, of its large municipal Royal Hospital for Sick Children, staff and has levelled is primarily personal contact with the Bristol up salaries with no racial discrimination. patient. We should value the essential and H. GOLDSTEIN It is thus to be hoped that the weigh.t of excellent help that they can give in overall National Children's Bureau, public as well as professional ominion may patient care when encouraged in this func- London W.1 yet bring about a change while the Nation- tion by members of the medical profession Butler, N. R., Goldstein, H., and Ross, E. M., alist government continues in am, British Medical Yournal, 1972, 2, 127. power.-I who do not find their presence threatening. 2 Yerushalmy, J., American Journal of Obstetrics etc., -We are, etc., and Gynecology, 1972, 112, 277. HUGH WOODMAN :1 Goldstein, H., American Yournal of Obstetrics GILLIAN STRATFORD and Gynecology, 1972, 114, 570. Delgany, Department of Psychiatry, Co. Wicklow, Eire Queen Elizabeth Hospital, Birmingham H. A. WALDRON Department of Social Medicine, Doctors in South Africa The Medical School, Alcoholism and the G.P. Birmingham SIR,-Apparently Mr. I. N. Bernadt (22 SIR,-In view of the considerable publicity September, p. 632) reads only the advertise- and controversy associated with the "Helping men-t pages of the South African Medical Hand" report on this matter' I would be Intracranial Venous Thrombosis Joumnal, otherwise he would know that the grateful for an opportunity to identify my and the Pill Medical Association of South Africa has position. In the lecture of mine quoted in done considerably more than utter verbal the report I said, "Studies suggest the gen- SIR,-I was surprised to see onlv the pro- condemnation of racial discrimination in the gestogen component of two oral contracep- eral practitioner is frequently not an effective medical field. It has reveatedly sent deouta- agent for picking up alcoholics. The reasons tives mentioned in an article on cerebral tions to the Minister of Health requesting thrombosis attributed to their use (16 June, would anpear to be two-fold. Firstly, the abolition of discrimination in salaries, result- patient or the patient's relatives are unwilling p. 647). ing at one stage in an (admittedly only Both contraceptive pills contain oestrogen to bring this .problem to the doctor. Secondly, slight) improvement. Over a year- ago in its the general practitioner is likely to miss cases as well: mestranol 0.1 mg in Ortho-Novin, it publicized the establishment of a and ethinyloestradiol 005 mg in Minovlar. journal of aloholism if his stereotype of the alco- Salary Equalization Fund for the receipt of holic is of a skid row figure-that is, the So far as I know, no episodes of thrombosis voluntary contrilbutions from non-African have been rer,orted as due to trogestogen- end state of the disease becomes the only doctors towards supplementing the official form recognized and his lack of awareness only contraceptives. On the other hand, salaries of their African colleagues. (I hope oestrogens are known to affect several blood that in the early stages alcoholismn present-s the fund will receive many contributions as a with Primarily social, rather than medical clotting factors, and the increased inci- result of Dr. Bernadt's and this letter.) dence of thromboem!bolic disease in women pathology." The fact that coloured doctors cannot, in Unfortunately in the majority of press re- taking combined creparations is accepted as South Africa, examine white patients is not due to the oestrogen component.-I am, etc., ports only the second reason was quoted, due to the attitude of the medical profession suggesting that I was unaware of the great in that country or even to the Government, difficulty the general Dractitioner has in deal- P. N. HOLBERTON Bernadt surely must know. With Kempsey, N.S.W., as Dr. ing with patients who deny their problem. Australia rare exceptions, white persons would refuse I am of course fully aware of this and had no -generally with vehemence-to be examined intention of criticizing general practitioners http://www.bmj.com/ by non-white doctors; and even if they at large in relation to their difficulty in iden- Smoking Hazards to the Fetus agreed, white nurses in attendance upon tifying the alcoholic. I was trying to empha- them would refuse to assist in such examina- size the importance of early detection and SIR,-Space does not permit a full analysis tions, generally with no less vehemence and how alcoholism will often present to a doc- of the letter from Dr. R. T. Hickey and his with the support of every member of parlia- tor in social rather than medical terms. In colleagues (1 September, p. 501) in which ment (goverrnment and opposition), except any comprehensive treatment service for al- they discuss the role of possible causative perhaps one, the vast majority of their white coholics the general practitioner has a major factors influencing the well-known statistical nursing colleagues, and South African role in diagnosis, and it is hosed that the association between maternal cigarette smok- Whites as a whole. These attitudes of white recent upsurge in interest among general on 30 September 2021 by guest. Protected copyright. ing in pregnancy and birth weight. patients and nurses long antedate 1948, the practitioners in the last two years, as evi- We are concerned, however, that they cite year in which the present political rulers of denced by requests for postgraduate lectures, our work' only to dismiss it as in "error." South Africa came first to power.-I am, articles in journals, and research studies, will We did not, in fact, make the elementary etc., be maintained.-I am, etc., error of suggesting that an association by G. W. GALE itself proves a causal relationship; nor, so Surbiton, Surrey B. D. HoRE Alcoholic Treatment Unit, far as we are aware, do other renorts in the Springfield Hospital, literature. We did in fact suggest that it Manchester might be possible to test the causal hypo- SIR,-Anyone with knowledge of the practice I Alcoholism and the G.P. London, Helping Hand thesis by a controlled trial in which women of medicine in South Africa will be ac- Organisation, 1973. were persuaded to give up smoking during quainted with the injustice of -the two salary pregnancy. scales for doctors and nurses, based on col- Dr. Hickey and his colleagues aptear to our, to which Dr. I. N. Bernadt refers in Shake Test on Amniotic Fluid and the dismiss a causal relationship because not all his letter (22 September, p. 632). Over the Respiratory Distress Syndrome babies of smokers are of low birth weight. Is years there have been demonstrations, pro- this really what they imply? The "alterna- tests, even resignations over this auestion, SIR,-I wish to comment on the suggestion tive" hypothesis which Yerushalmy2 is pur- and agitation mounts in the press and else- of Dr. P. M. Fisher and others (19 May, ported to have tested (namelv, that babies where against this system. p. 423) that, for assessing fetopulmonary born to women before they become smokers Apartheid remains dominant politically but maturity and the risk of neonatal respiratory will be lighter than those of non-smokers) it may be noted (1) that the South African distress syndrome, a critical amniotic fluid suffers from severe methodological short- Medical and Dental Council, equivalent to lecithin concentration of 35 mg!100 ml is comings,3 making it clearly untenable. We the G.M.C. at home, registers doctors in too low. Their suggestion is based on the would-, however, agree with them that the alphabetical order with no reference to col- evidence of pulmonary hypoperfusion in two "causal" question is still not settled, but we our or recognition or aLpartheid, all on the newborn infants with predelivery amniotic feel that it would be unfortunate if the pro- register having equal voting rights; (2) that fluid lecithin levels of 5 70 and 7-35 mg/ 100 gress so far made in discouraging mothers the Medical Association of South Africa has ml respectively and a negative bubble stab- from smoking in pregnancy were to be inter- similarly maintained this attitude and has ility test though the infants had no respira-