1334

parents to the trial of unnecessary investigations. The mainclue, of course, is the fact that health, vitality, appetite, andgrowth remain unimpaired-as Davidson and Wassermanhave so clearly demonstrated. Where there is an element ofdoubt after the first assessment, periodic weight checks willdefine those cases which merit further investigation for a

malabsorption syndrome.Although, as pointed out in your annotation, a temporary

enzyme deficiency is still a notional possibility, the clinical

picture strongly suggests that absorption from the smallintestine is unimpaired.

ARTHUR W. FERGUSON.

Bedford General Hospital(South Wing),

Kempston Road, Bedford.

CLASSIFYING PROTEIN-CALORIEMALNUTRITION

A. S. TRUSWELL

J. D. L. HANSEN.

Departments of Medicine and Child Health,University of Cape Town,

South Africa.

SIR,łThe hypothesis described by Dr. Islam (April 22,p. 898) to explain the fatty liver of kwashiorkor was outlined byus last year, together with some experimental support. 1 2 Wefound that serum P-lipoprotein cholesterols were lower in

patients with severe fatty liver than in those with mild fattyliver. However, a-lipoprotein cholesterols were not reduced inmost of our kwashiorkor patients. Full details will be publishedelsewhere.The scoring method suggested by Professor McLaren and

his colleagues (March 11, p. 533) is a welcome attempt to

classify syndromes objectively within the protein-calorie mal-nutrition (P.C.M.) " spectrum ". The method has the virtue of

simplicity and uses serum-albumin, which seems to be the mostreliable biochemical index of protein deficiency.3 Details willneed to be worked out. For example, electrophoresis and scan-ning gives rather lower serum-albumin values than by saltingout and biuret.4 Should the oedema be diagnosed on admission,when children are often dehydrated, or after fluid therapy ? 5Oedema may sometimes reflect potassium deficiency. Themethod deserves trial by workers in different parts of the worldwhen they report groups of patients with P.C.M.

Hyperlipasmia, which Professor McLaren and his colleaguespoint out to be a biochemical change characteristic of marasmus,was reported in " atrophic " infants by Ludmany et al.,’ 7and canbe seen in the data for marasmus in the paper by Lewis et al. 8

After serum-albumin, the following biochemical values mightbe useful for diagnostic classifications:

1. Serum- total-cholesterol.-This is the easiest lipid to measure inserum and gives some idea of lipoprotein synthesis. Levels are

relatively higher in marasmus than in kwashiorkor.92. Urinary-creatinine/height index.- This has been proposed for

grading the severity of protein depletion in P.c.m.10 It reflects musclemass but has the disadvantage of requiring a 24-hour-urine collection.

3. We suggest that the serum-uric-acid level should be looked intoas well. It has recently been reported significantly above normal inmarasmus, but not in kwashiorkor.1’ It rises very high in fastingadults.12We wish to make acknowledgements to C.S.I.R., and for U.S.

Public Health Service grant AM 03995.

1. Truswell, A. S., Hansen, J. D. L., Wittmann, W., Wannenburg, P.,Roberts, B., Watson, C. E. S. Afr. med. J. 1966, 40, 887.

2. Truswell, A. S., Hansen, J. D. L., Wittmann, W. Int. Congr. Nutr.1966, abstracts, p. 223.

3. Truswell, A. S., Wannenburg, P., Wittmann, W., Hansen, J. D. L.Lancet, 1966, i, 1162.

4. Truswell, A. S., Hansen, J. D. L., Freeseman, C., Smidt, T. F. S. Afr.med. J. 1963, 37, 527.

5. Hansen, J. D. L. Proceedings of Colloquium on Protein Deficienciesand Calorie Deficiencies, Cambridge, 1967 (in the press).

6. Hansen, J. D. L., Jenkinson, V. S. Afr. J. Lab. clin. Med. 1956, 2, 206.7. Ludmany, K., Csorba, S., Jezernicky, J. Z. Kinderheilk. 1965, 92, 299.8. Lewis, B., Hansen, J. D. L., Wittmann, W., Krut, L. H., Stewart, F.

Am. J. clin. Nutr. 1964, 15, 161.9. Pretorius, P. J., Wehmeyer, A. S. S. Afr. med. J. 1966, 40, 240.

10. Viteri, F. E., Arroyave, G., Béhar, M. Int. Congr. Nutr. 1966, abstracts,p. 46.

11. Khalil, M., El-Khateeb, S., Aref, G. H., Gurgis, F. K. J. trop. Med.Hyg. 1967, 70, 11.

12. Thomson, T. J., Runcie, J., Miller, V. Lancet, 1966, ii, 992.

DAMAGES

Dr. S. P. B. DONNAN and Dr. K. H. SUTTON, write:" The Press recently carried reports of a young house-surgeon whohas been ordered in the High Court to pay damages of E31,383 to anurse who was injured in 1963. She was a passenger in a car driven

by him when it collided with a lorry, but, as the car was hired andwas not insured for passenger liability, he has to pay the whole sumhimself. Currently this is at E3 per week, but the rate will increasewith his income. In this tragic situation the innocent victim has towait a lifetime before she receives the compensation the court hasawarded, whilst the newly qualified doctor is faced with a debt, per-haps amounting to a fifth of his total career earnings, which he willwork all his life to pay off. Doctors may be willing to help both theseunfortunate people by subscribing to a fund to pay part at least ofthe damages. Accordingly we have set up a trust fund to which weinvite members of the profession to subscribe. Contributions shouldbe sent to us c/o Westminster Bank, 292 Wimborne Road, Bourne-mouth. To avoid expenses acknowledgements will only be sent onrequest."

Parliament

QUESTION TIME

Capital Expenditure on Psychiatric HospitalsCapital expenditure on special hospitals, N.H.S. psychiatric

hospitals, and psychiatric facilities at other N.H.S. hospitalsduring 1967-68 is estimated at about m’5 million or just over10% of the total capital expenditure on N.H.S. hospitals.

Cost of Antidepressive DrugsThe ingredient cost of antidepressive drugs in 1966, as

analysed in the Ministry of Health statistics and dispensedby chemists, was E3-13 million, compared with E2-78 millionin 1965 and E2.37 million in 1964.

Women Medical Students

The number of women entering medical schools in 1966was 570, compared with 523 in 1962.

AppointmentsANTCLIFF, A. C., M.B. Lond.: consultant clinical pathologist, Chelmsford

hospital group.BRIERLEY, J. S. W., M.B. Leeds, D.P.H.: M.o.H., Huddersfield.NOALL, E. W. P., M.B. Lond., M.R.C.P., D.P.M.: consultant physician, Thames

hospital group.PILKINGTON, T. L., M.R.C.S., D.P.M.: consultant psychiatrist, Gogarburn

Hospital, Edinburgh.SMITH, R. S., M.B. Cantab., M.C.PATH. : consultant haematologist, Children’s

Hospital, Sheffield.

Manchester Regional Hospital Board:ABRAHAM, J. M., M.B. Baghdad, M.R.C.P., D.C.H.; consultant paediatrician,

Oldham and district and Ashton, Hyde and Glossop hospital groups.ALLCOCK, E. A., M.B. Manc., M.SC. Minnesota, F.R.C.S., F.R.A.C.S., F.D.S.

R.c.s.: consultant surgeon, South Cheshire hospital group.ATA, MOHAMMAD, M.B. Punjab, M.R.C.P.E., M.C.PATH. : consultant patho-

logist, with special experience in haematology, Rochdale and districthospital group.

GREEN, J. H., M.CH.ORTH. Lpool, F.R.C,S.E.: consultant traumatic and

orthopxdic surgeon, Salford hospital group.MADDOCK, SHEILA G., M.B. Lpool: consultant geriatric physician, Salford

hospital group.PITKEATHLEY, D. A., M.B. St. And., M.R.C.P.E., M.R.C.P.G.: consultant

rheumatologist, R.H.B. hospitals and United Manchester Hospitals.

Western Regional Hospital Board, Scotland:CARLISLE, J. M., M.B. Glasg., D.P.M.: consultant psychiatrist, Leverndale

Hospital.DONALD, J. R., M.B. Glasg., F.F.A. R.c.s.: consultant anxsthetist, Law and

Stonehouse Hospitals.LINTON, A. L., M.B. Edin., M.R.C.P.E., M.R.C.P.G. : consultant physician in

renal disease, Western Infirmary, Glasgow.

Liverpool Regional Hospital Board:CONWAY, C. F., M.B. N.u.I., F.F.A. R.C.S.: D.P.H., consultant anaathetist,

Chester Royal Infirmary.D’NETTO, PHYLLIS E., M.R.C.P.E., M.R.C.P.G., D.OBST.: consultant geria-

trician, Deva and Moston Hospitals.HARPER, PATRICK, M.B. Belf., D.P.M.: consultant psychiatrist, Rainhill

Hospital.HART, S. M., M.B. N.U.I., F.F.A. R.c.s.: consultant anesthetist, Broadgreen

Hospital.