1336

13. Coppage, W. S. Jr., Island, D., Smith, M., Liddle, G. W. J. clin.Invest. 1959, 38, 2101.

14. Liddle, G. W. in The Clinical Use of Aldosterone Antagonists (editedby F. C. Bartter); p. 14. Oxford, 1960.

the adrenal cortex, and so reduces secretion of the threemain corticoids-aldosterone, corticosterone, and corti-sol.3 13 Liddle 14 observed no significant differencesbetween this central inhibitor of aldosterone secretion anda peripherally acting, spirolactone in the urinary outputof sodium and p6tassium in a healthy subject maintainedon a constant high-sodium diet and prednisolone. On

p. 1330 of this issue, Dr. Shaldon and Miss McLarenreport their preliminary observations of the use of thehydrochloride of methbipyrapone-metopirone (Su-8874)-also a central inhibitor of aldosterone secretion, in2 cirrhotic patients. Both had longstanding asciteswhich had proved resistant to various conventional treat-ments. Metopirone alone caused slightly increased

urinary sodium levels in 1 but not in the other; and theclinical state of both patients remained unchanged. Theaddition of chlorothiazide promoted diuresis, indicatingthat it behaves synergistically with metopirone (a centralinhibitor) as well as with spironolactone (a peripheralantagonist of aldosterone). On theoretical grounds, itcould be predicted that spironolactone would beineffective if aldosterone production were being blockedby metopirone, and Shaldon and McLaren do not explainwhy they used this seemingly incompatible mixture.

Nonetheless, spironolactone was added to the combina-tion of metopirone and chlorothiazide with quite dramaticand unexpected potentiation of sodium diuresis. But

perhaps even more important are the theoretical implica-tions of these findings. The 11-desoxycorticoid precursorof aldosterone has not yet been isolated, but if it accumu-lates as a result of metopirone blockade, then possiblyit is antagonised by spironolactone. Although some of itsproperties can be surmised according to this hypothesis,the next essential step is to endeavour to isolate it.

THE OXFORD CLINICAL SCHOOL

IN its Michaelmas number, the Oxford Medical SchoolGazette (always a lively publication) has a symposium onthe future of the Oxford clinical school. This shows againthe difficulty of breaking a tradition-in this case the tradi-tion that the Oxford preclinical student leaves the rarefiedatmosphere of Oxford for " a little Smithfield Market atmo-sphere, or the like ". In writing of the present problemsof the school the five Nuffield professors suggest that thebiggest difficulty is that there are not enough students andthat their calibre is not high enough. This difficulty haspersisted even though the school, which is already wellestablished in graduate teaching and research, offers thestudent excellent facilities-facilities so good, indeed, thatthe Goodenough Committee suggested that its role shouldbe to turn out consultants, investigators, and teachers.The professors believe not only in what they can give tothe students but also in what the students can give to them,and they find unthinkable any suggestion that the wholescheme should be abandoned-after so much money andeffort have been invested in it.

The number of clinical students from Oxford wouldincrease if the Oxford preclinical teachers did not remain,for the most part, ignorant of what goes on in the teachinghospital some quarter of a mile from their laboratories.And the number of clinical students from elsewhere mightincrease if the Oxford clinical school advertised more

skilfully in other preclinical schools-not excluding

Cambridge. But the difficulty of finding the rightcandidates for medicine is something which all facealike. Most teachers agree that, of their more talentedscience pupils, the proportion choosing a medical careeris now lower than in the years immediately after the war.The propaganda of Ward 10 may encourage patients toentrust themselves to our care, but will hardly induceclever young men and women to become doctors. If someof the medical information given through television, soundbroadcasting, newspapers, popular lectures, and the likecould emphasise not only the human side of medicine butalso the scientific satisfaction to be derived from it, thenmore of the most able minds might be attracted to theprofession.

WATER

To judge from his report for 1959 Dr. I. Gordon,medical officer of health for Ilford, would have foundhimself among kindred souls at the recent UNESCO con-ference on the problems of the arid lands. The boroughdraws its water partly from the Metropolitan Water Boardand partly from the South Essex Water Company. Evenin 1959 the first gave almost all that was asked, but thesupplies from the latter were at times so insufficient thateven the school privies could not be flushed. No-oneseems to have-died of thirst, but 25 gallons per head perdiem is not really enough. The S.E.W.C. does not expectmuch improvement for several years. It has some largeengineering projects in hand, but the amount of waterwhich it draws from the M.W.B. cannot be increased until1968 and it is still uncertain whether it will get permissionto abstract more water from an unnamed river. (Essex isnot so rich in purling brooks as to make this puzzle verydifficult.) The M.o.H. is cross (and we do not blame himfor it) because the S.E.W.C. did not foresee the shortage,has no representative of his authority on its board, providesno annual report, and seems to have rather old-fashionedideas on public relations. The privately owned statutorywater companies are some of the most efficient utilities inthe land, but efficiency at any level is no excuse for failingto win the public confidence. Those who enjoy a monopolymust take the lead in exorcising the popular image of asuffering " we " and an omnipotent

"

theyThe fundamental worry of all suppliers of water in the

London basin is that it is one of the driest parts of

England and for more than sixty years the level of thewater table in the surrounding chalk has been falling.The M.W.B. makes up its supplies from springs and wellsin Hertfordshire and Kent and by drawing on the Thames.The S.E.W.C. serves a less favoured area without anygreat river and must do its best in a country notorious forbrackish waters. At the same time the demand continuesto increase. There are not only more people but also morebathrooms. Industry is insatiable, and we are sure thetime has come when some more pressure should be puton the more lavish users to find ways either of saving wateror of re-using it after purification. Rationing by price hasfailed. Some thirsty businesses, such as breweries, drawfrom their own artesian wells, but this water comes fromthe same strata that supply the general public. Thisindustrial lust for more and more water is not limited toLondon, and even in such places as Wales (where mostvisitors find water in excess) it has caused alarm and grief.Another class of users who have troubled some smaller

undertakings are the dairy farmers, who often, for reasonswhich are almost forgotten, enjoy a supply either at a fixed