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AID FOR THE ADOLESCENT

ANTHONY RYLE.

University Health Service,University of Sussex,

Falmer,Brighton, Sussex.

CLAIRE RAYNER.

Petticoat, IPC Magazines Ltd.,Fleetway House, Farringdon Street

London EC4A 4AD.

W. H. ALLCHIN.

66 Old Kennels Lane,Oliver’s Battery,

Winchester.

SIR,-It is hard to see how Mr. Brinton (Nov. 20p. 1139), able to describe a youngster as "on the vergeof suicide or some other idiocy " and prepared to be soarrogantly dismissive of the professional workers respon-sible for the care of the young, can himself bring muchaid to adolescents. He is also guilty of seriously under-valuing what they do for themselves, failing to note howfar they have been able to contain and limit the dangersposed by the ever-present availability of drugs, an achieve-ment still far short of the ideal, but the more admirablewhen one considers that all too often the help they areoffered by doctors (Brinton’s " heroic psychotropicdrugs ") is as irrelevant to their problems as are the drugswhich their own peer group can provide. He also seemsblind to the ways in which mutual tolerance and caringare far more prevalent in young people today than in thepast. Despite this greater mutual support, adolescentscan respect and seek help from adults who are able to listento them and to respect them, and many of them needprofessionals with the knowledge of psychology and theconcern for existential issues which Brinton seems to findso distasteful (or threatening ?).

Sir warmly support Mr. Henry Brinton regardingthe provision of counselling services for disturbed adoles-cents.

I deal with the Problem Page for this teenagers’ magazine,coping with the 4000 to 5000 letters per year all seekinghelp. A large number can be satisfied by information(sex education, in my experience, is still woefully in-

adequate in our society), others by being referred to Brookand F.P.A. clinics, marriage-guidance counsellors, theNational Council for the Unmarried Mother and Her

Child, reliable " pregnancy advisory services ", and thelike. But there remains a sizeable group who need, quitedesperately, someone to talk to. Someone who will treatthem as worth-while people, who will not sneer, makefacile moral judgments, or shrug them away as nuisances;I know they need this because they write to me after havingreceived precisely the opposite treatment from the adultsthey have already approached, such as parents, generalpractitioners (often!), and (occasionally) teachers.Where there are local youth counselling services I refer

readers, but there are far too few, and such as there aretend to be clustered in the large conurbations like Londonand Birmingham. For the rest there is, fortunately forthem and for the " professional " whose burden is takenup for them, the Samaritans-voluntary workers withgood selection and basic training provided by the organisa-tion. They care, and they will listen.Any practitioner faced with an adolescent with whom he

cannot come to terms, or who frankly bores and irritateshim, could do worse than swallow his professional pride andrefer his patient to this splendid organisation.

SiRjŅMr. Brinton’s article is certainly an interestingpiece, but its tone seemed to me surprisingly negative andeven somewhat sneering. And I think it would be fair tocomment that it was short of factual matter.However, some facts are available. For example, an up-

to-date and concise study, covering the care of 150 adoles-cents over five years, has been carried out in the Wessexregion by Dr. Mary Capes and two colleagues, a psycholo-

gist and a sociologist. 1 This gives details of some of theresources available to adolescents and their parents. Someof the help given is shown to be useful and effective. Thechild-guidance clinic seems to be anybody’s Aunt Sallythese days, and it may be true that it would fail to pass the" cost/benefit analysis " test. Personally, I doubt whetheranyone has the information available to confirm or refutethe suggestion. But it might be worth saying that manyof the most valuable activities in our community, in socialand personal terms, might also fail such an assessment,while some of our most pernicious institutions would passwith flying colours and profits.That we can offer only what often amounts to no more

than a first-aid service does not separate the child andadolescent field from that of adult psychiatry. Both thesedeficiencies are a disgrace to any community which hopesto be regarded as compassionate and humane, and to be-little what little we actually do at the present time does notseem to me to be constructive.

TOWARDS EASIER CHILDBIRTH

S. M. HALLIDAY.Fordingbridge,Hampshire.

SIR,-The article by Mr. Tachi (Nov. 20, p. 1134)makes it evident that he has never sat quietly observing anormal labour and delivery. One of the important dis-coveries he might otherwise have made is that a mother(and a father) is normally able to enjoy her baby withinone hour of delivery, often within one minute. Perhapshe is unable to sit quietly watching and listening, inwhich case he should never have been an obstetrician.

MYELO-OPTIC NEUROPATHYINDUCED BY CLIOQUINOL IN ANIMALS

SIR,-Concerning the stiology of subacute myelo-opticneuropathy (S.M.O.N.) in Japan, two theories have beenreported in The Lancet-the clioquinol theory 2-4 and thevirus theory.5,6 We administered clioquinol to dogs, cats,and a monkey orally for approximately six months andsucceeded in eliciting a similar syndrome to that in man,clinically as well as pathologically.Of 20 dogs given the substance, 3 did not develop any

symptoms, 5 died of acute poisoning with epileptic con-vulsions or general weakness, and 12 showed symptomsindicating chronic poisoning. Clinical symptoms of chronicpoisoning began with side-swaying of the hips, followed bymuscle weakness and increased tendon-jerks in the hind-legs. The longer administration was continued, the moresevere the signs became, until the dogs could not remainstanding even to eat. The visual acuity was apparentlyimpaired in 3 dogs, since they could not follow objectsproperly. 1 dog was incontinent of urine. The dose of

clioquinol required to elicit symptoms of chronic intoxi-cation ranged from 60 to 144 mg. per kg. per day. Exceptin 2 dogs, the symptoms appeared within 7-28 days onthe above toxic doses. 1 cat showed the same symptomsunder the same conditions. A monkey did not developfull symptoms of chronic poisoning, and died of broncho-pneumonia on the 84th day. As controls, 4 dogs, 3 cats,and 1 monkey were healthy throughout the experiments.

1. Capes, M., Gould, E., Townsend, M. Stress of Youth London, 1971.2. Tsubaki, T., Honma, Y., Hoshi, M. Lancet, 1971, i, 696.3. Igata, A. ibid. 1971, ii, 42.4. Nakae, K., Yamamoto, S., Igata, A. ibid. 1971, ii, 510.5. Inoue, Y., Nishibe. Y., Nakamura, Y. ibid. 1971, i, 853.6. Shimada, Y., Tsuji, T. ibid. 1971, ii, 41.

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Fig. 1-Demyelination of fasciculus gracilis and part offasciculus cuneatus in cervical cord of dog no. 1.Duration of symptoms, 159 days. Woelke stain.

Fig. 2-Demyelination of optic tract in dog no. 2.Duration of symptoms, 65 days. Optic tract arrowed. Woelke

stain.

All the animals with chronic poisoning which died orwere killed showed degenerative changes in the nervoussystem. The severity of the degeneration depended on theduration of symptoms. 6 dogs and 1 monkey which hadbeen affected for a relatively short time showed symmetricaland systemic changes in the fasciculus gracilis of thecervical cord-i.e., the systemic process began distally inthe nerve fibres, damaging the axons first then myelinsheaths. There was also degeneration in dorsal-rootganglia, although optic and peripheral neuropathies werenot obvious. But 3 dogs and 1 cat which had had symptomsfor longer (65-165 days) showed more advanced degenera-tion in the fasciculus gracilis, accompanied by distinctdemyelination (fig. 1) and accumulation of fat granules. Theoptic tract was also affected (fig. 2), as were the corticospinaltracts, dorsal-root ganglia, and peripheral nerves. De-

generative changes in the optic tract were similar to thosein the fasciculus gracilis. Inflammatory changes were notseen in these areas of degeneration.The myelo-optic neuropathy seen in these animals has

not previously been noted in animal experiments, and iswell in accord with the changes observed in S.M.O.N. inman. Therefore, clioquinol may well be a causative andaccelerating factor in this syndrome in Japan.

JUN TATEISHISHIGETOSHI KURODAAKIRA SAITOSABURO OTSUKI.

Department of Neuropsychiatry,Okayama University Medical School,

Okayama, Japan.

PRACTOLOL TREATMENT IN ASTHMATICS

SIR,ńWe should like to endorse Dr. Chang’s plea(Aug. 7, p. 321) for caution in the use of practolol inasthmatics.Over the past 2 years we have used practolol in some 40

hypertensive patients. Because of its cardioselective pro-perties we have made cautious use of it in 3 patients witha past history of asthma and in 4 patients with chronicbronchitis. In 4 of these 7 patients practolol has appearedto precipitate or aggravate bronchospasm.

Case 1.-A man now aged 52 presented in 1961 withmalignant hypertension. He had a casual blood-pressure(B.P.) of 240/150 mm. Hg, cardiomegaly, congestive changesin both lung-fields, and small pleural effusions. An intra-venous pyelogram (l.v.p.) was normal. For some years theB.P. was moderately well controlled on a diuretic with, inturn, guanethidine, methyldopa, bethanidine, and debriso-quine. He continued to smoke 20 cigarettes a day, had amoderate cough and occasional sputum, and developedwinter bronchitis. Angina began in 1969. His therapy waschanged in April, 1970, to oxprenolol, the thiazide beingcontinued. The dose of oxprenolol was gradually increasedover the next eleven months to 80 mg. three times a day,but he then developed severe wheezing. Practolol 300 mg.three times a day was substituted, but the wheezingpersisted unabated; after 12 days the practolol was stopped.He has since been able to take oxprenolol at a reduced doseof 40 mg. three times a day.

Case 2.-A 40-year-old woman was referred from thepsychiatric outpatient department because of a casual

blood-pressure reading of 220/140 mm. Hg. She was takingamitriptyline and chlorpromazine. She had had bronchitisfor 11-12 years and a moderately severe attack of asthma8 years previously but no recent wheezing. She smoked40 cigarettes a day. Physical examination revealed noabnormality apart from her agitated mental state. Fundishowed minor A-V crossing changes only. Renal functionand urinary catecholamines and vanillylmandelic acid werenormal. The B.P. was very variable, and cyclopenthiazide-K0’75 mg. per day did not control it. Practolol 50 mg. twice

daily was added to her regimen, most other antihypertensivedrugs being contraindicated by her antidepressant therapy.Within 2 days she had developed a wheeze, which wore off1 day after stopping practolol. A further 2-day challengewith practolol 50 mg. twice daily had a similar result.

Case 3.-A man now aged 31 had been attending fortreatment of hypertension since the age of 28. His B.P. hadbeen found to be raised during a hospital admission fornasal polypectomy. He had no symptoms apart from thoserelated to the nasal polypi. He had a past history of asthmauntil the age of 21 but had had no wheeze since that time.

Physical examination showed no abnormality. Investiga-tions showed normal renal function, normal l.v.p., andnormal chest X-ray. He was treated initially with clonidine,which caused some sedation, and subsequently with betha-nidine and cyclopenthiazide. He felt that bethanidine wasmaking his nasal congestion worse, and oxprenolol wassubstituted, initially 40 mg. a day and increasing to 120 mg.a day. After three months he developed quite severe asthma.Oxprenolol was stopped and bethanidine restarted: theasthma settled, but nasal stuffiness once again becametroublesome. The bethanidine dose was reduced andpractolol was started, initially 100 mg. a day. Over onemonth, the dose of practolol was increased to 300 mg. a day;but he developed daily asthma, especially severe about anhour after his evening practolol. Practolol was stopped andthe asthma abated.

Case 4.-A man now aged 68 presented with a casualblood-pressure of 220/116 mm. Hg in 1966. He had a

10-year history of winter bronchitis and mild wheeze. Hewas a non-smoker. Blood-pressure control was unsatis-