1269LEADING ARTICLES

A New Postgraduate Centre ?

THE LANCETLONDON 10 JUNE 1961

AT the end of last week The Times announced that

agreement had been reached between the Ministry ofHealth and the South West Metropolitan RegionalHospital Board to clear the way for a new PostgraduateHospital Centre in Chelsea; and on Monday it returnedto the subject in a leading article. This is, so far as weknow, the first published information about a schemefor the regrouping of some of the special hospitals ofLondon, with their associated teaching institutes, aboutwhich rumours have been circulating for some time.According to the original story, one of our more spec-

tacular millionaires had proposed that, in return for thesites of a number of small central hospitals, he shouldrebuild them all together on the site of an infectious-diseases hospital which was no longer essential. All thatwas true in this story, however, seems to be that aninteresting new suggestion had been made for a place inwhich to bring together some of the postgraduatehospitals-concentration of which was recommended inthe Gray-Topping report as long ago as 1945. The

suggestion was in fact found to be impracticable, becausea vast railway siding, next to the fever hospital, was notavailable as supposed. But the Ministry of Health,which had already reviewed some other possibilities, wasnot deterred from further inquiries; and after severalplaces had been considered it was agreed that the bestwas probably the combined sites of the BromptonHospital, the Chelsea Hospital for Women, the RoyalMarsden Hospital, St. Luke’s Hospital, and the

Brompton Oratory Convent School. Certainly this areaappears to have great possibilities.Condensation of some of the scattered small special

hospitals and their associated postgraduate instituteswould have some obvious advantages, alike for the

patients and for teaching. Catering, laundry, accounting,heating, pathological and X-ray services, and muchelse can be provided more efficiently for a groupedhospital than for a number of separate small ones; andfor some time it has been felt that special hospitalsought if possible to be closely associated with generalhospitals, or at least that related hospitals (e.g., fordiseases of the lungs and of the heart) should be asso-ciated with one another. Indeed, the more one thinksabout it, the more each specialty has links with otherspecialties. From the educational standpoint, medicaland surgical techniques of the special kinds might withadvantage be in closer contact-especially in London,which provides postgraduate education for doctorsfrom the Dominions and from foreign countries where

extreme specialisation cannot yet be practised. Andfrom the standpoint of research, the small special hos-pital, which was so perfect an instrument sixty yearsago, when individuals were developing their subjectson their own, is no longer the ideal place in an erawhen teamwork and the laboratory have taken the placeof the singlehanded clinician or surgeon.There are also possible disadvantages in the scheme.

Efficiency and economy would be poor rewards for anamalgamation which led to loss of the pride and tradi-tion of our medically great, though physically small,special hospitals; and a very large hospital can be aterrible thing. But, on the face of it, this is too big anopportunity to be thrown away: there is so much to begained that it will be better to concentrate on avoidingthe obvious dangers than to be frightened off by them.Clearly, to be sure of avoiding the disadvantagesthat might come of haste, there is need for careful thoughtand for discreet and sympathetic negotiation betweenthe bodies concerned. For example, to group the

hospitals and institutes appropriately would be important.On the proposed site, there is room for by no means allof them, and some might be better related to a generalhospital than to each other. Some of the larger specialhospitals and institutes are not involved in the presentscheme; nor is the Postgraduate Medical School at

Hammersmith. Indeed there might one day be anopportunity to form a second group on the site ofWormwood Scrubs Prison near Hammersmith Hos-

pital : for the moving of the prison into the country,which once was only a dream, has been seriously men-tioned in relation to prison rebuilding; and, by the timeit moves, the deplorable difficulty of getting to Worm-wood Scrubs may have been overcome by the buildingof the ultimately inevitable station on the Central Line.This means that a thoroughly appropriate groupingcould now be made on the Chelsea site with morefreedom of arrangement than would be possible if itrepresented the last and only scheme of developingspecial hospitals and postgraduate institutes.The Ministry of Health, for their part, are to be con-

gratulated on having brought this sensible project intothe region of possibility: and we hope that everyoneconcerned-particularly those of the medical profession-will try to take it further.

1. Tickner, A. Brit. J. Derm. 1961, 73, 88.

PsoriasisREVIEWING biochemical studies of psoriasis, TICKNER 1

characterises this as the skin disease which " has beenmore investigated than any other ". He cites about ahundred papers, but the gloomy fact remains that littlepractical help has resulted from all this effort.The idea that psoriasis may be a biochemical disorder

is far from new, but the evidence is still meagre. Clinic-

ally, psoriasis is an inflammation, at times even pustular,but sterile. It is often familial and may appear for thefirst time at almost any age, although it is rare in infancy.There is no evidence that it is due to a specific organism:it is not contagious. It cannot be ranked with the diseases

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of allergy or autoimmunity, and it is not significantlyrelated to other general maladies. It may be precipitatedby an infection such as a streptococcal sore throat; butphysical trauma, sunburn, and perhaps emotional tur-moil may also bring on an attack. No other tissue isinvolved, except the joints in the rare psoriatic arthro-pathy ; and even here the significance of the relationbetween skin and joint symptoms is disputed.

In pursuing the laboratory evidence of metabolic dis-turbance, almost any claim can be countered by a contra-dictory one. Some of these discrepancies may be due toinadequate methods of estimation or lack of appreciationof normal values. Disturbance of fat metabolism was oneof the earlier possibilities to be examined. In a study ofthe effect of a preparation of unsaturated fatty acids onpsoriasis, ENTICKNAP et awl. have found no change in theblood-levels of ten common lipids; these were initiallynormal, and there was no clinical improvement. A highphospholipid content in the scales of psoriasis wasreported as long ago as 1929; and this has been confirmedby STEIGLEDER 3 and JARRETT et al.4 DOGLIOTTI 5 foundsimilar quantities in seborrhoeic dermatitis, and someworkers attribute the presence of phospholipids to

lack of their utilisation for normal keratinisation. No

enzymes capable of removing such substances have beendetected in the epidermis, and their role remainsundecided. Excess SH groups have been demonstrated

histochemically in the parakeratotic epidermis of

psoriasis; and this may be due to the failure of thenormal formation of SS linkages. VAN ScoTT andFLESCH 6 have confirmed biochemically that SH groupsare present in excess; but MAGNUS has shown thatthis is not peculiar to psoriasis. Early workers hadsuggested that the total sulphur content of the psoriaticscale was high; but subsequent studies have shown thatscales produced on healthy skin with ultraviolet lightyielded similar figures. When methionine containingradioactive sulphur is given to patients with psoriasis, thesulphur makes a delayed appearance in the lesions andpersists longer than in healthy skin-which seems atvariance with the view that in psoriasis the growth of theepidermis is accelerated.

SCHMIDLI and PASCHOUD 8 reported low levels ofwater-soluble polypeptides in the lesions of psoriasisand later showed that the activity of several dipeptidaseswas significantly reduced. This was thought to be dueto the presence of an unidentified inhibitor in psoriaticscales. FLESCH believes that arginine is relativelyincreased in such scales, although other workers statethat their aminoacid composition resembles that ofscales produced by ultraviolet irradiation. Arginase isfound in normal skin, and is present in psoriatic scales ingreater amounts than in plantar callus. It is an essential

component of the urea-synthesising mechanism, andincreased quantities of urea might therefore be expectedon the surface of psoriatic skin: the reverse is true

2. Enticknap, J. B., Ryan, C. C., Lansley, T. S. ibid. p. 99.3. Steigleder, G. K. Arch. Derm. Syph., Berlin, 1952, 194, 296.4. Jarrett, A., Spearman, R. I., Hardy, J. A. Brit. J. Derm. 1959, 71, 277.5. Dogliotti, M. Hautarzt, 1953, 4, 17.6. Van Scott, E. J., Flesch, P. Arch. Derm. Syph., Chicago, 1954, 70, 1417. Magnus, I. A. Brit. J. Derm. 1956, 68, 243.8. Schmidli, B., Paschoud, J. M. Dermatologica, Basle, 1955, 110, 315.

according to ROTHMAN,9 but the scales seem to containan arginase inhibitor.TICKNER is impressed by the evidence that in psoriasis

fusion of primitive keratin filaments is defective. ROE 10extracted three kinds of protein (A, B, and C) from dis-persates of psoriatic scales. A, she concluded, was anormal intermediate of keratinisation which dis-

appeared when keratinisation was normally completed.B was a globular protein containing SH groups, prob-ably mucoprotein, present only in traces in normal

epidermis. C was a nucleoprotein probably representingremnants of the parakeratotic epidermal cell. TICKNERdraws attention to the X-ray diffraction studies ofSWANBECK 11 on the macromolecular organisation of

epidermal keratin, showing that keratin is synthesisedin filaments 100 A in diameter. These aggregatelaterally in bundles of 5 or 10 with a lipid coating 80Athick. In psoriasis the filaments fail to aggregate, andTICKNER asks whether this inhibition is due to Roe’s

protein B possibly together with lowered amino-

peptidase levels. Such failure might account for theincreased lipid content, if the fibres in psoriasis are

coated with lipid as in normal skin. He suggests that

protein B may have enzyme activity and account for theincreased arginase. He believes that systematic researchinto enzymes and components of normal and diseasedskin will reveal the presence of a metabolic block in

psoriasis, giving rise to the accumulation of a substancewhich inhibits normal keratinisation.

Others, too, have pursued the idea that the basic faultis in keratinisation; and of course scaling is a notablefeature of the disease-but so is inflammation. If the

primary defect is in the epidermis, the dermal vasodila-tation and cellular infiltration must still be explained.Other diseases of keratinisation, such as ichthyosis andtylosis, are not inflammatory. If the psoriatic epidermiscontains something which evokes a dermal response, itshould be possible to demonstrate this. Could not a

biological approach be made to show whether chemicalmediators of inflammation exist in the lesions of

psoriasis or in the blood ? Are such substances influencedby the known remedies for the disease-tar, dithranol,mercury, or ultraviolet irradiation? If psoriasis is an

epidermal lesion, does psoriatic arthropathy not exist?And why is the hair unaffected when the entire skin andall the nails are involved ?

The skin of the tail of the rat shows two types ofkeratinisation: around the hair follicles there is a

granular layer, but between them there is none. Whenvitamin A is applied to the rat’s tail, a granular layerappears where formerly it was absent.l2 JARRETT andSPEARMAN 13 reasoned that, if a granular layer could bere-established in psoriasis, keratinisation might berestored to normal. They achieved this by local applica-tion of vitamin A, but only after treatment with tri-amcinolone had controlled the proliferation of the

epidermis. In their early tests triamcinolone was given9. Rothman, S. Arch. Derm. Syph., Chicago, 1950, 62, 814.

10. Roe, D. A. Ann. N.Y. Acad. Sci. 1958, 73, 977.11. Swanbeck, G. Acta derm.-venereol., Stockh. 1959, 39, suppl. 43.12. Lawrence, D. J., Bern, H. A. J. invest. Derm. 1958, 18, 261.13. Jarrett, A., Spearman, R. I. Brit. J. Derm. 1959, 71, 267.

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by mouth, but later it was applied locally in an ointmentincorporating a special form of vitamin A. This treat-ment seems unlikely to prove applicable in many cases,if only for the reason of expense; and no commercialform of this ointment is yet on the market. But JARRETTand SPEARMAN argue their case with a wealth of histo-chemical evidence; and the treatment is the first to havea logical rather than an empirical basis.

The HandicappedIN the last twenty years or so, the position of handi-

capped children has changed. Because of the decrease indebilitating infections of childhood, the handicappedchild takes up a greater proportion of the time of psedi-atric departments; and because of more successful life-saving measures in infancy, many more of the severelyhandicapped children are surviving. As some diseases,such as tuberculosis and anterior poliomyelitis, decline,the type of disability has altered, and the child with mul-tiple handicaps has come to the fore. Lastly, and mostimportantly for these children, the education authoritiesare beginning to recognise their educational need andfuture potential.’Today, instead of helping a normally intelligent child

with a tuberculous hip or a flaccid paralysis of one limb,we may have to provide total care for a spastic child witha defect of sight and eye movements, possibly a hearingloss, a movement defect, epilepsy, educational back-wardness, and an emotional disturbance, shared byother members of the family; or for a hydrocephalicchild with spina bifida and flaccid paralysis of the legs,a urinary-tract abnormality, and an intelligence wellabove the average.Thus one child may be under the care of several

doctors, specialists, and educationalists. The work ofthese professional people may even be duplicated if thechild is away at a residential school and is under one

group of doctors during term-time and another in theholidays. It is not unknown for a child who has been

given appliances at a residential school to be seen inthe holidays by a different consultant who recom-mends an operation and entirely different appliances.With this lack of liaison, it is possible for a child to beadmitted for surgery at a time of particular emotionalstress, and thus sustain unnecessary psychologicaltrauma. At the centre of conflicting influences, the

parents may become worried and confused. Obviouslythere is need for one doctor to coordinate all the treat-ment ; and, at first sight, this should be the family doctor.But in any family practice over a period of years theremay be only one child with a particular handicap, andthe practitioner may not have an opportunity to under-stand the whole problem or know the facilities. It wouldbe a great pity if the child’s own doctor ceased to take aninterest and feel responsible; but many of these cases dorequire the regular attention of someone with a fairlyhigh degree of specialist knowledge and skill.What may perhaps be needed is a doctor who will

make a special study of one type of handicap. In a smalltown, it might be a general practitioner working for

several sessions on the staff of a local hospital. Again, anexperienced public-health doctor might have the neces-sary contacts to run a service for all the children in his

authority’s area. In larger centres, a paediatrician, apxdiatric neurologist, a physical-medicine specialist, ora surgeon might prove to be the right person. Whoeverhe is, the doctor in charge must not only be able to super-vise and organise treatment and referral to consultants;he must cooperate with the education authorities overthe child’s education, and have a contact with the specialschools, preferably as the medical adviser. He shouldbe interested in all the research in his specialty, befree to attend conferences, and be willing to try anypromising new form of treatment. He must be able tomake an early diagnosis of each handicap-i.e., deafness.His clinic must be a training centre.But if we are to have these special centres, it is

essential that each child should find his way to the most

appropriate. One possibility would be a large diagnosticand evaluation centre such as that run by Dr. FREDERICKRICHARDSON at the Johns Hopkins Hospital, Baltimore,which was set up after the problem had been studied bya special commission.1

Children with all types of disability-communicationdisorders, poliomyelitis, educational backwardness, andcerebral palsy-are sent to the centre for assessment. Thechild is seen by a team which includes a psychologist and asocial worker, and the appropriate consultants. After a

conference, a full report, with recommendations fortreatment and education, is sent to the family doctor, theschool service, and other interested agencies. The childis seen about once a year. In this way the whole child andhis problem is assessed and treated, and not one particularaspect of his handicap.

For the child with a multiple handicap a visit to adiagnostic clinic would be especially valuable. But evenhe would probably benefit from continuous care at aspecialised clinic dealing with his predominant syndrome;and another pattern of care would be for hospital andlocal-authority services to join forces to run a clinic.The hospital doctor could arrange treatment, drugs, andappliances, and the local-authority doctor provideclinic facilities, and arrange schooling, home-visiting,and housing. An asthma clinic, an epilepsy clinic, anenuresis clinic, or a clinic for the mentally handicappedcould be geographically placed to deal with most of thechildren in an area. An essential member of team wouldbe an educational psychologist; for only when a fullreport has been obtained on the child’s educational andintellectual level and his emotional problems can hishandicap be discussed with his parents. For some

handicaps, such as some of the rarer speech disorders, afew centres in the whole country might suffice to ensurethat all the children came under the care of a specialistwho had made a study of their condition. For example,cases of flaccid paraplegia benefit enormously by learningto swim; but only in a few centres have they a chanceto do so.

If clinics of this kind were held regularly, the family1. Report on Diagnostic and Rehabilitation Centers for Handicapped

Children, Maryland State Planning Commission 100, EquitableBuildings, Baltimore 2, Maryland, U.S.A. 1957. Pp. 30. 50 cents.