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be so cunning. We should reassess the value of pro-longed antibiotic therapy in the chronic bronchitic.Nature may not submit to our attack-her mood now iscertainly ugly and has left us licking our wounds. Letus hope her anger is spent.

THOMAS SIMPSON.Chase Farm Hospital,Enfield, Middlesex.

THE LIFE FOR ME

J. A. SCOTTMedical Officer of Health for the

County of London.Public Health Department,

London, S.E.1.

SIR,-Dr. Richard Cobbleigh’s accounts of his pro-gress through the medical jungle are always stimulatingreading, the more so as not all of us would agree with hisdiagnosis of what are false trails and blind ends. Even hismyths (such as the one in his Widdicombe letter of Feb.8-the " M.O.H. who still doesn’t believe that G.P.sexist ") throw some light, though only scanty illumination,on some obscure professional mental processes which per-haps merit more study from his newly adopted specialtythan they have yet received.

Apparently hydrocortisone ointment as a panacea forskins lets us all be dermatologists. It is not quite so clearwhether E.C.T. as a panacea for mental illness lets us all be

psychiatrists, but I hope that as the Cobbleigh Careerprogresses in this field it will encounter the growing edgewhich deals with prevention. Not a few of his new col-leagues have passed beyond empirical treatments likeE.c.T. to cope with the more difficult problems of trying tofind the psychological factors leading to problem families,juvenile delinquency, neurosis, and behaviour problems.And if our Angry Young Doctor-turned-psychiatrist ven-tures this far he may even once again find himself back in" those Clinics " where the M.o.H. has already extendeda warm welcome and an attentive ear to preventivepsychiatry.

I look forward eagerly to Dr. Cobbleigh’s reflections onhis further progress.

BETWEEN GUESSWORK AND CERTAINTY INPSYCHIATRY

A. B. MONRO.Long Grove Hospital,Epsom, Surrey.

SIR,-I agree most profoundly with Professor Lewis’scontention (Jan. 25) that, in certain directions, progress inpsychiatry requires collaboration between psychiatristsand psychologists. Speaking as a person trained in bothdisciplines, I would like to draw attention to certainmutual irritations which keep the two professions apart.By and large, psychologists are more research-mindedthan psychiatrists and have a better grounding in scientificmethod, and especially in statistics. Speaking for themoment as a psychologist, I would record with deep feelingthe fury which psychiatric colleagues can arouse by theirignorance of the significance of a simple statistical tech-nique which should present no challenge to the intellect ofanyone who has passed G.C.E. mathematics at 0 level.Therefore, if psychiatrists are to be acceptable colleaguesto psychologists they must at least learn some simplestatistics.

If I may now switch to my alter ego, the psychiatrist, hepoints out that the psychiatrist is more pragmatic than thepsychologist. Pragmatic is, to him, a more polite term for" not up in the clouds ". The psychiatrist wants tech-

niques which will work in the clinical hurly-burly ofwards and outpatient departments. He has no love for theirritating psychologist who keeps telling him that his petmethods have never been scientifically validated, but never

seems to offer an alternative which can be vouched for byscience.

It should not be beyond the united resources of the twoprofessions to solve this little problem in interpersonalrelationships.

1. Aird, I., Bentall, H. H., Mehigan, J. A., Roberts, J. A.. F. Brit. med. J1954, ii, 315.

2. Køster, K. H., Sindrup, E., Seele, V. Lancet, 1955, ii, 52.3. Peebles Brown, D. A., Melrose, A. G., Wallace, J. Brit. med. J. 1956,

ii, 135.4. Buckwalter, J. A., Wohlwend, E. B., Colter, D. C., Tidrick, R. T.,

Knowler, L. A. J. Amer. med. Ass. 1956, 162, 1215.5. Clarke, C. A., Cowan, W. K., Wyn Edwards, J., Howel-Evans, A. W.,

McConnell, R. B., Woodrow, J. C., Sheppard, P. M. Brit. med. J. 1955,ii, 643.

6. Westlund, K., Heistö, H. ibid. 1955, i, 847.

DUODENAL ULCER : AN OBSERVATION

SIR,-Data from several sources have shown an associa-tion between blood-group 0 and duodenal ulcer. Cumu-lative figures have been weighted to confirm this associa-tion in a manner appropriate to the varying incidence ofblood-group 0 in the differing communities from whichmaterial has been drawn. The object of this letter is todraw attention to a phenomenon which appears if ABO

blood-group data in subjects with duodenal ulcer are

compared with control blood-group data from the same

place, counting each observation as a separate and equi-valent unit.

The Aí A + 0 ratio in controls and of macroscopically provencases of duodenal ulcer from previously published data areshown in table i and presented graphically in fig. 1. There is a

significant correlation between the A ’/A - 0 ratio of duodenalulcer subjects and the A/A+0 ratio of the control populations

Fig. I-Duodenal ulcer: A/A+O ratio compared with controls from8 sources.

375

(r=0.823, p < 0-02). The position of the regression line showsthe association between blood-group 0 and duodenal ulcer.More interesting is the observation that the association with

blood-group 0 in duodenal ulcer increases as the proportionof blood-group A in the controls increases (x2-28’78,N=7, P < O.OO1).One possible interpretation of this phenomenon is that the

possession of blood-group A protects against duodenal ulcer,and as blood-group A increases in control populations there isselection against blood-group A in corresponding duodenal-ulcer populations.

If such selection does occur, one might expect that with thevarying prevalence of blood-group A between different popula-tions, there would also be a reciprocal variation in the prevalenceof duodenal ulcer. Direct prevalence figures are difficult toobtain, but crude mortality-rates, with their limitations, areavailable. As duodenal ulcer is a predominantly male disease,with the greatest number of deaths between 60 and 70 years, it

appears reasonable to compare crude mortality-rates in men ofthis age-group rather than standardised mortality-rates, pro-vided that the standard of death notification in communitiesto be compared is also comparable. From the figures providedby the World Health Organisation 10 for the years 1951-53

inclusive, the mortality-rates for Australia, Scotland, theUnited States, Denmark, and Norway can be used. Compari-son with ABO blood-group distributions will be valid only pro-vided that within each country there are no wide variations inthe ABO blood-group frequencies, and for this reason datafrom England and Wales cannot be included. From the blood-group data of the countries cited, blood-group-A gene frequen-cies have been calculated by the method of Dobson and Ikin, 11

7. Heist&ouml;, H. (1956), quoted by S&oslash;rensen, K. H. Danish med. Bull. 1957,4, 45.

8. Hogg, L., Pack, G. T. Gastroenterology, 1957, 32, 797.9. Simmons, R. T., Semple, N. M., Graydon, J. J. Med. J. Aust. 1951,

i, 105.10. Epidem. vit. Stat. Rep. 1955, 8, 398.11. Dobson, A. M., Ikin, E. W. J. Path. Bact. 1946, 58, 221.

Fig. 2-Duodenal ulcer: crude male mortality at age 60-69 from5 sources as a function of the prevalence of blood-group-A genein a control population.

and when they are compared with the selected male mortality-rates from duodenal ulcer (table II, fig. 2), an excellent negativecorrelation exists (r 0-992, p < 0-0001).The data will support the hypothesis that blood-group A

protects against duodenal ulcer, provided that the inheritanceof the disease is not related to ABO blood-groups, and thisappears to have been established by Clarke et al.J2 It has beenshown with gastric diseases 113 14 that the association with ABOblood-groups appears to be related to intragastric site,irrespective of the nature of the disease, and it seems likelytherefore that the association between duodenal ulcer and

blood-group 0 may be a similar manifestation of site-

susceptibility.From the work of Hartmann 15 the secretor status of an

individual appears to determine the amount of blood-groupsubstance present in the duodenal mucosa. If blood-group-Asubstance gives best protection against duodenal ulcer, itwould be reasonable to expect that where less material is

present there would also be less protection, and this mayexplain why Clarke et al. 12 16 show an excess of non-secretors insubjects with duodenal ulcer. These workers hold that blood-

group and secretor status are not independent factors in thegenesis of the disease, and this receives support from the dataof McConnell and Sheppard 17 where the variations from thecontrol ABO blood-group distribution are best shown induodenal-ulcer subjects who are non-secretors.

B. P. BILLINGTON.Department of Medicine,University of Sydney. N.S.W.

12. Clarke, C. A., Edwards, J. W., Haddock, D. R. W., Howel-Evans, A. W.,McConnell, R. B., Sheppard, P. M. Brit. med. J. 1956, ii, 725.

13. Billington, B. P. Aust. Ann. Med. 1956, 5, 141.14. Balme, R. H., Jennings, D. Lancet, 1957, i, 1219.15. Hartmann, G. Group Antigens in Human Organs. Copenhagen, 1941.16. Clarke, C. A., McConnell, R. B., Sheppard, P. M. Brit. med. J. 1957,

i, 758.17. McConnell, R. B., Sheppard, P. M. Acta genet. statist. med. 1957, 6, 574.18. Bourne, G. Lancet, 1957, ii, 1320.

PARADOXICAL ELECTROCARDIOGRAM INCORONARY EXERCISE TEST

MANUEL GARDBERG.

SIR,-Dr. Geoffrey Bourne 18 states that he has beenunable to find any previous report of the "paradoxical ...result of an exercise test". Dr. Bourne will find a numberof examples published in the papers of Alzamora-Castro.I have observed this phenomenon rather frequently whenischasmia is responsible for small inverted or diphasic Twaves.

Actually, in addition to the speculations quoted by Dr.Bourne there are two different ways in which the T wave maybe paradoxically reversed by exercise-by the occurrence ofan injury shift of opposite direction to that of the T wave, andas a result of increase in the rate of repolarisation in ischa:micmuscle due to increase in rate. A third and spurious mechan-ism must be considered. Even if the electrodes are fastened tothe chest, the altered position of the heart, due to respiratoryphenomena associated with exercise, changes the position ofthe electrodes in relation to the heart. This may be evidenced

by changes in the QRS complexes such as are seen in Dr.Bourne’s records. At times, however, the QRS change is notsufficiently great to be evident. Dr. Bourne (or anyone) maystrap the electrodes to the chest of his patient with diphasic Twaves and study the effects of a deep breath and of forcedexpiration.New Orleans. MANUEL GARDBERG.

SIR,-We have read with much interest Dr. Bourne’sarticle. 18 We have often observed the phenomenon hedescribes in the cardiological clinic of the Greek RedCross Hospital (director, Dr. C. Maroulis) in the pasttwo years, but have not published our observations.It is very important to know its prognostic significance,compared with that of the ordinary electrocardiographic