938

fatigue and weight-loss, perhaps with skin lesions,5,25followed by increasingly severe anaemia. The course isfulminant, the response to treatment slight. Probablysome of the cases of histiocytic medullary histiocytosisreported to have responded tosplenectomy were reallycases of leukaemic reticuloendothelioSiS,26 for theresponse to treatment of H.M.R. is usually disheart-ening. 3, 15, 27 Because of the rapid course the diagnosismay never be made. Liver biopsy, which workers inUganda 22,28 regard as the best way to make the

diagnosis, may be contraindicated by jaundice. 15One very odd feature of H.M.R. is its geographic

distribution. Of more than a hundred cases so

far reported, at least half have been in Chinese

(either inside 29 or outside 30,31 mainland China), orin Ugandans. 22, 23, 28a The clinical picture can mimicso many acute parasitic infestations or infections thatit is perhaps surprising how often it has been diag-nosed. It has been seen in Jamaica 32 and Japan,s3but in Uganda 23 cases were identified in a five-yearperiod 23 and Amsel and Bijlsma 28 saw 11 more intwo years. In Uganda they seek to identify in the liversinusoids the free-floating abnormal histiocytes ex-

hibiting phagocytosis. These histiocytes must thenbe distinguished from the Kupffer cells, which mayexhibit erythrophagocytosis in other conditions (e.g.," big-spleen " disease) .23 If, as may happen, demarca-ted collections of abnormal histiocytes are discoveredin the portal triads, these have to be distinguished fromthe cells of histiocytic sarcoma or monocytic leukaemiawhich can, like the Kupffer cells, occasionally showerythrophagocytosis. 3 4 Amsel and Bijlsma believethey can make the diagnosis at an early stage by identi-fying, especially in blood but also in bone-marrow,increased numbers of histiocytes,28 but most workerswould hesitate to diagnose H.M.R. in the absence oferythrophagocytosis. 11, 15,35.

H.M.R. also has to be distinguished from " adult"Letterer-Siwe disease, from other lymphomas, andespecially from the more acute forms of Hodgkin’sdisease. 15 Though the histological pictures are

different, 3,11,1:;,23 could these diseases be related ?Is there, indeed, a fulminant type of Hodgkin’sdisease that is not H.M.R.? Could H.M.R. be a fulminantform of Hodgkin’s disease ? There are records ofsurgeons who died of acute Hodgkin’s disease 36, 37 afterskin injuries inflicted while handling Hodgkin’sdisease tissue: did these die of this Hodgkin’s diseaseor of H.M.R. ? Although information on H.M.R. is

sparse in the extreme, there are epidemiologicalpointers in the occurrence of H.M.R. which suggest

25. Sams, W. M., Hanville, D. D., Winkelmann, R. K. Br. J. Dermat.1968, 80, 555.

26. Scamps, R. A., O’Neill, B., Purser, S. Med. J. Aust. 1971, ii, 956.27. Steiner, J. A., Perkins, K. W., McGovern, V. J. ibid. 1973, ii, 498.28. Trop. geog. Med. 1974, 26, 31.29. Chih-Fei, Y., Chung-Hang, T., Huai-Teh, H., Teh-Ts’ung, T.,

Hsi-Lien, K., Chin-T’ang, Y., Chieh, L. Chinese med. J. 1960,80, 466.

30. Civin, H., Gottschalk, H. C., Okazaki, K. Archs intern. Med. 1954,94, 375.

31. Bick, R. L., Adams, T. Western J. Med. 1974, 120, 163.32. Persaud, V., Wood, J. K. Am. J. clin. Path. 1967, 48, 396.33. Kamegaya, K., Noguchi, H. Acta path. Jap. 1964, 14, 231.34. Zawadzki, Z. A., Pena, C. E., Fisher, E. R. Acta hœmat. 1969, 42, 50.35. Clark, B. S., Dawson, P. J. Am. J. Med. 1969, 47, 314.36. Horder, T. in Research on Lymphadenoma (edited by M. H.

Gordon). Bristol.37. Bluefarb, S. M. Cutaneous Manifestations of the Malignant Lymph-

omas. Springfield, 1959.

likenesses to Hodgkin’s disease ,,-hints of urbanirural differences, of familial cases,39 of more severe andmore frequent cases in tropical and subtropic areas,and in Uganda of a bimodal age incidence.23 To getthe answers we shall need more patients, and this meansa high index of suspicion.

SOCIAL-WORK SUPPORT FOR THE HEALTHSERVICE" A FEW years hence we may wonder how anything

else seemed defensible," said The Lancet of theSeebohm recommendations on social-services re-

organisation 40. Six years later we have hardly reachedthat pitch of euphoria. Relations between doctors andsocial workers, in particular, are still plagued by anti-pathies and misunderstandings. As in the past, a majorcause of friction is the overlap in their territories ofwork. Social workers are so sensitive about medicaldomination that the word " support " was barelyacceptable in the title of a working-party on social-work support for the Health Service. The working-party’s report 41 reveals a silver lining inside the blackerclouds. Those who fear the advent of the " generic "

social worker are reassured that there is " nothing inSeebohm to imply the wholesale abandonment of

specialism in social-work practice ". Those doctorswho have lately had to deal with young and very in-experienced social workers are assured that this is atemporary effect of the rapid expansion of the services.On the matter of confidentiality the working-party issatisfied that, where working relationships are good,no difficulties should arise over the social worker’sduties to her local authority.

Just as Lord Halsbury is pressing for higher clinicalgrades among nurses, this working-party clearlyfavours a system whereby senior social workers cancontinue with some casework. It sets much store bypersonal interprofessional contacts, for with more ofthese many of the grievances would not have arisen.The core of the report is the section on teamwork:"... teamwork in a clinical situation means that allmembers of the team accept that each has a profes-sional contribution to make in his own right; and ...it is both the right and, equally, the responsibility ofeach member of the team to make that contribution ifthe patient needs it. Such a responsibility derivesnot from the prescription of the head of the team, butfrom the right of the patient to have the benefit of allthe team’s skills as he needs them ".The aim of Seebohm was to establish a service com-

petent to deal with all the interrelated social problemsof a person in his family setting. From the HealthService viewpoint, things have gone badly so far.The main value of this report is the airing it gives tomisunderstandings that have arisen in the past.What exactly does social work have to offer ? The

report seeks to answer that question too; and manywill find that helpful.

38. MacMahon, B. Cancer Res. 1966, 26, 1189.39. Boake, W. C., Card, W. H., Kimmey, J. F. Archs intern. Med. 1965,

116, 245.40. Lancet, 1968, ii, 201.41. Social Work Support for the Health Service: report of a working

party. H.M. Stationery Office. 68p.