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that recurrent ulceration is apt to follow any operationin which the pyloric mucous membrane is not removed,and second that the introduction of intestinal contentsinto the stomach is neither a normal digestive processnor a successful therapeutic device.

I know Mr. Aylett is a first-class surgeon. I admirehis ingenuity in planning this operation, his courage inperforming it, and his faith in its future. I know, too,that he will have the honesty, which so few gastricsurgeons have had in the past, to present his late aswell as his early results. The history of gastric surgeryhas taught us that the stomach will stand almost any-thing, that every gastric operation is a success till it isfound out, and that a lag period of about five yearsmust be expected before the failures start to accumulate.May I beg Mr. Aylett to publish in The Lancet of June,1958, a follow-up of one hundred consecutive cases

observed more than five years. I hope I slrall be thereto congratulate him.

London, W.l. HENEAGE OGILVIE.HENEAGE OGILVIE.

1. Parkes Weber, F. Practitioner, 1917, 99, 453.2. Lancet, 1935, ii, 885, 1347.3. Brit. J. Derm. 1926, 38, 1.4. Proc. R. Soc. Med. 1924, 17, sect. derm. 45; Ibid, 1927, 20,

sect. dis. child. 11.5. Medvei, V. C. Lancet, 1950, i, 1174.6. Romer, C. Ibid, 1950, ii, 825.7. Crofts, N. F., Macrae-Gibson, N. K. Ibid, p. 595.8. Kok, D’A. Ibid, p. 826.9. Simpson, S. L. Ibid, p. 415.

CUTANEOUS STRIÆ IN NORMAL BOYS

SiR,,-In recent months I have been surprised to seetypical striae cutis distensae in a number of normaladolescent boys-namely, in 39% of 317 boys aged14½—17½ years. These striae are purplish andusually occur on the lateral aspect of the thigh, in theregion of the trochanter major and downwards. There

may be many parallel striæ or only one or two. Some-times they are not parallel, but converge. Rarely theyare on the back, in the region just above the iliac crest.They never occur in boys in whom pubic hair has notyet developed, and the age of occurrence is mainlybetween 15 and 17. After 17 the striae become whiteand difficult to see. They are rare in obese boys, althoughI have seen them in one or two. They are not associatedwith particularly rapid growth ; the increase in heightand weight in these boys has been proceeding at thenormal rate, which is very similar before and duringpuberty.The first observer to describe striae in normal subjects

seems to have been Parkes Weber, who reported in1917, 1 case in a 17-year-old boy 1 and in 1935 3 furthercases in a male student, a 44-year-old man, and anadolescent girl.2 Parkes Weber has also described otherinstances of this condition seen after enteric fever andother infectious disorders.3 4 In 1950 several letters onthis subject appeared in The Lancet. Medvei 5 described1 case in a normal person, and Romer

6 mentioned aswell known the type of lanky adolescent rugger three-quarter who is teased in the changing-room because ofhis striæ. This is all I have been able to find aboutstriae in normal subjects. Their occurrence in pregnantwomen, Cushing’s syndrome, and some cases of chronicliver disease is known. Their occurrence in 42% of aseries of cases of pleural effusion has been described byCrofts and Macrae-Gibson and by Kok 8 in the samecorrespondence, to which Simpson 9 also contributed.Three points seem to be of importance :1. The striæ appear so commonly at a certain age that

they cannot be regarded as abnormal.2. They occur in the same age-group of boys as that in

which transient gynaecomastia, transient female type of

pubic hair, and transient bone growth of female proportionsare often seen.

3. In most cases they do not occur in sites where the skinappears to be abnormally stretched.

’

It is very likely that such striae occur also in normalgirls at a similar age, and it would be interesting to knowhow frequent they are in the female sex.

So far the cause of the strise is unknown. The onlything that seems to be certain is that distension of theskin is not the cause or is, at most, a secondary factor.Their appearance at an age when there are definitesigns of imbalance of sex-hormones, suggests a hormonalinfluence. This might also explain their occurrence inpregnancy, Cushing’s syndrome, and chronic liver disease,whilst their appearance in association with (tuberculous)pleural effusion and after other infectious conditionssuggests that still other factors may play a part.London, W.C.I. H. HEBXHEIMER.H. HERXHEIMER.

THE DAY HOSPITAL

SIR,-I have been asked to clarify statements recentlymade in the press concerning the " day hospital " experi-ment being made by the Oxford Geriatric Unit. Pendingthe publication of an article in the medical press describingin detail the formation of the day hospital, your readersmay like to know something of what is being attempted.The large majority of old people continue- to live at

home, and die in the family group ; and the admissionof old folk to chronic-sick hospitals and mental hospitalsis due in part to a failure to prevent illness and disabilityamong them. Because the Oxford Geriatric Unit is

exploring this field of preventive medicine it is findingmore and more examples of patients who can be dis-charged back to their own homes for greater or lesserperiods of time. In selected cases the care provided bytheir family can be supported by the efforts of thecommunity and local authority until it becomes desirable,for medical or sociological reasons, to readmit the oldperson to hospital permanently or temporarily. Thisapproach is especially valuable in the continued care

of the elderly confused patients. The only solution

previously offered has been certification under the

Lunacy Acts or permanent admission to a chronic-sickhospital.

I had found previously, first at Orsett and then at

Langthorne Hospital, that early admission for a period’ofassessment, for treatment of organic disease, and forrehabilitation resulted in an increased willingness on

the part of families to continue to care for their old

people, as long as they were offered : -(1) A limited responsibility for a period of time that could

be limited by the joint agreement of the family, the generalpractitioner and the geriatric unit’s doctor, and the socialworker or psychiatric social worker.

’

(2) Intermittent periods of freedom from that responsibilityby readmitting the patient for a limited period to the hospital.The summer holidays and rest periods thus made possibleenabled the relatives to continue the responsibility for a muchlonger time.

In selected cases a day-hospital régime has proved veryhelpful both for the treatment of the patient and forrelieving emotional stress in the family group. The

patient is removed from the family during the day andreturned home to sleep in the evening. During the dailyhospital stay he receives physiotherapy, in the form ofremedial exercises, to enable him to get about with lesspain and greater comfort, and incidentally to preventaccidents at home. More important still, he receives

occupational therapy, which is a good form of treatmentfor selected confused or psychiatric patients at any age.As a result, much nocturnal restlessness can be preventedand quiet nights obtained for patients and relatives alike.The occupational therapy should be given in a quieterroom than that part of the department where other

patients are treated. Not least in importance is the

provision of a nourishing meal at midday. There is thenan opportunity to observe the patient’s dietetic prefer-

205

ences, and to make sure that at one meal at least hisintake is adequate.A very important part of this work consists in the

coordination of the home and hospital environment bya medical social case worker or a psychiatric socialworker. I have found the services of the social workerin quietly overcoming home difficulties, keeping the

hospital informed of progress at home, and assessing thebuild-up of domestic emotional stresses, of the greatestvalue ; the serious stresses can be reduced by a,ppro-priate temporary admission. Without this sociologicalassistance this method of treating many more patientswithout increasing the number of beds would be far moredifficult.Some patients who at first have to attend the day

hospital for five full days a week are later found torequire only one, two, or three days a week. This is avaluable index of improvement or deterioration in thefamily group relationship as well as in the patient’sclinical status.The problem of transport, the help of voluntary organ-

isations, nutritional factors, family group interpersonalrelationships, techniques in occupational therapy, theadministration of the scheme, and fields of expansionwill be discussed in a more complete paper on this

attempt to bridge the gap made between hospital andhome.

As all our patients attending the day hospital wouldhave become early and permanent charges on chronic-sickor mental hospitals, each patient so treated means a

hospital bed saved. The scheme helps to maintain theintegrity of the family group by affording the relatives aservice of " care without tears." Its principles are thusbased on sound social, economic, and humanitarianfoundations.

L. Z. COSINClinical Director,Geriatric Unit.

Cowley Road Hospital,Oxford.

PERIODICITY OF MEASLES IN LONDON

SIR,—There seems to be a relationship between theproportion of susceptible people in a population, the

birth-rate, and the periodicity of measles. In a stationarypopulation maintained by a constant birth-rate (accordingto the current life-table), epidemics could be expectedto occur at equal intervals, assuming a constant case-rate.The change from pre-war biennial epidemics to annualones towards the end of the late war could therefore be

explained by the increase in susceptibles due to massevacuation, the absence of epidemics in the firsttwo years, and the increase in the birth-rate during thewar.

After 1946 the birth-rate began to fall and the effect onmeasles soon became apparent. In 1950 instead of the usualannual epidemic, with a peak about the 13th week, therewas a small midsummer outbreak followed almost immediatelyby the huge epidemic of 1950-51 with a peak in the 8thweek. The interval between this peak and that of 1949was 48 fortnights indicating that the period was lengtheningas the birth-rate fell. The incidence in this epidemic was101% of the population under the age of 10 perannum, the highest since notification became compulsoryin 1938.The variation of the period with the birth-rate is shown

in the accompanying table, in which the birth-rate and life-table birth-rate, together with the period, are set out for thepre-war years 1923-38 and the years 1943-51. The birth-ratewith which I am concerned is the number of annual birthsper cent. of the child population under 10 years (amongwhich occur 95% of measles cases in an epidemic). Thisrate, of course, will vary from year to year, but if the numberof births remained constant yearly for 10 years, no migrationtaking place in the interval, a " life-table " population under10 would result and the birth-rate per cent. of this populationwould be the life-table birth-rate (lo). This can be consideredas a limiting value to which the birth-rate, as defined above,

tends. The birth-rates refer to the interval between presentand previous epidemic and therefore to the first of the

epidemic years. It will be seen that in general the greaterthe difference between the birth-rates the shorter the period.

BIRTH-RATES AND PERIODICITY OF MEASLES EPIDEMICS

Period

Epidemic Hirth rate (% Life-table (fortnights from

period of population birth-rate (% peak of lastperiod 0-9) (b) of population epidemic to

’ ’ ’ 0-9) (lo) present peak)(T)

From these data the following regression equation isobtained :

&Dgr;T = -4502 &Dgr; b = -3-35 (r = - 0967),where &Dgr; T = T - 52 and &Dgr; b = b - lo. The life-tablerates have been obtained from the England and Wales lifetables, allowing for differences in mortality between Londonand the rest of the country and interpolating between censusyears. According to this equation, the natural period forLondon &Dgr; b = 0) is 48-7 fortnights. For a period of 52fortnights, the birth-rate under present conditions must fallto 9-6% (&Dgr; b = —0.74).With regard to the recent epidemic, the 1951 census has

enabled the birth-rate figure to be fixed for the first timesince the last census in 1931 ; the values of b and lo in 1951were 10-66 and 10-30 respectively. It is estimated that by1952 these rates had fallen to 10-50 and 10-29 respectively.Hence, substituting &Dgr; b = + 0-21 in the equation, we get&Dgr; T = - 4-3, giving a period of 47-7 fortnights. Since thepeak of the 1950-51 epidemic came in the 8th week of 1951,that of the present outbreak should occur therefore in the51st week of 1952. Actually the peak (2705 cases) wasrecorded in the 53rd week, but it was probably really in the52nd week, because of the carry-over of cases from Christmasweek.

Although, in general, one would not expect so close a

prediction on each occasion, there does seem to be a con-nection between the birth-rate and period ; and as freshdata accumulate, it may be possible to increase accuracy inforecasting the probable interval between peaks.

There is a similarity between the course of the recent

epidemic and that of 1950-51, which is not unexpected,since there has only been a slight fall in the birth-rate during the interim. They represent an intermediatestage between an annual and a biennial epidemic. It is ofinterest that the number of cases between the two peaks was58,420, the interval being 97 weeks. Taking the averagepopulation (0-9) as 492,500, the average incidence is 6-4%per annum; the figure for the epidemics during 1940—52was 6-1%.

Bromley, Kent. C. A. GOULD.C. A. GOULD.

LUNG CANCER AND SMOKING

SiR,,-There appears to-be general agreement that- theexposure of living tissues to long-life radioactive isotopesmay initiate the onset of a carcinoma. If an ordinaryM 6 tube is filled with cigarette or cigar ash a readingvarying from 70 to 170 counts per minute is recordedagainst a normal background of 12. The variabilitydepends on the particular type of cigarette or cigar thatis tested. These readings have been obtained usinga ’Panax’ type Geiger counter, model 44, with anE.R.D. liquid castle.The radioactive isotope in question is presumably the

long-life radioactive isotope of potassium, K4o, which ispresent in all potassium to the extent of 11 parts in