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could be attained in myasthenia gravis. With remissionreached, long-term high-dosage alternate-day corticosteroidtherapy is being continued to determine how long remissionwill persist. Our ultimate goal is sufficient suppression ofthe disease until a time when symptoms remain absent evenafter slow withdrawal of corticosteroid therapy. At the veryleast, the remarkable improvement in this patient is indi-cation for a carefully monitored use of alternate-dayprednisone in other selected patients with myastheniagravis.

J. R. WARMOLTSW. K. ENGELJ. N. WHITAKER.

Medical Neurology Branch,National Institute of

Neurological Diseases and StrokeBethesda, Maryland 20014.

WHY COLLECT STATISTICS ?

SIR,-Your editorial (Nov. 21, p. 1072) draws attentionto the inaccuracy of vital statistics and suggests that moresupervision should be given to housemen in completion ofcertificates. In a detailed study on the accuracy of deathcertification carried out on a representative sample of 2243adult deaths I showed 1 that, amongst 923 certificatescompleted by doctors for patients dying in hospital, 9%contained errors due to the order of the informationrecorded on the certificates and 28% were incorrect owingto the omission of the underlying cause of death, including7% where the certificate was issued before necropsy. Forthe certificates issued before necropsy, the Registrar Generalendeavours to correct the coding of the cause of death byuse of an inquiry to the certifying practitioner. Though itseems reasonable to suggest that education will reduce thelevel of errors, progress has been slow since 1939 and

great change is unlikely especially in face of the increasein competing demands for teaching time.You refer to the management of a complex health service

depending on basic statistical material, having only men-tioned accuracy of death and sickness-absence certificates.These crude instruments, though providing helpfulepidemiological pointers at a national level, are of littleuse to administrators and clinicians (in division and medicalexecutive committees). We require the development ofreproducible and valid measures of: the health needs of a

community; the work performance of the health services;the cost; the quality of care. As these become availablethe planners will more readily formulate tomorrow’sproblems and settle down to deploy our scanty resources.

M. R. ALDERSON.

University Department ofMedical Information Science,

Southampton.

RESERPINE IN RAYNAUD’S PHENOMENON

SIR,-Your editorial (Aug. 29, p. 454) prompts us toreport a case we treated with reserpine after reading thearticles by Peacock,2 Abboud,3 and Kontos.4 The patientwas a man of 32 who had had the disease for about 2 years.On admission to hospital he had some small necrotic areason the distal extremities of two fingers. The clinical diag-nosis of Raynaud’s phenomenon was easy, but we wereunable to find any underlying cause. The patient wastreated for 8 months with 0-25 mg. daily in the evenings.No other vasodilators were used. In the first 2 monthsthere was obvious improvement in the areas of necrosis,though there was still pain and pallor when they were

1. Alderson, M. R. M.D. thesis, University of London, 1965.2. Peacock, J. M. Lancet, 1960, ii, 65.3. Abboud, F. M., Eckstein, J. W., Lawrence, M. S. Circulation, 1967,

36, suppl. 2, p. 49.4. Kontos, H. A., Wasserman, J. A. ibid. 1969, 39, 259.

exposed to cold. Then, despite the cold, these featuresdisappeared altogether. There were no unpleasant side-effects during treatment.

C. G. H. DIMITRIUGAVRILA FLORIAN.

Medical Clinic,Emergency Hospital,

Bucharest,Rumania.

TRIETHYLENE TETRAMINE

SiR,-Weiser et al.1 have described the synergisticinteraction of ethylenediamine tetra-acetate and antibioticsagainst Pseudomonas aeruginosa. Walshe 2 subsequentlyreported the use of a new chelating agent, triethylenetetramine (T.E.T.A.), in the management of Wilson’s disease.I have performed preliminary tests which demonstratethat T.E.T.A. also can enhance antibiotic activity.

T.E.T.A. reduces the minimal inhibitory concentrations ofa variety of antibiotics, including carbenicillin, tetracycline,and trimethoprim/sulphamethoxazole, for Ps. ceruginosa.The T.E.T.A./antibiotic combination is also more effectivethan antibiotic alone in the treatment of experimentalPseudomonas infections in mice.

It is possible that T.E.T.A. acts by increasing the per-meability of the bacteria to antibiotics. If this is the case,T.E.T.A. is the first such agent suitable for systemic use.Further animal experiments are required to evaluate theclinical potential of this drug in combination therapy.

GODFREY SMITH.St Catharine’s College, Cambridge.

Parliament

Vehicles for Disabled HaemophiliacsMr. CHRISTOPHER WOODHOUSE argued that the three-

wheeled cars at present provided under the N.H.S. for dis-abled drivers were unsuitable for the 100 or so persons inBritain who were disabled by hxmophilia. Since theycould not carry a passenger in a three-wheeler, they were ina desperate position if a mishap occurred. They werepeculiarly vulnerable to any kind of physical shock andthey should be given the protection of a four-wheeledmini-car. Mr. MICHAEL ALISON, Under-Secretary of Statefor Health and Social Security, saw the suggestion as aclaim that because hxmophiliacs could not safely drive thevehicle issued they should be given cars. That introducedan entirely new concept into N.H.S. arrangements for

providing vehicles. The rule was that if a person could notsafely drive the vehicle issued, he was not issued with avehicle at all. Mr. Alison agreed that the present vehiclewas not entirely satisfactory and a much-improved versionwould, it was hoped, be in production next year.

Care of the ElderlyReplying to a debate on a motion calling attention to the

need to increase the allocation of resources to the elderlyin and out of hospital, Mr. Alison said this was recognisedas one of the key vulnerable sectors in which an extra expen-diture of El 10 million was planned for the health andpersonal social services over the next few years. About E40million of this was to be spent on improving hospital andlocal-authority services for old people and the mentallyill, bringing the total increase in expenditure on the im-provement of these services over the next four years to

nearly E300 million. The starting-point was to see that theelderly were an integral and natural part of society as a whole.The approach through centres for the elderly, holidays for

1. Weiser, R., Asscher, A. W., Wimpenny, J. Lancet, 1969, ii, 619.2. Walshe, J. M. ibid. p. 1401.