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effusions. Of the 53 minoxidil-treated patients with pericardialeffusions 17 had no evidence of renal impairment or otherknown cause of pericarditis. 3 of these 17 had tamponadewhich was successfully treated by pericardectomy and in 2 theminoxidil was continued without recurrence of effusion. In 5of the 17, effusions disappeared spontaneously without treat-ment while minoxidil was continued. Dr Martin suggests thateffusions developing in minoxidil-treated patients with normalrenal function may be part of the general fluid retention whichoccurs with this drug. The incidence may be less if fluid weightgain is prevented.Asymptomatic pericardial effusions may develop in patients

treated with minoxidil, and only a proportion of these willhave clinically detectable pericarditis. This may explain why sofew cases have been reported. Echocardiography should be aroutine part of the follow-up of patients on minoxidil untilmore is known about this complication.

Pericardial effusion with tamponade is a well-known compli-cation in patients on dialysis, but minoxidil therapy almost cer-tainly increases the incidence, and the suggestion that minoxi-dil is preferable to bilateral nephrectomy for refractoryhypertension in patients on dialysis2 seems to deserve closerexamination. When pericardial effusion develops in a patientwith normal renal function who is receiving minoxidil it maynot be necessary to stop the drug, but the patient should beobserved closely while excessive fluid retention is controlled.

Department of Medicine,Toronto Western Hospital,Toronto, Ontario, Canada

ANNA MARQUEZ-JULIOP. ROBERT ULDALL

HÆMOPERITONEUM IN A TRANSSEXUAL

SIR,-Long-term therapy with sex steroids is associatedwith liver damage. Dr Westaby and his colleagues (Aug. 6, p.261) found a high frequency of abnormal liver scans in femaletranssexuals taking 17 Ot-alkylated steroids while others3.4 havedescribed hepatic peliosis and neoplasia in females taking oralcontraceptives. These patients often present as surgical emer-gencies with haemorrhage into the liver, peritoneal cavity, orboth.A 69-year-old patient with Klinefelter’s syndrome was

admitted to the Radcliffe Infirmary with severe abdominalpain and ansmia. For 20 years he had lived as a female,receiving stilboestrol implants every 6 months until 1975, whensuppression of male secondary sex characteristics was con-tinued with ethinyloestradiol (0.5 5 mg daily). There was no his-tory of trauma. On admission he had right-upper-quadrantperitonitis, and a liver scan showed medial displacement of theright hepatic lobe. Coeliac angiography revealed zones ofdilated hepatic vasculature but no evidence of tumour. Atlaparotomy a hsmoperitoneum was released and a large sub-capsular hxmatoma adjacent to the right lobe of the liver wasdrained. This case is an indication that the use of long-termsex steroid therapy to induce gender change artificially has therisk of converting psychosexual problems into organic disease.

Nuffield Department of Surgery,Radcliffe Infirmary,Oxford

J. I. BELLM. C. BISHOPB. J. BRITTON

SEX AND HISTOCOMPATIBILITY TESTING

SIR,-The sex difference in histocompatibility matchingfound by Dr Opelz and Professor Terasaki (Aug. 27, p. 419)may indeed be due to the "less outspoken" character of femaleantigens, as Dr Ounsted and Dr Taylor suggest (Sept. 10, p.

2. Pettinger, W. A., Mitchell, H. C. New Engl. J. Med. 1973, 289, 167.3 Chnstopherson, W. M., Mays, E. T. J. natn. Cancer Inst. 1977, 58, 167.4 McAvoy, J. M., Tompkins, R. K., Longmire, W. P. Archs Surg. 1976, 111,

761.

563). It might also, however, be in some manner connectedwith the fact that the female mammal is adapted to life witha half-foreign fetus on board.

Since both this effect, and the fact that in mammals thefemale is homozygotic with respect to sex chromosomes, have t

been looked at by gerontologists as possible causes of the inher-ently lower age-specific mortality in females, it might be of in-terest to look at the histocompatibility of birds, where there isno close fetal connection and the female is heterozygotic. Anylight on the feminine advantages conferred by like sex chroma-tin and higher autoimmune tolerance would be of great inci-dental interest to gerontology since in birds there is some evi-dence1,2 that the longevity/sex correlation may be reversed infavour of the male.

Institute for Higher Studies,2311 Garden Street,Santa Barbara, California 93108, U.S.A. ALEX COMFORT

MANAGEMENT OF ALCOHOLISMSiR,-The finding by workers at the Institute of Psychiatry,

London, referred to in your editorial (Sept. 3, p. 488), that inrandomised samples of alcoholics "advice" alone did not leadto worse results than "treatment" is very surprising. Most ofthe alcoholics I saw in clinics and hospitals and on domiciliaryvisits could not have been safely left with advice. Even in theabsence of definite physical or mental complications, many hadabnormal liver-function tests; there were those who were verydepressed and talked of suicide or who were misusing otherdrugs and those who drove cars while affected by alcohol; somealcoholics lived on their own and could not look after them-

selves ; and there were wives who planned to leave homebecause their husbands had so often broken their promises tokeep off drink. In practice, since alcoholics were often not will-ing to have treatment (or treatment was not available) manydid get advice only-and they turned up again and again,often requiring admission elsewhere while in a much worsecondition, and sometimes when action was delayed the patientdied.

There must, therefore be some striking difference betweenthe "alcoholics" Dr Edwards and his colleagues studied andthose seen by me over the years. Among the criteria for inclu-sion in this study were "that a referring agent considered thepatient to have a drinking problem ... [and] the psychiatrist’sconfirmation that a drinking problem existed". The term

"drinking problem" is even more ambiguous than "alcoholic"."Problem drinkers" probably include some with minor alcoholproblems, and many problem drinkers will respond to in-

formed, sympathetic advice. But the situation is surely verydifferent for the addict with psychological and/or physicaldependence on alcohol.The drinkers all attended a family clinic with .their wives,

spending three hours in assessment; and there seems to havebeen no great discrepancy at assessment or during follow-upbetween the independent evidence of husband and wife. Thisis strange, because when a drinker and his wife are interviewed

independently their stories as a rule are so different that oneoften wonders whether the two are talking about the same per-son. Again this suggests that the research sample containedmore early problem drinkers than would be found in clinicalpractice. Informed advice such as that given to the untreatedgroup in this study may often be sufficient for problemdrinkers (especially when coupled with a recommendation thatthey join Alcoholics Anonymous), but for the many who

require treatment there is still a woeful lack of community andinpatient services. No-one doubts the overriding importance ofprevention or research, but to ask, as you do, for a radicalrecasting of the services for alcoholism in the light of a study

1. Eisner, E. Expl Geront. 1967, 2, 187.2. Cherkin, A., Eckhardt, M J. J. Geront 1977, 32, 38.3. Edwards, G., and others J. Stud. Alcohol, 1977, 38, 1004.4. Glatt, M. M. Alcoholism: a Social Disease; p. 193. London, 1976.