1427

or the ventricular c.s.F. by immunofluorescence,electronmicroscopy, or virus culture. Late con-

firmation in survivors may come from a rise of anti-bodies to H.s.v. in the c.s.F.The mortality of H.s.v. encephalitis is high and the

quality of survivors poor.s Some workers believethat reduction of intracranial pressure by medical(dexamethasone 8.9) or surgical means is an essentialelement in treatment. Rappel pleads for the additionof antiviral therapy when steroids are used, becauseof the theoretical dangers.10 Despite preliminaryenthusiasm for idoxuridine there has been no con-

vincing evidence that this drug is of any value inH.s.v. encephalitis. 8, 11 Cytosine arabinoside in vitroinhibits the growth of several D.N.A. viruses, includingH.s.v., and this is the drug the working-party proposesto use in the multicentre trial. Enthusiasts claim a

striking therapeutic effect in herpesvirus infections inindividual cases,12,13 but the only controlled trial in aherpes infection (disseminated zoster) did not showany benefit.14 Nevertheless, the outlook in H.s.v.

encephalitis is so poor that a properly conducteddouble-blind trial of an agent known to be active inthe laboratory is clearly justified if the drug treatmentis combined with routine supportive measures,including reduction of intracranial pressure. For

any treatment to be effective, really early diagnosis isprobably essential, maybe even within the first 48hours. This is a major difficulty because many patientsat this stage do not have symptoms which merit theinsult of a brain biopsy as an investigation procedure.

THE AGED AILING AFRICAN

MUCH of our knowledge of the prevalence ofdisease as uncovered by necropsies is based on youngpeople. But in Monroe County, New York, Kunitzand Edland 15 have noted a disproportionately highnecropsy-rate for young people of all races-partly areflection, they believe, of the feeling that death inthe young is somehow unnatural. In less affluentsocieties the disparity may be even greater. Thus, inUganda, where in 1948 about 11% of the populationwere living for 45 years, only 21 persons over 60

years old came to necropsy in the years 1931-47.16But now, with increasing numbers of people, thereare greater numbers living to an advanced age. In1959 Uganda had 248,000 aged 60 or more and in1969, 564,000: Drury 17 has written of the diseasesrevealed at necropsy in 373 Ugandans aged 60 orover. (In 1960 Thomas et al.1111 were able to find

necropsy reports in 245 Ugandans over 40 years ofage and 4 over 60, for comparison with age and sexmatched U.S. Blacks.) The major diseases (not8. Upton, A. R. M. Br. med. J. 1972, i, 226.9. Habel, A. H., Brown, J. K. Lancet, 1972, i, 695.

10. Rappel, M. Br. med. J. 1972, ii, 655.11. Juel-Jensen, B. E. Br. J. Hosp. Med. 1973, 10, 402.12. Jeul-Jensen, B. E., MacCallum, F. O. Herpes Simplex, Varicella

and Zoster: Clinical Manifestations and Treatment; p. 117.

London, 1972.13. Longson, M., Beswick, T. S. L. Lancet, 1971, i, 749.14. Stevens, D. A., Jordan, G. W., Waddall, T. F., Merigan, T. C.

New Engl. J. Med. 1973, 17, 873.15. Kunitz, S. J., Edland, J. F. J. forens. Sci. 1973, 18, 370.16. Davies, J. N. P. E. Afr. med. J. 1948, 25, 117.17. Drury, R. A. B. Trop. geog. Med. 1972, 24, 382.18. Thomas, W. A., Davies, J. N. P., O’Neal, R. M., et al. Am. J.

Cardiol. 1960, 5, 41.

necessarily the cause of death) in Drury’s subjectswere grouped into 8 categories and the infectivesubset into 3 categories-parasitic, tuberculous,and other. The male/female ratio was 4/1. Each

subject aged 60 or over was randomly matchedwith a control of the same sex and tribe but 30 yearsyounger. Though over-60s are over-represented inhospital admissions, biopsies, and operations,19 therewas little difference in the major causes of deathbetween them and their juniors by 30 years." The

important differences were a 65% increase in cancer(less obvious in women), an almost 50% reduction intraumatic deaths, and proportionately fewer deathsfrom tuberculosis. These findings emphasise threepoints. Firstly, in the elderly African the frequency ofpreventable and treatable infective diseases is highand very similar to that in younger Africans. Secondly,even in the aged African degenerative cardiovasculardisease is of little importance-only 6 (1-6%) of theover-60 group died of arteriosclerosis and a total of14 died of what could be termed degenerative diseases;thus ischsemic heart-disease, arteriosclerosis, and othercardiovascular conditions so common in elderlyWhites remain uncommon in the elderly Ugandan,as elsewhere in African. 20 0 Finally, the increased pro-portion of cancer does not mean that the discrepanciesfound in the past can now be disregarded. Theyremain as great as ever. 19,2 1 The only cancer seen inthe elderly and not present in their juniors wasprostatic cancer. Liver cancer, lymphomas and

leukasmia, and bladder cancer were the commonest,with oesophageal and prostatic cancers the runners-up.There is no evidence of the " missing " lung andbowel cancers which have been so much discussed.Before long, if the lessons of this report are heeded,we may have a report of a large series of necropsies inAfricans over 70, and surely there will be much tolearn from it.

COMMUNITY PHYSICIANS

PERHAPS Sir Keith Joseph is right to maintain themomentum of his reorganisation-keeping his headwhen all about him are losing theirs. But, as the pacequickens, difficulties come thick and fast. Most of

them, in themselves, are minor; clearly the StaffCommission has been overburdened-one hears, forinstance, of a doctor being shortlisted for a job he didnot apply for. Now the telescoped timetable hasproduced another irritant: regional and area medical-officer appointments are not to be announced till thesecond week of January, whereas the community-physician applications have to be in by Jan. 7. Thus,the future community physician cannot choose whohe will (or will not) work under. To slow downthe programme, it is said, would be bad for morale;here there seems a case for speeding it up: the StaffCommission should announce the medical-officer

appointments before Jan. 7. -

19. Davies, J. N. P., Knowelden, J., Wilson, B. A. J. natn. Cancer Inst.1965, 35, 789.

20. Williams, A. O., Resch, J. A., Loewenson, R. B. E. Afr. med. J.1971, 48, 152.

21. Templeton, A. C. (editor). Tumours in a Tropical Country. Berlin,1973.