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of the last treatment. Then there followed a course ofpsychotherapy lasting over two years which terminatedwhen I was called up for service with H.M. Forces. Ihave since been demobbed with my group and returned tomy civilian job and there has been no relapse.

I do not pretend that E.C.T. is a pleasant experience ;I was anxious about it, but " dread " would be the wrongword to use, and I would have it again if necessary. Apartfrom the pain in the back following the convulsions theexperience was not too bad. One is knocked out immediately. But it must be pointed out that even

psychotherapy is not altogether an enjoyable experience.After many stormy sessions one learns that, unlikeE.C.T., there is no anaesthesia ! !

It seems a pity to exaggerate about E.c.. Surely bynow a sufficient number of cases have been examined,treated, and followed up by competent psychiatrists forits true worth to be assessed ? P DOCTÓR- PATIENT.

SIR,-Dr. Learoyd (Nov. 23) disapproves of convulsiontherapy, and speaks of our mental hospitals as of Belsenswithin our gates. He is, of course, entitled to his views ;yet, To offend, and judge, are distinct offices, And ofopposed natures.

Truro. H. PULLAR-STRECKER.

EXERCISE AND CARDIAC HYPERTROPHY

SIR,-Sir Adolphe Abrahams’s case of cardiac hyper-trophy (Oct. 19, p. 565) in an otherwise normal man of 78,who was in his youth a successful long-distance cyclist,is of extraordinary interest. The old-established opinionof some clinicians that a normal heart never hyper-trophies, now queried in this paper, is overdue for revision.

There is considerable evidence that such hearts areacquired and not congenital. Whole series of oarsmenand long-distance runners show, as I have been able todemonstrate,l hypertrophy which can be recognised inthe X-ray picture at a glance. It would appear veryunlikely that these men- have become record-holders -through having large hearts.The main evidence is that the hearts of professional

sportsmen show, in the rare cases that come to necropsy,typical hypertrophy, affecting only those parts of theheart which are heavily strained. 2 Apart from this,there is plenty of evidence from training experimentswith rats and dogs that certain kinds of exercise causehypertrophy. It should not be necessary, therefore, topreserve the myth that the normal heart does nothypertrophy. It definitely does, and the importance ofthe case published is that the hypertrophy persisted intoold age-a possibility which, till now, has been doubtedby many, including myself.London, N:22. H. HERXHEIMER.

ARSENICAL ENCEPHALOPATHY

SiR,-Dr. J. R. Edge reports (Nov. 9) an interestingcase of myocardial fibrosis ending in fatal heart-failure,in a man who had been treated with neoarsphenaminefor early syphilis. After the second injection of hissecond course of treatment the patient passed intocoma, and on recovering was left with permanentbilateral pyramidal signs.The cardiac complication is unusual, and I would

suggest that the encephalopathy is worthy of furthercomment. Arsenical encephalopathy in Europeans isa very rare condition of which I have only seen oneexample. During the late war it was however verycommon amongst Indian troops. In two large v.D.

centres in India the incidence of encephalopathy over along period was as high as 1 in 73 cases treated, and inanother over several months the incidence rose to 1 in 55.This became a very serious matter as the mortality wasinvariably about 50 %.The factors underlying arsenical encephalopathy are

by no means clear. Dosage is only one factor, and Ihave seen a fatal outcome following a single injectionof 0.3 g. N.A.B. Probably a more important factor isthe relationship of dose to body-weight, and mostcases of encephalopathy in Indians occurred inthe undernourished ; incidentally, they were almostinvariably Tamils or Bengalis.

1. Grundriss der Sportmedizin, Leipzig, 1933.2. Kirch, E. Verh. dtsch. Ges. inn. Med. 1935, 47, 73.

The clinical picture is essentially one of coma andconvulsions, often of very rapid onset, but sometimespreceded for a few hours by confusion or other alteredmental states. Focal signs are usually absent, and,apart from dilated and sluggish pupils with bilateralextensor responses when coma was deep, I was neverable to elicit focal signs. Various forms of empiricaltherapy were tried (British anti-lewisite was not avail-able), but none seemed to influence the course of thedisease in any way. Among the 50 % who recovered, Idid not observe any sequelae. Dr. Edge’s case is thereforeunusual in that there were apparently no convulsionsand neurological sequelae were severe.

Dr. Edge refers to the commonest findings in the brainsof fatal cases. Major L. Krainer, R.A.M.C., found howeverthat in a large number of cases careful microscopydid not show any adequate cause of death, and certainlyin those cases which were rapidly fatal histologicalexamination was negative.

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Leeds. HUGH GARLAND.

MALT EXTRACT IN INFANT FEEDING

SiB,—An investigation at the Lister Institute hasshown that a combination of malt extract, wheat flour,and soya flour, in which about 70 % of the total solidsand about 30 % of the total protein is obtained from maltextract, possesses a mixture of proteins whose growth-promoting value for young rats is about equal to thatof the protein of milk. It is also concluded that sucha mixture, if used for baby food, would not need supple-mentation with food yeast or synthetic B vitamins.

Since these important findings may find direct applica-tion in the present food crises, it seems desirable toemphasise that malt extract can vary widely in com-position, as shown by the following data obtained in theselaboratories on a series of some 70 commercial maltextracts from over 30 different manufacturers, excludingsamples fortified with synthetic B vitamins 2 :

per 100 g. dry matterrange mean

protein ...... g. 1-36-8-37 5-31 0

Vitamin B1 ...... mg. 0-23-0-58 0.37

Riboflavin ...... mg. 0-27-0-56 0-42

Nicotinic acid ..... , mg. 9-3-16-5 12-6

The so-called " protein of malt extract (videB.P. 1932), being obtained by the action of malt enzymeson the crude protein of germinated barley, containsdigestion products of protein which are more readilyavailable to the actively growing baby or young rat.This should be borne in mind when seeking an explanationfor the marked improvement in the biological value ofthe protein mixture in ’ Maltavena ’ produced by therelatively small proportion (perhaps about a third)which can come from malt extract. Moreover, the growth-promoting properties of maltavena will also depend on itscontent of B vitamins, by far the greater part of whichshould be derived from the malt extract. The maltextracts we used in manufacturing the maltavena suppliedto Dr. Chick for her experiments had vitamin-B contentsclose to the maxima in the above table, and proteincontents well above the average. We can imagine thatif maltavena were made with less nutritious malt extractsit might not give such good results. It is thereforedesirable that the manufacture of maltavena for infantfeeding should, wherever possible, be controlled byestimation of the above factors.We emphasised this point strongly when discussing

the matter last year with Major McNeile, who was thenin charge of brewing and distilling in the British zonein Germany ; and we offered to undertake estimationson maltavena preparations which he was arranging tomake in Germany. We have not had the opportunityof examining any of the maltavena preparations whichhave been used in Germany, mainly in the Dortmundarea, and we sincerely hope that their contents of theabove factors have been controlled by other workers,and that such control will be exerted in any futureexperiments. T;O . . ---- -nT-

Ovaltine Research Laboratories,King’s Langley, Herts.

FRANK WOKESDirector of Research.

1. Chick, H., Slack, E. B. Lancet, Oct. 26, p. 601.2. See Klatzkin, C., Norris, F. W., Wokes, F. Quart. J. Pharm. 1946,

19, 376.