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term anticoagulant therapy, to diminish the risk ofsystemic embolism, may be needed. Again, in thosewhose age discourages an intrathoracic operation, theonset of fibrillation may not substantially affect

management. In the majority, however, tightstenosis is present and calls for relief. Sinus rhythmmay be restored postoperatively by electrical counter-shock, although the chance of lasting success israther poor. 3,4 A systemic embolism is likely to bringpressure on the physician to advise operation, buttight mitral stenosis must be present or operation willbe futile and perhaps dangerous. Preoperative anti-coagulation to lessen the risk of operative embolismshould be routine in patients with atrial fibrillation,if not in all. After a period of years the question of arepeat mitral valvotomy may arise, because of failureto lower left atrial pressure adequately at the firstoperation, or because of restenosis. The first is themore likely explanation, particularly if a metaldilator was not used.

Dilatation of the valve orifice may, however, fail toprovide relief if the cusps are much thickened andrigid or heavily calcified. In many other patients thecause of disability is reflux without obstruction, or acombination of the two. Under these circumstancesvalve replacement alone is likely to be effective. Insome patients with a dilated mitral orifice and

relatively little cusp damage, a repair operation toreduce the size of the valve ring may suffice, at leasttemporarily. The replacement has, until now, usuallybeen a prosthesis of the ball-in-cage or flat-disc

variety. Some success has lately been reported withheterograft aortic-valve grafts 5 or with valvesfashioned from the patient’s own fascia lata. Theuse of a prosthesis usually demands permanent anti-coagulant therapy, with its accompanying disadvan-tages of the risk of bleeding and the need for constantlaboratory supervision. Approximately 15% of

patients submitted to the operation will not leavehospital alive. For these reasons mitral-valve replace-ment should not at present be recommended for

patients whose lives are not seriously threatened.Judgment as to when this stage has been reached isof the very greatest difficulty, for prediction of thecourse of severe mitral disease and atrial fibrillationcan be considered only in terms of probability: forexample, it is impossible to predict fatal systemicembolism. Fortunately, embolism is rare in thosewith free regurgitation, for blood does not stagnate inthe left atrium unless the atrium is enormously dilated.

In prognosis, breathlessness is not very helpful.Nearly all patients who are being considered foroperation will have had symptoms for years; andworsening symptoms are often hidden by the resig-nation of the afflicted to a life of very little movement.

3. Resneskov, L., McDonald, L. Br. Heart J. 1968, 30, 786.4. McCarthy, C., Varghese, P. J., Barritt, D. W. ibid. 1969, 31, 496.5. Joneson, M. I., Wooler, G. H., Smith, D. R., Grimshaw, V. A.

Thorax, 1967, 22, 305.6. Ionescu, M. I., Ross, D. N. Lancet, 1969, ii, 335.

There are, however, three features which clearlymark the downhill trend and, together or separately,justify the decision to advise replacement. The firstis the occurrence or recurrence of congestive heart-failure with rising venous pressure (not due to

organic tricuspid disease). In this respect the levelof medical treatment is crucial, for if congestivefailure arises in a patient who is not being treatedwith digitalis and diuretics he may respond quicklyand survive for many years. On the other hand,if congestive failure appears in the face of full

digitalisation and daily diuretics, then the decision tooperate has been left dangerously late. Secondly,intrapulmonary pressure measurements are helpfulin defining deterioration and prognosis. Repeatedmeasurements offer incontrovertible evidence and

fortify the physician and surgeon who must advisethis serious step. Intrapulmonary pressure measure-ments are much less helpful in pure mitral reflux, forin some patients, particularly those with large leftatria, resting pulmonary-vein pressures may remainnear normal until death. Thirdly, overall heart-size isof importance in prognosis. Massive dilatation of theleft atrium poses little threat to life, but continualdilatation of the ventricles betokens not only earlyfatal heart-failure but also the risk that replacementof valves may not afford good recovery.The results of successful valve replacement

usually fully justify the risk taken. Intrapulmonarypressures fall, latent heart-failure is relieved, andpatients become aware of their former restrictions.It is reasonable to hope that the relief will endure. Ina few there is little benefit, for reasons which may notbe evident. Rheumatic damage to the myocardiumand the unsatisfactoriness of cumbersome prosthesesmay play a part, but these possible failures shouldcertainly not discourage attempts to restore reason-valve function in the hope of a dramatic improvement.

GonorrhœaGoNORRHCEA is now said to be the second most

common notifiable infectious disease in the world,only measles being more prevalent. With massmeasles vaccination just around the corner, it is a safebet that gonorrhoea will take first place before verylong. The problems of the control of gonorrhoeainclude socioeconomic factors; a very short incuba-tion period; high transmissibility, and little or no

lasting immunity; difficulty in diagnosis particularlyin women, who may be symptom-free; and finallyfailure to cure some patients owing to an increase inantibiotic resistance of the causal organism. Despiterepeated please 8 insufficient research is directedagainst this disease.

Epidemiological and basic pathological studies are7. Braunwald, E., Aida, W. C. Circulation, 1963, 27, 29.8. Lancet, 1968, i 675.

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hampered by the lack of a method for typing theorganism, and of a laboratory animal susceptible toinfection. Diagnosis still presents very considerableproblems in symptomless women and perhaps inchronic carriers, of both sexes. A reliable serologicaltest that can be used for mass screening is urgentlyrequired. Claims have been made for a method of

extracting antigens which gives both a sensitive anda relatively specific result in complement-fixationtests. 9 Using one of these antigens the detection-rate in infected females was found to be 82%,10which, with few false positives, is certainly a greatimprovement on any previous gonococcal comple-ment-fixation test. Further work on the antigens ofNeisseriagonorrhaeae should be undertaken in the hopeof evolving not only diagnostic antigens but perhapsa serological typing method. Nor should the

possibility of phage-typing be forgotten-thoughso far apparently bacteriophages have only beenisolated from other non-pathogenic Neisseria.11,12Research is still needed on the best media for provid-ing high yields of growth for serological studies andfor isolating the organism from pathological material.Arecent advance 13 in this field is a medium consistingof ’ Oxoid DST ’ agar plus 10% horse-blood lysedwith 10% saponin and incorporating 5 (Lg. per ml.

trimethoprim, 8 (Lg. per ml. colistin, and 3 (Lg. perml. vancomycin. This medium appears to offerseveral advantages over the previous selective mediumdescribed by THAYER and MARTIN,14 and it certainlyyields luxuriant growth of the gonococcus.Much more work is required on possible alterna-

tives to penicillin for treatment as reports continue tocome in from all over the world of high proportionsof penicillin-resistant strains. At St. Thomas’s

Hospital, London,15 relative resistance to penicillin isfound at present in 37% of gonococci isolated, andthose infected with these relatively resistant strainsshowed a higher relapse-rate when treated with

600,000 or even 2,500,000 units of penicillin; but themost recent (as yet unpublished) account from thiscentre shows that 5 mega-units of penicillin givenafter 1 g. of probenecid reduces the relapse-rate tovirtually zero and this has also been the experience inGreenland.16 It is doubtful if merely raising the doseof penicillin will be a final answer to this problem.The dose has been raised step by step already inefforts to deal with resistance. Careful studies shouldcontinue on the antibacterial activity of other drugsand combinations of drugs, on the lines of a study9. Danielsson, D. G., Schrnale, J. D., Peacock, W. L. J. Bact. 1969, 97,

1012.10. Reising, G., Schmale, J. D., Danielsson, D. G., Thayer, J. D. Appl.

Microbiol. 1969, 18, 337.11. Stone, R. L., Culbertson, C. G., Powell, H.M. J. Bact. 1956, 71, 516.12. Phelps, L. N. J. gen. Virol. 1967, 1, 529.13. Phillips, I. Personal communication.14. Thayer, J. D., Martin, J. E. Publ. Hlth. Rep., Wash. 1964, 79, 49.15. Nicol, C. S., Ridley. M., Symonds, M. A. E. Brit. J. vener. Dis. 1968,

44, 315. Nicol, C. S., Ridley, M., Symonds, M. A. E. Personalcommunication. Gray, R. C. F., Phillips, I., Nicol, C. S. Personalcommunication.

16. Olsen, G. A., Lomholt, G. Br. J. vener. Dis. 1969, 45, 144.

reported by the St. Thomas’s group on p. 263 of thisissue, in an effort to establish alternative treatmentwhich may be applied at a national or internationallevel in the hope of eventually restoring N. gonorrhaeaeto its pristine penicillin sensitivity.

A HEALTH SERVICES RESEARCH COUNCIL?

IN recent years the Department of Health and SocialSecurity has been quietly stepping up its allocation offunds for extramural research in the health and welfare

services-perhaps too quietly, for it is surprising howlittle publicity has been given to this valuable work.In a working-paper 1 prepared by the Department for aSocial Science Research Council conference in 1969, itwas shown that the Department’s expenditure onresearch and development in 1968-69 was E3-5 million,divided into five areas :

1. Clinical and public health.- The clinical element com-prises support for research programmes organised by hos-pital boards under the locally organised clinical researchscheme, and amounted to 20% of the total research anddevelopment expenditure by the Department. Public-health research and development was a further 5%.

2. Health and welfare services.-This comprises researchinto the need for health and welfare services, the use madeof them, and more effective ways of providing them. Itwas 25% of the total.

3. Special developments.-Rather less than 25% was

spent on new techniques and methods which have comeout of the applied-research stage but which are not suitableor not yet ripe for introduction as a general service.

4. Equipment.-A similar amount was spent on the deve-lopment of new and improved equipment to meet needsidentified in the service, and the trial and evaluation ofcommercially produced equipment.

5. Building and engineering.-About 5% was spent onresearch into problems associated with hospital and local-authority building and with hospital maintenance, andenvironmental studies aimed at improving conditions inexisting hospitals.A committee was appointed in 1967 by the Ministry

of Health to advise on the research and developmentprogramme. There could usefully be more informationand discussion about this committee’s activities. Whatis the strategy for research in the health services ? Is

enough money being devoted to such research? Howare research priorities assessed ? On what grounds, forexample, is it decided that five times as much shouldbe spent on research and development of equipment ason research into problems of hospital building andengineering ? The Department’s annual report 2 shedslittle light on these questions. For 1968 the Depart-ment’s research activities are described in less than five

pages scattered through the annual report. In contrast,the Social Science Research Council’s annual report for1968-69 3 gives a 222-page account of its stewardshipof less than El-5 million of grants, including a welltabulated and cross-indexed summary of all the pro-1. Government Research Activities in the Field of Health and Welfare

Services. London, 1969. Typescript copies available from SocialScience Research Council.

2. Annual Report of the Department of Health and Social Security forthe Year 1968. H.M. Stationery Office, 1969.

3. Report of the Social Science Research Council 1968-9. H.M.Stationery Office, 1969.