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homes are minimal. The residents of such homes inevitably add to the work load of community nurses and general practitioner services. The proprietors must find them attractive financially even at the present cost to residents of C80-,I120 for each person for each week. This cost must be compared with that of a geriatric bed or local authority part III accommodation. A geriatric bed in Devon costs five times as much as part III accommodation.' They therefore represent an attractive solution to the problem of too few places elsewhere, and more so at a time when there is a reduction in community services originally designed to keep people in their own homes as long as possible. Little seems to be known about the true costs of this type of residential provision, though one suspects that the economies are achieved by reduction in quantity and quality of staff. If this is so, should the NHS be moving in the same direction ? The consultative document A Good Home2 covers the question of registration of private homes well, and some of its recommendations if adopted may help. The experimental setting up of three "NHS nursing homes" by the department may give us some more information. I hope that they may be realistically compared with the private sector. The problem is with us now and requires urgent and close attention.

Southway, Plymouth PL6 6TA

SIR,-We are a group of doctors working in various branches of the NHS in East London. We are writing to protest at the Government's refusal to negotiate in the current health workers' pay dispute. We work in an area where there is high unemployment and where severe cutbacks in NHS and social services expenditure have placed increasing pressure on all health service workers and services to patients. The current battle has seen the Government spending £85 000 in one day alone to advertise its case in the press. Meanwhile, a significant percentage of health workers-skilled and unskilled-are expected to exist on wages that place them below the official government poverty line. One consequence of this policy is the steady flow of skilled nurses away from the public and into the private sector. Recruitment of trained staff in many London hospitals has now become a major problem. An increase in pay to bring wages in line with living standards is in the interests not only of health staff but of the NHS as a whole. Mr Fowler's comment that: "It is early days yet," in the stages of this dispute begs the question as to whose interests he serves. Our work as doctors is best served by a properly financed and staffed health service. We therefore urge our colleagues to write to Mr Fowler and their MPs in the coming weeks to J S GILMORE express their support for the present 12% claim and a speedy end to this dispute.

DHSS. Services for mental illness related to old age. London: HMSO, 1972. 2DHSS Welsh Office. A good home, 1982.

Enough is enough SIR,-I agree with every word of your leading article (11 September, p 669) but wish that you had gone further. Certainly, a fundamental inquiry into the objectives of the NHS, its structure, its staffing, and pay levels could be of great benefit. Ideally, it might place the NHS beyond the political football stadium where crowd pressures from left and right are squeezing all its staff into ugly shapes. Independent inquiries, however, tend to take many months to gather and assess evidence. It is for this reason that they are so favoured by politicians. If a week is a long time in politics, two years (an average time for a Royal Commission) is infinity. "The intransigent and polarised attitudes" of the present dispute require resolution within a few weeks if we are to avoid widespread misery and harm among our population. The BMA cannot sit on the wall any longer without suffering the fate of Humpty Dumpty. Without sycophancy, I can call on the BMA, the country's most highly respected professional organisation and ideally equipped through its industrial relations officers, its detailed knowledge, and its long experience as a founding member of the NHS, to mediate between the Government and its health workers. We owe no favours to either side; indeed the medical profession still bears the boot bruises on left and right buttocks. What we must acknowledge is our debt to those in the NHS who work hard for shamefully small wages. JOHN A T DUNCAN Dunfermline, Fife

NHS pay dispute

CAROL DEZATEUX ANNA LIVINGSTONE TONY JEWELL JANE TAYLOR

DAVID HICKS Viv TAYLOR JOHN ROBSON WENDY SAVAGE KAMBIZ BOOMLA

VOLUME 285

25 SEPTEMBER 1982

inactive. It could also account for the spontaneous improvement when the beta-blocker was stopped, as the thyroxine could then undergo alternative conversion to active triiodothyronine. I J GORDON Whiston Hospital, Prescot, Merseyside L35 5DR

SIR,-I was most interested to read the paper by Dr K Murakami and others on myxoedema coma induced by beta-adrenoreceptor-blocking agent (21 August, p 543). At the conclusion of the case report the authors say that the mechanisms by which the beta-blockers precipitate myxoedema coma include the agents' actions on cardiac function, depression of the central nervous system, or the effect of further peripheral blocking of beta-receptors on the reduced beta-adrenergic responsiveness in hypothyroid states. These mechanisms bear no actual relation with thyroid hormone and the resulting myxoedema coma. A much better mechanism is the known peripheral monodiodenation blocking effect of the beta-blocking drugs on thyroid hormone.1 2 Specifically, we know that the blocking agents decrease the peripheral conversion of thyroxine to triiodothyronine. It has been shown that 70-800' of circulating triiodothyronine (the major intracellular thyroid hormone) is derived from thyroxine.2 Thyroxine is sometimes called a "pro-hormone" since a major function is the supply of triiodothyronine. The blocking of this reaction may result in severely reduced thyroid hormone levels. This case report clearly alerts us to the possibility of beta-blocking drugs severely depressing thyroid hormone production. Careful monitoring is essential.

London

PEGGYANN ZAENGER

Myxoedema coma induced by beta-adrenoceptor-blocking agent

SIR,-With reference to the case report "Myxoedema coma induced by beta-adrenoceptor-blocking agents" (21 August, p 543) I would like to make several points. I can think of two ways in which spontaneous recovery in this patient could be accounted for. Firstly, if the cause was not myxoedema coma. With regard to this the patient obviously had some signs of myxoedema-that is, dry skin and facial oedema-but this is not surprising in view of the history and subsequent blood results. Her respirations, however, were normal, temperature was not markedly reduced, and there was no significant bradycardia. A semiconscious state which recovered spontaneously in six hours could just as well be explained by acute self-poisoning or hypoxia secondary to cardiac failure as it was noted that she did have cardiomegaly and pulmonary congestion which resolved when the beta-blockers were stopped. The fact that the patient recovered without thyroxine also favours an alternative cause. The second possibility is that in some way the beta-blocker prevented the action of thyroxine. It is known that propranolol can convert free thyroxine to reverse triiodothyronine, which is an inactive compound. I see no reason why bufetalol should not do this as well. It is therefore possible that this action also occurred in this patient; hence the small amount of circulating thyroxine present was rendered

St Vincent's Medical Center, Jacksonville, Florida

'Brennan MD. Mayo Clin Proc 1980;5:33-44. 2 McDougall IR. J ClGn Pharmacol 1981;21:365-84.

Clostridium difficile in toxic megacolon SIR,-Dr Robin Bolton and Professor Alan Read (14 August, p 475) suggest that infection by Clostridium difficile may be a pathogenetic mechanism of toxic dilatation in inflammatory bowel disease. Certainly a prospective study looking for Cl difficile in such cases would be of immense value. It is, however, unfortunate that no comment was made on the fact that toxic dilatation can complicate pseudomembranous, antibiotic-associated, or Cl difficile colitis in the absence of inflammatory bowel disease. The association has been previously reported,' and, as described by Dr Bolton and Professor Read, the dilatation can subside after treatment with antibiotics such as metronidazole and vancomycin. In addition an equally important but littlerecognised fact is that toxic dilatation in Cl difficile colitis may not always respond to appropriate antibiotic therapy. For example, as a histopathologist, I have been concerned with three cases during the last 18 months of pseudomembranous colitis with toxic megacolon that failed to respond to appropriate antibiotic therapy. All three cases were antibiotic-associated and Cl difficile was isolated in two. One patient required colectomy and two died. One of the fatal cases