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ACQUIRED TOXOPLASMOSIS
369 in the offcial Scientific Film Catalogue), and ,publishes quarterly the British Journal of Medical Hypnotism. Psychiatrists who wish to learn hypnotherapy can easily do so, provided they are prepared to undergo a proper course of training. Modern hypnotherapy does not consist in removing symptoms only by inducing a deep trance and saying " Now you are well," as many people still seem to think. The experimental and clinical literature is too vast for there to be any legitimate controversy as to the value of hypnotherapy. The only people who doubt its value are those who apparently think in terms of Mesmer, and, ostrich-like, refuse to acknowledge that there could be anv advance in the subiect. S. J. VAN PELT President,
London, W.1.
British
Society
of Medical
Hypnotists.
ACQUIRED TOXOPLASMOSIS
Srn,ņThe interesting article by
Dr. Skipper and his in your issue of Feb. 6 is a most valuable contribution to the clinical aspects of toxoplasmosis. I should like to draw attention to a review of reported cases of acquired toxoplasma meningo-encephalitis in childhood, published1 in 1951, which has possibly escaped your notice and that of Dr. Skipper and his colleagues. This review included the cases reported by Sabin2 and Robinson3 in which toxoplasma was isolated from the cerebrospinal fluid during the illness or from the brain at necropsy. A further case, considered to be one of acquired toxoplasma meningo-encephalitis in a London schoolboy, was also reported; the diagnosis was not confirmed by the isolation of the organism, but it was suggested by the clinical similarity to established cases and by positive complement-fixation and skin tests. It is important, therefore, in childhood, when meningoencephalitis and/or a glandular-fever-like illness occur (glandular fever and the more common causes of meningoencephalitis being excluded), that the possibility of toxoplasmosis should be carefully considered. O. D. FISHER. Belfast.
colleagues
BRONCHOGRAPHY WITH DIONOSIL
SiR,-We have read with interest your annotation (Dec. 26) on this subject and the subsequent correspondence (Jan. 16). have done some 500 bronchoOily.’ We agree with Colonel Mackay-Dick (Jan. 16) that dionosil oily is entirely non-irritant, and we have found it suitable for bronchography by any method, both in children and in adults. We have invariably used the cricothyroid route for bronchography in adults ; and for at least six years we have given only skin anaesthesia whether using iodised oil or dionosil oily. We do not use an aqueous suspension of dionosil because we have found this unsuitable without more widespread anaesthesia. It is, of course, the water, and not the dionosil, which is so irritant. In our view, with the increase in strength from 50 to 60% this substance is comparable radiographically with the iodised oils. We feel that its use has striking advantages over iodised oil, and there are no apparent disadvantages. It is more easy to administer, it remains in the bronchi long enough for any radiographic requirements, and yet in most cases it has cleared within twenty-four hours. Even more helpful is the absence, so far, of any immediate or delayed complication from
In the past two years grams withDionosil
we
bronchography.
As we have already noted,4 there are occasionally rather severe delayed reactions after the use of iodised oil; and it is advisable to keep patients under observation for ten days after bronchography. This period of 1. Gt Ormond St J. 1951, 1, 43. J. Amer. med. Ass. 1941, 116, 801. Ann. pœdiat. 1947, 168, 134. 4. Robertson, P. W., Morle, K. D. F. Lancet, 1951, i, 387.
2. Sabin, A. B. 3. Robinson, P.
observation is not necessary with dionosil, which is thus much more suitable for large numbers of cases (many of the patients may have travelled long distances for the
investigation). In view of its many obvious advantages, we now use 60% dionosil oily exclusively, both in children and in adults, and in tuberculous and non-tuberculous cases. Royal Air Force Hospital, West Kirby, Cheshire.
K. D. FORGAN MORLE PHILIP W. ROBERTSON.
CONTROL OF CANCER MORTALITY
SiR,ņThere is much to agree with in Professor McKinnon’s article in your issue of Jan. 30. He examines the accumulated findings of thousands of doctors, as expressed in death certificates for breast cancer, and finds evidence which confirms the observation made by many of them that the character of a tumour has a greater influence on prognosis than the type of treatment. He adds weight to the point which many of us have made, that variations in published survival-rates for breast cancer are usually due more to variation in the selection of the material reported than to differences in the treatment given, and that there is no sound basis for many of the claims to virtue put forward for special treatment techniques. He also maintains that decreasing survival-rates with increasing delay in applying treatment have not yet provided conclusiveevidence of any advantage in early treatment. In this study, however, he believes that he has examined " all that has been advanced as showing superiority of early or otherwise different treatment in preventing death," and concludes that neither education, earlier diagnosis, nor improvements in treatment have been of any value. This is a one-sided view. The picture of an individual human problem can never be seen in full or appreciated for its worth through collected mortality figures alone. Professor McKinnon is rightly critical of much that doctors write on patients’ notes and pathological reports and then misuse to support their claims, but he does not carry this criticism to the things they write on the death certificates which form his very raw material. He fails to find evidence in mortality figures that early or extensive treatment can prevent or postpone death from breast cancer. There is evidence to be found, however, in any large
treatment centre ; it is quite usual in these clinics to see women treated several years before for rapidly growing breast cancer. One of those I saw this week was treated 5 years ago for massive involvement of both breasts, both axillse, and one supraclavicular fossa. Her death has, in my opinion, been postponed; I think the evidence for this is good. We cannot prevent her death ; we all die. If she is now run over by a bus or dies of heart-disease, her death from breast cancer will have been prevented. If a bus is responsible she will probably not appear in the breast cancer mortality figures, but if it is her heart she probably will. Professor McKinnon believes that his failure to find evidence in mortality figures to convince him that results improve with early diagnosis is due to the fact that there is no such improvement because " in most, if not in all, lethal breast cancer, remote spread takes place via the blood stream before interference is practicable." I think there are other reasons, but if he is right and early spread is the only trouble then surely this is the best possible argument for still earlier diagnosis. His writings, for all their sensible insistence that we look at the facts, give me the uncomfortable feeling that if we did succeed in making a little further progress, slight extensions of the use of the words " lethal " and " major would be brought into play to show that all our efforts were still in vain. Cancer of the larynx is neither major " nor " lethal," but it kills the patients if they "
"
1. Smithers, D. W.
Lancet, 1952, ii, 1136.
London, W.1.
British
Society
of Medical
Hypnotists.
ACQUIRED TOXOPLASMOSIS
Srn,ņThe interesting article by
Dr. Skipper and his in your issue of Feb. 6 is a most valuable contribution to the clinical aspects of toxoplasmosis. I should like to draw attention to a review of reported cases of acquired toxoplasma meningo-encephalitis in childhood, published1 in 1951, which has possibly escaped your notice and that of Dr. Skipper and his colleagues. This review included the cases reported by Sabin2 and Robinson3 in which toxoplasma was isolated from the cerebrospinal fluid during the illness or from the brain at necropsy. A further case, considered to be one of acquired toxoplasma meningo-encephalitis in a London schoolboy, was also reported; the diagnosis was not confirmed by the isolation of the organism, but it was suggested by the clinical similarity to established cases and by positive complement-fixation and skin tests. It is important, therefore, in childhood, when meningoencephalitis and/or a glandular-fever-like illness occur (glandular fever and the more common causes of meningoencephalitis being excluded), that the possibility of toxoplasmosis should be carefully considered. O. D. FISHER. Belfast.
colleagues
BRONCHOGRAPHY WITH DIONOSIL
SiR,-We have read with interest your annotation (Dec. 26) on this subject and the subsequent correspondence (Jan. 16). have done some 500 bronchoOily.’ We agree with Colonel Mackay-Dick (Jan. 16) that dionosil oily is entirely non-irritant, and we have found it suitable for bronchography by any method, both in children and in adults. We have invariably used the cricothyroid route for bronchography in adults ; and for at least six years we have given only skin anaesthesia whether using iodised oil or dionosil oily. We do not use an aqueous suspension of dionosil because we have found this unsuitable without more widespread anaesthesia. It is, of course, the water, and not the dionosil, which is so irritant. In our view, with the increase in strength from 50 to 60% this substance is comparable radiographically with the iodised oils. We feel that its use has striking advantages over iodised oil, and there are no apparent disadvantages. It is more easy to administer, it remains in the bronchi long enough for any radiographic requirements, and yet in most cases it has cleared within twenty-four hours. Even more helpful is the absence, so far, of any immediate or delayed complication from
In the past two years grams withDionosil
we
bronchography.
As we have already noted,4 there are occasionally rather severe delayed reactions after the use of iodised oil; and it is advisable to keep patients under observation for ten days after bronchography. This period of 1. Gt Ormond St J. 1951, 1, 43. J. Amer. med. Ass. 1941, 116, 801. Ann. pœdiat. 1947, 168, 134. 4. Robertson, P. W., Morle, K. D. F. Lancet, 1951, i, 387.
2. Sabin, A. B. 3. Robinson, P.
observation is not necessary with dionosil, which is thus much more suitable for large numbers of cases (many of the patients may have travelled long distances for the
investigation). In view of its many obvious advantages, we now use 60% dionosil oily exclusively, both in children and in adults, and in tuberculous and non-tuberculous cases. Royal Air Force Hospital, West Kirby, Cheshire.
K. D. FORGAN MORLE PHILIP W. ROBERTSON.
CONTROL OF CANCER MORTALITY
SiR,ņThere is much to agree with in Professor McKinnon’s article in your issue of Jan. 30. He examines the accumulated findings of thousands of doctors, as expressed in death certificates for breast cancer, and finds evidence which confirms the observation made by many of them that the character of a tumour has a greater influence on prognosis than the type of treatment. He adds weight to the point which many of us have made, that variations in published survival-rates for breast cancer are usually due more to variation in the selection of the material reported than to differences in the treatment given, and that there is no sound basis for many of the claims to virtue put forward for special treatment techniques. He also maintains that decreasing survival-rates with increasing delay in applying treatment have not yet provided conclusiveevidence of any advantage in early treatment. In this study, however, he believes that he has examined " all that has been advanced as showing superiority of early or otherwise different treatment in preventing death," and concludes that neither education, earlier diagnosis, nor improvements in treatment have been of any value. This is a one-sided view. The picture of an individual human problem can never be seen in full or appreciated for its worth through collected mortality figures alone. Professor McKinnon is rightly critical of much that doctors write on patients’ notes and pathological reports and then misuse to support their claims, but he does not carry this criticism to the things they write on the death certificates which form his very raw material. He fails to find evidence in mortality figures that early or extensive treatment can prevent or postpone death from breast cancer. There is evidence to be found, however, in any large
treatment centre ; it is quite usual in these clinics to see women treated several years before for rapidly growing breast cancer. One of those I saw this week was treated 5 years ago for massive involvement of both breasts, both axillse, and one supraclavicular fossa. Her death has, in my opinion, been postponed; I think the evidence for this is good. We cannot prevent her death ; we all die. If she is now run over by a bus or dies of heart-disease, her death from breast cancer will have been prevented. If a bus is responsible she will probably not appear in the breast cancer mortality figures, but if it is her heart she probably will. Professor McKinnon believes that his failure to find evidence in mortality figures to convince him that results improve with early diagnosis is due to the fact that there is no such improvement because " in most, if not in all, lethal breast cancer, remote spread takes place via the blood stream before interference is practicable." I think there are other reasons, but if he is right and early spread is the only trouble then surely this is the best possible argument for still earlier diagnosis. His writings, for all their sensible insistence that we look at the facts, give me the uncomfortable feeling that if we did succeed in making a little further progress, slight extensions of the use of the words " lethal " and " major would be brought into play to show that all our efforts were still in vain. Cancer of the larynx is neither major " nor " lethal," but it kills the patients if they "
"
1. Smithers, D. W.
Lancet, 1952, ii, 1136.