- Email: [email protected]
DIAGNOSIS OF HYPERPARATHYROIDISM
1048
deny that there are at least a few patients who remain seriously disturbed for weeks or months, despite electroconvulsion therapy and despite a good deal of attention from nurses and doctors, until insulin-coma treatment is started. If the improvement then occurs in an expected time relationship to the start of treatment, it is legitimate to conclude that the treatment causes the improvement. This is the most elementary and generally applicable criterion on which to assess the value of a treatment. It is surprising that Dr. Bourne should have neglected it, for, although it contains a judgment of probability, it is in many respects a better criterion, when applied to each case in turn, than are the remission-rates in relatively large and heterogeneous series of cases upon which Dr. Bourne relies. He should perhaps have taken warning from Dr. Eysenck’s strange experience, for a similar study of remission-rates in psychoneurosis led Dr. Eysenck to conclude that psychotherapy was
ineffective.’ Insulin-coma treatment does relatively little damage. That it has caused remission in a significant number of cases when other methods have failed justifies its use, although it has often disappointed. Its immediate effects are worth while, even should it be shown—as it has not yet been-that it is ineffective in the long ’
run.
Psychological Laboratory, Cambridge.
D. RUSSELL DAVIS.
RECURRENT PAROTITIS SIR,—Seven years ago I described 13 instances of this disease.2 My experience is almost identical with that noted in your annotation (Sept. 26). Rambam Government Hospital, Haifa, Israel.
WALTER FALK.
DIAGNOSIS OF HYPERPARATHYROIDISM
SIR,—Reviewing my book, Clinical your issue of Oct. 31, you say :
Endocri-rzology,
in
"... for the diagnosis of hyperparathyroidism the aspirant will need more explicit information than is here provided : surely we are not going to turn these problems over to another specialist, the chemical pathologist ? "
With regard to the first half of this sentence, an account of the disturbances of calcium and phosphorus metabolism in hyperparathyroidism has been given in detail and I should have thought could be understood by the intelligent reader, for whom the book was written. The second half of your statement is truly remarkable, since hyperparathyroidism cannot be diagnosed without the services of the chemical pathologist. Would you be so good as to inform us how you would arrive at the diagnosis without such assistance? St. Bartholomew’s Hospital, London, E.C.1.
A. W. SPENCE.
*** Dr. Spence says on p. 238 of his book, under the heading diagnosis, that " in hyperparathyroidism there .is always a negative balance of calcium." This is where his aspirant might be led into error. Bony changes may be absent in some severe cases of hyperparathyroidism, as Dr. Spence reminds us on p. 236 ; this suggests that In some patients maintain their stores of calcium well. fact, Dr. Spence’s references include an instance where the measured balance of calcium was indeed strongly positive The diagnosis as long as the intake of calcium was liberal. of hyperparathyroidism may require, among other things, estimation of the urinary excretion of calcium -
while the intake of calcium is low ; and the normal findings might also have been given. But the intelligent reader can of course find, under the heading metabolic disturbances on p. 237, that " the urinary excretion of both [calcium and phosphorus] is increased, even when 1. Eysenck, H. J. Quart. Bull. Brit. psychol. Soc. 1952, 3, 41. 2. Harefuah, 1946, 31, 97.
the intake of calcium and phosphorus is low." He might not, however, realise that this was a condition for hi test. The physician knows what radiographs to ask for and In the same way. can usually interpret the findings. when lie is a clinical endocrinologist he can conduct his own investigations, though he may be ignorant of the chemical techniques ; and he can interpret the laboratory results. This is clearly also Dr. Spence’s view, since he gives detailed instructions for conducting, for example. the Kepler test. ()f course these tests cannot be done without the services of a laboratory, nor indeed was this suggested. Some of the best work in clinical endocrino. logy is being done by chemical pathologists ; their opinion, when available, is valued, but with few exception they do not look after the patient.-ED. L. ISOLATION OF PSYCHIATRIC HOSPITALS your annotation of Oct. 3 (p. 716) you referto the isolation of psychiatric hospitals and the need for an association—embracing all psychiatric hospitals in the country—that would provide a means for regular inter. change of ideas.
SIR,—In
It may interest your readers that in Surrey an Inter. Association was founded just over two years ago which locally fulfils this function. The hospitals forming the association are: Banstead, Belmont, Cane Hill, Horton, Long Grove, The Manor. Netherne, St. Ebba’s, West Park, and the Group
hospital Psychiatric
Laboratory. The
association holds regular clinical meeting. each member-hospital in rotation, at which cases from the hospital are presented and papers readbv members of its staff. The success of the meetings in the first two years has brought forth a desire for a further strengthening of clinical links between the hospital, Recently intramural clinical conferences have beeu to the staffs of all the member-hospitalsot thrown the association. General practitioners from the area aud the staff of neighbouring general hospitals attend the association’s meetings.
orgaiiised by
open
-NVe feel that there is an advantage in keepingan association of this kind within the bounds of not too large an area. JOSEPH ZELMANOWITS West Park Hospital, Hon. secretary, Surrey Inter-hospital Epsom, Surrey.
Psychiatric Association.
GOUT
SIR,—As advocate of " interval " salicylate therapy in the treatment of gout,l I was naturally interested ?iu Dr. Marson’s paper2 on the continuous salicylate treat. ment of the disease to which your leading article of Oct. 31 refers. As interval therapy now is under criticism, may I say that it was suggested at a time when salicylate therapy took second place to the more toxic drug, einchopheil, because given in this way sodium salicylate causeda better uric-acid excretion without toxic effects. It wa; admittedly a compromise and not a complete answer to the problem of the therapy of chronic gout; nor appa, rently is continuous salicylate therapy, which still allows fluctuations in the serum-uric-acid level and occasional attacks of acute gout, and is not always practicable because of salicylism. While I shall certainly try ? Marson’s method, I was disappointed to find hin apparently dismissing the interval therapy on the result of only one case, thrice tested for three days out of serel with salicylates, which showed moderate and symptomless rises in serum-uric acid in the therapy intervals The method has, after all, been tried and found caluab!C Rep. chron. rheum. Dis. 1937, 3, 106. 2. Marson, F. G. W. Quart. J. Med. 1953, 1.
3, 331.
deny that there are at least a few patients who remain seriously disturbed for weeks or months, despite electroconvulsion therapy and despite a good deal of attention from nurses and doctors, until insulin-coma treatment is started. If the improvement then occurs in an expected time relationship to the start of treatment, it is legitimate to conclude that the treatment causes the improvement. This is the most elementary and generally applicable criterion on which to assess the value of a treatment. It is surprising that Dr. Bourne should have neglected it, for, although it contains a judgment of probability, it is in many respects a better criterion, when applied to each case in turn, than are the remission-rates in relatively large and heterogeneous series of cases upon which Dr. Bourne relies. He should perhaps have taken warning from Dr. Eysenck’s strange experience, for a similar study of remission-rates in psychoneurosis led Dr. Eysenck to conclude that psychotherapy was
ineffective.’ Insulin-coma treatment does relatively little damage. That it has caused remission in a significant number of cases when other methods have failed justifies its use, although it has often disappointed. Its immediate effects are worth while, even should it be shown—as it has not yet been-that it is ineffective in the long ’
run.
Psychological Laboratory, Cambridge.
D. RUSSELL DAVIS.
RECURRENT PAROTITIS SIR,—Seven years ago I described 13 instances of this disease.2 My experience is almost identical with that noted in your annotation (Sept. 26). Rambam Government Hospital, Haifa, Israel.
WALTER FALK.
DIAGNOSIS OF HYPERPARATHYROIDISM
SIR,—Reviewing my book, Clinical your issue of Oct. 31, you say :
Endocri-rzology,
in
"... for the diagnosis of hyperparathyroidism the aspirant will need more explicit information than is here provided : surely we are not going to turn these problems over to another specialist, the chemical pathologist ? "
With regard to the first half of this sentence, an account of the disturbances of calcium and phosphorus metabolism in hyperparathyroidism has been given in detail and I should have thought could be understood by the intelligent reader, for whom the book was written. The second half of your statement is truly remarkable, since hyperparathyroidism cannot be diagnosed without the services of the chemical pathologist. Would you be so good as to inform us how you would arrive at the diagnosis without such assistance? St. Bartholomew’s Hospital, London, E.C.1.
A. W. SPENCE.
*** Dr. Spence says on p. 238 of his book, under the heading diagnosis, that " in hyperparathyroidism there .is always a negative balance of calcium." This is where his aspirant might be led into error. Bony changes may be absent in some severe cases of hyperparathyroidism, as Dr. Spence reminds us on p. 236 ; this suggests that In some patients maintain their stores of calcium well. fact, Dr. Spence’s references include an instance where the measured balance of calcium was indeed strongly positive The diagnosis as long as the intake of calcium was liberal. of hyperparathyroidism may require, among other things, estimation of the urinary excretion of calcium -
while the intake of calcium is low ; and the normal findings might also have been given. But the intelligent reader can of course find, under the heading metabolic disturbances on p. 237, that " the urinary excretion of both [calcium and phosphorus] is increased, even when 1. Eysenck, H. J. Quart. Bull. Brit. psychol. Soc. 1952, 3, 41. 2. Harefuah, 1946, 31, 97.
the intake of calcium and phosphorus is low." He might not, however, realise that this was a condition for hi test. The physician knows what radiographs to ask for and In the same way. can usually interpret the findings. when lie is a clinical endocrinologist he can conduct his own investigations, though he may be ignorant of the chemical techniques ; and he can interpret the laboratory results. This is clearly also Dr. Spence’s view, since he gives detailed instructions for conducting, for example. the Kepler test. ()f course these tests cannot be done without the services of a laboratory, nor indeed was this suggested. Some of the best work in clinical endocrino. logy is being done by chemical pathologists ; their opinion, when available, is valued, but with few exception they do not look after the patient.-ED. L. ISOLATION OF PSYCHIATRIC HOSPITALS your annotation of Oct. 3 (p. 716) you referto the isolation of psychiatric hospitals and the need for an association—embracing all psychiatric hospitals in the country—that would provide a means for regular inter. change of ideas.
SIR,—In
It may interest your readers that in Surrey an Inter. Association was founded just over two years ago which locally fulfils this function. The hospitals forming the association are: Banstead, Belmont, Cane Hill, Horton, Long Grove, The Manor. Netherne, St. Ebba’s, West Park, and the Group
hospital Psychiatric
Laboratory. The
association holds regular clinical meeting. each member-hospital in rotation, at which cases from the hospital are presented and papers readbv members of its staff. The success of the meetings in the first two years has brought forth a desire for a further strengthening of clinical links between the hospital, Recently intramural clinical conferences have beeu to the staffs of all the member-hospitalsot thrown the association. General practitioners from the area aud the staff of neighbouring general hospitals attend the association’s meetings.
orgaiiised by
open
-NVe feel that there is an advantage in keepingan association of this kind within the bounds of not too large an area. JOSEPH ZELMANOWITS West Park Hospital, Hon. secretary, Surrey Inter-hospital Epsom, Surrey.
Psychiatric Association.
GOUT
SIR,—As advocate of " interval " salicylate therapy in the treatment of gout,l I was naturally interested ?iu Dr. Marson’s paper2 on the continuous salicylate treat. ment of the disease to which your leading article of Oct. 31 refers. As interval therapy now is under criticism, may I say that it was suggested at a time when salicylate therapy took second place to the more toxic drug, einchopheil, because given in this way sodium salicylate causeda better uric-acid excretion without toxic effects. It wa; admittedly a compromise and not a complete answer to the problem of the therapy of chronic gout; nor appa, rently is continuous salicylate therapy, which still allows fluctuations in the serum-uric-acid level and occasional attacks of acute gout, and is not always practicable because of salicylism. While I shall certainly try ? Marson’s method, I was disappointed to find hin apparently dismissing the interval therapy on the result of only one case, thrice tested for three days out of serel with salicylates, which showed moderate and symptomless rises in serum-uric acid in the therapy intervals The method has, after all, been tried and found caluab!C Rep. chron. rheum. Dis. 1937, 3, 106. 2. Marson, F. G. W. Quart. J. Med. 1953, 1.
3, 331.