POST-STARVATION GYNÆCOMASTIA

1021 that the afferent path of the hiccup reflex is the via vagus, and the combined vagolytic effects of flaxedil, pethidine, and hexamethonium prevent its occurrence." Dr. McGillhas reported dramatic response of a patient with intractable hiccup to hexamethonium - which may be a vagal hint from a conscious subject. G. E. MOLONEY. MOLONE?. Radcliffe Infirmary, Oxford.

impression

.

ARTERIAL

GRAFTS "

SIR,—Even the concept of what is living " is elastic and ill-defined. In an annotation2 you state that arterial

crafts

" die " and become inert tubes which

are

soon

lined by intima from the host. You add that important elastic fibres persist and that the graft functions perfectly. In 1949, in collaboration with Dr. 0. Croxatto,3 I studied in dogs thoracic aortas that had been grafted for more than one year ; and we concluded that part of the graft could be considered " alive." Our main reason for this conclusion was that the elastic layer had degenerated only in the external third, while in the zones that were near the lumen of the aorta, from which the necessary elements had diffused, the elastic tissue retained its normal characteristics. Furthermore, isolated foci of necrosis were observed which made the normal aspect of the rest of the graft more noticeable. Naturally elastic fibres are not " living " cells ; but, being susceptible to degeneration and necrosis, their normal appearance one year after the operation justified the assumption that the graft was not " dead." In respect of the fate of cellular grafts, we have found that in homografted dog lungs, epithelial cells were well preserved 20 days after grafting. We were unable to obtain survival for more than 24 days.4 ALFREDO LANARI. Buenos Aims. Argentine. POST-STARVATION GYNÆCOMASTIA SIR,—In -connection with your annotation of March 22, I should like to mention that during the occupation of Greece by the Italians in 1942-43 I was held as prisoner ; and, since I served as a physician to the prisoners, I observed several cases of gynæcomastia in younger people when the food ration was improved in 1943. The patients presented the clinical features described by Musselman 5—"disc-like swellings in the subareolar I classified this as gynaecomastia of breast-tissue." " re-adolescent " type. You rightly accept " post-starvation gynaecomastia " as a distinct entity, and the explanation of it may be as follows : starvation activity of the hypophysis-testis axis diminishes owing to lack of proper amino-acids and/or vitamins (B complex, E). When these factors are again supplied the activity of the endocrine system, and especially the hypophysis, increases, with augmented secretion of gonadotropin and prolactin, causing the same effect as in adolescence. There is firstly stimulation of the breast-tissue with gynaecomastia, and secondly stimulation of the testis with increased production of androgens. This increase of androgens inhibits hormonal secretion by the hypophysis and restores normal function of the hypophysis-testis axis. This probably causes the disappearance of the gynsecomastia ; but we also have to consider the fact that androgens have a direct effect on the

During

breast-tissue. This opinion is supported by another clinicalobservation : that starvation was the main cause of secondary amenorrhcea in many women (previously with normal menstruation) during the starvation of occupied countries, and especially in Athens. Improvement of the food ration restored normal menses in all these women without any special hormonal treatment. L. G. POLYMENAKOS. Toronto, Ontario, Canada. 1. McGill, R. J. Lancet, 1951, i, 1018. 2. Lancet, 1951, ii, 1025. 3. Medicina, B. Aires, 1949, 9, 397. 4. Lanari, A., Molins, M., Croxatto, O. Ibid, 1951, 11, 12. 5. Musselman, M. M. War. Med. 1945, 8, 325.

VARICOSE ULCERS April 5 is both

timely and This neglected scrap-heap of surgery deserves more attention. Varicose ulceration causes much physical suffering and ill health, very much incapacity, and a very great economic loss of working hours-probably far more than fractures. Nevertheless fractures have now acquired special departments and specialised rightly orthopaedic treatment, thanks largely to Watson-Jones and McMurray. But the poor ulcer is still haphazardly dealt with by whomsoever cares to deal with it-newly SIR,—Your

annotation of

wise.

qualified house-surgeon, registrar, surgeon, dermatologist. A regular clinic is vitally required in each centrein charge of someone gifted with enlightened enthusiasm who ’will study the whole gamut of varicose conditions, and who will see to it that his staff of assistants and sisters and nurses are not for ever changing. There is no one cure for any type of ulcer. Each case must be studied. The director of the clinic will cure nearly all cases by means of the varied techniques, " dodges," remedies, and methods born of his experience. The real and only problem is the waterlogged dropsical Firm compressive bandaging of some kind -or leg. another, applied with the proper technique, is the answer to nearly all cases. Once cured (or healed) those legs need support always-either bandage or stocking. I tell the old ladies that their legs also need their own special supportive corsets-even as their bulging abdomens permanently need their own type of corset. The longer that I work in my clinic with its 100 cases. weekly-I have done this now for twenty-five yearsthe more do I realise the truth of the foregoing statements ; and the more do I realise that surgery is not very often indicated. The prevention of ulceration consists only very partially in dealing with varicose veins-because most cases of superficial varicosities do not lead on to ulceration. Mr. Partridge (April 19) raises one important point-about deep-seated varicosity and deep-seated Real prethrombi altering the course of circulation. vention lies in the maintenance of good healthpreventing obesity, avoiding tight garters, lessening the hours of standing, attending to women’s correct footwear, &c. This, surely, is the opportunity for us all alike-the family medical adviser, the houseman, the physician, and the surgeon, who should always also be a

good physician. Liverpool.

STUART MCAUSLAND. McAuSLAND.

SIR,—I have read with interest your annotation and the subsequent correspondence. I would strongly endorse the need for a combined dermatological and surgical approach to this problem, and would go further and plead for a general consideration of the patient as well as his visible local lesion. My interest in this condition has been stimulated by investigations that I have been making into the aminoacid content of the exudate of crural ulcers, following up German work on the effect of glycocoll on the healing of ulcerated surfaces.1 I have found that the amino-acid content of the exudate from a varicose ulcer is very different from that of normal serum. As. the ulcer heals the amino-acid pattern approaches that of normal serum. By applying a suitable dressing containing amino-acids the ulcer can be made to heal in a few weeks-but unless the underlying cause is eliminated, the ulcer will relapse. DAVID HALER. London, NV.1. SIR,—From Mr. Willson-Pepper’s letter last week it seem that I did not make myself clear regarding the cause of leg ulcers in my series (April 26). In 10.4%

would

it was the cause of failure of the leg-muscle pump and not the cause of ulceration which was doubtful. 1. Fargel, H. Munch. med. Wschr. 1951, 93, 602.