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RIGHT TO DIE
1319 HBO 200 light source, BG 12 excitor filter, a 530 nm. barrier filter, and an oil objective. 1000 spermatozoa were counted, and of these approximately 70% contained one F-body, approximately 5% contained two F-bodies, and the rest contained no obvious F-bodies. When two F-bodies were present they appeared as distinct fluorescent spots which tended to line up in the longitudinal axis of the sperm head. Usually, one of the two was brighter; this perhaps was due to their relative depth within the sperm head. The size of the F-bodies within a sperm head were approximately equal. They were located relatively close together, but they did not appear contiguous. A typical sperm with two F-bodies is shown in the accompanying figure. Since no technique is at present available for selectively staining the X chromosome in sperm, we cannot be certain of the percentage carrying the XY chromosomal complement. These are probably represented in the group containing one F-body. The finding of a small but significant number of sperm possessing two F-bodies raises the question of whether another explanation of the sex ratio in the progeny of XYY males should be invoked. Rather than considering the meiotic stage as providing an elimination mechanism, perhaps the selectivity lies in the sperm’s journey to the egg, and in the sperm’s " fitness to get there first. This work was
supported by a grant from the Ford Foundation.
Department of Obstetrics and
Gynecology, Yale University School of Medicine, New Haven, Connecticut.
ROBERT B. DIASIO ROBERT H. GLASS.
RIGHT TO DIE
SIR,-The argument about the so-called right to die is most confusing. In my opinion, Dr. D. W. Vere (Nov. 28, p. 1132) used the terms options and rights correctly, helping us to distinguish two different meanings in the cliche, the to die. I am therefore unable to agree with the criticisms of Dr. S. L. Henderson Smith (Dec. 12, p. 1249). i The term right has overtones of social and ethical approval; option is a neutral term for choice of matters which meet with approval or disapproval. Rights refer to general principles; options refer to particular choices in a certain set of circumstances. As chairman of a special panel of the Board of Science and Education of the British Medical Association on euthanasia (whose report has been accepted by the B.M.A. Council and will be published early next year) I read the literature put out by the Euthanasia Society. The term right to die means different things to different people. Your original editorial (Oct. 31, p. 915) states the difficulties encountered in the clinical decisions that are made in terminal illness, and the letter by F.R.C.P. (Oct. 31, p. 926) summarises well the reactions and fears of relatives. In my opinion, circumstances are so varied that the question of euthanasia does not lend itself to legislation. An intelligent discussion is needed both within the profession and among the general public, many of whom are poorly informed concerning the medical aspects. Clearly defined terms and concepts are essential. I hope that our report will aid discussion of a difficult subject. Some eminent members of our profession consider that the doctors can stand right outside this debate and the proposed procedure of euthanasia, leaving the matter entirely to the general public and legislature. Against this point of view there are three weighty objections. Firstly, the medical profession alone can tell the public what medical issues are involved in dying. Secondly, if legislation were enacted to make it permissible to terminate the life of a
right
person
suffering from an incurable, painful, physical illness, certify these
then it would be the doctors alone who could
Thirdly, all proposed legislation in Britain has envisaged the active cooperation of a fair proportion of the medical profession in performing euthanasia. So we, as a learned profession, cannot opt out of our right to practise medicine in the interests of our patients, due consideration being given to the views of the relatives.
facts.
The
trust
that all concerned
place
in
Fordingbridge,
us
is fundamental. HUGH TROWELL.
Hants.
FAMILIAL MACROCYTOSIS
SIR,-Familial macrocytosis is seen in a number of diseases, such as familial juvenile pernicious orotic-aciduria2 and familial megaloblastic anaemia, anxmia with proteinuria.3,4 In this department we have
well-defined
found macrocytes in smears of ear-blood from 3 brothers without being able to demonstrate any of the usual causes of macrocytosis. In the oldest brother (born 1899) macrocytes were observed for the first time in 1960 and several times in subsequent years; in the second brother (born 1900) macrocytes have been demonstrated since 1962; and in the youngest (born 1903) they were noted in 1968. Another 3 siblings and 3 children of the brothers have been investigated without similar findings. The peripheral-blood picture in all 3 brothers is the same, showing orthochromia and mild anisocytosis without any striking schizocytosis or
poikilocytosis. Hamoglobin (g./100 mI.) Case1 Case 2 3 Case
14-4 15-2 14-2 2
M. C. V. 7 92-7 105-8 105-8
M.C.H.C. 32-0 31-0 31-5 5
Scattered macrocytes are present, up to 2-3 per high-power field. The macrocytes are well saturated, some round, some oval. In all 3 brothers the white-cell count is normal, and so is the differential. There is no hypersegmentation; platelet-count is normal; and ocular micrometry and photomicrography shows that 1-4—1-8% of the red-cells have a diameter exceeding 10 . Sternal marrows were normal in all 3, showing occasional macroblasts. A bone-biopsy specimen from case 1 showed no evidence of myelofibrosis. None of the brothers is anxmic or ever has been. There are no indications that the macrocytosis is due to B12 or folic-acid deficiency. Serum-B’2 (ng./ml.)
Case 1 220 7-7 240 15-21
Case 2 300
Case 3 140-210 5-4 180 24
7-7 Serum-folic acid (ng./ml.) 120 Red-cell folic acid (ng./ml.) 21 Schillings test (%/24 hr.) has been demonstrated not Haemolysis by reticulocyteThe livercounts, serum-bilirubin, and haptoglobin. function tests (S.G.O.T., prothrombin-proconvertin time, alkaline phosphatase, protein electrophoresis, and serumbilirubin) are normal. Cholesterol and triglyceride values are also normal, as is the ratio of free to esterified cholesterol. Clinically the brothers are euthyroid and the values for protein-bound iodine and reflex-time are normal. The urinary excretion of orotic acid and of methylmaleic acid was measured and found normal in case 2. Haemoglobin electrophoresis is normal in all 3. All have the same ABO and Rh blood-group. It is worth mentioning that all showed borderline or slightly raised values of serumcreatine phosphokinase. (They have no signs of muscle disease.) There is no hepatomegaly or splenomegaly, and the radiographic appearances of the spleen are normal. 1. Waters, A. H., Murphy, M. E. B. Br. J. Hæmat. 1963, 9, 1. 2. Huguley, C. M., Bain, J. A. in The Metabolic Basis of Inherited Disease (edited by J. B. Stanbury, J. B. Wyngaarden, and D. S. Frederickson); p. 776. New York, 1960. 3. Jacobi, H., Heimpel, H., Cremer, H. J. Med. Wschr. 1967, 92, 1853. 4. Imerslund, O. Acta pœdiat. scand. 1960, 49, suppl. 119.
supported by a grant from the Ford Foundation.
Department of Obstetrics and
Gynecology, Yale University School of Medicine, New Haven, Connecticut.
ROBERT B. DIASIO ROBERT H. GLASS.
RIGHT TO DIE
SIR,-The argument about the so-called right to die is most confusing. In my opinion, Dr. D. W. Vere (Nov. 28, p. 1132) used the terms options and rights correctly, helping us to distinguish two different meanings in the cliche, the to die. I am therefore unable to agree with the criticisms of Dr. S. L. Henderson Smith (Dec. 12, p. 1249). i The term right has overtones of social and ethical approval; option is a neutral term for choice of matters which meet with approval or disapproval. Rights refer to general principles; options refer to particular choices in a certain set of circumstances. As chairman of a special panel of the Board of Science and Education of the British Medical Association on euthanasia (whose report has been accepted by the B.M.A. Council and will be published early next year) I read the literature put out by the Euthanasia Society. The term right to die means different things to different people. Your original editorial (Oct. 31, p. 915) states the difficulties encountered in the clinical decisions that are made in terminal illness, and the letter by F.R.C.P. (Oct. 31, p. 926) summarises well the reactions and fears of relatives. In my opinion, circumstances are so varied that the question of euthanasia does not lend itself to legislation. An intelligent discussion is needed both within the profession and among the general public, many of whom are poorly informed concerning the medical aspects. Clearly defined terms and concepts are essential. I hope that our report will aid discussion of a difficult subject. Some eminent members of our profession consider that the doctors can stand right outside this debate and the proposed procedure of euthanasia, leaving the matter entirely to the general public and legislature. Against this point of view there are three weighty objections. Firstly, the medical profession alone can tell the public what medical issues are involved in dying. Secondly, if legislation were enacted to make it permissible to terminate the life of a
right
person
suffering from an incurable, painful, physical illness, certify these
then it would be the doctors alone who could
Thirdly, all proposed legislation in Britain has envisaged the active cooperation of a fair proportion of the medical profession in performing euthanasia. So we, as a learned profession, cannot opt out of our right to practise medicine in the interests of our patients, due consideration being given to the views of the relatives.
facts.
The
trust
that all concerned
place
in
Fordingbridge,
us
is fundamental. HUGH TROWELL.
Hants.
FAMILIAL MACROCYTOSIS
SIR,-Familial macrocytosis is seen in a number of diseases, such as familial juvenile pernicious orotic-aciduria2 and familial megaloblastic anaemia, anxmia with proteinuria.3,4 In this department we have
well-defined
found macrocytes in smears of ear-blood from 3 brothers without being able to demonstrate any of the usual causes of macrocytosis. In the oldest brother (born 1899) macrocytes were observed for the first time in 1960 and several times in subsequent years; in the second brother (born 1900) macrocytes have been demonstrated since 1962; and in the youngest (born 1903) they were noted in 1968. Another 3 siblings and 3 children of the brothers have been investigated without similar findings. The peripheral-blood picture in all 3 brothers is the same, showing orthochromia and mild anisocytosis without any striking schizocytosis or
poikilocytosis. Hamoglobin (g./100 mI.) Case1 Case 2 3 Case
14-4 15-2 14-2 2
M. C. V. 7 92-7 105-8 105-8
M.C.H.C. 32-0 31-0 31-5 5
Scattered macrocytes are present, up to 2-3 per high-power field. The macrocytes are well saturated, some round, some oval. In all 3 brothers the white-cell count is normal, and so is the differential. There is no hypersegmentation; platelet-count is normal; and ocular micrometry and photomicrography shows that 1-4—1-8% of the red-cells have a diameter exceeding 10 . Sternal marrows were normal in all 3, showing occasional macroblasts. A bone-biopsy specimen from case 1 showed no evidence of myelofibrosis. None of the brothers is anxmic or ever has been. There are no indications that the macrocytosis is due to B12 or folic-acid deficiency. Serum-B’2 (ng./ml.)
Case 1 220 7-7 240 15-21
Case 2 300
Case 3 140-210 5-4 180 24
7-7 Serum-folic acid (ng./ml.) 120 Red-cell folic acid (ng./ml.) 21 Schillings test (%/24 hr.) has been demonstrated not Haemolysis by reticulocyteThe livercounts, serum-bilirubin, and haptoglobin. function tests (S.G.O.T., prothrombin-proconvertin time, alkaline phosphatase, protein electrophoresis, and serumbilirubin) are normal. Cholesterol and triglyceride values are also normal, as is the ratio of free to esterified cholesterol. Clinically the brothers are euthyroid and the values for protein-bound iodine and reflex-time are normal. The urinary excretion of orotic acid and of methylmaleic acid was measured and found normal in case 2. Haemoglobin electrophoresis is normal in all 3. All have the same ABO and Rh blood-group. It is worth mentioning that all showed borderline or slightly raised values of serumcreatine phosphokinase. (They have no signs of muscle disease.) There is no hepatomegaly or splenomegaly, and the radiographic appearances of the spleen are normal. 1. Waters, A. H., Murphy, M. E. B. Br. J. Hæmat. 1963, 9, 1. 2. Huguley, C. M., Bain, J. A. in The Metabolic Basis of Inherited Disease (edited by J. B. Stanbury, J. B. Wyngaarden, and D. S. Frederickson); p. 776. New York, 1960. 3. Jacobi, H., Heimpel, H., Cremer, H. J. Med. Wschr. 1967, 92, 1853. 4. Imerslund, O. Acta pœdiat. scand. 1960, 49, suppl. 119.