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A FIBROSARCOMA WITH HYPOGLYCÆMIA AND A HIGH SERUM-INSULIN LEVEL
835 is sheer fantasy. The remarks on " certain governmentcontrolled hospitals of Copenhagen " and the physicians’ lack of freedom to decide what is’best for the patients are equally remote
from reality.
It would be more valuable if Professor Wright would submit new material of his own to elucidate the problem.
MOGENS BJØRNBOE N. B. KRARUP.
Bispebjerg Hospital, Copenhagen.
MALE NURSES IN THE FORCES
SIR,-As a male State-registered nurse who is advocating the entry of male S.R.N.S into the Nursing Services of the Armed Forces with equal rank and status as our female colleagues, I should be most grateful for the opinions of the medical profession. The War Minister has said that it is not possible to commission male nurses in the R.A.M.C., direct from civilian nursing, non-medical-officer commissions being extremely limited. As nurses, however, we feel that the R.A.M.C. is not the answer to our problem, since, as non-medical officers, we would not be employed on nursing duties, but on administrative duties. To enlist male s.R.N.s with commissioned rank into the R.A.M.C. (as 2nd lieutenants) would certainly release the medical officers from some of their non-medical duties, but it would not give the nurse the equality that is lacking under the present policy. The Services have provided a nursing section, which should be open to all who are suitably qualified. But the Minister of Defence, in a recent letter on this matter, stated: " The Medical Directorates of the three Services have once again given consideration to the problem of equal recognition in respect of Male State Registered Nurses in the Armed Forces, but feel that no change in policy is envisaged at present." From this are we to understand the obstructing force is not within our own profession, but in the medical profession ? I should very much like the opinion of your readers on these questions. Should male s.R.N.s receive junior commissions in the R.A.M.C., and release medical officers from non-medical duties ?’ And should male S.R.N.s be commissioned in the Nursing Services with equal rank and status as their female
colleagues. Public Dispensary and Leeds.
Hospital,
S. ARMITAGE.
A FIBROSARCOMA WITH HYPOGLYCÆMIA AND A HIGH SERUM-INSULIN LEVEL
SIR,-Iread with much interest the article by Dr. and others (Aug. 25), which reviewed all the possible explanations for the hypoglycxmia which accompanies such tumours. But these theories do not explain the paroxysmal nature of these hypoglycsemic states. Some of these patients have hypoglycxmia when a meal is omitted, which indicates that there is a constant dis-
Oleesky
charge of insulin into the circulation. Yet there are other patients who have hypoglycsmia unrelated to food intake, which suggests a sudden release of large amounts of active insulin. Normally insulin circulates in the blood in two forms 1: a "free" form, and a form bound to basic proteins. " The insulin-like activity in the whole serum is characterised as the free portion of insulin and insulin in its‘ bound ’form is devoid of insulin activity when examined under specific "
"
conditions."" The fact that insulin is bound and released probably accounts for" brittlediabetes, where the glycasmia swings from high to low without apparent cause. I suggest that a similar mechanism is responsible in these tumours. The tumour contains some substance, possibly a basic protein, which binds and mactivates the endogenous insulin. This insulin is either trapped n the tumour or continues to circulate in a bound inactive 1.
Antoniades, H.
N.,
et
al.
Endocrinology, 1961, 69,
45.
state, and is later suddenly released by various factors (one of which might be leucine). In this way hypoglycsemia is produced. There are several ways in which this theory could be tested. The addition of the tumour extract to insulin might decreaseB glucose uptake by the rat’s diaphragm. If so, the further addition of leucine to the medium might inhibit the effect of the tumour extract and the insulin activity might be recovered. If the tumour extract is devoid of insulin-like activity it still might contain inactive bound insulin, which may be freed by passage through a’cationic ion exchanger.! Another possibility is to use the method of Butterfield et a1.2-i.e., to inject insulin into the nutrient artery of the tumour and to measure it in the draining vein. A different mechanism is also possible. Antoniades and Gundersen3 have shown that adipose-tissue extract dissociates the bound insulin from its basic protein and thus the insulinlike activity of the medium is increased. The tumour tissue might also possess this dissociative activity, as a result of which the equilibrium between the two forms of insulin is shifted towards the free form. This effect of the tumour might be demonstrated by the addition of the tumour extract, devoid of insulin-like activity, to human serum. An increase of the insulin-like activity of the serum might prove significant. Since fibrosarcoma with hypoglycsemia is rare I should like to suggest these experiments to anyone who comes
this tumour. Diabetes Clinic and Medical Department A, Central Negev Hospital, Beer Sheva, Israel.
across
A. RAVINA.
DEATH OF A DIABETIC
SIR,-It is stated in Dr. Pyke’s letter (Oct. 13) that the necropsy in
question was performed " some days " after death. This is not at all uncommon where coroners’ postmortems are concerned, and the inference is that there are not enough medicolegal pathologists. Whether this is due to lack of interest in this type of work, lack of opportunities for training, or indifference on the part of the police, coroners, and local authorities, I do not know; but surely the time has come when facilities for medicolegal work should be made available on a national scale and not left to the whims of local councils. The woeful state of many public mortuaries has been well described in the report of the Association of Clinical Pathologists’ committee on mortuary design and hazards4 who suggest that local authorities and’hospitals might collaborate in the joint use of mortuaries. This could work well, but since the coroner’s pathologist thereby would have all the advantages of the National Health Service at his disposal, yet remaining outside it, it seems to me that we might just as well put the whole thing on a sound basis and have a National Medicolegal Service based on suitable general-hospital laboratories run by specially qualified and trained pathologists. At present, much valuable material is lost because the coroner’s pathologist (essentially a piece-worker) has not time to do more than rule out unnatural causes of death. I can hear the shouts of dissent, but I am certain that in time this will have to be-and the sooner the better. St. Peter’s
Hospital, C. F. C F Ross. Ross Chertsey, Surrey.... Surrey.
SIR, The facts disclosed in relation to this problem (described in your issue of Oct. 6, p. 718) are very disturbing. Surely we can learn something from history ? Until 1948 local-authority hospitals had a duty to find a bed for any case said to be in need of hospital treatment. There seems to be no reason why the same responsibility 2. 3. 4.
Butterfield, W. J. H., Kinder, C. H., Mahler, R. F. Lancet, 1960, i, 703. Antoniades, H. N., Gundersen, K. Endocrinology, 68, 36. J. clin. Path. 1961, 14, 103.
from reality.
It would be more valuable if Professor Wright would submit new material of his own to elucidate the problem.
MOGENS BJØRNBOE N. B. KRARUP.
Bispebjerg Hospital, Copenhagen.
MALE NURSES IN THE FORCES
SIR,-As a male State-registered nurse who is advocating the entry of male S.R.N.S into the Nursing Services of the Armed Forces with equal rank and status as our female colleagues, I should be most grateful for the opinions of the medical profession. The War Minister has said that it is not possible to commission male nurses in the R.A.M.C., direct from civilian nursing, non-medical-officer commissions being extremely limited. As nurses, however, we feel that the R.A.M.C. is not the answer to our problem, since, as non-medical officers, we would not be employed on nursing duties, but on administrative duties. To enlist male s.R.N.s with commissioned rank into the R.A.M.C. (as 2nd lieutenants) would certainly release the medical officers from some of their non-medical duties, but it would not give the nurse the equality that is lacking under the present policy. The Services have provided a nursing section, which should be open to all who are suitably qualified. But the Minister of Defence, in a recent letter on this matter, stated: " The Medical Directorates of the three Services have once again given consideration to the problem of equal recognition in respect of Male State Registered Nurses in the Armed Forces, but feel that no change in policy is envisaged at present." From this are we to understand the obstructing force is not within our own profession, but in the medical profession ? I should very much like the opinion of your readers on these questions. Should male s.R.N.s receive junior commissions in the R.A.M.C., and release medical officers from non-medical duties ?’ And should male S.R.N.s be commissioned in the Nursing Services with equal rank and status as their female
colleagues. Public Dispensary and Leeds.
Hospital,
S. ARMITAGE.
A FIBROSARCOMA WITH HYPOGLYCÆMIA AND A HIGH SERUM-INSULIN LEVEL
SIR,-Iread with much interest the article by Dr. and others (Aug. 25), which reviewed all the possible explanations for the hypoglycxmia which accompanies such tumours. But these theories do not explain the paroxysmal nature of these hypoglycsemic states. Some of these patients have hypoglycxmia when a meal is omitted, which indicates that there is a constant dis-
Oleesky
charge of insulin into the circulation. Yet there are other patients who have hypoglycsmia unrelated to food intake, which suggests a sudden release of large amounts of active insulin. Normally insulin circulates in the blood in two forms 1: a "free" form, and a form bound to basic proteins. " The insulin-like activity in the whole serum is characterised as the free portion of insulin and insulin in its‘ bound ’form is devoid of insulin activity when examined under specific "
"
conditions."" The fact that insulin is bound and released probably accounts for" brittlediabetes, where the glycasmia swings from high to low without apparent cause. I suggest that a similar mechanism is responsible in these tumours. The tumour contains some substance, possibly a basic protein, which binds and mactivates the endogenous insulin. This insulin is either trapped n the tumour or continues to circulate in a bound inactive 1.
Antoniades, H.
N.,
et
al.
Endocrinology, 1961, 69,
45.
state, and is later suddenly released by various factors (one of which might be leucine). In this way hypoglycsemia is produced. There are several ways in which this theory could be tested. The addition of the tumour extract to insulin might decreaseB glucose uptake by the rat’s diaphragm. If so, the further addition of leucine to the medium might inhibit the effect of the tumour extract and the insulin activity might be recovered. If the tumour extract is devoid of insulin-like activity it still might contain inactive bound insulin, which may be freed by passage through a’cationic ion exchanger.! Another possibility is to use the method of Butterfield et a1.2-i.e., to inject insulin into the nutrient artery of the tumour and to measure it in the draining vein. A different mechanism is also possible. Antoniades and Gundersen3 have shown that adipose-tissue extract dissociates the bound insulin from its basic protein and thus the insulinlike activity of the medium is increased. The tumour tissue might also possess this dissociative activity, as a result of which the equilibrium between the two forms of insulin is shifted towards the free form. This effect of the tumour might be demonstrated by the addition of the tumour extract, devoid of insulin-like activity, to human serum. An increase of the insulin-like activity of the serum might prove significant. Since fibrosarcoma with hypoglycsemia is rare I should like to suggest these experiments to anyone who comes
this tumour. Diabetes Clinic and Medical Department A, Central Negev Hospital, Beer Sheva, Israel.
across
A. RAVINA.
DEATH OF A DIABETIC
SIR,-It is stated in Dr. Pyke’s letter (Oct. 13) that the necropsy in
question was performed " some days " after death. This is not at all uncommon where coroners’ postmortems are concerned, and the inference is that there are not enough medicolegal pathologists. Whether this is due to lack of interest in this type of work, lack of opportunities for training, or indifference on the part of the police, coroners, and local authorities, I do not know; but surely the time has come when facilities for medicolegal work should be made available on a national scale and not left to the whims of local councils. The woeful state of many public mortuaries has been well described in the report of the Association of Clinical Pathologists’ committee on mortuary design and hazards4 who suggest that local authorities and’hospitals might collaborate in the joint use of mortuaries. This could work well, but since the coroner’s pathologist thereby would have all the advantages of the National Health Service at his disposal, yet remaining outside it, it seems to me that we might just as well put the whole thing on a sound basis and have a National Medicolegal Service based on suitable general-hospital laboratories run by specially qualified and trained pathologists. At present, much valuable material is lost because the coroner’s pathologist (essentially a piece-worker) has not time to do more than rule out unnatural causes of death. I can hear the shouts of dissent, but I am certain that in time this will have to be-and the sooner the better. St. Peter’s
Hospital, C. F. C F Ross. Ross Chertsey, Surrey.... Surrey.
SIR, The facts disclosed in relation to this problem (described in your issue of Oct. 6, p. 718) are very disturbing. Surely we can learn something from history ? Until 1948 local-authority hospitals had a duty to find a bed for any case said to be in need of hospital treatment. There seems to be no reason why the same responsibility 2. 3. 4.
Butterfield, W. J. H., Kinder, C. H., Mahler, R. F. Lancet, 1960, i, 703. Antoniades, H. N., Gundersen, K. Endocrinology, 68, 36. J. clin. Path. 1961, 14, 103.