452 my countrymen will not accuse me of lack of patriotism if I say that I do not think the standards of medical education are higher in Spain than in...

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452 my countrymen will not accuse me of lack of patriotism if I say that I do not think the standards of medical education are higher in Spain than in those countries.

I know from experience that it is much harder to pass an examination in a foreign language, and I am sure that the generally lower pass-rate of the European candidates, as compared with the British, is mostly due to the examinations being carried out in English. Liverpool Royal Infirmary, Pembroke Place, Liverpool, 3.



SIR,-Dr. Quibell (June 30) has rightly stressed the need for coordinated services for thalidomide-damaged infants, and his remarks must be extended to apply to the needs of all children born with severe limb defects whose problem has been highlighted by the recent increase in their numbers as the result of this particular drug. Unfortunately-as you yourself emphasise in your leading article of Aug. 18-discussion of the correct management of these cases and anticipation of their very diverse needs in the years to come is bedevilled by ignorance not only of the total number of cases to be considered, but also of the incidence within that number of the various types and degrees of defect, of the coincidence of other congenital abnormalities, of the family social backgrounds, and even of the geographical distribution. Arrangements for collecting this information are still inadequate. Two areas had notification systems for congenital defects before the thalidomide disaster, but for the rest of the country we can only guess. Recently the Ministry of Health has asked medical officers of health to collect data for their areas, and doctors have been urged to refer cases needing prostheses to the limb-fitting centres within the first few months of life. But neither of the arrangements is likely to lead to a comprehensive and continuing list. As the problem is one of extreme urgency, lest the early months of life of the defective children, so essential to their future, are lost, we should like to offer the facilities of our Disabled Living Research Unit, Mary Marlborough Lodge, Nuffield Department of Orthopaedic Surgery, Oxford, to start and maintain a register of cases of congenital limb defect until a final decision is taken by the appropriate authorities. Cases should be registered as soon as possible after birth, but registration at any age will be acceptable. All cases will be given a code number and personal details will not be revealed without the consent of the family and/or doctor concerned. We shall welcome the cooperation of all organisations, official and voluntary, and of the many specialties concerned in this field, and will be happy to hear from them of any particular information which they would like us to collect. We shall be happy to receive informal registrations any time from now, at first in any form, to give us an idea of the numbers involved. We hope that previous or simultaneous notification of a case to the Ministry of Health or a limb-fitting centre or other authority will not deter from registration on the Register of Congenital Limb Defects. Northern Ireland, Scotland, and Wales may well prefer to keep their own registers, but in the meantime we shall be happy to temporarily hold registrations for these countries also with a view to transferring them later if they wish. Nuffield Department of J. TRUETA Orthopaedic Surgery, MARGARET AGERHOLM. Oxford.

THALIDOMIDE AND CONGENITAL ABNORMALITIES the end of November, 1961, a warning was SIR,-At sent by the medical authorities of the Netherlands to

pharmacists and general practitioners advising them no longer to sell or prescribe thalidomide preparations. The funds that provide the medical care of 80% of the population had not allowed prescription of a thalidomide preparation. The preparations used in the Netherlands wereSoftenon ’, ’Noctosediv ’, and ’Enterosediv’. The chief medical authorities, in cooperation with the Dutch Paediatric Society, made a survey among paediatricians, obstetricians, and general practitioners to determine the number of infants with severe malformations of the extremities born since Jan. 1, 1959, and to investigate the use of thalidomide preparations in pregnancy. Until June 27, 1962, 87% of the general practitioners had replied to this questionnaire. Until that date 12 cases of malformations in children became known in which the mother had certainly taken thalidomide preparation during pregnancy. In 6 other cases the use of such a preparation is still uncertain. However, the conclusion is justified that in the Netherlands, with a population of about 11 million, the catastrophe has been limited. H. J. DIJKHUIS S. VAN CREVELD C. DE MONCHY J. H. HAGENBEEK B. V. BEKKER G. A. DE JONGE The Hague.

Office of the Chief Medical Officer.

SIR,-May I enlarge graph (Aug. 4).



Committee of the Dutch Psediatric Pædiatric


Mary Seller’s final para-

We must escape from Nephelococcygia and face the fact that the most careful tests of a new drug’s effects on animals may tell us little of its effects on humans. There can be no doubt that thalidomide was subjected to the most careful scrutiny. I myself took part in a trial to investigate its possible goitrogenic effect on man, even such improbable hazards having been considered by its British distributors. The fallacy of animal trials works both ways. I was given carbimazole for clinical trial, and had come to the conclusion that it was the least toxic antithyroid drug available when the conscientious makers became aware of its severe toxic effects on rats. They stopped the supply and tried to persuade me to stop my experiment. I had gone far enough to realise that what was true of rats was not true of man; with the aid of another maker I established my case, which has so far remained unshaken.2 There are no drugs which do good which do not sometimes do harm. Animal experiments cannot obviate the risk and may even prevent the use of excellent substances. We must accept some risk or-perhaps the wiser coursedo without new drugs. RAYMOND GREENE. London, W.1. ADVERTISING CIGARETTE SMOKING

SIR,-Surely all will support Dr. Hart’s protest (Aug. 18) the sale of sweet " cigarettes for children. I have talked with hundreds of smokers-through the medium of an anti-smoking clinic and elsewhere-and I have never "


the person who wished their children to smoke. I have before me two other forms of novelty cigarette sold to children-one of them four for a shilling-which puffs out a cloud of chalk-like powder with each breath. Near the shop selling this product was a tobacco manufacturer’s poster in attractive colours fifty times the size of our own poster offering


1. 2.


Greene, R., Farran, H. E. A. Brit. med. J. 1958, ii, 1355. Greene, R., Farran, H. E. A., Morgan, D. C. J. clin. Endocrin. 1956, 16, 391.


healthy way of life. Can nothing be done to prevent advertiseexploiting youthful romance and sex appeal in the cause of more cigarette smoking ? J. L. BURN Health Department,

laboratory a precise evaluation they are dealing with.






Division of Research, Ormonoterapia Richter S.p.A., Milan, Italy.

of the


of the


Medical Officer of Health.


EVALUATION OF THE ANABOLIC ACTIVITY OF STEROIDS international the congress on hormonal SIR,-At an entire session was in Milan held steroids recently But the comof steroids. action to the anabolic devoted did not allow conclusions to be read munications precise of the dealt with drawn about the activity products by the various contributors, because of the different methods employed, the different ways of administration, and the different criteria for interpretation of the data. In addition technical details were not always made sufficiently clear. The accompanying table shows figures for anabolic activity and the anabolic/androgenic ratio of some wellknown steroids as reported to the congress by different observers. The methods employed to determine these figures are also shown. It will be seen that even where the same criteria were adopted the results differed. There is an urgent need for a suitable and generally accepted method of standardisation which would enable any investigator to test the activity of these compounds regardless of the laboratory he is working in. One may hope that workers will reach an agreement on the choice of a standard method, or at the least that they will supply sufficient information to make possible in Stucki, J. C., Duncan, G. W., Lyster, S. C. (The Upjohn Co., Kalamazoo, Michigan) Excerpta Medica International Congress Series no. 51, International Congress on Hormonal Steroids, 1962, p. 65. 2. Potts, G. O., Beyler, A. A., Beyler, A. L. (Sterling Winthrop Research Institute, Rensselaer, New York) ibid. p. 211. 3. Edgren, R. A., Smith, H. (Wyeth Laboratories, Philadelphia, Pa.) ibid. p. 68. 4. Suchowsky, G. K., Junkmann, K. (Research Laboratories Schering AG., Berlin) ibid. p. 68. 1.

SIR,-The study reported by Dr. Davis and Dr. Badenoch (July 7) is of considerable interest. They found an apparent increase in the absorption of iron from a standard iron-containing diet in patients with chronic pancreatitis; yet the proportion of an oral dose of radioactive iron which appeared in the peripheral blood was small. The authors discussed the possible mechanisms by which an increased iron absorption may occur in chronic pancreatitis. We wish to comment on the low percentage of the apparently absorbed iron which was present in the peripheral blood eleven days after the dose had been given to these patients. Although data for iron saturation of the plasma were not given, the figures for the serum-iron suggest that the intravascular iron pool was not enlarged in the patients with chronic pancreatitis (with the possible exception of case 20). The amount of radioactive iron which appeared in the peripheral blood, expressed as a percentage of that not excreted in the faeces, varied between 25% and 130% in the healthy subjects, between 25% and 100% in those with acute pancreatitis, and between 2% and 15% in those with chronic pancreatitis. (Case 19 in the last group was exceptional: 60% of the absorbed dose was utilised.) Of the total radioactive iron given to the patients, the mean recoveries (iron excreted in the faeces plus iron in the peripheral blood) for the normal, idiopathic steatorrhoea, and acute and chronic pancreatitis groups were 98-3%, 96-0%, and 76-7% respectively (excluding case 14, where the figure for iron excretion is presumably a typist’s error). We would be interested to know the authors’ views on the fate of the iron unaccounted for in the chronicpancreatitis group. Possibly it is stored in the liver, spleen, or marrow, without being utilised for haemoglobin