- Email: [email protected]
ANASTOMOSIS IN THE CORONARY CIRCULATION
1372 circulation of "substandard" cortisone tablets constitutes a hazard of the greatest magnitude to such
patients. We know that these tablets have been purchased by other hospitals and feel that physicians should be aware of their existence since they may be the cause of unexpected adrenal insufficiency in their patients. Medical Unit, University College Hospital Medical School, London, W.C.1.
M. L. ROSENHEIM E. J. Ross.
PLASMA-CALCIUM IN PRIMARY THYROIDISM
HYPERPARA-
SiR,ńIn connection with the paper by Dr. Lloyd and Dr. Rose (Dec. 13) on ionised-calcium determination in the diagnosis of hyperparathyroidism, I am wondering what the objection is to estimating the cerebrospinal-fluid calcium, which surely is almost entirely the diffusible fraction and, since the complexed fraction forms such a small proportion of this and apparently does not significantly alter in hyperparathyroidism, would be much simpler to determine. Group Laboratory, Hospital, Chertsey, Surrey.
St. Peter’s
C. F. Ross.
A SEARCH REWARDED
SIR,-In your issue of Feb. 15 you published an annotation on the R.A.M.C. Historical Museum, which ended on a diswith the pious hope that " Any reader used horse-drawn heavy ambulance-wagon in his garage is invited to offer it to the museum ". The search may now be called off! Having combed the various dumps and vehicle stores throughout the kingdom with the help of our friends in the R.A.S.C. and R.A.O.C. with no result, we had almost given up hope when a local contractor, living barely half a
lighting
BREAST CANCER
SiR,ńThe contentions raised in the recent contributions on this subject are helpful. Before the advent of radiotherapy there was little argument in the disadvantages of radical mastectomy, for at that stage it was the one chance. When radiotherapy became feasible it was welcomed as an added form of attack, and for some years now the issue has been on how far it should replace surgery. But when a breast obviously contains invasive materialand it is obvious the condition is advanced, whatever the clinical findings-is management to be wholly standardised and committed to one routine or varied according to the patient ? Is there to be no distinction between the old and the young, the thin and the obese, the dark and the fair, the tough and the not so tough ? I am still, I am afraid, unconvinced of any finality in the balance between surgery and radiotherapy. The operation of mastectomy, whether simple or radical, is a mutilation. There is also a risk of performing the worst form of biopsy by dividing invasive tissue at the level of the axilla or at the first rib interspace. Alternatively eradication may be complete. Radiotherapy is less certain in its eradication, though it affords greater coverage, and however skilled the administration may leave a feeling of fatigue as a temporary or more often a permanent complaint. It may, too, initiate gross obstruction to the lymphatic drainage of the arm, but a certain penalty is unavoidable if life is to be prolonged. Statistics do not tell the whole story, and I feel they are more use as a guide than a directive. A final question. Are we for ever committed to the word cancer ? A word that haunts and does not help. A change from a very old interpretation of this disease a
seems
overdue.
F. D. SANER. ANASTOMOSIS IN THE CORONARY CIRCULATION SIR,-We note with interest that in your issue of Nov. 29 Dr. Pepler confirms our finding that a large proportion of the Bantu possess coronary anastomoses of
functional significance. We should like to comment Pepler’s letter.
on
certain
points in
Dr.
(1) We did not overlook the possibility that our findings only to the Bantu; the original title of our paper was Coronary Anastomosis in the Bantu. We accepted the new title since we agreed that probably our findings were of general application; we do not consider the techniques of " tha pioneers " in this field to be as satisfactory as ours in demonstrating anastomoses. Remote though the possibility is that the differences we reported are racial we naturally took steps to investigate this; this work continues and a report will relate
Horse-drawn ambulance wagon used in 1914-18
war.
mile away, told us that he had purchased such a vehicle at a sale of Army stores in 1922; it had been put to a variety of domestic purposes during the last thirty-six years but still bore the load table and red crosses. Mr. Cranstone has generously presented it to the museum. Its war record is obscure. It is certainly not the 1911 vintage which many of us remember in use in 1914, but tallies almost exactly with the variety used in the South African war as described in the R.A.M.C. Manual of 1908. It is quite possible, therefore, that it is an old South African veteran again pressed into the service for the Kaiser’s War. Refurbished and repainted it now stands before our museum. R.A.M.C. Historical Museum, Queen Elizabeth Barracks, Crookham, Hants.
R. E. BARNSLEY.
follow. (2) Dr.
Pepler is wrong in assuming that he can speak for a significant proportion of other South African pathologists when he challenges our finding that the Bantu do suffer commonly from coronary heart-disease. There is a paper at present in press (Laurie, Woods, and Roach) in which we prove this statement and quote material checked independently by six other histopathologists. (3) Brink’s conclusionshave not been substantiated, and for this reason we did not quote him. From a small series of 33 cases, Brink claimed that the majority of the Bantu possess a left coronary circulation very different from that of the European and suggested this as a possible cause of the differences in the incidence of frank coronary occlusion. Elliott2 was the first to question this conclusion; and later Singer, the anatomist, showed in a series (not yet published) ten times bigger than 1. 2.
Brink, A. J. Clin. Proc. 1949, 8, 137. Elliott, G. A. Leech, 1953, 23, 25.
1373
that of Brink that there coronary circulation.
were no
racial differences in the left
MEDICAL ASPECTS OF ADOPTION SIR,ńThe article by Dr. Black and Dr. Stone (Dec. 13) seemed very reasonable and useful. I agree entirely that anyone who passes a 2-3 weeks’ old baby for adoption indeed rash. I have even heard without seeing it of prematurely born babies being passed for adoption a week or two after birth. I personally would never pass a full-term baby for adoption before the age of 6 weeks.
It is remarkable with what tenacity the view is held that the Almighty has cast the Bantu in a mould different from all mankind. This view is unlikely to appeal to the serious worker. Public Health Commission, Perth, Western Australia. Department of Cardiology, University of Alberta, Edmonton, Canada.
again is
W. LAURIE
J.
Though one can probably diagnose most cases of mental deficiency by the age of 6 to 8 weeks, one is on much safer grounds at the age of 6 to 8 months, when there are several important fields of development available for assessing the baby. By that age the likelihood of error should be
D. WOODS.
HOW MANY OF US SHOULD THERE BE? SIR,-Dr. Ffrangcon Roberts (Dec. 13) has, I think,
done his short-term arithmetic quite correctly. But his very small. long-term picture is faulty. He has failed to allow for the I am a little concerned whether some people, reading ultimate bulge in the Harlow death-rate, which must the article by Dr. Black and Dr. Stone, might read too occur thirty or forty years from now. Moreover, the much into their call for caution where certain prenatal Development Corporation has left space for old people’s or perinatal factors are present. I am sure that it would be bungalows, against the time when these will be needed, to altogether wrong to exclude babies from adoption, or to release bigger houses for the new families. Again, he has delay adoption proceedings much, because a parent was neglected the natural movement of population; in all mentally defective, or because there was foetal distress, communities, something like 4% of homes are vacated perinatal anoxia, considerable prematurity, or emotional each year. One way or another, Harlow’s children’s deprivation in the early months. The great majority of children should be able to find the homes they need, if infants with these adverse antecedents grow up to be they want to stay in Harlow. normal It children. must perfectly constantly be borne and on the words " in mind that it is a By italicising dwelling sending very great tragedy for a baby to be the fact that this had been dubbed for unsuitable away " specifically adoption when in fact it is normal. the Dr. One has to consider the rejected by Development Corporation), Ffrangcon baby as well as the adopting Roberts has created a chimaera. He might care instead to parents. turn his attention to those communities around London, I feel unhappy about the wisdom of implanting doubt built between the wars, where children are already having and fears in the minds of adopting parents concerning the to go elsewhere because no space was left for the next possibility of signs of " brain damage " appearing later. homes. Because the Harlow generation’s Development By the age of 6 to 8 months all but the milder forms of the is 4000-5000 homes to be filled by spastic type of cerebral palsy should be picked up, though Corporation leaving natural increase, we face the future with reasonable one certainly could not eliminate the possibility of confidence. athetosis manifesting itself later. I presume that Dr. Black and Dr. Stone have in mind recent work concerning the All the same, I still hope Harlow may continue to higher incidence of certain behaviour problems in children retain a net reproduction-rate of over 1. For four years who had anoxia at birth than in those who did not. It we have had in Harlow excellent birth-control clinics run by the Family Planning Association. Nevertheless, would surely be wrong to exclude from adoption all the Harlow families continue to grow. Can it be that the very many babies who are asphyxiated at birth, on the ground that they might subsequently develop these parents actually think life in a new town is worth living, problems. I doubt whether the authors mean that, but it and a large family the best basis for family happiness ? may be read into their paper. Is it not too much of a I hope so. If, as again I hope, some of the young people generalisation to say bluntly " The hyperkinetic child is a of Harlow in due course decide to strike out for themselves in new places in Britain or overseas, they will take; brain-damaged child " ? I would have thought that it would be more accurate to say that " There is some with them memories of a happy childhood. No lessi valuable, they will also take the knowledge that industriall evidence that one of the causes of abnormal hyperkinesis is cerebral anoxia in the foetus ". towns need not be squalid, but that, properly planned andl The sooner a baby is placed with adopting parents the built, they can be as good places to live in as Cambridge better for the baby. Adoption proceedings can be comor even Chesham, Bucks. TAYLOR. menced, but if the final examination, before the adoption is clinched, could be deferred to the age of 6 to 8 months, Dr. Roberts’ view that Lord I believe that many of the tragic errors in the assessment SIR,-With Ffrangcon direct his abilities to the should of babies could be eliminated. great Taylor " propagation of birth-control many will agree : this is a matter to I have recently gone through my notes of 800 children which all should direct their abilities, whether great or with cerebral palsy or mental retardation, and have been small. But to confine our attention to this country is to impressed by the number of those who were adopted be parochial. Let it be borne in mind that there are children. Dr. Black and Dr. Stone have done a service in already 175 million Americans in the world, that the calling for greater caution in assessing babies for adoption. 400 millionth Indian will be here soon, and that The University of Sheffield Department of Child Health, China’s population is increasing by about 13 millions R. S. ILLINGWORTH. The Children’s Hospital, Sheffield.
(despite
,
"
a vear.
L. N. JACKSON. Honorary Editor, International Planned Parenthood Federation, 69, Eccleston Square, London, S.W.1.
News ofPopulation and Birth Control.
SIR,-I read with great interest the article by Dr. Black and Dr. Stone in your issue of Dec. 13, and I find myself in almost complete agreement with them. As a medical
patients. We know that these tablets have been purchased by other hospitals and feel that physicians should be aware of their existence since they may be the cause of unexpected adrenal insufficiency in their patients. Medical Unit, University College Hospital Medical School, London, W.C.1.
M. L. ROSENHEIM E. J. Ross.
PLASMA-CALCIUM IN PRIMARY THYROIDISM
HYPERPARA-
SiR,ńIn connection with the paper by Dr. Lloyd and Dr. Rose (Dec. 13) on ionised-calcium determination in the diagnosis of hyperparathyroidism, I am wondering what the objection is to estimating the cerebrospinal-fluid calcium, which surely is almost entirely the diffusible fraction and, since the complexed fraction forms such a small proportion of this and apparently does not significantly alter in hyperparathyroidism, would be much simpler to determine. Group Laboratory, Hospital, Chertsey, Surrey.
St. Peter’s
C. F. Ross.
A SEARCH REWARDED
SIR,-In your issue of Feb. 15 you published an annotation on the R.A.M.C. Historical Museum, which ended on a diswith the pious hope that " Any reader used horse-drawn heavy ambulance-wagon in his garage is invited to offer it to the museum ". The search may now be called off! Having combed the various dumps and vehicle stores throughout the kingdom with the help of our friends in the R.A.S.C. and R.A.O.C. with no result, we had almost given up hope when a local contractor, living barely half a
lighting
BREAST CANCER
SiR,ńThe contentions raised in the recent contributions on this subject are helpful. Before the advent of radiotherapy there was little argument in the disadvantages of radical mastectomy, for at that stage it was the one chance. When radiotherapy became feasible it was welcomed as an added form of attack, and for some years now the issue has been on how far it should replace surgery. But when a breast obviously contains invasive materialand it is obvious the condition is advanced, whatever the clinical findings-is management to be wholly standardised and committed to one routine or varied according to the patient ? Is there to be no distinction between the old and the young, the thin and the obese, the dark and the fair, the tough and the not so tough ? I am still, I am afraid, unconvinced of any finality in the balance between surgery and radiotherapy. The operation of mastectomy, whether simple or radical, is a mutilation. There is also a risk of performing the worst form of biopsy by dividing invasive tissue at the level of the axilla or at the first rib interspace. Alternatively eradication may be complete. Radiotherapy is less certain in its eradication, though it affords greater coverage, and however skilled the administration may leave a feeling of fatigue as a temporary or more often a permanent complaint. It may, too, initiate gross obstruction to the lymphatic drainage of the arm, but a certain penalty is unavoidable if life is to be prolonged. Statistics do not tell the whole story, and I feel they are more use as a guide than a directive. A final question. Are we for ever committed to the word cancer ? A word that haunts and does not help. A change from a very old interpretation of this disease a
seems
overdue.
F. D. SANER. ANASTOMOSIS IN THE CORONARY CIRCULATION SIR,-We note with interest that in your issue of Nov. 29 Dr. Pepler confirms our finding that a large proportion of the Bantu possess coronary anastomoses of
functional significance. We should like to comment Pepler’s letter.
on
certain
points in
Dr.
(1) We did not overlook the possibility that our findings only to the Bantu; the original title of our paper was Coronary Anastomosis in the Bantu. We accepted the new title since we agreed that probably our findings were of general application; we do not consider the techniques of " tha pioneers " in this field to be as satisfactory as ours in demonstrating anastomoses. Remote though the possibility is that the differences we reported are racial we naturally took steps to investigate this; this work continues and a report will relate
Horse-drawn ambulance wagon used in 1914-18
war.
mile away, told us that he had purchased such a vehicle at a sale of Army stores in 1922; it had been put to a variety of domestic purposes during the last thirty-six years but still bore the load table and red crosses. Mr. Cranstone has generously presented it to the museum. Its war record is obscure. It is certainly not the 1911 vintage which many of us remember in use in 1914, but tallies almost exactly with the variety used in the South African war as described in the R.A.M.C. Manual of 1908. It is quite possible, therefore, that it is an old South African veteran again pressed into the service for the Kaiser’s War. Refurbished and repainted it now stands before our museum. R.A.M.C. Historical Museum, Queen Elizabeth Barracks, Crookham, Hants.
R. E. BARNSLEY.
follow. (2) Dr.
Pepler is wrong in assuming that he can speak for a significant proportion of other South African pathologists when he challenges our finding that the Bantu do suffer commonly from coronary heart-disease. There is a paper at present in press (Laurie, Woods, and Roach) in which we prove this statement and quote material checked independently by six other histopathologists. (3) Brink’s conclusionshave not been substantiated, and for this reason we did not quote him. From a small series of 33 cases, Brink claimed that the majority of the Bantu possess a left coronary circulation very different from that of the European and suggested this as a possible cause of the differences in the incidence of frank coronary occlusion. Elliott2 was the first to question this conclusion; and later Singer, the anatomist, showed in a series (not yet published) ten times bigger than 1. 2.
Brink, A. J. Clin. Proc. 1949, 8, 137. Elliott, G. A. Leech, 1953, 23, 25.
1373
that of Brink that there coronary circulation.
were no
racial differences in the left
MEDICAL ASPECTS OF ADOPTION SIR,ńThe article by Dr. Black and Dr. Stone (Dec. 13) seemed very reasonable and useful. I agree entirely that anyone who passes a 2-3 weeks’ old baby for adoption indeed rash. I have even heard without seeing it of prematurely born babies being passed for adoption a week or two after birth. I personally would never pass a full-term baby for adoption before the age of 6 weeks.
It is remarkable with what tenacity the view is held that the Almighty has cast the Bantu in a mould different from all mankind. This view is unlikely to appeal to the serious worker. Public Health Commission, Perth, Western Australia. Department of Cardiology, University of Alberta, Edmonton, Canada.
again is
W. LAURIE
J.
Though one can probably diagnose most cases of mental deficiency by the age of 6 to 8 weeks, one is on much safer grounds at the age of 6 to 8 months, when there are several important fields of development available for assessing the baby. By that age the likelihood of error should be
D. WOODS.
HOW MANY OF US SHOULD THERE BE? SIR,-Dr. Ffrangcon Roberts (Dec. 13) has, I think,
done his short-term arithmetic quite correctly. But his very small. long-term picture is faulty. He has failed to allow for the I am a little concerned whether some people, reading ultimate bulge in the Harlow death-rate, which must the article by Dr. Black and Dr. Stone, might read too occur thirty or forty years from now. Moreover, the much into their call for caution where certain prenatal Development Corporation has left space for old people’s or perinatal factors are present. I am sure that it would be bungalows, against the time when these will be needed, to altogether wrong to exclude babies from adoption, or to release bigger houses for the new families. Again, he has delay adoption proceedings much, because a parent was neglected the natural movement of population; in all mentally defective, or because there was foetal distress, communities, something like 4% of homes are vacated perinatal anoxia, considerable prematurity, or emotional each year. One way or another, Harlow’s children’s deprivation in the early months. The great majority of children should be able to find the homes they need, if infants with these adverse antecedents grow up to be they want to stay in Harlow. normal It children. must perfectly constantly be borne and on the words " in mind that it is a By italicising dwelling sending very great tragedy for a baby to be the fact that this had been dubbed for unsuitable away " specifically adoption when in fact it is normal. the Dr. One has to consider the rejected by Development Corporation), Ffrangcon baby as well as the adopting Roberts has created a chimaera. He might care instead to parents. turn his attention to those communities around London, I feel unhappy about the wisdom of implanting doubt built between the wars, where children are already having and fears in the minds of adopting parents concerning the to go elsewhere because no space was left for the next possibility of signs of " brain damage " appearing later. homes. Because the Harlow generation’s Development By the age of 6 to 8 months all but the milder forms of the is 4000-5000 homes to be filled by spastic type of cerebral palsy should be picked up, though Corporation leaving natural increase, we face the future with reasonable one certainly could not eliminate the possibility of confidence. athetosis manifesting itself later. I presume that Dr. Black and Dr. Stone have in mind recent work concerning the All the same, I still hope Harlow may continue to higher incidence of certain behaviour problems in children retain a net reproduction-rate of over 1. For four years who had anoxia at birth than in those who did not. It we have had in Harlow excellent birth-control clinics run by the Family Planning Association. Nevertheless, would surely be wrong to exclude from adoption all the Harlow families continue to grow. Can it be that the very many babies who are asphyxiated at birth, on the ground that they might subsequently develop these parents actually think life in a new town is worth living, problems. I doubt whether the authors mean that, but it and a large family the best basis for family happiness ? may be read into their paper. Is it not too much of a I hope so. If, as again I hope, some of the young people generalisation to say bluntly " The hyperkinetic child is a of Harlow in due course decide to strike out for themselves in new places in Britain or overseas, they will take; brain-damaged child " ? I would have thought that it would be more accurate to say that " There is some with them memories of a happy childhood. No lessi valuable, they will also take the knowledge that industriall evidence that one of the causes of abnormal hyperkinesis is cerebral anoxia in the foetus ". towns need not be squalid, but that, properly planned andl The sooner a baby is placed with adopting parents the built, they can be as good places to live in as Cambridge better for the baby. Adoption proceedings can be comor even Chesham, Bucks. TAYLOR. menced, but if the final examination, before the adoption is clinched, could be deferred to the age of 6 to 8 months, Dr. Roberts’ view that Lord I believe that many of the tragic errors in the assessment SIR,-With Ffrangcon direct his abilities to the should of babies could be eliminated. great Taylor " propagation of birth-control many will agree : this is a matter to I have recently gone through my notes of 800 children which all should direct their abilities, whether great or with cerebral palsy or mental retardation, and have been small. But to confine our attention to this country is to impressed by the number of those who were adopted be parochial. Let it be borne in mind that there are children. Dr. Black and Dr. Stone have done a service in already 175 million Americans in the world, that the calling for greater caution in assessing babies for adoption. 400 millionth Indian will be here soon, and that The University of Sheffield Department of Child Health, China’s population is increasing by about 13 millions R. S. ILLINGWORTH. The Children’s Hospital, Sheffield.
(despite
,
"
a vear.
L. N. JACKSON. Honorary Editor, International Planned Parenthood Federation, 69, Eccleston Square, London, S.W.1.
News ofPopulation and Birth Control.
SIR,-I read with great interest the article by Dr. Black and Dr. Stone in your issue of Dec. 13, and I find myself in almost complete agreement with them. As a medical