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EVOLUTION OF THE TOXIC THYROID GLAND
1185 THE DOCTOR’S OATH 8 contains an account of
SIR,—Your issue of Dec.
discussion by the General Medical Council of the declaration adopted by the World Medical Association at Geneva. I wish to make the following comments. It is utterly useless for qualifying medical practitioners to take any oath affirming respect for human life and pledging themselves not to use medical knowledge contrary to the laws of humanity, unless such an oath is interpreted literally. In times of war, or other emergency in which creed or country are at stake, few doctors would interpret the oath literally. A literal interpretation excludes membership of Armed Forces, since it is the duty of the doctor in the forces to keep men fit to fight, and to kill if necessary. Once any latitude is allowed in the interpretation of the oath to respect human life, then its meaning will vary according to the weight given to other obligations. It may not be difficult to decide not to become medical officer to a gang of thieves or murderers, but when country or creed are at stake the opponent, and that for which he stands, are considered so evil that respect for human life is of secondary importance. PETER DUPRÉ. Withyham, Sussex. A COLLEGE OF GENERAL PRACTITIONERS ?
at the the threshold of an EVOLUTION OF THE TOXIC THYROID GLAND intellectual renaissance. For the last few years medicoSIR,—Mr. Levitt’s attempt (Nov. 24, p. 957) to unify political issues have kept below the surface a slow but our concept of the various diseases of the thyroid gland steady evolution of ideas in the minds of thinking into one of transition from epithelial hyperplasia through doctors in and out of general practice ; and increasingly increasing lymphoid infiltration to Hashimoto’s disease these ideas are coming out into the open for discussion, and final fibrosis is interesting but not completely criticism, and consideration in the medicaljournals. convincing. From Dr. Hunt and Dr. Rose has come a lead which, In 1948 Dr. Davson and I’studied a series of 121 if resolutely followed, might enable many of these in whom thyroidectomy had been performed patients evolutionary developments to find concrete expression. and where the histological sections showed various stages General practice is not a specialty. It is the senior form of lymphocytic infiltration. The histological pictures of medical discipline, and has been carried on, well or grouped themselves conveniently into a continuous badly, in many forms, for as many centuries as man series, from typical thyrotoxicosis to lymphadenoid has cared for the health of man. Only in recent history goitre, with intervening changes of increasing lymphoid has it given birth to specialties within itself-medicine, Huertle-cell changes, fibrosis, and increasing infiltration, surgery, obstetrics, and others. and disorganisation of the vesicles. Clinically atrophy By the very nature of their work in the corporate this series presented a gradual over-all change from toxic departments of the developing hospitals, the specialists goitre to non-toxic enlargement of the thyroid gland. have been able and encouraged to combine and pool But this was only to be expected if histological intertheir knowledge in the interest of their calling. They has any value. What our investigation did not pretation organised themselves, and the country must be for ever prove, and Mr. Levitt has not proved either, is that these grateful that as a result of their actions the three great are changes through which the most advanced cases have Royal Colleges were born. passed and the less advanced cases may pass By tradition the general practitioner worked alone previously in future. No case of lymphadenoid goitre has ever been he lived with his patients and worked in his practice observed to change to Riedl’s thyroiditis. McClintock area as an independent unit of health care. No opporand 2 reported a case of recurrent lymphadenoid tunity arose for the body of knowledge in the minds of goitreWright where partial thyroidectomy was performed twice those in general practice to become combined and with an interval of 9 years. Histological sections showed coordinated ; and general practice, the mother of the no progression towards Riedl’s disease. specialties, remained static while her children prospered From our cases it seemed to us more likely that both and outgrew her. While the good work of the colleges lymphocytic infiltration and epithelial proliferation ar& went on, before and after their royal charters were expressions of the functional state of the thyroid gland. granted to them, the work in general practice never What determines the difference in the behaviour of the ceased. Practitioners lived and died, each having learnt in different patients is a matter for speculation. gland much and published little or nothing. The general We tried to show that it depend on the capacity of practitioners handled, and they handle to this day, at the gland to increase its may either focally or blood-supply, least 75% of the country’s illness, and they carry this in response to the functional demands of throughout, burden alone. increased thyrotropic stimulation. If and where this. Dr. Hunt and Dr. Rose have shown us how we may fails, the relative ischaemia leads to lymphocytic infiltraachieve the fulfilment of the next stage in the natural, tion instead of the epithelial changes of thyrotoxicosis. and inevitable, evolution and development of general As failure to increase blood-supply is more likely to occur practice ; for the establishment of a College of General with increasing age, it may not be surprising that Mr. Practitioners would be no more and no less than this. Levitt’s series showed an increase in age with increasing’ General practitioners must achieve their college as infiltration. lymphocytic their right and just due. They owe it to the memory of Victoria Memorial Jewish Hospital, countless generations of predecessors in their practices H. M. GOLDBERG. Manchester. that they accept no compromise title which carries with 1. Goldberg, H. M., Davson, J. Brit. J. Surg. 1948, 36, 41. it the implication of inferiority to a college. General 2. McClintock, J. C., Wright, A. W. Ann. Surg. 1937, 106, 11.
SIR,—The general practice of medicine could
present
.
have been in a position of inferiority vis-a-vis the specialists for years, and it is this that they seek to amend. Were such an alternative title to be accepted, future general practitioners would bear the handicap of a decision made on the grounds of the political expediency of the moment, and they would have good cause to reproach those who lacked the courage to stand firm. In British usage a college will always rank higher than any other academic body, and no lesser title .can be acceptable for the senior discipline of the medical art. The Royal Colleges have nothing to fear from general practice. Nothing in its successes or failures can dim the lustre of their achievements of the past and future ; but they will be the first to admit that general practice is not a new development seeking to establish itself as a specialty beside them, but the oldest medical discipline of all, becoming articulate for the first time in its history. A renaissance of general medical practice could not but benefit medicine as a whole, and if every branch and division of medical thought gives of its best to add flesh and substance to the College of General Practitioners, that college will take its place worthily alongside all other organisations of men with the interest of their profession at heart. R. J. F. H. PINSENT. Birmingham.
practitioners a
moment be
standing
on
SIR,—Your issue of Dec.
discussion by the General Medical Council of the declaration adopted by the World Medical Association at Geneva. I wish to make the following comments. It is utterly useless for qualifying medical practitioners to take any oath affirming respect for human life and pledging themselves not to use medical knowledge contrary to the laws of humanity, unless such an oath is interpreted literally. In times of war, or other emergency in which creed or country are at stake, few doctors would interpret the oath literally. A literal interpretation excludes membership of Armed Forces, since it is the duty of the doctor in the forces to keep men fit to fight, and to kill if necessary. Once any latitude is allowed in the interpretation of the oath to respect human life, then its meaning will vary according to the weight given to other obligations. It may not be difficult to decide not to become medical officer to a gang of thieves or murderers, but when country or creed are at stake the opponent, and that for which he stands, are considered so evil that respect for human life is of secondary importance. PETER DUPRÉ. Withyham, Sussex. A COLLEGE OF GENERAL PRACTITIONERS ?
at the the threshold of an EVOLUTION OF THE TOXIC THYROID GLAND intellectual renaissance. For the last few years medicoSIR,—Mr. Levitt’s attempt (Nov. 24, p. 957) to unify political issues have kept below the surface a slow but our concept of the various diseases of the thyroid gland steady evolution of ideas in the minds of thinking into one of transition from epithelial hyperplasia through doctors in and out of general practice ; and increasingly increasing lymphoid infiltration to Hashimoto’s disease these ideas are coming out into the open for discussion, and final fibrosis is interesting but not completely criticism, and consideration in the medicaljournals. convincing. From Dr. Hunt and Dr. Rose has come a lead which, In 1948 Dr. Davson and I’studied a series of 121 if resolutely followed, might enable many of these in whom thyroidectomy had been performed patients evolutionary developments to find concrete expression. and where the histological sections showed various stages General practice is not a specialty. It is the senior form of lymphocytic infiltration. The histological pictures of medical discipline, and has been carried on, well or grouped themselves conveniently into a continuous badly, in many forms, for as many centuries as man series, from typical thyrotoxicosis to lymphadenoid has cared for the health of man. Only in recent history goitre, with intervening changes of increasing lymphoid has it given birth to specialties within itself-medicine, Huertle-cell changes, fibrosis, and increasing infiltration, surgery, obstetrics, and others. and disorganisation of the vesicles. Clinically atrophy By the very nature of their work in the corporate this series presented a gradual over-all change from toxic departments of the developing hospitals, the specialists goitre to non-toxic enlargement of the thyroid gland. have been able and encouraged to combine and pool But this was only to be expected if histological intertheir knowledge in the interest of their calling. They has any value. What our investigation did not pretation organised themselves, and the country must be for ever prove, and Mr. Levitt has not proved either, is that these grateful that as a result of their actions the three great are changes through which the most advanced cases have Royal Colleges were born. passed and the less advanced cases may pass By tradition the general practitioner worked alone previously in future. No case of lymphadenoid goitre has ever been he lived with his patients and worked in his practice observed to change to Riedl’s thyroiditis. McClintock area as an independent unit of health care. No opporand 2 reported a case of recurrent lymphadenoid tunity arose for the body of knowledge in the minds of goitreWright where partial thyroidectomy was performed twice those in general practice to become combined and with an interval of 9 years. Histological sections showed coordinated ; and general practice, the mother of the no progression towards Riedl’s disease. specialties, remained static while her children prospered From our cases it seemed to us more likely that both and outgrew her. While the good work of the colleges lymphocytic infiltration and epithelial proliferation ar& went on, before and after their royal charters were expressions of the functional state of the thyroid gland. granted to them, the work in general practice never What determines the difference in the behaviour of the ceased. Practitioners lived and died, each having learnt in different patients is a matter for speculation. gland much and published little or nothing. The general We tried to show that it depend on the capacity of practitioners handled, and they handle to this day, at the gland to increase its may either focally or blood-supply, least 75% of the country’s illness, and they carry this in response to the functional demands of throughout, burden alone. increased thyrotropic stimulation. If and where this. Dr. Hunt and Dr. Rose have shown us how we may fails, the relative ischaemia leads to lymphocytic infiltraachieve the fulfilment of the next stage in the natural, tion instead of the epithelial changes of thyrotoxicosis. and inevitable, evolution and development of general As failure to increase blood-supply is more likely to occur practice ; for the establishment of a College of General with increasing age, it may not be surprising that Mr. Practitioners would be no more and no less than this. Levitt’s series showed an increase in age with increasing’ General practitioners must achieve their college as infiltration. lymphocytic their right and just due. They owe it to the memory of Victoria Memorial Jewish Hospital, countless generations of predecessors in their practices H. M. GOLDBERG. Manchester. that they accept no compromise title which carries with 1. Goldberg, H. M., Davson, J. Brit. J. Surg. 1948, 36, 41. it the implication of inferiority to a college. General 2. McClintock, J. C., Wright, A. W. Ann. Surg. 1937, 106, 11.
SIR,—The general practice of medicine could
present
.
have been in a position of inferiority vis-a-vis the specialists for years, and it is this that they seek to amend. Were such an alternative title to be accepted, future general practitioners would bear the handicap of a decision made on the grounds of the political expediency of the moment, and they would have good cause to reproach those who lacked the courage to stand firm. In British usage a college will always rank higher than any other academic body, and no lesser title .can be acceptable for the senior discipline of the medical art. The Royal Colleges have nothing to fear from general practice. Nothing in its successes or failures can dim the lustre of their achievements of the past and future ; but they will be the first to admit that general practice is not a new development seeking to establish itself as a specialty beside them, but the oldest medical discipline of all, becoming articulate for the first time in its history. A renaissance of general medical practice could not but benefit medicine as a whole, and if every branch and division of medical thought gives of its best to add flesh and substance to the College of General Practitioners, that college will take its place worthily alongside all other organisations of men with the interest of their profession at heart. R. J. F. H. PINSENT. Birmingham.
practitioners a
moment be
standing
on