- Email: [email protected]
GENEALOGY OF LIPOID PROTEINOSIS
162 and increase assets of E8 million (they have grown in three years from E4 6 million) Nature relates that the Fund’s new laboratory will cost El-75 million and that the consequent increase in running costs will mean an extra E700,000 a year. The Lancet believes thrt the Fund is well equipped to meet this outlay-and much more-from its rapidly multiplying resources. As for the argument that the Fund must secure, augment, and protect vast capital in order to derive an income which matches what the Institute gets from the M.R.C. and the B.E.C.C.R., that view discounts the contention of Nature (and presumably of the what Fund) that " a more fruitful line of thought is constitutes cancer research ". Cancer research is anything which will conceivably help to solve a problem that is almost certainly finite. Why, the obvious question runs, cannot more of the E8 million be spent quickly in the hope of reaching one or two of the answers in ten years rather than twenty ?-ED. L. ...
MALIGNANCY IN THYROID NODULES
SIR,-May we make certain points in reply to the letter of Dr. Condon and Dr. Kendall (July 12, p. 109) ? We did not claim that over 4% of the Glasgow population had a solitary thyroid nodule. There have been no large-scale population studies in this area to supply such data. What we did say was that our experience was similar to the Framingham study in that solitary thyroid nodules were rarely malignant. Although we adopt a more conservative policy towards thyroid nodules than the Chicago group, we in fact recommended operation on 198 solitary nodules over a six-year period as compared with 91 solitary nodules operated on in a five-year period in Chicago. In only 5 of the 198 patients was an unsuspected tumour found in the resected specimen. If the figures of Dr. Condon and Dr. Kendall do have worldwide applicability this would imply that in our selection process we have managed to select for operation all the non-neoplastic glands while leaving most of the neoplastic glands in situ. Careful clinical follow-up has shown
no
evidence of this.
This low incidence of malignancy must be set against the morbidity of thyroidectomy-which is by no means negligible-when recommending excision of all nodules. One further point is that the scanning procedure used by the authors (a manual scan using a simple end-window Geiger tube) would not now be accepted as giving a reliable separation of the uptake of 131I in a nodule from
that in the surroundins tissue.1 University Department of Medicine, Royal Infirmary, Glasgow C.4.
JOHN A. THOMSON IVOR M. D. JACKSON.
CODING OF DISEASES
SIR,-Many governments are committed to using the but this International Classification of Diseases, &c., classification is becoming so complex that some countries may be forced to stop using it simply for reasons of economy. Frequent revisions of the classification clearly endanger the continuity of statistics, but the situation is now so out of hand that revision seems essential-with regard to the tumour classification, at least. For neoplasms, the
existing system
uses
99
numbers, of which only about two-thirds relate 1.
primary to
the
Thomson, J. A., Jackson, I. M. D. Br. J. Surg. 1969, 56, 351.
anatomical classification of malignant tumours. Most of the remainder are used for the designation of benign and undetermined types; so benign and malignant tumours at the same site have quite different designations. At the same time, anatomical entities may have to be designated by three digits-for example, the appendix must be classified by an additional digit for the large intestine. Also, the designation of premalignant and preinvasive lesions causes
problems. The solution seems quite simple. Those who do the revision should classify all neoplasms according to site-which is reasonably closely related to aetiology (so far as it is known), symptoms, methods of diagnosis and treatment, and prognoses. More detailed anatomical subdivisions might be devised for certain sites and could in part be optional. Then, for each site, a digit could be added to indicate the degree of malignancy-e.g., unde-
next
termined=0; benign = 1, premalignant=2; preinvasive=3; locally invasive=4; malignant=5; metastasis 6. A histological classification presents difficulties because of differences in technique and nomenclature; but a classification might be based on the fact that the histological types of neoplasm at any given site are limited, and that usually a few types predominate. Thus, if the number of possible types should exceed the nine possibilities allowed by one digit, a single number would usually suffice to categorise the rarer types. If analogous changes are needed in other areas, then clearly the whole classification should be revised. A simplified system, such as that proposed above, would save much of the time of coding clerks; and countries which are considering abandoning the International Classification because of its complexity might be dissuaded from
doing
so.
Danish Cancer Registry,
Copenhagen.
JOHANNES CLEMMESEN.
GENEALOGY OF LIPOID PROTEINOSIS
SIR,-I was greatly interested in the article by Dr. Gordon colleagues1 about a genealogical study of lipoid proteinosis in an isolated Cape Coloured community in South Africa. The results of their study are in close agree-
and his
with similar investigations which I have undertaken. I traced the antecedents of 9 White South African patients with lipoid proteinosis. These belonged to 4 apparently quite unrelated families coming from the Cape Peninsula, the Northwestern Cape, the Orange Free State, and the Transvaal respectively. All 4 families could be traced to the original Cloetes who either came to the Cape of Good Hope with the founder of the settlement, Jan van Riebeeck, or arrived shortly afterwards. Jacob Cloete of Cologne, Germany, with his wife, Fytje Raderotjes, were among the first freeburghers at the Cape. His sister, Elsje Cloete, joined them in 1668 and married Schalk Willem v/d Merwe a year later. In my study I could trace all 4 families to either Jacob or Elsje Cloete, or to both. From these findings I presume that all South African " patients of Dutch " extraction with lipoid proteinosis, are descended from the Cloete family. However, extensive research at the Cape Archives failed to produce evidence that any of the original Cloetes had the disease. Apart from the White (" European ") patients, I have also studied 4 Cape Coloured patients. All 4 are descendents of Cloetes, but I have not investigated their exact relationship. They come from the same area as the patients in Dr. Gordon’s series, so they are presumably related to these. It seems to me that the investigative terrain should now
ment
1.
Gordon, H., Gordon, W., Botha,
V.
Lancet, 1969, i,
1032.
163
shift to Cologne, Germany. In this respect it may be important to remember that Cloete was originally spelt in a number of ways—e.g., Kloote, Klute, Kloeten, &c. Bellville, South Africa.
T. HEYL.
ULTRASONICS IN MEDICINE Dr. DOUGLAS GORDON writes: " At the First World Congress on Ultrasonic Diagnosis in Medicine, held in Vienna from June 2 to 7, it was decided to set up an International Federation of Medical Ultrasonics based on the American Institute of Ultrasound in Medicine, the Japanese Society of Ultrasonics in Medicine, and the Societas Intemationalis de Diagnostica Ultrasonica in Ophthalmologia. The British contingent was very small, and was
mainly composed of physicists and representatives of commercial firms. It was therefore decided to defer any decision the formation of a British society to join the International
on
or on the terminology adopted at the congress, until all those interested had had a chance to express an opinion. All those interested, who are not already members of the Ultrasonics Group of the British Hospital Physicists Association, are asked to write to me at Moorfields Eye Hospital, High Holbom, London W.C.l."
Federation,
Appointments BRADFORD, ELIZABETH M. W., M.B. Edin., F.F.A. R.C.S. : consultant anxsthetist, Glasgow Royal Infirmary and associated hospitals. CHEW, H. E. R., M.B. Lond., F.F.A. R.c.s.: consultant anaesthetist, Forest hospital group. DOAR, J. W. H., M.B. Cantab., M.R.C.P. : consultant physician, diabetic clinic, Doncaster hospital group. DUNNIGAN, M. G., M.D. Glasg., M.R.C.P.G., M.R.C.P.E. : consultant physician, Stobhill General Hospital, Glasgow. HAZLETT, J. J., M.B. Dubl., F.F.A. R.c.s.: consultant anaesthetist, Birkenhead and North Wirral hospital groups. HILL, S. M. B., M.B.E., M.B. Belf.: chief M.o., United Kingdom Atomic Energy Authority. HOUSTON, J. R. McN., M.A., M.B. Dubl., F.F.A. R.c.s.: consultant anxsthetist, Forest hospital group. KEEFE, MARY F., M.B. L’pool: deputy senior administrative M.o., personal and child health services, Birmingham. MCCREADIE, COLIN, M.B. Glasg., F.R.C.S.E.: consultant urological surgeon, Victoria Hospital, Kirkcaldy. PENNINGTON, J. H., M.D. Cantab., M.C.PATH.: consultant pathologist, Sefton General Hospital, Liverpool. RowE-JONES, D. C., M.B. Lond., F.R.C.S:: consultant general surgeon, Bournemouth and East Dorset area. S. A., M.B. St. Andrews, M.R.C.P.E. : consultant geriatrician, Border Counties. TRANTER, A. W., M.B. Lond., D.P.H., D.C.H. : M.O.H., Lewisham. VERRIER JONES, E. R., M.B. Cantab., M.R.C.P.E., M.R.C.P., D.C.H. : consultant pediatrician, St. David’s Hospital, Cardiff. WILSON, JAMES, M.B. Edin., F.F.A. R.c.s.: consultant anaesthetist. United Leeds Hospitals.
STEPHEN,
Notes and News CHARGES FOR DENTURES AND SPECTACLES
REGULATIONS1 to increase charges on National Health Service spectacles and dentures were laid before Parliament on July 8. The cost of a single lens for spectacles has been put up by 3s. 6d. to 16s., and for bifocals and multifocals by 5s. to 25s. The increase in the charge for dentures depends on the number of teeth specified. A denture with less than 3 teeth will now cost 56s., a rise of lls., with 4 to 8 teeth 62s., a rise of 12s., with more than 8 teeth 69s., a rise of 14s. For a complete course of dental treatment, including the provision of dentures, no-one should pay more than E65s., an increase of 25s. on the former maximum charge. People will be exempt from charges if dentures are supplied to them by hospitals, after they have had an operation which affected the mouth, or as part of treatment for invasive tumours. These new charges will come into force on
Aug. 11. ABORTIONS REFERRING to reports that many women were coming to London from abroad to seek abortion, Mr. Richard Crossman, Secretary of State for Social Services, said last week2 that he was more concerned about the influx of girls from other regions of Britain for abortions in London than about anyone coming from Denmark or Finland. The nationality of patients seeking abortion was not asked for, but Mr. Crossman said that replies from seven London nursing-homes registered for the termination of pregnancy showed that only four Danish women had had abortions between June 1 and July 4 of this year. Much more important than the furore about abortions was the need for a full family-planning service. With some hospitals he was " on the war-path " to see that every woman who had a baby was given advice on contraception. He was not certain that Mr. St. John-Stevas’s proposed amendments to the Abortion Act (see p. 148) would make much difference to the working of the Act. Could not two consultants be found to cover one nursing-home? The situation since the Act was passed was better, not worse, because it had brought into the open what had occurred in back streets. STANDARD MACHINERY FOR COMPLAINTS IN HOSPITALS
in
P. W., M.B. Cantab., M.R.C.P. : consultant physician, Oxford and Banburv area. HILLS, ELIZABETH A., M.B. Lond., M.R.C.P. : consultant physician, Aylesbury and High Wycombe area. PREECE, J. M., M.B., B.sc., Lond., M.C.PATH. : consultant pathologist, High Wycombe and Amersham area.
wish. to make complaints do. The Report of the on Working Party Suggestions and Complaints in Hospitals3 shows that 25 (about a third) of the hospital groups in Scotland have an accepted procedure for dealing with complaints and suggestions, but in only 4 has this procedure been written down. The report recommends that information booklets should be made available to patients, and that notices should be put up in outpatient departments. The ward sister, says the report, should be the first to receive the complaint, preferably oral rather than written, and she should refer comments which cannot be handled at ward level to a senior officer appointed by the board of management. In mental hospitals the nominated officer could refer cases to the Mental Welfare Commission, or patients could approach the Commission directly. More serious cases should be considered by the board of management, and if necessary passed on to the regional board for
Western Regional Hospital Board, Scotland: FLETCHER, D. J. B., M.B. Glasg., D.P.H. : administrative M.O. McCuRLEt, JOHN, M.B. Glasg., D.P.M. : consultant psychiatrist, Dykebar Hospital and Riccartsbar Hospital, Paisley. MowAT, WILLIAM, M.B. Aberd., D.M.R.D.: consultant radiologist, Law Hospital, Carluke.
1. National Health Service (Charges for Appliances) Regulations, 1969. S.I. 1969/906. 2. Times, July 15, 1969. 3. Report of the Working Party on Suggestions and Complaints in Hospitals. Scottish Home and Health Department. H.M. Stationery Office. 5s. 6d.
-
Manchester Regional Hospital Board CHARI, JOSEPH, M.B. Rangoon, F.F.A. R.c.s.: consultant anesthetist, Burnley and District hospital group. KANJILAL, G. C., M.B. Patna, D.T.M., D.P.M. : consultant psychiatrist and medical director, Cranage Hall and Mary Dendy Hospitals, Cheshire.
PURNELL,
L. W., M.B. Lond., M.R.C.O.G. : consultant obstetrician and gynecologist, Rochdale and District hospital group.
Oxford Regional Hospital Board: FISHER,
MANY
patients
may well have
no
hospital who
idea what
to
MALIGNANCY IN THYROID NODULES
SIR,-May we make certain points in reply to the letter of Dr. Condon and Dr. Kendall (July 12, p. 109) ? We did not claim that over 4% of the Glasgow population had a solitary thyroid nodule. There have been no large-scale population studies in this area to supply such data. What we did say was that our experience was similar to the Framingham study in that solitary thyroid nodules were rarely malignant. Although we adopt a more conservative policy towards thyroid nodules than the Chicago group, we in fact recommended operation on 198 solitary nodules over a six-year period as compared with 91 solitary nodules operated on in a five-year period in Chicago. In only 5 of the 198 patients was an unsuspected tumour found in the resected specimen. If the figures of Dr. Condon and Dr. Kendall do have worldwide applicability this would imply that in our selection process we have managed to select for operation all the non-neoplastic glands while leaving most of the neoplastic glands in situ. Careful clinical follow-up has shown
no
evidence of this.
This low incidence of malignancy must be set against the morbidity of thyroidectomy-which is by no means negligible-when recommending excision of all nodules. One further point is that the scanning procedure used by the authors (a manual scan using a simple end-window Geiger tube) would not now be accepted as giving a reliable separation of the uptake of 131I in a nodule from
that in the surroundins tissue.1 University Department of Medicine, Royal Infirmary, Glasgow C.4.
JOHN A. THOMSON IVOR M. D. JACKSON.
CODING OF DISEASES
SIR,-Many governments are committed to using the but this International Classification of Diseases, &c., classification is becoming so complex that some countries may be forced to stop using it simply for reasons of economy. Frequent revisions of the classification clearly endanger the continuity of statistics, but the situation is now so out of hand that revision seems essential-with regard to the tumour classification, at least. For neoplasms, the
existing system
uses
99
numbers, of which only about two-thirds relate 1.
primary to
the
Thomson, J. A., Jackson, I. M. D. Br. J. Surg. 1969, 56, 351.
anatomical classification of malignant tumours. Most of the remainder are used for the designation of benign and undetermined types; so benign and malignant tumours at the same site have quite different designations. At the same time, anatomical entities may have to be designated by three digits-for example, the appendix must be classified by an additional digit for the large intestine. Also, the designation of premalignant and preinvasive lesions causes
problems. The solution seems quite simple. Those who do the revision should classify all neoplasms according to site-which is reasonably closely related to aetiology (so far as it is known), symptoms, methods of diagnosis and treatment, and prognoses. More detailed anatomical subdivisions might be devised for certain sites and could in part be optional. Then, for each site, a digit could be added to indicate the degree of malignancy-e.g., unde-
next
termined=0; benign = 1, premalignant=2; preinvasive=3; locally invasive=4; malignant=5; metastasis 6. A histological classification presents difficulties because of differences in technique and nomenclature; but a classification might be based on the fact that the histological types of neoplasm at any given site are limited, and that usually a few types predominate. Thus, if the number of possible types should exceed the nine possibilities allowed by one digit, a single number would usually suffice to categorise the rarer types. If analogous changes are needed in other areas, then clearly the whole classification should be revised. A simplified system, such as that proposed above, would save much of the time of coding clerks; and countries which are considering abandoning the International Classification because of its complexity might be dissuaded from
doing
so.
Danish Cancer Registry,
Copenhagen.
JOHANNES CLEMMESEN.
GENEALOGY OF LIPOID PROTEINOSIS
SIR,-I was greatly interested in the article by Dr. Gordon colleagues1 about a genealogical study of lipoid proteinosis in an isolated Cape Coloured community in South Africa. The results of their study are in close agree-
and his
with similar investigations which I have undertaken. I traced the antecedents of 9 White South African patients with lipoid proteinosis. These belonged to 4 apparently quite unrelated families coming from the Cape Peninsula, the Northwestern Cape, the Orange Free State, and the Transvaal respectively. All 4 families could be traced to the original Cloetes who either came to the Cape of Good Hope with the founder of the settlement, Jan van Riebeeck, or arrived shortly afterwards. Jacob Cloete of Cologne, Germany, with his wife, Fytje Raderotjes, were among the first freeburghers at the Cape. His sister, Elsje Cloete, joined them in 1668 and married Schalk Willem v/d Merwe a year later. In my study I could trace all 4 families to either Jacob or Elsje Cloete, or to both. From these findings I presume that all South African " patients of Dutch " extraction with lipoid proteinosis, are descended from the Cloete family. However, extensive research at the Cape Archives failed to produce evidence that any of the original Cloetes had the disease. Apart from the White (" European ") patients, I have also studied 4 Cape Coloured patients. All 4 are descendents of Cloetes, but I have not investigated their exact relationship. They come from the same area as the patients in Dr. Gordon’s series, so they are presumably related to these. It seems to me that the investigative terrain should now
ment
1.
Gordon, H., Gordon, W., Botha,
V.
Lancet, 1969, i,
1032.
163
shift to Cologne, Germany. In this respect it may be important to remember that Cloete was originally spelt in a number of ways—e.g., Kloote, Klute, Kloeten, &c. Bellville, South Africa.
T. HEYL.
ULTRASONICS IN MEDICINE Dr. DOUGLAS GORDON writes: " At the First World Congress on Ultrasonic Diagnosis in Medicine, held in Vienna from June 2 to 7, it was decided to set up an International Federation of Medical Ultrasonics based on the American Institute of Ultrasound in Medicine, the Japanese Society of Ultrasonics in Medicine, and the Societas Intemationalis de Diagnostica Ultrasonica in Ophthalmologia. The British contingent was very small, and was
mainly composed of physicists and representatives of commercial firms. It was therefore decided to defer any decision the formation of a British society to join the International
on
or on the terminology adopted at the congress, until all those interested had had a chance to express an opinion. All those interested, who are not already members of the Ultrasonics Group of the British Hospital Physicists Association, are asked to write to me at Moorfields Eye Hospital, High Holbom, London W.C.l."
Federation,
Appointments BRADFORD, ELIZABETH M. W., M.B. Edin., F.F.A. R.C.S. : consultant anxsthetist, Glasgow Royal Infirmary and associated hospitals. CHEW, H. E. R., M.B. Lond., F.F.A. R.c.s.: consultant anaesthetist, Forest hospital group. DOAR, J. W. H., M.B. Cantab., M.R.C.P. : consultant physician, diabetic clinic, Doncaster hospital group. DUNNIGAN, M. G., M.D. Glasg., M.R.C.P.G., M.R.C.P.E. : consultant physician, Stobhill General Hospital, Glasgow. HAZLETT, J. J., M.B. Dubl., F.F.A. R.c.s.: consultant anaesthetist, Birkenhead and North Wirral hospital groups. HILL, S. M. B., M.B.E., M.B. Belf.: chief M.o., United Kingdom Atomic Energy Authority. HOUSTON, J. R. McN., M.A., M.B. Dubl., F.F.A. R.c.s.: consultant anxsthetist, Forest hospital group. KEEFE, MARY F., M.B. L’pool: deputy senior administrative M.o., personal and child health services, Birmingham. MCCREADIE, COLIN, M.B. Glasg., F.R.C.S.E.: consultant urological surgeon, Victoria Hospital, Kirkcaldy. PENNINGTON, J. H., M.D. Cantab., M.C.PATH.: consultant pathologist, Sefton General Hospital, Liverpool. RowE-JONES, D. C., M.B. Lond., F.R.C.S:: consultant general surgeon, Bournemouth and East Dorset area. S. A., M.B. St. Andrews, M.R.C.P.E. : consultant geriatrician, Border Counties. TRANTER, A. W., M.B. Lond., D.P.H., D.C.H. : M.O.H., Lewisham. VERRIER JONES, E. R., M.B. Cantab., M.R.C.P.E., M.R.C.P., D.C.H. : consultant pediatrician, St. David’s Hospital, Cardiff. WILSON, JAMES, M.B. Edin., F.F.A. R.c.s.: consultant anaesthetist. United Leeds Hospitals.
STEPHEN,
Notes and News CHARGES FOR DENTURES AND SPECTACLES
REGULATIONS1 to increase charges on National Health Service spectacles and dentures were laid before Parliament on July 8. The cost of a single lens for spectacles has been put up by 3s. 6d. to 16s., and for bifocals and multifocals by 5s. to 25s. The increase in the charge for dentures depends on the number of teeth specified. A denture with less than 3 teeth will now cost 56s., a rise of lls., with 4 to 8 teeth 62s., a rise of 12s., with more than 8 teeth 69s., a rise of 14s. For a complete course of dental treatment, including the provision of dentures, no-one should pay more than E65s., an increase of 25s. on the former maximum charge. People will be exempt from charges if dentures are supplied to them by hospitals, after they have had an operation which affected the mouth, or as part of treatment for invasive tumours. These new charges will come into force on
Aug. 11. ABORTIONS REFERRING to reports that many women were coming to London from abroad to seek abortion, Mr. Richard Crossman, Secretary of State for Social Services, said last week2 that he was more concerned about the influx of girls from other regions of Britain for abortions in London than about anyone coming from Denmark or Finland. The nationality of patients seeking abortion was not asked for, but Mr. Crossman said that replies from seven London nursing-homes registered for the termination of pregnancy showed that only four Danish women had had abortions between June 1 and July 4 of this year. Much more important than the furore about abortions was the need for a full family-planning service. With some hospitals he was " on the war-path " to see that every woman who had a baby was given advice on contraception. He was not certain that Mr. St. John-Stevas’s proposed amendments to the Abortion Act (see p. 148) would make much difference to the working of the Act. Could not two consultants be found to cover one nursing-home? The situation since the Act was passed was better, not worse, because it had brought into the open what had occurred in back streets. STANDARD MACHINERY FOR COMPLAINTS IN HOSPITALS
in
P. W., M.B. Cantab., M.R.C.P. : consultant physician, Oxford and Banburv area. HILLS, ELIZABETH A., M.B. Lond., M.R.C.P. : consultant physician, Aylesbury and High Wycombe area. PREECE, J. M., M.B., B.sc., Lond., M.C.PATH. : consultant pathologist, High Wycombe and Amersham area.
wish. to make complaints do. The Report of the on Working Party Suggestions and Complaints in Hospitals3 shows that 25 (about a third) of the hospital groups in Scotland have an accepted procedure for dealing with complaints and suggestions, but in only 4 has this procedure been written down. The report recommends that information booklets should be made available to patients, and that notices should be put up in outpatient departments. The ward sister, says the report, should be the first to receive the complaint, preferably oral rather than written, and she should refer comments which cannot be handled at ward level to a senior officer appointed by the board of management. In mental hospitals the nominated officer could refer cases to the Mental Welfare Commission, or patients could approach the Commission directly. More serious cases should be considered by the board of management, and if necessary passed on to the regional board for
Western Regional Hospital Board, Scotland: FLETCHER, D. J. B., M.B. Glasg., D.P.H. : administrative M.O. McCuRLEt, JOHN, M.B. Glasg., D.P.M. : consultant psychiatrist, Dykebar Hospital and Riccartsbar Hospital, Paisley. MowAT, WILLIAM, M.B. Aberd., D.M.R.D.: consultant radiologist, Law Hospital, Carluke.
1. National Health Service (Charges for Appliances) Regulations, 1969. S.I. 1969/906. 2. Times, July 15, 1969. 3. Report of the Working Party on Suggestions and Complaints in Hospitals. Scottish Home and Health Department. H.M. Stationery Office. 5s. 6d.
-
Manchester Regional Hospital Board CHARI, JOSEPH, M.B. Rangoon, F.F.A. R.c.s.: consultant anesthetist, Burnley and District hospital group. KANJILAL, G. C., M.B. Patna, D.T.M., D.P.M. : consultant psychiatrist and medical director, Cranage Hall and Mary Dendy Hospitals, Cheshire.
PURNELL,
L. W., M.B. Lond., M.R.C.O.G. : consultant obstetrician and gynecologist, Rochdale and District hospital group.
Oxford Regional Hospital Board: FISHER,
MANY
patients
may well have
no
hospital who
idea what
to