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HEREDITARY HÆMORRHAGIC TELANGIECTASIA
35 the 46
cases
that have been described included 11 in
palsy resulted. Campbell emphasises that, though they are growing, these tumours are pathologically benign and .that there is no justification for deliberate sacrifice of the facial nerve. The nerve runs an extremely superficial course in young children, but a careful technique should ensure that accidental damage is rare. Further knowledge of the natural history of the lesion, which facial
however, would make it easier to decide whether the
operation is always justified or whether there may be a group in which it is wisest to delay. The impression is that this is one of those subjects in which much more experience and knowledge must exist than has been recorded. HEREDITARY HÆMORRHAGIC
TELANGIECTASIA
THE odd condition called hereditary haemorrhagic which can cause serious bleeding from mucous membranes, especially from the nose, has been known for a long time. Gawen Sutton,1 in 1864, described some curious cases of recurrent epistaxis, and Babington,2 in 1865, contributed a letter to our columns briefly listing members of 5 generations in a single family who had suffered from epistaxis ; but neither of these physicians had any clue to the cause of3 the epistaxis in their patients. Just 80 years ago Legg gave a paper to the Royal Medico-Chirurgical Society of London on a case of haemophilia complicated by multiple naevi " ;; we should not now use the name haemophilia, but there is no doubt about the nævi. This seems to be the first case of haemorrhagic telangiectasia to be properly described, though the credit is usually given to Rendu4 in 1896 and Osler 5 in 1901, who really gave an adequate description of the disease, noted its hereditary character, and correctly ascribed the haemorrhage to disease of the blood-vessels and not to any abnormality in blood-
telangiectasia,
"
clotting. Eponyms are now out haemorrhagic telangiectasia
of favour, and hereditary is the name used in all the textbooks. There are, as Stefanini and Dameshek 6 point out, two basic vascular abnormalities : in the first. there are localised areas where the walls of the capillaries are extremely thin, being reduced to the endothelial layer only ; in the second, there are visible dilatations of arterioles and capillaries which can lead to the formation of arteriovenous aneurysms, especially in the lung. The telangiectases are normally much brighter in colour, with bigger visible vessels, than the spider nævi associated with liver disease. Their commonest site is in the nose, but careful inspection of affected patients nearly always reveals them on the lips and tongue, under the nails, and elsewhere in the skin, especially of the face and ears. The commonest form of bleeding is epistaxis, but haemoptysis, melsena, and hæmaturia are quite frequent. Landau et al. described a family in which conjunctival and retinal lesions were prominent. The hereditary nature of the abnormality is well established as a simple dominant affecting both sexes. The most striking example is that given in Wintrobe’s textbook 8 : a Mormon with hæmorrhagic telangiectasia had 22 children by his 4 wives and 10 of these children were affected in their turn ; these affected members of the family passed on the disease for another three or four generations, and no less than 82 affected descendants of the original progenitor were known in this family when the list was put together. It is clear from this and other examples 1. 2.
Sutton, H. G. Medical Mirror, 1864, 1, 769. Babington, B. G. Lancet, 1865, ii, 362. 3. Legg, W. Ibid, 1876, ii, 856. 4. Rendu, M. Bull. mém. Soc. méd. Hôp., Paris, 1896, 13, 731. 5. Osier, W. Johns Hopk. Hosp. Bull. 1901, 12, 333. 6. Stefanini, M., Dameshek, W. The Hemorrhagic Disorders. New York, 1955 ; p. 49. 7. Landau, J., Nelken, E., Davis. E. Lancet, 1956, ii, 230. 8. Wintrobe, M. M. Clinical Hematology. London, 1951 ; p. 794.
that unaffected individuals do not pass on the disease. There is also some evidence suggesting that the type of lesion is also inherited ; thus, arteriovenous aneurysms are common in some affected families and never occur in others. The diagnosis of the disease is not difficult if its existence is borne in mind and if the characteristic lesions on the lips, tongue, or face, or under the nails are sought in every case of recurrent epistaxis, melaena, or other bleeding for which there is no obvious cause. The disease can be quite mild or it can be a serious burden to the patient because of the gradually increasing anaemia caused by repeated bleeding over many years. The anaemia is of the iron-deficiency type, and, if the condition has been neglected, it often fails to respond to oral iron and needs parenteral iron for its effective treatment. Sometimes blood-transfusion is needed to restore the haemoglobin content of the blood as soon as possible to a safe level. The seriously affected patient may lead a miserable existence, always at the mercy of a recurrent haemorrhage that his family doctor may be unable to control; and, if the bleeding is from an inaccessible site like the alimentary tract, admission to hospital and blood-transfusion are inevitable. The nasal, labial, and buccal telangiectases can be directly attacked. Several methods of applying pressure have been devised, and direct application of a thrombin Various escharotics, spray will often stop the including X rays, radium, and electrocoagulation, have been tried, but they nearly always fail because new lesions tend to appear near the site of their application. Cochrane and Leslie,9 however, were able to check bleeding in a patient with angiomas of the scalp and face by a small dose of contact X rays. A quite different approach has been by way of treatment with cestrogens. This method arose from the observation that in affected women bleeding seemed to be worse at the end of the menstrual cycle and sometimes subsided spontaneously shortly after the onset of menstruation ; so the bleeding was worst at a time when secretion of cestrogens is low and urinary excretion of gonadotrophins is relatively increased. Acting on this idea, Koch et al.10treated 5 patients with ethinyl cestradiol, using doses of 0.25 mg. daily-about ten times In the dose given to control menopausal symptoms. males, 5 mg. daily of methyl testosterone was given to counteract feminising side-effects. Koch et al. claimed considerable success, but Stefanini and Dameshek,6 for example, found the treatment of no value. Harrison,l1 at Guy’s Hospital, has lately re-examined this form of treatment applied to 4 patients (2 men and 2 women) He began by giving 0.25 mg. with typical lesions. cestradiol ethinyl daily, but gradually increased the dose to 1 mg. daily in both women and 1 of the men ; the men were also given 5 mg. methyl testosterone daily. In spite of these large doses, the only side-effect was that 1 of the women had a uterine haemorrhage after three months, but this did not recur in spite of continued treatment. All the patients were much improved, and the haemorrhages from the telangiectases were much less At the time of his common or even stopped altogether. Harrison had not the treatment ; Koch report, stopped et al. found that bleeding returned three weeks after oestrogens were stopped, and Harrison therefore proposed to reduce the dose gradually to try to find a minimum level for each patient; but he had no results to report at the time. Sections of tissue from the inferior turbinates were taken before and after treatment in 2 cases, and they showed that the normal columnar epithelium had changed to a squamous one. It may in fact be this change which protects the telangiectases from trauma
bleeding.
9. Cochrane, T., Leslie, G. Lancet, 1950, i, 255. 10. Koch, H. J., Escher, G. C., Lewis, J. S. J. Amer. med. Ass. 1952, 149, 1376. 11. Harrison, D. F. N. Guy’s Hosp. Rep. 1956, 105, 246.
36 and therefore makes them less likely to bleed. The oestrogen treatment of telangiectasia thus seems worth a trial in severely handicapped patients ; but, as Harrison emphasises, it is unwise to give 1 mg. of oestrogen a day for long periods to young persons, and he suggests that the treatment should be restricted to women who have passed the menopause and to men of comparable age.
TOADSTOOLS To garner and consume the wild fruits of the earth is a pursuit so innocent and with such happy associations that the rare death caused by poisonous fungi is the more Our European neighbours are bitter to contemplate. more venturesome than we are and are said to pay the penalty more often.12 It surprised us to learn that the same peril threatens the ignorant in the Union of South Africa and that our own Amanita phalloides may be the species responsible. (Is it a native of those parts or a chance introduction given in exchange for the nerine and the gladiolus ?) Steyn et awl. describe two disasters which ended in the death of 5 out of 9 of those who had been tempted by the prevalence of "mushrooms" in a place where the arid climate makes them a rarity. The history and symptoms showed no unusual features, but the account includes a valuable résumé of the present knowledge of the toxic effects of fungi other than A. phalloides. There is a satisfying agreement between the pharmacology of the specifically poisonous species and the symptoms which they produce. A. phalloides contains amanitine with a delayed hepatotoxic action, like phosphorus. A. muscaria and A. pantherina contain muscarine (parasympathomimetic) and myceto-atropine (parasympatholytic) : symptoms and treatment will depend upon which of these antagonists is the more abundant. Both species, by the way, taste horrid. The Besides- these, genus Inocybe contains muscarine alone. there are many species described as " sometimes poison" ous and that should be warning enough, even though one of these is named Helvella esculenta. The traveller in France who finds strange and flabby shapes on his plate will be comforted if he sees others eating the same dish ; in some instances his palate will be rewarded. If on his return he wishes to persuade his wife to add variety to his diet, he will be foolish if he does not arm himself with the Ministry of Agriculture’s guide to epicurean adventure.4 THYROXINE-LIKE ACTION OF ASPIRIN As long ago as 1919, Barbour and Devenis5 showed that single doses of aspirin caused an increase in both oxygen consumption and carbon-dioxide output in normal persons. These observations were confirmed a few years ago by Cochran,6and now Alexander and Johnsonhave shown that the low basal oxygen consumption (B.M.R.) of patients with myxœdema can be restored to normal by giving aspirin in doses of about 8 g. (gr. 120) daily. They also showed that their patients’ serum-cholesterol levels fell during treatment with aspirin. The two measurements of B.M.R. and serum-cholesterol are normally taken as the best objective index of response to thyroid-hormone treatment ; and in both these respects Alexander and Johnson’s patients responded as well to aspirin as they did to triiodothyronine. But they did not feel any better : although warmer, they were still sluggish and sleepy ; skin and voice remained characteristic of the myxcedematous state ; and they did not These observations recall Dodds and lose weight. 1. 2. 3.
4. 5. 6. 7.
Dubash, H. J., Teare, D. Brit. med. J. 1946, i, 45. Lewes, D. Ibid, 1948, ii, 383. Steyn, D. G., Steyn, D. W., van der Westhuizen, G. C. A., Louwrens, B. A. S. Aft. med. J. 1956, 30, 885. Edible and Poisonous Fungi. Ministry of Agriculture, Fisheries, and Food Bulletin no. 23. H.M. Stationery Office, 1952. Barbour, H. G., Devenis, M. M. Arch. intern. Med. 1919, 24, 617. Cochran, J. B. Brit. med. J. 1952, ii, 964. Alexander, W. D., Johnson, K. W. M. Clin. Sci. 1956, 15, 594.
Robertson’s demonstration8 that dinitro-o-cresol can restore the B.M.R. to normal, without changing the clinical signs of myxœdema-although in this instance the analogy with thyroxine is less close, because dinitrophenols do Alexander and not affect the serum-cholesterol,9 Johnson’s work shows clearly that neither a rise in B.M.R. nor a fall in serum-cholesterol, even occurring simultaneously, can be regarded as specific effects of the thyroid hormones. Alexander and Johnson have drawn certain practical conclusions from their findings. Two of their patients had angina, which was apparently unaffected by the rise in B.M.R. brought about by aspirin, although it became when an approximately equal rise was induced with triiodothyronine. They go on to suggest that a mixture of aspirin with very small doses of triiodothyro. nine or thyroxine might be rational treatment for those difficult cases of myxoedema in which angina is induced (or aggravated) by thyroid preparations. But it is hard to see that such patients would be any better off after the consumption of large doses of aspirin, for Alexander and Johnson showed that it does not make them feel any better. The only hypothetical benefit from this combined treatment would come from the lowering of the serum. cholesterol level. There is certainly some as yet undefined association between serum-cholesterol levels and the occurrence of coronary atherosclerosis ; but it is not known whether lowering the serum-cholesterol level actually retards the development of coronary disease. At the moment, this hypothesis, interesting though it is, hardly seems to justify imposing on patients the side. effects of large doses of aspirin. In a further suggestion of more immediate practical importance, Alexander and Johnson point out that patients with rheumatic heart-disease are .often treated with large doses of aspirin, and that in some cases the increase in metabolic rate induced by aspirin may add considerably to the burden on the heart. This is clearly something that needs investigation, but in the meantime it seems desirable not to prolong aspirin medication in acute rheumatism after the rheumatic - process has subsided. THE REFUGEES OF the two-score medical refugees who have so far reached these shores from Hungary, some plan to remain All are here and others to continue their journey. anxious for news of when they can travel or how they may obtain employment here. Employment.-The Ministry of Health has not announced worse
any special arrangements for the employment of refugee doctors in British hospitals ; but there is reason to hope that regional boards will establish temporary supernumerary posts. Inquiries regarding professional opportunities here and overseas may be addressed to the British Medical Association’s International Medical Visitors Bureau, B.M.A. House, Tavistock Square, London, W.C.1 (tel. Euston 4499). Finance.- Refugees who have left official transit camps and hostels rnay apply to the local office of the National Assistance Board for regular grants. Those needing money for special expenses, such as clothes and necessary journeys, should write to the Lancet office, where a small fund has been started for this purpose.lo Accommodation.-We are in touch with medical households who have offered accommodation to Hungarian colleagues, and will try to find a temporary home for anyone needing it. -
Inquiries or requests for help should be addressed either office or to Brigadier H. A. Sandiford, M.C.,
to this
medical director of the B.M.A.’s International Medical Visitors Bureau. 8. 9.
Dodds, E. C., Robertson, J. D. Lancet, 1933, ii, 1197. Cutting, W. C., Ryfand, D. A., Tanifer, M. L. J. clin. Invest. 1934, 13, 547. 10. Further contributions would be welcome, and are likely to be quickly used : the aim is to distribute immediately small sums for emergency needs. Cheques should be made out to The Editor and crossed "Hungarian Doctors Account."
cases
that have been described included 11 in
palsy resulted. Campbell emphasises that, though they are growing, these tumours are pathologically benign and .that there is no justification for deliberate sacrifice of the facial nerve. The nerve runs an extremely superficial course in young children, but a careful technique should ensure that accidental damage is rare. Further knowledge of the natural history of the lesion, which facial
however, would make it easier to decide whether the
operation is always justified or whether there may be a group in which it is wisest to delay. The impression is that this is one of those subjects in which much more experience and knowledge must exist than has been recorded. HEREDITARY HÆMORRHAGIC
TELANGIECTASIA
THE odd condition called hereditary haemorrhagic which can cause serious bleeding from mucous membranes, especially from the nose, has been known for a long time. Gawen Sutton,1 in 1864, described some curious cases of recurrent epistaxis, and Babington,2 in 1865, contributed a letter to our columns briefly listing members of 5 generations in a single family who had suffered from epistaxis ; but neither of these physicians had any clue to the cause of3 the epistaxis in their patients. Just 80 years ago Legg gave a paper to the Royal Medico-Chirurgical Society of London on a case of haemophilia complicated by multiple naevi " ;; we should not now use the name haemophilia, but there is no doubt about the nævi. This seems to be the first case of haemorrhagic telangiectasia to be properly described, though the credit is usually given to Rendu4 in 1896 and Osler 5 in 1901, who really gave an adequate description of the disease, noted its hereditary character, and correctly ascribed the haemorrhage to disease of the blood-vessels and not to any abnormality in blood-
telangiectasia,
"
clotting. Eponyms are now out haemorrhagic telangiectasia
of favour, and hereditary is the name used in all the textbooks. There are, as Stefanini and Dameshek 6 point out, two basic vascular abnormalities : in the first. there are localised areas where the walls of the capillaries are extremely thin, being reduced to the endothelial layer only ; in the second, there are visible dilatations of arterioles and capillaries which can lead to the formation of arteriovenous aneurysms, especially in the lung. The telangiectases are normally much brighter in colour, with bigger visible vessels, than the spider nævi associated with liver disease. Their commonest site is in the nose, but careful inspection of affected patients nearly always reveals them on the lips and tongue, under the nails, and elsewhere in the skin, especially of the face and ears. The commonest form of bleeding is epistaxis, but haemoptysis, melsena, and hæmaturia are quite frequent. Landau et al. described a family in which conjunctival and retinal lesions were prominent. The hereditary nature of the abnormality is well established as a simple dominant affecting both sexes. The most striking example is that given in Wintrobe’s textbook 8 : a Mormon with hæmorrhagic telangiectasia had 22 children by his 4 wives and 10 of these children were affected in their turn ; these affected members of the family passed on the disease for another three or four generations, and no less than 82 affected descendants of the original progenitor were known in this family when the list was put together. It is clear from this and other examples 1. 2.
Sutton, H. G. Medical Mirror, 1864, 1, 769. Babington, B. G. Lancet, 1865, ii, 362. 3. Legg, W. Ibid, 1876, ii, 856. 4. Rendu, M. Bull. mém. Soc. méd. Hôp., Paris, 1896, 13, 731. 5. Osier, W. Johns Hopk. Hosp. Bull. 1901, 12, 333. 6. Stefanini, M., Dameshek, W. The Hemorrhagic Disorders. New York, 1955 ; p. 49. 7. Landau, J., Nelken, E., Davis. E. Lancet, 1956, ii, 230. 8. Wintrobe, M. M. Clinical Hematology. London, 1951 ; p. 794.
that unaffected individuals do not pass on the disease. There is also some evidence suggesting that the type of lesion is also inherited ; thus, arteriovenous aneurysms are common in some affected families and never occur in others. The diagnosis of the disease is not difficult if its existence is borne in mind and if the characteristic lesions on the lips, tongue, or face, or under the nails are sought in every case of recurrent epistaxis, melaena, or other bleeding for which there is no obvious cause. The disease can be quite mild or it can be a serious burden to the patient because of the gradually increasing anaemia caused by repeated bleeding over many years. The anaemia is of the iron-deficiency type, and, if the condition has been neglected, it often fails to respond to oral iron and needs parenteral iron for its effective treatment. Sometimes blood-transfusion is needed to restore the haemoglobin content of the blood as soon as possible to a safe level. The seriously affected patient may lead a miserable existence, always at the mercy of a recurrent haemorrhage that his family doctor may be unable to control; and, if the bleeding is from an inaccessible site like the alimentary tract, admission to hospital and blood-transfusion are inevitable. The nasal, labial, and buccal telangiectases can be directly attacked. Several methods of applying pressure have been devised, and direct application of a thrombin Various escharotics, spray will often stop the including X rays, radium, and electrocoagulation, have been tried, but they nearly always fail because new lesions tend to appear near the site of their application. Cochrane and Leslie,9 however, were able to check bleeding in a patient with angiomas of the scalp and face by a small dose of contact X rays. A quite different approach has been by way of treatment with cestrogens. This method arose from the observation that in affected women bleeding seemed to be worse at the end of the menstrual cycle and sometimes subsided spontaneously shortly after the onset of menstruation ; so the bleeding was worst at a time when secretion of cestrogens is low and urinary excretion of gonadotrophins is relatively increased. Acting on this idea, Koch et al.10treated 5 patients with ethinyl cestradiol, using doses of 0.25 mg. daily-about ten times In the dose given to control menopausal symptoms. males, 5 mg. daily of methyl testosterone was given to counteract feminising side-effects. Koch et al. claimed considerable success, but Stefanini and Dameshek,6 for example, found the treatment of no value. Harrison,l1 at Guy’s Hospital, has lately re-examined this form of treatment applied to 4 patients (2 men and 2 women) He began by giving 0.25 mg. with typical lesions. cestradiol ethinyl daily, but gradually increased the dose to 1 mg. daily in both women and 1 of the men ; the men were also given 5 mg. methyl testosterone daily. In spite of these large doses, the only side-effect was that 1 of the women had a uterine haemorrhage after three months, but this did not recur in spite of continued treatment. All the patients were much improved, and the haemorrhages from the telangiectases were much less At the time of his common or even stopped altogether. Harrison had not the treatment ; Koch report, stopped et al. found that bleeding returned three weeks after oestrogens were stopped, and Harrison therefore proposed to reduce the dose gradually to try to find a minimum level for each patient; but he had no results to report at the time. Sections of tissue from the inferior turbinates were taken before and after treatment in 2 cases, and they showed that the normal columnar epithelium had changed to a squamous one. It may in fact be this change which protects the telangiectases from trauma
bleeding.
9. Cochrane, T., Leslie, G. Lancet, 1950, i, 255. 10. Koch, H. J., Escher, G. C., Lewis, J. S. J. Amer. med. Ass. 1952, 149, 1376. 11. Harrison, D. F. N. Guy’s Hosp. Rep. 1956, 105, 246.
36 and therefore makes them less likely to bleed. The oestrogen treatment of telangiectasia thus seems worth a trial in severely handicapped patients ; but, as Harrison emphasises, it is unwise to give 1 mg. of oestrogen a day for long periods to young persons, and he suggests that the treatment should be restricted to women who have passed the menopause and to men of comparable age.
TOADSTOOLS To garner and consume the wild fruits of the earth is a pursuit so innocent and with such happy associations that the rare death caused by poisonous fungi is the more Our European neighbours are bitter to contemplate. more venturesome than we are and are said to pay the penalty more often.12 It surprised us to learn that the same peril threatens the ignorant in the Union of South Africa and that our own Amanita phalloides may be the species responsible. (Is it a native of those parts or a chance introduction given in exchange for the nerine and the gladiolus ?) Steyn et awl. describe two disasters which ended in the death of 5 out of 9 of those who had been tempted by the prevalence of "mushrooms" in a place where the arid climate makes them a rarity. The history and symptoms showed no unusual features, but the account includes a valuable résumé of the present knowledge of the toxic effects of fungi other than A. phalloides. There is a satisfying agreement between the pharmacology of the specifically poisonous species and the symptoms which they produce. A. phalloides contains amanitine with a delayed hepatotoxic action, like phosphorus. A. muscaria and A. pantherina contain muscarine (parasympathomimetic) and myceto-atropine (parasympatholytic) : symptoms and treatment will depend upon which of these antagonists is the more abundant. Both species, by the way, taste horrid. The Besides- these, genus Inocybe contains muscarine alone. there are many species described as " sometimes poison" ous and that should be warning enough, even though one of these is named Helvella esculenta. The traveller in France who finds strange and flabby shapes on his plate will be comforted if he sees others eating the same dish ; in some instances his palate will be rewarded. If on his return he wishes to persuade his wife to add variety to his diet, he will be foolish if he does not arm himself with the Ministry of Agriculture’s guide to epicurean adventure.4 THYROXINE-LIKE ACTION OF ASPIRIN As long ago as 1919, Barbour and Devenis5 showed that single doses of aspirin caused an increase in both oxygen consumption and carbon-dioxide output in normal persons. These observations were confirmed a few years ago by Cochran,6and now Alexander and Johnsonhave shown that the low basal oxygen consumption (B.M.R.) of patients with myxœdema can be restored to normal by giving aspirin in doses of about 8 g. (gr. 120) daily. They also showed that their patients’ serum-cholesterol levels fell during treatment with aspirin. The two measurements of B.M.R. and serum-cholesterol are normally taken as the best objective index of response to thyroid-hormone treatment ; and in both these respects Alexander and Johnson’s patients responded as well to aspirin as they did to triiodothyronine. But they did not feel any better : although warmer, they were still sluggish and sleepy ; skin and voice remained characteristic of the myxcedematous state ; and they did not These observations recall Dodds and lose weight. 1. 2. 3.
4. 5. 6. 7.
Dubash, H. J., Teare, D. Brit. med. J. 1946, i, 45. Lewes, D. Ibid, 1948, ii, 383. Steyn, D. G., Steyn, D. W., van der Westhuizen, G. C. A., Louwrens, B. A. S. Aft. med. J. 1956, 30, 885. Edible and Poisonous Fungi. Ministry of Agriculture, Fisheries, and Food Bulletin no. 23. H.M. Stationery Office, 1952. Barbour, H. G., Devenis, M. M. Arch. intern. Med. 1919, 24, 617. Cochran, J. B. Brit. med. J. 1952, ii, 964. Alexander, W. D., Johnson, K. W. M. Clin. Sci. 1956, 15, 594.
Robertson’s demonstration8 that dinitro-o-cresol can restore the B.M.R. to normal, without changing the clinical signs of myxœdema-although in this instance the analogy with thyroxine is less close, because dinitrophenols do Alexander and not affect the serum-cholesterol,9 Johnson’s work shows clearly that neither a rise in B.M.R. nor a fall in serum-cholesterol, even occurring simultaneously, can be regarded as specific effects of the thyroid hormones. Alexander and Johnson have drawn certain practical conclusions from their findings. Two of their patients had angina, which was apparently unaffected by the rise in B.M.R. brought about by aspirin, although it became when an approximately equal rise was induced with triiodothyronine. They go on to suggest that a mixture of aspirin with very small doses of triiodothyro. nine or thyroxine might be rational treatment for those difficult cases of myxoedema in which angina is induced (or aggravated) by thyroid preparations. But it is hard to see that such patients would be any better off after the consumption of large doses of aspirin, for Alexander and Johnson showed that it does not make them feel any better. The only hypothetical benefit from this combined treatment would come from the lowering of the serum. cholesterol level. There is certainly some as yet undefined association between serum-cholesterol levels and the occurrence of coronary atherosclerosis ; but it is not known whether lowering the serum-cholesterol level actually retards the development of coronary disease. At the moment, this hypothesis, interesting though it is, hardly seems to justify imposing on patients the side. effects of large doses of aspirin. In a further suggestion of more immediate practical importance, Alexander and Johnson point out that patients with rheumatic heart-disease are .often treated with large doses of aspirin, and that in some cases the increase in metabolic rate induced by aspirin may add considerably to the burden on the heart. This is clearly something that needs investigation, but in the meantime it seems desirable not to prolong aspirin medication in acute rheumatism after the rheumatic - process has subsided. THE REFUGEES OF the two-score medical refugees who have so far reached these shores from Hungary, some plan to remain All are here and others to continue their journey. anxious for news of when they can travel or how they may obtain employment here. Employment.-The Ministry of Health has not announced worse
any special arrangements for the employment of refugee doctors in British hospitals ; but there is reason to hope that regional boards will establish temporary supernumerary posts. Inquiries regarding professional opportunities here and overseas may be addressed to the British Medical Association’s International Medical Visitors Bureau, B.M.A. House, Tavistock Square, London, W.C.1 (tel. Euston 4499). Finance.- Refugees who have left official transit camps and hostels rnay apply to the local office of the National Assistance Board for regular grants. Those needing money for special expenses, such as clothes and necessary journeys, should write to the Lancet office, where a small fund has been started for this purpose.lo Accommodation.-We are in touch with medical households who have offered accommodation to Hungarian colleagues, and will try to find a temporary home for anyone needing it. -
Inquiries or requests for help should be addressed either office or to Brigadier H. A. Sandiford, M.C.,
to this
medical director of the B.M.A.’s International Medical Visitors Bureau. 8. 9.
Dodds, E. C., Robertson, J. D. Lancet, 1933, ii, 1197. Cutting, W. C., Ryfand, D. A., Tanifer, M. L. J. clin. Invest. 1934, 13, 547. 10. Further contributions would be welcome, and are likely to be quickly used : the aim is to distribute immediately small sums for emergency needs. Cheques should be made out to The Editor and crossed "Hungarian Doctors Account."