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HÆMOGLOBIN E AND ERYTHROCYTE GLUCOSE-6-PHOSPHATE DEHYDROGENASE
268 from the neck, but Mr. Knight’s paper makes the mechanism clear. Headaches have now become one of the most rewarding conditions to treat. A single manipulation is usually sufficient, but, like pains referred in this way from other parts of the spine, they often recur at intervals of a year or two, and I now find that patients who have been relieved in this way come up spontaneously and ask to have their " necks wrung " when they get a recurrence.
thalassaemia major, 2 individuals with haEmoglobin-D trait, a family in which 2 members had sickle-cell anxmia and 2 had sickle-cell trait, and a family in which 5 members had hamo-
globin-L
trait.
These results form parts of versity of Singapore.
a PH.D.
Department of Biochemistry, University of Khartoum, Khartoum, Sudan.
thesis
presented
to
the Uni-
F. VELLA.
PETER A. WALFORD. TORSION OF THE TESTICLE
TREATMENT OF ECZEMA
SIR,-Dr. Holti and Professor Ingram (Jan. 19) make overwhelming case for the use of hydrocortisone occlusive bandages in the treatment of infantile eczemas and other eczema of the limbs. Occlusive bandages out an
have been used for the treatment of eczema in Sheffield since 1954, and I would agree wholeheartedly that occlusive bandages have altered the management of chronic eczema; but I am not so convinced that hydro-
cortisone-impregnated bandages are always necessary or that they always give the best results. For the last eight months, when occlusive bandages have been prescribed in our department, one limb has been treated with a proprietary tar occlusive bandage (J. Smith & Nephew) and the other with the hydrocortisone bandage used in Newcastle. In the majority of patients good results are obtained by both methods and there is little to choose between them. In a few, hydrocortisone bandages are superior; and in an equal number the tar bandages appear to be better’for an individual patient than the hydrocortisone bandage. There is no doubt that the tar bandages are not as elegant as the hydrocortisone, but nor are they as expensive. We have had few complaints about the smell of the tar, but perhaps the Yorkshire tyke is more used to this than the Geordie. My purpose is to draw attention to the fact that there are other occlusive bandages made, indeed by the same firm, which have stood the test of time and which are more eco-
nomical. Rupert Hallam Department of Dermatology, Royal Infirmary, Sheffield, 6.
I. B. SNEDDON.
HÆMOGLOBIN E AND ERYTHROCYTE GLUCOSE6-PHOSPHATE DEHYDROGENASE SIR,-In their study of erythrocyte glucose-6-phosphate dehydrogenase (G.-6-P.D.) and malaria in Thailand, Kruatrachue and coworkers reported that they found 9%of 33 male subjects heterozygous for haemoglobin E to have a deficiency of this enzyme. They considered that there was no correlation between Q.-6-P.D. deficiency and hxmoglobin-E trait. During 1959 a similar conclusion was reached by me while working in Singapore. I tested blood samples from unrelated individuals whose haemoglobin had the following patterns on paper electrophoresis at pH 8-8 (’Veronal’ buffer): A and E (hsemoglobin-E trait), 15; E alone (homozygosity fQr hxmoglobin E), 2; E and F (haemoglobin-E/thalassaemia), 8. The method for detecting G.-6-P.D. activity was the same as that of the Thai workers-i.e., the dye-decolourisation test with brilliant cresyl blue devised by Motulsky and Campbell. Failure to decolourise within 120 minutes in duplicate tests was interpreted as indicating G.-6-P.D. deficiency. These blood samples were obtained mainly from Malay and only occasionally from Chinese (presumably of mixed origin) subjects. The hxmoglobin-E trait and G.-6-P.D. deficiency in Malays were found to be less frequent than they are in Thailand, amounting to 4-81% (of 500 samples) and 0-65% (of 165 male adults) respectively. No instances of G.-6-P.D. deficiency were found in the following : 19 individuals with thalassaemia minor, 3 patients with 1. Kruatrachue, M., Charoenlarp, P., Chongsuphajaisiddhi, T., Harinasuta, C. Lancet, 1962, ii, 1183.
SIR,-One point in Mr. Angell’s article of Jan. 5 deserves comment. He records 13 proven examples of torsion of the fully descended testis and during the same period notes that there were probably 3 cases of torsion of the inguinal testis. He questions the statement that 50% of cases of torsion occur in the undescended testisand rightly. This statement is frequently made and occurs in the most recent edition of a standard surgical textbook for students. Smith, in an analysis of cases
seen at the Radcliffe Infirmary thirteen years noted " only 5 out of 31 torsions occurred in ectopic testis ". In our unit we have seen 13 cases of torsion in the last three years and none of them affected an undescended testis. The truth seems to be that torsion of the testis is many times commoner when fully descended than when undescended. Previous figures may be explained by the fact that the condition in the fully descended testis was so often overlooked and was diagnosed as epididymo-orchitis. Students need to be taught that the condition is not a rarity. Every house-surgeon has a good chance of seeing a case during his six months’ service in a
over
general hospital. C. G. SCORER. POTENTIATION OF THE ANTIDEPRESSIVE EFFECT OF A MONOAMINE-OXIDASE INHIBITOR BY TRYPTOPHAN SiR,ņThe paper by Dr. Coppen and his colleagues (Jan. 12) is of the greatest interest, and for this reason I hope I may be allowed to draw attention to two possible sources of error in their trial, so that these may perhaps be avoided or minimised when the work is repeated. The first possible source of error is an obvious one. " Of the twelve patients who received tryptophan, many" complained of particular side-effects, and that these sideeffects were of some severity is emphasised by the authors’ against the general use of tryptophan in depression warning " at this stage." No similar side-effects occurred in the thirteen patients who did not receive tryptophan. In the absence of a specific statement to the contrary, the reader cannot avoid concluding that the psychiatrist who made the clinical assessments may have been biased by a presumption that the patients with side-effects were on tryptophan. The second possible source of error is less obvious, but it is one which has become increasingly common in reports of psychiatric clinical trials. This error stems from the adding together of rating scores. Thus, in table i, each of the numbers given as being " ratings of patient’s symptoms " is, in fact (on the Hamilton scale) the sum of the ratings of twenty-one different symptoms. Now if, during the course of a depressive illness, the change in severity of these twenty-one symptoms were entirely unrelated to one another, it would be permissible to add their rating scores together and use the total as an index of the patient’s clinical state at any one time. On the other hand, it seems clear that if there were a complete correlation between changes in severity of the symptoms during the "
course of the illness, then no new information about the change of clinical state would be obtained by comparing summed rating scores; summation would simply give a total having no more accuracy than if a single rating score were multiplied by
1.
Smith, K. H. Brit. J. Surg. 1957, 45, 280.
thalassaemia major, 2 individuals with haEmoglobin-D trait, a family in which 2 members had sickle-cell anxmia and 2 had sickle-cell trait, and a family in which 5 members had hamo-
globin-L
trait.
These results form parts of versity of Singapore.
a PH.D.
Department of Biochemistry, University of Khartoum, Khartoum, Sudan.
thesis
presented
to
the Uni-
F. VELLA.
PETER A. WALFORD. TORSION OF THE TESTICLE
TREATMENT OF ECZEMA
SIR,-Dr. Holti and Professor Ingram (Jan. 19) make overwhelming case for the use of hydrocortisone occlusive bandages in the treatment of infantile eczemas and other eczema of the limbs. Occlusive bandages out an
have been used for the treatment of eczema in Sheffield since 1954, and I would agree wholeheartedly that occlusive bandages have altered the management of chronic eczema; but I am not so convinced that hydro-
cortisone-impregnated bandages are always necessary or that they always give the best results. For the last eight months, when occlusive bandages have been prescribed in our department, one limb has been treated with a proprietary tar occlusive bandage (J. Smith & Nephew) and the other with the hydrocortisone bandage used in Newcastle. In the majority of patients good results are obtained by both methods and there is little to choose between them. In a few, hydrocortisone bandages are superior; and in an equal number the tar bandages appear to be better’for an individual patient than the hydrocortisone bandage. There is no doubt that the tar bandages are not as elegant as the hydrocortisone, but nor are they as expensive. We have had few complaints about the smell of the tar, but perhaps the Yorkshire tyke is more used to this than the Geordie. My purpose is to draw attention to the fact that there are other occlusive bandages made, indeed by the same firm, which have stood the test of time and which are more eco-
nomical. Rupert Hallam Department of Dermatology, Royal Infirmary, Sheffield, 6.
I. B. SNEDDON.
HÆMOGLOBIN E AND ERYTHROCYTE GLUCOSE6-PHOSPHATE DEHYDROGENASE SIR,-In their study of erythrocyte glucose-6-phosphate dehydrogenase (G.-6-P.D.) and malaria in Thailand, Kruatrachue and coworkers reported that they found 9%of 33 male subjects heterozygous for haemoglobin E to have a deficiency of this enzyme. They considered that there was no correlation between Q.-6-P.D. deficiency and hxmoglobin-E trait. During 1959 a similar conclusion was reached by me while working in Singapore. I tested blood samples from unrelated individuals whose haemoglobin had the following patterns on paper electrophoresis at pH 8-8 (’Veronal’ buffer): A and E (hsemoglobin-E trait), 15; E alone (homozygosity fQr hxmoglobin E), 2; E and F (haemoglobin-E/thalassaemia), 8. The method for detecting G.-6-P.D. activity was the same as that of the Thai workers-i.e., the dye-decolourisation test with brilliant cresyl blue devised by Motulsky and Campbell. Failure to decolourise within 120 minutes in duplicate tests was interpreted as indicating G.-6-P.D. deficiency. These blood samples were obtained mainly from Malay and only occasionally from Chinese (presumably of mixed origin) subjects. The hxmoglobin-E trait and G.-6-P.D. deficiency in Malays were found to be less frequent than they are in Thailand, amounting to 4-81% (of 500 samples) and 0-65% (of 165 male adults) respectively. No instances of G.-6-P.D. deficiency were found in the following : 19 individuals with thalassaemia minor, 3 patients with 1. Kruatrachue, M., Charoenlarp, P., Chongsuphajaisiddhi, T., Harinasuta, C. Lancet, 1962, ii, 1183.
SIR,-One point in Mr. Angell’s article of Jan. 5 deserves comment. He records 13 proven examples of torsion of the fully descended testis and during the same period notes that there were probably 3 cases of torsion of the inguinal testis. He questions the statement that 50% of cases of torsion occur in the undescended testisand rightly. This statement is frequently made and occurs in the most recent edition of a standard surgical textbook for students. Smith, in an analysis of cases
seen at the Radcliffe Infirmary thirteen years noted " only 5 out of 31 torsions occurred in ectopic testis ". In our unit we have seen 13 cases of torsion in the last three years and none of them affected an undescended testis. The truth seems to be that torsion of the testis is many times commoner when fully descended than when undescended. Previous figures may be explained by the fact that the condition in the fully descended testis was so often overlooked and was diagnosed as epididymo-orchitis. Students need to be taught that the condition is not a rarity. Every house-surgeon has a good chance of seeing a case during his six months’ service in a
over
general hospital. C. G. SCORER. POTENTIATION OF THE ANTIDEPRESSIVE EFFECT OF A MONOAMINE-OXIDASE INHIBITOR BY TRYPTOPHAN SiR,ņThe paper by Dr. Coppen and his colleagues (Jan. 12) is of the greatest interest, and for this reason I hope I may be allowed to draw attention to two possible sources of error in their trial, so that these may perhaps be avoided or minimised when the work is repeated. The first possible source of error is an obvious one. " Of the twelve patients who received tryptophan, many" complained of particular side-effects, and that these sideeffects were of some severity is emphasised by the authors’ against the general use of tryptophan in depression warning " at this stage." No similar side-effects occurred in the thirteen patients who did not receive tryptophan. In the absence of a specific statement to the contrary, the reader cannot avoid concluding that the psychiatrist who made the clinical assessments may have been biased by a presumption that the patients with side-effects were on tryptophan. The second possible source of error is less obvious, but it is one which has become increasingly common in reports of psychiatric clinical trials. This error stems from the adding together of rating scores. Thus, in table i, each of the numbers given as being " ratings of patient’s symptoms " is, in fact (on the Hamilton scale) the sum of the ratings of twenty-one different symptoms. Now if, during the course of a depressive illness, the change in severity of these twenty-one symptoms were entirely unrelated to one another, it would be permissible to add their rating scores together and use the total as an index of the patient’s clinical state at any one time. On the other hand, it seems clear that if there were a complete correlation between changes in severity of the symptoms during the "
course of the illness, then no new information about the change of clinical state would be obtained by comparing summed rating scores; summation would simply give a total having no more accuracy than if a single rating score were multiplied by
1.
Smith, K. H. Brit. J. Surg. 1957, 45, 280.