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LOSS OF BLOOD-GROUP-B ANTIGEN IN CHRONIC LYMPHATIC LEUKÆMIA
512
A ban on the use of new, untried drugs on women in the early stages of pregnancy has been suggested.8 A similar ban should apply to all substances with possible teratogenic effect-such as podophyllum. I should like
thank Mr. D. Beaton and Dr. D.
G. Vulliamy for Miss S. A. Lloyd-Worth for secretarial assistance; and Miss D. Gibbs for pharmaceutical help. to
permission to publish the case; Portwey Hospital, Weymouth, Dorset.
J. E. CULLIS.
VARICOCELE SiR,—With grateful thanks but humble apologies to your leading article of Aug. 25, I should like to make two comments. You say that the postulated heat-exchange mechanism between arterial and venous supply of the testis " does not explain how varicose veins in one testis diminish spermatogenesis in the second testis ". In fact, varicose veins on both sides are by no means uncommon; but even in the unilateral cases I was unable to record any significant difference of temperature between the two scrotal pouches. In other words, a unilateral varicocele or hydrocele interfered with heat loss from both sides of the scrotum. One further comment if I may. You say " and fertility would remain unimpaired if a ventilated support were worn ". With humility I say that any form of " support " is bad, since it holds the testicles in contact with the heat of the body instead of allowing them to hang loose. Even fur-lined " open-leg pants " would be better than the " string vest type " of tight Y pants! London, W. 1.
HOWARD G. HANLEY.
SIR,-Iread with interest your leading article of Aug. 25. I have operated on 2 cases of varicocele since reading the paper by Hanley and Harrison, 9 but I did not find the condition described by them. Ligature at the deep inguinal ring with partial excision of the affected veins-which are inside the capsule-has been most satisfactory in my limited experience. I have operated on one case of varicosity limited to the superficial veins-the so-called cremasteric veins. This patient also had varicose veins of the leg on the same side. Beckett Hospital,
Barnsley, Yorkshire.
B. S. KUMAR.
ORAL CONTRACEPTIVES AND VENOUS THROMBOSIS SIR,-In the light of recent discussion 10-12 of possible thromboembolic complications of oral contraceptive treatment we should like to record the history of a patient of Dr. J. W. Paulley who developed femoral
thrombosis while endometriosis.
venous
boses, varicose veins,
8. Woollam, D. H. M. Brit. med. J. July 28, 1962, ii, 236. 9. Hanley, H. G., Harrison, R. G. Brit. J. Surg. 1962, 50, 64. 10. Brit. med. J. Aug. 4, 1962, p. 315. 11. Venning, G. R. ibid. Aug. 18, 1962, p. 478. 12. Jordan, W. M. Lancet, 1961, ii, 1146.
trauma, and her
general health was
pain and her left leg was and pulseless. No abnormality cold, blue, swollen, tender, was found in the chest, abdomen, nervous system, or rectum. Her temperature was 100°F and pulse 110 per minute. Haemoglobin was 11.8 g. per 100 ml. and white-cell count 12,000 per c.mm. A diagnosis of femoral venous thrombosis with arterial spasm was made, and she was treated with paravertebral sympathetic block, heparin, pethidine, and brandy. Within two days a faint femoral pulse returned; her fever subsided and in a week the limb regained normal colour and pulsation and was no longer painful. Considerable swelling remains. On Aug. 31 haemoglobin was 14-6 g. per 100 ml. and white-cell count 6000 per c.mm. On admission she
The
was
in
severe
relationship of oral contraceptives
to spontaneous thrombosis is obscure at present, and so the significance of individual reports is uncertain. It is interesting that our patient, like 19% in a Birmingham clinical trial," suffered from cramp-like abdominal pain: in this respect, at least, her response to the drug was not uncharacteristic. CHRISTINA M. JENKINSON Ipswich and East Suffolk PAUL LEWIS. Hospital.
venous
COLOUR-BLINDNESS AND BLOOD-GROUP Xga SIR,-The locus or loci for protan and deutan types of red-green colour-blindness are not closely linked on the X chromosome with that for the recently reported Xg3 blood-group.14 We have tested 459 subjects from 31 different families and have found 16 families which provide linkage data. Crossing over took place in 5 of 7 families with the protan type of colour-blindness: 9 children could be considered non-crossovers and 5 could be considered crossovers. Crossing over ,took place in 7 of 9 families with the deutan type of colour-blindness: 20 children could be considered non-crossovers and 10 could be considered crossovers. These results exclude the possibility of close linkage between the locus or loci for these types of red-green colour-blindness and that for the xga blood-group, and are compatible with other data showing close linkage of
the glucose-6-phosphate dehydrogenase locus and the colour-blindness locus or loci," and a loose linkage of the glucose-6-phosphate dehydrogenase locus and the Xg3 locus.16 This work has been supported in part by a U.S. Public Health Service
srant.
Caylor-Nickel Clinic, Bluffton, Indiana, U.S.A. Butterworth Hospital, Grand Rapids, Michigan, U.S.A.
CHARLES E. JACKSON WILLIAM E. SYMON. JOSEPH D. MANN.
LOSS OF BLOOD-GROUP-B ANTIGEN IN CHRONIC LYMPHATIC LEUKÆMIA SIR,-We were interested in Dr. Richards’ paper from
takingEnovid’ tablets for
A married woman of 35 was admitted on Aug. 8, 1962. For two days her left leg had felt tight; 18 hours before admission she awoke with swelling of the left ankle, and during the day the whole leg became swollen and painful. A course of enovid had begun three months earlier, the initial daily dose of 2-5 mg. doubling at fortnightly intervals to the recommended maintenance level of 20 mg. After taking tablets at 9.30 P.M. the patient every night experienced severe cramp-like pelvic pain (" like labour pain ") which woke her up at 4 A.M. and lasted for an hour. Her obstetric history included six abortions and a premature live birth. There was no history of throm-
or
good.
Canada (July 28) since we are at the moment investigating patient whose red cells group as A but who has no anti-B agglutinin in her serum.
a
This 57-year-old woman was found to have chronic lymphatic leukxmia 3 years ago, at which time she was treated with irradiation to the neck. Her present white cell-count is 200,000 per c.mm., the cells being mainly adult lymphocytes. Lately, she was found to be anaemic (haemoglobin 8-9 g. per 100 ml.), and it was decided to transfuse two pints of blood. Grouping 13. 14. 15. 16.
Eckstein, P., Waterhouse, J. A. H., Bond, G. M., Mills, W. G., Sandilands, D. M., Shotton, D. M. Brit. med. J. 1962, i, 1172. Mann, J. D., Cahan, A., Gelb, A. G., Fisher, N., Hamper, J., Tippett, P., Sanger, R., Race, R. R. Lancet, 1962, i, 8. Porter, I. H., Schulze, J., McKusick, V. A. Nature, Lond. 1962, 193, 506. Adam, A., Sheba, C., Race, R. R., Sanger, R., Tippett, P., Hamper, J., Gavin, J. Lancet, 1962, i, 1188.
513
cross-matching were therefore performed: her red cells A, dce dce; after incubating the red cells with anti-B serum, washing three times with saline, and adding antiglobulin serum, no agglutination was present, suggesting that anti-B serum had not been absorbed by a latent B antigen. She was given two pints of group A Rh-negative blood, compatible both in the cross-match and clinically. On ten subsequent examinations made in the course of 1 month, her serum was found to contain neither anti-A nor anti-B agglutinin; incubation with pooled B cells, washing three times with saline, and the addition of antiglobulin serum led to no agglutination. Estimation of y-globulins in her serum gave a figure of 1-27 g. and
Notes and News
were
per 100 ml. which is within the normal range. The absence of anti-B agglutinin in a group A adult is
Comparison with Dr. Richards’ case suggests that our patient was group AB but has lost the B antigen with the development of chronic lymphatic leukaemia. Unfortunately, we have no record of her blood-group before the disease was discovered. The fate of her ABO antigen rare.
agglutin state will be followed with interest. A somatic mutation is one possible explanation of incongruous blood-group findings in leukxmia, and an awareness of this possibility among hospital pathologists and
might
well
help
to
broaden
Department of Pathology, General Hospital, Sault Sainte Marie, Canada.
our
knowledge. LESLIE MICHAELS ELIZABETH MCNAMARA.
Medicine and the Law Legal Aid for Father of Deformed Baby ON Aug. 31 the legal aid committee of the Law Society granted the father of a deformed baby a legal-aid certificate to cover the initial stages of a proposed action against the manufacturers of thalidomide.
Public Health Smallpox THE sister, aged 8, and brother, aged 4, of the patient removed from the liner Oronsay with smallpoxare now regarded as having highly modified smallpox. The conjectured date of infection is Aug. 12, when the Oronsay was still at sea. Both children have been isolated since Aug. 15, when the Oronsay arrived at Tilbury. 1. See
Lancet, Aug. 25, 1962, p. 411.
DOKITA
OUT of Africa always something new. Dokita (Nigerian pidgin for " doctor ") is in several senses something new among medical periodicals. It is the Journal of the Students’ Clinical Society of University College Hospital, Ibadan, in Nigeria.
Paper, print, reproduction of photographs, and general make-up excellent; and it succeeds in conveying the impression of a young, eager, and enterprising medical school and teaching hospital finding and making their way in surroundings at once stimulating and almost overwhelming. British origins and the example of British medical schools are evident enough, but the journal itself is predominantly African with an African editorial board and a predominance of are
African contributors. Contributions come from students and from teaching staff, with one from the head almoner and from the Principal of the school of nursing. Clinical contributions include an admirably illustrated account of kwashiorkor; an account of sickle-cell anasmia, as seen locally, and of some of the social problems it raises; a careful study, with well-reproduced radiographs, of a case of staphylococcal pneumonia and interlobar empyema in an infant; and a verbatim account of a clinicopathological conference. Other studies reveal a wealth of clinical material and no lack of modern technical resources for investigation and treatment in the hospital.
No less evident are the difficulties, internal and external, confronting a hospital and medical school in western Nigeria. That they are candidly and courageously recognised does not make them less. The abiding impression is of work doing and work to be done. Quite clearly any healthy British doctor who may find the practice of medicine in our materially comfortable Welfare State unadventurous and unsatisfying and wants to pit himself against something tougher may find that something in Ibadan, inside or outside its teaching hospital. TEACHING OF OBSTETRICS AND GYN1ECOLOGY THE British Medical Students’ Association has been publishing a series of reports on teaching in the undergraduate curriculum; the most recent deals with obstetrics and gynaecology.l Heads of departments in twenty medical schools were asked for details of their teaching programmes, and comments were invited from a number of final-year students. Systematic lectures in both subjects were criticised by th6 students - firstly, because they often failed to follow a logical sequence, and, secondly, because there was little or no integration between the lectures and courses of practical instruction. The report suggests that the number of lectures in obstetrics should be kept down to about twelve; these should be repeated four times a year so that each student could choose the course of lectures best suited to his own timetable. In
general, the students attached much greater value to tutorial teaching, particularly in obstetrics, than to systematic lectures. The students thought attendance at antenatal and postnatal clinics was useful in giving a full picture of the progress of mother and child; yet fully half had elected not to attend postnatal clinics. The only reason seemed to be that such attendance was not compulsory. Students from several schools complained that pupil midwives, because they must attend a certain number of deliveries, often take priority over medical students. This allegation may or may not be true. Midwives are in close contact with patients throughout labour, whereas medical students tend to be called just before delivery; because of this practice, or because of their own indolence, students may seldom have a chance of observing the course of normal labour. In American university hospitals where there is no competition from pupil midwives, students have a very close relation with their patients in labour, and carry out many of the duties normally performed by midwives in this country. Half the students complained that they had no opportunity of seeing domiciliary obstetrics, but one or two had accompanied the flying squad and thought the experience had been of great value. All but a few agreed that postgraduate training in hospital was essential for those doctors who wished to practise obstetrics. The main complaint about gynaecological teaching was that too much attention is paid to the surgical side of the subject at the expense of the medical. The students suggested that compulsory attendance in theatre be substantially reduced, and that more time be devoted to the many medical, psychological, and marital problems which the family doctor may have to deal with in his practice. Their pleas for 1.
on the Teaching of Obstetrics and Gynæcology in the British Medical Schools. British Medical Students’ Association, London, 1962.
Report
A ban on the use of new, untried drugs on women in the early stages of pregnancy has been suggested.8 A similar ban should apply to all substances with possible teratogenic effect-such as podophyllum. I should like
thank Mr. D. Beaton and Dr. D.
G. Vulliamy for Miss S. A. Lloyd-Worth for secretarial assistance; and Miss D. Gibbs for pharmaceutical help. to
permission to publish the case; Portwey Hospital, Weymouth, Dorset.
J. E. CULLIS.
VARICOCELE SiR,—With grateful thanks but humble apologies to your leading article of Aug. 25, I should like to make two comments. You say that the postulated heat-exchange mechanism between arterial and venous supply of the testis " does not explain how varicose veins in one testis diminish spermatogenesis in the second testis ". In fact, varicose veins on both sides are by no means uncommon; but even in the unilateral cases I was unable to record any significant difference of temperature between the two scrotal pouches. In other words, a unilateral varicocele or hydrocele interfered with heat loss from both sides of the scrotum. One further comment if I may. You say " and fertility would remain unimpaired if a ventilated support were worn ". With humility I say that any form of " support " is bad, since it holds the testicles in contact with the heat of the body instead of allowing them to hang loose. Even fur-lined " open-leg pants " would be better than the " string vest type " of tight Y pants! London, W. 1.
HOWARD G. HANLEY.
SIR,-Iread with interest your leading article of Aug. 25. I have operated on 2 cases of varicocele since reading the paper by Hanley and Harrison, 9 but I did not find the condition described by them. Ligature at the deep inguinal ring with partial excision of the affected veins-which are inside the capsule-has been most satisfactory in my limited experience. I have operated on one case of varicosity limited to the superficial veins-the so-called cremasteric veins. This patient also had varicose veins of the leg on the same side. Beckett Hospital,
Barnsley, Yorkshire.
B. S. KUMAR.
ORAL CONTRACEPTIVES AND VENOUS THROMBOSIS SIR,-In the light of recent discussion 10-12 of possible thromboembolic complications of oral contraceptive treatment we should like to record the history of a patient of Dr. J. W. Paulley who developed femoral
thrombosis while endometriosis.
venous
boses, varicose veins,
8. Woollam, D. H. M. Brit. med. J. July 28, 1962, ii, 236. 9. Hanley, H. G., Harrison, R. G. Brit. J. Surg. 1962, 50, 64. 10. Brit. med. J. Aug. 4, 1962, p. 315. 11. Venning, G. R. ibid. Aug. 18, 1962, p. 478. 12. Jordan, W. M. Lancet, 1961, ii, 1146.
trauma, and her
general health was
pain and her left leg was and pulseless. No abnormality cold, blue, swollen, tender, was found in the chest, abdomen, nervous system, or rectum. Her temperature was 100°F and pulse 110 per minute. Haemoglobin was 11.8 g. per 100 ml. and white-cell count 12,000 per c.mm. A diagnosis of femoral venous thrombosis with arterial spasm was made, and she was treated with paravertebral sympathetic block, heparin, pethidine, and brandy. Within two days a faint femoral pulse returned; her fever subsided and in a week the limb regained normal colour and pulsation and was no longer painful. Considerable swelling remains. On Aug. 31 haemoglobin was 14-6 g. per 100 ml. and white-cell count 6000 per c.mm. On admission she
The
was
in
severe
relationship of oral contraceptives
to spontaneous thrombosis is obscure at present, and so the significance of individual reports is uncertain. It is interesting that our patient, like 19% in a Birmingham clinical trial," suffered from cramp-like abdominal pain: in this respect, at least, her response to the drug was not uncharacteristic. CHRISTINA M. JENKINSON Ipswich and East Suffolk PAUL LEWIS. Hospital.
venous
COLOUR-BLINDNESS AND BLOOD-GROUP Xga SIR,-The locus or loci for protan and deutan types of red-green colour-blindness are not closely linked on the X chromosome with that for the recently reported Xg3 blood-group.14 We have tested 459 subjects from 31 different families and have found 16 families which provide linkage data. Crossing over took place in 5 of 7 families with the protan type of colour-blindness: 9 children could be considered non-crossovers and 5 could be considered crossovers. Crossing over ,took place in 7 of 9 families with the deutan type of colour-blindness: 20 children could be considered non-crossovers and 10 could be considered crossovers. These results exclude the possibility of close linkage between the locus or loci for these types of red-green colour-blindness and that for the xga blood-group, and are compatible with other data showing close linkage of
the glucose-6-phosphate dehydrogenase locus and the colour-blindness locus or loci," and a loose linkage of the glucose-6-phosphate dehydrogenase locus and the Xg3 locus.16 This work has been supported in part by a U.S. Public Health Service
srant.
Caylor-Nickel Clinic, Bluffton, Indiana, U.S.A. Butterworth Hospital, Grand Rapids, Michigan, U.S.A.
CHARLES E. JACKSON WILLIAM E. SYMON. JOSEPH D. MANN.
LOSS OF BLOOD-GROUP-B ANTIGEN IN CHRONIC LYMPHATIC LEUKÆMIA SIR,-We were interested in Dr. Richards’ paper from
takingEnovid’ tablets for
A married woman of 35 was admitted on Aug. 8, 1962. For two days her left leg had felt tight; 18 hours before admission she awoke with swelling of the left ankle, and during the day the whole leg became swollen and painful. A course of enovid had begun three months earlier, the initial daily dose of 2-5 mg. doubling at fortnightly intervals to the recommended maintenance level of 20 mg. After taking tablets at 9.30 P.M. the patient every night experienced severe cramp-like pelvic pain (" like labour pain ") which woke her up at 4 A.M. and lasted for an hour. Her obstetric history included six abortions and a premature live birth. There was no history of throm-
or
good.
Canada (July 28) since we are at the moment investigating patient whose red cells group as A but who has no anti-B agglutinin in her serum.
a
This 57-year-old woman was found to have chronic lymphatic leukxmia 3 years ago, at which time she was treated with irradiation to the neck. Her present white cell-count is 200,000 per c.mm., the cells being mainly adult lymphocytes. Lately, she was found to be anaemic (haemoglobin 8-9 g. per 100 ml.), and it was decided to transfuse two pints of blood. Grouping 13. 14. 15. 16.
Eckstein, P., Waterhouse, J. A. H., Bond, G. M., Mills, W. G., Sandilands, D. M., Shotton, D. M. Brit. med. J. 1962, i, 1172. Mann, J. D., Cahan, A., Gelb, A. G., Fisher, N., Hamper, J., Tippett, P., Sanger, R., Race, R. R. Lancet, 1962, i, 8. Porter, I. H., Schulze, J., McKusick, V. A. Nature, Lond. 1962, 193, 506. Adam, A., Sheba, C., Race, R. R., Sanger, R., Tippett, P., Hamper, J., Gavin, J. Lancet, 1962, i, 1188.
513
cross-matching were therefore performed: her red cells A, dce dce; after incubating the red cells with anti-B serum, washing three times with saline, and adding antiglobulin serum, no agglutination was present, suggesting that anti-B serum had not been absorbed by a latent B antigen. She was given two pints of group A Rh-negative blood, compatible both in the cross-match and clinically. On ten subsequent examinations made in the course of 1 month, her serum was found to contain neither anti-A nor anti-B agglutinin; incubation with pooled B cells, washing three times with saline, and the addition of antiglobulin serum led to no agglutination. Estimation of y-globulins in her serum gave a figure of 1-27 g. and
Notes and News
were
per 100 ml. which is within the normal range. The absence of anti-B agglutinin in a group A adult is
Comparison with Dr. Richards’ case suggests that our patient was group AB but has lost the B antigen with the development of chronic lymphatic leukaemia. Unfortunately, we have no record of her blood-group before the disease was discovered. The fate of her ABO antigen rare.
agglutin state will be followed with interest. A somatic mutation is one possible explanation of incongruous blood-group findings in leukxmia, and an awareness of this possibility among hospital pathologists and
might
well
help
to
broaden
Department of Pathology, General Hospital, Sault Sainte Marie, Canada.
our
knowledge. LESLIE MICHAELS ELIZABETH MCNAMARA.
Medicine and the Law Legal Aid for Father of Deformed Baby ON Aug. 31 the legal aid committee of the Law Society granted the father of a deformed baby a legal-aid certificate to cover the initial stages of a proposed action against the manufacturers of thalidomide.
Public Health Smallpox THE sister, aged 8, and brother, aged 4, of the patient removed from the liner Oronsay with smallpoxare now regarded as having highly modified smallpox. The conjectured date of infection is Aug. 12, when the Oronsay was still at sea. Both children have been isolated since Aug. 15, when the Oronsay arrived at Tilbury. 1. See
Lancet, Aug. 25, 1962, p. 411.
DOKITA
OUT of Africa always something new. Dokita (Nigerian pidgin for " doctor ") is in several senses something new among medical periodicals. It is the Journal of the Students’ Clinical Society of University College Hospital, Ibadan, in Nigeria.
Paper, print, reproduction of photographs, and general make-up excellent; and it succeeds in conveying the impression of a young, eager, and enterprising medical school and teaching hospital finding and making their way in surroundings at once stimulating and almost overwhelming. British origins and the example of British medical schools are evident enough, but the journal itself is predominantly African with an African editorial board and a predominance of are
African contributors. Contributions come from students and from teaching staff, with one from the head almoner and from the Principal of the school of nursing. Clinical contributions include an admirably illustrated account of kwashiorkor; an account of sickle-cell anasmia, as seen locally, and of some of the social problems it raises; a careful study, with well-reproduced radiographs, of a case of staphylococcal pneumonia and interlobar empyema in an infant; and a verbatim account of a clinicopathological conference. Other studies reveal a wealth of clinical material and no lack of modern technical resources for investigation and treatment in the hospital.
No less evident are the difficulties, internal and external, confronting a hospital and medical school in western Nigeria. That they are candidly and courageously recognised does not make them less. The abiding impression is of work doing and work to be done. Quite clearly any healthy British doctor who may find the practice of medicine in our materially comfortable Welfare State unadventurous and unsatisfying and wants to pit himself against something tougher may find that something in Ibadan, inside or outside its teaching hospital. TEACHING OF OBSTETRICS AND GYN1ECOLOGY THE British Medical Students’ Association has been publishing a series of reports on teaching in the undergraduate curriculum; the most recent deals with obstetrics and gynaecology.l Heads of departments in twenty medical schools were asked for details of their teaching programmes, and comments were invited from a number of final-year students. Systematic lectures in both subjects were criticised by th6 students - firstly, because they often failed to follow a logical sequence, and, secondly, because there was little or no integration between the lectures and courses of practical instruction. The report suggests that the number of lectures in obstetrics should be kept down to about twelve; these should be repeated four times a year so that each student could choose the course of lectures best suited to his own timetable. In
general, the students attached much greater value to tutorial teaching, particularly in obstetrics, than to systematic lectures. The students thought attendance at antenatal and postnatal clinics was useful in giving a full picture of the progress of mother and child; yet fully half had elected not to attend postnatal clinics. The only reason seemed to be that such attendance was not compulsory. Students from several schools complained that pupil midwives, because they must attend a certain number of deliveries, often take priority over medical students. This allegation may or may not be true. Midwives are in close contact with patients throughout labour, whereas medical students tend to be called just before delivery; because of this practice, or because of their own indolence, students may seldom have a chance of observing the course of normal labour. In American university hospitals where there is no competition from pupil midwives, students have a very close relation with their patients in labour, and carry out many of the duties normally performed by midwives in this country. Half the students complained that they had no opportunity of seeing domiciliary obstetrics, but one or two had accompanied the flying squad and thought the experience had been of great value. All but a few agreed that postgraduate training in hospital was essential for those doctors who wished to practise obstetrics. The main complaint about gynaecological teaching was that too much attention is paid to the surgical side of the subject at the expense of the medical. The students suggested that compulsory attendance in theatre be substantially reduced, and that more time be devoted to the many medical, psychological, and marital problems which the family doctor may have to deal with in his practice. Their pleas for 1.
on the Teaching of Obstetrics and Gynæcology in the British Medical Schools. British Medical Students’ Association, London, 1962.
Report