- Email: [email protected]
MONEY FOR CANCER RESEARCH
161
education in developing countries is still devoted
to rote
understanding. These students are learning therefore more likely to react favourably to programmed instruction, which matches the " learning set " which they rather than
to
It would be a grave disservice to students from overseas if teachers were to reinforce their "knowledgeonly " learning set by encouraging them to make use of
acquired at home.
learning programmes. The examination is part of the educational process, and it is a serious criticism of current studies of " objective " tests in medical education that none of them has been concerned with the type of learning-and hence of comprehensionwhich these tests evoke. Programmed teaching is essentially " a knowledge-only " approach to a subject, and one would expect that teaching by this method would result in higher scores on multiple-choice tests than on essays. One would also expect, on the basis of Meyer’s experiment,2 that it would result in more rapid forgetting of the subject; and therefore that if retested without warning those students who had used the teaching machine would achieve lower " scores (even on an objective " test) than those who attended the conventional course. Department of Child Psychiatry, Guy’s Hospital, London S.E.1.
J. McFIE.
CŒLIAC DISEASE IN A DIABETIC CHILD SIR,-We wish to comment on the cases reported by Dr. Walker-Smith and Dr. Grigorand by Dr. Komrower.2 We accept that the child described by Dr. Walker-Smith and Dr. Grigor may have had coeliac disease before the onset of diabetes. Pronounced morphological alterations of the small intestine were present only a few weeks after diabetes became apparent. In the patient reported by Dr. Komrower, however, diabetes and gluten-sensitive sprue began simultaneously. This observation, together with the conclusions we drew from our own patients,33 could provide support for the concept that there is a causal relationship between the two conditions.
published our article on diabetes and malabwe have investigated 6 other diabetic in children,3 sorption children. 2 of these had not yet been treated. The other 4 had been insulin-treated for 3, 9, and 18 months, and 7 years, and were difficult to control. Although none had a history of diarrhoea we did gastrointestinal-function tests on all of them. Steatorrhaea (5 g. fat or more per 24 hours), and an increased excretion of lactic acid (500 mg. or more per 24 hours) was found in 1 patient who had not yet been treated, and in 2 who were poorly controlled. 2 of these 3 patients were also found to have an increased excretion of glucose (100 mg. per 100 g. and 200 mg. per 100 g.) on chromatographic examination of the faeces. A smallbowel biopsy was done in all 6 cases. 4 were normal or showed only minimal abnormality. Flattening of the villi with oedema and infiltration of the lamina propria was found in the other 2. Of these 2, 1 was a case of untreated diabetes. This boy of 5 had been on corticosteroids for a nephrotic syndrome since he was 3. He had had glycosuria for a year, and after oral glucose the blood-sugar rose to 740 mg. per 100 ml. He had steatorrhoea (7 g. per 24 hours), and increased faecal excretion of lactic acid (980 mg. per 24 hours), and glucose (200 mg. per 100 g.) was found. The other patient was a 9-year-old girl who had had poorly controlled diabetes for 11J2 years, but no steatorrhoea. In a girl of 15 who had had poorly Since
1. 2. 3.
we
Walker-Smith, J. A., Grigor, W. Lancet, 1969, i, 1021. Komrower, G. M. ibid. p. 1215. Hooft, C., Devos, E., Kriekemans, J., van Damme, J. Helv. pœdiat. Acta, 1968, 5, 478.
controlled diabetes since she was 7 years old, and who also had steatorrhcea (9 g. fat per 24 hours), only discrete lesions were found on histological examination of the small-bowel biopsy specimen. It seems unlikely that coeliac disease preceded diabetes in this patient. This, and the finding that 3 out of 6 non-selected diabetic children had definite signs of malabsorption, together with our observation in a previous series 3 that 10 out of 13 non-selected diabetic patients had malabsorption, adds force to our opinion that in most of the cases the coincidence of diabetes and malabsorption was not purely fortuitous. C. HOOFT Department of Pædiatrics, E. DEVOS Rijksuniversiteit, Gent, Belgium. J. VAN DAMME.
MONEY FOR CANCER RESEARCH
SIR,-As chairman of the committee of management of the Institute of Cancer Research, I wish to correct any wrong impression which might be gained from reading your leading article (July 5, p. 33). I should like to emphasise that the Institute is happy in its relationship with its two principal sponsors, the Medical Research Council and the British Empire Cancer Campaign for Research, and that it has no feeling of being at variance with either of them. that the Institute’s reserves are being used balance annual income with expenditure. increasingly Also, that if this situation continues without a reappraisal of research priorities and without an increase of income, a critical stage may be reached sooner than later. However, it is unjust to imply that our sponsors have by a deliberate policy of pegging support levels precipitated this situation. The fact is that the M.R.C. level of support is increasing at 6% per annum on a quinquennial basis and the B.E.C.C.R. support at 2% per annum on a triennial basis. Therefore, so far from pegging support levels, both sponsors have given progressive increases during the grant period for which they have provided funds. I am therefore certain that the interest and support, which both have given to the Institute since it was established in its present form in 1951, will not only be maintained but will be increased as far as their differing roles and resources
It is
correct
to
allow. For very good reasons, I refrain from commenting on the wider issues concerning the other cancer-research organisations to which your article referred. Institute of Cancer Research, 34 Sumner Place, London S.W.7.
HALSBURY.
*** Lord Halsbury’s letter confirms the precarious state of the Institute; and what is an annual increase of 2% if not pegging ? His assurance that the Institute is happy in its relations with the M.R.C. and the B.E.C.C.R. is hardly necessary, since nothing in the leader suggested that they were at loggerheads. The leader criticised the policy of the Imperial Cancer Research Fund, and the Fund has been defended in an editorial in last week’s Nature,1 which refers to Lord Halsbury’s letter (the Editor of Nature must have known its contents before The Lancet did) and which a superficial attack on the accuses The Lancet of I.C.R.F., which seems to have been singled out for criticism because of its success ". Readers may judge that comment by looking again at p. 33 in our issue of July 5. In defence of the Fund’s apparent intention to maintain "
...
1.
Nature, Lond. July 12, 1969, p. 116.
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.
education in developing countries is still devoted
to rote
understanding. These students are learning therefore more likely to react favourably to programmed instruction, which matches the " learning set " which they rather than
to
It would be a grave disservice to students from overseas if teachers were to reinforce their "knowledgeonly " learning set by encouraging them to make use of
acquired at home.
learning programmes. The examination is part of the educational process, and it is a serious criticism of current studies of " objective " tests in medical education that none of them has been concerned with the type of learning-and hence of comprehensionwhich these tests evoke. Programmed teaching is essentially " a knowledge-only " approach to a subject, and one would expect that teaching by this method would result in higher scores on multiple-choice tests than on essays. One would also expect, on the basis of Meyer’s experiment,2 that it would result in more rapid forgetting of the subject; and therefore that if retested without warning those students who had used the teaching machine would achieve lower " scores (even on an objective " test) than those who attended the conventional course. Department of Child Psychiatry, Guy’s Hospital, London S.E.1.
J. McFIE.
CŒLIAC DISEASE IN A DIABETIC CHILD SIR,-We wish to comment on the cases reported by Dr. Walker-Smith and Dr. Grigorand by Dr. Komrower.2 We accept that the child described by Dr. Walker-Smith and Dr. Grigor may have had coeliac disease before the onset of diabetes. Pronounced morphological alterations of the small intestine were present only a few weeks after diabetes became apparent. In the patient reported by Dr. Komrower, however, diabetes and gluten-sensitive sprue began simultaneously. This observation, together with the conclusions we drew from our own patients,33 could provide support for the concept that there is a causal relationship between the two conditions.
published our article on diabetes and malabwe have investigated 6 other diabetic in children,3 sorption children. 2 of these had not yet been treated. The other 4 had been insulin-treated for 3, 9, and 18 months, and 7 years, and were difficult to control. Although none had a history of diarrhoea we did gastrointestinal-function tests on all of them. Steatorrhaea (5 g. fat or more per 24 hours), and an increased excretion of lactic acid (500 mg. or more per 24 hours) was found in 1 patient who had not yet been treated, and in 2 who were poorly controlled. 2 of these 3 patients were also found to have an increased excretion of glucose (100 mg. per 100 g. and 200 mg. per 100 g.) on chromatographic examination of the faeces. A smallbowel biopsy was done in all 6 cases. 4 were normal or showed only minimal abnormality. Flattening of the villi with oedema and infiltration of the lamina propria was found in the other 2. Of these 2, 1 was a case of untreated diabetes. This boy of 5 had been on corticosteroids for a nephrotic syndrome since he was 3. He had had glycosuria for a year, and after oral glucose the blood-sugar rose to 740 mg. per 100 ml. He had steatorrhoea (7 g. per 24 hours), and increased faecal excretion of lactic acid (980 mg. per 24 hours), and glucose (200 mg. per 100 g.) was found. The other patient was a 9-year-old girl who had had poorly controlled diabetes for 11J2 years, but no steatorrhoea. In a girl of 15 who had had poorly Since
1. 2. 3.
we
Walker-Smith, J. A., Grigor, W. Lancet, 1969, i, 1021. Komrower, G. M. ibid. p. 1215. Hooft, C., Devos, E., Kriekemans, J., van Damme, J. Helv. pœdiat. Acta, 1968, 5, 478.
controlled diabetes since she was 7 years old, and who also had steatorrhcea (9 g. fat per 24 hours), only discrete lesions were found on histological examination of the small-bowel biopsy specimen. It seems unlikely that coeliac disease preceded diabetes in this patient. This, and the finding that 3 out of 6 non-selected diabetic children had definite signs of malabsorption, together with our observation in a previous series 3 that 10 out of 13 non-selected diabetic patients had malabsorption, adds force to our opinion that in most of the cases the coincidence of diabetes and malabsorption was not purely fortuitous. C. HOOFT Department of Pædiatrics, E. DEVOS Rijksuniversiteit, Gent, Belgium. J. VAN DAMME.
MONEY FOR CANCER RESEARCH
SIR,-As chairman of the committee of management of the Institute of Cancer Research, I wish to correct any wrong impression which might be gained from reading your leading article (July 5, p. 33). I should like to emphasise that the Institute is happy in its relationship with its two principal sponsors, the Medical Research Council and the British Empire Cancer Campaign for Research, and that it has no feeling of being at variance with either of them. that the Institute’s reserves are being used balance annual income with expenditure. increasingly Also, that if this situation continues without a reappraisal of research priorities and without an increase of income, a critical stage may be reached sooner than later. However, it is unjust to imply that our sponsors have by a deliberate policy of pegging support levels precipitated this situation. The fact is that the M.R.C. level of support is increasing at 6% per annum on a quinquennial basis and the B.E.C.C.R. support at 2% per annum on a triennial basis. Therefore, so far from pegging support levels, both sponsors have given progressive increases during the grant period for which they have provided funds. I am therefore certain that the interest and support, which both have given to the Institute since it was established in its present form in 1951, will not only be maintained but will be increased as far as their differing roles and resources
It is
correct
to
allow. For very good reasons, I refrain from commenting on the wider issues concerning the other cancer-research organisations to which your article referred. Institute of Cancer Research, 34 Sumner Place, London S.W.7.
HALSBURY.
*** Lord Halsbury’s letter confirms the precarious state of the Institute; and what is an annual increase of 2% if not pegging ? His assurance that the Institute is happy in its relations with the M.R.C. and the B.E.C.C.R. is hardly necessary, since nothing in the leader suggested that they were at loggerheads. The leader criticised the policy of the Imperial Cancer Research Fund, and the Fund has been defended in an editorial in last week’s Nature,1 which refers to Lord Halsbury’s letter (the Editor of Nature must have known its contents before The Lancet did) and which a superficial attack on the accuses The Lancet of I.C.R.F., which seems to have been singled out for criticism because of its success ". Readers may judge that comment by looking again at p. 33 in our issue of July 5. In defence of the Fund’s apparent intention to maintain "
...
1.
Nature, Lond. July 12, 1969, p. 116.
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.