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NOMENCLATURE OF THYROID DISEASE: AN INTERNATIONAL MEETING?
1065 and retrogressive, a defeat for truth. And where the competition is direct, rivalry enters to make the opposition more acute. It is for this reason that the modus vivendi achieved in China seems so remarkable to me. The applied science of medicine depends on interpersonal relations, whether we are concerned with communities or individuals ; and this is the field of medical knowledge which is least developed. MERVYN SUSSER. of social and Preventive Medicine, Manchester, 13.
Department
PNEUMOCONIOTIC NEUROSIS Macdonald (Sept. 28 and Oct.
19) and have been in dispute about the various standards of assessing disablement of pneumoconiotic miners. Both are right, but we believe some of their views to be wrong. Some pneumoconiosis panels, no doubt, reject the claims for compensation of men severely disabled by dyspnoea, the result of lung changes due to chronic inhalation of dust to which they were exposed at work. Rejection is based on the absence of radiographic appearances of pneumoconiosis ; boards will usually accept claims only when the radiological evidence is unequivocal. It is true, to our knowledge, that claimants who have either normal or atypical radiographs are not always examined clinically. The panel’s members need not be blamed, however, because in the circumstances their decisions are governed by the strict legal definition of pneumoconiosis within a general legal directive. On the other hand, there are an unknown number who judge such a procedure to be unjust, not to say inhumane. It is good to know, from one’s experience of these cases, that some panels do not abide by the strict letter of the law in assessing claims. A few workers who, on our suggestion, applied for compensation have been granted it, in spite of a negative or atypical radiograph. SIR,-Dr.
Dr. Holt
(Oct. 12)
For several years,
have tried (not always with success) of men who were disabled by industrial dust inhalation in the later years of life. In these men radiographic evidence was either lacking or not typical of pneumoconiosis. Several necropsy findings were striking : numerous rather large emphysematous bullae, often subpleural ; localised emphysema ; small bullae, either localised or distributed more widely in the lungs, giving the impression of a " miliary spread "; generalised, bilateral emphysema. Microscopically, " focal emphysema," which is constantly part of simple pneumoconiosis, was fairly common. These types cannot always be identified radiographically, even in tomographs. There are differences of opinion on the point, but, for our part, we have been unable to detect focal emphysema on radiographs. One of us (L. D.) was glad to be confirmed in this view at the recent 3rd International Congress on Pneumoconiosis. in Dr. Worth, the invited speaker on Munster, Germany. emphysema, said that he had been unable to diagnose focal emphysema merely on radiographic findings. Such lesions are pommonest in men up to the age of 50 years, from which one may deduce that it is not a senile change in lung parenchyma ; in all, severe bronchitis had been present during life. Combination of two or more of these types of emphysema, or an advance degree of a single type, accounts for the crippling dyspnoea in these men.! One is justified in regarding their bronchitis and emphysema as a direct result of inhaling irritant dusts during part or whole of their working lives; Certainly, dust has been shown to cause focal emphyto obtain
we
necropsies
At any rate, our clinical, radiological, and morbidinatomical observation show that many industrial workers become disabled by occupational lung disease j-hen the grade of emphysema is severe. Such men are lot, of course, interested in whether their disablement is ittributable to emphysema or pneumoconiosis. In this espect, it seems that the law should be extended to cover ;ases that are not, in the present legal sense, pneumooniotic. Then, the medical members of panels would clinically examine and positively assess men disabled by sema.
1.
Dünner, L. Zlb. Arbeitsmed. 1957, 7, 137.
dyspncea
who had been
exposed
to
dust, irrespective of
+.bA radiographic nvirianr.n
LASAR DÜNNER R. HARDY.
SIR,-The length and content of his latest letter (Nov. 16) lead me to believe that Dr. Holt has been stimulated to think harder about the problem of respiraand he seems to have altered his view that all was well with regard to pneumoconiosis assessment. Besides making a suggestion for improving the panels, he now admits that " a change in the definition of the disease as given in the Act would be helpful." He goes on to say this would be " picking at the problem." Why pick at it ?’I In South Africa and Australia it has been found possible to review the position, and in this country we now know " beyond a peradventure " that the present regulations are based on a misconception -i.e., that the radiograph is all important. I would reiterate that the opportunity should be taken now for a complete re-examination-legislative and medical-of the problem as it affects this country. The present regulations date back to 1943. On the subject of panel examinations, I would add, in case it has not already been made clear, that, on submitting a claim, each applicant should have a complete physical examination, a chest X-ray, and a respiratory-function test. Why not ?’I
tory disease amongst miners ;
Clare Hall Hospital, South Mimms, Barnet.
NORMAN MACDONALD.
NOMENCLATURE OF THYROID DISEASE: AN INTERNATIONAL MEETING?
SiR,-The interesting and important contribution by Dr. Goudie and his colleagues (Nov. 16) on the precipitin tests in thyroid disease merits careful consideration. In their series of 32 cases of "Hashimoto’s disease", the diagnosis " depended on the demonstration of serumprotein abnormalities or on the characteristic z1 findings-methods which have been shown to be of value in confirming the clinical diagnosis of Hashimoto’s disease ". 17 of these 32 patients (53%) were diagnosed without biopsy. The precipitin test was found to be positive in 66% of Hashimoto’s disease " and in 14% of primary "
myxcedema. Without entering into minutiae of the problem of " Hashimoto’s disease ", which I have discussed extensively in a recently published symposiumand elsewhere,2--4 the following facts appear to be pertinent. The valuable recent additions to our knowledge of thyroid disease make it increasingly obvious that they be founded on a truly scientific basis. I have used the precipitin and other immunological tests, electrophoretic globulin estimations, and serum-flocculation tests extensively to assist clinical diagnosis in everyday practice and in research. But, in my opinion, scientific evaluation of the thyroid must always be confirmed by adequate histological studies of the gland itself. Needle biopsies are of limited use in assessing the predominant pathological phase of this organ. ’I still have to meet the clinician who can always accurately assess the presence or size of every goitre by palpation, or the predominant pathological state of the thyroid without an adequate study of the histology of the gland. Radioiodine estimations, too, can be notoriously
misleading. However, with the strong impact of radioiodine during past decade and the recent impressive contributions of
the the
study
of
immunology
function, the failure to 1. Levitt, T. 2. Levitt, T.
on
understanding of thyroid correctly the pathological
the
assess
Postgrad. med. J. 1957, 33, 352. Lancet, 1951, ii, 957. 3. Levitt, T. Ann. R. Coll. Surg. Engl. 1952, 10, 369. 4. Levitt, T. The Thyroid. Edinburgh, 1953.
1066
thyroid would invalidate a vast amount of valuable work now being done. Criteria of thyroid disease must be clearly defined, understood and generally agreed upon. Then and then only will pathologist be able to converse intelligibly on this subject with pathologist. Then too will clinician, surgeon, biochemist, radiotherapist, immunologist, and research-worker understand the pathologist and one another. Now is the time for a conference, on an international level, which will bring together representatives of the various disciplines concerned. A precisely defined terminology and nomenclature may then emerge to replace the ill-understood and chaotic eponymic designations of the controversial past. T. LEVITT. state of. the
BACTERIA AND INFLUENZA
SiR,-We have read with interest your leader (Oct. 26) and the recent communications (Nov. 9) on influenzal pneumonia. It is curious that Dr. Roberts (Nov. 9, p. 944) makes no reference to the sensitivity to erythromycin of the organisms (Staphylococcus aureus), which he isolated from his cases. Nor does its use appear to have been considered. Surely, in view of Dr. Zinnemann’s observations (Nov. 9, p. 948) on the sensitivity of Hcemophilus influenzc&, and the probability of overwhelming staphylococcal infection in many cases, erythromycin is the antibiotic of choice. Our experience with erythromycin in the treatment of segmental pneumoniasuggests that a very rapid response to treatment may be obtained, and this is surely what is required in the pneumonia of fulminating influenza. B. M. D. ROSTEN G. MELOTTE. FULMINATING INFLUENZA
SiR,-I should like
to
Dr. Roberts on his excellent and timely article (Nov. 9). It is to be hoped that his clear exposition of the pathology in such cases will help the enthusiastic operator to desist from per-
congratulate
forming. The heamorrhagic
state of the trachea may be well but if that is not a sufficient deterrent to the known, passage of instruments through the trachea, then surely the knowledge that the secretions are so deeply situated in the lungs will be. I have even seen bronchoscopy (therapeutic) performed in this fulminating influenza. Recurrent bronchoscopies and a tracheotomy had to be done to remove the fibrinous exudate thus formed in the bronchial tree. These seem additional hazards for a desperately ill patient to bear. A patient black with tracheal obstruction would obviously call for tracheotomy, but otherwise there is surely no logical basis for endotracheal manoeuvres. Dr. Roberts’ conclusion (4) needs wholehearted support. D. W. S. SHELDON. INFLUENZAL PNEUMONIA TREATED WITH CORTISONE AND ANTIBIOTICS SiR,-I was very interested to read the conflicting views of Dr. Breen and Dr. Gunn in last week’s Lancet. It would be of great clinical interest and value if the indication and contraindication for cortisone in influenzal pneumonia were published. I asked in my letter of Nov. 2 for its mode of action, but there has been no reply. I have heard it said that cortisone is of value in peripheral circulatory failure but not in myocardial failure complicating such cases. Again the age-groups are not mentioned in cases cited for and against cortisone therapy. 1. Rosten, B. M. D., Melotte, G.
Practitioner, 1956, 177, 196.
Perhaps have had to
give
this letter will stimulate our cardiologists, who great deal of experience in such cases recently, their expert views on the subject. ISAAC ROSE.
a
us
THE FLUORIDATION DEBATE IN NEW ZEALAND
SIR,-Your annotation (Nov. 9) on the report of the New Zealand Commission of Inquiry on the fluoridation of public water-supplies suggests that the commission recognised that individuals have a right to pure water, but that this right is not infringed by fluoridation because alternative private sources are accessible to New Zealand citizens. This is a little misleading. The commission in fact rejected the claim that persons necessarily have a right to pure water, or that when they do have any right to a supply of pure water this right refers to any particular kind of purity other than wholesomeness. Furthermore, they maintained that fluoridation does not affect the purity of the water but does, if anything, increase its wholesomeness. The availability of private supplies was held to rebut the claim that fluoridation compelled people to drink fluoridated water, or that it infringed any right that there may be to drink unfluoridated water. The word pure ought not now to be applied to drinking water. It was once a permissible assumption that wholesome water should be as near as practicable to pure water in constitution, but it is now a mere popular
chemically
misconception. R. B. D. STOCKER. PENICILLIN HYPERSENSITIVITY
SIR,-In your review of this subject (Nov. 9) you mention varying views on the significance of the delayed reaction to intradermal testing in cases of suspected systemic sensitivity. It appears possible that under certain conditions this reaction may have a quite definite
significance. Experimental work on provides a close analogy to
serum sensitisation, 1-4 which many aspects of systemic drug sensitisation, indicated that delayed reaction to an intradermal test could imply a likelihood that, had a full dose been given, serum-sickness would have developed at about the corresponding time. The intradermal reaction a of the generalised reaction, to be miniature appeared depending on the same two factors : fixation of antigen in the skin and liberation of antibody in response to stimulation by the antigen administered. In patients already sensitised this will occur in an " accelerated serum-sickness timing, which in fact is variable. Delayed reaction to intradermal penicillin may develop within twenty-four hours or may suddenly flare out after several days ; I have also seen the latent period lengthen in successive tests at lengthening intervals from the original episode of reaction. One may get the impression of a gradually receding degree of immunological readiness ; this recession must often be rapid and complete since many patients have developed urticaria after one course of penicillin, and later taken a further course without trouble. But in other cases a liability to produce accelerated immune response may persist, and such patients may show the delayed intradermal reaction, though not generally remaining in the acute state of immediate anaphylactic reactivity. "
There is, however, a possibility of a phase of anaphylactic sensitivity arising at critical times in such cases. In the work on serum it appeared that many patients would be in this state at the time of the immunological response ; not only could serum administration, repeated after the due interval, produce
shock, but the temporary presence of the immediate wealing reaction to intradermal test was not uncommon, even in cases 1. 2. 3. 4.
Kellett, C. E. J. Path. Bact. 1936, 43, 503. Voss, E. A. Z. Immun. Forsch. 1938, 94, 281. Karelitz, S., Stempien, S. S. J. Immunol. 1942, 44, 285. Karelitz, S. ibid. 1942, 44, 285.
Department
PNEUMOCONIOTIC NEUROSIS Macdonald (Sept. 28 and Oct.
19) and have been in dispute about the various standards of assessing disablement of pneumoconiotic miners. Both are right, but we believe some of their views to be wrong. Some pneumoconiosis panels, no doubt, reject the claims for compensation of men severely disabled by dyspnoea, the result of lung changes due to chronic inhalation of dust to which they were exposed at work. Rejection is based on the absence of radiographic appearances of pneumoconiosis ; boards will usually accept claims only when the radiological evidence is unequivocal. It is true, to our knowledge, that claimants who have either normal or atypical radiographs are not always examined clinically. The panel’s members need not be blamed, however, because in the circumstances their decisions are governed by the strict legal definition of pneumoconiosis within a general legal directive. On the other hand, there are an unknown number who judge such a procedure to be unjust, not to say inhumane. It is good to know, from one’s experience of these cases, that some panels do not abide by the strict letter of the law in assessing claims. A few workers who, on our suggestion, applied for compensation have been granted it, in spite of a negative or atypical radiograph. SIR,-Dr.
Dr. Holt
(Oct. 12)
For several years,
have tried (not always with success) of men who were disabled by industrial dust inhalation in the later years of life. In these men radiographic evidence was either lacking or not typical of pneumoconiosis. Several necropsy findings were striking : numerous rather large emphysematous bullae, often subpleural ; localised emphysema ; small bullae, either localised or distributed more widely in the lungs, giving the impression of a " miliary spread "; generalised, bilateral emphysema. Microscopically, " focal emphysema," which is constantly part of simple pneumoconiosis, was fairly common. These types cannot always be identified radiographically, even in tomographs. There are differences of opinion on the point, but, for our part, we have been unable to detect focal emphysema on radiographs. One of us (L. D.) was glad to be confirmed in this view at the recent 3rd International Congress on Pneumoconiosis. in Dr. Worth, the invited speaker on Munster, Germany. emphysema, said that he had been unable to diagnose focal emphysema merely on radiographic findings. Such lesions are pommonest in men up to the age of 50 years, from which one may deduce that it is not a senile change in lung parenchyma ; in all, severe bronchitis had been present during life. Combination of two or more of these types of emphysema, or an advance degree of a single type, accounts for the crippling dyspnoea in these men.! One is justified in regarding their bronchitis and emphysema as a direct result of inhaling irritant dusts during part or whole of their working lives; Certainly, dust has been shown to cause focal emphyto obtain
we
necropsies
At any rate, our clinical, radiological, and morbidinatomical observation show that many industrial workers become disabled by occupational lung disease j-hen the grade of emphysema is severe. Such men are lot, of course, interested in whether their disablement is ittributable to emphysema or pneumoconiosis. In this espect, it seems that the law should be extended to cover ;ases that are not, in the present legal sense, pneumooniotic. Then, the medical members of panels would clinically examine and positively assess men disabled by sema.
1.
Dünner, L. Zlb. Arbeitsmed. 1957, 7, 137.
dyspncea
who had been
exposed
to
dust, irrespective of
+.bA radiographic nvirianr.n
LASAR DÜNNER R. HARDY.
SIR,-The length and content of his latest letter (Nov. 16) lead me to believe that Dr. Holt has been stimulated to think harder about the problem of respiraand he seems to have altered his view that all was well with regard to pneumoconiosis assessment. Besides making a suggestion for improving the panels, he now admits that " a change in the definition of the disease as given in the Act would be helpful." He goes on to say this would be " picking at the problem." Why pick at it ?’I In South Africa and Australia it has been found possible to review the position, and in this country we now know " beyond a peradventure " that the present regulations are based on a misconception -i.e., that the radiograph is all important. I would reiterate that the opportunity should be taken now for a complete re-examination-legislative and medical-of the problem as it affects this country. The present regulations date back to 1943. On the subject of panel examinations, I would add, in case it has not already been made clear, that, on submitting a claim, each applicant should have a complete physical examination, a chest X-ray, and a respiratory-function test. Why not ?’I
tory disease amongst miners ;
Clare Hall Hospital, South Mimms, Barnet.
NORMAN MACDONALD.
NOMENCLATURE OF THYROID DISEASE: AN INTERNATIONAL MEETING?
SiR,-The interesting and important contribution by Dr. Goudie and his colleagues (Nov. 16) on the precipitin tests in thyroid disease merits careful consideration. In their series of 32 cases of "Hashimoto’s disease", the diagnosis " depended on the demonstration of serumprotein abnormalities or on the characteristic z1 findings-methods which have been shown to be of value in confirming the clinical diagnosis of Hashimoto’s disease ". 17 of these 32 patients (53%) were diagnosed without biopsy. The precipitin test was found to be positive in 66% of Hashimoto’s disease " and in 14% of primary "
myxcedema. Without entering into minutiae of the problem of " Hashimoto’s disease ", which I have discussed extensively in a recently published symposiumand elsewhere,2--4 the following facts appear to be pertinent. The valuable recent additions to our knowledge of thyroid disease make it increasingly obvious that they be founded on a truly scientific basis. I have used the precipitin and other immunological tests, electrophoretic globulin estimations, and serum-flocculation tests extensively to assist clinical diagnosis in everyday practice and in research. But, in my opinion, scientific evaluation of the thyroid must always be confirmed by adequate histological studies of the gland itself. Needle biopsies are of limited use in assessing the predominant pathological phase of this organ. ’I still have to meet the clinician who can always accurately assess the presence or size of every goitre by palpation, or the predominant pathological state of the thyroid without an adequate study of the histology of the gland. Radioiodine estimations, too, can be notoriously
misleading. However, with the strong impact of radioiodine during past decade and the recent impressive contributions of
the the
study
of
immunology
function, the failure to 1. Levitt, T. 2. Levitt, T.
on
understanding of thyroid correctly the pathological
the
assess
Postgrad. med. J. 1957, 33, 352. Lancet, 1951, ii, 957. 3. Levitt, T. Ann. R. Coll. Surg. Engl. 1952, 10, 369. 4. Levitt, T. The Thyroid. Edinburgh, 1953.
1066
thyroid would invalidate a vast amount of valuable work now being done. Criteria of thyroid disease must be clearly defined, understood and generally agreed upon. Then and then only will pathologist be able to converse intelligibly on this subject with pathologist. Then too will clinician, surgeon, biochemist, radiotherapist, immunologist, and research-worker understand the pathologist and one another. Now is the time for a conference, on an international level, which will bring together representatives of the various disciplines concerned. A precisely defined terminology and nomenclature may then emerge to replace the ill-understood and chaotic eponymic designations of the controversial past. T. LEVITT. state of. the
BACTERIA AND INFLUENZA
SiR,-We have read with interest your leader (Oct. 26) and the recent communications (Nov. 9) on influenzal pneumonia. It is curious that Dr. Roberts (Nov. 9, p. 944) makes no reference to the sensitivity to erythromycin of the organisms (Staphylococcus aureus), which he isolated from his cases. Nor does its use appear to have been considered. Surely, in view of Dr. Zinnemann’s observations (Nov. 9, p. 948) on the sensitivity of Hcemophilus influenzc&, and the probability of overwhelming staphylococcal infection in many cases, erythromycin is the antibiotic of choice. Our experience with erythromycin in the treatment of segmental pneumoniasuggests that a very rapid response to treatment may be obtained, and this is surely what is required in the pneumonia of fulminating influenza. B. M. D. ROSTEN G. MELOTTE. FULMINATING INFLUENZA
SiR,-I should like
to
Dr. Roberts on his excellent and timely article (Nov. 9). It is to be hoped that his clear exposition of the pathology in such cases will help the enthusiastic operator to desist from per-
congratulate
forming. The heamorrhagic
state of the trachea may be well but if that is not a sufficient deterrent to the known, passage of instruments through the trachea, then surely the knowledge that the secretions are so deeply situated in the lungs will be. I have even seen bronchoscopy (therapeutic) performed in this fulminating influenza. Recurrent bronchoscopies and a tracheotomy had to be done to remove the fibrinous exudate thus formed in the bronchial tree. These seem additional hazards for a desperately ill patient to bear. A patient black with tracheal obstruction would obviously call for tracheotomy, but otherwise there is surely no logical basis for endotracheal manoeuvres. Dr. Roberts’ conclusion (4) needs wholehearted support. D. W. S. SHELDON. INFLUENZAL PNEUMONIA TREATED WITH CORTISONE AND ANTIBIOTICS SiR,-I was very interested to read the conflicting views of Dr. Breen and Dr. Gunn in last week’s Lancet. It would be of great clinical interest and value if the indication and contraindication for cortisone in influenzal pneumonia were published. I asked in my letter of Nov. 2 for its mode of action, but there has been no reply. I have heard it said that cortisone is of value in peripheral circulatory failure but not in myocardial failure complicating such cases. Again the age-groups are not mentioned in cases cited for and against cortisone therapy. 1. Rosten, B. M. D., Melotte, G.
Practitioner, 1956, 177, 196.
Perhaps have had to
give
this letter will stimulate our cardiologists, who great deal of experience in such cases recently, their expert views on the subject. ISAAC ROSE.
a
us
THE FLUORIDATION DEBATE IN NEW ZEALAND
SIR,-Your annotation (Nov. 9) on the report of the New Zealand Commission of Inquiry on the fluoridation of public water-supplies suggests that the commission recognised that individuals have a right to pure water, but that this right is not infringed by fluoridation because alternative private sources are accessible to New Zealand citizens. This is a little misleading. The commission in fact rejected the claim that persons necessarily have a right to pure water, or that when they do have any right to a supply of pure water this right refers to any particular kind of purity other than wholesomeness. Furthermore, they maintained that fluoridation does not affect the purity of the water but does, if anything, increase its wholesomeness. The availability of private supplies was held to rebut the claim that fluoridation compelled people to drink fluoridated water, or that it infringed any right that there may be to drink unfluoridated water. The word pure ought not now to be applied to drinking water. It was once a permissible assumption that wholesome water should be as near as practicable to pure water in constitution, but it is now a mere popular
chemically
misconception. R. B. D. STOCKER. PENICILLIN HYPERSENSITIVITY
SIR,-In your review of this subject (Nov. 9) you mention varying views on the significance of the delayed reaction to intradermal testing in cases of suspected systemic sensitivity. It appears possible that under certain conditions this reaction may have a quite definite
significance. Experimental work on provides a close analogy to
serum sensitisation, 1-4 which many aspects of systemic drug sensitisation, indicated that delayed reaction to an intradermal test could imply a likelihood that, had a full dose been given, serum-sickness would have developed at about the corresponding time. The intradermal reaction a of the generalised reaction, to be miniature appeared depending on the same two factors : fixation of antigen in the skin and liberation of antibody in response to stimulation by the antigen administered. In patients already sensitised this will occur in an " accelerated serum-sickness timing, which in fact is variable. Delayed reaction to intradermal penicillin may develop within twenty-four hours or may suddenly flare out after several days ; I have also seen the latent period lengthen in successive tests at lengthening intervals from the original episode of reaction. One may get the impression of a gradually receding degree of immunological readiness ; this recession must often be rapid and complete since many patients have developed urticaria after one course of penicillin, and later taken a further course without trouble. But in other cases a liability to produce accelerated immune response may persist, and such patients may show the delayed intradermal reaction, though not generally remaining in the acute state of immediate anaphylactic reactivity. "
There is, however, a possibility of a phase of anaphylactic sensitivity arising at critical times in such cases. In the work on serum it appeared that many patients would be in this state at the time of the immunological response ; not only could serum administration, repeated after the due interval, produce
shock, but the temporary presence of the immediate wealing reaction to intradermal test was not uncommon, even in cases 1. 2. 3. 4.
Kellett, C. E. J. Path. Bact. 1936, 43, 503. Voss, E. A. Z. Immun. Forsch. 1938, 94, 281. Karelitz, S., Stempien, S. S. J. Immunol. 1942, 44, 285. Karelitz, S. ibid. 1942, 44, 285.