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SIDE-EFFECTS OF LONG-TERM TREATMENT WITH CORTICOSTEROIDS AND CORTICOTROPHIN
257
engine provides a visible justification for the pithy Ghanaian appraisal of the Westerner as Man without legs ". The potential dangers of excessive intake of simple carbohydrates have been graphically demonstrated by Smith et al.,2 who produced hypertension, coronary-artery lesions, and myocardial infarction in pigs by subjecting them to a regimen of alternating starvation and overfeeding with glucose. With regard to the patient who is confined to bed following a myocardial infarction, one must be careful not to kill him by
CANCER OUTSIDE HOSPITAL
"
overnutrition. Hence, the effective exclusion of sugar from his official and unofficial diets should be an essential preliminary to any academic discussion around the pros and cons of anticoagulant therapy. In support of the crusade to shift the emphasis from hasmatological to metabolic aspects of heart-disease, the necropsy series of Ehlrich and Shinohara3 may be cited. By careful dissection and serial sections, these workers demonstrated occlusive thrombosis of the coronary arteries in only 42% of cases of death from myocardial infarction. The Western world is not short of sugar. Australia, which
to a hiatus he finds that registration: 8-9 °of patients in Sheffield certified as having died with malignant disease had not attended hospital. These final diagnoses were not necessarily inaccurate, but clinical assessment was not corroborated by histological evidence. Reference to hospital, however, cannot always be equated with accurate diagnosis, as my detailed study of colonic cancer shows.
SIR,-Dr. Wilkes (June 20) draws attention
in
accurate cancer
For the years 1951-60, 266 cases of alleged carcinoma of the colon in the population of Bath were extracted from the South
belongs geographically to the East but genetically to the West, has a high rate of coronary-artery disease and a thriving sugar industry, the average consumption of sugar and syrups amounting to no less than a kilogramme per week per head of population, or about 20% of dietary " calories ".4 When " boiling the billy ", it may prove healthier to flavour the brew with a gum leaf rather than with sugar. Tea is an undeniable requirement for " cool heads in a hot world ". Perhaps, Sir, we still have much to learn from the Chinese, who have found over many centuries that tea without sugar is an effective lubricant of good conversation and philosophical debate. Canberra
City, A.C.T.,
Australia.
Carcinoma of colon in
S. B. FURNASS.
LONDON SURGEON? SIR,-Having read the Widdicombe File (July 18) may I quote ? " The kind of school you go to pretty well fixes the ceiling on your future potentialities ... unless (he) manages to get further schooling " (The Status Seekers by Vance Packard, p. 258). And he was not using financial reward as the only criterion in judgment of potentialities. P. G. is, of course, absolutely right. London,
W.I.
A. E. CARTER.
SIDE-EFFECTS OF LONG-TERM TREATMENT WITH CORTICOSTEROIDS AND CORTICOTROPHIN
SIR,-Dr. Treadwell and his coworkers (May 23) found that osteoporosis and bruising were commoner in women than in men as side-effects of long-term corticosteroid treatment.
In the course of treating 700 menopausal women with implants of sex hormones,s 6 I observed improvement not only of the menopausal syndrome, but also of the arthritis and osteoporosis, if present. Androgens as well as oestrogens are known to relieve pain in osteoporosis, but combined oestrogen and androgen therapy is more effective than when either is given alone. Bruising is due to fragility of skin capillaries resulting from a lack of oestrogen8 If rheumatoid arthritis is to be treated with cortisone,
these side-effects might well be prevented by implants of sex
hormones.
London. W 1
E. SCHLEYER-SAUNDERS.
Smith, G. S., Smith, J. L., Mameesh, M. S., Simon, J., Johnson, B. C. J. Nutr. 1964, 82, 173. 3. Ehlrich, J. C., Shinohara, Y. Circulation, 1962, 26, 710. 4. Commonwealth Bureau of Census and Statistics: Report on Food Production and the Apparent Consumption of Foodstuffs and Nutrients in Australia, 1961-62. 5. Schleyer-Saunders, E. Med. Pr. 1960, 244, 337. 6. Schleyer-Saunders, E. Backache in Women. Bristol, 1955. 7. Brewer, J. I. Amer. J. Obstet. Gynec. 1938, 36, 597. 8. Clementson, C. A. B. ibid. 1962, 83, 1269. 2.
The percentages refer cases, and 44 unreferred
to
175
Bath, 1951-60.
proved
cases, 37
partly investigated
cases.
Western Regional Cancer Bureau’s records, the medical officer of health’s death register, and hospital notes. Tumours of the caecum and rectosigmoid are included. Of these, 10 were certified unsatisfactorily. For instance, 3 known and proved rectal cancers were certified as colonic cancers at death. Of the remaining 256 cases, 44 (17%) had no hospital records; and, of the 212 referred to hospital, 37 (14%) had been partly investigated but never diagnosed with certainty. Thus, only 175 (68 %) were cancers proved by biopsy, surgical intervention, or postmortem examination. Dr. Wilkes’ figures suggest that, related to their individual incidence, the colon is second only to the stomach as a cancer likely to forgo reference to hospital. As he points out, many such patients are elderly and any enthusiasm for hospital investigation is tempered by coexisting senility, cardiovascular complications, and the advanced state of the malignancy on presentation. This is confirmed by the ages of the unreferred cases in Bath, which contrast sharply with the ages of the proved hospital cases, while the unproven hospital attenders are of an intermediate age-group (see accompanying figure). On the basis of 256 cases, the rate per 100,000 of the population is 32, compared with 25 in Sheffield’s probably younger population. In the ninth decade, however, the rate per 100,000 rises to 292. The tendency for malignancy to be out of hand among the elderly when a doctor is first called is confirmed by the advanced age of the 36 proved cases of colonic cancer in patients who were so ill on admission that no definitive surgical treatment was possible. If one adds to this the 26 patients who had a palliative colostomy and the 17 a palliative excision, only 96 (3800) out of 256 remain as potential surgical cures, and these are the youngest group of all. Finally, of 81 certificates (37 unreferred cases plus 44 referred but unproved cases) stating carcinoma of the colon among the causes of death, the colonic site was indicated in 18. 6 were in the sigmoid, the commonest site for colonic growths; but no less than 8 were in the caecum, which has a reputation for giving rise to insidious ansmia and general
engine provides a visible justification for the pithy Ghanaian appraisal of the Westerner as Man without legs ". The potential dangers of excessive intake of simple carbohydrates have been graphically demonstrated by Smith et al.,2 who produced hypertension, coronary-artery lesions, and myocardial infarction in pigs by subjecting them to a regimen of alternating starvation and overfeeding with glucose. With regard to the patient who is confined to bed following a myocardial infarction, one must be careful not to kill him by
CANCER OUTSIDE HOSPITAL
"
overnutrition. Hence, the effective exclusion of sugar from his official and unofficial diets should be an essential preliminary to any academic discussion around the pros and cons of anticoagulant therapy. In support of the crusade to shift the emphasis from hasmatological to metabolic aspects of heart-disease, the necropsy series of Ehlrich and Shinohara3 may be cited. By careful dissection and serial sections, these workers demonstrated occlusive thrombosis of the coronary arteries in only 42% of cases of death from myocardial infarction. The Western world is not short of sugar. Australia, which
to a hiatus he finds that registration: 8-9 °of patients in Sheffield certified as having died with malignant disease had not attended hospital. These final diagnoses were not necessarily inaccurate, but clinical assessment was not corroborated by histological evidence. Reference to hospital, however, cannot always be equated with accurate diagnosis, as my detailed study of colonic cancer shows.
SIR,-Dr. Wilkes (June 20) draws attention
in
accurate cancer
For the years 1951-60, 266 cases of alleged carcinoma of the colon in the population of Bath were extracted from the South
belongs geographically to the East but genetically to the West, has a high rate of coronary-artery disease and a thriving sugar industry, the average consumption of sugar and syrups amounting to no less than a kilogramme per week per head of population, or about 20% of dietary " calories ".4 When " boiling the billy ", it may prove healthier to flavour the brew with a gum leaf rather than with sugar. Tea is an undeniable requirement for " cool heads in a hot world ". Perhaps, Sir, we still have much to learn from the Chinese, who have found over many centuries that tea without sugar is an effective lubricant of good conversation and philosophical debate. Canberra
City, A.C.T.,
Australia.
Carcinoma of colon in
S. B. FURNASS.
LONDON SURGEON? SIR,-Having read the Widdicombe File (July 18) may I quote ? " The kind of school you go to pretty well fixes the ceiling on your future potentialities ... unless (he) manages to get further schooling " (The Status Seekers by Vance Packard, p. 258). And he was not using financial reward as the only criterion in judgment of potentialities. P. G. is, of course, absolutely right. London,
W.I.
A. E. CARTER.
SIDE-EFFECTS OF LONG-TERM TREATMENT WITH CORTICOSTEROIDS AND CORTICOTROPHIN
SIR,-Dr. Treadwell and his coworkers (May 23) found that osteoporosis and bruising were commoner in women than in men as side-effects of long-term corticosteroid treatment.
In the course of treating 700 menopausal women with implants of sex hormones,s 6 I observed improvement not only of the menopausal syndrome, but also of the arthritis and osteoporosis, if present. Androgens as well as oestrogens are known to relieve pain in osteoporosis, but combined oestrogen and androgen therapy is more effective than when either is given alone. Bruising is due to fragility of skin capillaries resulting from a lack of oestrogen8 If rheumatoid arthritis is to be treated with cortisone,
these side-effects might well be prevented by implants of sex
hormones.
London. W 1
E. SCHLEYER-SAUNDERS.
Smith, G. S., Smith, J. L., Mameesh, M. S., Simon, J., Johnson, B. C. J. Nutr. 1964, 82, 173. 3. Ehlrich, J. C., Shinohara, Y. Circulation, 1962, 26, 710. 4. Commonwealth Bureau of Census and Statistics: Report on Food Production and the Apparent Consumption of Foodstuffs and Nutrients in Australia, 1961-62. 5. Schleyer-Saunders, E. Med. Pr. 1960, 244, 337. 6. Schleyer-Saunders, E. Backache in Women. Bristol, 1955. 7. Brewer, J. I. Amer. J. Obstet. Gynec. 1938, 36, 597. 8. Clementson, C. A. B. ibid. 1962, 83, 1269. 2.
The percentages refer cases, and 44 unreferred
to
175
Bath, 1951-60.
proved
cases, 37
partly investigated
cases.
Western Regional Cancer Bureau’s records, the medical officer of health’s death register, and hospital notes. Tumours of the caecum and rectosigmoid are included. Of these, 10 were certified unsatisfactorily. For instance, 3 known and proved rectal cancers were certified as colonic cancers at death. Of the remaining 256 cases, 44 (17%) had no hospital records; and, of the 212 referred to hospital, 37 (14%) had been partly investigated but never diagnosed with certainty. Thus, only 175 (68 %) were cancers proved by biopsy, surgical intervention, or postmortem examination. Dr. Wilkes’ figures suggest that, related to their individual incidence, the colon is second only to the stomach as a cancer likely to forgo reference to hospital. As he points out, many such patients are elderly and any enthusiasm for hospital investigation is tempered by coexisting senility, cardiovascular complications, and the advanced state of the malignancy on presentation. This is confirmed by the ages of the unreferred cases in Bath, which contrast sharply with the ages of the proved hospital cases, while the unproven hospital attenders are of an intermediate age-group (see accompanying figure). On the basis of 256 cases, the rate per 100,000 of the population is 32, compared with 25 in Sheffield’s probably younger population. In the ninth decade, however, the rate per 100,000 rises to 292. The tendency for malignancy to be out of hand among the elderly when a doctor is first called is confirmed by the advanced age of the 36 proved cases of colonic cancer in patients who were so ill on admission that no definitive surgical treatment was possible. If one adds to this the 26 patients who had a palliative colostomy and the 17 a palliative excision, only 96 (3800) out of 256 remain as potential surgical cures, and these are the youngest group of all. Finally, of 81 certificates (37 unreferred cases plus 44 referred but unproved cases) stating carcinoma of the colon among the causes of death, the colonic site was indicated in 18. 6 were in the sigmoid, the commonest site for colonic growths; but no less than 8 were in the caecum, which has a reputation for giving rise to insidious ansmia and general