THYROID FUNCTION IN CRETINS

202 and a similar highly selective tissue The dose given was 1 tablet of chloroquinsulphate (’ Nivaquine ’) daily-equivalent to 150 mg. base. The immediate effect was most striking and gratifying. The cutaneous inflammation died down rapidly. After four weeks the arms had cleared completely and except for old scarring the face is now almost normal. She continues to take 1 tablet daily and improvement is maintained.

action to

mepacrine

distribution.

This condition seldom appears in the practice of a general physician, and I am reporting the case so that further trial may be given to the drug by others in a. better position to test it. J. C. SHEE. Bulawayo. GROWTH HORMONE AND CHRONIC ARTHRITIS

SIR,—The following experimental facts some

seem

interest in relation to your annotation of

to be of May 30.

As we stated in your issue of March 14 (p. 549) the adrenal medulla plays an important part in permeability mechanisms in connection with different injuries. On the other hand, the physiopathological r6le of cortisone in these mechanisms is doubtful. We demonstrated that excision of the adrenal medulla* abolishes salicylate and adrenaline protection against

hyaluronidase oedema, despite

a

functioning corticotrophin-

cortisone mechanism. We have further observed that not only testicular extracts containing hyaluronidase but also human sera can induce acute permeability changes in our rat hind-paw test. But both testicular extracts and " positive " human sera (possessing an enhanced capacity to induce increased permeability in rats) repeatedly failed to cause appreciable oedema in rats which had been hypophysectomised* 1-2 weeks before. It seems, therefore, that experimental facts support the physiopathological r6le of both neural and endocrine structures in permeability mechanisms in the rat. A seemingly similar action of cortisone, however, if it develops, seems to be

pharmacological. E. K. M. L.

Szeged, Hungary.

KELEMEN KOVÁCS EOVACS KOLTAY HAJDU.

DISSEMINATED SCLEROSIS AND DIABETES

SIR,—While nothing is known of the causes of disseminated sclerosis, it is interesting to observe the association of this disease with diabetes. In this hospital for the chronic sick there are 249 patients, 195 women and 54 men. Of these, 17 men and 36 women have disseminated sclerosis. Of the 17 men, 5 are diabetics ; 3 require insulin treatment, None of the and the other 2 are stabilised by diet. I can women with disseminated sclerosis has diabetes. also recall a further 5 men, now dead, who suffered from the two diseases ; I have the records of 4 of them. In our population of 43,800,000 there were 3703 deaths from diabetes mellitus (1219 men and 2484 women) in 1951-the latest year for which figures are available-and in the same year 910 deaths from disseminated sclerosis (352 men and 558 women). I can find no figures for deaths of patients suffering from both diseases, nor indeed any association of them in the literature. This is interesting in view of the fact that both diseases are more common in women, and I can find no evidence of both diseases coinciding in any female patients. Disseminated sclerosis affects 3 women for every 2 men, and in diabetes the proportion is 2 : 1. It is not supposed that there is an infective cause for diabetes, and it is also possible that there is not one for disseminated sclerosis either. Both diseases may be a manifestation of a biochemical disorder with an underlying genetic factor accounting for the sex discrepancy. Royal Hospital and Home for Incurables, Putney,

VERNA KENDALL.

London, S.W.15. *

The operative sections.

procedures

are

controlled in serial

histological

SURGICAL TREATMENT OF VARICOSE VEINS

SrsR,-The surgical treatment of varicose veins has fortunately been simplified, and the results greatly improved, by the general acceptance of the need for stripping out the main stem of the great or lesser saphenThis method is now widely practised, but it is ous vein. doubtful from recent articles whether the most effective way of stripping is sufficiently known. A long malleable stripper of the Myers type is intro. duced into the great saphenous vein at the ankle through a small incision and passed up to the incision in the groin. In many cases the whole great saphenous vein can be removed from below upwards through these two small incisions, although in some instances a third incision may be necessary below the knee.

The chief advantage of stripping from the ankle is that large tributaries are stretched and torn in sucha way that residual varicosities seldom constitute an after-problem. The simplicity of the technique is equalled by the excellence of results, which fully justify the claims of its strongest advocate in this country, Mr. Rowden Foote. I believe that this procedure will become the standard surgical treatment for incompetent veins in the lower limb. Whipps Cross Hospital D. LANG STEVENSON. London, E.11. THYROID FUNCTION IN CRETINS

SIR,—Lerman et all and Stanbury and Hedge2 observed rapid and increased radioactive-iodine uptake by the thyroid in cretins. Dr. McGirr and Dr. Hutchinson (June 6) have described 9 familial-goitrous cretins who accumulated iodine in their thyroid more rapidly than normal, and whose greatest uptake was well above the normal. Of the 4 patients in whom they estimated protein-bound iodine at 24 hours, the results were in the thyrotoxic range in 3, and in the normal range in 1. The protein-bound fraction in 2 of these cases might be di-iodothyrosine. Dr. Hubble, also in your issue of June 6, describes a family of 4 cretins ; the presence of thyroxine in the thyroid gland and in the plasma of one of them was shown by chromatography. Hubble notes a dissociation between the clinical diagnosis (hypothyroidism) and the results of the radioiodine diagnostic tests, which may suggest hyperthyroidism ; but he judges that both endemic and sporadic cretinism denote a relative and progressive Other workers, however, insufficiency of thyroxine. have described cases of true hyperthyroidism in cretins.s In our researches in cretins, especially endemic, but sometimes also familial, we have found : (1) that their thyroid shows a rapid and increased uptake of radioactive iodine (always where there is no iodine prophylaxis) ; (2) that they have a high conversion ratio; and (3) that it is possible to find in their serum (with paperchromatography) di-iodothyrosine and thyroxine 24 hours after the administration of 50 µC of p3l. Endemic cretins were found usually to have a normal or raised basal metabolic rate, and a normal or belownormal blood-cholesterol level. Their thyroid secretes iodinated protein- substances (protein-bound iodine) at the lower limits of the normal or below normal, but it is readily sensitive to thyroid-stimulating hormone. After administration of this hormone their protein-boundiodine level may rise to values observed in hyperthyroidism. That these iodinated substances may be taken as a measure of the amount of circulating thyroxine can be accepted, because when the protein-bound iodine -

1. Lerman, J., Jones, H. W., Calkins, E. Ann. intern. Med. 1946, 25, 677. 2. Stanbury, J. B., Hedge, A. N. J. clin. Endocrin. 1950, 10, 1471. 3. Hurxthal, L., Musulin, M. Amer. J. Med. 1946, 1, 56. McGavack, T. H. The Thyroid. St. Louis, 1951. Bertels, E. Surg. Clin. N. Amer. 1945.

203 increases the basal metabolic rate also increases, and the

blood-cholesterol level decreases. Because of these

proofs-and

many others

already

observed by the earlier workers--we have to admit that the cretin may be sometimes

a

hypothyroid patient,

sometimes a euthyroid, and perhaps sometimes a hyperthyroid. Cawadias4 wrote : "... hypothyroidism is only a part of the physiopathological and clinical picture of cretinism, and does not, by itself

Nowadays... a better study of the diseases allows of another conception constitutional deep leading to a better understanding of the ’sui generis ’ clinical history of cretinism." constitute cretinism.

By such

a

concept hypothyroidism

is not

always

a

necessary condition for this disease, and the results of the tests which can indicate thyrotoxicosis should not

regarded necessarily

be

as

contradictory.

Mauriziano Hospital, Turin, Italy.

AURELIO COSTA.

ASSISTANT MEDICAL OFFICERS’ SALARY

SIR,—The salary-scale for assistant medical oflicers iu public-health service has now been amended, and

the

to get £1300 maximum. If this be accepted as fair and just remuneration, then we shall see the decline and fall of this very valuable service. We deserve, and should get, a grading comparable with senior hospital medical officers and not senior registrars. Most of us have spent some years in public health, having come in after three years’ postgraduate experience which included hospital appointments and the D.P.H. qualification. We can claim to be at the height of our professional work, and not trainees in the service as the new salary-scale suggests. we are a

fulfil the educational requirements mentioned hy Mr. Lingard. Such a step would, in their view, prevent many candidates who would make excellent assistant nurses from attempting a course from which they are unlikely to profit, and in which they are unlikely to

qualify. Royal College of Nursing, Henrietta Place,

CHEMOTHERAPY AND ANTIBIOTICS SIR,—Such is the affinity of the medical profession for misleading terminology that it may already be too late to hope that the collective appellation of drugs directed against micro-organisms may be revised. The current usage of the terms " chemotherapeutic " and

" antibiotic," however, seems peculiarly inept. The former should logically apply to all drugs of

and fixed composition, while the apparently implications of the latter provide a striking contrast to the aspirations with which such drugs are prescribed. Even assuming that the &bgr;ío&sfgr; refers to the parasite and not to the host, there is no warranty for limiting the term

known lethal

substances which are derived from microneither is the distinction of more than historical interest except to the biologist. It seems, therefore, that the present use of the term " chemotherapy " is too restricted for accuracy. The term " antibiotic may appropriately be applied to any drug which has an inimical effect on micro-organisms. to

those

organisms ;

"

NURSING PROBLEMS IN THE PROVINCES SiR, May I point out to your correspondent, Professor Vining (July 11), that it is not the Royal College of Nursing but the nurses’ statutory body, the General Nursing Council, which lays down the basic training and age of admission of students training for the State Register of Nurses, and of pupils training for the State Roll of Assistant Nurses. The Royal College of Nursing, which he criticises, has no statutory powers, and is concerned with specialist training only after the nurse has become State-registered. Nevertheless its council warmly supports the imposition by the General Nursing Council of a minimum age of entry for students in training for the State register; also its efforts (so far unavailing) to prevail on the Minister of Health to sanction the reimposition of an entrance test for those who do not 4.

Cawadias,

A. P.

Clinical Endocrinology. London, 1947.

K. H. NICKOL.

Dorking, Surrey. OBESITY

A.M.O.

SITTING DOWN TO SURGERY SIR,—The article by Mr. George Sacks in your issue of April 4 was long our due. Surgeons have been quite negligent of the strain which operations under modern conditions put upon their energies. A minor attack of angina in July, 1951, made it imperative for me to perform my operative work sitting down. Since August of that year I have been doing all I have found that this my operations sitting down. greatly contributes to calm and quiet in the theatre. But unlike Mr. Sacks I have not had to import costly stools. A plain wooden stool answers my purpose, and I have not found it necessary to change the standard positions during the operation ; I only have to alter the height of the operation-table. My operation lists have included thyroidectomies for recurrent toxic goitre, gastrectomy, cholecystectomy, hemicolectomy, a bdominoperineal excision of rectum, and prostatectomy. At the end of a long day I have felt more full of energy than I did when I used to operate standing. Rajindra Hospital, Patiala, JOGDISH SINGH. Pepsu, India.

MARY F. CARPENTER Director, Education Department.

London, W.1.

SIR,—I read with interest your annotation of July 18. As the control of obesity is one of the most practical forms of preventive medicine within the scope of the general practitioner, I have become an enthusiastic reducer of weight. Assuming that all tissues of the body, including fat, are continually being broken down and replaced, it should be possible to reduce the fat depots by withholding replacements. Also, assuming that the body is only able readily to replace its fat depots from carbohydrate, and that it will only utilise protein and fat itself for this purpose under duress, it should be possible to treat obesity by allowing the patient as much protein and fat as he is able to consume, and eliminating carbohydrate from his diet. In practice this does not produce ketosis, nor does the patient lose glandular or muscular tissue ; and of course it provides a very varied if rather expensive diet. Without restricting the calorie intake in any way, losses of up to one stone in weight in a month have been attained, and I have gained the impression that such a diet is successful in a surprisingly large proportion of Further observation of these cases is necessary cases. before I can be satisfied with the efficacy of the method, but results so far certainly seem to support the work of Pennington1 which you rather lightly dismiss. E. C. HAMLYN. Devonport. THE PROBLEM OF

PEPTIC ULCERATION

SIR,—I hesitate to intrude on your columns again, but before I depart tomorrow for New Zealand I should like to answer Mr. Aylett’s letter in your issue of June 13. Gastrectomy, in the hands of many surgeons whose work I know, is nearly 100% safe and 100% satisfactory. I think Mr. Aylett has been unlucky. I have not yet tried the Aylett operation because it seems to me to transgress two of the principles of gastric surgery that have been learned by experience : first 1.

Pennington, A. W.

New

Engl. J. Med. 1953, 248, 959.