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TREATMENT OF THYROTOXICOSIS WITH POTASSIUM PERCHLORATE
1173
prevalence
of the
common
diseases,
to
man
as
if all his
was
occupational groups ! The second requires a fundamental change in approach —namely, to make provision under the National Health Insurance Scheme for adequate benefits for the disof how the disablement has been If this were done, epidemiological studies could return to their primary objective-prevention. We agree with Dr. Macdonald (Nov. 23) that the time has come for a further review of the position to see whether it is possible to achieve any better compromise than the abled
irrespective
caused.
present
one.
Pneumoconiosis Research Unit,
Llandough Hospital, Penarth, Glamorgan. Postgraduate Medical School, London, W.12.
TOO MANY DOCTORS?
compensate
any due to this disability occupation. This would remove the injustices which your correspondents claim to exist, but only at the expense of introducing new ones. With the growth of epidemiological research, more and more differences from occupation to occupation in the incidence of the common diseases will be discovered until, after an interval during which compensation will depend perhaps more on the order in which investigations are carried out than on the actual hazard of the occupation, the only uncompensated disabled will be those in small or ill-defined
disabled
J. C. GILSON P. D. OLDHAM F. MEADE.
PHILIP HUGH-JONES.
CLASSIFICATION OF DISEASES IN GENERAL
StR,—It is to be hoped that the findings of the Willink Committee will not be accepted by the medical schools. We still live in a free and country and it is no part of the duty of a university or school to refuse to educate all those can accommodate on the grounds that some may not find safe jobs. Are we to assume that all those trained at British medical schools are to be employed in the National Health Service ? Many of them may wish to lead a fuller or more adventurous life. They may wish to be private practitioners, or missionaries in China, or to take up practice in India or Malaya. Are we so satisfied with medicine that we are content to think that it will be the same in twenty years’ timeQ By that time we may really have a National Health Service in place of the present National Sickness Service. We should need many more doctors if we had an adequate system of medical examinations to maintain the nation in health. It may even be the case that the people of this country will follow the lead of others in deciding that health is worth paying for. In that case thousands of private practitioners would be employed in carrying out routine comprehensive examinations to detect early’ signs of disease. These are just one or two random possibilities which may prove the planners wrong. Planners may be very sane people who always keep their hair on, but they don’t always keep the roofs on. KENNETH C. HUTCHIN.
competitive
they
PRACTICE
SiR,-With the publication of a new edition of the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Deatla,’ may I suggest to those general practitioners who are considering recording the cases in their practices that this volume forms an excellent basis for such a record. Using a four-hundred-sheet 5 in. x 8 in. loose-leaf book and the three-digit categories I have found this system quite adeauate. E. W. BEDFORD-TURNER TREATMENT OF THYROTOXICOSIS WITH POTASSIUM PERCHLORATE
SiR,-We were pleased to see the article by Professor Smellie in your issue of Nov. 23 on the treatment of juvenile thyrotoxicosis with potassium perchlorate. Since the publication of our article in 19542 we have continued to use this drug in the treatment of adult thyrotoxicosis, with satisfactory results. No untoward effects, other than two skin rashes, have been noted ; and the two apparent instances of gastric irritation on further investigation,3 to have been no more than coincidental. We should, however, like to take this opportunity of confessing that the initial adult dose recommended by us (400 mg. daily) has subsequently proved to be too low, and this no doubt accounts for the rather slow response noted in some of our early cases. We now begin treatment with 1600 mg. daily, given in four separate doses. The dose is subsequently lowered according to the patient’s progress to a minimum of 200 mg. daily. It would appear from Professor Smellie’s results that the dosage levels effective in children are a great deal lower. It should also be emphasised that we use potassium perchlorate for long-term medical treatment only. It is not a satisfactory drug for preoperative preparation, since the antithyroid effect is lost immediately iodides are given, as Professor Smellie Doints out. M. E. MORGANS University College Hospital Medical School, London, W.C.1. W. R. TROTTER.
proved,
1. See Lancet, Nov. 2, 1957, p. 882. 2. Morgans, M. E., Trotter, W. R. ibid. 1954, i, 749. 3. Morgans, M. E., Trotter, W. R. ibid. p. 883.
ELECTROENCEPHALOGRAPHIC STUDY OF SYNCOPE
SiR,-May I take advantage of your correspondence columns to express some criticisms of the article by Professor Gastaut and Dr. Fischer-Williams in your issue of Nov. 23 ?’? They say that they use " syncope " to describe a loss of consciousness with or without convulsions. I infer from this that the presence or absence of convulsions is not a part of their definition of syncope, and I conclude that they use syncope to describe a loss of consciousness. Since loss of consciousness is also part of their definition of epilepsy it seems that a patient who has epilepsy also has syncope. But I suspect that cerebral anoxia is part of their definition of syncope and the absence of cerebral anoxia is part of their definition of epilepsy. No-one, I am sure, will be surprised to learn that if the heart stops beating sufficiently long the patient becomes unconscious and goes into decerebrate rigidity while his E.E.G. becomes fiat. Indeed the dictionary definition of syncope given by Professor Gastaut and Dr. Fischer-Williams indicates that the condition may be fatal. They should not conclude (from the observation that a patient becomes unconscious when his heart stops beating due to compression of his eyes) that in a spontaneous loss of consciousness the heart stops beating, for if such an argument is valid they would also have to conclude that in a spontaneous loss of consciousness someone is pressing upon the patient’s eyes. In other words, to show that a provoked cerebral anoxia leads to a loss of consciousness does not allow the inference that a spontaneous loss of consciousness is due to cerebral anoxia. They state, by way of a conclusion, that the tonic anoxic seizures of syncope are not epileptic. But they defined epilepsy as a loss of consciousness -with convulsions, and I do not see why they had to experiment to arrive at this conclusion, since, by definition, " no convulsions,
no
epilepsy."
I understand them to say that pressing on a patient’s eyes is a valuable test, for if the heart slows considerably the patient is suffering from syncope. Since some of their patients with syncope had convulsions, is it to be assumed
prevalence
of the
common
diseases,
to
man
as
if all his
was
occupational groups ! The second requires a fundamental change in approach —namely, to make provision under the National Health Insurance Scheme for adequate benefits for the disof how the disablement has been If this were done, epidemiological studies could return to their primary objective-prevention. We agree with Dr. Macdonald (Nov. 23) that the time has come for a further review of the position to see whether it is possible to achieve any better compromise than the abled
irrespective
caused.
present
one.
Pneumoconiosis Research Unit,
Llandough Hospital, Penarth, Glamorgan. Postgraduate Medical School, London, W.12.
TOO MANY DOCTORS?
compensate
any due to this disability occupation. This would remove the injustices which your correspondents claim to exist, but only at the expense of introducing new ones. With the growth of epidemiological research, more and more differences from occupation to occupation in the incidence of the common diseases will be discovered until, after an interval during which compensation will depend perhaps more on the order in which investigations are carried out than on the actual hazard of the occupation, the only uncompensated disabled will be those in small or ill-defined
disabled
J. C. GILSON P. D. OLDHAM F. MEADE.
PHILIP HUGH-JONES.
CLASSIFICATION OF DISEASES IN GENERAL
StR,—It is to be hoped that the findings of the Willink Committee will not be accepted by the medical schools. We still live in a free and country and it is no part of the duty of a university or school to refuse to educate all those can accommodate on the grounds that some may not find safe jobs. Are we to assume that all those trained at British medical schools are to be employed in the National Health Service ? Many of them may wish to lead a fuller or more adventurous life. They may wish to be private practitioners, or missionaries in China, or to take up practice in India or Malaya. Are we so satisfied with medicine that we are content to think that it will be the same in twenty years’ timeQ By that time we may really have a National Health Service in place of the present National Sickness Service. We should need many more doctors if we had an adequate system of medical examinations to maintain the nation in health. It may even be the case that the people of this country will follow the lead of others in deciding that health is worth paying for. In that case thousands of private practitioners would be employed in carrying out routine comprehensive examinations to detect early’ signs of disease. These are just one or two random possibilities which may prove the planners wrong. Planners may be very sane people who always keep their hair on, but they don’t always keep the roofs on. KENNETH C. HUTCHIN.
competitive
they
PRACTICE
SiR,-With the publication of a new edition of the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Deatla,’ may I suggest to those general practitioners who are considering recording the cases in their practices that this volume forms an excellent basis for such a record. Using a four-hundred-sheet 5 in. x 8 in. loose-leaf book and the three-digit categories I have found this system quite adeauate. E. W. BEDFORD-TURNER TREATMENT OF THYROTOXICOSIS WITH POTASSIUM PERCHLORATE
SiR,-We were pleased to see the article by Professor Smellie in your issue of Nov. 23 on the treatment of juvenile thyrotoxicosis with potassium perchlorate. Since the publication of our article in 19542 we have continued to use this drug in the treatment of adult thyrotoxicosis, with satisfactory results. No untoward effects, other than two skin rashes, have been noted ; and the two apparent instances of gastric irritation on further investigation,3 to have been no more than coincidental. We should, however, like to take this opportunity of confessing that the initial adult dose recommended by us (400 mg. daily) has subsequently proved to be too low, and this no doubt accounts for the rather slow response noted in some of our early cases. We now begin treatment with 1600 mg. daily, given in four separate doses. The dose is subsequently lowered according to the patient’s progress to a minimum of 200 mg. daily. It would appear from Professor Smellie’s results that the dosage levels effective in children are a great deal lower. It should also be emphasised that we use potassium perchlorate for long-term medical treatment only. It is not a satisfactory drug for preoperative preparation, since the antithyroid effect is lost immediately iodides are given, as Professor Smellie Doints out. M. E. MORGANS University College Hospital Medical School, London, W.C.1. W. R. TROTTER.
proved,
1. See Lancet, Nov. 2, 1957, p. 882. 2. Morgans, M. E., Trotter, W. R. ibid. 1954, i, 749. 3. Morgans, M. E., Trotter, W. R. ibid. p. 883.
ELECTROENCEPHALOGRAPHIC STUDY OF SYNCOPE
SiR,-May I take advantage of your correspondence columns to express some criticisms of the article by Professor Gastaut and Dr. Fischer-Williams in your issue of Nov. 23 ?’? They say that they use " syncope " to describe a loss of consciousness with or without convulsions. I infer from this that the presence or absence of convulsions is not a part of their definition of syncope, and I conclude that they use syncope to describe a loss of consciousness. Since loss of consciousness is also part of their definition of epilepsy it seems that a patient who has epilepsy also has syncope. But I suspect that cerebral anoxia is part of their definition of syncope and the absence of cerebral anoxia is part of their definition of epilepsy. No-one, I am sure, will be surprised to learn that if the heart stops beating sufficiently long the patient becomes unconscious and goes into decerebrate rigidity while his E.E.G. becomes fiat. Indeed the dictionary definition of syncope given by Professor Gastaut and Dr. Fischer-Williams indicates that the condition may be fatal. They should not conclude (from the observation that a patient becomes unconscious when his heart stops beating due to compression of his eyes) that in a spontaneous loss of consciousness the heart stops beating, for if such an argument is valid they would also have to conclude that in a spontaneous loss of consciousness someone is pressing upon the patient’s eyes. In other words, to show that a provoked cerebral anoxia leads to a loss of consciousness does not allow the inference that a spontaneous loss of consciousness is due to cerebral anoxia. They state, by way of a conclusion, that the tonic anoxic seizures of syncope are not epileptic. But they defined epilepsy as a loss of consciousness -with convulsions, and I do not see why they had to experiment to arrive at this conclusion, since, by definition, " no convulsions,
no
epilepsy."
I understand them to say that pressing on a patient’s eyes is a valuable test, for if the heart slows considerably the patient is suffering from syncope. Since some of their patients with syncope had convulsions, is it to be assumed