- Email: [email protected]
TUTANKHAMUN'S BREASTS
201
probably preserved, but the intense stimulation can produce several unpleasant side-effects. For instance, altered globulins secreted during the humoral response may cause hyperthyroidism, thrombocytopenia, or perhaps myasthenia, while sensitised lymphocytes may later destroy many parenchymal cells, so that organs may fail. One endresult of the conflagration is acquired immune deficiency ", but, even then, the increased liability to neoplasms remains, Those as long as the cell-mediated immunity persists. and invasive thymomas which pseudolymphomas heal be themselves, may end-stages of sarcoidsurprisingly osis. Unless lymphocyte sensitisation tests prove to be specific in this disease, however, the diagnosis can be made only unsatisfactorily, by exclusion.
veillance is
before we can accept the hypothesis that Tutankhamun inherited anything but an artistic convention from his curious predecessor. Department of Medicine, Royal Infirmary, Manchester M13 9WL.
J. D. SWALES.
"
"
"
"
Wood
Cottage, Chilworth, Surrey.
GERALD A. MACGREGOR.
A NEW LYMPHOMA SYNDROME
SIR,-It is a pity that your interesting leading article on histiocytosis with massive lymphadenopathy " (Jan. 20, p. 139) carried the misleading title " a new lymphoma syndrome " and that the disease is referred to as a new lymphoma ". As the article states elsewhere, the disease " does not seem a malignant process ", and as Rosai and Dorfman1 state, malignant lymphoma can be excluded on clinical and pathological grounds ". The clinical and histological features, indeed, strongly suggest At present, an increasing a specific infective lesion. number of lymphadenopathies, which might previously have been labelled as lymphomas, are being recognised as " sinus
"
"
host of viral or other stimuli. It is this new lymphadenopathy should that important, therefore, not be lightly labelled as a neoplasm, or treated as such.
reactive processes
to a
Christie Hospital and Holt Radium Institute,
Withington, Manchester M20 9BX.
O. G. DODGE.
TUTANKHAMUN’S BREASTS
SIR,-George III must bear a heavy responsibility for the current popularity of retrospective diagnosis upon historical figures. In your columns it has been proposed that Tutankhamun suffered from adrenal feminisation (Dec. 16, p. 1312) and Klinefelter’s syndrome or Wilson’s disease (Jan. 13, p. 109). It is true that some figures of the Pharaoh do show female breast development and a sagging abdominal wall. The medical historian (clinical) should bear in mind, however, that such abnormalities are mild compared with those shown by representations of his immediate predecessor, Akhenaten, who is represented in such a grotesque and effeminate form that the diagnosis of Frohlich’s syndrome has been entertained.3 Even more worrying for the retrospective diagnostician, members of Akhenaten’s male entourage (e.g., Bek, the Master of Works) are also shown as having female breast development which greatly exceeds that of Tutankhamun. Whilst close in-breeding was common, it seems improbable to say the least that pathological feminisation had reached such epidemic proportions in the New Kingdom. It is more likely that a style of representing the human form persisted for a while after the death of Akhenaten. The latter’s influence is evident in other articles in Tutankhamun’s tomb,4 which may date from the earlier part of Tutankhamun’s reign. Strong evidence is surely needed 1. 2. 3. 4.
TREATMENT OF VARICOSE VEINS
"
Rosai, J., Dorfman, R. F. Cancer, 1972, 30, 1174. Butler, J. H. Natn. Cancer Inst. Monogr. 1969, 32, 233. Aldred, C. Akhenaten. London, 1968. Desroches-Noblecourt, C. Tutankhamun. Harmondsworth, 1965.
SIR,-We read with great interest the two articles 1,2 on varicose veins, but we disagree profoundly with the conclusions. In a personal series (R. A. N.), more than 4000 operations have been performed for varicose veins, and a larger number of patients have received only injections. At present, a complete stripping for varicose veins is being performed on a fully ambulatory basis (general anaesthesia). The entire procedure has also been performed under local anxsthesia. The patient is admitted at 7.30 A.M. and is discharged at 5 P.M. that same day. He is instructed to return to work and all usual activities the day after surgery. With this technique there has been a great saving of hospital beds and work-hours lost to industry. Chant et al.1 state that " there is no significant difference between the results of these two forms of treatment ". This has not been our experience. Every patient is different and should be treated individually. If there are large varicose veins and severe valvular insufficiency at the saphenofemoral junction or shortsaphenous/popliteal vein junction, operative treatment has been very effective and injection treatment is followed by a high recurrence-rate. On the other hand, if the varicose veins are scattered and there is no retrograde flow resulting from severe valvular insufficiency, injection treatment is very effective. The authors also describe the operative " technique as follows: If the route of the stripper passed close to the site of the i.p.v.s and associated varicosities, a simple strip was performed." In our experience, the operative results are not satisfactory unless each and every site of valvular insufficiency is ligated flush with the deep veins. In order to compare surgery and injection treatment, the surgical technique considered must be meticulous. The success of operation depends proportionately upon the ability of the surgeon to detect and excise all sources of valvular insufficiency at their source. Many patients have been operated upon several times and large varices continue to recur because the saphenous veins had not been ligated flush with the femoral or popliteal veins or incompetent perforators had been missed. The article1 also states that " It is less disruptive to family life to make six or seven attendances at an outpatient clinic than to make the arrangements needed for admission to hospital that may last two to three days or possibly much longer." With the ambulatory surgical technique there is very little disruption of family life. In addition, an elastic support is necessary for one week postoperatively, whereas with the injection/compression technique the bandage is often used for six weeks or more. This extended use of a compression bandage would not be acceptable to many of our patients. Piachaud and Weddell2 say that " the cost to the patients, in terms of days taken off work, showed that those in the surgical group lost 31-3 days compared with 6,4 days lost by those treated with injection/compression sclerotherapy "; " The average loss of earnings in the " It is two groups was £118 and E29 respectively." concluded that it would benefit the patient, the health service, and the community if the majority of patients with varicose veins were treated as outpatients by injec-
tion/compression sclerotherapy." 1. 2.
Chant, A. D. B., Jones, H. O., Weddell, J. M. Lancet, 1972, ii, 1188. Piachaud, D., Weddell, J. M. ibid. p. 1191.
probably preserved, but the intense stimulation can produce several unpleasant side-effects. For instance, altered globulins secreted during the humoral response may cause hyperthyroidism, thrombocytopenia, or perhaps myasthenia, while sensitised lymphocytes may later destroy many parenchymal cells, so that organs may fail. One endresult of the conflagration is acquired immune deficiency ", but, even then, the increased liability to neoplasms remains, Those as long as the cell-mediated immunity persists. and invasive thymomas which pseudolymphomas heal be themselves, may end-stages of sarcoidsurprisingly osis. Unless lymphocyte sensitisation tests prove to be specific in this disease, however, the diagnosis can be made only unsatisfactorily, by exclusion.
veillance is
before we can accept the hypothesis that Tutankhamun inherited anything but an artistic convention from his curious predecessor. Department of Medicine, Royal Infirmary, Manchester M13 9WL.
J. D. SWALES.
"
"
"
"
Wood
Cottage, Chilworth, Surrey.
GERALD A. MACGREGOR.
A NEW LYMPHOMA SYNDROME
SIR,-It is a pity that your interesting leading article on histiocytosis with massive lymphadenopathy " (Jan. 20, p. 139) carried the misleading title " a new lymphoma syndrome " and that the disease is referred to as a new lymphoma ". As the article states elsewhere, the disease " does not seem a malignant process ", and as Rosai and Dorfman1 state, malignant lymphoma can be excluded on clinical and pathological grounds ". The clinical and histological features, indeed, strongly suggest At present, an increasing a specific infective lesion. number of lymphadenopathies, which might previously have been labelled as lymphomas, are being recognised as " sinus
"
"
host of viral or other stimuli. It is this new lymphadenopathy should that important, therefore, not be lightly labelled as a neoplasm, or treated as such.
reactive processes
to a
Christie Hospital and Holt Radium Institute,
Withington, Manchester M20 9BX.
O. G. DODGE.
TUTANKHAMUN’S BREASTS
SIR,-George III must bear a heavy responsibility for the current popularity of retrospective diagnosis upon historical figures. In your columns it has been proposed that Tutankhamun suffered from adrenal feminisation (Dec. 16, p. 1312) and Klinefelter’s syndrome or Wilson’s disease (Jan. 13, p. 109). It is true that some figures of the Pharaoh do show female breast development and a sagging abdominal wall. The medical historian (clinical) should bear in mind, however, that such abnormalities are mild compared with those shown by representations of his immediate predecessor, Akhenaten, who is represented in such a grotesque and effeminate form that the diagnosis of Frohlich’s syndrome has been entertained.3 Even more worrying for the retrospective diagnostician, members of Akhenaten’s male entourage (e.g., Bek, the Master of Works) are also shown as having female breast development which greatly exceeds that of Tutankhamun. Whilst close in-breeding was common, it seems improbable to say the least that pathological feminisation had reached such epidemic proportions in the New Kingdom. It is more likely that a style of representing the human form persisted for a while after the death of Akhenaten. The latter’s influence is evident in other articles in Tutankhamun’s tomb,4 which may date from the earlier part of Tutankhamun’s reign. Strong evidence is surely needed 1. 2. 3. 4.
TREATMENT OF VARICOSE VEINS
"
Rosai, J., Dorfman, R. F. Cancer, 1972, 30, 1174. Butler, J. H. Natn. Cancer Inst. Monogr. 1969, 32, 233. Aldred, C. Akhenaten. London, 1968. Desroches-Noblecourt, C. Tutankhamun. Harmondsworth, 1965.
SIR,-We read with great interest the two articles 1,2 on varicose veins, but we disagree profoundly with the conclusions. In a personal series (R. A. N.), more than 4000 operations have been performed for varicose veins, and a larger number of patients have received only injections. At present, a complete stripping for varicose veins is being performed on a fully ambulatory basis (general anaesthesia). The entire procedure has also been performed under local anxsthesia. The patient is admitted at 7.30 A.M. and is discharged at 5 P.M. that same day. He is instructed to return to work and all usual activities the day after surgery. With this technique there has been a great saving of hospital beds and work-hours lost to industry. Chant et al.1 state that " there is no significant difference between the results of these two forms of treatment ". This has not been our experience. Every patient is different and should be treated individually. If there are large varicose veins and severe valvular insufficiency at the saphenofemoral junction or shortsaphenous/popliteal vein junction, operative treatment has been very effective and injection treatment is followed by a high recurrence-rate. On the other hand, if the varicose veins are scattered and there is no retrograde flow resulting from severe valvular insufficiency, injection treatment is very effective. The authors also describe the operative " technique as follows: If the route of the stripper passed close to the site of the i.p.v.s and associated varicosities, a simple strip was performed." In our experience, the operative results are not satisfactory unless each and every site of valvular insufficiency is ligated flush with the deep veins. In order to compare surgery and injection treatment, the surgical technique considered must be meticulous. The success of operation depends proportionately upon the ability of the surgeon to detect and excise all sources of valvular insufficiency at their source. Many patients have been operated upon several times and large varices continue to recur because the saphenous veins had not been ligated flush with the femoral or popliteal veins or incompetent perforators had been missed. The article1 also states that " It is less disruptive to family life to make six or seven attendances at an outpatient clinic than to make the arrangements needed for admission to hospital that may last two to three days or possibly much longer." With the ambulatory surgical technique there is very little disruption of family life. In addition, an elastic support is necessary for one week postoperatively, whereas with the injection/compression technique the bandage is often used for six weeks or more. This extended use of a compression bandage would not be acceptable to many of our patients. Piachaud and Weddell2 say that " the cost to the patients, in terms of days taken off work, showed that those in the surgical group lost 31-3 days compared with 6,4 days lost by those treated with injection/compression sclerotherapy "; " The average loss of earnings in the " It is two groups was £118 and E29 respectively." concluded that it would benefit the patient, the health service, and the community if the majority of patients with varicose veins were treated as outpatients by injec-
tion/compression sclerotherapy." 1. 2.
Chant, A. D. B., Jones, H. O., Weddell, J. M. Lancet, 1972, ii, 1188. Piachaud, D., Weddell, J. M. ibid. p. 1191.