a two-week history of malaise, night sweats, and slight weight ... At this stage investigations were unhelpful and ... clinically normal parents and a normal sister.
1594
19 December 1964
much by attention to the details of failure as to the details of success, and it is in an attempt to avoid a future tragedy from the same causes that this report is made. I am grateful to Dr. R. A. B. Dikko, Permanent Secretary, Ministry of Health, Northern Nigeria, for permission to publish this letter. -I am, etc., J. S. DODGE. Regional Malarial Unit, P.M..B. 2106, Kaduna, N. Nigeria.
Hookworm Anaemia SIR,-I have read with great interest your leading article on hookworm anaemia (14 November, p. 1216). I would like to make one comment about your statement, " These larvae develop only if the faeces of such persons contaminate warm moist earth, and normal sanitary arrangements-and often the weather-in Britain preclude this." In Oxford, Dr. S. C. Truelove and myself have carried out some experiments on faeces infected with hookworm ova.' In one of these experiments a part of the infected faeces was covered with moist earth in a flower-pot and left in the open (the garden of the Radcliffe Infirmary), under a classic English weather in June and July for six weeks. We were able to identify three stages of hookworm larvae, of which the third one was a typical filariform. infective larva. We have pointed out that such infection can occur in Great Britain if bad sanitary conditions are allowed to exist, particularly among immigrants. We have also drawn the attention of the public health authorities and the physicians in this country to be aware of the condition, emphasizing the point that the English weather is not a strong barrier against the spread of the disease.-I am, etc., S. N. SALEM. Nuffield Department of Clinical Medicine, The Radcliffe Infirmary, Oxford. REFERENCE Salem, S. N., and Truelove, S. C., 1964, in press.
Hodgkin's Disease Limited to the Liver STR,-It is well established that the liver may be involved in Hodgkin's disease. However, Hodgkin's disease affecting the liver alone is-very rare, and the following case was therefore thought worth while reporting. The patient, a 15-year-old girl, was first seen at St. Thomas's Hospital in October 1963 with a two-week history of malaise, night sweats, and slight weight loss. On examination at that time there were no physical abnormalities; she was afebrile, and investigations showed: Hb 85%, E.S.R. 3, chest x-ray normal. She was not seen again until November 1963, when she was admitted to the ward with a three-week history of swelling of the legs and abdomen. On examination she was febrile and had tense ascites. No intra-abdominal masses were palpable, but there was considerable ankle and sacral oedema. Investigations at that time showed slight anaemia and thrombocytopenia. At this stage investigations were unhelpful and laparotomy was performed. At operation the liver and spleen were seen to be enlarged, the former having a mottled grevish appearance. There were no enlarged glands. Attempt at portal venography on the table was unsuccessful owing to technical reasons. A splenunculus and liver biopsy were taken for histology.
Correspondence Microscopically the splenunculus was normal, but the liver showed round-cell infiltration predominantly in the portal tracts, with liver-cell necrosis. The histological picture at this stage did not show conclusive evidence of lymphoma, and the diagnosis rested between this and an inflammatory process. Post-operatively she was given antibiotics and transfused with intravenous albumin, which temporarily raised her serum-albumin level (which had been only 2.9 g./100 ml.) to 4.3 g./100 ml. However, she remained unwell with swinging fever, jaundice appeared, and the ascites reaccumulated. Further investigations in December 1963 showed among other things: bilirubin 1.9 mg./100 ml., and alkaline phosphatase 85 units. As she remained so ill the diagnosis of malignant reticulosis became more likely, and she was treated with prednisone, 20 mg. four times a day, and vinblastine, which had to be discontinued after two weeks owing to progressive leucopenia. The steroids had no effect on either her fever or liver-function tests. She died on 12 January 1964. At necropsy the liver was grossly enlarged, all the hepatic tissue being replaced by yellowish firm tissue. The portal vein, hepatic vein, and inferior vena cava were all fully patent. The spleen was grossly enlarged with a deep purple cut surface. There were enlarged lymph-nodes along the aorta and pancreas. Post-mortem histology showed evidence of lymphocytic and histiocytic infiltration with irregular giant cells and increase of fibrous tissue in both the glands and liver. The diagnosis was that of a malignant reticulosis allied to Hodgkin's disease. Liver involvement is quite common in Hodgkin's disease,' 2 and indeed liver biopsy may be used to make the diagnosis.' How-
ever, only two cases have been reported of Hodgkin's disease affecting only the liver.' ' Possibly the liver as a primary site is more common than is realized, as by the time that most patients come to necropsy the disease has become widespread. I am indebted to Dr. H. K. Goadby for permission to publish this case and to Dr. R. Kittermaster for reporting on the sections.
-I am, etc., St. Thomas's Hospital, London S.E.1.
C. A. LOEHRY.
RaPERENcEs l Levitan, R., Diamond, H. D., and Craver, L. F., Amer. 7. Med. 1961. 30, 99. 2 Gut, 1961, 2, 60. MacLeod, M., and Stalker, A. L., Brit. med. 7. 1962, 1, 1449. G oia, I., Sang, 1935, 9, 367. Symmers, D., Arch.' intern. Med., 1944, 74, 163.
Inheritance in Gaucher's Disease SIR,-We have recently described' typical Gaucher cells in the bone-marrow of both clinically normal parents and a normal sister of two children with overt Gaucher's disease. This finding had, to our knowledge, previously not been reported. We have regarded our findings as an indication of heterozygosity (incomplete recessivity). Meanwhile we have been able to examine parents and siblings of another patient with Gaucher's disease. This 17-year-old patient suffers from clinically and histologically proved Gaucher's disease and underwent splenectomy eight years ago. Parents, two sisters (9 and 11 years old), and one 16-yearold brother are clinically normal. In the bone-marrow of both parents and sisters typical Gaucher cells could be demonstrated. The bone-marrow of the brother was normal. We therefore differ from the views of Klein and Franceschetti? but agree with Hsia's'
BJONAL opinion that the recessive mode of inheritance isthe most frequent one in Gaucher's disease. -We are, etc., H. GERKEN. E. GRAUCOB. Paediatric Department, H.-R. WIEDEMANN. Christian-Albrecht's University,
Kiel, Western Germany. REFERENCES 1 Gerken, H., and Wiedemann, H.-R., Ann. paediat. (Basel) in press. Klein, D, and Franceschetti, A., in Handbuch der Humangenetik, 1964, vol. IV, edited by P. E. Becker. Thieme, Stuttgart. 3 Hsia, D. Y. Y., Naylor, J., and Bigler, J. A., New Engl. 7. Med., 1959, 261, 164.
Another Television Hazard? SIR,-" Emergency-Ward 10 " had just finished when my 50-year-old patient developed sudden giddiness, while sitting in his viewing-chair. An hour later he was still chair-bound and afraid to move his head, as this increased his vertigo. He was found to have a normal heart and blood-pressure. Abnormal findings included a phasic nystagmus, unsustained to the right, but sustained with a rotary component to the left; a poorly moving palate; an equivocal right extensor plantar response; and minimal incoordination of his right leg. There was definite loss of appreciation of pin-prick over his left face, right limbs, and trunk. These findings were felt to be strongly suggestive of vertebro-basilar insufficiency. He made a good recovery over the succeeding week. Reconstructing the events prior to the incident, it was found that his chair was positioned at an approximate angle of 60' to the plane of the screen. This meant that for comfortable viewing a compensatory head rotation of some 300 was required. There was an additional tendency to extend the head over the top of the back-rest for greater comfort. One or both these factors may well have jeopardized the vertebral arterial flow in the manner shown by Brain.' The postprandial state, modified by the presence of an old partial gastrectomy, may have provided the backcloth of temporarily reduced arterial flow to the brain against which the above postural factors played a critical role.' A repetition should be less likely if the patient in future pays special attention to his head posture, assuming, of course, that he still cares for television.-I am, etc., London W.11. 2
KLAUS HEYMANN.
REFERENCES Brain, Lord, Brit. med. Y., 1963, 1, 771. Williams, D., ibid., 1964, 1, 84.
Professional Patients SIR,-Dr. T. L. Dunn's suggestion (3 October, p. 879), that a study be made of those who choose to play the role of patient in order to avoid the responsibilities expected from healthy people, is timely. Our experience leads us to conclude that such people are only a few of those who are not prepared to accept the task of fulfilling an adult role in society. We are also of the opinion that doubt need not be cast upon the choice being conscious by the qualification " almost." Such manipulative behaviour is often considered " neurotic " and regarded as sickness by the medical profession, whereas it is behaviour designed to lead unsuspecting
19 December 1964 doctors into sending the "patients " in the direction they want to go or keeping them the way they are. The ethics of such behaviour is not only a medical problem but a moral issue, with economic implications of some magnitude. Study and definition are certainly needed to clarify terms of reference.-We are, etc., L. J. F. WARNANTS. D. H. MARJOT. Psychiatric Department, British Military Hospital, c/o G.P.O., Singapore.
Mongolian Spots SIR,-For the sake of the completeness of the record an addition which should be made to Dr. D. B. Jelliffe's list (21 November, p. 1330) of races in which some neonates exhibit "Mongolian spots " is that of the Eskimos. I have frequently seen them on young Eskimo infants in Labrador, and I have no doubt they are also found in the other Eskimo communities. As Dr. Jelliffe implies, they are of neither clinical nor ethnological significance.-I am, etc., JACK CORMACK. Edinburgh 12.
Accidents in Coal Mines SIR,-On the morning on which your issue was published containing comment on Accidents in Coal Mines (5 December, p. 1411), I was attending a conference of management and union representatives called to discuss safety, and subsequently widely reported in the local press. We, working in the mining industry, would agree that it is more profitable to study working conditions; accidents, we believe, are caused, they do not just happen. What does not emerge from your comment is the considerable problems which have arisen as a result of the technical revolution which has taken place in mining in a decade. There has been no lack of awareness among mining and safety engineers, but, as your article indicates, the problems are subtle and not always capable of easy definition.-I am, etc., R. McL. ARCHIBALD. Northumberland and Durham Division. National Coal Board, Gateshead 11, Co. Durham.
Sugar and Dental Caries SIR,-I should like to attempt an answer to the question raised by Dr. H. Maitland Moir (5 December, p. 1463) on the relationship of breast and artificial feeding to dental caries. Whilst there is little evidence to suggest a positive relationship between breast feeding and subsequent immunity to dental decay there is an increasing awareness in the relationship of this disease to prolonged bottle feeding.' ' In a recent study I have conducted into this problem (to be published) a highly positive relationship has been shown between decay in the deciduous dentition and the use of feeding bottles given to comfort children over prolonged periods of time. I was surprised to find that in a control group of pre-school children 57% had been given comforter bottles up to an average age of I year 11 months. Most of these bottles con-
Correspondence
BRiIH__
1595
three malignant hot nodules.`5 This series has since become much larger but our early conclusions have not been upset by subsequent experience. If one neglects the investigation by means of radioactive iodine the overall percentage of single nodules found to be malignant 'was 13%, twice the figure of 6.6% quoted by Veith et al.' On the contrary, the incidence of cancer in multinodular glands has been found to be 8%,' compared with the 13.3% found by Veith et al. Your leader lays stress on the importance of sex. The ratio of female to male patients in thyroid disorder is about 8 1. In thyroid carcinoma the ratio falls to 5 1' or even to 2 1.' We therefore agree that suspicion of malignancy should be more easily aroused when the patient is a male. We are less surely in agreement with you in the matter of age. In saying that "in women under 40 years single thyroid nodules Dept. of Children's Dentistry, should be removed surgically without delay " Eastman Dental Hospital, you neglect the question of whether they are London W.C. 1. " hot " or " cold " and the frequency of REFERENCES harmless nodularity in puberal goitres. In James, P. M. C., Parfitt, G. J., and Falkner, F., respiting women over the age of 40 unless Brit. dent. 7., 1957, 103, 37. 2 Robinson, S., and Naylor, S. R., ibid., 1963,. the increase in size is unequivocal you seem 115, 250. to neglect the higher incidence of undifferenHargreaves, J. A., ibid., 1964, 116, 386. tiated carcinoma in the old. We have dealt with 150 cases of thyroid cancer in the last 10 years., Our conclusions Infant Feeding are that cold single nodules should be reSIR,-Dr. F. P. Hudson's letter (17 moved immediately (because of the great risk October, p. 1011) on Liga low-protein biscuits of malignancy); that hot and neutral single has prompted me to draw attention to two nodules should be treated with thyroxine and more Liga products which have a useful place removed if they do not get smaller in six in infant formulas owing to their composition months (because we have seen one malignant and digestibility. neutral nodule); that non-toxic multinodular The " Liga three-way infant food " biscuits goitres need only be removed if they are enhave been fed to healthy infants and pre- larging or causing pain or signs or symptoms matures, and to infants recovering from feed- of pressure despite treatment with thyroxine, ing breakdowns. When added crushed in a undergoing a change in consistency, or in any 5-10% concentration to the appropriate milk way producing signs or symptoms suggestive mixture they provide a well-balanced diet up of malignancy.-We are, etc., to 6 months of age. They appeal to the RAYMOND GREENE. infants' taste and their smooth mixing quality allows concentrated bottle-feeding without W. E.SINGER. New End Hospital, W IGR London N.W.3. blockage of the teat. To older babies the biscuit can be offered either as a snack or REFERENCES mixed with fruit or vegetable pulp. 1 Greene, R., Ann. roy, Coll. Surg., 1957, 21, 73. The other product " Liga gluten-free" Farran, H. E. A., and Greene, R., Le Tireopatie, biscuits proved a well-tolerated nutrient in 1957, 5, 221. M., and Slater, S. L., New Engl. 7. the treatment of coeliac disease during the 3 Perlmutter, Med., 1956, 255, 65. crisis and later in place of gluten-free bread 4 Attie, J. N., Surgery, 1960, 47, 611. P. M., 7. Amer. med. Ass., 1961, 177, or other farinaceous food a valuable ampli- 5 Meadows, 229. fication of the reparation and maintenance 6 Veith, F. J., Brooks, J. R., Grigsby, W. P., and Selenkow, H. A., New Engl. 7. Med., 1964, diet. The difficult coeliac patient takes these 270, 431. biscuits well for long periods. His nutritional Piercy, J. E., Postgrad. med. 7., 1957, 33, 346. Trotter, W. R., Diseases of the Thyroid, p. 156, requirements seem adequately supplemented, 1962. Blackwell, Oxford. as shown by the speed of recovery and the absence of relapses.-I am, etc., tained fresh cow's milk, but even more significant was the fact- that 91 % had been sweetened by the addition of sugar (sucrose). Although these studies have only demonstrated a relationship between the prolonged use of sugared comforters and dental decay in the deciduous dentition, nevertheless a highly positive correlation has been shown between caries susceptibility in the deciduous and permanent dentition,' thus suggesting that the prolonged use of sweetened comforter bottles in infancy and early childhood may predetermine the caries potential for many years. In view of the significance given by Professor John Yudkin (5 December, p. 1458) to the present high consumption of sugar in this country, dental caries may be only one aspect of the problem created by the sweetened comforter bottle.-I am, etc., G. B. WINTER.
M. DYNSKI-KLEIN. West Middlesex Hospital, Isleworth, Middlesex.
Thyroid Nodules and Cancer SIR,-We read with interest but some disappointment your leading article (24 October, p. 1022). We were especially surprised to see therein no mention of the importance of directional scanning of thyroid glands in which single nodules are palpable. One of us' described the results of this process in a Hunterian Lecture in 1956. Of 109 " cold " nodules, 20% were definitely malignant and a further 6% possibly so; whereas of 54 " hot" and " neutral " nodules removed, none was malignant. Later2 a malignant " neutral " nodule was seen and others have reported
Local Analgesics SIR,-In an article " To-day's Drugs " (28 November, p. 1380) it is suggested that as yet no local anaesthetic drug superior to lignocaine has appeared. I appreciate that in a review of this brevity the writer cannot cover all the advantages and disadvantages of the numerous drugs that are now available, but I am sorry to see he dismisses prilocaine so lightly. There is no doubt that some drugs-for instance, procaine-have a special effectiveness in conduction or infiltration anaesthesia and yet little action as a topical agent. I believe that prilocaine has an action superior to lignocaine as far as the tracheobroncho tree is concerned. We have a busy endoscopy clinic in my, hospital, in which a minimum of
