professional career ? Personally, I have already decided. Although I will always be indebted to the consultants concerned (and my other colleagues), after my compulsory preregistration year of exploitation I shall never again seek a
clinical post. M. D. BUCKLEY-SHARP.
THROMBOLYTIC THERAPY IN PULMONARY EMBOLISM with Dr. Thomas (Aug. 22, p. 418) that, SIE,-We agree with present knowledge of the mode of action of heparin and the extension of thrombi, it is justifiable to give heparin as soon as pulmonary embolism is suspected. There is invariably some delay before the diagnosis is confirmed by pulmonary angiography and, during this time, heparin may prevent secondary thrombosis distal to the embolus. Once it has been decided, however, that the patient is suitable for thrombolytic therapy, no time should be wasted in starting streptokinase. Our studies 1,2 in patients with deep-vein thrombosis in the legs, where the effect of therapy can be measured with much greater precision than in the lungs, have clearly shown that heparin has little or no effect in dissolving a thrombus. The second problem, presented by Dr. Carmichael and his colleagues (Aug. 22, p. 418), is the possibility that streptokinase given 48 hours after an operation may be dangerous. We have had extensive experience with both streptokinase and heparin in these circumstances, and the problem of bleeding has arisen only in those patients with extensive raw areas, such as radical vulvectomy and radical mastectomy. Certainly, under such circumstances, the administration of heparin is no safer than thrombolytic
therapy.1 In all 4 patients who survived, recovery was rapid, and in 2 repeat pulmonary angiograms showed complete dissolution of thrombi. In both the patients who died, some degree of lysis of emboli was seen post mortem. It was difficult to say with certainty whether this change was ante or post mortem, because of the interval between death and necronsv. V. V. KAKKAR King’s College Hospital, E. B. RAFTERY. London S.E.5.
PROSTAGLANDINS IN FERTILITY CONTROL SIR,-A few months ago the possible use of prostaglandins for fertility control was discussed in your columns.3-5 The two important questions asked were: (a) whether selfadministration of prostaglandins could be effective in stimulating the human uterus; and (b) whether these substances so administered would be non-toxic. From recent work with prostaglandins E2 and F2G( in this department it has become apparent that when self-administered these two prostaglandins are absorbed into the circulation and can stimulate the human uterus to contract. Both prostaglandins E2 and F2G( taken by mouth have been used for the induction of labour in women at or near term without producing any side-effects. As with the intravenous route much higher doses of these two prostaglandins are required to stimulate the non-pregnant uterus or uterus in early pregnancy. When given orally at such higher dose levels, prostaglandins in addition to stimulating the uterus produce diarrhoea and vomiting. Kakkar, V. V., Flanc, C., Howe, C. T., O’Shea, M., Flute, P. I. Br. med. J. 1969, i, 806. 2. Kakkar, V. V., Flanc, C., O’Shea, M., Flute, P. T., Howe, C. T. Br. J. Surg. 1969, 56, 178. 3. Speidel, J. J., Ravenholt, R. T. Lancet, 1970, i, 565. 4. Gillespie, A., Beazley, J. M. ibid. p. 717. 5. Karim, S. M. M. ibid. p. 1115. 1.
With the vaginal route of administration both these prostaglandins are effective in stimulating the uterus throughout pregnancy without producing any toxic effect. They have to induce abortion in the first and second trimesters of pregnancy, and to induce menstruation within 6 a few days after the first missed period.
already been used
Department of Pharmacology and Therapeutics, Makerere University, Medical School, P.O. Box 7072, Kampala, Uganda.
S. M. M. KARIM.
G.M.C. RETENTION FEE SIR,-The diehards of our profession should be grateful to Mr. Hart (Sept. 5, p. 530) for his letter on behalf of the General Medical Council. He makes two points that have been consistently ignored. First, the act of registration involves no contract between Council and doctor. Second, and more important, the Council is a statutory body with specific duties laid upon it by Acts of Parliament, which it is not free to curtail. Parliament represents the people. It is therefore logical to suggest that it is the duty of the people through Parliament to provide the fully reliable source of income stressed by Mr. Hart. This should be done through general taxation and not by retention fee. Chadwell Heath Hospital, Romford,
I. M. LIBRACH.
CARRAGEENAN AND GALACTOSÆMIA SiR,ŁThe possible effects of ingested carrageenan, as discussed by Dr. Bonfils, Professor Maillet, and their coworkers (Aug. 22, p. 414), require very careful consideration in view of the increasing use of these gums in foods, especially in the new substitute or synthetic " foods which will inevitably play an increasing role in foods all over the world. It is well recognised in microbiology that a new use, or an increasing use, of any substance can lead to the development of the ability of normally present organisms to attack it, or to the " evolution " or appearance of new types of organism able to do so. These gums often contain very large amounts of galactose (30%-40%). Admittedly this is very firmly bound and apparently resistant to ordinary biochemical and bacterial liberation; nevertheless, microorganisms are capable of an infinite variety of tricks. The danger of such a degradation for galactosasmic infants is obvious, and the widespread use of carrageenan in foods for infants as well as for adults merits a thorough study of the problem. J. G. DAVIS. "
AUTOIMMUNITY IN DIABETES MELLITUS SIR,-Having read the paper on thyroid and gastric autoimmunity in diabetes mellitus by Dr. Irvine and his colleagues (July 25, p. 163), we should like to communicate some related findings of our own from a study of 133 diabetics and a control group matched for age and sex. Like Dr. Irvine and his colleagues, we found the prevalence of circulating antibodies to thyroid cytoplasm and to gastricparietal-cell cytoplasm to be significantly increased in the sera of diabetics (p < 0-001 and p < 0.01 respectively). No correlation could be demonstrated between presence of thyroid antibodies and age, sex, or type or duration of diabetes. Gastric-parietal-cell antibody, however, was found most commonly in sera from patients with a duration 6.
Karim, S. M. M. Unpublished.
611 Antibodies to thyromore than 10 years. found more often in the sera from diabetics than in the control sera, but the difference was not statistically significant. Titres of thyroglobulin antibody 2500 were found only in sera from diabetics. Salivary-duct antibody and antinuclear factor were found with equal frequency in patients and controls. A clinical association between idiopathic Addison’s disease and diabetes mellitus is more frequent than would be expected by chance,1,2and antibody to cytoplasmic components of adrenocortical cells is regularly found in sera from patients with idiopathic Addison’s disease, but it is extremely rare in other conditions.3,4 In our series of 133 diabetics, circulating antibody against adrenocortical-cell cytoplasm was detected in 3 insulin-dependent patients. This finding accords with the conclusion of Dr. Irvine and his colleagues that there seems to be a disorder of the immunological system related to insulin-dependent diabetes with respect to the formation of autoantibodies and the occurrence of organ-specific autoimmune disease. We have also shown that an organ-specific, anti-adrenal cellular hypersensitivity can be demonstrated in diabetics with circulating anti-adrenal antibody but without Addison’s disease.5 This observation seems to indicate that the immunological disorder in insulin-dependent diabetes also involves cell-mediated autoimmunity. of diabetes of
Medical Department A, Rigshospitalet, University Hospital, Copenhagen. Medical Department TA, Rigshospitalet, University Hospital, Copenhagen.
JØRN NERUP. GUNNAR BENDIXEN.
Hvidøre Hospital, Klampenborg, Denmark.
CHILDREN IN ISOLATION UNITS SIR,-Hospital planners should take note of your comments (Sept. 5, p. 509) on the difficulties peculiar to the care of children in isolation units. The children should be transferred as soon as possible to open wards where contact with each other and with the staff is less inhibited, and where play therapy or schooling can more easily be provided. Isolation hospitals without open wards are as out of date as children’s hospitals without isolation facilities. Ruchill Hospital,
H. G. EASTON.
SELECTION OF HOUSEMEN SIR,-Your annotation (Aug. 29, p. 452) rightly mentions some of the minor defects in the computer-matching procedures which have been reported from Edinburgh 6 and Newcastle.’ As far as Edinburgh is concerned, we wish to point out that these defects have been completely eliminated by the separate allocation of winter and summer posts and the adoption of a new computer-matching program which is based on lines similar to those used by the National Intern and Resident Matching Program in the United States. In our new procedure, used successfully in 1969 and 1970, mathematical weights or products are not employed, only the rank order of consultants’ and applicants’
preferences being of importance. In this scheme, weighting in favour of either the consultant and neither party runs Turkington, R. W., Lebovitz, H.
5. 6. 7.
the applicant does not the risk of being penalised if or
E. Am. J. Med. 1967, 43, 499. Solomon, N., Carpenter, C. C. J., Bennett, I. L., Jr., Harvey, A. M. Diabetes, 1965, 14, 300. Nerup, J., Søborg, M., Halberg, P., Brøchner-Mortensen, K. Acta med. scand. 1966, suppl. 445, p. 383. Irvine, W. J., Stewart, A. G., Scarth, L. Clin. exp. Immun. 1967. 2, 31. Nerup, J., Bendixen, G. ibid. 1969, 5, 355. Doig, A., Munday, G. Lancet, 1969, i, 1250. Leishman, A. G., Ryan, R. P. ibid. Aug. 29, 1970, p. 459.
the first few choices on a preference list do not materialise. Further details of the present Edinburgh scheme are being prepared for publication. A. DOIG H. R. A. TOWNSEND Medical School, R. C. HEADING. University of Edinburgh.
THE FIST AS EXTERNAL CARDIAC PACEMAKER SIR,-The three cases of cardiac asystole treated by chest pounding (Aug. 29, p. 436) bring to mind two similar cases in this unit. A 48-year-old man attended casualty because of recent onset of fainting attacks. He had had chest pain two to three weeks previously. While being examined he became unconscious, and an electrocardiograph showed complete heart-block, with an inadequately slow ventricular rate. External cardiac massage, airway intubation, and intravenous therapy were started, and after a few minutes the chest was pounded. A ventricular complex resulted on the E.C.G. and the procedure was repeated. Adequate cardiac output with palpable peripheral pulses was maintained. The patient regained consciousness, and complained of the pain the pounding was causing. The situation was briefly explained to him and he accepted it. During the insertion of a transvenous pacing catheter, asystole was controlled by chest pounding. The patient made an uneventful recovery. A 73-year-old woman had a demand-type pacemaker with epicardial leads inserted in August, 1969, for Stokes-Adams attacks. She was well until May, 1970, when the attacks recurred. A transvenous bipolar pacing catheter was inserted. Nineteen days after insertion, she had a further Stokes-Adams attack. Chest pounding was successful in restoring consciousness, and spontaneous ideoventricular rhythm took over after a short time and maintained adequate circulation to allow a new catheter to be inserted. Her
later successfullv reimplanted.
Liverpool Regional Cardiac Centre, Sefton General Hospital, Liverpool, L15 2HE.
L-DOPA, PARKINSONISM, AND DEPRESSION SIR,-In a clinical trial of L-dopa in parkinsonism (to be published elsewhere) we used both standard neurological and psychiatric evaluation. 30 patients assessments in the trial which lasted for six months (two participated months in hospital, and at least four months as outpatients). Psychiatric assessment included psychometric evaluation on admission to hospital and weekly clinical assessments with muti-item rating scales. During the second month of the trial depression was diagnosed in 13 patients. These cases were separated, according to aetiology, into the following groups: reactive (5), endogenous (5), organic (2), and symptomatic (1). We kept an eye on the depressive symptoms during the time L-dopa was being given for parkinsonism. No other drugs were taken either for parkinsonism or
for depression. In 5 of these 13
patients the depressive symptoms got (4 endogenous and 1 symptomatic). All the other patients either improved or stayed the same. On a neurological level the response was very good, and consonant with the results in the patients with no symptoms of worse
mental illness. These results may throw some light on the findings of Goodwin et al.l These workers treated 9 cases of depression with L-dopa and cx-methvldopa hydrazine (MK 485) and 1.
Goodwin, F. K., Brodie, H. K., Murphy, Lancet, 1970, i, 908.