574 us who devote our life’s work to bringing our of medicine to the service of industry have knowledge often heard the views to which Dr. Todd has dr...

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574 us who devote our life’s work to bringing our of medicine to the service of industry have knowledge often heard the views to which Dr. Todd has drawn attention ; we spend a good deal of time in trying to overcome them. The Association of Industrial Medical Officers is publishing a booklet this month entitled the Functions of an Occupational Health Service in an Industrial Organisation. I am sure that after reading it Dr. Todd will be convinced that we are entirely Hippocratic in our outlook and work. Our nation has much to gain if we doctors continue to bring high principles and technical resources to the service of industry. Shall we work together to this end ? L. G. NORMAN. London.

Those of


SIR, Dr. Hodgkin’s figures (Aug. 25) confirm the impression that a large group of disorders dealt with in family practice are never seen in hospital. The remedy is certainly to introduce the undergraduate to general practice and this is better done, not in the ward round where the attendant general practitioner can merely talk about cases which aren’t there to be demonstrated, but in the surgery and the home-natural environment of doctor and patient. In addition to seeing some of the 75% of disorders which never get to hospital he finds there a new aspect of medicine-illness in relation to the family-which will broaden his knowledge of and colour his thinking about the patients he sees in hospital. The earlier in the clinical course this introduction is effected the better. For some years I have been one of several general practitioners introducing first-clinical-year students to general practice. They sit in on our surgeries and come out on our rounds. My impression is that the experience has neither muddled them nor been regarded as an irrelevant extra, but has shown them what a satisfactory life general practice can be. ANDREW SMITH. Newcastle upon Tyne. PRIMARY ALDOSTERONISM

to Dr. Jacobides’s remarks would like to make the following points.

SIR,-In we


(Sept. 1)

The boy was indeed small for his age, he had hypogonadism, his bone age was 13 years, and there was no axillary hair and little pubic hair. According to Dr. Jacobides, these abnormalities indicate " some pituitary dysfunction." In our paper, however, we mentioned that aldosterone production showed a marked increase (excretion 34 µg, in 24 hours), while no indications were found which could suggest still another abnormality of the adrenal cortex, for the patient had a normal excretion of 17-ketosteroids with a normal differentiation (Dr. Huis in’t Veld) and normal levels of 17-hydroxycorticoids, of pregnandiol, and of gonadotrophins. The corticotrophin test was also normal. In the resected adrenals Dr. Wettstein found normal hydrocortisone and corticosterone levels. It has been established that retardation of growth and development may be caused by potassium deficiency. 1--3 This may be related to the fact that potassium is required for the formation of cytoplasm. Patients with primary aldosteronism have a marked potassium depletion. It seems therefore probable that the physical signs are due to potassium depleThe polyuria, polydipsia, and electrocardiographic tion. abnormalities are also the result of lack of potassium. The glucose-tolerance test does not show a " lag " curve. The levels did not exceed 180 mg. per 100 ml., but the fall was delayed. This curve may be explained by the combined effects of aldosterone and potassium depletion on carbohydrate metabolism. This point will be elaborated in a paper to be published in the Acta Eradocrarzologaca. In hypopituitarism the zona glomerulosa may be markedly atrophic. In one case we found only small fragments of the 1. Grijns, G. Z. Physiol. Chem. 1938, 251, 97. 2. Brokaw. A. Amer. J. Physiol. 1953, 172, 333. 3. Offerijns, F. G. J. Thesis, University of Amsterdam, 1955.

but the zona fasciculata though than usual was much better preserved.4 A case of pituitary dwarfism showed a considerable of the zona glomerulosa. The zona fasciculata while




less changed.5 to disturbances of the due Crises " may occur in hypopituitarism. was "


electrolyte met

of the zona fa In Conn’s photo graph 6 the cells of the adenoma showeda closely resembling that found by us in the hyper It is therefore highly probable zona fasciculata. the cells in the zona fasciculata are concerned wit production of aldosterone. F. S. P. VAN BUCH H. DOORENBOS H. S. ELINGS. Holland. Groningen,



patient hyperplasia

was the predominant feature.

THROMBOSIS OF THE SIGMOID SINUS SIR,- In the modern world, and especially in tLe developed countries, thrombosis of the sigmoid as a complication of aural suppuration is rare. Reading and Mr. Schurr’s article last week is th they say, an obituary, but its conclusion shou even in an obituary, pass without comment. I discussed elsewherecertain principles of the path of this condition, and, as all the sources quot Mr. Reading and Mr. Schurr are of earlier date,

recapitulation of mentary obituary notice. a




as a


Sinus thrombosis was at one time the commonest cranial complication of aural infection. It occurs the course of acute, suppurative (and usually coa mastoiditis, and also in acute exacerbations of mastoiditis. As the former type of infection has vi disappeared, the latter is the origin of nearly all th occurring nowadays (as well as, incidentally, of ne other intracranial complications). Thrombosis is the natural reaction of a blood-v injury, and is a specific instance of the pathology of inf tion and repair. If the blood-vessel is ligated in co beyond the thrombus, or if a portion of the vessel is r thrombi will again form at the points of surgical inter It is thus impossible to remove all clot, as it inevitably r after the act of removal. In the absence of inf thrombus is firm and tenacious and adherent to th of the vessel. Occasionally pieces may be swept aw cause remote embolism, an unfortunate imperfection defence mechanism, nothing in Nature being abs perfect ;; but generally speaking the mechanism admirably. Aseptic infarction of any magnitude r from lateral-sinus thrombosis is almost unknown, and ignored for all practical purposes. The danger lies thrombus becoming infected and therefore friable, and dissemination of fragments of clot containing path bacteria. This was first described in 1880 by Zauf advised treatment by opening up the sinus, evacuat septic clot, and sometimes ligating the internal jugu The surgeon’s knife was in his day his only weapo was also probably dealing with virulent types of i which

are now rare.

The two principles of modern treatment are to the source of infection, by mastoidectomy, and to the clot, thus either preventing embolism, or rate ensuring that the emboli are not infected. therapy is the weapon of choice in applying this principle, for it can penetrate more deeply th. Only when chemothera surgeon’s knife. demonstrably failed to control the pyaemia or bsrtc is surgical interferencewith the sinus just necessary. In such a case the clot has probably

Bnchem, F. S. P. Acta endocr., Copenhagen, 1955, Buchem, F. S. P., Arends, A. Acta med. scand. 1953, 152, 81. 6. Conn, J. W., Lawrence, H. L. Ann. intern. Med. 1956, 44, 1. 7. Ellis, M. In Modern Trends in Diseases of the Ear, Nose a Throat. Edited by M. Ellis. London, 1954; p. 177. 8. Zaufal, E. Prag. med. Wschr. 1880, 5, 516.

4. 5.