justified, and Mr. Browne is doing good service to surgery by frequently saying so. As to hormone therapy, I pointed out at the. Royal Society of Medicine discussion UNIVERSITY REMUNERATION that chronological puberty is not identical with physiological puberty ; and many of these patients do not member of staff a whole-time a university SIR,—As If attain physiological puberty until their late teens. with full clinical appointments, I read with alarm and this happens, or-if their endocrine pattern suggests for the remuneration of the specialists. dismay proposals that this will happen, it would appear to me that hormone Two discrepancies were immediately apparent. Firstly, therapy is well justified to accelerate a process that the whole-time clinical staff in medical schools will The might occur spontaneously at a belated time. receive remuneration according to the new scale from other reason for hormone therapy is excessive anxiety of all other branches service the whereas April 1, 1949, of the patient and the parents about the absence of the will be remunerated in retrospect from July 5, 1948 ; testicles from the scrotum in contrast with other boys, and secondly, such university clinical specialists will be especially at boarding-schools. rated financially at approximately £1000 per annum It seems a pity that this relatively simple overlapping whole-time their clinical less than purely colleagues branch of endocrinology and surgery should be unnecein teaching hospitals. sarily complicated by over-elaborated controversy. The first point defies explanation and the second S. L. SIMPSON. London, W.l. apparently follows a tradition which can no longer be justified or maintained. Personally I feel that the OPTICIANS AND PHARMACISTS proposed scales are quite unjust to those holding whole-time clinical posts in medical schools. SIR,—In reply to Mr. Giles (March 12), I should like to say that I was quite aware of the standards of G. MATTHEW. DOUGLAS Edinburgh. examination required by the British Optical Association. HÆMOGLOBINURIA The association is, however, not the only body which SIR,-I agree with Dr. Dacie (March 19) that Stats, grants a registrable qualification in optics ; other Wasserman, and Rosenthalare unnecessarily cautious examining bodies do not require such strict standards from intending candidates, and courses of study for in their advocacy of parsimony in blood-transfusion in these examinations can be completed on a part-time cases of nocturnal haemoglobinuria.
case of a woman of 33, who had suffered from this for some five years, haemoglobin had been passed in the urine continuously for weeks before I first saw her ; and her general condition was extremely poor. Seventeen days ago her urine was port-wine colour before I comrnenced a replacement transfusion, during which 51/2 pints of blood were drawn off, and 7 pints of citrated blood with 5 of concentrated corpuscles were given.. Half-way through the operation the urine was brownish-pink, but two hours after the operation, although still turbid, the urine contained no haemoglobin. Now it is still free from hæmoglobin.
My only reason for publishing this note at so early a stage is to support Dr. Dacie’s assertion that bloodtransfusion is not necessarily contra-indicated in nocturnal haemoglobinuria ; and to point out that we are no longer as therapeutically impotent as we were. At a later date, Dr. P. H. Willcox and I hope to publish a detailed study of our case. A. PINEY. London, W.1. THE UNDESCENDED TESTICLE
SIR,—Mr. Denis Browne’s presentation, last week, of his illuminating work and views would not encourage the comprehensive objectivity he appears to miss in your annotation of the previous week. Clinical diagnosis can be sound whether or not his new anatomy should replace the older. If a testicle is palpable, few clinicians who see many cases will fail to decide correctly whether it is ectopic or not. If both testicles are not palpable, few clinicians will venture to predict whether or not there is a mechanical obstruction to their descent. If one testicle only is not palpable, it can perhaps be predicted with some confidence, though not with certainty, that there is such an obstruction. If gonadotrophins produce descent of testicles into the scrotum, then obviously there was no mechanical obstruction to their descent. If they fail to do so, the opposite conclusion is admittedly less certain. As to the alleged danger of overdosage, chorionic gonadotrophins are usually used, and I know of no practical danger of overdosage and certainly none of injury to the testicle. Testosterone or methyl testosterone is occasionally used ; this is less effective, and its use involves the danger of producing sexual precocity, and possibly some temporary involution of the testicle, if therapy is too intensive or prolonged. Endocrinologists and surgeons are agreed that some 75 % of "undescended testicles " will descend spontaneously at puberty, and both endocrinologists and surgeons (according to Mr. Browne) treat such cases, by hormones and surgery respectively; before puberty with effective results. Of course the surgery is not 1.
Stats, D., Wasserman, L. R., Rosenthal, N. Path. 1948, 18, 757.
Amer. J. clin.
basis. For the pharmacist there is only one body empowered to grant registration-the Pharmaceutical Society of Great Britain. For a considerable number of years the minimum standards of training recognised by the Pharmaceutical Society have been 2 years’ full-time study with a practical training of 2 or 3 years. ARTHUR G. SHAW. London, W.9. VITAMIN B12 SIR,—Your leading article of Jan. 22 contains the following statement : " ... but we know that liver extracts, particularly the more purified types, have’at best only a partial effect on the organic signs and symptoms of those patients with subacute combined degeneration who have no significant anæmia
This statement suggests that it has been demonstrated that liver extracts of less purified type are for some reason more effective than are those of greater purification in the control of the signs and symptoms caused by subacute combined degeneration of the spinal cord. Such a statement is not supported by the facts available and should be corrected because of its misleading implication in respect to the highly refined and potent extracts available, which are still the treatment of choice for patients with pernicious anaemia with or without combinedsystem disease. The amount of improvement in the signs and symptoms which will occur as the result of treatment varies considerably, depending on a number of factors which need not be re-enumerated here ; but it is, unfortunate that statements of this sort, made at first carelessly, and not based on the results of controlled investigation, should be quoted as fact. WILLIAM P.
Dr. Murphy for drawing ** grateful attention to this point, on which the article was insufficiently explicit. The suggestion that the less highly purified liver extracts- should be used in the treatment of neurological complications of pernicious anaemia finds some support in textbooks. For example, Wintrobe (Clinical Hematology, 2nd ed., p. 328) says : * We
" ... for
patients with involvement
of the central
system it has been recommended that whole liver and crude extracts of liver, rather than refined, be used ; in the process of concentration, factors necessary for the nervous system may be unknowingly lost or destroyed. For this view there is little evidence. Nevertheless, since little is known about the cause of the lesions in the central system, it seems wise to ensure a plentiful supply of nutritive factors."
dealt with : (1) subacute without significant anaemia,
combined which is