131 found


useful addition

to our

armamentarium. We have

recently, however, encountered a somewhat unexpected complication in that with very small tumours-e.g., the size of a pea-it is possible to obtain a negative biopsy even though the operator believes that he has transfixed the

formed, dirt collected in unshod feet and infection developed. Recurrent fissuring in the scar tissue would seem to provide a sufficient explanation of progressive cicatricial fibrosis in persons predisposed to overproduction


of fibrous tissue in the dermis.



It is thus

exceedingly important to realise that only a positive biopsy is of value-as with all other methods of diagnosis in the breast. We have, therefore, adopted a modified approach in that, if there is any doubt whatsoever that a tumour might exist, we are much more prepared to remove the whole breast. This, however, is not such an ordeal for the patient, since for these early cases it is possible to carry out an immediate replacement of the breast with one of the newer type of prosthesis as a primary procedure. General Hospital, Steelhouse Lane, Birmingham B4 6NH.


HORMONE REPLACEMENT THERAPY SIR,-As members of the " small but highly vocal " group of doctors concerned with hormone replacement therapy in the climacteric, we welcome the balanced objectivity of your timely leader (June 7, p. 1282) and fully agree with the prediction of the emergence of new multihormone preparations in the near future. Cyclical oestrogen therapy will remain the cornerstone of treatment of the symptoms of the menopausal state, but the addition of other ovarian steroids will allow individualisation of treatment in accordance with the age of the patient and the type of presenting or residual symptoms following initial oestrogen

therapy. We agree that the problems of vaginal bleeding on longterm therapy have yet to be overcome. Cyclical oestrogen therapy for three weeks out of four produces a withdrawal bleed in perhaps two or three cycles per year, whereas the monthly addition of a progestogen will guarantee scheduled bleeding in virtually every cycle. At the Menopause Research Clinic in this hospital we have tried to reach a compromise by initiating scheduled withdrawal bleeds with a progestogen at quarterly intervals in the belief that this would also have the advantage of preventing the re-emergence of vasomotor symptoms in the seven days off treatment. However, we have found that the frequency of unscheduled bleeding with this therapy was still too high to be acceptable. We submit that induced monthly bleeds remain the price to be paid for the advantage of continuous oral or implant hormone therapy. Breakthrough bleeding can usually be avoided, but if it does occur we would stress that an endometrial biopsy, taken without discomfort by Vabra curettage, is mandatory. .


King’s College Hospital, Denmark Hill, London SE5 9RS.

AINHUM interested in the editorial on ainhum SIR,-I (July 5, p. 19), having made a clinical and astiological study1 of 83 cases in 1961, and having presented the distinctive and differentiating features of ainhum as shown in 100 patients in the former Belgian Congo and Nigeria.22 Contrary to your view, I found that the process began, not " in the cleft between the fourth and little toe ", but either in the skin-groove at the plantar-digital junction of the little toe, or on the dorsal aspect of the little toe, where the proximal phalanx was hyperextended. Into the sulci was

1. Browne, S. G. Ann. trop. Med. Parasit. 1961, 55, 314. 2. Browne, S. G. J. Bone Jt Surg. 1965, 47B, 52.



scar or

At the time of the first open fissure was present

in two-thirds of the patients. To modify a statement you made, I found that the groove in the region of the anatomical base of the little toe (that is, about the middle third of the proximal phalanx) was formed of contracting scar tissue, which in time tended to encircle the toe by linear extension. Although you dismiss yaws as an aetiological factor, it is worthy of note that in 58 persons out of 83, the fissuring and scarring in the African patients were associated with framboesial plantar hyperkeratosis, and all the 6 patients seen in the 10-19 age-group had the typical active plantar (and palmar) hyperkeratosis attributable to tertiary yaws and responding to anti-treponemal treatment. A similar condition seen in the finger may be associated with tylosis, but may also result from a deepening scar that eventually encircles the finger,3 as in the case of a Nigerian boy of 14 who had framboesial hyperkeratosis of palms and soles. I have yet to see ainhum of the finger in the fairly common tylosis palmaris of the Near East, or in

disease with palmar hyperkeratosis. I have adduced2 reasons for rejecting the cases reported by Aggarwal and Singh4 and others as ainhum in the


usually accepted


Leprosy Study Centre, 57A Wimpole Street, London W1M 7DF.



SIR,—The commendable effort of the Royal College of Psychiatrists to mount a randomised,prospective, controlled trial of psychosurgery was welcomed in your editorial (May 24, p. 1175). It was not too early to begin such a study, because the main criticism of psychosurgery has been that its effects have not been fully documented. In addition to those in Britain, controlled clinical trials are in progress in several countries-for example, Finland and Sweden. In Helsinki such a trial began in August, 1974. The outlines are as follows. After definitive failure of psychiatric treatment, the patient is admitted to the neurosurgical unit, where a multidisciplinary team tests him and accepts him for, or excludes him from, the trial. At the time of admission the patient is informed that the tests are done only to find out whether surgical treatment can be recommended. According to the dominant symptoms, one of the four stereotactic lesion targets-cingulum, knee of the corpus callosum, frontal internal capsule, or subcaudate region-is chosen. After the randomisation, the surgical patients are informed of all possible risks and benefits of surgery and, if they wish to have an operation, it will be carried out. Those patients who fall into the group of continued conservative therapy are told that surgery, at present at least, is not recommended, since its effects are not sufficiently known. Follow-up examinations are undertaken at regular intervals by the same multidisciplinary team, but the neurosurgeon is excluded from the assessment and comparison of results. The psychiatrist of the team has nothing to do with the pre-test treatment of the patients. After the randomisation, he must make every effort to guarantee that both the surgical and the conservative group will get equally active psychiatric treatment. It seems to us that many surgical patients become amenable after operation 3. Browne, S. G. W. Afr. med. J. 1962, 11, 168. 4. Aggarwal, N. D., Singh, H. J. Bone Jt Surg. 1963, 45B, 376.

Letter: Hormone replacement therapy.

131 found a useful addition to our armamentarium. We have recently, however, encountered a somewhat unexpected complication in that with very sma...
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