1562
would infringe on the freedom of choice of the individual. Nor can the argument about difficulties in enforcement be used as an excuse, since infringement is so easy to detect. When seat-belt legislation was introduced in the State of Victoria' the majority of people complied without enforcement being necessary. The Australian experience has a number of other useful lessons for us. It was only as a result of strong pressure from the doctors that seat-belt legislation was introduced. In Victoria all road traffic accident casualties are required by law to have a blood alcohol test taken. This has allowed a much more accurate appraisal to be made of the very significant contribution of alcohol to the road accident problem. We may well have a good record in road accident deaths and injuries when compared with other countries. We have also made a great deal of progress in road safety. There is still so much more that we could do by relatively simple legislation and by tightening up of some of our existing laws. GORDON AVERY Harbury, Warwicks CV33 9HG McDermott, F, Annals of the Royal College of Surgeons of England, 1978, 60, 437.
Rheumatoid arthritis and the gut SIR,-As a supplement to your leading article on rheumatoid arthritis and the gut (28 April, p 1104) I would like to report my results on the development of rheumatoid arthritis based on longitudinal investigations of several thousands of cases of infections with Yersinia enterocolitica, serotype 3. My observations derive from an area in which Y enterocolitica infections are endemic. Extensive population studies indicate that there are about 250 000 new cases per year in this country. Most of them present as enteritis or mesenterial lymphadenitis or both.1 2 The infection is to a high degree self-limiting. Some people-and not only those of the tissue type HLA B27-develop complications of the acute intestinal infection one to three weeks later. These complications present as reactive inflammations, especially in the joints and the skin (connective tissue), but might also present as thyroid disease, glomerulonephritis, or inflammation of the eye. The complication rate is not finally settled but can be estimated as about 5(10. Most of the cases seen in hospital are of the arthritis types, both rather mild cases of a few weeks' duration and acute, fulminant cases of polyarthritis of several years' duration. The latter are usually associated with the HLA B27 tissue type. On the basis of longitudinal studies ( < 8 years) of hundreds of such cases it is now clear that some of them do not remit but-over months and years-develop into rheumatoid arthritis, some also with the development of rheumatoid factor.3 It can be estimated that such cases account for about 1 per 1000 of those with the primary infection. Longitudinal serological investigations of old-established cases of seropositive rheumatoid arthritis reveal that Y enterocolitica infection is involved in more than 70% of the cases.35 With regard to the connection between HLA B27 and Yersinia infection it must be emphasised that the acute intestinal infection does not appear only in persons of this tissue type. All sorts of people and age groups, and both sexes, are involved. If a person of that tissue type, however, is infected he has a very
BRITISH MEDICAL JOURNAL
high risk of developing a high-titre, severe arthritis, usually of long duration. If the case develops into a chronic one it will usually appear as the spondylitic type. As a whole the B27 Yersinia cases appear as the top of the iceberg of Yersinia complications. In conclusion, it can therefore be said that my findings support the conception of rheumatoid arthritis as a primarily enteropathic arthropathy. My findings are based on observations of the effects of an established arthritogenic micro-organism, in contrast to most other aetiological observations, and they clearly demonstrate the development of an acute enteric infection into the complication of an acute reactive arthritis, which in turn develops into a chronic reactive arthritis (rheumatoid arthritis or ankylosing spondylitis).6 My hypothesis is that these findings on Yersinia infection (the Yersinia model) might be applicable to similar infections prevailing in other areas-streptococcal and Neisseria infections, salmonelloses, shigelloses, and brucelloses. J0RGEN HANNOVER LARSEN Department of Clinical Microbiology,
Copenhagen County Hospitals,
DK-2800 Lyngby, Denmark
Larsen, J H, Ugeskrift for Laeger, 1975, 137, 565, 570. 2Larsen, J H, Ugeskrift for Laeger, 1977, 139, 2627. 3Larsen, J H, Jarner, D, and Jarlov, N V, Ugeskrift for Laeger, 1977, 139, 1478. 4Jarner, D, Jarl0v, N V, and Larsen, J H, Ugeskrift for Laeger, 1977, 139, 1481. 5 Larsen, J H, in Infection and Immunology in the Rheumatic Diseases, ed D C Dumonde, p 133. Oxford, Blackwell Scientific Publications, 1976. Larsen, J H, Contributions to Microbiology and Immunology, in press.
Endoscopy for all? SIR,-The results of the one-visit endoscopic clinic reported by Dr A K Beavis and others (26 May, p 1387) are interesting, but perhaps optimism about such a service should be guarded. Although Dr Beavis and his colleagues state that only 3000 of the results of investigations were normal, on closer examination only in 23 (12-50o) was either an ulcer or a cancer found. This is less than in our recently reported direct referral system for general practitioners (17 February, p 457), which avoided hospital consultation altogether. Most of the other diagnostic groups mentioned are arbitrary, open to observer variation, and probably not related to symptoms. We followed up a group of such patients (see accompanying table) and found that they did not behave differently from those with' completely normal findings. Finally, it is known that investigation of dyspeptic patients is unrewarding under the age of 55,1 and it is worrying that, while nearly 600o of the patients were under 45 in this study, only five out of the 205 referred to the clinic avoided endoscopy. These findings confirm ours: that is, by making endoscopy more readily available one is merely attracting the younger dyspeptic patient who previously
9 JuNE 1979
avoided investigation. There is no evidence that those patients with more sinister pathology are seen earlier in the course of their disease. GREGORY HOLDSTOCK MARTIN WISEMAN Professorial Medical Unit, Southampton General Hospital, Southampton S09 4XY
Mead, G M, et al, British Medical Journal, 1977, 1, 1461.
What shall we teach andergraduates? SIR,-It is astonishing that in their recent article on the teaching of undergraduates (24 March, p 805) Professor V Wright and his colleagues made no mention of radiological anatomy. Throughout a period of rapid and sometimes drastic changes in the medical curriculum, including a notable decline in the value placed on the teaching of anatomy, one crucial fact appears to have been almost universally ignored. In the same span of time there has been an enormous increase in the development and utilisation of imaging techniques of all kinds, fundamental to which is a secure basis of anatomical knowledge. It follows that the study of anatomy is not less important than was previously the case but-quite the contrary -is of greater importance than ever before. Yet the time allocated to it in some centres could now be said to approach vanishing point compared with past allocations, which ranged from five full terms to three academic years. There seems to be a growing impression among anatomists, clinicians, and radiologists that the process of change in our medical schools may have been taken too far and too fast, for there is agreement that the general level of anatomical knowledge shown by our young graduates does not measure up to the standard required in day-to-day hospital practice. This discovery is made at least twice a year in x-ray departments throughout the country, whenever a new intake of house officers appear on the scene. It is all too often crystal-clear to the radiologist and his colleagues that, however well the many lists of diagnostic options have been taught and memorised, there is no firm foundation of normal radiological anatomy against which possibilities can be construed as either probabilities or certainties. This order of deficiency illustrates the essential difference between training and education. The problem is of such proportions that, in many x-ray departments, more queries currently arise from ignorance of radiological anatomy, of the wide range of normal appearances, and of normal variants which can simulate disease than from specific pathological conditions. A study carried out by John F Holt, director of radiology at the University of Michigan, has shown that questions concerning radiological anatomy outnumber those regarding pathological entities by three to one.'
Six-month follow-up of patients undergoing endoscopy for dyspepsia, excluding ulcers and cancers Endoscopic diagnosis
Normal.. Hiatus hernia Gastritis Duodenitis
.. . .. .. .. .
No
with continuing symptoms
% on antacids
Alternative
100 50 50 50
66 64 62 64
52 50 64 60
4% 4%
diagnosis
400
8%
9 JUNE 1979
1563
This deplorable state of affairs, which is a cause of much wasted time and many unnecessary x-ray examinations, can be directly related to the very severe reduction in the amount of time which our medical schools allocate to the teaching and study of anatomy. In practical terms, it means that students become involved with contemplation of the abnormal before they have acquired a sound knowledge of the normal. Perhaps the tide is now beginning to turn, for, during the past year or so, there have been at least three publications affirming the importance of teaching radiological anatomy from the outset of the preclinical course. Can this really be just a coincidence ?
of hypnosis in a classically psychosomatic (so-called) condition such as asthma, to my mind the point is not proved beyond doubt. Moreover, the very first controlled study3 showed that hypnotic suggestion failed to produce any improvement in 25 asthmatic children. Dr E W Rees (14 April, p 1018) in his first paragraph appears to discount the value of scientific evidence, yet goes on to emphasise the value of the "evidence" in favour of hypnosis. Again, he (and also Dr Waxman-19 May, p 1354) seems to link hypnosis with psychotherapy. This is surely unfortunate in view of the grave doubts of many about the scientific status of psychotherapy, not to mention its potential negative effects.4 5 The comments of Dr P G F Nixon and Dr G D K Flint (5 May, p 1212) are helpful and interesting, but miss my main points. Of course, any doctor or dentist may practise hypnosis if he finds it useful, just as he may employ acupuncture, transcendental meditation, or any other paramedical technique; but to suggest that resources should be poured into their widespread application before their value has been firmly ascertained is, in my opinion, unjustified. The controlled trials that have been done do not show a convincing superiority for hypnosis over waking suggestion or other simple placebo techniques such as breathing exercises. Finally, with regard to the importance of suggestion in this area, may I refer your correspondents to the current analogous controversy in your columns about the value of the "fringe" technique of homoeopathy, in particular Dr R S Walker's opinion (28 April, p 1147) that its practitioners appear to have surprisingly little insight into the powers of suggestion ? H G KINNELL
BRITISH MEDICAL JOURNAL
and for comparison I have used figures given in the literature for short-term treatment failure and five-year survival rate. It is clear that, despite adverse prognostic factors,'-3 these patients have done surprisingly well. The quoted incidence rate of short-term treatment failure at 12, 18, and 24 months is 12 20, 21 20o, and 41 2%o respectively'; of my 27 patients, only one died 11 months after surgery. The overall five-year survival rate ranges from 46"0 to 65°03; only one of my 15 patients followed up for over five years has so far died of breast cancer (93-3`0 five-year survival rate). These figures, though based on a small series, justify optimism and I feel that physicians should judiciously inform the KENNETH SWINBURNE public of this "good news." It may help to break through the fear barrier anid lead young Wharfedale General Hospital, Otley, W Yorks LS21 2LY women to examine their breasts more regularly Keats, T E, Atlas of Normal Roentgen Variants. and report early any abnormal findings. Earlier diagnosis can only improve their Chicago, Year Book Medical Publishers, 1973. 2Swinburne, K, Lancet, 1978, 1, 433. chances of survival. 3 Golberg, B, British Medical3Journal, 1978, 1, 1017. H HONORE 4Reidy, J, et al, Clinical Radiology, 1978, 29, 591.
SIR,-The 28 specialties listed in the survey by Professor V Wright and others (24 March, p 805) would obviously relate very much to what medical practitioners had themselves learned in medical school. To us it was most striking, but not surprising, that no mention was made of nutrition at all, except to suggest metaphorically that medical students know what they enjoy academically, but not necessarily what is good for them: "The student knows what is palatable, but not always what is nutritious." Ironically, this is literally the situation in practice for those graduating with the curricular emphases suggested in this present study. The absurd paradox of not including such a universal subject as nutrition in the curriculum is highlighted most clearly by current correspondence in the same issue (p 818) concerning "Prescription for a better British diet." How, one may ask, can the medical profession make the slightest informed input into these decisions if they have no knowledge because of an almost complete lacuna in their training? More importantly still, how can they advise their patients appropriately ? D B JELLIFFE E F PATRICE JELLIFFE Division of Population, Family, and International Health, University School of Public Health, Los Angeles, California 90024, USA
Breast cancer in young women
SIR, I was interested in your leading article on age and death in breast cancer (27 January, p 211). I would like to present further data supporting the thesis that breast cancer in young women is less aggressive than is currently believed. Twenty-seven women (27-45 years old) were treated by modified radical mastectomy and those with large tumours and extramammary spread also received radiotherapy with or without chemotherapy and oophorectomy. The lymph nodes, all containing macrometastases, were not grouped by levels, the value of which is now in doubt.' Of these 27 patients, 20 had moderately welldifferentiated carcinomas, two infiltrating comedocarcinomas, two invasive lobular carcinomas, and one a medullary carcinoma. I have no similar data on my older patients
Memorial University of Newfoundland, Grace General Hospital, St John's, Newfoundland, Canada Fisher, E R, et al, Cancer, 1978, 42, 2032. 2Fisher, E R, Gregorio, R M, and Fisher, B, Cancer, 1975, 36, 1. Diekamp, U, Bitran, J, and Ferguson, D J, Journal of Reproductive Medicine, 1976, 5, 255.
Hypnosis SIR,-I was most interested in your correspondents' reactions to my submission that the hypnosis lobby has not yet conclusively proved its case. Regarding Dr H K Gooding's comments (14 April, p 1017), of course Dr D Waxman (19 August, 1978, p 571) uses the method responsibly; but will all the others attracted to this still esoteric therapeutic technique? Again, Dr Gooding's rapport with his smoking patient is obviously of excellent placebo value at least. Is there any more to it ? He himself is, of course, not obliged to conduct controlled trials with individual patients (though the simple mirror-image trial, using the patient as his own control, is always open to him); but he should always remember that spectacular "results" may not be due to the treatment given. Dr Gooding refers to the studies of Dr G P Maher-Loughnan as proving the efficacy of the hypnotic approach. However, the latter's first paper' describing a controlled trial of hypnosis in the symptomatic treatment of asthma admits that his finding of its value "is based purely on a subjective assessment, and there remain many questions to be solved concerning satisfactory objective methods of assessment." There do indeed. When objective methods-that is, lung function tests-were included in a later, much larger, controlled trial,2 the results of these were the same in the experimental and control groups, suggesting that hypnosis does not exert a physiological effect, that any improvement is a subjective, placebo one. Even with regard to the various subjective assessments used, while independent clinical assessors did find the asthma much better in more of the hypnosis group (59%O as against 43 X in the controls, not a huge advantage), there was no difference (for males) in the scores for wheezing or bronchodilator use. Females differed, for some obscure reason. If, then, this is the definitive trial of the value
University Department of Psychological Medicine, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE Maher-Loughnan, G P, et al, British Medical_Journal, 1962, 2, 371. British Tuberculosis Association, British Medical journal, 1968, 4, 71. 3 Burns, C L C, and Morrison Smith, J, British_Journal of Diseases of the Chest, 1960, 54, 78. ' Rachman, S, The Effects of Psychotherapy. Oxford, Pergamon Press, 1971. 5Kinnell, H G, Lancet, 1978, 1, 882. 2
Oestrogen-induced hypocalcaemia in hypoparathyroidism SIR,-I read with great interest the fascinating observation of a case of hypoparathyroidism whose symptoms and biological features were aggravated by the administration of oestrogens, as reported by Drs D Verbeelen and M Fuss (24 February, p 522). This is- reminiscent of the observations reported more than three decades ago by Klotz and Barbier,' who demonstrated this phenomenon up to four times in one of their hypoparathyroid patients. One decade therefore before the introduction of sodium EDTA as a calcium-lowering agent a test of sudden hypocalcaemia was devised, using oestradiol benzoate 20 mg intramuscularly or subcutaneously2 3 to evaluate parathyroid reserve. The degree and the duration of the hypocalcaemia were proportional to the severity of the hypoparathyroid state. Experimental support for this oestrogen-induced hypocalcaemia had been provided by the work performed in Liege by Mathieu and coworkers4 in parathyroidectomised dogs.
would infringe on the freedom of choice of the individual. Nor can the argument about difficulties in enforcement be used as an excuse, since infringement is so easy to detect. When seat-belt legislation was introduced in the State of Victoria' the majority of people complied without enforcement being necessary. The Australian experience has a number of other useful lessons for us. It was only as a result of strong pressure from the doctors that seat-belt legislation was introduced. In Victoria all road traffic accident casualties are required by law to have a blood alcohol test taken. This has allowed a much more accurate appraisal to be made of the very significant contribution of alcohol to the road accident problem. We may well have a good record in road accident deaths and injuries when compared with other countries. We have also made a great deal of progress in road safety. There is still so much more that we could do by relatively simple legislation and by tightening up of some of our existing laws. GORDON AVERY Harbury, Warwicks CV33 9HG McDermott, F, Annals of the Royal College of Surgeons of England, 1978, 60, 437.
Rheumatoid arthritis and the gut SIR,-As a supplement to your leading article on rheumatoid arthritis and the gut (28 April, p 1104) I would like to report my results on the development of rheumatoid arthritis based on longitudinal investigations of several thousands of cases of infections with Yersinia enterocolitica, serotype 3. My observations derive from an area in which Y enterocolitica infections are endemic. Extensive population studies indicate that there are about 250 000 new cases per year in this country. Most of them present as enteritis or mesenterial lymphadenitis or both.1 2 The infection is to a high degree self-limiting. Some people-and not only those of the tissue type HLA B27-develop complications of the acute intestinal infection one to three weeks later. These complications present as reactive inflammations, especially in the joints and the skin (connective tissue), but might also present as thyroid disease, glomerulonephritis, or inflammation of the eye. The complication rate is not finally settled but can be estimated as about 5(10. Most of the cases seen in hospital are of the arthritis types, both rather mild cases of a few weeks' duration and acute, fulminant cases of polyarthritis of several years' duration. The latter are usually associated with the HLA B27 tissue type. On the basis of longitudinal studies ( < 8 years) of hundreds of such cases it is now clear that some of them do not remit but-over months and years-develop into rheumatoid arthritis, some also with the development of rheumatoid factor.3 It can be estimated that such cases account for about 1 per 1000 of those with the primary infection. Longitudinal serological investigations of old-established cases of seropositive rheumatoid arthritis reveal that Y enterocolitica infection is involved in more than 70% of the cases.35 With regard to the connection between HLA B27 and Yersinia infection it must be emphasised that the acute intestinal infection does not appear only in persons of this tissue type. All sorts of people and age groups, and both sexes, are involved. If a person of that tissue type, however, is infected he has a very
BRITISH MEDICAL JOURNAL
high risk of developing a high-titre, severe arthritis, usually of long duration. If the case develops into a chronic one it will usually appear as the spondylitic type. As a whole the B27 Yersinia cases appear as the top of the iceberg of Yersinia complications. In conclusion, it can therefore be said that my findings support the conception of rheumatoid arthritis as a primarily enteropathic arthropathy. My findings are based on observations of the effects of an established arthritogenic micro-organism, in contrast to most other aetiological observations, and they clearly demonstrate the development of an acute enteric infection into the complication of an acute reactive arthritis, which in turn develops into a chronic reactive arthritis (rheumatoid arthritis or ankylosing spondylitis).6 My hypothesis is that these findings on Yersinia infection (the Yersinia model) might be applicable to similar infections prevailing in other areas-streptococcal and Neisseria infections, salmonelloses, shigelloses, and brucelloses. J0RGEN HANNOVER LARSEN Department of Clinical Microbiology,
Copenhagen County Hospitals,
DK-2800 Lyngby, Denmark
Larsen, J H, Ugeskrift for Laeger, 1975, 137, 565, 570. 2Larsen, J H, Ugeskrift for Laeger, 1977, 139, 2627. 3Larsen, J H, Jarner, D, and Jarlov, N V, Ugeskrift for Laeger, 1977, 139, 1478. 4Jarner, D, Jarl0v, N V, and Larsen, J H, Ugeskrift for Laeger, 1977, 139, 1481. 5 Larsen, J H, in Infection and Immunology in the Rheumatic Diseases, ed D C Dumonde, p 133. Oxford, Blackwell Scientific Publications, 1976. Larsen, J H, Contributions to Microbiology and Immunology, in press.
Endoscopy for all? SIR,-The results of the one-visit endoscopic clinic reported by Dr A K Beavis and others (26 May, p 1387) are interesting, but perhaps optimism about such a service should be guarded. Although Dr Beavis and his colleagues state that only 3000 of the results of investigations were normal, on closer examination only in 23 (12-50o) was either an ulcer or a cancer found. This is less than in our recently reported direct referral system for general practitioners (17 February, p 457), which avoided hospital consultation altogether. Most of the other diagnostic groups mentioned are arbitrary, open to observer variation, and probably not related to symptoms. We followed up a group of such patients (see accompanying table) and found that they did not behave differently from those with' completely normal findings. Finally, it is known that investigation of dyspeptic patients is unrewarding under the age of 55,1 and it is worrying that, while nearly 600o of the patients were under 45 in this study, only five out of the 205 referred to the clinic avoided endoscopy. These findings confirm ours: that is, by making endoscopy more readily available one is merely attracting the younger dyspeptic patient who previously
9 JuNE 1979
avoided investigation. There is no evidence that those patients with more sinister pathology are seen earlier in the course of their disease. GREGORY HOLDSTOCK MARTIN WISEMAN Professorial Medical Unit, Southampton General Hospital, Southampton S09 4XY
Mead, G M, et al, British Medical Journal, 1977, 1, 1461.
What shall we teach andergraduates? SIR,-It is astonishing that in their recent article on the teaching of undergraduates (24 March, p 805) Professor V Wright and his colleagues made no mention of radiological anatomy. Throughout a period of rapid and sometimes drastic changes in the medical curriculum, including a notable decline in the value placed on the teaching of anatomy, one crucial fact appears to have been almost universally ignored. In the same span of time there has been an enormous increase in the development and utilisation of imaging techniques of all kinds, fundamental to which is a secure basis of anatomical knowledge. It follows that the study of anatomy is not less important than was previously the case but-quite the contrary -is of greater importance than ever before. Yet the time allocated to it in some centres could now be said to approach vanishing point compared with past allocations, which ranged from five full terms to three academic years. There seems to be a growing impression among anatomists, clinicians, and radiologists that the process of change in our medical schools may have been taken too far and too fast, for there is agreement that the general level of anatomical knowledge shown by our young graduates does not measure up to the standard required in day-to-day hospital practice. This discovery is made at least twice a year in x-ray departments throughout the country, whenever a new intake of house officers appear on the scene. It is all too often crystal-clear to the radiologist and his colleagues that, however well the many lists of diagnostic options have been taught and memorised, there is no firm foundation of normal radiological anatomy against which possibilities can be construed as either probabilities or certainties. This order of deficiency illustrates the essential difference between training and education. The problem is of such proportions that, in many x-ray departments, more queries currently arise from ignorance of radiological anatomy, of the wide range of normal appearances, and of normal variants which can simulate disease than from specific pathological conditions. A study carried out by John F Holt, director of radiology at the University of Michigan, has shown that questions concerning radiological anatomy outnumber those regarding pathological entities by three to one.'
Six-month follow-up of patients undergoing endoscopy for dyspepsia, excluding ulcers and cancers Endoscopic diagnosis
Normal.. Hiatus hernia Gastritis Duodenitis
.. . .. .. .. .
No
with continuing symptoms
% on antacids
Alternative
100 50 50 50
66 64 62 64
52 50 64 60
4% 4%
diagnosis
400
8%
9 JUNE 1979
1563
This deplorable state of affairs, which is a cause of much wasted time and many unnecessary x-ray examinations, can be directly related to the very severe reduction in the amount of time which our medical schools allocate to the teaching and study of anatomy. In practical terms, it means that students become involved with contemplation of the abnormal before they have acquired a sound knowledge of the normal. Perhaps the tide is now beginning to turn, for, during the past year or so, there have been at least three publications affirming the importance of teaching radiological anatomy from the outset of the preclinical course. Can this really be just a coincidence ?
of hypnosis in a classically psychosomatic (so-called) condition such as asthma, to my mind the point is not proved beyond doubt. Moreover, the very first controlled study3 showed that hypnotic suggestion failed to produce any improvement in 25 asthmatic children. Dr E W Rees (14 April, p 1018) in his first paragraph appears to discount the value of scientific evidence, yet goes on to emphasise the value of the "evidence" in favour of hypnosis. Again, he (and also Dr Waxman-19 May, p 1354) seems to link hypnosis with psychotherapy. This is surely unfortunate in view of the grave doubts of many about the scientific status of psychotherapy, not to mention its potential negative effects.4 5 The comments of Dr P G F Nixon and Dr G D K Flint (5 May, p 1212) are helpful and interesting, but miss my main points. Of course, any doctor or dentist may practise hypnosis if he finds it useful, just as he may employ acupuncture, transcendental meditation, or any other paramedical technique; but to suggest that resources should be poured into their widespread application before their value has been firmly ascertained is, in my opinion, unjustified. The controlled trials that have been done do not show a convincing superiority for hypnosis over waking suggestion or other simple placebo techniques such as breathing exercises. Finally, with regard to the importance of suggestion in this area, may I refer your correspondents to the current analogous controversy in your columns about the value of the "fringe" technique of homoeopathy, in particular Dr R S Walker's opinion (28 April, p 1147) that its practitioners appear to have surprisingly little insight into the powers of suggestion ? H G KINNELL
BRITISH MEDICAL JOURNAL
and for comparison I have used figures given in the literature for short-term treatment failure and five-year survival rate. It is clear that, despite adverse prognostic factors,'-3 these patients have done surprisingly well. The quoted incidence rate of short-term treatment failure at 12, 18, and 24 months is 12 20, 21 20o, and 41 2%o respectively'; of my 27 patients, only one died 11 months after surgery. The overall five-year survival rate ranges from 46"0 to 65°03; only one of my 15 patients followed up for over five years has so far died of breast cancer (93-3`0 five-year survival rate). These figures, though based on a small series, justify optimism and I feel that physicians should judiciously inform the KENNETH SWINBURNE public of this "good news." It may help to break through the fear barrier anid lead young Wharfedale General Hospital, Otley, W Yorks LS21 2LY women to examine their breasts more regularly Keats, T E, Atlas of Normal Roentgen Variants. and report early any abnormal findings. Earlier diagnosis can only improve their Chicago, Year Book Medical Publishers, 1973. 2Swinburne, K, Lancet, 1978, 1, 433. chances of survival. 3 Golberg, B, British Medical3Journal, 1978, 1, 1017. H HONORE 4Reidy, J, et al, Clinical Radiology, 1978, 29, 591.
SIR,-The 28 specialties listed in the survey by Professor V Wright and others (24 March, p 805) would obviously relate very much to what medical practitioners had themselves learned in medical school. To us it was most striking, but not surprising, that no mention was made of nutrition at all, except to suggest metaphorically that medical students know what they enjoy academically, but not necessarily what is good for them: "The student knows what is palatable, but not always what is nutritious." Ironically, this is literally the situation in practice for those graduating with the curricular emphases suggested in this present study. The absurd paradox of not including such a universal subject as nutrition in the curriculum is highlighted most clearly by current correspondence in the same issue (p 818) concerning "Prescription for a better British diet." How, one may ask, can the medical profession make the slightest informed input into these decisions if they have no knowledge because of an almost complete lacuna in their training? More importantly still, how can they advise their patients appropriately ? D B JELLIFFE E F PATRICE JELLIFFE Division of Population, Family, and International Health, University School of Public Health, Los Angeles, California 90024, USA
Breast cancer in young women
SIR, I was interested in your leading article on age and death in breast cancer (27 January, p 211). I would like to present further data supporting the thesis that breast cancer in young women is less aggressive than is currently believed. Twenty-seven women (27-45 years old) were treated by modified radical mastectomy and those with large tumours and extramammary spread also received radiotherapy with or without chemotherapy and oophorectomy. The lymph nodes, all containing macrometastases, were not grouped by levels, the value of which is now in doubt.' Of these 27 patients, 20 had moderately welldifferentiated carcinomas, two infiltrating comedocarcinomas, two invasive lobular carcinomas, and one a medullary carcinoma. I have no similar data on my older patients
Memorial University of Newfoundland, Grace General Hospital, St John's, Newfoundland, Canada Fisher, E R, et al, Cancer, 1978, 42, 2032. 2Fisher, E R, Gregorio, R M, and Fisher, B, Cancer, 1975, 36, 1. Diekamp, U, Bitran, J, and Ferguson, D J, Journal of Reproductive Medicine, 1976, 5, 255.
Hypnosis SIR,-I was most interested in your correspondents' reactions to my submission that the hypnosis lobby has not yet conclusively proved its case. Regarding Dr H K Gooding's comments (14 April, p 1017), of course Dr D Waxman (19 August, 1978, p 571) uses the method responsibly; but will all the others attracted to this still esoteric therapeutic technique? Again, Dr Gooding's rapport with his smoking patient is obviously of excellent placebo value at least. Is there any more to it ? He himself is, of course, not obliged to conduct controlled trials with individual patients (though the simple mirror-image trial, using the patient as his own control, is always open to him); but he should always remember that spectacular "results" may not be due to the treatment given. Dr Gooding refers to the studies of Dr G P Maher-Loughnan as proving the efficacy of the hypnotic approach. However, the latter's first paper' describing a controlled trial of hypnosis in the symptomatic treatment of asthma admits that his finding of its value "is based purely on a subjective assessment, and there remain many questions to be solved concerning satisfactory objective methods of assessment." There do indeed. When objective methods-that is, lung function tests-were included in a later, much larger, controlled trial,2 the results of these were the same in the experimental and control groups, suggesting that hypnosis does not exert a physiological effect, that any improvement is a subjective, placebo one. Even with regard to the various subjective assessments used, while independent clinical assessors did find the asthma much better in more of the hypnosis group (59%O as against 43 X in the controls, not a huge advantage), there was no difference (for males) in the scores for wheezing or bronchodilator use. Females differed, for some obscure reason. If, then, this is the definitive trial of the value
University Department of Psychological Medicine, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE Maher-Loughnan, G P, et al, British Medical_Journal, 1962, 2, 371. British Tuberculosis Association, British Medical journal, 1968, 4, 71. 3 Burns, C L C, and Morrison Smith, J, British_Journal of Diseases of the Chest, 1960, 54, 78. ' Rachman, S, The Effects of Psychotherapy. Oxford, Pergamon Press, 1971. 5Kinnell, H G, Lancet, 1978, 1, 882. 2
Oestrogen-induced hypocalcaemia in hypoparathyroidism SIR,-I read with great interest the fascinating observation of a case of hypoparathyroidism whose symptoms and biological features were aggravated by the administration of oestrogens, as reported by Drs D Verbeelen and M Fuss (24 February, p 522). This is- reminiscent of the observations reported more than three decades ago by Klotz and Barbier,' who demonstrated this phenomenon up to four times in one of their hypoparathyroid patients. One decade therefore before the introduction of sodium EDTA as a calcium-lowering agent a test of sudden hypocalcaemia was devised, using oestradiol benzoate 20 mg intramuscularly or subcutaneously2 3 to evaluate parathyroid reserve. The degree and the duration of the hypocalcaemia were proportional to the severity of the hypoparathyroid state. Experimental support for this oestrogen-induced hypocalcaemia had been provided by the work performed in Liege by Mathieu and coworkers4 in parathyroidectomised dogs.
