Empire Cancer Campaign Covering the Year 1961 is to court disappointment if one is trying to find the answer to the cancer problem." This is in spite of the.
1060 OCT. 20, 1962
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firm diagnosis at the outset and early therapy with corticoids would in fact have reversed the disease process. The clinical picture is an extremely rare and unusual one, but it does suggest that where there are doubtful pulmonary lesions, together with evidence of heart block and cardnac irregularity for which there is no good explanhation, the possibility of sarcoidosis should be borne in mind. The pattern of the illness indeed pointed to a progressive lesion, and, when serological examinations were negative and there was no other obvious explanation to offer, the possibility of sarcoid was not an unlikely one.-I am, etc.. P. C. MALLAM. United Oxford Hospitals, Oxfos d.
SIR,-I was very interested in the article on myocardial sarcoidosis by Drs. G. Forbes and A. Usher (September 22, p. 771) as I have had two cases of sudden death from this cause within a few months of each other, both of which were referred to me for necropsy by the coroner's officer. I feel, therefore, that it may be of interest to give a brief summary of these two cases. Kirchheinerl reviewed 40 cases of myocardial
sarcoidosis from the literature and found that sudden unexpected death occurred in seven of these cases. I-le
also found that various degrees of heart block. paroxysmal tachycardia, ven.tricular extrasystoles, and an abnormal E.C.G. were present in these cases with cardiac symptoms. The first of these two cases showed these features, but the second was quite unexpected sudden death in a previously apparently fit woman. Case 1.-A civil servant, aged 41, was suffering from breathlessness and fainting attacks, following a feverish cold in November, 1959. On examination his pulse rate was 48 a minute with occasional extrasystoles; cardiac apex in the mid-clavicular line; blood-pressure 120/80; E.C.G.
PR interval 0.2 seconds. Low voltage curve: low Tl. Cone shaped P2. Small R2 with an inverted T curve. Lead 3 inverted T curve. Lead Vf ST segment raised with T inverted. T inverted also in Leads VI to 6, most maTked in V5. Diagnosis was ? posterior infarct. A radiograph of the chest in December, 1959, was clear. There were no physical signs in the lungs or abdomen.
The patient was again seen in December, 1959, when the E.C.G. was basically the same with ventricular extrasystoles and coupling and incomplete heart block. His physician. Dr. W. Ramsden, suspected some unusual myocarditis, but toxoplasma tests and W.R. were both negative. A radiograph on December 23, 1959, showed the heart to be smaller than previously, but some ? tuberculous fibrosis and one or two old foci were reported in the upper lobe of the right lung, In February, 1960, the patient was complaining of epigastric pain after his meals, and radiography showed a bulge in the left ventricular wall. On May 19, 1960, the patient suddenly collapsed and died at his home, and as his general practitioner was on holiday and there was no one to sign the death certificate the matter was reported to the coroner. At post-mortem examination the body was fouind to be that of a well-nourished middle-aged man. Height, 6 ft. (1.8 m.). The heart weighed 12- oz. (0.354 kg.) and was slightly enlarged. The myocardium showed extensive infiltration of the whole heart, and the left ventricle in particular, by rather glistening white tissue which did not have the consistency or appearance of normal post-infarction fibrosis. In the right ventricle it could be seen to be formed by the coalescing of numerous miliary nodules less than 1 mm. in diameter, some of which were visible on the endocardial surface. The valves were normal and the coronary arteries showed no evidence of atheroma or occlusion. Lungs: right, 21 o.z. (0.595 kg.); left. 26 oz.
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(0.737 kg.). Both were congested and oedematous, presumably due to terminal left ventricular failure, but in both upper lobes there was infiltration by white tissue and miliary nodules having a peribronchial distribution, and being similar in appearance to the tissue in the heart. Sections of the heart showed massive replacement of the myocardium by fibrous tissue, amongst which were numerous large giant cells and epithelial cells, very similar to the photographs shown by Drs. Forbes and Usher. Case 2.-A married woman, aged 66, was found dead in the bathroom of a friend's house where she was staying for a holiday. There was no history of any previous illness, and inquiries from her own practitioner confirmed that she had not had any known illness for at least the last 10 years. Death was therefore quite unexpected and sudden. On post-mortem examination the body was that of a rather obese old lady. The heart weighed 121 oz. (0.354 kg.) and was enlarged due to hypertrophy of the left ventricular wall. The whole of the left ventricle, especially the posterior wall, showed widespread replacement wth white fibrouslooking tissue, and in other parts of the myocardium there were nLumerous nodules and streaks of yellow-white tissue among the muscle fibres. The endocardium of the left ventricle showed a finely granular appearance due to minute miliary nodules coalescing to form the yellow-white tissue. The valves and the coronary arteries were normal. Both lungs were diffusely infiltrated by miliary nodules coalescing in places to form nodules I to 2 cm. in diameter. The histological appearance of the myocardium and the lungs and lymph glands showed typical giant-cell granulomata of the sarcoid type. -I am, etc.,
Pembury, Kent.
W. M. R. HENDERSON. REFERENCE
Kirchlheiner, B., Acta med. scand.,
1960, 168, 223.
Hospital Addiction SIR,-Since Asher' first described the Munchausen syndrome, attention has been focused on the difficult problem of prevention and treatment created by these patients, who were better described by Barker2 as suffering from hospital addiction. A patient who was recently admitted to this hospital under the care of Dr. Michael Ashby demonstrates the futility of present methods of dealing with the problem. He is a 53-year-old man who has been a patient in 68 different hospitals on more than 140 occasions during the last 10 years. In spite of being on many hospital blacklists, always using his own name, he has succeeded in gaining admission to every London teaching hospital. In the past exposure in the journals under a pseudonym has been shown to be ineffectual by the description of the same patient at different times and in different journals. For this reason administrative action has been suggested. In 1958 the senior medical officers of regional boards met with representatives of the Ministry of Health and decided that it was impracticable to take central action after considering the merits, dangers, and ethics of circulating such information. Although we have obtained from the patient both a photograph and written permission to use any information necessary to discourage further hospital admission, it has been considered inmpractical and unethical to use it. Psychiatric attempts at rehabilitation oft-en fail, partly because of the patient's own uncooperative attitude, but also because this is not a condition which excites much interest or sympathy. Our patient was seen by 18 different psychiatrists, and has been in eight mental hospitals. Even with all the correlated information
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CORRESPONDENCE
available, there are no grounds for permanent detention under the Mental Health Act. Barker has suggested that action may be taken under Part V, Sections 60 and 62, which allow a court to order the patient's detention in hospital for a stipulated period. This only becomes possible if a criminal offence has been committed, and it has been invoked once.3 On several occasions these patients have appeared in court charged with obtaining food and drugs by falsely pretending to be ill,4 and it might be possible to extend Section 60 to all addicts on these grounds. Such action would hardly be within the spirit of the Act or the conscience of many individual doctors. Ordinary legal proceedings do not deter these patients. In 1958 our patient was charged with attempted suicide and was conditionally discharged for one year. During that time he repeated the offence on several occasions, but escaped detection. In 1960 he was sentenced to prison for six months for obtaining barbiturates under false pretences, and two months after release he was admitted to hospital with another overdose. The most cogent reason for detaining these patients is that they are a danger to themselves. Yet our patient has survived at least 50 barbiturate overdoses and six laparotomies, and such a record is not unusual. Although they are undeniably masochistic, these patients seem largely indestructible, and their apparent urge to self-destruction is not sufficient reason for indefinite compulsory detention. The economic burden they impose has been exaggerated. An active addict costs the Health Service about £5,000 during his career, but Barker has pointed out that any industrious criminal can do more damage in less time. The alternative of permanent detention is more costly, and the psychopathic personality these patients invariably possess could well be channelled into more expensive and destructive outlets for the community to bear. Finally, a doctor feels a natural dislike towards patients who not only waste his time but also cause humiliation by successfully misleading him. It would be wiser to reflect that the credulous doctor stands to make less dangerous mistakes than the incredulous, and to accept that these patients can offer valuable diagnostic lessons, and may sometimes have a genuine co-existing
'illness. After confronting our patient with all the facts we were able to persuade him to undergo prolonged voluntary treatment. With a genuine intorest in the problem and a knowledge of the full history this may be possible in other cases. It seems probable that no -other steps are practicable or justifiable, and that, whatever calls these patients make upon our time and patience, they can only be regarded as a small group -of mentally ill psychopaths whose actions must be -tolerantly borne by the profession.-I am, etc., B. BLACKWELL. The Whittington Hospital, London
N.19.
REFERENCES 1 Asher, R., Lancet, 1951, 1, 339. 2 Barker, J. C., J. ment. Sci., 1962, 108, 167. Brit. med. J., 1961, 1, 60. I bid., 195 8, 2, e96.
Thalidomide and the Mouse SIR,-I was very much interested in Dr. D. H. M. Woollam's letter and photograph (October 6, p. 920) showing lack of development in a young mouse whose
MEDICAL JOURNAL
parents had been given thalidomide. He has shown that this drug, besides causing malformation, has caused reduction of litters and stunting of growth, and he has even suggested that obliteration of the family would take place if the thalidomide were continued. I would suggest that the lack of growth and development in the thalidomide mouse is due to interference with the developing young cell, possibly by some subtle change in the cellular genetic structure. As cancer cells are also immature developing cells they could possibly be inhibited by thalidomide. I consider that the Cambridge experiments on the thalidomide mouse are important, and should be extended to include the effect of thalidomide on the developing cancer cell. The selective destruction of the immature cancer cell by radium, radiotherapy, alkylating agents, etc., is well known. In suggesting that you give this idea an airing I would quote your own comments on the scientific report of the British Empire Cancer Campaign (July 21, p. 172): " To search the 664 pages of the recently published scientific section of the Thirty-ninth Annutal Report of the British Empire Cancer Campaign Covering the Year 1961 is to court disappointment if one is trying to find the answer to the cancer problem." This is in spite of the fact that 25 research projects are under review.-I am, etc., J. T. RICE EDWARDS. Newport, Mon.
SIR,-Since it appears that thalidomide has a stultifying effect on the development of certain embryonic tissue in utero, is it unreasonable to anticipate the discovery of its lethal effect on new growths of the most undifferentiated type ? Maybe already the research laboratories are working feverishly along this line.-I am, etc., Hexham, Northumberland.
RICHARD BELL.
Reaotion to Oral Poliomyelitis Vaccine SIR,-I was interested in the letter from Dr. R. W. G. Stewart (September 8, p. 675) referring to an unexpected reaction to oral poliomyelitis vaccine. Over the past seven months, during which time about 2,500 doses of oral poliomyelitis vaccine have been administered in the various Cardiganshire county clinics, I have personally been approached by about ten people who had experienced symptoms after being given this vaccine. Each person complained of some or all of the following symptoms: malaise, fever, rigors, headache, back and limb pains, and fainting attacks, occurring from 12-48 hours after the vaccine was administered and lasting up to 24 hours. The most constant complaint was of limb pains. None of them had called in the family doctor, partly because they live in outlying farms, and anyway the symptoms were never very severe. Only one, a woman of 26 years, had had to go to bed, and the rest had been able to carry on with their work. Some did not complain until after the third dose, and in these cases they stated that the symptoms had recurred after each dose but had been less severe each time. These cases occurred in widely separated clinics and where whole families were vaccinated together from the same bottle of vaccine. In no case were two members of the same family affected.
