Derrick Dunlop

Eight-six Cases of Addison's Disease

Hypoadrenalism is a not uncommon condition nowadays: a defective function of the adrenals occurs as the result of hypopituitarism-a greater or less degree of which condition is more common than used to be supposed, and becoming more so as the result of the activity of the neurosurgeons in this sphere; adrenocortical activity, of course, ceases completely after bilateral adrenalectomyan operation unknown till comparatively recent years, but now increasingly undertaken for Cushings syndrome, metastatic mammary cancer, and even, occasionally, for hypertension; lastly, defective function for a variable and unknown period always follows long-continued corticosteroid therapy and constitutes one of the great problems of modern medicine. A knowledge of the diagnosis and management of hypoadrenalism is thus of importance nowadays, and creates one of the many new burdens which modern doctors have to assume and of which we were comparatively free in my young days. It is not, however, of these types of hypoadrenalism which I wish to discuss here, but of the disorder first described so beautifully by Thomas Addison in 1855-a state of chronic adrenal insufficiency resulting from primary disease of the adrenals due to tuberculosis or idiopathic atrophy (possibly the result of an autoimmunizing reaction similar to Hashimotos goitre); occasionally to infarction and malignant disease; and very rarely to syphilis, the reticuloses, and giant-cell granuloma. Since 1928 1 have personally looked after 86 cases of Addisons disease, and hoped that an account of the experience so acquired might be of some interest, if only from a historical point of view. Pathology During 1928 to 1938 1 saw 34 cases, but, though all these patients died, 1 was able to secure necropsies on only 24 of them (Table I). In 19 (79%) of these the disease had resulted from tuberculosis-a higher tuberculous incidence than in other published series. For example, Guttman (1930), reviewing 333 necropsies on patients with Addisons disease conducted in different centres between 1900 and 1930, reported a tuberculous aetiology in 68%, atrophy in

Diabetic Fertility, Maternal Mortality, and Foetal Loss Rate

One further social problem is that of marriage. On the basis of the evidence about the heredity of epilepsy formerly noted, the chance of a child of an epileptic also becoming epileptic has been variously estimated as from 1 in 10 to 1 in 40 (Brain, 1926; Lennox, 1945b). The risk of transmission is probably much less still if attacks begin in adult life, or if the patient has no family history of epilepsy; also if attacks are the result of a definite brain injury. A family history in both partners greatly increases the risk. Electrical records of epileptic type in either partner or both partners have probably the same significance. The prospect. of producing epileptic children is therefore far less than is generally believed, and this we can conscientiously explain to those concerned. The real risks in marriage are the anxieties and dangers caused in the home and at work by the attacks themselves: these known risks can be calculated and faced. Nevertheless, so great is the dread of epilepsy that many patients decline marriage or refuse to have children. Both decisions are probably wrong, but they are understandable.

Drug Control and the British Health Service

Abstract The British National Health Service of 1948 was a social advance of great magnitude, bringing medical care to those who could least afford it. Nevertheless, the elimination of the financia...

A Survey of Prescribing in Scotland in 1951

A survey of 17,301 prescriptions issued on Form E.C.10 in England in 1949 (Dunlop et al., 1952) provided an incentive to a further and more extended investigation of prescribing, and in addition indicated how a subsequent study could be planned in order to give more varied and statistically valid information, and to avoid some of the errors to which our attention was drawn in the previous paper. Scotland was chosen as the area to be surveyed, as it formed a manageable unit and represented all types of medical practice.

Use and Abuse of Drugs

It is right and proper that from time to time we should remember and praise the name of Sir Charles Hastings. To be invited to act as the channel along which our praise of him should flow is an honour of which I am deeply sensible. Nevertheless, when I think of the immense erudition and distinction of most of my predecessors in this lectureship my pride at joining their company is tinctured with the natural diffidence and alarm which might be felt by a yokel introduced for the first time to polite society, very conscious of the straw sticking out of his ears and the dung all over his boots. Charles Hastings founded the Provincial Medical and Surgical Association, from which the British Medical Association developed, and through it was in a large measure responsible for the Medical Act of 1858, which did so much for the status of our profession and for the protection of the public against impostors. He not only excelled, like most Edinburgh graduates, in the practice of his profession, and in addition

Cortisone in practice.

[As we announced last week, on December S the Ministry of Health and Department of Health for Scotland are freeing cortisone and hydrocortisone for general prescription by the profession in the United Kingdom. Oral, parenteral, and topical preparations will be available. Corticotrophin (A.C.T.H.), however, will continue to be supplied only through hospitals (see Journal, November 12, p. 1217). We interrupt our weekly series on emergencies in general prac-, tice to print this article on cortisone, written by Professor D. M. Dunlop at our request.]

The work of the Medicines Commission.

undertones as well as overtones.) Various Food and Drug and Therapeutic Substances Acts have done much to ensure the purity and strength of medicines. Cancer and Venereal Diseases Acts and the Pharmacy and Medicines Act prevent charlatans from deluding the public by advertising quack nostrums for the treatment of serious diseases, and Poisons Regulations and Dangerous Drugs Acts prevent the counter sale of certain medicines without

Adverse Reactions—Seeking the Culprit

This is the first volume of a collection of essays on problems of contemporary toxicology by the professor of toxicological pathology at the University of Zurich, who is also a consultant to a number of governmental agencies regulating the control of drugs. This book is concerned with adverse reactions to drugs, which in the last 25 years have become a new dimension in the aetiology of disease. The first chapter is concerned with formal toxicology, on which the clinical trial and marketing of new drugs depends, often predetermined by official regulations. In this sphere the practising toxicologist is concerned mostly with demonstrating the safety rather than the toxicity of new products. As there is probably no such thing as an effective and completely safe drug the second chapter on speculative toxicology describes the methods employed in attempting to anticipate the probable adverse reactions to a new drug from its chemical and physical properties. The third and fourth chapters discuss respectively comparative and pharmacodynamic toxicology, and include cocment on experiments on the extent to which the toxicity developed by a drug in animals can be extrapolated to its therapeutic use in man. This is followed by symptomatic toxicology-a consideration of how to identify the offending drug and its mechanism of action in producing the adverse clinical effect. Such an investigation is often more akin to a criminal investigation than to scientific research: it detects suspected problems to be more thoroughly investigated, leading possibly to the eventual apprehension of the criminal. The next sectionsystematic toxicologyclassifies chemical substances according to their structure, physical properties, or pharmacological action and aids the understanding of the relationship of toxicology to chem;ical structure. Lastly, a thought-provoking essay on geographical toxicology discusses the puzzling variations which occur in the incidence of adverse reactions to drugs in different parts of the world. This is sometimes due to the variety of fashions in prescribing which exist, to environmental factors such as climate, or to the dissimilarity in their reaction to drugs shown by different human races just as they are by a variety of animal species. These essays are not only full of accurate scientific and technical information but also of wisdom. It is odd that on such an unlikely subject the culture and humour of the author becomes evident. Just as English is often attractive when spoken with a foreign inflection, so one would not for the world alter the small grammnatical liberties with the language of Shakespeare which occasionally pervade the text. This and subsequent volumes will repay reading by toxicologists, clinical pharmacologists, research workers in the pharmaceutical industry, and by those engaged in governmental regulatory agencies.

Efficiency of the Health Service

Whole-time professors of medicine are often depicted as living in ivory towers utterly divorced from reality and completely lacking in clinical judgement, common sense, or compassion. Possibly there is sometimes a little fire to this smoke and it is, of course, regrettable that most medical academicians nowadays have never had the experience of looking after patients in their own homes. Professor Butterfield has, however, done much to refute the common caricature of the professorial clinical scientist, for though he himself is one of them of no mean repute he is also rich in medical philosophy, scholarship, charm, common sense, and humanitarianism. These attributes are exemplified in his Rock Carling Monograph of 1968 in which he reviews the vast organization built up in recent years in this country to combat its sickness and-to a much lesser extent-to encourage its health. Though further considerable financial resources are unlikely to become available to the Health Service in the near future, he points out that there is yet much which can be done to improve its efficiency from those already available. To do this he has enumerated certain priorities which his studies-conducted at various times from Guys Hospital in Bermondsey, Bedford, and Thamesmead-have suggested are necessary to help patients and morale in the National Health Service. Professor Butterfield outlines the reasonably simple but effective measures which positive health education can initiate to prevent or postpone the onset of degenerative and metabolic disease, and the steps required to be taken to reorganize our hospitals and their outpatient services to enable them to cope with modem conditions. Finally he makes a plea that the executive in charge of one of the biggest corporations in this country employing some 400,000 people-the Minister of Healthshould be a permanent member of the Cabinet. This thoughtful series of essays will appeal to all those interested in the health services of the country. DERRICK DUNLOP.

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