794 EPONYMOUS DISORDERS
CLINICAL EMBRYOLOGY
SiR,—Ienjoyed Dr Boyd and J. A. Woodman’s paper on the Jekyll-and-Hyde syndrome (Sept, 23, p. 671) not only because of the light relief it provided among the heavier going of the surrounding articles but also because the name exactly describes the conditions seen in varying degrees in so many elderly patients. Named diseases have been increasingly displaced over the years by more scientific descriptive titles. There is, of course, a danger that having put a label on a patient his medical attendants will feel there is nothing further to say or look for.
my book Clinical Embryology be involved in teaching students-for whom this book is intended-otherwise he would appreciate that it is much more important that they understand how an embryological event occurs than when. Many students find it confusing to have to remember dates of developmental events. May I also take issue with your reviewer over the precision in dating of embryological processes whose disturbance may lead to anomalies. Development is continuous, and it is often im-
Provided this risk is avoided, a brief eponymous title is a convenient and agreeable shorthand for disorders, especially symptom or behaviour complexes, in which the aetiology varies or is unknown. The Peter Pan syndrome of congenital hypopituitarism is long established, as is the Munchausen syndrome described by Asher over twenty years ago. Clark’ described the Diogenes syndrome of wilful self-neglect, and now we have Jekyll-and-
SIR,-Your reviewer of
(Sept. 2,
p.
505)
cannot
possible to pinpoint an embryological event to a given day or week, particularly in the organs he mentions. Prenatal development of the kidney cortex, for example, occurs over a period of at least twenty weeks. Department of Anatomy,
University of Liverpool, Liverpool L69 30X
R. G. HARRISON
Hyde. For several years in this unit I have used "Oblomov syndrome" (from the novel by Ivan Goncharov) to describe a condition of wakeful and sociable apathy or laziness not associated with any other evident mental or physical disturbance or subnormality. All of us, no doubt, exhibit minor forms of this at times. My most exaggerated example was of a woman of 74 who had confined herself to bed for almost all of the previous 40 years; apparently she had been advised by her family doctor to rest during an attack of ’flu in the 1930s, but as he had omitted to revisit shortly afterwards she had remained in bed (except for toilet purposes and very occasional excursions downstairs) ever since. The condition is not necessarily irreversible ; this particular woman was eventually rehabilitated to fairly normal independent activity. Other suggested syndromes are "Humpty Dumpty" (repeated falls and multiple fractures), "Tweedledum and Tweedledee" (some cases of folie a deux), and "Huckleberry Finn" (persistent truancy). The possibilities are endless-perhaps others of your readers can suggest further characters in search of a (medical) author. Trinity Hospital, 19 Trinity Road,
Taunton
PETER F. ROE
RESPECT FOR THE CLASSICS
SIR,-Mr Trigg, secretary of the nomenclature committee, British Pharmacopoeia Commission, properly corrects the error in the first paragraph of Mr Schablin’s letter (Sept. 16, p. 663), but it seems that in doing so he errs. He states that the International Union of Pure and Applied Chemistry assigned the name eicosane to the parent hydrocarbon substance containing twenty straight-chain carbon atoms, but I understood that this was changed (stupidly) by the LU.P.A.C. commission on nomenclature of organic chemistry, 1975, to icosane. This erroneous spelling is followed in the 1976 recommendations of the LU.P.A.C.-LU.B. commission on biochemical nomenclature2which therefore wants arachidonic acid to be 5,8,11,14-icosatetraenoic acid. Presumably even you Sir, have to follow divinities that rough-hew our words shape them how we will, and that in doing so show disrespect for the classics.
INSULIN, CATECHOLAMINES, AND HEART-DISEASE
SIR,-Your editorial (July 15, p. 138) drew attention to the association between hypertension and diabetes, and Dr Marti (Aug. 19, p. 429) reported the association to be statistically significant ; among diabetics ischxmic heart-disease was the leading cause of death (41.2%). A possible mechanism which would explain both the hypertension and the coronary heart-disease is the blocking role of insulin on the action of the catecholamines on the heart and tissues. Alexander and Oakel studied the effect of insulin on vascular reactivity to noradrenaline. They concluded that the hypotension observed with insulin therapy was produced by insulin itself, and they showed that one significant mechanism by which this effect was produced was an attenuation of the normal vasoconstrictor response of peripheral blood-vessels to noradrenaline. Lee and Downing2 showed that insulin significantly attenuated the negative inotropic action of noradrenaline on mammalian heart muscle and exerted in turn a positive inotropic effect. Insulin also prevents the catecholamine-triggered release of fatty acids from adipose tissue and in general interferes with the action of the catecholamines. It is reasonable to assume that untreated or poorly controlled diabetics will have low insulin levels or resistance to the action of insulin. Christensen3showed that there were significantly higher plasma noradrenaline and adrenaline levels in untreated diabetics than in normal controls but this difference was no longer observed when the diabetics were well controlled. I believe that catecholamines may play a significant role in the xtiology and pathogenesis of coronary heart-disease, and this has been discussed by Kjekshus.4 Certainly the association of diabetes and hypertension can be explained by low insulin levels or tissue resistance to insulin, and I think the association with coronary heart-disease can also be so explained. These findings are important for two reasons. Tansey et al. noted that obese women diabetics had twice the mortality of non-diabetics, and they suggested a therapeutic trial in such to assess whether insulin affects infarct size. Secondly, these findings throw light on the aetiology of coronary heart-disease, particularly the role of catecholamines.
patients
Department of Community Medicine and Health, Kingston and Richmond Area Health Authority, Richmond, Surrey TW10 6EF
JOHN
A. LEE
Magdalen College, Oxford
1. 2.
HUGH SINCLAIR
Clark, A. N. G., Mankikar, G. D., Gray, I. Lancet, 1975, i, 366. Eur. J. Biochem. 1977, 79, 11.
1. Alexander, W. D Oake, R. J. Diabetes, 1977, 26, 611. 2. Lee, J. C., Downing, S. E. Am. J. Physiol. 1976, 230, 1360. 3. Christensen, N. J. ibid. 1974, 23, 1. 4. Kjekshus, J. J. Rec. Adv. Stud. cardiac Structure Metab. 1975, 6, 183. 5. Tansey, M. J. B., Opie, L. H., Kennelly, B. M. Br. med. J. 1977, i, 1624.
CLINICAL EMBRYOLOGY
SiR,—Ienjoyed Dr Boyd and J. A. Woodman’s paper on the Jekyll-and-Hyde syndrome (Sept, 23, p. 671) not only because of the light relief it provided among the heavier going of the surrounding articles but also because the name exactly describes the conditions seen in varying degrees in so many elderly patients. Named diseases have been increasingly displaced over the years by more scientific descriptive titles. There is, of course, a danger that having put a label on a patient his medical attendants will feel there is nothing further to say or look for.
my book Clinical Embryology be involved in teaching students-for whom this book is intended-otherwise he would appreciate that it is much more important that they understand how an embryological event occurs than when. Many students find it confusing to have to remember dates of developmental events. May I also take issue with your reviewer over the precision in dating of embryological processes whose disturbance may lead to anomalies. Development is continuous, and it is often im-
Provided this risk is avoided, a brief eponymous title is a convenient and agreeable shorthand for disorders, especially symptom or behaviour complexes, in which the aetiology varies or is unknown. The Peter Pan syndrome of congenital hypopituitarism is long established, as is the Munchausen syndrome described by Asher over twenty years ago. Clark’ described the Diogenes syndrome of wilful self-neglect, and now we have Jekyll-and-
SIR,-Your reviewer of
(Sept. 2,
p.
505)
cannot
possible to pinpoint an embryological event to a given day or week, particularly in the organs he mentions. Prenatal development of the kidney cortex, for example, occurs over a period of at least twenty weeks. Department of Anatomy,
University of Liverpool, Liverpool L69 30X
R. G. HARRISON
Hyde. For several years in this unit I have used "Oblomov syndrome" (from the novel by Ivan Goncharov) to describe a condition of wakeful and sociable apathy or laziness not associated with any other evident mental or physical disturbance or subnormality. All of us, no doubt, exhibit minor forms of this at times. My most exaggerated example was of a woman of 74 who had confined herself to bed for almost all of the previous 40 years; apparently she had been advised by her family doctor to rest during an attack of ’flu in the 1930s, but as he had omitted to revisit shortly afterwards she had remained in bed (except for toilet purposes and very occasional excursions downstairs) ever since. The condition is not necessarily irreversible ; this particular woman was eventually rehabilitated to fairly normal independent activity. Other suggested syndromes are "Humpty Dumpty" (repeated falls and multiple fractures), "Tweedledum and Tweedledee" (some cases of folie a deux), and "Huckleberry Finn" (persistent truancy). The possibilities are endless-perhaps others of your readers can suggest further characters in search of a (medical) author. Trinity Hospital, 19 Trinity Road,
Taunton
PETER F. ROE
RESPECT FOR THE CLASSICS
SIR,-Mr Trigg, secretary of the nomenclature committee, British Pharmacopoeia Commission, properly corrects the error in the first paragraph of Mr Schablin’s letter (Sept. 16, p. 663), but it seems that in doing so he errs. He states that the International Union of Pure and Applied Chemistry assigned the name eicosane to the parent hydrocarbon substance containing twenty straight-chain carbon atoms, but I understood that this was changed (stupidly) by the LU.P.A.C. commission on nomenclature of organic chemistry, 1975, to icosane. This erroneous spelling is followed in the 1976 recommendations of the LU.P.A.C.-LU.B. commission on biochemical nomenclature2which therefore wants arachidonic acid to be 5,8,11,14-icosatetraenoic acid. Presumably even you Sir, have to follow divinities that rough-hew our words shape them how we will, and that in doing so show disrespect for the classics.
INSULIN, CATECHOLAMINES, AND HEART-DISEASE
SIR,-Your editorial (July 15, p. 138) drew attention to the association between hypertension and diabetes, and Dr Marti (Aug. 19, p. 429) reported the association to be statistically significant ; among diabetics ischxmic heart-disease was the leading cause of death (41.2%). A possible mechanism which would explain both the hypertension and the coronary heart-disease is the blocking role of insulin on the action of the catecholamines on the heart and tissues. Alexander and Oakel studied the effect of insulin on vascular reactivity to noradrenaline. They concluded that the hypotension observed with insulin therapy was produced by insulin itself, and they showed that one significant mechanism by which this effect was produced was an attenuation of the normal vasoconstrictor response of peripheral blood-vessels to noradrenaline. Lee and Downing2 showed that insulin significantly attenuated the negative inotropic action of noradrenaline on mammalian heart muscle and exerted in turn a positive inotropic effect. Insulin also prevents the catecholamine-triggered release of fatty acids from adipose tissue and in general interferes with the action of the catecholamines. It is reasonable to assume that untreated or poorly controlled diabetics will have low insulin levels or resistance to the action of insulin. Christensen3showed that there were significantly higher plasma noradrenaline and adrenaline levels in untreated diabetics than in normal controls but this difference was no longer observed when the diabetics were well controlled. I believe that catecholamines may play a significant role in the xtiology and pathogenesis of coronary heart-disease, and this has been discussed by Kjekshus.4 Certainly the association of diabetes and hypertension can be explained by low insulin levels or tissue resistance to insulin, and I think the association with coronary heart-disease can also be so explained. These findings are important for two reasons. Tansey et al. noted that obese women diabetics had twice the mortality of non-diabetics, and they suggested a therapeutic trial in such to assess whether insulin affects infarct size. Secondly, these findings throw light on the aetiology of coronary heart-disease, particularly the role of catecholamines.
patients
Department of Community Medicine and Health, Kingston and Richmond Area Health Authority, Richmond, Surrey TW10 6EF
JOHN
A. LEE
Magdalen College, Oxford
1. 2.
HUGH SINCLAIR
Clark, A. N. G., Mankikar, G. D., Gray, I. Lancet, 1975, i, 366. Eur. J. Biochem. 1977, 79, 11.
1. Alexander, W. D Oake, R. J. Diabetes, 1977, 26, 611. 2. Lee, J. C., Downing, S. E. Am. J. Physiol. 1976, 230, 1360. 3. Christensen, N. J. ibid. 1974, 23, 1. 4. Kjekshus, J. J. Rec. Adv. Stud. cardiac Structure Metab. 1975, 6, 183. 5. Tansey, M. J. B., Opie, L. H., Kennelly, B. M. Br. med. J. 1977, i, 1624.
