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reasonable to limit the use of dopamine and other ino-tropic agents to patients in whom there is a reasonableprospect of recovery to independent existence. Inotropicagents should not be used to flog needlessly a nearlydead heart.

THYROID HEART-DISEASE

THYROXINE (T4) and triiodothyronine (T3) are

believed to be responsible for the cardiovascular distur-bances in thyroid-gland dysfunction. When thyrotoxi-cosis is superimposed on preexisting heart-disease, theclinical picture may mislead both endocrinologist andcardiologist-the one identifying no more than a simplehigh-output circulatory state in his hyperthyroid pa-tient, the other failing to order thyroid-function tests inhis patient with obscure cardiac disease. Now a newdimension is added to the association of thyrotoxicosisand heart-disease. Six years ago Symons and his col-leaguesl observed that the analogues of T3 and T4, triacand tetrac, were present in one of their patients withheart-disease. They then gave thyroxine or triac to ani-mals, in doses too small to produce overt thyrotoxicosis,and the result was severe cardiac hypertrophy (espec-ially in the triac group). So striking were the changesthat these workers wondered whether hypertrophic car-diomyopathy might be induced in the same way (in man,this condition is sometimes associated with thyrotoxico-sis3). They postulated that the effect of triac on cardiacmuscle might be greater on the developing heart, and onp. 221 this week we see their first results. By giving triacto pregnant rats, Dr Olsen and his co-workers have in-duced the changes of hypertrophic cardiomyopathy, atelectronmicroscopic level, in the fetal (but not in thematernal) heart.

Several questions now arise. Could hypertrophic car-diomyopathy in man simply be an extreme form ofmuscle hypertrophy? Might it result from the action ofhormones in susceptible fetuses? Might it regress if thechemical stimulus were removed? The mechanism ofaction of triac and tetrac is unknown. When given toanimals in amounts which do not affect total bodyoxygen use these interesting compounds do stimulate car-diac-muscle oxygen consumption,4 but orally, in man,their overall activity is less than a fifth that of their par-ent compounds.s We now need better techniques formeasuring these circulating hormones. Meanwhile,endocrinologists and cardiologists should be aware ofthe value of standard thyroid-function tests in the occa-sional patient with obscure heart disease.

AN ISLAMIC TWIST

THERE are hazards in the fast of Ramadan-at leastfor the Pushtoons of Afghanistan. In 13 months Dukeand Yar6 saw 26 Pushtoon men with primary small-bowel volvulus, and in 19 the condition arose duringRamadan, the annual period when faithful Mohamme-dans abstain from food during daylight and consume a

1. Symons, C., Richardson, P. J., Wood, J. B. Lancet, 1971, ii, 1163.2. Symons, C., Olsen, E. G. J., Hawkey, C. M. J. Endocr. 1975, 65, 341.3. Symons, C., Richardson, P. J., Feizi, O. Thorax, 1974, 29, 713.4. Pittman, C. S., Barker, S. B. J. clin. Invest. 1962, 41, 696.5. Lerman, J., Pitt-Rivers, R. J. clin. Endocr. 1956, 16, 1470.6. Duke, J. H., Jr., Yar, M. S. Archs Surg. 1977, 112, 685.

single large meal after dark. Evidently the Pushtoonsare unusually susceptible to small-bowel volvulus, andDuke and Yar attribute this to their strict observance ofthe dietary rules of Ramadan and to their veryhigh-fibre diets. Volvulus of the whole small bowel, inthe absence of congenital bands or postoperative adhe-sions, is seldom seen in Western Europe or North Amer-ica. Like volvulus of the sigmoid colon, it is much morecommon in certain African, Asian, and Middle Easterncountries. There may be genetic peculiarities and varia-tions in mesenteric length, but a more exciting aetiologi-cal possibility is the great difference in diet betweenthese two groups of nations. Large amounts of dietaryfibre, taken infrequently, could well predispose to intes-tinal torsion. Fortunately, surgical management ofsmall-bowel volvulus is easy-untwisting or resection.The patient presents with acute small-bowel obstruction,and the Western surgeon, though he may see only onesuch case in his lifetime, will have no difficulty in decid-ing to undertake exploratory laparotomy; even in thestraitened circumstances of the National Health Servicethe sun is still not allowed to rise and set on an un-

opened acute intestinal obstruction. Unfortunately, thissimple surgical philosophy does not apply to sigmoid vol-vulus, which is apt to be misdiagnosed as diverticulardisease or colonic cancer. This leads to a more expectantmanagement, and the result may be strangulation orperforation of the twisted colon; the subsequent oper-ation can be very taxing. As the message "bran is bestfor bowels" reaches more and more ears, perhaps weshall see Western epidemics of small-bowel volvulus, ashigh-liquid revels are followed by the high-fibre break-fast.

NOT FOR BURNING

ON Sept. 18, 1976, a man of 70 died in hospital ofbronchopneumonia due to a cerebrovascular accident.Accordingly, the medical referee authorised his crema-tion. It takes about 60 minutes at 8000C to cremate a

body. During the process, the operator looks through ahatch and controls the gas and air supply. On this occasionthe gas was turned off after 35 minutes and 5 minuteslater there were five explosions in rapid succession. Fivemetal discs and a metal plate were found amongst thecremated remains and the inner lining of the strongbrick walling of the oven had a hole punched into it.’The mercury zinc battery of a pacemaker had exploded.Damage was slight, but the operator might easily havereceived serious, even fatal, injuries.

This year two further explosions have been reported,despite warnings to all crematoriums and the HomeOffice. In Solihull, the scene of the first explosion, thecremation form now asks whether a pacemaker (orradioactive material) has been inserted in the body and,if so, whether it has been removed. As a result, two pace-makers have been taken out after death. Local authori-ties are considering asking relatives of the deceased forindemnity against injury. Lithium batteries are now

superseding mercury-zinc batteries and they are said tobe twice as explosive. Nuclear-powered pacemakerswithstand 1300°C for 90 minutes, but there is much tobe said for removal of such devices before cremation,Accidents, as the Windscale inquiry shows, can happen.

1. Morrell, P. J. Practitioner, 1977, 219, 109.