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in 10 hearts there was neuronophagia of the ganglia andsubendocardial nerves. All these lesions were evident inthe 4 cases in which leishmania were found; but noleishmania were found in any part of the autonomicsystem examined in these 12 hearts.While no reference is made to the apical endocardial

herniation evident in so many Chagasic hearts, thiscareful study adds further information about the severityand frequency of the lesions of the autonomic nervoussystem in the heart in this disease; and to the establishedloss of ganglion cells can now be added severe damageto the nerves themselves. Precisely how this comes aboutis uncertain, but the pathological substratum of thefunctional changes in the heart has been identified. Thedetails of the functional changes and the pharmacologicalresponses have yet to be worked out. But there in Brazilare the partially denervated hearts.

HEPARIN AND OSTEOPOROSIS

APART from hxmorrhagic complications, heparin hasfew side-effects. Anaphylactoid reactions, alopecia, andthrombocytopenia are uncommon, and dysesthesia pedis(" burning feet ") is extremely rare. But the pharmacolo-gical actions of heparin are not limited to its complexinterference with the coagulation mechanism. It acceler-ates the clearing of post-prandial lipxmia by activatingblood-lipases and prevents the agglutination and break-down of platelets in freshly drawn blood. Furthermore,there is evidence 2 to suggest that heparin may competewith chondroitin sulphate to alter or replace the normalmatrix mucopolysaccharides of bone, and this is now ofpossible clinical importance since there are reports of

osteoporosis and multiple fractures associated with long-term therapy.

Griffith et awl. studied 117 patients on long-termsodium-heparin therapy. In 107 who received 10,000units or less daily for one to fifteen years, no evidence ofosteoporosis was found. Of 10 treated daily with largerdoses (15,000-30,000 units) for six months or longer,spontaneous fractures of vertebrx or ribs developed in 6,and bone biopsy showed soft bony matrix. 5 of these 6

patients improved after withdrawal of heparin and con-tinuation of treatment with coumarin drugs. Supportivetreatment with anabolic agents, calcium diphosphate,hydrotherapy, and a back-support seemed beneficial.

Jaffe and Willis described a 41-year-old man withangina pectoris who received 20,000 units daily by deepsubcutaneous injection for about a year before fracturesdeveloped in several ribs and vertebras. Once again,withdrawal of heparin and substitution of sodium warfarinwas followed by satisfactory bone healing and no furtherfractures. Biochemical investigations in these patientsrevealed no apparent disorder of calcium or phosphatemetabolism, nor was there evidence of malignant deposits.There are several ways in which heparin might produce

osteoporosis. Goldhaber 5 reported that heparin poten-tiates the action of parathyroid hormone in causingresorption of bone in tissue culture, but there was noevidence of parathyroid dysfunction in these patients. Thepossibility that heparin may compete with chondroitin1. Robinson, J. J., VanderVeer, J. B. Archs intern. Med. 1963. 111, 153.2. Stinchfield, F. E., Sankaran, B., Samilson, R. J. Bone Jt Surg. 1956,

38A, 270.3. Griffith, G. C., Nichols, G., Asher, J. D., Flanagan, B. J. Am. med. Ass.

1965, 193, 91.4. Jaffe, M. D., Willis, P. W. ibid. p. 158.5. Goldhaber, P. Science, 1965, 147, 407.

sulphate has already been mentioned. A third intriguingsuggestion is that of Griffith and his colleagues,3 based onexperimental data in rats, that heparin increases collageno-lytic activity, secondary to a decrease in the stability oflysosome-like bodies in bone cells which contain theenzyme collagenase. They draw attention to the occur-rence in mast-cell disease (in which an excess of heparin-like activity is found) of radiolucent zones and areas ofincreased bone density corresponding to regions of boneresorption and proliferation. Moreover, such conditionsas Marfan’s syndrome and Hurler’s disease characteristic-ally show elevated systemic levels of heparin and otheracid polysaccharides and skeletal involvement. It may bethat these represent naturally occurring hyper-heparinstates, with resulting disorders of lysosomal stability.

In this country doubts about the value of long-termanticoagulant therapy are such that relatively few patientsare at risk. Where such treatment is indicated, however,and especially where high doses of heparin would berequired, it seems reasonable to use an oral agent such assodium warfarin rather than risk the production of

osteoporosis and its potential dangers

PREVENTION OF ENDEMIC GOITRE

INQUIRIES into the causes of endemic goitre have beenmany since the classical work of McCarrison,l whichindicated that the origins of endemic goitre were complex,being related both to infection with the coliform group oforganisms and to a faulty and unbalanced diet. Subsequentstudies have shown that iodine deficiency is a primaryfactor in endemic goitre in the Andes 2 ; and similar workhas demonstrated that this is also true in the Himalayas 3and perhaps in Iraq.4

Estimates of the probable numbers of sufferers fromgoitre throughout the world give figures of the order of200 million,5 so it is not a rare disease and attempts to

prevent it are obviously important. Sooch and Ramaling-aswami describe a controlled trial in which iodine, eitheras potassium iodide or as potassium iodate, was added tosalt. Superficially, this experiment seems deceptively easy.They chose three areas in the Himalayas: in one, normalsalt only was supplied; in the second salt enriched withpotassium iodide was provided; and in the third saltenriched with potassium iodate was given. A proportionof the population was examined in each area to estimatethe prevalence of goitre at the start of the investigation in1956, and repeat examinations in the three areas were per-formed at the end of the experiment in 1962. The Indianworkers are to be congratulated on successfully carryingout this ambitious experiment. They do not relate whatdifficulties they met in the introduction of a preventivemeasure in the areas they chose. If fluoridation experi-ence within this country is anything to go by, the

opposition may have been considerable.A striking reduction was recorded in the prevalence of

endemic goitre in the two areas which received the iodisedsalt; and it is said that some existing goitres got lessin individuals examined on the two occasions. But thetrial was not strictly controlled since the observers1. McCarrison, R., Madhava, K. B. Indian J. med. Res. 1932, memoir

no. 23.2. Stanbury, J. B., Brownell, G. L., Higgs, D. S., Perinetti, H., Itoiz, J.,

del Castillo, E. B. Endemic Goitre: the Adaptation of Man to IodineDeficiency. Cambridge, Mass., 1954.

3. Ramalingaswami, V. Bull. Wld Hlth Org. 1953, 9, 275.4. Caughey, J. E., Follis, R. H. Lancet, 1965, i, 1032.5. Kelly, F. C., Snedden, W. W. Monograph Ser. W.H.O. 1960, no. 44.6. Sooch, S. S., Ramalingaswami, V. Bull. Wld Hlth Org. 1965, 32, 299.

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knew which of the people had eaten the iodisedsalt and which had not. The need for such control isdemonstrated by the fact that the major change foundwas a reduction in the intermediate grade of goitre, whichwould be the grade in which most mistakes were likely tobe made. (The figures for endemic goitre in Iraq havebeen questioned on the ground that precise resultsof examination are hard to ensure.) In each of the areasthe male/female ratio in the children of school ageexamined was of the order of 3 or 4 to 1. The authorsstate that they were unable to examine random samples,but they did believe that their samples were representative,though this sex-ratio suggests they may have beenmistaken.

SHADOWS IN SINUSES

MANY patients with nasal symptoms, headaches,respiratory disease, and eye disorders have their sinusesX-rayed. The interpretation of any abnormalities seen inthe maxillary antra depends on the appearances andon the radiologist. Thus, varying degrees of opacity,mucosal thickening, polypi, and fluid levels may haveclinical labels attached to them by some of the braverinterpreters. While the clinician may not always agreewith the radiologist about the significance of some types ofshadowing in the maxillary antrum, the " fluid level " isusually accepted by all as virtually certain evidence ofsinusitis. The free fluid may be mucoid, purulent, orrarely blood; and its presence is generally proved byfurther X-rays taken with the head tilted. The occipito-mental view is customarily used as the most important indemonstrating the antrum, and if the " fluid level "again becomes horizontal in the tilted position, fluid isdeclared to be present. Occasionally, however, sub-

sequent antrum lavage fails to yield fluid, and Glass 8demonstrates some of the possible sources of error in theradiological investigation of sinuses. The " fluid level "

may sometimes consist of a loose cyst or mobile polyp,and the customary partial tilt will give the false impressionof a horizontal fluid level. Such errors can be avoided bytaking views fully tilted to a right-angle in all three planes,and Glass recommends that partial tilting should beabandoned. While this improved X-ray technique willavoid some errors, proof puncture is still the best way ofdemonstrating the fluid content of the maxillary antrum.

LOSS OF PARENTS

ALL manner of evil consequences have come to be

expected when a child is separated from its parents. Thepossibility that such early deprivation contributes to theonset of mental illness in later life is theoreticallyplausible; but some observations 9 by Munro suggestthat there may be more theory here than fact.Though there have been many attempts to establish

an association between mental illness and an unusuallyhigh rate of parental loss in childhood, the rate thatshould be regarded as normal among the general popu-lation has not hitherto been defined; and this deficiencyMunro set out to make good. His subjects were out-patients attending the non-psychiatric clinics of a large

7. Salem, S. N. Lancet, July 10, 1965, p. 85.8. Glass, M. Med. Proc. 1965, 11, 178.9. Munro, A. Br. J. prev. soc. Med. 1965, 19, 69.

general hospital in Edinburgh. He compared the medicaland surgical patients among them on fourteen chosencounts, found no significant differences between them,and argued that his overall sample was therefore pro-bably representative of the population from which it wasdrawn. He interviewed patients consecutively, after theirclinic consultation, using a standard list of questions.No-one giving a history suggestive of psychotic illnesswas included in the series. 10 subjects were excludedfor this reason, and another 2 because they seemeddepressed at interview. Only those over sixteen years ofage were questioned. 210 patients took part in the

inquiry.Of the 210, 30 had lost a parent by death before their

sixteenth birthday. Another 68, or nearly a third of thesample, recalled parental separation of more than threemonths’ duration. In all, therefore, 98 subjects, or 47%of the total, testified to some form of parental deprivationduring their first sixteen years. Surprisingly few (25)said that they were emotionally distressed at the time.As many as 38 of the 210 regarded their childhood

relationship with one or other parent rs disturbed byfactors other-than separation. Munro wonders whetherintegrity of the parent-child relationship may be lessvital to normal emotional development than some

authorities have maintained.

DOCTORS OR DRUIDS?

A PATIENT in Kampala may say he has been bewitchedby a crocodile and another in Kensington may say hisdaughter’s blood needs cooling-and a doctor may handout vitamin B121 persuading himself as well as the patientthat it is a good tonic. Fashions in superstition maychange, but no community, national or professional,seems able to do without a mass of customs and beliefsof which the rationale is seldom questioned.As a surgeon practising in Uganda, Burkitt is well

placed to study superstition in the raw, and he reports 1that " the superstitious practices still adhered to by moreprimitive peoples are not far removed from much towhich we still adhere even in this century in Westernmedicine ". Among recently discarded practices heincludes hot fomentations, quinine for colds, and thedropping of medicaments into a pus-filled ear (havethey all really been discarded ?). But his main attack ison the hallowed and futile practices in which the under-staffed hospitals of Africa squander time that they cannotafford. They include counting the respirations of everypatient, and the number of times in the day he says he haspassed urine (or, rather, recording fictitious numbers incolumns representing these functions), the use of fractureboards regardless of the type of fracture, various piecesof preoperative nonsense, and the disinfection of

operating-theatres if anyone dies in them. ’.Perhaps some hospitals in Britain have put these and

other idolatrous practices behind them; others, if theysearch their consciences, may find that Burkitt’s observa-tions could have been made outside Africa. He does notmake the mistake of condemning every practice that is notsupported by scientific proof; to do so would rob medicineof much that, for all its seeming illogicality, is humaneand useful. He asks only that we should not waste timethat could be better spent, and this plea must be as validin England as Uganda.

1. Burkitt, D. E. Afr. med. J. 1965, 42, 305.