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babe within us, that comes into the forefront in illness

very often needs satisfaction by mouth. Such longingshave to be considered in scientific treatment, too, or

else the scientific view would be incomplete. We neednot feel ashamed or guilty because, in full knowledgeof their effect, we have prescribed preparations whichhave no easily definable pharmacological action upon anisolated organ or system.

Let us define then (and reject) any treatment thatis given without the doctor fully knowing and under-standing what he does by treating the patient-as.a placebo for the doctor.

Southall, Middlesex. M. B. CLYNE.

SiR,-Dr. Barham Carter (Oct. 17) is wrong, accordingto all principles of psychotherapy, to give psychoneu-rotic patients a placebo as " a material sign to establishconfidence so that they will benefit from the real helpfulpsychotherapy that follows." Once it has been estab-lished that the patient does not require medicinaltreatment, he will create in this patient, not confidence,but the conviction that there is some medicinally treat-able condition. If the patient already believes that"words can’t help my trouble," he makes his job of

giving the patient effective psychotherapy almost hope-less. The exhibition of placebos is a regression to pre-Freudian days. It could even culminate, as I have

experienced, in this trend of "

reasoning " : the patientwill not accept the psychogenic basis of his disorder ;therefore, if I help him to convert his psychoneurosisinto an organ-neurosis, I can treat this by drugs. Ifwe are dealing with a somatopsychic disorder-e.g.,asthma, mucous colitis, duodenal ulcer, neuroder-

matitis-palliative medicinal treatment is, of course,indicated, and this should be fully explained as palliative.Drug treatment in psychiatry is also indicated in the

well-recognised and defined syndromes-e.g., vegetativeimbalance or concomitant emaciation-but again this

requires full explanation to the patient, as to what itis intended to produce or effect. But placebos No !

M. B. CLYNE.

D. J. SALFIELD.Winterton Hospital,Sedgefield, Co. Durham.

POSTURE, BACKACHE, AND HEALTH

MUNGO DOUGLAS.

SiR,—In your issue of Oct. 17, Mr. W. E. Tuckerdiscusses human reaction as illustrated by the manneremployed by a person in his standing and sitting. Now,in standing and sitting, as in all the variations of humanreaction, the relationships between the various parts ofthe person are guided and controlled by means of sensorycommunications known medically as kinsesthesia. The

way a person adjusts himself as a whole depends uponhow well kinaesthesia works, and this again depends uponhow the communicating mechanisms are adjusted. Whenthe means of communication are badly adjusted thestandard of kinaesthetic guidance is low ; when they arewell adjusted, the standard is high. Mr. Tucker mustbe aware that Rudolph Magnus demonstrated that theadjustment of the animal as a whole enabling the sensoryand motor communicating mechanisms to operate attheir best and, therefore, in a reliable way, was an

adjustment which he showed was associated with acertain relativity of the head to the neck. Sherringtonalso acknowledged the importance of the head-neckrelativity in connection with knowing how to controlhuman reaction. In the light of the views of thesegreat experimenters, it must be clear that where a persondoes not react in accordance with a principle enablinghim to use the psycho-physical mechanism or self in away associated with a control over the relativity ofthe head to the neck ensuring a rising standard of kin-festhetic sensory appreciation, he is bound to doinjury to the working of the self and, therefore, tohis health. a

One of the consequences of failing to observe this

principle is that we form wrong beliefs about how theself works and are led along roads to knowledge whichare misleading. The burden of retracing our steps alongthese wrong roads grows the greater the longer wepostpone the admission that wrong means will neverenable us to gain the best possible control over humanreaction in its many and complex variations.

Bolton, Lanes. MUNGO DOUGLAS.

1. Costa, A. Rass. biochim. sci. July, 1953, p. 189.

PERIODIC MEDICAL OVERHAUL

ERNEST H. CAPEL,

SiR,-Sir Adolphe Abrahams (Oct. 24) considers that thepurpose of the periodic medical overhaul is to examinethe patient when well. If by

" well " he means healthy,then by definition the medical overhaul will reveal

nothing. If by " well " he means that the patient says

he feels well, many diseases are symptomless in theearly stages and many otherwise sensible people acceptsome symptoms-e.g. fatigue, cough, obesity-as normal.Their statement that they feel well does not mean theyare healthy.My criteria for periodic medical overhaul are that

it should be done at appropriate intervals and that itshould be thorough. The presence or absence of symptomsis immaterial.

Reigate, Surrey. ERNEST H. CAPEL.

HYPERTHYROIDISM IN CRETINS

SIR,-Dr. McGirr and Dr. Hutchison (Aug. 22) saythat, in their opinion, the terms hypothyroid, euthyroid,and hyperthyroid should continue to refer to the clinicalstate of the patient and should not be used to refer tothe functional state of the thyroid gland.

I have observed an endemic cretin with these func.tional thyroid data :

Basal metabolic rate (B.M.R.) z 18% ; protein-bound iodine(P.B.I.) 8-9 t.g. per 100 ml. ; serum-protein (Pullfrich) 7-2 g.per 100 ml. ; blood-cholesterol 105 mg. per 100 ml. ; radio-iodine uptake of the thyroid 87% after 2 hours, 81% after24 hours ; follicle-stimulating hormone in urine. + 10, - 20mouse units per 24 hours (Gorbman’s method) ; pregnanediol4-5 mg. per litre (nearly 15 days after previous recurrence).

This patient received 20 mg. of thyroid-stimulating hormone(T.s.H. Armour) daily on three consecutive days, and afterthis we obtained these values : B.M.R. + 39% ; P.B.I. 9-25 (g.per 100 ml. ; blood-cholesterol 93 mg. per 100 ml.

These changes show a ready secretion response of thethyroid to treatment with T.S.H. and a ready tissue

response to the increase of thyroid secretion.Recently in our hospital thyroidectomy was done on a

non-endemic-goitrous cretin, whose thyroid functiondata were :

B.M.R. z- 11 % ; r.B.i. 9-11 .g. per 100 ml. ; thyroid uptakeof J131 after 1 hour 28-8%, after 24 hours 34-1% (conversionratio 60%) ; blood-cholesterol 133 mg. per 100 ml. Histo-

logical examination showed many areas with indications ofhyperfunctioning adenoma.

Why should we not call these patients " hyper-thyroid," as we call all other patients with such bio-chemical data ? Of course we do not judge these patientsto have Basedow’s disease.Some workers suggest that the cretins we have des-

cribed were probably hypothyroid in their early years,and became hyperthyroid later.We answer :1. Nearly all endemic cretins we have studied showed a

high B.M.R., a high J131 uptake, a high conversion rate, readyforming of labelled thyroxine, and a low P.B.I. But ther.B.i. value was never as low as in true hypothyroidism (theaverage value in 21 patients was 4-54 .g. per 100 ml.).

2. We do not believe that their high radio-iodine uptakeis due to a low iodine availability, because normal people, andthe nurses eating the same food, have a normal thyroid uptake.