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Figure.
A wife brought her husband with her for her review endocrine consultation. She had had successful treatment for her acromegaly 10 years previously and had now reached a satisfactory endocrinological cure of the condition so that she no longer had the characteristic facial features of acromegaly. The experienced consultant endocrinologist, who had not seen the wife for some time, made a spot diagnosis as the couple entered the consulting room and directed his remarks entirely to the husband, who was clearly acromegalic. Neither the husband nor the wife had recognised the gradual change in the husband's features, and both were quite baffled at him being considered to be the patient rather than the relative. Eventually the consultant endocrinologist's opinion was proved to be correct, and the husband too has now been successfully treated. The incidence of acromegaly in Northern Ireland (population 1 million adults) is four cases a year (range three to six cases), so the probable total number of patients with acromegaly is 100. As acromegaly can develop during roughly 40 years, the probability of a person developing the disease in their lifetime is 1 in 6250. The probability of a husband and wife developing the disease (1 in 39 070 000) is rarer than tossing 25 heads in a row with a coin, drawing the ace of spades four times in a row from a shuffled pack of playing cards, or picking eight Scrabble pieces from their bag to spell “H Cushing.”
Specimens of pituitary tumours from both patients are now being analysed to see if they share any molecular characteristics to suggest an environmental link to explain such a rare occurrence.
A B Atkinson, professor, D R Hadden, professor, Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast B12 6BA; M C Atkinson, Faculty of Education, University of Edinburgh, Edinburgh EH8 8AQ
Figure.
The Kettering hypertherm was used in treating neurological syphilis before the advent of penicillin. Patients were kept at a temperature of 106°F (41.1°C) for six hours; the regimen consisted of eight treatments at weekly intervals. Careful monitoring of temperature was essential—temperatures over 107°F could “poach” the brain, which was rapidly fatal. When the patient was inside, the upper part was locked down, as restless and angry patients would try to force it open to escape. The breeze from the fan, cold sponging to the head, and sucking ice provided some comfort to the patients.
Charles Kettering (1876-1958), the inventor of the hypertherm, is best known for designing auto parts for Cadillac and later for General Motors. He also invented the motorised cash register, the oxyhaemograph to save the lives of “blue babies,” and the mechanical heart. In retirement he worked on finding a cure for cancer—and on further automobile inventions.
Figure.
Even in our “medical” family (two medical parents and consultant orthodontist uncle and aunt) the three siblings, aged 10, 8, and 5, were somewhat surprised to lose a baby tooth each during the course of a six hour period one day in May 2001—an expensive night for the tooth fairy.
David Sandler, consultant physician, Clare Sandler, clinical assistant, Chesterfield S40 3NX
Figure.
A 69 year old man was referred to our ophthalmology unit by his optician, who had picked up a visual field defect at a routine examination. The patient was delighted to learn that the “smiling face” defect was in fact an artefact.
P Shah, consultant ophthalmic surgeon, Birmingham and Midland Eye Centre, Birmingham B18 7QH
Figure.
A schoolboy had been kicked in the ankle by another player during an informal football game. To occupy time while he was waiting to be seen, and long before we knew the result of his x ray examination, he drew the picture above to explain his injury. Not only was it helpful clinically to know exactly where the problem was, it turned out to be very accurate. His radiograph showed a small avulsion fracture on the tip of the lateral malleolus. This is a perfect validation of the Ottawa ankle rules in children.
Rebecca Torrens, specialist registrar in paediatric A&E, Bristol Royal Hospital For Children, Bristol BS2 8BJ