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immunity ; but they do not disprove that there is a clinicaland immunological relationship between thyroid disease,pernicious anxmia, and probably adrenal insufficiency.

W. J. IRVINES. H. DAVIES.

Royal Infirmary and M.R.C.Clinical Endocrinology

Research Unit,Edinburgh.

ALMONERS VERSUS SOCIAL WORKERS

SHERIDAN RUSSELLMedical Social Worker.

National Hospital,Queen Square, London, W.C.1.

SIR,-Doctors nowadays seldom shave their .patientsand are no longer called surgeon barbers. Medical socialworkers seldom give alms to their patients, so are nolonger called almoners. I am thankful for the change,having for many years suffered from being called a ladyalmoner.

F.R.C.S.

L. L. W. PETERS.

SIR,-Last year I wrote astringently about the unsatis-factory system of training specialists in this country. Therecent change of requirements for the F.R.c.s. announcedby the Royal College of Surgeons represents a phenomenalhedging of the real issues.The proposals embrace a triangle: that candidates should

have spent a year in the British Isles; that their traineeship beextended from 2 to 3 years; and that they have held a post asregistrar in an approved hospital for 1 year. In the president’swords, the intention is to ensvre better fellows more representa-tive of British surgery.2 But Britain and other countries needcompetent surgeons, not better fellows.The college has in effect put the F.R.c.s. further out of reach

without solving the problems of training. It talks of approvedhospitals but disregards standards, which vary bewilderinglyfrom place to place. It does not require an all-round trainingand competence. I have worked in hospitals, approved merelyby virtue of the number of beds, of desperate standards, as wellas in smaller non-approved ones of excellent standards.

Yet again, the burden of disadvantage falls on the over-seas graduate.

London, N.W.3. L. L. W. PETERS.

INFECTIONS BY TETRACYCLINE-RESISTANT

HÆMOLYTIC STREPTOCOCCI

SiR,—Dr. Mitchell and Mr. Baber (Jan. 2) have rightlydirected attention to the increasing incidence of

tetracycline-resistant strains of Streptococcus pyogenes,which are responsible for causing infections of the upperrespiratory tract, especially acute otitis media.My laboratory receives specimens from patients attending

the Royal National Throat, Nose, and Ear Hospital, London,and we can confirm that the proportion of tetracycline-resistantstrains of Srr. pyor;enes isolated has steadily increased in the lastfew years. During 1964, out of a total of 311 strains isolated,no less than 131 i,42’ ,) were found to be resistant to tetracyclinebv the disc method (10 ng. concentration, Oxoid’). The

origin of these strains was as follows:Resistant to tetracycline

Scirrcz 7’oral isolated No. %Ear r 171 61 36ose and sinuses 46 21 45Throat 72 33 46Surgicai rounds . 15 13 87

Sputnt .. 7 3 43Totai 311 131 42

Multiple isolations from the same patient have been disregarded.Cases of acute otitis media accounted for 102 of the strainsisolated from ears, and of these 43 were resistant to tetracycline.16 out of 38 strains isolated from cases of sinusitis were tetra-

cycline-resistant, as were 5 out of 7 strains isolated from

patients with quinsies.The majority of the isolations, other than from surgical

1. Lancet, 1964, ii, 634.2. ibid. Jan. 23, 1964, p. 208.

wounds and sputa, were made on the first attendance of thepatient at hospital, which supports the findings of Dr. Mitchelland Mr. Baber that tetracycline-resistant strains are encounteredno less frequently outside hospital.We have also found a strain of a group-C hsemolytic

streptococcus and another of group-G to be tetracycline-resistant. Both these organisms were isolated from ears.There is little doubt that the usefulness of tetracycline

in the treatment of bacterial infections of the upperrespiratory tract is now severely limited.

J. V. DADSWELL.

Department of Pathology and Bacteriology,Institute of Laryngology and Otology,

Royal National Throat, Nose, and Ear Hospital,London, W.C.1.

EMERGENCY HÆMORRHOIDECTOMY

J. F. HICKEY.St. Luke’s Hospital,

Anua, Uyo,Eastern Nigeria.

SIR,-Professor Tinckler’s article rocked me back inmy chair. I admire his courage, but have no intention of

embarking on emergency hxmorrhoidectomy for prolapsedpiles..The very high postoperative rate of pyrexia and

pulmonary complications is accepted far too lightly. Threeof the patients developed rectal stricture. I have nodoubt this is far too high a price to pay for convenience.The results of conservative management are excellent.

This certainly cannot be said for Professor Tinckler’sseries, where I fear too much reliance is being placed onantibiotics.

INTRA-ARTERIAL CYTOTOXIC THERAPY ANDX-RAY THERAPY FOR CANCER

SIR,-Helman and his colleagues (Jan. 16) are surelycorrect in advocating cytotoxic drug therapy for advancedcarcinoma before rather than after radiotherapy. A possiblerationale is that after cytotoxic infusion the tumour isshrunk and the vascularity of some of it, previouslyanoxic, is increased so that it is more radiosensitive.

Further, the patient’s general condition may improve,perhaps by resolution of much of the malignant masswhich may contain " locked-up " sepsis. In addition,isolated malignant cells outside the area of radiation maysuccumb to infusion alone.

Recurrence usually follows a policy of " infuse, wait,

and see ", and often little can then be done. The authorshave rightly emphasised the necessity for great attention todetail, so essential for success in infusion-therapy. Askilled vascular surgeon is of tremendous help.The authors did not make quite clear whether simplified

methods of irradiation were used because the disease was"

hopeless " or because they made irradiation easier toapply; every patient should have the best possible techniqueof irradiation should this have any advantages, and I haveno doubt this was done in their cases.The following case-notes illustrate the use of similar

principles at this hospital:Case 1.-Squamous carcinoma of left side of base of tongue;

very hard and large fixed lump, with glands near-by. Tworadiotherapists considered that cobalt radiation offered little

hope. An infusion of methotrexate was given via the superficialtemporal artery. This was followed by marked regression ofthe lump, which became soft, and then by accurately plannedhigh-dose radiation. The patient is now well after over

2 years.Case 2.-Recurrent sarcoma of the arm. Treated by a

single infusion of nitrogen mustard which was blocked in thelimb by arterial clips and a tourniquet. Systemic neutralisation

1. Tinckler, L. F., Baratham, G. Lancet, 1964, ii, 1145.