1354

(3) There was no interference with the lochia or with the

subsequent involution of the uterus.The only disadvantage is a large diuresis. Its nuisance

value was minimised by taking the second tablet in mid-afternoon. Most mothers agree that their babies requireattention at least once a night, and a call to micturate then isnot troublesome.

If this method of suppressing lactation became widelyused, a further advantage would be that syntheticoestrogens would be less readily available to the generalpublic for procuring abortions.

London, N.19. MAURICE HEALY.MAURICE HEALY.

IRON IN RHEUMATOID-ARTHRITIS ANÆMIA

G. D. KERSLEY.

SIR,-In view of the recent fears that intramusculariron injections caused cancer, and the obvious dangers anddifficulties of intravenous therapy, a further short thera-peutic trial has been carried out of oral and parenteraltreatment of the anaemia in rheumatoid arthritis. It hasbeen suggested that intravenous therapy, besides its effecton the anaemia, may be of therapeutic benefit otherwise.Hence sedimentation-rate, general improvement, and

degree of pain in joints were also noted.30 consecutive cases of typical rheumatoid arthritis admitted

to hospital with positive differential agglutination tests andhaemoglobin levels below 75% were divided by randomsampling into three groups. Group A was given intravenously1’5 ml., and then five doses of 10 ml. saccharated oxide of iron-’Ferrivenin’ (Bengers), 200 mg. in 10 ml.-a total of 1-03 g.Group B received intramuscularly 1 ml., and then four dosesof 5 ml. ferric-hydroxide dextran-’ Imferon’ (Bengers),250 mg. in 5 ml.-a total of 1-05 g. Group C were given bymouth 600 mg. (gr. 10) ferrous sulphate (’ Fersolate’, Glaxo)three times a day for the period of the experiment-i.e., threemonths. The patients were all assessed monthly by the sameobserver, who did not know to which group each belonged.All patients were in hospital for the first month, receivingonly physical treatment, and thereafter they were treated asoutpatients.The sedimentation-rate tended to improve in all groups (see

accompanying table), but improvement was not significant at

RESULTS OF TREATMENT OF "RHEUMATOID" ANaeMIA WITH IRON

the end of the experiment in any group, because of the scatterand variability.When joint pain and general feeling of fitness were assessed,

6 or 7 in each group of 10 claimed definite improvement. Only1, treated with ferrivenin, stated that she was getting more painin the joints at the end of the three months, as compared withthe pre-treatment assessment.The haemoglobin changes were examined by the randomised

block method. This showed that in all groups the treatmenthad a significant effect upon the haemoglobin levels. Thedifference was highly significant in the groups treated withintravenous and oral preparations. The greater p value forimferon is accounted for by the greater variability of responsein patients in that group. There was no significant differencebetween the increases in hxmoglobin levels in the three groups.

This small series of cases therefore suggests that all

forms of iron therapy are valuable in treating " rheu-matoid " anasmia. The absence of a statistically significantincreased benefit from parenteral iron, together with thedangers of such therapy, suggests that such treatmentshould be reserved for patients who fail to respond tooral treatment, and not given as a routine to all patientswith rheumatoid anaemia.

Bath. G. D. KERSLEY.

1. Walker, R. S., Hannah, R. Diabetes (in the press).

DETECTION OF LUNG CANCER

F. J. H. WALTERSMedical Director.

South West Metropolitan RegionalHospital Board

Mass Radiography Service,Worcester Park, Surrey.

SIR,-Your leading article of June 3 quotes recordsfrom the Philadelphia Tuberculosis Health Associationshowing an incidence of lung cancer of 10-8 per 1000examined by 70 mm. photofluorograms in a group of menaged 45 years and older (66 cases in 6137 volunteers).

In 1959 and 1960 the Surrey mass-radiography unitsexamined 35,037 men in this age-group by normal mass-radiography methods and found 60 cases of lung cancer (1’7 per1000 examinees). At the same time a mobile " general-practitioner chest X-ray service " has operated in the area andexamined 3852 men aged 45 years and older. 88 cases of lungcancer were found (22-8 per 1000 examinees).

Follow-up of these patients confirmed the higher operability-rate in the normal mass-radiography group reported by Brett.

Despite the lower operability-rate in patients referred bytheir own doctors, more cases of operable cancer were found inthis group than in normal mass radiography.

Older men seem reluctant to volunteer for normal mass-radiography examination, and there are not the facilities in

Surrey to offer a routine chest X-ray to every older man everysix months, even if this were desirable.With the cooperation of general practitioners, men of 45

years and older attending their surgeries, who have not had achest X-ray within the last six months, could be referred for aroutine film, even if no chest symptoms were present.

Shortage of radiographers may limit the number of general-practitioner cases acceptable by hospital X-ray departments,but because of the diminished incidence of pulmonary tuber-culosis in the population some mass-radiography units are nowable to offer a general-practitioner chest X-ray service in theirarea to meet this demand.A combined effort by the general practitioners and mass-

radiography units could be of immense help in the earlydiagnosis of lung cancer.

METFORMIN HYDROCHLORIDE IN

DIABETES

SIR,-Having used phenformin and metformin fairlyextensively in the past three years, we find the letterof Dr. Jackson and Dr. Herman (May 27) interesting.They make two criticisms of phenformin and base their

preference for metformin on these :(1) The incidence of gastrointestinal irritation with phenformin is

high and they quote " up to 50% ".(2) The necessity of using small initial doses with gradual incre-

ments is a disadvantage.These statements are misleading without qualification.The high incidence of gastrointestinal irritation is based on

early studies with phenformin in large initial doses and is notsustained in later work.1 On reviewing our first 62 cases (thenumber of cases reported by Dr. Jackson and Dr. Herman),in which phenformin was used, gastrointestinal irritationnecessitated withdrawal in 7 cases, while in the last 62 cases,when smaller doses were used initially, gastrointestinal irrita-tion necessitated withdrawal in only 4. These figures comparewith the incidence of 6 in 62 quoted by Dr. Jackson and Dr.Herman for metformin.