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experience shows the drug to be a promising advance in thetreatment of depression, and well worthy of furtherresearch.

ALAN D. BROADHURST.West Suffolk General Hospital

Bury St. Edmunds.

TREATMENT OF PHOBIAS

SiR,ŅThe article by Dr. Mawson (May 23, p. 1084) isof special interest to doctors using medical hypnosis intreatment of phobias and other conditions amenable todesensitisation. In this trial, when patients were beingtreated by progressive muscular relaxation, were theyconsidered to be in a state of hypnosis ? It would appearthat they were not.

Significant differences in results obtained by hypno/auto-hypnosis as compared with muscular relaxation havebeen found by investigators in a variety of conditions; anexample is the work of Davidson in obstetrics.1 The auto-hypnotic technique is now widely used, especially inallergic conditions such as asthma.2 The method is easy inexperienced hands and not time-consuming. The advan-tages of hypno/auto-hypnosis over simple relaxation,however deep, are that:

1. Posthypnotic suggestions can be made that, during the daily15 minutes’ autohypnosis prescribed, the patient will experienceto some degree the benefit achieved during hypnosis by thedoctor.

2. Desensitisation is reinforced when applied under hypnosis.3. The method can be further helped by appropriate ego-

strengthening, specifically worded for each individual.34. Patients can be trained, when confronted by a trigger situa-

tion, to abolish incipient panic or other symptom by a brief,partial use of their autohypnotic-induction technique.

It would be of great interest if a further trial could bemade comparing desensitisation under methohexitone,under muscular relaxation, and thirdly under hypno/auto-hypnosis using modem permissive methods ofinduction and deepening to which patients never seem toobject.

LUCY HAMSON,Chairman of the Academic Committee,

British Society of Medicaland Dental Hypnosis.London S.W.5.

TUMOUR IMMUNITY IN PATIENTS WITHBURKITT LYMPHOMA

SIR,-Your leading article on this subject (May 16,p. 1033) is both timely and informative. You properly callattention to the biological implications of the correlationbetween clinical behaviour and delayed hypersensitivityresponses to intradermal injections of tumour extracts.

Nor would I argue with your conclusion that such observa-tions on Burkitt-lymphoma and melanoma patients provideevidence that an individual may sometimes mount aneffective immune response against his own tumour and thatsuch a response may materially alter the course of hisdisease. However, I should point out that the response ofthe lympho-reticuloendothelial (L.-R.E.) system to theintradermal injection of a tumour extract is no more dis-tinctive a measure of hypersensitivity than the structuralchanges in the L.-R.E. system secondary to a spontaneoustumour. Certainly few would argue that the tuberculin testis a more valid index of hypersensitivity than the formationof tubercles in the tuberculous patient. I must thereforerecall the extensive literature on the prognostically signifi-1. Davidson, J. A. Br. med. J. 1962, ii, 951.2. Report to the Research Committee of the British Tuberculosis

Association (prepared by G. P. Maher-Loughnan and B. J.Kinsley). ibid. 1968, iv, 71.

3. Hartland, J. Medical and Dental Hypnosis; p. 190. London, 1966.

Cant L.-R.E. responses in cancer patients, a subject to whichour own laboratory has made numerous contributions.1 Itshould be emphasised that such observations include thou-sands of patients with breast and gastric carcinoma as wellas diverse other types of cancer. In a 1959 review of cancerimmunology, we specifically related the prognosticallysignificant findings of lymphocytic infiltrations in theprimary tumour and sinus histiocytosis of regional lymph-nodes to delayed hypersensitivity, and made a plea forstudies of delayed hypersensitivity in human cancer.2 2

Similar conclusions were also voiced in succeeding reportsfrom this and other laboratories. 3-5 The biological import-ance and immunological significance of lymph-nodereactivity was further evidenced by the demonstration thatsinus histiocytosis was most prominent in auxillary lymph-nodes draining in-situ breast carcinoma. In the light ofsuch extensive documentation of the value of lymph-nodestructure as an index of immunological responses againstautologous tumours, we noted with surprise that " theextensive immunologic and pathologic studies of Burkitt’slymphoma have not included systematic studies of the con-trol lymph-nodes draining the lymphoma ". 7

In view of the above, it seems more realistic to describethe still fragmentary observations on Burkitt lymphoma andmelanoma as additional and entirely expected evidencerather than as " some of the best evidence " that an indivi-dual can sometimes mount an effective immune responseagainst his own tumour. I submit that this distinction isfar from picayune. To the contrary, it properly acknow-ledges the contributions of surgical pathology and empha-sises that the research potential of surgical pathologicalmaterial has yet to be fully exploited with modern investiga-tive techniques.

MAURICE M. BLACK.

Department of Pathology,New York Medical College,

N.Y. 10029.

THE RECURRENT LARYNGEAL NERVES ATTHYROIDECTOMY

SiR,-In his letter of June 6 (p. 1227), Mr. Michie statesa case against routine identification of the recurrent laryn-geal nerves at thyroidectomy, and quotes a nerve-injuryrate which compares favourably with figures published bysurgeons who practice nerve identification.

In the hands of a surgeon such as Mr. Michie, withextensive experience of thyroid operations, there is verylittle risk of damage to the recurrent nerve whether or notit is identified. In the hands of the majority of surgeonshowever, I am convinced that the risk of permanent nerveinjury, as opposed to transient paralysis, is far less if thenerve has been identified. I, therefore, consider that thenerve should, if possible, be identified whenever a total orsubtotal thyroidectomy is carried out.

Disregarding figures entirely, is it not a fundamental

principle in operative surgery that an important structurein the operative field liable to injury should be identifiedand preserved ? I cannot believe that any surgeon wouldadvocate a cholecystectomy without identification of thecommon hepatic, cystic, and common bile-ducts, or wouldexcise the rectum without identifying the ureters. Surelythis principle applies with equal force in thyroid surgery.

HILARY WADE.Cardiff.

1. Black, M. M. in Progress in Clinical Cancer; p. 26. New York, 1955.2. Black, M. M., Speer, F. D. Surgery Gynec. Obstet. 1959, 109, 105.3. Cutler, S. J., Black, M. M., Mork, T., Harvei, S., Freeman, C.

Cancer, N. Y. 1969, 24, 653.4. Hamlin, I. M. E. Br. J. Cancer, 1968, 22, 383.5. Anastassiades, O. Th., Pryce, D. M. ibid. 1966, 20, 239.6. Black, M. M., Chabon, A. B. in Pathology Annual; p. 185. New

York, 1969.7. Black, M. M. N. Y. St. J. Med. 1970, 70, 962.