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BRETYLIUM TOSYLATE IN THE TREATMENT OF HYPERTENSION
544
Letters
to
work and domiciliary consultations. But why should such services be so remunerated ? Why should they not be part of the job for which the man is paid a fair salary ? I have the temerity to suggest that if domiciliary consultations carried no extra pay they would very soon be reduced in number to those that are really necessary, and that that number would be found to be a small fraction of the present inflated figure. Is a domiciliary visit really necessary for tonsillitis ?
the Editor
PRIVATE PATIENTS IN THE NATIONAL SCHEME
Snt, The complex arguments of your annotation and the ensuing letters have blurred the simple issue: free drugs were promised to all, irrespective of whether they were private or N.H.S. patients. Under existing arrangements, the private patient is in danger of receiving the lower grade of treatment which you so rightly deplore, since in treating his private patient the doctor is tempted to be unwisely economical in the use of drugs that are many times the cost of the consultation fee. This inevitably invites the conscientious G.P. to encourage his private patient to join the uniformed ranks of N.H.S.
Swansea.
BRETYLIUM TOSYLATE IN THE TREATMENT OF HYPERTENSION
SIR,-Recent reports and observations in your journal 22 on the use of bretylium tosylate prompt us to record our preliminary impressions of the use of adrenergicblockers in the management of patients with severe
patients.
hypertension.
Your comments seem to imply that this would be a desirable policy. Yet one of the greatest dangers of our times is the pressure that is constantly thrust upon us to conform to the standards of the multitudes. Let the discriminating be encouraged to spend their money as they please, and let this choice be extended into the realm of professional services. By these means, those that dread food-office waiting-rooms, dreary delays, and hurried consultations, can enjoy the trimmings which a free society should offer. Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham.
M. E. N. SMITH.
N. E. WINSTONE.
SIR,-As an intelligent and humane person I find myself inevitably in complete agreement with your opposition to boxing, and I was therefore glad to see the letter from Dr. Waycott in last week’s Lancet. Myattention was arrested by the truth of his final paragraph, and I could not resist the temptation to transfer it in context to another matter that is currently exercising the minds though not the intelligence of many of your correspondents-namely, the very real threat of two standards of treatment in the N.H.S., to which your recent annotation alluded with complete clarity and justice. It is not entirely Abraham Lincoln’s responsibility that the West is dedicated to the proposition that all men are created equal in the sight of God. This is said to be a Christian country and therefore, in principle at least, Lincoln’s dictum was accepted some little time before Gettysburg-in fact shortly after the landing of St. Augustine. This, in Dr. Waycott’s words, is the underlying principle that some people find difficulty in grasping. Under it, a doctor cannot escape the conclusion that no man’s body is more important than another’s. If he does adopt two standards of practice, and gives an inferior service to those who cannot or will not pay the money demanded, he has not only ceased to be a Christian but is no longer civilised, since he has abandoned the Christian ethic on which Western civilisation, whether we like it or not, is founded. Thus it is no defence for a man to offer the excuse that he: never was a Christian anyway. The more intelligent of your readers will perceive that private practice is not open to condemnation when it is the only forml of practice available, as for example in the U.S.A. A State: service is not compulsory. But if a State service is acceptedand the medical profession of this country has accepted itthen the mandate for private practice disappears immediately and completely. How can it be otherwise ? If a doctor renders two standards of care he is sinning against God. If he does not, he is a cheat, because he is charging his patients money for something to which they are entitled free of cost. One other point, if you will bear with me. Dr. Howard, also in last week’s issue, attempts to uphold the fee-for-service system by quoting certain examples of it, such as obstetrical ’
--
We have so far treated 26 patients with bretylium tosylate and 8 with the longer-acting guanethidine drug,’Ismelin ’. In our series no patient has had an initial diastolic blood-pressure of below 120 mm. Hg, and in fact, three-quarters of them have had pressures of 140 nun. Hg or higher. A large proportion of them had previously been treated with ganglion-blocking agents. Using bretylium tosylate, the difficulties with tolerance and instability that we have encountered are essentially the same as those recorded by Dr. Turner and Dr. Lowther. In view of our experience with three patients who responded dramatically to subcutaneous bretylium tosylate, we are exploring the responsiveness to parenteral treatment of those patients who have become tolerant to oral therapy. Of the side-effects, nasal stuffiness seems to be the most common but least troublesome. We have not seen dizziness in the absence of postural hypotension, but unexplained exertional dyspnoea has been so prominent in some cases as to limit the dose administered. We have encountered severe parotid pain, but excessive salivation and sweating have not been seen, and no patients have complained of tinnitus. Diarrhoea is readily controlled with propantheline bromide. It seems to us that the two most serious side-effects are mental changes and profound muscular weakness. In 1 patient who was on a high dose of bretylium tosylate a confusional state with hallucinations developed but abated on withdrawal of the drug. Another patient on ismelin developed a paranoid psychosis which recovered on cessation of treatment, and recurred when the drug was restarted. Profound muscular weakness with abnormal electromyographic patterns necessitated the withdrawal of bretylium tosylate in another patient. The introduction of adrenergic-blocking drugs is clearly a major advance in the treatment of severe hypertension. The large majority of patients previously treated with ganglionblocking drugs prefer bretylium tosylate because of the relative absence of side-effects. Tolerance has however been more frequent and troublesome with bretylium tosylate than with the ganglion blockers and this has demanded much closer supervision of patients in the follow-up clinic. Apart from this problem of increasing tolerance, bretylium tosylate suffers from the disadvantages common to all the relatively short-acting antihypertensive drugs. Our experience with the longer-acting ismelin has shown it to be a promising advance, though it is, as yet, too early to comment on its long-term usefulness.
We endorse the view that at this early stage in the use o these new drugs, anyone using them should be full; aware of their disadvantages, and particularly of th possibility of their causing toxic psychoses or profound muscular weakness. Department of Medicine, JOHN M. EVANSON The Royal Infirmary, H. T. N. SEARS. Manchester. 1. Dollery, C. T., Emslie-Smith, D., McMichael, J. Lancet, 1960, i, 296. Turner, R., Lowther, C. ibid. p. 381.
2.
Letters
to
work and domiciliary consultations. But why should such services be so remunerated ? Why should they not be part of the job for which the man is paid a fair salary ? I have the temerity to suggest that if domiciliary consultations carried no extra pay they would very soon be reduced in number to those that are really necessary, and that that number would be found to be a small fraction of the present inflated figure. Is a domiciliary visit really necessary for tonsillitis ?
the Editor
PRIVATE PATIENTS IN THE NATIONAL SCHEME
Snt, The complex arguments of your annotation and the ensuing letters have blurred the simple issue: free drugs were promised to all, irrespective of whether they were private or N.H.S. patients. Under existing arrangements, the private patient is in danger of receiving the lower grade of treatment which you so rightly deplore, since in treating his private patient the doctor is tempted to be unwisely economical in the use of drugs that are many times the cost of the consultation fee. This inevitably invites the conscientious G.P. to encourage his private patient to join the uniformed ranks of N.H.S.
Swansea.
BRETYLIUM TOSYLATE IN THE TREATMENT OF HYPERTENSION
SIR,-Recent reports and observations in your journal 22 on the use of bretylium tosylate prompt us to record our preliminary impressions of the use of adrenergicblockers in the management of patients with severe
patients.
hypertension.
Your comments seem to imply that this would be a desirable policy. Yet one of the greatest dangers of our times is the pressure that is constantly thrust upon us to conform to the standards of the multitudes. Let the discriminating be encouraged to spend their money as they please, and let this choice be extended into the realm of professional services. By these means, those that dread food-office waiting-rooms, dreary delays, and hurried consultations, can enjoy the trimmings which a free society should offer. Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham.
M. E. N. SMITH.
N. E. WINSTONE.
SIR,-As an intelligent and humane person I find myself inevitably in complete agreement with your opposition to boxing, and I was therefore glad to see the letter from Dr. Waycott in last week’s Lancet. Myattention was arrested by the truth of his final paragraph, and I could not resist the temptation to transfer it in context to another matter that is currently exercising the minds though not the intelligence of many of your correspondents-namely, the very real threat of two standards of treatment in the N.H.S., to which your recent annotation alluded with complete clarity and justice. It is not entirely Abraham Lincoln’s responsibility that the West is dedicated to the proposition that all men are created equal in the sight of God. This is said to be a Christian country and therefore, in principle at least, Lincoln’s dictum was accepted some little time before Gettysburg-in fact shortly after the landing of St. Augustine. This, in Dr. Waycott’s words, is the underlying principle that some people find difficulty in grasping. Under it, a doctor cannot escape the conclusion that no man’s body is more important than another’s. If he does adopt two standards of practice, and gives an inferior service to those who cannot or will not pay the money demanded, he has not only ceased to be a Christian but is no longer civilised, since he has abandoned the Christian ethic on which Western civilisation, whether we like it or not, is founded. Thus it is no defence for a man to offer the excuse that he: never was a Christian anyway. The more intelligent of your readers will perceive that private practice is not open to condemnation when it is the only forml of practice available, as for example in the U.S.A. A State: service is not compulsory. But if a State service is acceptedand the medical profession of this country has accepted itthen the mandate for private practice disappears immediately and completely. How can it be otherwise ? If a doctor renders two standards of care he is sinning against God. If he does not, he is a cheat, because he is charging his patients money for something to which they are entitled free of cost. One other point, if you will bear with me. Dr. Howard, also in last week’s issue, attempts to uphold the fee-for-service system by quoting certain examples of it, such as obstetrical ’
--
We have so far treated 26 patients with bretylium tosylate and 8 with the longer-acting guanethidine drug,’Ismelin ’. In our series no patient has had an initial diastolic blood-pressure of below 120 mm. Hg, and in fact, three-quarters of them have had pressures of 140 nun. Hg or higher. A large proportion of them had previously been treated with ganglion-blocking agents. Using bretylium tosylate, the difficulties with tolerance and instability that we have encountered are essentially the same as those recorded by Dr. Turner and Dr. Lowther. In view of our experience with three patients who responded dramatically to subcutaneous bretylium tosylate, we are exploring the responsiveness to parenteral treatment of those patients who have become tolerant to oral therapy. Of the side-effects, nasal stuffiness seems to be the most common but least troublesome. We have not seen dizziness in the absence of postural hypotension, but unexplained exertional dyspnoea has been so prominent in some cases as to limit the dose administered. We have encountered severe parotid pain, but excessive salivation and sweating have not been seen, and no patients have complained of tinnitus. Diarrhoea is readily controlled with propantheline bromide. It seems to us that the two most serious side-effects are mental changes and profound muscular weakness. In 1 patient who was on a high dose of bretylium tosylate a confusional state with hallucinations developed but abated on withdrawal of the drug. Another patient on ismelin developed a paranoid psychosis which recovered on cessation of treatment, and recurred when the drug was restarted. Profound muscular weakness with abnormal electromyographic patterns necessitated the withdrawal of bretylium tosylate in another patient. The introduction of adrenergic-blocking drugs is clearly a major advance in the treatment of severe hypertension. The large majority of patients previously treated with ganglionblocking drugs prefer bretylium tosylate because of the relative absence of side-effects. Tolerance has however been more frequent and troublesome with bretylium tosylate than with the ganglion blockers and this has demanded much closer supervision of patients in the follow-up clinic. Apart from this problem of increasing tolerance, bretylium tosylate suffers from the disadvantages common to all the relatively short-acting antihypertensive drugs. Our experience with the longer-acting ismelin has shown it to be a promising advance, though it is, as yet, too early to comment on its long-term usefulness.
We endorse the view that at this early stage in the use o these new drugs, anyone using them should be full; aware of their disadvantages, and particularly of th possibility of their causing toxic psychoses or profound muscular weakness. Department of Medicine, JOHN M. EVANSON The Royal Infirmary, H. T. N. SEARS. Manchester. 1. Dollery, C. T., Emslie-Smith, D., McMichael, J. Lancet, 1960, i, 296. Turner, R., Lowther, C. ibid. p. 381.
2.