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DIARRHOEAL DISEASES CONTROLLED: WHAT THEN?
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About 25% of those attending the new hospital have their regular sessions in other hospitals in the city, and this would apply wherever the hospital were situated in Southampton. With the current unemployment of junior doctors, the provision of five additional posts, with the opportunity of studying for examinations concurrently, must be an attractive proposition. I would also question the accuracy of the statement that the hospital would "not be bound by national wage agreements" since I understand that, as in most independent hospitals, the wages paid to nurses, radiographers, and so on are precisely the same as the Whitley scales for equivalent staff in the N.H.S., so there is no question of "bribing" such staff to leave. There may indeed be an element of competition with the N.H.S., but this might be highly beneficial to the N.H.S.; it could induce it to be more flexible in its conditions of employment and to provide better facilities for its employees. The geographical situation of the hospital-which, after all, is what concerns the planners-would seem to be ideal. Its proximity to the Southampton General Hospital will save considerable time, which might otherwise be wasted in travelling, for most staff attending there. I would have thought that for a hospital of the size proposed, the main considerations for the local planning officers were just those mentioned; their brief does not include the political merits or demerits of private medicine.
In your Jan. 9 editorial on population you noted that food produc. tion in the developing countries is just keeping pace with population growth. If the growth of population is not consciously controlled by the widespread use of modern contraceptive techniques, it will be controlled ultimately by famine, pestilence, and war, as Malthus
predicted. Who feeds and educates those thousands of children whose life has been saved by the simple and low cost techniques of oral rehydration? Experience in Third World countries shows that parents do not stop procreation when more children than expected survive. If these children cannot be taken care of they only die a little later. What is the use of a diarrhoeal diseases programme that has not been designed in a holistic way-i.e., to include the necessary supportive measures for survival? The programme will end in another pyrrhic victory for modern medicine. What happens when the programme succeeds in areas where food, housing, education, and health care can be provided in more or less adequate and acceptable ways, as for instance in the slums of the fast-growing cities of the developing countries? There will be a considerable additional increase of population-unless the diarrhoeal diseases control programme is accompanied by a vigorous contraceptive programme. Sprensenbühlstrasse
10
(Apt 2),
CH-80 32 Zürich, Switzerland
FRANZ PERABO
Shackleton
Department of Anaesthetics, Southampton General Hospital, Southampton SO9 4XY
JAMES M. B. BURN TOTAL ALLERGY SYNDROME
PRIVATE DRUG ADDICTION TREATMENT
SIR,-I write in support of your Jan. 9 editorial noting the epidemic of private involvement in the management of drug addiction in Britain. Though currently training in the National Health Service, to which I am an unashamed convert, I would staunchly defend the general right to private medical practice, which is so prevalent in my native Australia. However, my short experience in one of the London drug dependence clinics has convinced me of the pitfalls in private treatment of drug addiction. Let me cite the example of two of my young male patients, both unemployed, who have recently left the clinic for the lure of amphetamine-like drugs and excessive injectable methadone. Neither has the means to pay the 20 or so for weekly attendance, plus DO-20 for dispensing of the script. One of them was honest enough to admit that the payment would either come from stealing or selling his drugs. One retail pharmacist has confided to me his unease at dispensing injectable methadone, prescribed by a private doctor, that he had no doubt was immediately entering the black market.
Though some would claim that they are undermining the opiate black market by their private prescription, I would argue that, when this occurs in an unmonitored fashion, in a significant proportion of patients criminal activity is encouraged. This ignores the medical complications of unwarranted amphetamine-like agents or parenteral methadone. In the treatment of opiate addiction prescription of methadone must be restricted to the clinics or licensing of its prescription must be enforced. We cannot be satisfied with the status quo. St George’s Hospital, London SW17 0QT
P. B. MITCHELL
DIARRHOEAL DISEASES CONTROLLED: WHAT THEN?
SIR,-In your Round the World column of Feb. 13 your Geneva correspondent refers to the W.H.O. Executive Board’s discussions of progress in two ofW.H.O.’s special programmes, the diarrhoeal diseases control programme and the expanded programme on immunisation. He reports that: "Progress in the reduction of infant mortality from diarrhoeal disease in developing countries has already been achieved by the widespread provision of oral rehydration salts. The programme is geared to rapid expansion and has wide support in developing countries".
SIR,-I have been interested in the recent correspondence on the total allergy syndrome. My experience with this clinical situation is limited to one girl now aged 15 years. From my point of view her main clinical problem is atopic eczema. Recently I reached a therapeutic impasse in that every ointment I used was said to sting her skin, and virtually all oral medication was rejected because the patient was adamant that she was also allergic to tablets. Most common foods were also rejected for the same reason. During an inpatient stay it became apparent that this very anxious girl had globus hystericus shortly after almost anything was placed in her mouth. This symptom, together with the attendant panic, was interpreted by the patient and her family as indicating allergy to whatever was in her mouth. Other hysterical symptoms have
subsequently developed, including a left-sided hemiparesis. The alleged allergies are used, now largely subconsciously, by both the patient and her family to avoid difficult situations, such as school. I am worried that this girl may acquire frank anorexia nervosa, rationalised in terms of the so-called "total allergy syndrome". Whilst one swallow does not make a summer, I feel it is important to investigate this symptom complex, if only to prevent other susceptible females playing a very hard and expensive game of allergyl with their doctors and with society. Dermatology Department, General Infirmary at Leeds, Leeds LS1 3EX
J. A. COTTERILL
SIR,-The "total allergy syndrome", commented upon by Dr Nixon (Feb. 13, p. 404) and Dr Lum (Feb. 27, p. 516) is very rare, if, indeed, it exists. It is thus open to a myriad of interpretationsincluding fluctuating hypocarbia (to which your correspondents allude) and, much more obviously, hysterical manipulation. Recent articles in the newspapers, lay and medical,2 have encouraged belief in an organic (e.g., allergic) aetiology for the condition, another interesting example of the hold that clinical ecology has today. Not only journalists, however, but also general practitioners, paediatricians, and psychiatrists have been espousing this fringe approach. One must be very careful to exclude classical psychiatric diseases such as anorexia nervosa or personality disorder. As far as I know, no-one has demonstrated an organic aetiology for this condition. 1 Cctterill JA. Dermatological games. Br J Dermatol 1981; 105: 311. 2. Cousins J Cold shoulder. Hosp Doctor, Feb. 11, 1982: 8.
About 25% of those attending the new hospital have their regular sessions in other hospitals in the city, and this would apply wherever the hospital were situated in Southampton. With the current unemployment of junior doctors, the provision of five additional posts, with the opportunity of studying for examinations concurrently, must be an attractive proposition. I would also question the accuracy of the statement that the hospital would "not be bound by national wage agreements" since I understand that, as in most independent hospitals, the wages paid to nurses, radiographers, and so on are precisely the same as the Whitley scales for equivalent staff in the N.H.S., so there is no question of "bribing" such staff to leave. There may indeed be an element of competition with the N.H.S., but this might be highly beneficial to the N.H.S.; it could induce it to be more flexible in its conditions of employment and to provide better facilities for its employees. The geographical situation of the hospital-which, after all, is what concerns the planners-would seem to be ideal. Its proximity to the Southampton General Hospital will save considerable time, which might otherwise be wasted in travelling, for most staff attending there. I would have thought that for a hospital of the size proposed, the main considerations for the local planning officers were just those mentioned; their brief does not include the political merits or demerits of private medicine.
In your Jan. 9 editorial on population you noted that food produc. tion in the developing countries is just keeping pace with population growth. If the growth of population is not consciously controlled by the widespread use of modern contraceptive techniques, it will be controlled ultimately by famine, pestilence, and war, as Malthus
predicted. Who feeds and educates those thousands of children whose life has been saved by the simple and low cost techniques of oral rehydration? Experience in Third World countries shows that parents do not stop procreation when more children than expected survive. If these children cannot be taken care of they only die a little later. What is the use of a diarrhoeal diseases programme that has not been designed in a holistic way-i.e., to include the necessary supportive measures for survival? The programme will end in another pyrrhic victory for modern medicine. What happens when the programme succeeds in areas where food, housing, education, and health care can be provided in more or less adequate and acceptable ways, as for instance in the slums of the fast-growing cities of the developing countries? There will be a considerable additional increase of population-unless the diarrhoeal diseases control programme is accompanied by a vigorous contraceptive programme. Sprensenbühlstrasse
10
(Apt 2),
CH-80 32 Zürich, Switzerland
FRANZ PERABO
Shackleton
Department of Anaesthetics, Southampton General Hospital, Southampton SO9 4XY
JAMES M. B. BURN TOTAL ALLERGY SYNDROME
PRIVATE DRUG ADDICTION TREATMENT
SIR,-I write in support of your Jan. 9 editorial noting the epidemic of private involvement in the management of drug addiction in Britain. Though currently training in the National Health Service, to which I am an unashamed convert, I would staunchly defend the general right to private medical practice, which is so prevalent in my native Australia. However, my short experience in one of the London drug dependence clinics has convinced me of the pitfalls in private treatment of drug addiction. Let me cite the example of two of my young male patients, both unemployed, who have recently left the clinic for the lure of amphetamine-like drugs and excessive injectable methadone. Neither has the means to pay the 20 or so for weekly attendance, plus DO-20 for dispensing of the script. One of them was honest enough to admit that the payment would either come from stealing or selling his drugs. One retail pharmacist has confided to me his unease at dispensing injectable methadone, prescribed by a private doctor, that he had no doubt was immediately entering the black market.
Though some would claim that they are undermining the opiate black market by their private prescription, I would argue that, when this occurs in an unmonitored fashion, in a significant proportion of patients criminal activity is encouraged. This ignores the medical complications of unwarranted amphetamine-like agents or parenteral methadone. In the treatment of opiate addiction prescription of methadone must be restricted to the clinics or licensing of its prescription must be enforced. We cannot be satisfied with the status quo. St George’s Hospital, London SW17 0QT
P. B. MITCHELL
DIARRHOEAL DISEASES CONTROLLED: WHAT THEN?
SIR,-In your Round the World column of Feb. 13 your Geneva correspondent refers to the W.H.O. Executive Board’s discussions of progress in two ofW.H.O.’s special programmes, the diarrhoeal diseases control programme and the expanded programme on immunisation. He reports that: "Progress in the reduction of infant mortality from diarrhoeal disease in developing countries has already been achieved by the widespread provision of oral rehydration salts. The programme is geared to rapid expansion and has wide support in developing countries".
SIR,-I have been interested in the recent correspondence on the total allergy syndrome. My experience with this clinical situation is limited to one girl now aged 15 years. From my point of view her main clinical problem is atopic eczema. Recently I reached a therapeutic impasse in that every ointment I used was said to sting her skin, and virtually all oral medication was rejected because the patient was adamant that she was also allergic to tablets. Most common foods were also rejected for the same reason. During an inpatient stay it became apparent that this very anxious girl had globus hystericus shortly after almost anything was placed in her mouth. This symptom, together with the attendant panic, was interpreted by the patient and her family as indicating allergy to whatever was in her mouth. Other hysterical symptoms have
subsequently developed, including a left-sided hemiparesis. The alleged allergies are used, now largely subconsciously, by both the patient and her family to avoid difficult situations, such as school. I am worried that this girl may acquire frank anorexia nervosa, rationalised in terms of the so-called "total allergy syndrome". Whilst one swallow does not make a summer, I feel it is important to investigate this symptom complex, if only to prevent other susceptible females playing a very hard and expensive game of allergyl with their doctors and with society. Dermatology Department, General Infirmary at Leeds, Leeds LS1 3EX
J. A. COTTERILL
SIR,-The "total allergy syndrome", commented upon by Dr Nixon (Feb. 13, p. 404) and Dr Lum (Feb. 27, p. 516) is very rare, if, indeed, it exists. It is thus open to a myriad of interpretationsincluding fluctuating hypocarbia (to which your correspondents allude) and, much more obviously, hysterical manipulation. Recent articles in the newspapers, lay and medical,2 have encouraged belief in an organic (e.g., allergic) aetiology for the condition, another interesting example of the hold that clinical ecology has today. Not only journalists, however, but also general practitioners, paediatricians, and psychiatrists have been espousing this fringe approach. One must be very careful to exclude classical psychiatric diseases such as anorexia nervosa or personality disorder. As far as I know, no-one has demonstrated an organic aetiology for this condition. 1 Cctterill JA. Dermatological games. Br J Dermatol 1981; 105: 311. 2. Cousins J Cold shoulder. Hosp Doctor, Feb. 11, 1982: 8.