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NEW METHOD OF PHENOBARBITONE ADMINISTRATION
1022
While it seems paradoxical that sodium deficiency should produce thirst, it nevertheless seems to do soj 2 if thirst is defined as a desire for water.-ED. L. NEW METHOD OF PHENOBARBITONE ADMINISTRATION
SlR,—I find it difficult to understand the letters written by Dr. Pearson (April 19) and Dr. Penman (March 29). Dr. Penman states in his opening sentence that " no conclusion whatever can be drawn from the data presented by Dr. O’Connor last week ". Dr. Pearson writes that " I cannot agree that Dr. O’Connor has really
demonstrated anything ". It appears to me that Dr. O’Connor has demonstrated that when he treated 18 cases of epilepsy with the longacting phenobarbitone ’Spansules ’, he virtually cured all the patients he treated. On re-reading Dr. O’Connor’s article, I agree that it is open to criticism in many ways. Nevertheless, if we are to believe what he has written, he has shown that with this long-acting phenobarbitone therapy a method has been suggested which may be of great value in the treatment of epilepsy. His work may have been uncontrolled, but he has still demonstrated, even if only as a clinical observation, that all the cases he treated improved to such an extent that the results are really striking. These results surely should not be ignored, even though he cannot explain them satisfactorily. Dr. O’Connor has produced enough evidence to stimulate a trial of delayed-absorption phenobarbitone in epilepsy by others. H. N. LEVITT.
SiR,-In
INDIRECT BILIRUBINÆMIA your issue of April 19, Dr. Schmid and his
colleagues comment on our recent report dealing with the reduction of indirect bilirubinsemia. They state that they have not been able to duplicate our results; they suggest that we may be doing harm by driving bilirubin from the blood to the tissues, increasing the risk of brain damage; and they urge all to desist from this therapy until further pharmacodynamic studies of glucuronic acid are carried out. It goes without saying that all new drugs should be thoroughly tested before clinical use and that they should not be used without due information in regard to their pharmacodynamic action. We might point out, however, that glucuronic acid, although not previously used for this particular purpose, is by no means a new drug. It has been known for two generations and its safe and toxic levels are documented.3 There are numerous references dealing with its administration to experimental animals and to man. Our critics do not document the basis of their expressed fear that by lowering the blood-bilirubin we are driving it into the tissues. We have not, to be sure, taken biopsies of the brain before and after glucuronic-acid therapy, but we have observed a diminution of jaundice and biopsies of the subcutaneous fat have shown a reduction in indirect bilirubin coincident with the fall in blood levels. It would seem that the discrepancy between the results of the Boston workers and our own may be explained by differences in technique. This matter is now being explored. It would seem to us unfortunate if the concern 1.
Cizek, L. J., Semple, R. E., Huang, K. C., Gregersen, Physiol. 1951, 164, 415.
M. I. Amer.
2. Strauss, M. B. Arch. intern. Med. 1958, 101, 216. 3. Artz, N. E., Osman, E. M. Biochemistry of Glucuronic Acid. New 1950.
J.
York,
of our Boston colleagues were to result in discontinuance of further studies with this promising therapeutic
approach. New York University College of Medicine.
STUART DANOFF CHARLOTTE GRANTZ AUDREY BOYER L. EMMETT HOLT, JR.
THE ROYAL COMMISSION AND RESTORATION OF GENERAL PRACTICE SIR,-Lord Moran, in his evidence to the Royal Commission in January, pictured a professional ladder, consultants on the rungs and general practitioners at its foot, pay corresponding. A "little later, in The Lancet (Jan. 25, p. 216), he wrote of the very high standard of general practice" as he had known it ". That the family what he used to be ", coming from a doctor is not medical authority and at a time of reduced public leading amounts to a professional calamity. The following esteem, brief study serves to show that there is sufficient underlying cause for impaired service in the bad conditions of work in general practice.. Until these defects are remedied by the Ministry of Health it is imprudent to impugn the professional ability of the doctors. During the strain of war, the work of general practitioners was a decisive factor in maintaining national physique and morale. Doctors are due to share in the benefits of victory; but the Government leaves them with antiquated machinery to carry on, as best they can, waging their unceasing war against disease and suffering in the community. To strike for better conditions is, naturally, rather repugnant to them as it would cause some -interruption in the treatment of their patients. Conditions in General Practice The inherent difficulties of day-to-day practice are daunting enough. The doctor’s patients are " on his doorstep " or have to be visited in the vicinity. Calls come any time, day or night, and epidemics upset his routine and deprive him of his rest. Whatever the ailment, it has to be diagnosed, the patient satisfied and anxious relatives coped with. Such duties call for all the virtues, a wearing business. A haggling and cheeseparing attitude on the part of the Government towards them is likely to intensify the present grievance of general practitioners. The bad conditions in practice have persisted since the 1948 Act owing to the complacency of the authorities. They involve patients in avoidable suffering and act as a damper on professional zeal and enterprise. Among glaring examples is the permission of too high a maximum number of patients. This danger is all the greater when modern aids to effective treatment go unprovided. These ancillaries should at least equal standards current in commerce. Technical and secretarial assistance as well as up-to-date equipment are wanted. Time for due deliberation is an indispensable ingredient of successful clinical work; and this truth is endorsed by Sir Hugh Watson speaking" at and as a member of the Commissionwhen he said, Assuming that they have the time to do it ?" These words reveal a layman’s uneasiness about the harassed doctor. Finally, to gain its ideal objective, the cultivation of a healthy nation, not merely to alleviate disease, the Ministry needs to recognise that general practice is the proper and effective agency. Only the family doctor has access to the intimacies of family life and his instruction on simple principles of the care of the body will be acceptable to parents. The population is now sufficiently educated to cooperate. If the Ministry will include this provision in their functions, it will at last be justified in calling itself a National Health service. The cost will be repaid by the gradual elimination of the huge expenditure on sickness benefits and on drugs at present required owing to ignorant abuse of the human body. 1. Brit. med.
J. Jan. 25, 1958, suppl, p. 31.
While it seems paradoxical that sodium deficiency should produce thirst, it nevertheless seems to do soj 2 if thirst is defined as a desire for water.-ED. L. NEW METHOD OF PHENOBARBITONE ADMINISTRATION
SlR,—I find it difficult to understand the letters written by Dr. Pearson (April 19) and Dr. Penman (March 29). Dr. Penman states in his opening sentence that " no conclusion whatever can be drawn from the data presented by Dr. O’Connor last week ". Dr. Pearson writes that " I cannot agree that Dr. O’Connor has really
demonstrated anything ". It appears to me that Dr. O’Connor has demonstrated that when he treated 18 cases of epilepsy with the longacting phenobarbitone ’Spansules ’, he virtually cured all the patients he treated. On re-reading Dr. O’Connor’s article, I agree that it is open to criticism in many ways. Nevertheless, if we are to believe what he has written, he has shown that with this long-acting phenobarbitone therapy a method has been suggested which may be of great value in the treatment of epilepsy. His work may have been uncontrolled, but he has still demonstrated, even if only as a clinical observation, that all the cases he treated improved to such an extent that the results are really striking. These results surely should not be ignored, even though he cannot explain them satisfactorily. Dr. O’Connor has produced enough evidence to stimulate a trial of delayed-absorption phenobarbitone in epilepsy by others. H. N. LEVITT.
SiR,-In
INDIRECT BILIRUBINÆMIA your issue of April 19, Dr. Schmid and his
colleagues comment on our recent report dealing with the reduction of indirect bilirubinsemia. They state that they have not been able to duplicate our results; they suggest that we may be doing harm by driving bilirubin from the blood to the tissues, increasing the risk of brain damage; and they urge all to desist from this therapy until further pharmacodynamic studies of glucuronic acid are carried out. It goes without saying that all new drugs should be thoroughly tested before clinical use and that they should not be used without due information in regard to their pharmacodynamic action. We might point out, however, that glucuronic acid, although not previously used for this particular purpose, is by no means a new drug. It has been known for two generations and its safe and toxic levels are documented.3 There are numerous references dealing with its administration to experimental animals and to man. Our critics do not document the basis of their expressed fear that by lowering the blood-bilirubin we are driving it into the tissues. We have not, to be sure, taken biopsies of the brain before and after glucuronic-acid therapy, but we have observed a diminution of jaundice and biopsies of the subcutaneous fat have shown a reduction in indirect bilirubin coincident with the fall in blood levels. It would seem that the discrepancy between the results of the Boston workers and our own may be explained by differences in technique. This matter is now being explored. It would seem to us unfortunate if the concern 1.
Cizek, L. J., Semple, R. E., Huang, K. C., Gregersen, Physiol. 1951, 164, 415.
M. I. Amer.
2. Strauss, M. B. Arch. intern. Med. 1958, 101, 216. 3. Artz, N. E., Osman, E. M. Biochemistry of Glucuronic Acid. New 1950.
J.
York,
of our Boston colleagues were to result in discontinuance of further studies with this promising therapeutic
approach. New York University College of Medicine.
STUART DANOFF CHARLOTTE GRANTZ AUDREY BOYER L. EMMETT HOLT, JR.
THE ROYAL COMMISSION AND RESTORATION OF GENERAL PRACTICE SIR,-Lord Moran, in his evidence to the Royal Commission in January, pictured a professional ladder, consultants on the rungs and general practitioners at its foot, pay corresponding. A "little later, in The Lancet (Jan. 25, p. 216), he wrote of the very high standard of general practice" as he had known it ". That the family what he used to be ", coming from a doctor is not medical authority and at a time of reduced public leading amounts to a professional calamity. The following esteem, brief study serves to show that there is sufficient underlying cause for impaired service in the bad conditions of work in general practice.. Until these defects are remedied by the Ministry of Health it is imprudent to impugn the professional ability of the doctors. During the strain of war, the work of general practitioners was a decisive factor in maintaining national physique and morale. Doctors are due to share in the benefits of victory; but the Government leaves them with antiquated machinery to carry on, as best they can, waging their unceasing war against disease and suffering in the community. To strike for better conditions is, naturally, rather repugnant to them as it would cause some -interruption in the treatment of their patients. Conditions in General Practice The inherent difficulties of day-to-day practice are daunting enough. The doctor’s patients are " on his doorstep " or have to be visited in the vicinity. Calls come any time, day or night, and epidemics upset his routine and deprive him of his rest. Whatever the ailment, it has to be diagnosed, the patient satisfied and anxious relatives coped with. Such duties call for all the virtues, a wearing business. A haggling and cheeseparing attitude on the part of the Government towards them is likely to intensify the present grievance of general practitioners. The bad conditions in practice have persisted since the 1948 Act owing to the complacency of the authorities. They involve patients in avoidable suffering and act as a damper on professional zeal and enterprise. Among glaring examples is the permission of too high a maximum number of patients. This danger is all the greater when modern aids to effective treatment go unprovided. These ancillaries should at least equal standards current in commerce. Technical and secretarial assistance as well as up-to-date equipment are wanted. Time for due deliberation is an indispensable ingredient of successful clinical work; and this truth is endorsed by Sir Hugh Watson speaking" at and as a member of the Commissionwhen he said, Assuming that they have the time to do it ?" These words reveal a layman’s uneasiness about the harassed doctor. Finally, to gain its ideal objective, the cultivation of a healthy nation, not merely to alleviate disease, the Ministry needs to recognise that general practice is the proper and effective agency. Only the family doctor has access to the intimacies of family life and his instruction on simple principles of the care of the body will be acceptable to parents. The population is now sufficiently educated to cooperate. If the Ministry will include this provision in their functions, it will at last be justified in calling itself a National Health service. The cost will be repaid by the gradual elimination of the huge expenditure on sickness benefits and on drugs at present required owing to ignorant abuse of the human body. 1. Brit. med.
J. Jan. 25, 1958, suppl, p. 31.