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"A LITTLE SOMETHING BETWEEN MEALS": MASKED ADDICTION NOT LOW BLOOD-SUGAR
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grouping 3.8litres (standardised to mean height) shown in the table certainly reflects high-normal lung function. The table shows that in each F.E.v.l class, the yearly incidence of hard C.H.D. was related to lifetime total number of cigarettes smoked (current cigarette smoking showed clearly the same relationship); in the high-normal F.E.V.! class, the increased incidence with heavier smoking was highly significant. A multivariate analysis of risk factors, making use of an exponential model which takes account of differences in follow-up,4 revealed that number of cigarettes (t=4.5, P<0.0001), cholesterol (t=4.3, P<0.0001), and systolic bloodwere significantly related to incipressure (t=2.3, P<0.05) dence of hard C.H.D. whereas F.E.v., (t=0.1) was not. Another study5-which reported an association between lung function and hard C.H.D. dealt with subjects aged .24-84, some with other chronic diseases including angina pectoris, but cigarette smoking was still a more important risk factor. It seems clear that, in the context of at least one important disease associated with cigarette smoking, the direct effect of smoking is more significant than any indirect effect via reduced lung function. This conclusion may not hold in older subjects where cigarette smoking has not been found to be strongly related to C.H.D. deaths.6 This work was supported by le Groupe d’Etude sur 1’Epidemiologie de l’Athérosc1érose a joint venture of l’Institut National de la Sante et de la Recherche Médicale (INSERM) and the Prefecture de Paris, with a grant from the French Ministrv of Health. -
INSERM Unit 169, 94800 Villejuif, France
JULIA
B. ZALOKAR
"A LITTLE SOMETHING BETWEEN MEALS": MASKED ADDICTION NOT LOW BLOOD-SUGAR
Marks and Rose’ call attention to the "vague symptoms of discomfort, irritability, tenseness, mental vagueness and inability to concentrate, which are frequently expressed, even by normal a meal, particularly afternoon tea or people when they miss " morning ’elevenses.’ These symptoms, "though not generally recognizable as being due to hunger, are relieved by food". They are not properly termed "hypoglycaemic", since "the concentration of glucose in the blood is not abnormally low at a time when symptoms are present, nor like hunger, are they relieved by intravenously administered glucose", and "there is at present no satisfactory explanation". This mystery may be solved by reference to the literature on food allergy-specifically, Rinkel’s concept of masked food allergy2 and Randolph’s concept of stimulatory and withdrawal levels of ecological disturbance.3 Masked addiction to commonly and frequently ingested foods may be suspected when similar symptoms occur upon failure to consume them regularly. Moreover, the foods most usually consumed at tea and for "elevenses"-milk, white flour, coffee, tea, and sugar-are amongst those most often found to cause masked addictions. The symptoms described by Marks and Rose represent various (- to - - - in Randolph’s terminology) withdrawal levels of response in ecologically maladapted individuals, and the "lift" which constitutes one of people’s main motivations to partake of mid-meal breaks represents a + level stimulatory reaction following re-exposure to the addictant(s).
SIR,-In their classic monograph
on
hypoglycsemia.
VICKY RIPPERE
Lellouch, J., Rakotovao, R. Rev. Epidémiol. Santé publ. 1976, 24, 123. Friedman, G. D., Klatsky, A. L., Siegelaub, A. B. New Engl. J. Med. 1976, 294, 1071. 6 Gordon, T., Castelli, W. P., Hjortland, M. C., Kannel, W. B., Dawber, T. R. J. Am. med. Ass. 1977, 238, 497. 1. Marks, V., Rose, F. C. Hypoglycæmia. Oxford, 1965. 4. 5.
Illinois, 1976.
THE ENGLISH-SPEAKING WORLD
SiR,—In 1972 the Conference of Surgical Colleges met in Cape Town, and later in Ottawa and Chicago. These meetings remarkable. For the first time the American College of Surgeons, represented by its President, joined the Colleges of England, Edinburgh, Glasgow, Ireland, Australasia, Canada, and South Africa and played a full part in the discussions and decisions, the main topic being training for a career in surgery. Not only was there a very great measure of agreement upon all important matters but also the future appeared bright, with the representatives from all Colleges speaking of the value of unity and looking forward to an increasing measure of intercollegiate cooperation. For several years afterwards the pattern had been set and the wish of the Colleges to work together governed educational debates and the designing of training were
programmes and examinations. But now-what has gone wrong? What has happened to all these good intentions? Everywhere one looks, the spectacle of this surgical college or that taking a decision in isolation, even at times in defiance, of the views of other colleges catches the eye: "do it our way" is the cry on all sides "or let us abandon
unity as an objective". Another meeting of the Conference of Surgical Colleges is planned for October of this year. We urge those who represent their Colleges to attend it determined to find again that earlier spirit of unity which, if not lost, has at least been temporarily mislaid. The combined wisdom and experience of the Colleges represented can lead the surgical world, provided the influence of the Conference is exercised as a single unit and that the Colleges of which it is composed are seen to be in cooperation rather than competition. HEDLEY ATKINS, Past-president, R.C.S. England JOHN MCAULIFFE CURTIN, Past-president, R.C.S.I. FRANK DUFF, Past-president, R.C.S.I.
J. ENGLEBERT DUNPHY, Past-president, A.C.S.
EDWARD HUGHES, Past-president, R.A.C.S. WILLIAM LONGMIRE, Past-president, A.C.S.
BROCK, Past-president,
R.C.S.
CHARLES
England
DRAKE,
Past-president, R.C.P.S. Canada GEORGE DUNLOP, Past-president, A.C.S. D. J. DUPLESSIS, Past-president, College of Medicine, South Africa ANDREW WATT
KAY,
Past-president, R.C.P.S. Glasgow
JANNIE LOUW, Past-president, College of Medicine, South Africa
STANLEY
MCCOLLUM,
Past-president, R.C.S.I.
HARRY
Past-president,
PORRITT,
R.
PLATT,
R.C.S.
England
SALTER,
Past-president, R.C.S. England Past-president, R.C.P.S. Canada THOMAS HOLMES SELLORS, SMITH, Past-president, R.C.S. England Past-president, R.C.S. England CLAUDE WELCH, FRANK STINCHFIELD, Past-president, A.C.S. Past-president, A.C.S. ROBERT WRIGHT, Past-president, R.C.P.S. Glasgow
GENERAL PRACTITIONER AS GENERAL PHYSICIAN
Department of Psychology, Institute of Psychiatry, London, SE5 8AF.
2. Rinkel, H. J. Ann. Allergy, 1944, 2, 115. 3. Randolph, T. G. in Clinical Ecology (edited by
COOPERATION AMONG SURGICAL COLLEGES IN
L. D.
Dickey). Springfield,
SIR The iconclasm of Dr Lefever (May 26, p. 1133) makes me feel like saying that if he wishes to see lots of major illness for a low income, there are plenty of mission hospitals in the Third World where he could do just that. Equally it may be that he hankers after North American general practice where patients with British type minor illnesses get the hospital type works-for the doctor’s protection and to make a large fee seem worthwhile. However, many doctors in the U.K. still have an altruistic attitude, and Lefever is not alone in
grouping 3.8litres (standardised to mean height) shown in the table certainly reflects high-normal lung function. The table shows that in each F.E.v.l class, the yearly incidence of hard C.H.D. was related to lifetime total number of cigarettes smoked (current cigarette smoking showed clearly the same relationship); in the high-normal F.E.V.! class, the increased incidence with heavier smoking was highly significant. A multivariate analysis of risk factors, making use of an exponential model which takes account of differences in follow-up,4 revealed that number of cigarettes (t=4.5, P<0.0001), cholesterol (t=4.3, P<0.0001), and systolic bloodwere significantly related to incipressure (t=2.3, P<0.05) dence of hard C.H.D. whereas F.E.v., (t=0.1) was not. Another study5-which reported an association between lung function and hard C.H.D. dealt with subjects aged .24-84, some with other chronic diseases including angina pectoris, but cigarette smoking was still a more important risk factor. It seems clear that, in the context of at least one important disease associated with cigarette smoking, the direct effect of smoking is more significant than any indirect effect via reduced lung function. This conclusion may not hold in older subjects where cigarette smoking has not been found to be strongly related to C.H.D. deaths.6 This work was supported by le Groupe d’Etude sur 1’Epidemiologie de l’Athérosc1érose a joint venture of l’Institut National de la Sante et de la Recherche Médicale (INSERM) and the Prefecture de Paris, with a grant from the French Ministrv of Health. -
INSERM Unit 169, 94800 Villejuif, France
JULIA
B. ZALOKAR
"A LITTLE SOMETHING BETWEEN MEALS": MASKED ADDICTION NOT LOW BLOOD-SUGAR
Marks and Rose’ call attention to the "vague symptoms of discomfort, irritability, tenseness, mental vagueness and inability to concentrate, which are frequently expressed, even by normal a meal, particularly afternoon tea or people when they miss " morning ’elevenses.’ These symptoms, "though not generally recognizable as being due to hunger, are relieved by food". They are not properly termed "hypoglycaemic", since "the concentration of glucose in the blood is not abnormally low at a time when symptoms are present, nor like hunger, are they relieved by intravenously administered glucose", and "there is at present no satisfactory explanation". This mystery may be solved by reference to the literature on food allergy-specifically, Rinkel’s concept of masked food allergy2 and Randolph’s concept of stimulatory and withdrawal levels of ecological disturbance.3 Masked addiction to commonly and frequently ingested foods may be suspected when similar symptoms occur upon failure to consume them regularly. Moreover, the foods most usually consumed at tea and for "elevenses"-milk, white flour, coffee, tea, and sugar-are amongst those most often found to cause masked addictions. The symptoms described by Marks and Rose represent various (- to - - - in Randolph’s terminology) withdrawal levels of response in ecologically maladapted individuals, and the "lift" which constitutes one of people’s main motivations to partake of mid-meal breaks represents a + level stimulatory reaction following re-exposure to the addictant(s).
SIR,-In their classic monograph
on
hypoglycsemia.
VICKY RIPPERE
Lellouch, J., Rakotovao, R. Rev. Epidémiol. Santé publ. 1976, 24, 123. Friedman, G. D., Klatsky, A. L., Siegelaub, A. B. New Engl. J. Med. 1976, 294, 1071. 6 Gordon, T., Castelli, W. P., Hjortland, M. C., Kannel, W. B., Dawber, T. R. J. Am. med. Ass. 1977, 238, 497. 1. Marks, V., Rose, F. C. Hypoglycæmia. Oxford, 1965. 4. 5.
Illinois, 1976.
THE ENGLISH-SPEAKING WORLD
SiR,—In 1972 the Conference of Surgical Colleges met in Cape Town, and later in Ottawa and Chicago. These meetings remarkable. For the first time the American College of Surgeons, represented by its President, joined the Colleges of England, Edinburgh, Glasgow, Ireland, Australasia, Canada, and South Africa and played a full part in the discussions and decisions, the main topic being training for a career in surgery. Not only was there a very great measure of agreement upon all important matters but also the future appeared bright, with the representatives from all Colleges speaking of the value of unity and looking forward to an increasing measure of intercollegiate cooperation. For several years afterwards the pattern had been set and the wish of the Colleges to work together governed educational debates and the designing of training were
programmes and examinations. But now-what has gone wrong? What has happened to all these good intentions? Everywhere one looks, the spectacle of this surgical college or that taking a decision in isolation, even at times in defiance, of the views of other colleges catches the eye: "do it our way" is the cry on all sides "or let us abandon
unity as an objective". Another meeting of the Conference of Surgical Colleges is planned for October of this year. We urge those who represent their Colleges to attend it determined to find again that earlier spirit of unity which, if not lost, has at least been temporarily mislaid. The combined wisdom and experience of the Colleges represented can lead the surgical world, provided the influence of the Conference is exercised as a single unit and that the Colleges of which it is composed are seen to be in cooperation rather than competition. HEDLEY ATKINS, Past-president, R.C.S. England JOHN MCAULIFFE CURTIN, Past-president, R.C.S.I. FRANK DUFF, Past-president, R.C.S.I.
J. ENGLEBERT DUNPHY, Past-president, A.C.S.
EDWARD HUGHES, Past-president, R.A.C.S. WILLIAM LONGMIRE, Past-president, A.C.S.
BROCK, Past-president,
R.C.S.
CHARLES
England
DRAKE,
Past-president, R.C.P.S. Canada GEORGE DUNLOP, Past-president, A.C.S. D. J. DUPLESSIS, Past-president, College of Medicine, South Africa ANDREW WATT
KAY,
Past-president, R.C.P.S. Glasgow
JANNIE LOUW, Past-president, College of Medicine, South Africa
STANLEY
MCCOLLUM,
Past-president, R.C.S.I.
HARRY
Past-president,
PORRITT,
R.
PLATT,
R.C.S.
England
SALTER,
Past-president, R.C.S. England Past-president, R.C.P.S. Canada THOMAS HOLMES SELLORS, SMITH, Past-president, R.C.S. England Past-president, R.C.S. England CLAUDE WELCH, FRANK STINCHFIELD, Past-president, A.C.S. Past-president, A.C.S. ROBERT WRIGHT, Past-president, R.C.P.S. Glasgow
GENERAL PRACTITIONER AS GENERAL PHYSICIAN
Department of Psychology, Institute of Psychiatry, London, SE5 8AF.
2. Rinkel, H. J. Ann. Allergy, 1944, 2, 115. 3. Randolph, T. G. in Clinical Ecology (edited by
COOPERATION AMONG SURGICAL COLLEGES IN
L. D.
Dickey). Springfield,
SIR The iconclasm of Dr Lefever (May 26, p. 1133) makes me feel like saying that if he wishes to see lots of major illness for a low income, there are plenty of mission hospitals in the Third World where he could do just that. Equally it may be that he hankers after North American general practice where patients with British type minor illnesses get the hospital type works-for the doctor’s protection and to make a large fee seem worthwhile. However, many doctors in the U.K. still have an altruistic attitude, and Lefever is not alone in