- Email: [email protected]
A CHEESE REACTION
561
crebrospina1 fluid remained abnormal with a fluctuating cell-coant for an unusually long time. This was a very instructive case which perhaps points out the importance of virus studies in acute diseases of the nervous systems.
Military Hospital, Colchester Essex.
H. FOSTER. A CHEESE REACTION
SIR,-Last September you published my letteron possible provocation of hypertensive attacks by the ingestion of cheese in patients under treatment with tranylcypromine. At that time I stated our view that it the
’
counsel all ! practitioners to advise their patients against eating cheese in these circumstances. Nevertheless we felt that the possibility should be carefully considered by doctors was
then premature and unscientific
to
’
prescribing tranylcypromine. Since that time we have received numerous additional clinical reports of the association, and our tentative hypothesis that tyramine present in certain cheeses might be the responsible sympathomimetic agent has received support from the metabolic study of Asatoor et awl. My colleague, Dr. I. L. Natoff, has demonstrated the role of tyramine and of certain cheeses in eliciting pressor responses in cats treated with tranylcypromine and other
monoamine-oxidase inhibitors. We feel that this work provides scientific confirmation for the clinical observations. For the past few months, on the strength of the latter, we have been warning in our prescribing information about this adverse reaction and adrising that eating cheese is contraindicated. This advice now has scientific as well as clinical support. I am grateful to all those who have provided clinical observations which have enabled us to investigate this problem and which indicated the need for additional exnerimental work. Smith Kline & French Laboratories Limited, Welwyn Garden City, Hertfordshire.
VARICOSE VEINS AND GRAVITATIONAL ULCERS SlR,-The correspondence about varicose veins encourages me to write about the method used here for treatment of gravitational ulcers. This relies on one essential detail which I have not yet seen mentioned in print or in discussion. The method is based on the view that gravitational ulcers owe their persistence entirely to faulty haemodynamics. This fault is corrected by encasing the leg in a glycerin/zinc-oxide bandage, and-here is the essential point-doing this when the leg is at its minimal distension. In practice this means that it must only be done in the patient’s home before he has got out of bed in the morning, and after he has in addition had the leg elevated, for at least half an hour, above the level of the body. Bo additional dressing is needed for the ulcer area, which heals remarkably quickly. The patient is up and about, and :he bandage is changed after ten to fourteen days. I ask only one thing-will some manufacturer provide " an elastic stocking with a suitable flat znicroZipp ’ :asttner"" to enable a well-fitting stocking to be put on ’.’.’rhout a struggle ?? Andover.
"
wilderness. Yet it would be so easy to marry the undertrained doctor to the understaffed peripheral hospital-by means of a sort of postregistration circuit-something like the rotating internship which it could follow. This circuit could be a planned series of posts automatically following each other which would cover in turn all the major branches of one’s subject. Ideally the circuit would start at postregistration-houseman grade and end at registrar grade at the central hospital of the group or area-preferably a teaching hospital. The sandwich would be filled with a succession of short jobs, on circuit, at peripheral hospitals associated with the central hospital. A circuit lasting, say, two years could provide a great number of doctors with the same sort of general experience (and a job at their own hospital) that only a handful now get in a longer period. It would solve the staffing problems of a lot of peripheral hospitals; and it would end for young doctors the twice-yearly convulsion when we all crawl from one job to the next like hermit crabs, secure only until we outgrow our shells in six months’ time. Would some teaching hospital please consider it ?
J. C. P. WEBER.
-ED. L.
1 W eber,
SIR,-Most of my contemporaries, who qualified in 1960, would, I believe, welcome Sir Charles Illingworth’s suggestions for improving medical education (Feb. 8). Very few of those I have spoken to feel satisfied with their training either before or after qualifying. In particular, postgraduate education, outside a few exclusive centres, desperately needs reorganising. In medicine, for example, it is very difficult to acquire a good general training. One gains experience where one can, in an uneconomical, unsystematic, haphazard manner. Inevitably, there are gaps in both training and earning. At the same time, vast amounts of superb teaching material go unexploited in the peripheral " hospitals. Few of us who want to become consultants in this country have the courage to accept a job at one of these hospitals. We would rather wait unemployed, for a short or long while, than commit professional suicide by going into the
London, W.1.
*** A Preliminary Communication from Dr. Natoff appears on p. 532; there are also papers from Dr. Cooper (p. 527) and Dr. Blackwell and Dr. Marley (p. 530); and the subject is discussed in a leading article on p. 540.
Derrydown Clinic, St Mary Bourne,
MEDICAL EDUCATION
JOHN W. EVANS.
J.C.P. Lancet, 1963, ii, 587. 2 Acatcor, A. M., Levi, A. J., Milne, M. D. ibid. p. 733.
NICHOLAS GROSS. INSULIN ANTIBODIES
SiR,-We have read with interest the results of Pav et al.l with the complement-consumption test, which point to the existence of antibodies against endogenous insulin. Using the same method, we investigated the sera of 100 healthy blood-donors and 103 diabetics, and our findings were:
Unlike Pav et al., we found no antibodies in the sera of the healthy blood-donors or the untreated diabetics. Antibodies were present only in 3 patients already treated with insulin. One of these patients had received 12 units of insulin during four months; one 48 units during five years, and one 56 units during four years. We must conclude that: (1) in our hands the complement-consumption test is not very sensitive for the detection of insulin antibodies; (2) antibodies are found only in subjects treated with insulin; and (3) the clinical significance of these antibodies is not clear. Department of Medicine, TH. W. M. VAN DE WIEL Hospital "De Goddelijke Voorzienigheid", H. VAN DE WIEL-DORFMEYER. Sittard, Holland. 1. Páv, J., Jezková, Z., Skrha, F. Lancet, 1963, ii, 221.
crebrospina1 fluid remained abnormal with a fluctuating cell-coant for an unusually long time. This was a very instructive case which perhaps points out the importance of virus studies in acute diseases of the nervous systems.
Military Hospital, Colchester Essex.
H. FOSTER. A CHEESE REACTION
SIR,-Last September you published my letteron possible provocation of hypertensive attacks by the ingestion of cheese in patients under treatment with tranylcypromine. At that time I stated our view that it the
’
counsel all ! practitioners to advise their patients against eating cheese in these circumstances. Nevertheless we felt that the possibility should be carefully considered by doctors was
then premature and unscientific
to
’
prescribing tranylcypromine. Since that time we have received numerous additional clinical reports of the association, and our tentative hypothesis that tyramine present in certain cheeses might be the responsible sympathomimetic agent has received support from the metabolic study of Asatoor et awl. My colleague, Dr. I. L. Natoff, has demonstrated the role of tyramine and of certain cheeses in eliciting pressor responses in cats treated with tranylcypromine and other
monoamine-oxidase inhibitors. We feel that this work provides scientific confirmation for the clinical observations. For the past few months, on the strength of the latter, we have been warning in our prescribing information about this adverse reaction and adrising that eating cheese is contraindicated. This advice now has scientific as well as clinical support. I am grateful to all those who have provided clinical observations which have enabled us to investigate this problem and which indicated the need for additional exnerimental work. Smith Kline & French Laboratories Limited, Welwyn Garden City, Hertfordshire.
VARICOSE VEINS AND GRAVITATIONAL ULCERS SlR,-The correspondence about varicose veins encourages me to write about the method used here for treatment of gravitational ulcers. This relies on one essential detail which I have not yet seen mentioned in print or in discussion. The method is based on the view that gravitational ulcers owe their persistence entirely to faulty haemodynamics. This fault is corrected by encasing the leg in a glycerin/zinc-oxide bandage, and-here is the essential point-doing this when the leg is at its minimal distension. In practice this means that it must only be done in the patient’s home before he has got out of bed in the morning, and after he has in addition had the leg elevated, for at least half an hour, above the level of the body. Bo additional dressing is needed for the ulcer area, which heals remarkably quickly. The patient is up and about, and :he bandage is changed after ten to fourteen days. I ask only one thing-will some manufacturer provide " an elastic stocking with a suitable flat znicroZipp ’ :asttner"" to enable a well-fitting stocking to be put on ’.’.’rhout a struggle ?? Andover.
"
wilderness. Yet it would be so easy to marry the undertrained doctor to the understaffed peripheral hospital-by means of a sort of postregistration circuit-something like the rotating internship which it could follow. This circuit could be a planned series of posts automatically following each other which would cover in turn all the major branches of one’s subject. Ideally the circuit would start at postregistration-houseman grade and end at registrar grade at the central hospital of the group or area-preferably a teaching hospital. The sandwich would be filled with a succession of short jobs, on circuit, at peripheral hospitals associated with the central hospital. A circuit lasting, say, two years could provide a great number of doctors with the same sort of general experience (and a job at their own hospital) that only a handful now get in a longer period. It would solve the staffing problems of a lot of peripheral hospitals; and it would end for young doctors the twice-yearly convulsion when we all crawl from one job to the next like hermit crabs, secure only until we outgrow our shells in six months’ time. Would some teaching hospital please consider it ?
J. C. P. WEBER.
-ED. L.
1 W eber,
SIR,-Most of my contemporaries, who qualified in 1960, would, I believe, welcome Sir Charles Illingworth’s suggestions for improving medical education (Feb. 8). Very few of those I have spoken to feel satisfied with their training either before or after qualifying. In particular, postgraduate education, outside a few exclusive centres, desperately needs reorganising. In medicine, for example, it is very difficult to acquire a good general training. One gains experience where one can, in an uneconomical, unsystematic, haphazard manner. Inevitably, there are gaps in both training and earning. At the same time, vast amounts of superb teaching material go unexploited in the peripheral " hospitals. Few of us who want to become consultants in this country have the courage to accept a job at one of these hospitals. We would rather wait unemployed, for a short or long while, than commit professional suicide by going into the
London, W.1.
*** A Preliminary Communication from Dr. Natoff appears on p. 532; there are also papers from Dr. Cooper (p. 527) and Dr. Blackwell and Dr. Marley (p. 530); and the subject is discussed in a leading article on p. 540.
Derrydown Clinic, St Mary Bourne,
MEDICAL EDUCATION
JOHN W. EVANS.
J.C.P. Lancet, 1963, ii, 587. 2 Acatcor, A. M., Levi, A. J., Milne, M. D. ibid. p. 733.
NICHOLAS GROSS. INSULIN ANTIBODIES
SiR,-We have read with interest the results of Pav et al.l with the complement-consumption test, which point to the existence of antibodies against endogenous insulin. Using the same method, we investigated the sera of 100 healthy blood-donors and 103 diabetics, and our findings were:
Unlike Pav et al., we found no antibodies in the sera of the healthy blood-donors or the untreated diabetics. Antibodies were present only in 3 patients already treated with insulin. One of these patients had received 12 units of insulin during four months; one 48 units during five years, and one 56 units during four years. We must conclude that: (1) in our hands the complement-consumption test is not very sensitive for the detection of insulin antibodies; (2) antibodies are found only in subjects treated with insulin; and (3) the clinical significance of these antibodies is not clear. Department of Medicine, TH. W. M. VAN DE WIEL Hospital "De Goddelijke Voorzienigheid", H. VAN DE WIEL-DORFMEYER. Sittard, Holland. 1. Páv, J., Jezková, Z., Skrha, F. Lancet, 1963, ii, 221.