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AN APPEAL FOR CHRISTMAS
510
Letters
to
dizziness, loss of energy, &c.
the Editor
AN APPEAL FOR CHRISTMAS SiB,—It is my privilege this year to ask you to submit to your readers the Christmas Gifts appeal which for so many years has been issued by the late Sir Thomas Barlow and so generously supported by the medical press., The Christmas Gifts appeal has a special significance this year; for, although peace has come, the material blessings which peace is supposed to bring are as yet merely dreams without substance. Food is monotonous and scarce ; fuel is terribly short and its cost fantastic ; clothing and prices generally are on the same high level, and even for those in fairly comfortable circumstances the outlook for the festive season is distinctly drab. Inevitably the burden of high prices and shortage falls most heavily on the poor, and for them there will be little money for celebrations of any sort this coming
Christmas. Last year there was collected a record sum of 31817, which was distributed as follows : 483 of our people each received a Christmas Gift of ;&bgr;3 at a cost of B1449 ; in addition we were able to give 184 of our poorest a further sum of jB2 each as a New Year’s gift, costing j3368. I feel that we must, if possible, do at least as much as last year, and indeed I am pleading for another record. If, for instance, subscriptions amounted to 22000, we should be able to give everybody a Christmas Gift of 24, and there would still be sufficient over to give some of the poorest an extra Bl. Is it too much to ask ? A very generous profession has already done so much, but my excuse is the hard times which still lie ahead. Believe me, the gratitude these gifts evoke is very great and often
extremely moving. Donations may be sent (marked " Christmas Gifts ") to the Secretary of the RMBF, who will gratefully acknowledge them. Royal Medical Benevolent Fund, ARNOLD LAWSON, 1, Balliol House, Manor Fields, Putney, SW15.
President.
HYPOPIESIA
SiB,—Perusal of Sir Maurice Cassidy’s rejoinder to my letter surprises in his abrupt dismissal of symptomproducing hypotension as a blood-pressure neurosis," and disappoints in the apparent bankruptcy of all idea on his part of any remedy. Presumably Sir Maurice believes that symptomatic hypotension exists only in the imagination of patient and doctor, so needs no treatment. It would be right to say that, amongst medical men, all the points he makes are common knowledge and an old story. Much of his letter is critically destructive, which doubtless he feels justifiably so, though it is just possible that his attitude towards the hypopietic may be wrong. Apart from the commonly associated neurasthenia shown by the hypotensive patient, his appearance and his several subjective symptoms indicate low bloodpressures, and in my view are distinctive enough ; circulatory mostly, never referable to the heart itself, and only needing confirmation by instrument. To withhold from the sufferer all information about his low-pressure readings does not rid him of these symptoms, which do in reality exist in some hypopietics though clearly not in all, most probably occurring with temporary falls in pressure. Does Sir Maurice deny that they happen at all, only to ignore them ; is reassurance the full of the treatment he would offer ? If so, there measure is cold comfort for the hypotensive subject who appeals to him for advice and guidance. To label hypopiesia merely a neurosis is to scoff at the patient for his complaints, to be blind to his symptoms, and to do literally nothing for him ; so seems to me rather more likely to perpetuate," not the admitted "
"
neurotic element, but the disorder with all its discomforts.
S. WATSON SMITH. SiB,—1 fear that not many cardiologists will agree with Sir Maurice Cassidy that hypopiesia is not an abnormal condition. After lowering the systolic pressure we found a decrease in cardiac output, impairment of renal function, &c. (Harris and Platt, Lancet, 1931, ii, 629). Indeed this type of patient frequently complains of Bournemouth.
The neurosis in these
cases
physical basis. Their end-results are of interest. Judging by my experience, which, however, is limited, hypotension predisposes to cerebral disease. Possibly some neurologist will tell us whether cerebral thrombosis is frequent in this condition. I have often seen hypotension turning into hypertension. It is clear that if a satisfactory method were available this condition ought to be treated. may
possibly
have
a
I. HARRIS.
Liverpool.
SIR,—Sir Maurice Uassidy criticised the letter ot Dr. Watson Smith " in order not to perpetuate " the opinion of a distinguished physician which he considers wrong. For the same reason I feel compelled to object to the opinion expressed by Sir Maurice. Our time-which is full of worries, fears, and dangers -can be regarded as a mass experiment in proof of my doctrine that arteriosclerosis develops from arterioatony, and that it does not represent a disease sui generis but is the means of healing the damage caused in the atonic arteries. As to the arterio-atony, it represents only a part of the general atony, whatever may be its cause, as I have always held (Lancet 1932, i, 385). Arterioatony is a state in which the subsequent development of the sclerosis can be forestalled by adequate treatment. Watson Smith in his letter gives the full classical description of general atony, but errs when he regards the hypopiesia as the cause rather than as a consequence. In Sir Maurice’s opinion it is a " a widespread delusion that a pressure of120 in a subject of forty to fifty is pathological and that in an individual of any age pressure of or below 110 calls for alarm and despondency." He maintains that " systolic pressures as low as 100 can and should be disregarded, and that on no account should the patient’s symptoms be attributed to them." I think that Sir Maurice’s doctrine, if followed, may be detrimental not only for the present but for the Mature fate of the patient. It may be that he shares the general opinion which regards high pressure as an alarming symptom. In my experience low pressure statistically involves more dangers and more serious complications than high blood-pressure. I am thinking here especially of the dangers of thrombosis and embolIn this point I believe every observant ism, cramps, &c. practitioner will agree with me. If hypopiesia is commoner today than in. previous decades the cause can easily be found in our disturbed times, and therefore the mass appearance must be The fact that atony mostly represents a psychogenic. " neurosis " does not entitle us to minimise its significance or to disregard its treatment. If Dr. Watson Smith has seen but little success from galenic treatment, I sadly agree with him. Other and more effective methods are tonics, like arsenic, different vitamins, and hydro-, climato-, and thalasso- therapies may help ; but a strong warning must be sounded against violent exercise which may suddenly increase the blood-pressure whereby the sluggish arterial wall with impaired resistance may be over-distended and injured. The arteries thus damaged later become sclerotic. I would not like to think so little of the application of the elastic belt recommended by Dr. Watson Smith as Sir Maurice Cassidy does. The belt may help the weakened circulation by supporting the abdominal wall. Because of the psychological origin of the hypopiesia, we may expect the greatest benefit from psychological treatment. A good drink, a good cigar, or a cup of strong coffee to eliminate the inhibitions of the tired brain ; a trip in cheerful company, a gay show or some
Hollywood
nonsense, to
distract the patient
from his sorrows and worries ; but most of all a holiday should be advised in the old Roman sense of otium:: full occupation of the patient by his hobby, by something different from his usual pursuits. J. PLESCH. London, Wl. THE " PERFECT AP "
SIR,-Dr. George Day writes in your issue of Oct. 6 that it came as’ a new idea to those present when, in 1935, Jacobeus reported to the Tuberculosis Association that with a person lying on his side the lower lung does more work than the upper lung. As a matter of fact, Mr. Cortlandt MacMahon made this observation during
Letters
to
dizziness, loss of energy, &c.
the Editor
AN APPEAL FOR CHRISTMAS SiB,—It is my privilege this year to ask you to submit to your readers the Christmas Gifts appeal which for so many years has been issued by the late Sir Thomas Barlow and so generously supported by the medical press., The Christmas Gifts appeal has a special significance this year; for, although peace has come, the material blessings which peace is supposed to bring are as yet merely dreams without substance. Food is monotonous and scarce ; fuel is terribly short and its cost fantastic ; clothing and prices generally are on the same high level, and even for those in fairly comfortable circumstances the outlook for the festive season is distinctly drab. Inevitably the burden of high prices and shortage falls most heavily on the poor, and for them there will be little money for celebrations of any sort this coming
Christmas. Last year there was collected a record sum of 31817, which was distributed as follows : 483 of our people each received a Christmas Gift of ;&bgr;3 at a cost of B1449 ; in addition we were able to give 184 of our poorest a further sum of jB2 each as a New Year’s gift, costing j3368. I feel that we must, if possible, do at least as much as last year, and indeed I am pleading for another record. If, for instance, subscriptions amounted to 22000, we should be able to give everybody a Christmas Gift of 24, and there would still be sufficient over to give some of the poorest an extra Bl. Is it too much to ask ? A very generous profession has already done so much, but my excuse is the hard times which still lie ahead. Believe me, the gratitude these gifts evoke is very great and often
extremely moving. Donations may be sent (marked " Christmas Gifts ") to the Secretary of the RMBF, who will gratefully acknowledge them. Royal Medical Benevolent Fund, ARNOLD LAWSON, 1, Balliol House, Manor Fields, Putney, SW15.
President.
HYPOPIESIA
SiB,—Perusal of Sir Maurice Cassidy’s rejoinder to my letter surprises in his abrupt dismissal of symptomproducing hypotension as a blood-pressure neurosis," and disappoints in the apparent bankruptcy of all idea on his part of any remedy. Presumably Sir Maurice believes that symptomatic hypotension exists only in the imagination of patient and doctor, so needs no treatment. It would be right to say that, amongst medical men, all the points he makes are common knowledge and an old story. Much of his letter is critically destructive, which doubtless he feels justifiably so, though it is just possible that his attitude towards the hypopietic may be wrong. Apart from the commonly associated neurasthenia shown by the hypotensive patient, his appearance and his several subjective symptoms indicate low bloodpressures, and in my view are distinctive enough ; circulatory mostly, never referable to the heart itself, and only needing confirmation by instrument. To withhold from the sufferer all information about his low-pressure readings does not rid him of these symptoms, which do in reality exist in some hypopietics though clearly not in all, most probably occurring with temporary falls in pressure. Does Sir Maurice deny that they happen at all, only to ignore them ; is reassurance the full of the treatment he would offer ? If so, there measure is cold comfort for the hypotensive subject who appeals to him for advice and guidance. To label hypopiesia merely a neurosis is to scoff at the patient for his complaints, to be blind to his symptoms, and to do literally nothing for him ; so seems to me rather more likely to perpetuate," not the admitted "
"
neurotic element, but the disorder with all its discomforts.
S. WATSON SMITH. SiB,—1 fear that not many cardiologists will agree with Sir Maurice Cassidy that hypopiesia is not an abnormal condition. After lowering the systolic pressure we found a decrease in cardiac output, impairment of renal function, &c. (Harris and Platt, Lancet, 1931, ii, 629). Indeed this type of patient frequently complains of Bournemouth.
The neurosis in these
cases
physical basis. Their end-results are of interest. Judging by my experience, which, however, is limited, hypotension predisposes to cerebral disease. Possibly some neurologist will tell us whether cerebral thrombosis is frequent in this condition. I have often seen hypotension turning into hypertension. It is clear that if a satisfactory method were available this condition ought to be treated. may
possibly
have
a
I. HARRIS.
Liverpool.
SIR,—Sir Maurice Uassidy criticised the letter ot Dr. Watson Smith " in order not to perpetuate " the opinion of a distinguished physician which he considers wrong. For the same reason I feel compelled to object to the opinion expressed by Sir Maurice. Our time-which is full of worries, fears, and dangers -can be regarded as a mass experiment in proof of my doctrine that arteriosclerosis develops from arterioatony, and that it does not represent a disease sui generis but is the means of healing the damage caused in the atonic arteries. As to the arterio-atony, it represents only a part of the general atony, whatever may be its cause, as I have always held (Lancet 1932, i, 385). Arterioatony is a state in which the subsequent development of the sclerosis can be forestalled by adequate treatment. Watson Smith in his letter gives the full classical description of general atony, but errs when he regards the hypopiesia as the cause rather than as a consequence. In Sir Maurice’s opinion it is a " a widespread delusion that a pressure of120 in a subject of forty to fifty is pathological and that in an individual of any age pressure of or below 110 calls for alarm and despondency." He maintains that " systolic pressures as low as 100 can and should be disregarded, and that on no account should the patient’s symptoms be attributed to them." I think that Sir Maurice’s doctrine, if followed, may be detrimental not only for the present but for the Mature fate of the patient. It may be that he shares the general opinion which regards high pressure as an alarming symptom. In my experience low pressure statistically involves more dangers and more serious complications than high blood-pressure. I am thinking here especially of the dangers of thrombosis and embolIn this point I believe every observant ism, cramps, &c. practitioner will agree with me. If hypopiesia is commoner today than in. previous decades the cause can easily be found in our disturbed times, and therefore the mass appearance must be The fact that atony mostly represents a psychogenic. " neurosis " does not entitle us to minimise its significance or to disregard its treatment. If Dr. Watson Smith has seen but little success from galenic treatment, I sadly agree with him. Other and more effective methods are tonics, like arsenic, different vitamins, and hydro-, climato-, and thalasso- therapies may help ; but a strong warning must be sounded against violent exercise which may suddenly increase the blood-pressure whereby the sluggish arterial wall with impaired resistance may be over-distended and injured. The arteries thus damaged later become sclerotic. I would not like to think so little of the application of the elastic belt recommended by Dr. Watson Smith as Sir Maurice Cassidy does. The belt may help the weakened circulation by supporting the abdominal wall. Because of the psychological origin of the hypopiesia, we may expect the greatest benefit from psychological treatment. A good drink, a good cigar, or a cup of strong coffee to eliminate the inhibitions of the tired brain ; a trip in cheerful company, a gay show or some
Hollywood
nonsense, to
distract the patient
from his sorrows and worries ; but most of all a holiday should be advised in the old Roman sense of otium:: full occupation of the patient by his hobby, by something different from his usual pursuits. J. PLESCH. London, Wl. THE " PERFECT AP "
SIR,-Dr. George Day writes in your issue of Oct. 6 that it came as’ a new idea to those present when, in 1935, Jacobeus reported to the Tuberculosis Association that with a person lying on his side the lower lung does more work than the upper lung. As a matter of fact, Mr. Cortlandt MacMahon made this observation during