- Email: [email protected]
HAPPY HOSPITALS ?
1039
probable cause is pulmonary collapse due depressed breathing,"although in common with Bendixen al.’* we have been unable to demonstrate radiographic changes in the chest. Our observations have been extended to patients with a lower alveolar oxygen tension. We found the alveolar-arterial P02 difference larger than can be explained by the shunt found while a high concentration of oxygen is breathed.3 This suggests appreciable maldistribution (areas of low ventilation/perfusion ratio) in addition to the frank shunt. The observation by Taylor et al. of normal arterial oxygen levels within thirty minutes of the end of operation is most surprising. It is unlikely that the conflict with the findings of Nunn and Payne ’can be resolved on grounds of inaccuracy of
whereas, in my earlier series of 90 subcapital fractures
heart output. The
treated by Smith-Petersen nailing, the functional result
to et
was
satisfactory in only 53% of the survivors.
Pembury Hospital, Pembury, Tunbridge Wells, Kent.
J. H. MAYER.
EFFECTS OF CHLOROFORM AND HALOTHANE ANÆSTHESIA ON LIVER FUNCTION SIR,-Professor Tisdale made three relevant points in his letter (April 18). First, our paper was unnecessary as the literature was " replete with similar clinical experiments ". He supported this with one reference. So far as we are aware there are no reports of the comparative effects of chloroform and halothane on liver function in man. There are reports comparing halothane with many other agents, and we gave the references in our paper. His reference to Little et al. is among them. " Second, its use is unjustified ". He supports this with one reference. Siebecker1 in 1956 showed that the use of chloroform was unjustified in patients with long-standing pulmonary tuberculosis who had received protracted chemotherapy and who were subjected to thoracotomy and anaesthesia lasting many hours. Episodes of anoxia, hypercarbia, and hypotension were frequent. 2 of the 7 patients died of acute liver damage: 1 was known to be an alcoholic with early Laennec’s cirrhosis; and in the other the operation lasted four hours fifty minutes. We agree with Siebecker. It might be apposite to point out that in the last five years chloroform has been administered to more than 1500 patients without clinical signs of hepatic dysfunction. It has been given by modern techniques, with adequate ventilation and oxygenation. It has been used to achieve analgesia and areflexia, but not to produce muscle relaxation. It has not been administered to patients in whom liver damage was known to exist It has not been used in operations which last over three hours; and, finally, it has been administered by an experienced anaesthetist. With these qualifications we believe its use is justified. Third, liver-function tests twenty-four hours after anaesthesia might fail to indicate hepatic dysfunction. The S.G.O.T. and S.G.P.T. tests, which we regarded as the most reliable indications of hepatocellular damage, were repeated on the third postoperative day and were found to be within normal limits in both groups of patients, but this table was omitted from the results. This we regret. Royal Infirmary, H. W. C. GRIFFITHS. Edinburgh, 3. RESPIRATORY EFFECTS OF GENERAL ANESTHESIA
SiR,ŁThe continuity of observations and control of variables in the study of Dr. Taylor and his coworkers (April 18) make an important contribution to our knowledge of the factors influencing oxygenation during anaesthesia. Their findings after premedication (administered intramuscularly) accord with the finding of Nunn and Bergman2 that intravenous atropine has no effect on the arterial oxygen tension of healthy volunteers during the inhalation of air, 11 % oxygen, or 100 % oxygen. Taylor et al. report a mean arterial oxygen tension of 350 mm. Hg during the operation. Under the conditions of their study, it seems probable that this indicates an alveolararterial P02 gradient of the order of 250 mm. Hg, which agrees well with our own figures3 and those of Bendixen et a1.4 and Stark and Smithy At high levels of P02 the gradient is likely to be explained almost entirely by right-to-left shunt which, under these circumstances, is probably 10-20% of the right1. 2. 3. 4.
5.
Siebecker, K. L., Orth, O. S. Anesthesiology, 1956, 17, 792. Nunn, J. F., Bergman, N. A. Brit. J. Anœsth. 1964, 36, 68. Nunn, J. F. ibid. (in the press). Bendixen, H. H., Hedley-Whyte, J., Laver, M. B. New Engl. J. Med. 1963, 269, 991. Stark, D. C. C., Smith, H. Brit. J. Anœsth. 1960, 32, 460.
the indirect method of determination of Po2, since, in one group of patients, Po2 was determined directly with a polarograph which was regularly checked against tonometerequilibrated blood. The degree of postoperative hypoxia was comparable with the disturbance found during operation in a group of 12 patients with the same alveolar Po2 (see accom-
panying table). OXYGEN TENSION RELATED TO OPERATION
I
I
I
"
calculated shunt " of the These figures correspond to a order of 20-25% of pulmonary blood-flow, which is little greater than the frank shunt demonstrated by all three groups during anaesthesia with a high concentration of oxygen in the inhaled gas. In view of the large number of reports of postoperative hypoxxmia, the absence of hypoxsmia so unequivocally demonstrated by Dr. Taylor is of particular interest. London, W.C.2.
SIR,-Isee
J. F. NUNN. HAPPY HOSPITALS ? you mention (April 11) the Revans report
for the Nuffield Provincial Hospitals Trust.8
Wisely, you restrained your comments to the problems of staff-happiness and did not question the report’s deduction that staff-happiness is related to length of patient-stay. If only the report’s writers had done the same and not pushed on to their obviously anticipated conclusion that patient-stay is long when staff-happiness is low. To get there, they compare stay-rates after certain operations between the hospitals they are studying. This is difficult enough if you know all the variables, and useless if you leave them out, which is what they do. The fabric of their argument is a total tatter, and I quote this as a solitary stitch for criticism. They have found a difference in patient-stay rates after certain operations between their hospitals; they now want to know if units differ within one hospital. So what do they do ? They take the appendicectomies of the hospital, divide them into the four units, and find there is no appreciable difference between each unit. Therefore (to them) a hospital’s standard (of all other operations) is the same for all units; that is, hospitals vary against each other but not within each other. But they haven’t proved anything of the sort. By taking appendicectomy they have not provided a test (and units tend to do different work so that it is difficult even to find a suitable test operation), and anyhow nearly all these appendicectomies will have been done by the registrars (two men at the most and possibly one). They have not compared the units at all; all they have declared is that particular hospital’s stay-rate after appendicectomy, and that it happens to be uniform between the units, a feature which suggests that each unit has the same policy for the cold case. For if a number of cold gridiron appendicectomies are done (and those with laparotomy exploration left under 6. Mead, J., Collier, C. J. appl. Physiol. 1959, 14, 669. 7. 8.
Nunn, J. F., Payne, J. P. Lancet, 1962, ii, 631. Revans, R. W. Standards for Morale: Cause and Effect in Hospitals. London, 1964.
1040 "
laparotomy ") then the stay-rate is short, and not to be compared with a hospital or unit pursuing the opposite policy. There are numerous points of this nature which have not been considered. It is unfortunate that
a
report which has been received
seriously and widely should rely on such deficient evidence. OLIVER JELLY. Manchester, 3. FISSURE-IN-ANO
SiR,—In general practice
my
of
experience
treating
fissure-in-ano is so limited that it came as a surprise to learn that there was any method other than dilatation for simple, superficial fissure-in-ano. I have always treated it by means of dilatation under local anaesthesia (usually 1% lignocaine with adrenaline), and I cannot recall ever having to repeat the procedure more than once, or having to refer a simple fissure to the surgeon. How dilatation effects a cure is best explained, I think, as follows: the epidermal edge of the fissure adheres to the fibrous stroma of its base; dilation tears the inelastic fibrotic area, undermines the skin margins, opens capillary loops, and leaves the freshened surfaces apposed. The tissues heal readily, with complete and immediate relief, which makes the pain of perianal injection, though severe, worth supporting. The regular application of balms and suppositories is uniformly disappointing and likelier to leave a wide and vulnerable scar. Kingston
upon Thames.
CHARLES STEER.
GASTRIC INTRINSIC FACTOR
SIR,-We have some difficulty in understanding the precise objections that Dr. Abels and his coworkers (April 25) have to our method for intrinsic-factor (I. F.) assay.! However, we believe the different interpretation of results to be dueto their reluctance to accept the evidence that under the conditions of the Of. assay more vitamin B12 is retained by serum in the presence of Of. than in its absence, and further, that this increased uptake of vitamin B12 by serum can be related to the amount of l.F. available. As Dr. Abels and his colleagues point out (Feb. 1), the of B12 retained by gastric I.F. when the dialysis method is used is the same as the amount of B12 retained by the gastric juice in the presence of serum when our assay method is used. In the dialysis method the impermeability of the sac to the B12-I.F. complex makes it impossible to detect the further link of the complex to serum, and this step is not important for the success of the dialysis method of Of. assay. Charcoal removes the free B12-I.F. complex in the absence of a serum receptor, but in the presence of serum all the B12-I.F. complex is linked to serum and is thereafter not affected by charcoal. This forms the basis of our method of Of. assay. If Dr. Abels and his colleagues are unwilling to accept the evidence for a serum link of the B12-I.F. complex, then they are unlikely to be persuaded that this link is abolished when the action of I.F. is nullified by the presence of the antibody. This evidence is set out fully in our original communication. We showed that the I.F.-mediated uptake of B12 by an antibodycontaining serum was restored to normal when the antibody (7S y-globulin) was removed; and similarly the B12 uptake of a normal serum was largely abolished when this same 7S y-globulin was added to it. We entirely agree with Dr. Abels and his colleagues that the presence of the I.F. antibody results in " the inhibition of binding of vitamin B12 to l.F.", and in order to bring about this reaction we incubated gastric juice with antiserum as part of the first stage of the assay. We have not suggested that the J.F.-antibody functioned at any other site; nor have we suggested, as we believe Dr. Abels and his colleagues to suppose, that the antibody acts on the B12-J.F. complex, thereby preventing an attachment to serum. amount
The data furnished by Dr. Abels and his colleagues (April 21) do not seem relevant to the events in the assay method we propose. But they do provide an explanation for the lesser sensitivity of the electrophoretic method for the detection of I.F. antibodies described by Jeffries et al. 2 in which the antibody against I.F. reacted directly with the B12-I.F. complex.
The data given by Dr. Abels and his colleagues, as well the success of the electrophoretic method for I.F.antibody detection, also indicate that the conclusion, that prior incubation of gastric juice with B12 abolishes the subsequent reaction with an I.F. antibody, is incorrect. S. ARDEMAN Experimental Hæmatology Research Unit, St. Mary’s Hospital Medical School, I. CHANARIN. London, W.2.
as
TRIAMTERENE IN MYASTHENIA GRAVIS
SIR,-Dr. Satoyoshi and his colleagues say in one part of their article (April 4) that " aldosterone antagonists have been thought to counteract aldosterone in the renal tubules thus reducing the excretion of potassium and water and retaining sodium in the body ". Yet in another part they say that triamterene " increases urinary excretion of sodium and chloride ". Which is true ? Pengam,
*** Dr. Ray’s letter has been shown to Dr. Satoyoshi, who writes : " In the first of the quoted passages’retaining sodium ’ would have been better expressed asthe retention of sodium ’. Aldosterone antagonists reduce sodium retention in the body by increasing urinary excretion of sodium and chloride."-ED. L. FRINGE MEDICINE SiR,—Your review (April 18) of my Fringe Medicine concludes a scrupulously fair summary of my thesis with
the admonition: " Inglis and those whose work he expounds should not ignore the fact that an examination of their claims by ’orthodox’ scientific inquiry is the best way of ridding their critics of the suspicion that much of fringe medicine is compounded of misconception, superstition, distortion, self-deception, and plain hocus
pocus." Is it the best way ? In 1924 Horder and some colleagues investigated the Abrams’ Box, and reported that " no more convincing exposition of the reality of the phenomena could reasonably be desired ". I am not aware that this pronouncement has done anything to rid orthodox critics of their suspicion that radiesthesia is plain hocus pocus. In 1936 Barker gave a demonstration of his manipulative technique in St. Thomas’s, whose results your esteemed contemporary the British Medical Journal enthused over as " astonishingly good ". Yet in your pages only a few weeks ago (March 14) Dr. James Cyriax admits that " most doctors look askance at manipulation ... bracketing it in their minds with quackery ". What on earth is the use of having such inquiries, if the results are ignored unless they happen to confirm the orthodox view? There is also the difficulty, which I feel you underestimate, of arranging " orthodox " tests suitable for unorthodox practices. Dr. Shine (May 2) quotes the unwillingness of the homoeopaths to indulge in double-blind experiments as an indication of the absurdity of my acceptance of their case; but this is unreasonable. If it is a basic tenet of homoeopathic philosophy that the remedy must be related to the individual patient, and not just to the symptoms (and this is surely reasonable if you are concentrating on stimulating the patients vis medicatrix nature), then double-blind tests are irrelevant -just as they are for psychoanalysis.
I am sure, though, that many fringe practices could be tested by methods acceptable to orthodoxy, if the 2.
1.
Ardeman, S., Chanarin, I. Lancet, 1963, ii,
1350.
D. K. RAY.
Monmouthshire.
Jeffries, G. H., Hoskins, 41, 1106.
D.
W., Sleisenger, M. H. J. clin. Invest. 1962,
probable cause is pulmonary collapse due depressed breathing,"although in common with Bendixen al.’* we have been unable to demonstrate radiographic changes in the chest. Our observations have been extended to patients with a lower alveolar oxygen tension. We found the alveolar-arterial P02 difference larger than can be explained by the shunt found while a high concentration of oxygen is breathed.3 This suggests appreciable maldistribution (areas of low ventilation/perfusion ratio) in addition to the frank shunt. The observation by Taylor et al. of normal arterial oxygen levels within thirty minutes of the end of operation is most surprising. It is unlikely that the conflict with the findings of Nunn and Payne ’can be resolved on grounds of inaccuracy of
whereas, in my earlier series of 90 subcapital fractures
heart output. The
treated by Smith-Petersen nailing, the functional result
to et
was
satisfactory in only 53% of the survivors.
Pembury Hospital, Pembury, Tunbridge Wells, Kent.
J. H. MAYER.
EFFECTS OF CHLOROFORM AND HALOTHANE ANÆSTHESIA ON LIVER FUNCTION SIR,-Professor Tisdale made three relevant points in his letter (April 18). First, our paper was unnecessary as the literature was " replete with similar clinical experiments ". He supported this with one reference. So far as we are aware there are no reports of the comparative effects of chloroform and halothane on liver function in man. There are reports comparing halothane with many other agents, and we gave the references in our paper. His reference to Little et al. is among them. " Second, its use is unjustified ". He supports this with one reference. Siebecker1 in 1956 showed that the use of chloroform was unjustified in patients with long-standing pulmonary tuberculosis who had received protracted chemotherapy and who were subjected to thoracotomy and anaesthesia lasting many hours. Episodes of anoxia, hypercarbia, and hypotension were frequent. 2 of the 7 patients died of acute liver damage: 1 was known to be an alcoholic with early Laennec’s cirrhosis; and in the other the operation lasted four hours fifty minutes. We agree with Siebecker. It might be apposite to point out that in the last five years chloroform has been administered to more than 1500 patients without clinical signs of hepatic dysfunction. It has been given by modern techniques, with adequate ventilation and oxygenation. It has been used to achieve analgesia and areflexia, but not to produce muscle relaxation. It has not been administered to patients in whom liver damage was known to exist It has not been used in operations which last over three hours; and, finally, it has been administered by an experienced anaesthetist. With these qualifications we believe its use is justified. Third, liver-function tests twenty-four hours after anaesthesia might fail to indicate hepatic dysfunction. The S.G.O.T. and S.G.P.T. tests, which we regarded as the most reliable indications of hepatocellular damage, were repeated on the third postoperative day and were found to be within normal limits in both groups of patients, but this table was omitted from the results. This we regret. Royal Infirmary, H. W. C. GRIFFITHS. Edinburgh, 3. RESPIRATORY EFFECTS OF GENERAL ANESTHESIA
SiR,ŁThe continuity of observations and control of variables in the study of Dr. Taylor and his coworkers (April 18) make an important contribution to our knowledge of the factors influencing oxygenation during anaesthesia. Their findings after premedication (administered intramuscularly) accord with the finding of Nunn and Bergman2 that intravenous atropine has no effect on the arterial oxygen tension of healthy volunteers during the inhalation of air, 11 % oxygen, or 100 % oxygen. Taylor et al. report a mean arterial oxygen tension of 350 mm. Hg during the operation. Under the conditions of their study, it seems probable that this indicates an alveolararterial P02 gradient of the order of 250 mm. Hg, which agrees well with our own figures3 and those of Bendixen et a1.4 and Stark and Smithy At high levels of P02 the gradient is likely to be explained almost entirely by right-to-left shunt which, under these circumstances, is probably 10-20% of the right1. 2. 3. 4.
5.
Siebecker, K. L., Orth, O. S. Anesthesiology, 1956, 17, 792. Nunn, J. F., Bergman, N. A. Brit. J. Anœsth. 1964, 36, 68. Nunn, J. F. ibid. (in the press). Bendixen, H. H., Hedley-Whyte, J., Laver, M. B. New Engl. J. Med. 1963, 269, 991. Stark, D. C. C., Smith, H. Brit. J. Anœsth. 1960, 32, 460.
the indirect method of determination of Po2, since, in one group of patients, Po2 was determined directly with a polarograph which was regularly checked against tonometerequilibrated blood. The degree of postoperative hypoxia was comparable with the disturbance found during operation in a group of 12 patients with the same alveolar Po2 (see accom-
panying table). OXYGEN TENSION RELATED TO OPERATION
I
I
I
"
calculated shunt " of the These figures correspond to a order of 20-25% of pulmonary blood-flow, which is little greater than the frank shunt demonstrated by all three groups during anaesthesia with a high concentration of oxygen in the inhaled gas. In view of the large number of reports of postoperative hypoxxmia, the absence of hypoxsmia so unequivocally demonstrated by Dr. Taylor is of particular interest. London, W.C.2.
SIR,-Isee
J. F. NUNN. HAPPY HOSPITALS ? you mention (April 11) the Revans report
for the Nuffield Provincial Hospitals Trust.8
Wisely, you restrained your comments to the problems of staff-happiness and did not question the report’s deduction that staff-happiness is related to length of patient-stay. If only the report’s writers had done the same and not pushed on to their obviously anticipated conclusion that patient-stay is long when staff-happiness is low. To get there, they compare stay-rates after certain operations between the hospitals they are studying. This is difficult enough if you know all the variables, and useless if you leave them out, which is what they do. The fabric of their argument is a total tatter, and I quote this as a solitary stitch for criticism. They have found a difference in patient-stay rates after certain operations between their hospitals; they now want to know if units differ within one hospital. So what do they do ? They take the appendicectomies of the hospital, divide them into the four units, and find there is no appreciable difference between each unit. Therefore (to them) a hospital’s standard (of all other operations) is the same for all units; that is, hospitals vary against each other but not within each other. But they haven’t proved anything of the sort. By taking appendicectomy they have not provided a test (and units tend to do different work so that it is difficult even to find a suitable test operation), and anyhow nearly all these appendicectomies will have been done by the registrars (two men at the most and possibly one). They have not compared the units at all; all they have declared is that particular hospital’s stay-rate after appendicectomy, and that it happens to be uniform between the units, a feature which suggests that each unit has the same policy for the cold case. For if a number of cold gridiron appendicectomies are done (and those with laparotomy exploration left under 6. Mead, J., Collier, C. J. appl. Physiol. 1959, 14, 669. 7. 8.
Nunn, J. F., Payne, J. P. Lancet, 1962, ii, 631. Revans, R. W. Standards for Morale: Cause and Effect in Hospitals. London, 1964.
1040 "
laparotomy ") then the stay-rate is short, and not to be compared with a hospital or unit pursuing the opposite policy. There are numerous points of this nature which have not been considered. It is unfortunate that
a
report which has been received
seriously and widely should rely on such deficient evidence. OLIVER JELLY. Manchester, 3. FISSURE-IN-ANO
SiR,—In general practice
my
of
experience
treating
fissure-in-ano is so limited that it came as a surprise to learn that there was any method other than dilatation for simple, superficial fissure-in-ano. I have always treated it by means of dilatation under local anaesthesia (usually 1% lignocaine with adrenaline), and I cannot recall ever having to repeat the procedure more than once, or having to refer a simple fissure to the surgeon. How dilatation effects a cure is best explained, I think, as follows: the epidermal edge of the fissure adheres to the fibrous stroma of its base; dilation tears the inelastic fibrotic area, undermines the skin margins, opens capillary loops, and leaves the freshened surfaces apposed. The tissues heal readily, with complete and immediate relief, which makes the pain of perianal injection, though severe, worth supporting. The regular application of balms and suppositories is uniformly disappointing and likelier to leave a wide and vulnerable scar. Kingston
upon Thames.
CHARLES STEER.
GASTRIC INTRINSIC FACTOR
SIR,-We have some difficulty in understanding the precise objections that Dr. Abels and his coworkers (April 25) have to our method for intrinsic-factor (I. F.) assay.! However, we believe the different interpretation of results to be dueto their reluctance to accept the evidence that under the conditions of the Of. assay more vitamin B12 is retained by serum in the presence of Of. than in its absence, and further, that this increased uptake of vitamin B12 by serum can be related to the amount of l.F. available. As Dr. Abels and his colleagues point out (Feb. 1), the of B12 retained by gastric I.F. when the dialysis method is used is the same as the amount of B12 retained by the gastric juice in the presence of serum when our assay method is used. In the dialysis method the impermeability of the sac to the B12-I.F. complex makes it impossible to detect the further link of the complex to serum, and this step is not important for the success of the dialysis method of Of. assay. Charcoal removes the free B12-I.F. complex in the absence of a serum receptor, but in the presence of serum all the B12-I.F. complex is linked to serum and is thereafter not affected by charcoal. This forms the basis of our method of Of. assay. If Dr. Abels and his colleagues are unwilling to accept the evidence for a serum link of the B12-I.F. complex, then they are unlikely to be persuaded that this link is abolished when the action of I.F. is nullified by the presence of the antibody. This evidence is set out fully in our original communication. We showed that the I.F.-mediated uptake of B12 by an antibodycontaining serum was restored to normal when the antibody (7S y-globulin) was removed; and similarly the B12 uptake of a normal serum was largely abolished when this same 7S y-globulin was added to it. We entirely agree with Dr. Abels and his colleagues that the presence of the I.F. antibody results in " the inhibition of binding of vitamin B12 to l.F.", and in order to bring about this reaction we incubated gastric juice with antiserum as part of the first stage of the assay. We have not suggested that the J.F.-antibody functioned at any other site; nor have we suggested, as we believe Dr. Abels and his colleagues to suppose, that the antibody acts on the B12-J.F. complex, thereby preventing an attachment to serum. amount
The data furnished by Dr. Abels and his colleagues (April 21) do not seem relevant to the events in the assay method we propose. But they do provide an explanation for the lesser sensitivity of the electrophoretic method for the detection of I.F. antibodies described by Jeffries et al. 2 in which the antibody against I.F. reacted directly with the B12-I.F. complex.
The data given by Dr. Abels and his colleagues, as well the success of the electrophoretic method for I.F.antibody detection, also indicate that the conclusion, that prior incubation of gastric juice with B12 abolishes the subsequent reaction with an I.F. antibody, is incorrect. S. ARDEMAN Experimental Hæmatology Research Unit, St. Mary’s Hospital Medical School, I. CHANARIN. London, W.2.
as
TRIAMTERENE IN MYASTHENIA GRAVIS
SIR,-Dr. Satoyoshi and his colleagues say in one part of their article (April 4) that " aldosterone antagonists have been thought to counteract aldosterone in the renal tubules thus reducing the excretion of potassium and water and retaining sodium in the body ". Yet in another part they say that triamterene " increases urinary excretion of sodium and chloride ". Which is true ? Pengam,
*** Dr. Ray’s letter has been shown to Dr. Satoyoshi, who writes : " In the first of the quoted passages’retaining sodium ’ would have been better expressed asthe retention of sodium ’. Aldosterone antagonists reduce sodium retention in the body by increasing urinary excretion of sodium and chloride."-ED. L. FRINGE MEDICINE SiR,—Your review (April 18) of my Fringe Medicine concludes a scrupulously fair summary of my thesis with
the admonition: " Inglis and those whose work he expounds should not ignore the fact that an examination of their claims by ’orthodox’ scientific inquiry is the best way of ridding their critics of the suspicion that much of fringe medicine is compounded of misconception, superstition, distortion, self-deception, and plain hocus
pocus." Is it the best way ? In 1924 Horder and some colleagues investigated the Abrams’ Box, and reported that " no more convincing exposition of the reality of the phenomena could reasonably be desired ". I am not aware that this pronouncement has done anything to rid orthodox critics of their suspicion that radiesthesia is plain hocus pocus. In 1936 Barker gave a demonstration of his manipulative technique in St. Thomas’s, whose results your esteemed contemporary the British Medical Journal enthused over as " astonishingly good ". Yet in your pages only a few weeks ago (March 14) Dr. James Cyriax admits that " most doctors look askance at manipulation ... bracketing it in their minds with quackery ". What on earth is the use of having such inquiries, if the results are ignored unless they happen to confirm the orthodox view? There is also the difficulty, which I feel you underestimate, of arranging " orthodox " tests suitable for unorthodox practices. Dr. Shine (May 2) quotes the unwillingness of the homoeopaths to indulge in double-blind experiments as an indication of the absurdity of my acceptance of their case; but this is unreasonable. If it is a basic tenet of homoeopathic philosophy that the remedy must be related to the individual patient, and not just to the symptoms (and this is surely reasonable if you are concentrating on stimulating the patients vis medicatrix nature), then double-blind tests are irrelevant -just as they are for psychoanalysis.
I am sure, though, that many fringe practices could be tested by methods acceptable to orthodoxy, if the 2.
1.
Ardeman, S., Chanarin, I. Lancet, 1963, ii,
1350.
D. K. RAY.
Monmouthshire.
Jeffries, G. H., Hoskins, 41, 1106.
D.
W., Sleisenger, M. H. J. clin. Invest. 1962,