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TEENAGE MORALS
1404 The fetish of the " doctor’s letter " for fee-paying patients in Harley Street is an inroad into the liberties of the patient in as far as it makes a highly private choice dependent on another’s knowledge and consent. G. BLUNT. London, E.C.2. TEENAGE MORALS read with interest the article in your issue of SIR,-I
administration an attempt was made to lower the bodytemperature, this resulting in a fall of rectal temperature of 3°C in a matter of some four hours. Other observations were, of course, made during this procedure, but we have confined ourselves to the information relevant to the article. Finally, knowing well the dangers of premature conclusions on inadequate grounds, we should like it to be clearly realised that no special claim is being made on the basis of one case so treated.
June
17 (p. 1335). Dr. Comfort refers
to the word " teenager " saying " the name itself has been coined to steady the aim of the denouncer ". This is surely nonsense since we all know that it was created by those who hope to sell their products to this now affluent age-group. In any case it seems to have lost its normal connotation and to be reaching out so as almost to link with that other unfortunate title " middle-
aged ". point is his reference to the raising of the school-leaving age. Surely he cannot believe that this is the work of the " professional middle-class ". If they possess children who cannot qualify for grammar-school education they will, as far as one knows from experience, make personal sacrifices to send them to paying schools if they consider it desirable. The general raising of the school-leaving age is deplored by any thinking person, and A further
here we agree with Dr. Comfort and the schoolmaster to whom he refers. In conclusion, my eldest daughter and her friends
entirely normal, though possibly "’square ", young people. They receive instruction through school and
appear
Church in sexual education and take it all with the required pinch of salt.
J. J. E. E. F. Richmond, Surrey.
GUERITZ. UERITZ.
CEREBRAL FAT-EMBOLISM SUCCESSFULLY TREATED BY CARBON-DIOXIDE INHALATION
SIR,-We feel that some details of the management of reported by Dr. Broom (June 17) should be re-stated and indeed amplified. It is unfortunate that we did not have the opportunity of seeing this communication before publication, since we would have immediately realised that certain errors had occurred, due to the fact that the author’s knowledge of the patient was entirely retrospective, and that he might be unaware of many pertinent personal observations. our case
We should like to state that, firstly, endotracheal intubation possible under local anaesthesia, and it was necessary to produce muscular relaxation by succinyl dicholine (20 mg. intravenously) before the larynx could be anaesthetised and the tube passed. Artificial respiration was then instituted for about one minute after which spontaneous respiration returned, and a mixture of 20% carbon dioxide in oxygen was then administered. The immediate response to this was a marked and increasing tachypnoea, associated with an increase in the minute volume to 30 litres. The fresh-gas flow at this time, and subsequently, naturally had to be maintained at a rate consistent with the minute volume as measured intermittently by a dry-gas meter. It is incorrect to say that " there was no obvious alteration in pulse, respiration-rate, temperature, blood-pressure ..." as, of course, there was an initial rise in blood-pressure from the resting level of 125/70 mm. Hg to 210/90 in the first 30 minutes of inhalation, this thereafter falling progressively to 140/80. The respiration-rate increased from a resting level of 30 per min. to a maximum of 46 per min., eventually stabilising at a rate of 25 to 30 per min., with a minute volume of not less than 18 litres. During the period of carbon-dioxide was not
A. E. RICHARDSON W. G. G. LOYN.
Whittington Hospital, London, N.19
EFFECTS OF COD-LIVER OIL
SIR,-Ishould like to comment on the interesting letters of Dr. Kingsbury (May 6) and of Mr. Tunnicliffe (May 27) in reply to mine of April 29. I must apologise to Dr. Kingsbury and his colleagues (April 8) if my impression was incorrect, that some association existed between the amount of cod-liver oil administered and the degree of hypocholesterolxmic effect. If however the bloodcholesterol values of the 4 groups of subjects given cod-liver oil are graphed against time, it does seem that the steepest falls in blood-cholesterol were shown by 3 of the subjects (C, D, F) who had received the highest daily doses (50 g.). The observation made by Mr. Tunnicliffe regarding the notable fall in blood-cholesterol when lower doses were employed for a longer time had not escaped me; but in the 3 subjects to whom I have referred, extrapolation of the curves of the fall in blood-cholesterol indicates that this might have been even greater had the highest doses been given for four weeks instead of for only twelve days. The size of dose for future experimental work in adults does not seem to me to be as important as the amount of cod-liver oil which a parent might think it reasonable to give to his child. I would agree with Mr. Tunnicliffe that adults are unlikely to take more than 2 tablespoonfuls daily. But he must remember that small children do not take drugs, but are given them. This is, I think, an important distinction; and there is no doubt that many small children are given, and retain, surprisingly large amounts of unpalatable drugs. Mr. Tunnicliffe refers to the opinion of Bicknell and Prescott1 that 10,000 LV. is the lowest daily dose of vitamin D2 which might be considered toxic to children. I do not think that this would now be accepted. Graham,2 in a review of 38 cases of idiopathic hypercalcsemia, showed that the highest daily dose before the onset of symptoms was 8800 i.u., and that in 8 of his patients the daily intake was less than 1000 LU. I did not suggest that idiopathic hypercalcaemia in recent years had been caused by vitamin D3 but this does not mean that it could not do so if it were to be used as extensively as vitamin D2 has been. I agree that Thatcher’s patient3 seems likely to have suffered from idiopathic hypercaicsmia, but in this instance the source of vitamin D was cod-liver oil, and the daily intake does not appear to have exceeded 1200 LV. I would suggest that the correct conclusions to be drawn from Malmberg’s experiment4 with large doses of cod-liver oil given to 2 premature infants are that this substance can cause myocardial atrophy and that this effect may be produced within a few days or weeks. It is an encouraging suggestion that toxic effects such as this may have been attributable to the impurity of the cod-liver oil used at that time, but this I think cannot be
regarded
as
proven.
Mr. Tunnicliffe has referred to the many years of clinical experience in the use of cod-liver oil, but I doubt if we have gained sufficient experience to be sure that the substance is quite harmless. Clinical experience with vitamin D2 was also extensive, but a decade elapsed after the fortification of infant foods and the institution of 1.
Bicknell, F., Prescott,
F. The Vitamins in
Medicine; p. 840. London,
1953. 2. Graham, S. Postgrad. Med. 1959, 25, 67. 3. Thatcher, L. Lancet, 1936, i, 20. 4. Malmberg, N. Acta pœdiat., Stockh. 1928, 8, 364.
administration an attempt was made to lower the bodytemperature, this resulting in a fall of rectal temperature of 3°C in a matter of some four hours. Other observations were, of course, made during this procedure, but we have confined ourselves to the information relevant to the article. Finally, knowing well the dangers of premature conclusions on inadequate grounds, we should like it to be clearly realised that no special claim is being made on the basis of one case so treated.
June
17 (p. 1335). Dr. Comfort refers
to the word " teenager " saying " the name itself has been coined to steady the aim of the denouncer ". This is surely nonsense since we all know that it was created by those who hope to sell their products to this now affluent age-group. In any case it seems to have lost its normal connotation and to be reaching out so as almost to link with that other unfortunate title " middle-
aged ". point is his reference to the raising of the school-leaving age. Surely he cannot believe that this is the work of the " professional middle-class ". If they possess children who cannot qualify for grammar-school education they will, as far as one knows from experience, make personal sacrifices to send them to paying schools if they consider it desirable. The general raising of the school-leaving age is deplored by any thinking person, and A further
here we agree with Dr. Comfort and the schoolmaster to whom he refers. In conclusion, my eldest daughter and her friends
entirely normal, though possibly "’square ", young people. They receive instruction through school and
appear
Church in sexual education and take it all with the required pinch of salt.
J. J. E. E. F. Richmond, Surrey.
GUERITZ. UERITZ.
CEREBRAL FAT-EMBOLISM SUCCESSFULLY TREATED BY CARBON-DIOXIDE INHALATION
SIR,-We feel that some details of the management of reported by Dr. Broom (June 17) should be re-stated and indeed amplified. It is unfortunate that we did not have the opportunity of seeing this communication before publication, since we would have immediately realised that certain errors had occurred, due to the fact that the author’s knowledge of the patient was entirely retrospective, and that he might be unaware of many pertinent personal observations. our case
We should like to state that, firstly, endotracheal intubation possible under local anaesthesia, and it was necessary to produce muscular relaxation by succinyl dicholine (20 mg. intravenously) before the larynx could be anaesthetised and the tube passed. Artificial respiration was then instituted for about one minute after which spontaneous respiration returned, and a mixture of 20% carbon dioxide in oxygen was then administered. The immediate response to this was a marked and increasing tachypnoea, associated with an increase in the minute volume to 30 litres. The fresh-gas flow at this time, and subsequently, naturally had to be maintained at a rate consistent with the minute volume as measured intermittently by a dry-gas meter. It is incorrect to say that " there was no obvious alteration in pulse, respiration-rate, temperature, blood-pressure ..." as, of course, there was an initial rise in blood-pressure from the resting level of 125/70 mm. Hg to 210/90 in the first 30 minutes of inhalation, this thereafter falling progressively to 140/80. The respiration-rate increased from a resting level of 30 per min. to a maximum of 46 per min., eventually stabilising at a rate of 25 to 30 per min., with a minute volume of not less than 18 litres. During the period of carbon-dioxide was not
A. E. RICHARDSON W. G. G. LOYN.
Whittington Hospital, London, N.19
EFFECTS OF COD-LIVER OIL
SIR,-Ishould like to comment on the interesting letters of Dr. Kingsbury (May 6) and of Mr. Tunnicliffe (May 27) in reply to mine of April 29. I must apologise to Dr. Kingsbury and his colleagues (April 8) if my impression was incorrect, that some association existed between the amount of cod-liver oil administered and the degree of hypocholesterolxmic effect. If however the bloodcholesterol values of the 4 groups of subjects given cod-liver oil are graphed against time, it does seem that the steepest falls in blood-cholesterol were shown by 3 of the subjects (C, D, F) who had received the highest daily doses (50 g.). The observation made by Mr. Tunnicliffe regarding the notable fall in blood-cholesterol when lower doses were employed for a longer time had not escaped me; but in the 3 subjects to whom I have referred, extrapolation of the curves of the fall in blood-cholesterol indicates that this might have been even greater had the highest doses been given for four weeks instead of for only twelve days. The size of dose for future experimental work in adults does not seem to me to be as important as the amount of cod-liver oil which a parent might think it reasonable to give to his child. I would agree with Mr. Tunnicliffe that adults are unlikely to take more than 2 tablespoonfuls daily. But he must remember that small children do not take drugs, but are given them. This is, I think, an important distinction; and there is no doubt that many small children are given, and retain, surprisingly large amounts of unpalatable drugs. Mr. Tunnicliffe refers to the opinion of Bicknell and Prescott1 that 10,000 LV. is the lowest daily dose of vitamin D2 which might be considered toxic to children. I do not think that this would now be accepted. Graham,2 in a review of 38 cases of idiopathic hypercalcsemia, showed that the highest daily dose before the onset of symptoms was 8800 i.u., and that in 8 of his patients the daily intake was less than 1000 LU. I did not suggest that idiopathic hypercalcaemia in recent years had been caused by vitamin D3 but this does not mean that it could not do so if it were to be used as extensively as vitamin D2 has been. I agree that Thatcher’s patient3 seems likely to have suffered from idiopathic hypercaicsmia, but in this instance the source of vitamin D was cod-liver oil, and the daily intake does not appear to have exceeded 1200 LV. I would suggest that the correct conclusions to be drawn from Malmberg’s experiment4 with large doses of cod-liver oil given to 2 premature infants are that this substance can cause myocardial atrophy and that this effect may be produced within a few days or weeks. It is an encouraging suggestion that toxic effects such as this may have been attributable to the impurity of the cod-liver oil used at that time, but this I think cannot be
regarded
as
proven.
Mr. Tunnicliffe has referred to the many years of clinical experience in the use of cod-liver oil, but I doubt if we have gained sufficient experience to be sure that the substance is quite harmless. Clinical experience with vitamin D2 was also extensive, but a decade elapsed after the fortification of infant foods and the institution of 1.
Bicknell, F., Prescott,
F. The Vitamins in
Medicine; p. 840. London,
1953. 2. Graham, S. Postgrad. Med. 1959, 25, 67. 3. Thatcher, L. Lancet, 1936, i, 20. 4. Malmberg, N. Acta pœdiat., Stockh. 1928, 8, 364.