THE ELDERLY SMOKER

1027 build his own presentation, mixing slides from the set with slides from other sources. The preparation of this kind of teaching material still ranks low in academic circles compared with publishing a paper even in an obscure journal, and it is not easy to find colleagues who are willing to undertake the task. Yet to assemble a coherent slide set requires academic skills and insights of a degree which surprises those who attempt to acquire them, and delights those who succeed. We should be pleased to hear from anyone who is willing to take part in this underrated but demanding and creative activity, to help TALC to provide material that is appreciated and wanted by so many teachers in developing countries. can

DAVID MORLEY FELICITY SAVAGE

Institute of Child Health, London WC1N 1EH

threw the substitute away my appetite was back to normal in about two weeks and I have put on 6 kg or so over the past year. This allergy may be rare, but it is so dangerous that it should be far more

widely appreciated. Another obscure illness is myalgic encephalomyelitis. This condition is difficult to diagnose. Whilst not wishing to challenge current theories (eg, viral) for myalgic encephalomyelitis may I suggest that some sufferers could really have the chicory allergy. At least, if they take chicory they should try throwing it away. Many of the symptoms that characterise myalgic encephalomyelitis resemble those I had (eg, extreme fatigue, confusion of thought, no sign of recovery, muscle weakness, and muscular pains). Department of Chemistry, University of Leicester, Leicester LEI 7RH

ATTITUDES TO ALCOHOL

ACUTE AORTIC DISSECTION

SiR,—Your Oct 1 (p 806) note about alcohol consumption in the

workplace refers to our paper.1 Your summary of what was a description of confused and contradictory attitudes to alcohol, contains an inaccuracy. It was 90% of those people who described their previous week’s drinking pattern as atypical who said they normally drink less-not, as suggested, 90% of all respondents. Those who described their previous week’s drinking as atypical comprised 27% of the workplace sample. Thus about 25% of the total sample reported that their intake in the previous week had been untypically high. This is still a high figure, which we think indicates unease about their level of drinking. Department of Community Medicine, King’s College School of Medicine and Dentistry,

RON ROBERTS JAMES MCEWEN

London SE5 8RX

MARTYN C. R. SYMONS

SiR,—Your Oct 8 editorial discusses acute aortic dissection. Physical signs in this condition may be transitory and when present can be diagnostic. A 66-year-old woman presented to the accident and emergency department with severe chest pain of sudden onset followed by syncope. She was normotensive and no abnormal cardiac signs were detected. However, the brachial and femoral pulses on the right were only intermittently palpable. A loud systolic bruit was also audible for a few minutes over the interscapular area only. Aortography confirmed proximal dissection extending to the femoral arteries. These transitory signs probably represent an evolving dissection. Repeat examination of patients with suspected acute aortic dissection is therefore essential. Cardiac Department,

King’s College Hospital, London SE5 9RS

DYLMITR RITTOO

1. Roberts R, Cyster R, McEwen J. Alcohol consumption in the workplace prospects for change? Publ Health 1988; 102: 463-69

CEREBRAL BLOOD FLOW IN PANIC DISORDER THE ELDERLY SMOKER

SiR,—Dr Bliss (Oct 15,

p

908)

concentrates too

much

on

the

possible deprivation for some long-term elderly smokers in hospital. Any such deprivation can easily be prevented by designating a small sitting (day) room in the ward for the small number of patients for whom a ban on smoking would be inhumane. She seems to disregard the increasing number of other patients, often admitted with acute or chronic chest conditions, who are either ex-smokers or non-smokers, where the irritant stimulus caused by tobacco smoke from patients near them may exacerbate the very condition they may have been admitted for, besides often causing considerable discomfort. I strongly support the chief medical officer’s renewed pressure. Marjory Warren Medical Centre, West Middlesex University Hospital, Middlesex TW7 6AF

JAMES ANDREWS

STRANGE ALLERGY TO CHICORY

Sirhave lately recovered from an unusual, but potentially dangerous, illness which turned out to be an allergy. Others may have the same problem without realising it (I know of one such case). I had lost about 9 kg and was 14% below my normal weight, which up to then had been stable. I had typical symptoms of malnutrition, and was perpetually tired and very weak. Medical investigations were instigated, and I began to make a great effort to eat. The essential problem was not that I did not want to eat but that I positively disliked eating, however tempting the food. With great effort and much discomfort I managed to regain a little weight. Medical experts at two different hospitals could find no cause despite extensive studies; nor could a psychiatrist. How long I could have maintained my enforced eating I do not know. Happily my wife heard by chance that some people were allergic to dried chicory, a major symptom being loss of appetite. Three years earlier I had stopped drinking coffee and had started to drink a "health food" called ’Barleycup’. This is rich in dried chicory, and must have been slowly turning me off food. When I

SIR,-Dr Woods and colleagues (Sept 17, p 678) report reduced regional cerebral blood flow after yohimbine infusion in patients with panic disorder. They conclude that "If confirmed in a larger series, the data would suggest roles for altered noradrenergic regulation of frontal cortical and possibly thalamic function or perfusion in panic disorder." There are three arguments against this interpretation. Hypocapnia secondary to hyperventilation commonly occurs during anxiety attacksl and reduces cerebral blood flow by causing vasoconstriction.2 Lactate, which does not share yohimbine’s adrenoreceptor blocking effect, but does induce anxiety, causes a similar reduction in regional cerebral blood flow when given to patients with panic disorder.3 Patients who have panic attacks show heightened sensitivity to a variety of other pharmacological agents including caffeine and CO2 inhalation, which suggests that such agents act as non-specific arousing stimuli rather than via specific pharmacological mechanisms.’ Woods and colleagues are not justified in assuming that their finding is specific to panic disorder. Gur et als have demonstrated that high levels of situational anxiety in normal subjects are associated with a decrease in cerebral blood flow. Indeed, Wood et al say that one control subject became anxious and showed such a decrease. Department of Psychological Medicine, King’s College Hospital, London SE5 9RS

MICHAEL MURPHY CHRISTOPHER BASS

C, Chambers JC, Kiff PJ, Cooper D, Gardner WN. Panic anxiety and hyperventilation in patients with chest pain: a controlled study. QJ Med (in press). 2. Hauge A, Thoresen M, Walle L. Changes in cerebral blood flow during hyperventilation and CO2 breathing measured transcutaneously in humans by a directional, pulsed ultrasound Doppler blood velocity meter. Acta Physiol Scand 1. Bass

1980; 110: 167-73 RS, Devous MD, Rush AJ,

et al. Cerebral blood flow changes during sodium-lactate-induced panic attacks. Am J Psychiatry 1986; 145: 442-49 4. Ehlers A, Margraf J, Roth WJ, et al. Lactate infusions and panic attacks: do patients and controls respond differently? Psychiat Res 1986; 17: 295-308. 5. Gur RC, Gur RE, Resnick SM, et al The effect of anxiety on cortical cerebral blood flow and metabolism. J Cereb Blood Flow Metab 1987; 7: 173-77

3 Stewart