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THE FRONTIERS OF MEDICINE
850
Thorpe, who was chairman of the Section of General Practice of the American Medical Association last year, read a paper on obesity at the 100th annual meeting of the A.M.A. " The simplest to prepare and most easily obtainable highprotein, high-fat, low-carbohydrate diet " he said " and one that will produce the most rapid loss of weight without hunger, weakness, lethargy, or constipation, is made up of meat, fat, and water. The total quantity eaten need not be noted." This evidence and the evidence of history is very convincing, but what is needed to clinch the matter now is a long-term prospective study of obese people treated on these lines. This is a subject which might well engage the attention of the College of General Practitioners. RICHARD MACKARNESS.
as a third type of gastric ulcer, have more in with duodenal ulcers than with " ordinary" or type-I gastric ulcers. Incidentally, the three kinds of gastric ulcer have quite different prognoses and call for different methods of treatment. Combined ulcers have a particularly bad record of intractability and haemorrhage. Royal Free Hospital, H. DAINTREE JOHNSON. London, W.C.1.
I have
regarded
common
THE FRONTIERS OF MEDICINE .
SIR,-Professor Stuart-Harris (Aug. 30) said that when it was common to feel that was a student (1930) patients were admitted to the medical wards to lie and rot ", and Dr. Marshall (Sept. 20) has very deeply "
he
"
"
IRON DEFICIENCY IN MAN
SIR, Your leading article1 on this subject was extremely interesting and instructive. It is certain that a large group of patients in need of intensive iron therapy are intolerant to the usual available preparations. In fact, the changes of the gastrointestinal mucosa in irondeficiency anxmia make it less -tolerant than during a repleted state. The new oral chelated-iron compounds represent common
a
was
Treatment received
was:
distinct advance in the treatment of this very
condition.
disappointed that no mention was made of widely explored iron chelate/ferroglycine sulphate complex. Our own clinical experience was indicated in a recent publtcation: " The therapeutic and performance indexes of ferroglycine sulphate complex (’ Ferronord ’) are optimal in the treatment of iron-deficiency anoemia."2 It was quite evident that this new oral iron chelate provided the best therapeutic
I the
this statement. As one who felt with the resented Professor and who felt further that many patients were admitted solely for teaching purposes and the exercise of the higher diagnostic skills, may I quote a few figures in support of this view. Here is an analysis, which I made when a student, of the treatment and outcome of 30 consecutive admissions to two medical wards of a general hospital in 1932.
somewhat
most
results with the least evidence of side-effects. This was expressed as a therapeutic index which is a useful measurement of the value of any drug. Our results have been reproduced by a large group of investi3-9 attests to the unanimity congators. A long bibliography the index of the oral iron chelate/ferrocerning therapeutic
Only 2 cases showed any improvement as a result of the special " treatment available only in hospital. This is a very small series, but I think it is a fair random sample of conditions prevailing at that time. As regards impact on the student mind, some of us were diverted to the less lucrative but, as we felt, more honest pursuit of funda-
sivcine sulphate complex.
mental research.
JULIUS POMERANZE.
"
M.R.C.
Radiobiological Unit, Harwell.
COMBINED GASTRIC AND DUODENAL ULCER
read Dr. Billington’s analysis happy I recorded in your pages last the fact (Oct. 4) confirming 10-that combined-ulcer patients genetically resemble year with duodenal ulcers alone rather than those with subjects gastric ulcers alone.
SIR,-Iam
to
In earlier papers 11 12 I showed why this should be so, for an analysis of 135 combined-ulcer cases demonstrated that the duodenal ulcer was probably always there first, the gastric ulcer appearing later, usually as a complication of duodenal or pyloric stenosis with gastric retention. Combined-ulcer patients were also shown to have gastric secretion patterns similar to those of duodenal-ulcer patients, and, of course, different from those of the gastric-ulcer subjects. Gastric ulcers complicating duodenal ones appear to be a special variety which should probably be dealt with separately from other gastric ulcers in statistical analysis. My figures have differed from those of Dr. Billington, however, in that they have suggested that prepyloric ulcers, which 1. Lancet, 1958, i, 1162. 2. Pomeranze, J., Gadek, R. J. New Engl. J. Med. 1957, 257, 73. 3. Rummel, W., Candon, B. H. Int. Rec. Med. 1956, 12, 783. 4. Feldman, H. S., Rummel, W. Med. Times, 1956, 84, 1329. 5. Dwyer, T. A. Clin. Med. 1957, 4, 457. 6. Clancy, J. B., Aldrich, R. H., Rummel, W., Candon, B. H. Amer. Pract. Digest Treat. 1957, 8, 1948. 7. O’Brien, T. E., Onorato, R. R., Dwyer, T. A., Candon, B. H. West. J. Surg. 1957, 65, 29. 8. Wagner, H. Landarzt, 1955, 31, 496. 9. Jorgensen, G. Arztl. Wschr. 1955, 10, 92. 10. Johnson, H. D. Lancet, 1957, ii, 518. 11. Johnson, H. D. ibid. 1955, i, 266. 12. Johnson, H. D. Surg. Gynec. Obstet. 1956, 102, 287.
O. A. TROWELL.
FLICKERING LARYNGOSCOPES
SIR,-There is nothing more irritating to an anxsthedst than for the light of his laryngoscope to flicker, and sometimes fail altogether, just as the glottis has been visualised. This is a rather common failing of the standard Macintosh laryngoscope, and is almost invariably due, in my opinion, to
the fact that it is impossible to get any instrument on to the bulb to tighten it properly. The accompanying photograph, which is considerably enlarged, shows a small adaptation to the Macintosh laryngoscope blade which has proved to be very satisfactory, and which consists only of filing a small hole into both sides of the blade so that the body of the bulb can be held by a pair of artery forceps, which enables a really tight fit to be made between the bulb and the bulb-holder. J. D. M. BARTON.
Thorpe, who was chairman of the Section of General Practice of the American Medical Association last year, read a paper on obesity at the 100th annual meeting of the A.M.A. " The simplest to prepare and most easily obtainable highprotein, high-fat, low-carbohydrate diet " he said " and one that will produce the most rapid loss of weight without hunger, weakness, lethargy, or constipation, is made up of meat, fat, and water. The total quantity eaten need not be noted." This evidence and the evidence of history is very convincing, but what is needed to clinch the matter now is a long-term prospective study of obese people treated on these lines. This is a subject which might well engage the attention of the College of General Practitioners. RICHARD MACKARNESS.
as a third type of gastric ulcer, have more in with duodenal ulcers than with " ordinary" or type-I gastric ulcers. Incidentally, the three kinds of gastric ulcer have quite different prognoses and call for different methods of treatment. Combined ulcers have a particularly bad record of intractability and haemorrhage. Royal Free Hospital, H. DAINTREE JOHNSON. London, W.C.1.
I have
regarded
common
THE FRONTIERS OF MEDICINE .
SIR,-Professor Stuart-Harris (Aug. 30) said that when it was common to feel that was a student (1930) patients were admitted to the medical wards to lie and rot ", and Dr. Marshall (Sept. 20) has very deeply "
he
"
"
IRON DEFICIENCY IN MAN
SIR, Your leading article1 on this subject was extremely interesting and instructive. It is certain that a large group of patients in need of intensive iron therapy are intolerant to the usual available preparations. In fact, the changes of the gastrointestinal mucosa in irondeficiency anxmia make it less -tolerant than during a repleted state. The new oral chelated-iron compounds represent common
a
was
Treatment received
was:
distinct advance in the treatment of this very
condition.
disappointed that no mention was made of widely explored iron chelate/ferroglycine sulphate complex. Our own clinical experience was indicated in a recent publtcation: " The therapeutic and performance indexes of ferroglycine sulphate complex (’ Ferronord ’) are optimal in the treatment of iron-deficiency anoemia."2 It was quite evident that this new oral iron chelate provided the best therapeutic
I the
this statement. As one who felt with the resented Professor and who felt further that many patients were admitted solely for teaching purposes and the exercise of the higher diagnostic skills, may I quote a few figures in support of this view. Here is an analysis, which I made when a student, of the treatment and outcome of 30 consecutive admissions to two medical wards of a general hospital in 1932.
somewhat
most
results with the least evidence of side-effects. This was expressed as a therapeutic index which is a useful measurement of the value of any drug. Our results have been reproduced by a large group of investi3-9 attests to the unanimity congators. A long bibliography the index of the oral iron chelate/ferrocerning therapeutic
Only 2 cases showed any improvement as a result of the special " treatment available only in hospital. This is a very small series, but I think it is a fair random sample of conditions prevailing at that time. As regards impact on the student mind, some of us were diverted to the less lucrative but, as we felt, more honest pursuit of funda-
sivcine sulphate complex.
mental research.
JULIUS POMERANZE.
"
M.R.C.
Radiobiological Unit, Harwell.
COMBINED GASTRIC AND DUODENAL ULCER
read Dr. Billington’s analysis happy I recorded in your pages last the fact (Oct. 4) confirming 10-that combined-ulcer patients genetically resemble year with duodenal ulcers alone rather than those with subjects gastric ulcers alone.
SIR,-Iam
to
In earlier papers 11 12 I showed why this should be so, for an analysis of 135 combined-ulcer cases demonstrated that the duodenal ulcer was probably always there first, the gastric ulcer appearing later, usually as a complication of duodenal or pyloric stenosis with gastric retention. Combined-ulcer patients were also shown to have gastric secretion patterns similar to those of duodenal-ulcer patients, and, of course, different from those of the gastric-ulcer subjects. Gastric ulcers complicating duodenal ones appear to be a special variety which should probably be dealt with separately from other gastric ulcers in statistical analysis. My figures have differed from those of Dr. Billington, however, in that they have suggested that prepyloric ulcers, which 1. Lancet, 1958, i, 1162. 2. Pomeranze, J., Gadek, R. J. New Engl. J. Med. 1957, 257, 73. 3. Rummel, W., Candon, B. H. Int. Rec. Med. 1956, 12, 783. 4. Feldman, H. S., Rummel, W. Med. Times, 1956, 84, 1329. 5. Dwyer, T. A. Clin. Med. 1957, 4, 457. 6. Clancy, J. B., Aldrich, R. H., Rummel, W., Candon, B. H. Amer. Pract. Digest Treat. 1957, 8, 1948. 7. O’Brien, T. E., Onorato, R. R., Dwyer, T. A., Candon, B. H. West. J. Surg. 1957, 65, 29. 8. Wagner, H. Landarzt, 1955, 31, 496. 9. Jorgensen, G. Arztl. Wschr. 1955, 10, 92. 10. Johnson, H. D. Lancet, 1957, ii, 518. 11. Johnson, H. D. ibid. 1955, i, 266. 12. Johnson, H. D. Surg. Gynec. Obstet. 1956, 102, 287.
O. A. TROWELL.
FLICKERING LARYNGOSCOPES
SIR,-There is nothing more irritating to an anxsthedst than for the light of his laryngoscope to flicker, and sometimes fail altogether, just as the glottis has been visualised. This is a rather common failing of the standard Macintosh laryngoscope, and is almost invariably due, in my opinion, to
the fact that it is impossible to get any instrument on to the bulb to tighten it properly. The accompanying photograph, which is considerably enlarged, shows a small adaptation to the Macintosh laryngoscope blade which has proved to be very satisfactory, and which consists only of filing a small hole into both sides of the blade so that the body of the bulb can be held by a pair of artery forceps, which enables a really tight fit to be made between the bulb and the bulb-holder. J. D. M. BARTON.