- Email: [email protected]
THE METRIC SYSTEM IN MEDICINE
596
entering her office I sat for the first time, and was again asked to explain my lateness. The arrangements for ’travelling had, in fact, been made by the hospital. After signing a book, I was told a list of rules, from
which I discovered that I must rise at 7.30 a.m. and go to bed at 8.30 P.M. Breakfast was at 8.30 A.M. followed by prayers after which we had to return to the dormitory to make our beds. We were not given our post until this was over, and were not allowed to return to the dormitory again till bed-time. I protested that I was not well enough to be up and dressed all those hours, but was told that if patients wanted to rest they could lie on couches in the sitting-room ; but there were only three couches for twelve patients, and one could not always expect to have one of them. We took turns in washing up the dishes after meals. No difference in treatment was made for patients arriving in a state of great weakness and those who had been there several weeks. The food was plain but good, though there were no special diets or extra milk for anyone, whatever their
There was no nursing, and we only doctor once, for two minutes, while he signed Visitors were not allowed in the house papers. but. were asked to go to the back-garden gate to wait for their relations ; this seemed particularly ironic to me after reading an article on Broadmoor where I gather the prisoners can be seen on visiting days taking tea with their friends under the shady trees in the saw our
complaints.
a
prison grounds!
I stuck it for two weeks and then left to stay with a in another seaside town, but most of the patients were working women who could not afford to do that. It seems that those who can afford to pay for expensive homes are waited on hand and foot, while the poor-who all too soon are coping with heavy housework and queueing-are regimented back into health almost as if they were mentally deficient or delinquent, and too often in an atmosphere of charity. There was certainly no intention of being cruel or unkind in this home. It was just sheer lack of imagination. The house was pleasant, nicely furnished. and within a few minutes’ walk of the sea. The matron, who meant well enough, warned us on the first day that we were expected to settle in happily with no grumbles and no tears, as she would rather have an empty bed than an unhappy patient. It was quite impossible to relax in such an atmosphere, and the more sensitive patients showed signs of strain which never left them during their stay there. A PATIENT.
kindly landlady
THE METRIC SYSTEM IN MEDICINE
SiR—Mr. Finnemore lays down in his article (Oct. 11) that " All preparations for internal administration should be written for the single dose... the number of doses then being stated." May I point out that, where dangerous drugs are concerned, such practice is illegal in this country ? Under the Dangerous Drugs Act the total amount of the drug must be clearly prescribed. G. E. BREEN. SYMPTOMS FOLLOWING GASTRECTOMY
SiR,—I am more than interested in the recent views symptoms following partial gastrectomy. Without going into the previous literature I refer more especially to the article of Gilbert and Dunlop in the British ltJedical Journal of Aug. 30, and the article by Barnes, with an accompanying editorial, in your last issue. I suffer from somewhat similar symptoms myself. These started a fortnight after a partial gastrectomy, during a somewhat stormy convalescence. After taking a glass of milk, in bed of course, I had an immediate sensation on
of extreme exhaustion and tiredness, with a consciousness of the heart’s action. The really salient feature was the feeling of exhaustion. The symptoms lasted about half an hour, and as soon as I was no longer conscious of the heart’s action I felt perfectly normal. The pulse-rate rose from about 70 to a little over 90, with an occasional extra-systole. This was over a year ago and since then I have had fairly frequent similar attacks, always with exactly similar onset; first 1 have a vague sinking feeling in the pit of the stomach : next
I
conscious of the heart’s action ; and then I get this of extreme exhaustion. The symptoms may come on after a meal, but seem to run in cycles ; that is to say, one time I would have them always after breakfast, another time always after tea, and so on. I might get three or four attacks a week, and then go a week without any. They come on immediately after a meal, and I am convinced that if I lie down or rest half an hour after a meal I don’t get an attack. Once an attack is over I am perfectly fit and can do anything, until the next meal. The nature of the food taken seems to have no influence on the attacks. In fact, I got a slight attack immediately after taking glucose for the purposes of performing a bloodsugar curve. The curve rose to 200 mg. per 100 ml. in 40 minutes, was 100 mg. in 70 minutes, and finally fell to 67 mg. in 130 minutes. But, as I say, an attack started within 10 minutes of taking the glucose, when my blood-sugar was 181 mg. I really cannot see that any of the suggested explanations of this condition apply to my own .case. I may add that my age is 60, my blood-pressure is quite normal, and I have no pain or discomfort whatever referable to the stomach. The gastrectomy was performed for a am
feeling
chronic gastric ulcer which had recurred several times, and which did not respond to medical treatment. IODINE AND GOITRE
SI[R,-In your leading article of May 31 you discussed a recent paper of mine.1 You properly stated that " anyone who sets out to ’debunk’ some established method of preventing disease assumes a certain responsibility." I have no desire to evade responsibility for or any other, anything I have written, in that paper but I certainly question the use of " established in reference to the prophylactic use of iodine. You gave your readers a good and detailed account of my paper, although you did not agree with me. Space does not permit a recapitulation of those of my arguments that you discussed and rejected. Your readers must judge between us on the basis of your summary and your remarks, referring to the original paper for the actual evidence. There were, however, a few considerations that you did not mention. In the first place, locally produced foods play only a small part in the feeding of the large cities of the U.S.A. Most of the food comes from the If the published data are even same distant sources. approximately correct, the amount of iodine furnished by the drinking water and by the local produce cannot be very different in such cities as Cleveland (goitrous) and New York (non-goitrous). The leading Continental " iodine-lack hypothesis, von protagonist of the Fellenberg, conceded in 1938that he was unable to find a relation between the iodine content of the food and the occurrence of goitre in one community. This report has been severely neglected by proponents of the iodine-lack hypothesis. Even though it be conceded that this hypothesis is false, it might still be true that the administration of iodine should have prophylactic value, just as quinine and mepacine are useful in the prevention of malaria. Unfortunately, the evidence for the value of iodine is not satisfactory. You did not mention the fact that only two of those who reported beneficial results controlled their observations in any way, nor did you refer to the two reports 3of an increase in the incidence of goitre after the use of iodine. Post hoc, ergo propter hoc is the oldest of the fallacies. The history of goitre is replete with instances of reduction in severity, at least as marked as any that have been claimed to follow the use of iodine, that were observed without any known change in the intake of iodine and without the slightest reason for supposing that there had been any. Two such instances were mentioned in the paper under discussion and a reference was given to "
"
a
previous report containing
5 many more.
1. Greenwald, I. J. clin. Endocrin. 1916, 6, 708. Mitt. Lebensm. Hyg., Bern. 1938, 29, 290. 2. von Fellenberg, T. 3. Shore, R. A., Andrew, R. L. New Zealand, Dept. of Scientific and Industrial Research and Dept. of Health Bulletin, 1934, 4. 5.
p. 45. Ash, W. M. J. St. Med. 1926, 34, 627. Greenwald, I. Bull. Hist. Med. 1945. 17, 229.
entering her office I sat for the first time, and was again asked to explain my lateness. The arrangements for ’travelling had, in fact, been made by the hospital. After signing a book, I was told a list of rules, from
which I discovered that I must rise at 7.30 a.m. and go to bed at 8.30 P.M. Breakfast was at 8.30 A.M. followed by prayers after which we had to return to the dormitory to make our beds. We were not given our post until this was over, and were not allowed to return to the dormitory again till bed-time. I protested that I was not well enough to be up and dressed all those hours, but was told that if patients wanted to rest they could lie on couches in the sitting-room ; but there were only three couches for twelve patients, and one could not always expect to have one of them. We took turns in washing up the dishes after meals. No difference in treatment was made for patients arriving in a state of great weakness and those who had been there several weeks. The food was plain but good, though there were no special diets or extra milk for anyone, whatever their
There was no nursing, and we only doctor once, for two minutes, while he signed Visitors were not allowed in the house papers. but. were asked to go to the back-garden gate to wait for their relations ; this seemed particularly ironic to me after reading an article on Broadmoor where I gather the prisoners can be seen on visiting days taking tea with their friends under the shady trees in the saw our
complaints.
a
prison grounds!
I stuck it for two weeks and then left to stay with a in another seaside town, but most of the patients were working women who could not afford to do that. It seems that those who can afford to pay for expensive homes are waited on hand and foot, while the poor-who all too soon are coping with heavy housework and queueing-are regimented back into health almost as if they were mentally deficient or delinquent, and too often in an atmosphere of charity. There was certainly no intention of being cruel or unkind in this home. It was just sheer lack of imagination. The house was pleasant, nicely furnished. and within a few minutes’ walk of the sea. The matron, who meant well enough, warned us on the first day that we were expected to settle in happily with no grumbles and no tears, as she would rather have an empty bed than an unhappy patient. It was quite impossible to relax in such an atmosphere, and the more sensitive patients showed signs of strain which never left them during their stay there. A PATIENT.
kindly landlady
THE METRIC SYSTEM IN MEDICINE
SiR—Mr. Finnemore lays down in his article (Oct. 11) that " All preparations for internal administration should be written for the single dose... the number of doses then being stated." May I point out that, where dangerous drugs are concerned, such practice is illegal in this country ? Under the Dangerous Drugs Act the total amount of the drug must be clearly prescribed. G. E. BREEN. SYMPTOMS FOLLOWING GASTRECTOMY
SiR,—I am more than interested in the recent views symptoms following partial gastrectomy. Without going into the previous literature I refer more especially to the article of Gilbert and Dunlop in the British ltJedical Journal of Aug. 30, and the article by Barnes, with an accompanying editorial, in your last issue. I suffer from somewhat similar symptoms myself. These started a fortnight after a partial gastrectomy, during a somewhat stormy convalescence. After taking a glass of milk, in bed of course, I had an immediate sensation on
of extreme exhaustion and tiredness, with a consciousness of the heart’s action. The really salient feature was the feeling of exhaustion. The symptoms lasted about half an hour, and as soon as I was no longer conscious of the heart’s action I felt perfectly normal. The pulse-rate rose from about 70 to a little over 90, with an occasional extra-systole. This was over a year ago and since then I have had fairly frequent similar attacks, always with exactly similar onset; first 1 have a vague sinking feeling in the pit of the stomach : next
I
conscious of the heart’s action ; and then I get this of extreme exhaustion. The symptoms may come on after a meal, but seem to run in cycles ; that is to say, one time I would have them always after breakfast, another time always after tea, and so on. I might get three or four attacks a week, and then go a week without any. They come on immediately after a meal, and I am convinced that if I lie down or rest half an hour after a meal I don’t get an attack. Once an attack is over I am perfectly fit and can do anything, until the next meal. The nature of the food taken seems to have no influence on the attacks. In fact, I got a slight attack immediately after taking glucose for the purposes of performing a bloodsugar curve. The curve rose to 200 mg. per 100 ml. in 40 minutes, was 100 mg. in 70 minutes, and finally fell to 67 mg. in 130 minutes. But, as I say, an attack started within 10 minutes of taking the glucose, when my blood-sugar was 181 mg. I really cannot see that any of the suggested explanations of this condition apply to my own .case. I may add that my age is 60, my blood-pressure is quite normal, and I have no pain or discomfort whatever referable to the stomach. The gastrectomy was performed for a am
feeling
chronic gastric ulcer which had recurred several times, and which did not respond to medical treatment. IODINE AND GOITRE
SI[R,-In your leading article of May 31 you discussed a recent paper of mine.1 You properly stated that " anyone who sets out to ’debunk’ some established method of preventing disease assumes a certain responsibility." I have no desire to evade responsibility for or any other, anything I have written, in that paper but I certainly question the use of " established in reference to the prophylactic use of iodine. You gave your readers a good and detailed account of my paper, although you did not agree with me. Space does not permit a recapitulation of those of my arguments that you discussed and rejected. Your readers must judge between us on the basis of your summary and your remarks, referring to the original paper for the actual evidence. There were, however, a few considerations that you did not mention. In the first place, locally produced foods play only a small part in the feeding of the large cities of the U.S.A. Most of the food comes from the If the published data are even same distant sources. approximately correct, the amount of iodine furnished by the drinking water and by the local produce cannot be very different in such cities as Cleveland (goitrous) and New York (non-goitrous). The leading Continental " iodine-lack hypothesis, von protagonist of the Fellenberg, conceded in 1938that he was unable to find a relation between the iodine content of the food and the occurrence of goitre in one community. This report has been severely neglected by proponents of the iodine-lack hypothesis. Even though it be conceded that this hypothesis is false, it might still be true that the administration of iodine should have prophylactic value, just as quinine and mepacine are useful in the prevention of malaria. Unfortunately, the evidence for the value of iodine is not satisfactory. You did not mention the fact that only two of those who reported beneficial results controlled their observations in any way, nor did you refer to the two reports 3of an increase in the incidence of goitre after the use of iodine. Post hoc, ergo propter hoc is the oldest of the fallacies. The history of goitre is replete with instances of reduction in severity, at least as marked as any that have been claimed to follow the use of iodine, that were observed without any known change in the intake of iodine and without the slightest reason for supposing that there had been any. Two such instances were mentioned in the paper under discussion and a reference was given to "
"
a
previous report containing
5 many more.
1. Greenwald, I. J. clin. Endocrin. 1916, 6, 708. Mitt. Lebensm. Hyg., Bern. 1938, 29, 290. 2. von Fellenberg, T. 3. Shore, R. A., Andrew, R. L. New Zealand, Dept. of Scientific and Industrial Research and Dept. of Health Bulletin, 1934, 4. 5.
p. 45. Ash, W. M. J. St. Med. 1926, 34, 627. Greenwald, I. Bull. Hist. Med. 1945. 17, 229.