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THE TRUTH SHOULD OUT
349 CARBOHYDRATE METABOLISM IN THE NEWBORN
curves after an intravenous glucose load before the first feed. There was wide variation in insulin response, but of particular interest was the observation that three small-fordates babies with symptomatic hypoglycxmia all showed an active insulin response.
IN the newborn blood-glucose levels tend to be lower than in the adult, and values of 15-30 mg. and even below 10 mg. per 100 ml. are not rare in babies who may appear perfectly well. The significance of these low levels has often been questioned. In 1959, Cornblath and his colleaguesdescribed 8 infants with various symptomsapnoea, cyanosis, jitteriness, convulsions, and comaTHE TRUTH SHOULD OUT appearing on the 2nd or 3rd day of life and associated with The were symptoms rapidly THE importance of treating a patient as a person with a profound hypoglycxmia. relieved by parenteral glucose administration. Sympto- family background, a past, and a future, was the main matic hypoglycsemia may be followed by permanent theme of a meeting of the Institute for Religion and neurological damagebut when the low blood-glucose is Medicineon Jan. 25, at which doctors, clergy, nurses, not accompanied by overt symptoms then irreversible and social workers discussed matters of common interest. brain damage is less likely. Hypoglycxmia in the lst week All agreed that the patient could not be the exclusive of life is defined as a blood-glucose below 20 mg. per property of any specific discipline: only if all concerned 100 ml. in the infant of low birth-weight, below 30 mg. got together and pooled their resources could he and his in the full-term less than 72 hours old, and below 40 mg. family receive the help that was their due. Nevertheless, in the full-term baby after 72 hours.4 97-98% of deterthere was clearly a long way to go before this ideal could minations are above these levels, and when the blood- be reached. glucose falls below, symptoms may occur. Transient General practice and hospital medicine were well symptomatic neonatal hypoglycsemia has been estimated represented at the meeting, though clergy of all denominato occur in 2-3 per 1000 live births, and the true figure tions were slightly in a majority. Misunderstandings and may well be higher. causes of friction were freely ventilated. Hospital chaplains The relatively low blood-glucose in the normal neonate clearly felt that they were not regarded as members of the has been attributed to many factors known to influence team, not told the diagnosis, and not sufficiently fully glucose homoeostasis in the adult, but it is now established informed to be of the greatest help to patients, relatives, that the rate of insulin secretion is diminished and glucose and hospital staffs. It was essential that they should act in tolerance is reduced in the first days after birth.5-7 Recent integration and not in isolation. " What were the doctors evidence also places no blame on adrenocortical function afraid of ? one chaplain asked. Answers ranged from and catecholamine production.1 A slow rate of glucoof confidence and the breach possessiveness of the doctorneogenesis probably forms part of the true explanation, patient relationship to the fear of challenge to the doctor’s and this is supported by consideration of those infants own beliefs and philosophies. A general practitioner told predominantly affected by symptomatic hypoglyceemia- how his group practice welcomed clergy as well as publicthe " small for dates ", the premature, the smaller of health doctors, social workers, district nurses, health twins (where disparity in size is large), and infants with visitors, and midwives, so that all concerned could discuss respiratory distress or with symptoms of cold exposure. In problems related to patients or parishioners. He claimed all these categories the liver-glycogen content is low, and that no ethical barrier existed between any of the workers, the onset of symptoms coincides with the time at which whose only object was the welfare of a patient and his the liver-glycogen would be almost depleted. The brain/ family. They must explain to each other their special liver ratio in a malnourished infant greatly exceeds that in languages and methods of thought, for, as one cleric said, the normal neonate,8 and the metabolic requirements of "Doctors don’t always realise that there is good religion the disproportionately large brain may exceed the capacity and bad religion, just as there is good doctoring and bad of the liver to maintain blood-glucose levels before doctoring." feeding and gluconeogenesis are properly established. Who should tell the patient what ? Discussion centred Lowy and Schiff9 measured urinary excretion of almost entirely round the problems of those dying from insulin in healthy newborn babies. They found that malignant disease and of their relatives. A consultant insulin excretion was low on the 1 st day of life, irrespective emphasised the need to be honest with patients yet not of type or absence of feeding, and had increased sixfold by take hope away, to speak only when diagnosis and progthe 5th day. As Lowy and Schiff suggest, this supports nosis were reasonably certain, and then to explain fully. the view that increased glucose tolerance in the 1st week One general practitioner also believed in taking patients of life is dependent on insulin secretion. It would be into confidence as soon as possible: hospitals who lied to interesting to know whether these findings also hold for patients (and sometimes to relatives) left an impossible small-for-dates babies, in particular those with sympsituation for the general practitioner when the patient tomatic hypoglycasmia. That this may not be so is hinted failed to improve; those working in homes for terminal at in a preliminary report 10 on serum-insulin and glucose care would echo this. A ward-sister regarded her role as that of a coordinator to help the medical staff to under1. Shelley, H. J., Neligan, G. A. Br. med. Bull. 1966, 22, 34. 2. Cornblath, M., Odell, G. B., Levin, E. Y. J. Pediat. 1959, 55, 545. stand what sort of person the patient was and so to plan 3. Anderson, J. M., Milner, R. D. G., Strich, S. J. J. Neurol. Neurosurg. the best approach in explaining his or her illness. ImporPsychiat. 1967, 30, 295. "
Cornblath, M., Schwartz, R. in Disorders of Carbohydrate Metabolism in Infancy. Philadelphia, 1966. 5. Baird, J., Farquar, J. W. Lancet, 1962, i, 71. 6. Bowie, M. D., Mulligan, P. B., Schwartz, R. Pediatrics, Springfield, 1963, 31, 590. 7. Cornblath, M., Wybregt, S. H., Baens, G. S. ibid. 32, 1007. 8. Dawkins, M. J. R. Ann. N.Y. Acad. Sci. 1963, 111, 538. 9. Lowy, C., Schiff, D. Lancet, 1968, i, 225. 10. Tiernan, J. R., Kemball, M. L., Smith, C. A. Abstr. Soc. Pediat. Res. 1967, p. 169. 4.
troubling the patient often came to light during casual conversation, and this could be a guide to the doctor, nurse, and priest in giving the patient the help he sought. Many speakers pointed out that some consultants not only lied to the patients but instructed the relatives to lie, and this caused great bitterness when the tant matters
1. Institute of
Religion
and
Medicine,
58a
Wimpole Street, London W.1.
350 realised he had been deceived. Truth was necessary between patients and their families. Many patients, perhaps most, became aware of their condition, although
patient
they were not willing to talk about it, before those around them realised; for these patients the conspiracy of silence and optimism might be hard to bear.
HALLUCINATIONS, ALCOHOL WITHDRAWAL, AND THIAMINE DEFICIENCY
How much of what happens when the alcoholic patient becomes shaky and hallucinated is simply the result of withdrawal of a cerebral-depressant drug; or are these phenomena due to dietary disturbance and vitamin deficiency ? Morganadds fresh and interesting evidence to the old debate. He made detailed observations of the physical and mental state of 17 alcoholics in hospital during the acute withdrawal stage, and in these same patients he studied pyruvate tolerance. Discussing results, he first divides the patients into two groups8 who became hallucinated and 9 who did not. The two groups differ in a number of ways: those in the hallucinated group tended to have limb tremor that lasted longer and to have truncal ataxia; they had been drinking daily before admission for significantly longer than the others; pyruvate-tolerance tests revealed definite evidence of thiamine deficiency in 4 out of the 8 cases in the first group, but in only 1 of the patients in the non-hallucinated group.
Morgan then examined in further detail the histories of the patients who had had hallucinations, and he noted the time relationship between onset of hallucinations and alcohol withdrawal: in only 3 instances was the sequence of events such that he regarded withdrawal as definitely related to precipitation of the hallucinatory illness, and these 3 cases happened to include all those patients in this series who had a fully developed attack of delirium tremens. In only 1 of these 3 patients did the pyruvate studies suggest thiamine deficiency. Morgan therefore concludes that delirium tremens is an alcohol-withdrawal rather than a thiamine-deficiency syndrome, and here his views are in accord with those of other investigators.23 When it comes to the aetiology of the mild hallucinatory states which fall short of delirium tremens, Morgan’s views are more controversial. His evidence, he believes, shows that alcohol withdrawal may sometimes have contributed. In other instances nothing, in his view, suggested that withdrawal was implicated, but there was strong evidence of thiamine deficiency. He seems to be proposing a dichotomy: on the one hand, delirium tremens, which is to be seen as a withdrawal syndrome; and, on the other, a subacute hallucinatory state whose origin may be variously alcohol withdrawal, thiamine deficiency, or an interaction of the two. The view that thiamine deficiency is important in the genesis of the subacute hallucinatory state has some strong evidence to contend with. Mendelson et al.,4 studying the withdrawal symptoms of volunteers, all of whom had throughout the experiment an adequate diet and full vitamin supplements, found that 5 out of 10 subjects had a mild hallucinatory illness, much like the 1. 2.
Morgan, H. G. Br. J. Psychiat. 1968, 114, 85. Victor, M., Adams, R. D. Res. Pubis Ass. Res. nerv. ment. Dis. 1953, 32, 526. 3. Isbell, H., Fraser, H. F., Wilder, A., Belleville, R. E., Eisenman, A. J. Q. Jl Stud. Alcohol, 1955, 16, 1. 4. Mendelson, J. H., La Dou, J., Solomon, P. ibid. 1964, suppl. no. 2, p. 40.
condition Morgan is considering. Alcohol withdrawal, in circumstances which preclude vitamin deficiency, can certainly cause mild hallucinations. But where Morgan believes the history rules out time relationship between withdrawal and onset of symptoms, can partial withdrawal really be dismissed as a cause ? Isbell et al.3 showed that a decrease of only a few millilitres in daily alcohol intake of people who were drinking heavily could upset equilibrium and result in a dramatic fall of blood-alcohol level. Morgan’s work does not claim to provide any final answers about genesis of alcoholic hallucinations, but the ideas he puts forward certainly provide some valuable leads. CONCORDE AND COSMONAUT
THE pressure which a man can survive without special precautions runs from about half an atmosphere to two atmospheres, figures which correspond, respectively, to an altitude of 18,000 feet and a sea depth of 33 feet. Outside these limits, a host of technical and physiological problems arise, and they have been solved (at the cost of geometrically increasing complexity) to the extent that the Concorde will fly at 60,000 feet and men, in loose suits, have dived to a depth of 1000 feet. These were some of the matters discussed at a joint meeting of the British Occupational Hygiene Society and the Society for Radiological Protection in London on Feb. 6 on radiation and hygiene problems in enclosed environments. Decompression times, for the very brief exposures possible at such depths, run into days; the penalties which are exacted for incorrect technique at quite moderate depths include air-embolism leading to disasters in the brain or pulmonary artery, rupture of the lung, pneumothorax, and air in the tissues. Rising pressure may close the eustachian tubes and cause collapse of the middle ear; and a nasal polyp may act as a flap valve and seal off a sinus during rising or falling pressure, with very painful consequences.
The completely sealed hull of a nuclear submarine may be occupied for months, so a source of oxygen is needed, and electrolysis of water is at present favoured. Absorption of carbon dioxide is usually achieved by monoethanolamine, a compound which can be regenerated by heat. Since the air is constantly recirculated, quite small amounts of contaminants are troublesome; complex monitoring systems are in use, and a strict discipline controls all materials allowed on board lest they give rise to vapour or
particulate pollution.
Cosmonauts and high-flying aircraft are exposed to radiation of far greater intensity than is found below 40,000 feet. The main sources are cosmic rays of galactic origin, solar flares (which happen once or twice a year), and electrons trapped by the earth’s magnetic field in the Van Allen belts at 600-10,000 km. and 12,000-70,000 km. Much effort is being devoted to estimating the intensity of these radiations and the likely exposures. For instance, a space vehicle on a moon flight might traverse the Van Allen belts in 50 minutes and receive, during the outward and return journeys, some 25 rads; or the captain of a Concorde might receive instrumental warning of the eruption of unusual solar activity and decide to decrease his altitude to 40,000 feet, putting a secure blanket of air between the zone of dangerous intensity and his passengers and crew. 5. The papers and discussions
pational Hygiene.
are to
be
published
in the Annals
of Occu-
curves after an intravenous glucose load before the first feed. There was wide variation in insulin response, but of particular interest was the observation that three small-fordates babies with symptomatic hypoglycxmia all showed an active insulin response.
IN the newborn blood-glucose levels tend to be lower than in the adult, and values of 15-30 mg. and even below 10 mg. per 100 ml. are not rare in babies who may appear perfectly well. The significance of these low levels has often been questioned. In 1959, Cornblath and his colleaguesdescribed 8 infants with various symptomsapnoea, cyanosis, jitteriness, convulsions, and comaTHE TRUTH SHOULD OUT appearing on the 2nd or 3rd day of life and associated with The were symptoms rapidly THE importance of treating a patient as a person with a profound hypoglycxmia. relieved by parenteral glucose administration. Sympto- family background, a past, and a future, was the main matic hypoglycsemia may be followed by permanent theme of a meeting of the Institute for Religion and neurological damagebut when the low blood-glucose is Medicineon Jan. 25, at which doctors, clergy, nurses, not accompanied by overt symptoms then irreversible and social workers discussed matters of common interest. brain damage is less likely. Hypoglycxmia in the lst week All agreed that the patient could not be the exclusive of life is defined as a blood-glucose below 20 mg. per property of any specific discipline: only if all concerned 100 ml. in the infant of low birth-weight, below 30 mg. got together and pooled their resources could he and his in the full-term less than 72 hours old, and below 40 mg. family receive the help that was their due. Nevertheless, in the full-term baby after 72 hours.4 97-98% of deterthere was clearly a long way to go before this ideal could minations are above these levels, and when the blood- be reached. glucose falls below, symptoms may occur. Transient General practice and hospital medicine were well symptomatic neonatal hypoglycsemia has been estimated represented at the meeting, though clergy of all denominato occur in 2-3 per 1000 live births, and the true figure tions were slightly in a majority. Misunderstandings and may well be higher. causes of friction were freely ventilated. Hospital chaplains The relatively low blood-glucose in the normal neonate clearly felt that they were not regarded as members of the has been attributed to many factors known to influence team, not told the diagnosis, and not sufficiently fully glucose homoeostasis in the adult, but it is now established informed to be of the greatest help to patients, relatives, that the rate of insulin secretion is diminished and glucose and hospital staffs. It was essential that they should act in tolerance is reduced in the first days after birth.5-7 Recent integration and not in isolation. " What were the doctors evidence also places no blame on adrenocortical function afraid of ? one chaplain asked. Answers ranged from and catecholamine production.1 A slow rate of glucoof confidence and the breach possessiveness of the doctorneogenesis probably forms part of the true explanation, patient relationship to the fear of challenge to the doctor’s and this is supported by consideration of those infants own beliefs and philosophies. A general practitioner told predominantly affected by symptomatic hypoglyceemia- how his group practice welcomed clergy as well as publicthe " small for dates ", the premature, the smaller of health doctors, social workers, district nurses, health twins (where disparity in size is large), and infants with visitors, and midwives, so that all concerned could discuss respiratory distress or with symptoms of cold exposure. In problems related to patients or parishioners. He claimed all these categories the liver-glycogen content is low, and that no ethical barrier existed between any of the workers, the onset of symptoms coincides with the time at which whose only object was the welfare of a patient and his the liver-glycogen would be almost depleted. The brain/ family. They must explain to each other their special liver ratio in a malnourished infant greatly exceeds that in languages and methods of thought, for, as one cleric said, the normal neonate,8 and the metabolic requirements of "Doctors don’t always realise that there is good religion the disproportionately large brain may exceed the capacity and bad religion, just as there is good doctoring and bad of the liver to maintain blood-glucose levels before doctoring." feeding and gluconeogenesis are properly established. Who should tell the patient what ? Discussion centred Lowy and Schiff9 measured urinary excretion of almost entirely round the problems of those dying from insulin in healthy newborn babies. They found that malignant disease and of their relatives. A consultant insulin excretion was low on the 1 st day of life, irrespective emphasised the need to be honest with patients yet not of type or absence of feeding, and had increased sixfold by take hope away, to speak only when diagnosis and progthe 5th day. As Lowy and Schiff suggest, this supports nosis were reasonably certain, and then to explain fully. the view that increased glucose tolerance in the 1st week One general practitioner also believed in taking patients of life is dependent on insulin secretion. It would be into confidence as soon as possible: hospitals who lied to interesting to know whether these findings also hold for patients (and sometimes to relatives) left an impossible small-for-dates babies, in particular those with sympsituation for the general practitioner when the patient tomatic hypoglycasmia. That this may not be so is hinted failed to improve; those working in homes for terminal at in a preliminary report 10 on serum-insulin and glucose care would echo this. A ward-sister regarded her role as that of a coordinator to help the medical staff to under1. Shelley, H. J., Neligan, G. A. Br. med. Bull. 1966, 22, 34. 2. Cornblath, M., Odell, G. B., Levin, E. Y. J. Pediat. 1959, 55, 545. stand what sort of person the patient was and so to plan 3. Anderson, J. M., Milner, R. D. G., Strich, S. J. J. Neurol. Neurosurg. the best approach in explaining his or her illness. ImporPsychiat. 1967, 30, 295. "
Cornblath, M., Schwartz, R. in Disorders of Carbohydrate Metabolism in Infancy. Philadelphia, 1966. 5. Baird, J., Farquar, J. W. Lancet, 1962, i, 71. 6. Bowie, M. D., Mulligan, P. B., Schwartz, R. Pediatrics, Springfield, 1963, 31, 590. 7. Cornblath, M., Wybregt, S. H., Baens, G. S. ibid. 32, 1007. 8. Dawkins, M. J. R. Ann. N.Y. Acad. Sci. 1963, 111, 538. 9. Lowy, C., Schiff, D. Lancet, 1968, i, 225. 10. Tiernan, J. R., Kemball, M. L., Smith, C. A. Abstr. Soc. Pediat. Res. 1967, p. 169. 4.
troubling the patient often came to light during casual conversation, and this could be a guide to the doctor, nurse, and priest in giving the patient the help he sought. Many speakers pointed out that some consultants not only lied to the patients but instructed the relatives to lie, and this caused great bitterness when the tant matters
1. Institute of
Religion
and
Medicine,
58a
Wimpole Street, London W.1.
350 realised he had been deceived. Truth was necessary between patients and their families. Many patients, perhaps most, became aware of their condition, although
patient
they were not willing to talk about it, before those around them realised; for these patients the conspiracy of silence and optimism might be hard to bear.
HALLUCINATIONS, ALCOHOL WITHDRAWAL, AND THIAMINE DEFICIENCY
How much of what happens when the alcoholic patient becomes shaky and hallucinated is simply the result of withdrawal of a cerebral-depressant drug; or are these phenomena due to dietary disturbance and vitamin deficiency ? Morganadds fresh and interesting evidence to the old debate. He made detailed observations of the physical and mental state of 17 alcoholics in hospital during the acute withdrawal stage, and in these same patients he studied pyruvate tolerance. Discussing results, he first divides the patients into two groups8 who became hallucinated and 9 who did not. The two groups differ in a number of ways: those in the hallucinated group tended to have limb tremor that lasted longer and to have truncal ataxia; they had been drinking daily before admission for significantly longer than the others; pyruvate-tolerance tests revealed definite evidence of thiamine deficiency in 4 out of the 8 cases in the first group, but in only 1 of the patients in the non-hallucinated group.
Morgan then examined in further detail the histories of the patients who had had hallucinations, and he noted the time relationship between onset of hallucinations and alcohol withdrawal: in only 3 instances was the sequence of events such that he regarded withdrawal as definitely related to precipitation of the hallucinatory illness, and these 3 cases happened to include all those patients in this series who had a fully developed attack of delirium tremens. In only 1 of these 3 patients did the pyruvate studies suggest thiamine deficiency. Morgan therefore concludes that delirium tremens is an alcohol-withdrawal rather than a thiamine-deficiency syndrome, and here his views are in accord with those of other investigators.23 When it comes to the aetiology of the mild hallucinatory states which fall short of delirium tremens, Morgan’s views are more controversial. His evidence, he believes, shows that alcohol withdrawal may sometimes have contributed. In other instances nothing, in his view, suggested that withdrawal was implicated, but there was strong evidence of thiamine deficiency. He seems to be proposing a dichotomy: on the one hand, delirium tremens, which is to be seen as a withdrawal syndrome; and, on the other, a subacute hallucinatory state whose origin may be variously alcohol withdrawal, thiamine deficiency, or an interaction of the two. The view that thiamine deficiency is important in the genesis of the subacute hallucinatory state has some strong evidence to contend with. Mendelson et al.,4 studying the withdrawal symptoms of volunteers, all of whom had throughout the experiment an adequate diet and full vitamin supplements, found that 5 out of 10 subjects had a mild hallucinatory illness, much like the 1. 2.
Morgan, H. G. Br. J. Psychiat. 1968, 114, 85. Victor, M., Adams, R. D. Res. Pubis Ass. Res. nerv. ment. Dis. 1953, 32, 526. 3. Isbell, H., Fraser, H. F., Wilder, A., Belleville, R. E., Eisenman, A. J. Q. Jl Stud. Alcohol, 1955, 16, 1. 4. Mendelson, J. H., La Dou, J., Solomon, P. ibid. 1964, suppl. no. 2, p. 40.
condition Morgan is considering. Alcohol withdrawal, in circumstances which preclude vitamin deficiency, can certainly cause mild hallucinations. But where Morgan believes the history rules out time relationship between withdrawal and onset of symptoms, can partial withdrawal really be dismissed as a cause ? Isbell et al.3 showed that a decrease of only a few millilitres in daily alcohol intake of people who were drinking heavily could upset equilibrium and result in a dramatic fall of blood-alcohol level. Morgan’s work does not claim to provide any final answers about genesis of alcoholic hallucinations, but the ideas he puts forward certainly provide some valuable leads. CONCORDE AND COSMONAUT
THE pressure which a man can survive without special precautions runs from about half an atmosphere to two atmospheres, figures which correspond, respectively, to an altitude of 18,000 feet and a sea depth of 33 feet. Outside these limits, a host of technical and physiological problems arise, and they have been solved (at the cost of geometrically increasing complexity) to the extent that the Concorde will fly at 60,000 feet and men, in loose suits, have dived to a depth of 1000 feet. These were some of the matters discussed at a joint meeting of the British Occupational Hygiene Society and the Society for Radiological Protection in London on Feb. 6 on radiation and hygiene problems in enclosed environments. Decompression times, for the very brief exposures possible at such depths, run into days; the penalties which are exacted for incorrect technique at quite moderate depths include air-embolism leading to disasters in the brain or pulmonary artery, rupture of the lung, pneumothorax, and air in the tissues. Rising pressure may close the eustachian tubes and cause collapse of the middle ear; and a nasal polyp may act as a flap valve and seal off a sinus during rising or falling pressure, with very painful consequences.
The completely sealed hull of a nuclear submarine may be occupied for months, so a source of oxygen is needed, and electrolysis of water is at present favoured. Absorption of carbon dioxide is usually achieved by monoethanolamine, a compound which can be regenerated by heat. Since the air is constantly recirculated, quite small amounts of contaminants are troublesome; complex monitoring systems are in use, and a strict discipline controls all materials allowed on board lest they give rise to vapour or
particulate pollution.
Cosmonauts and high-flying aircraft are exposed to radiation of far greater intensity than is found below 40,000 feet. The main sources are cosmic rays of galactic origin, solar flares (which happen once or twice a year), and electrons trapped by the earth’s magnetic field in the Van Allen belts at 600-10,000 km. and 12,000-70,000 km. Much effort is being devoted to estimating the intensity of these radiations and the likely exposures. For instance, a space vehicle on a moon flight might traverse the Van Allen belts in 50 minutes and receive, during the outward and return journeys, some 25 rads; or the captain of a Concorde might receive instrumental warning of the eruption of unusual solar activity and decide to decrease his altitude to 40,000 feet, putting a secure blanket of air between the zone of dangerous intensity and his passengers and crew. 5. The papers and discussions
pational Hygiene.
are to
be
published
in the Annals
of Occu-