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TOBACCO-SMOKING
676 have been designed by Captain the modifications described in my earlier article, reference to which will show the difficulties of manual pumping and of getting access to the patient. R. E. SMITH. Rugby. All these
improvements
Smith-Clarke,
as
were
PREMENSTRUAL TENSION SiR,-May I comment on your leading
article of
Sept. 12 ? In the first place premenstrual tension is not as rare you suggest, for it was the main source of complaint in 3% of 2000 hospital patients. Secondly, your suggestion that progesterone treatment is highly successful is not borne out in my experience, for though it is true that about half the cases are adequately relieved there is little result in the remainder. On the contrary, most patients find ethisterone in large doses nauseating, and the common delay in the appearance of the next menstrual period is a source of anxiety to the majority of patients. Inhibition of ovulation by androgen therapy during the first fortnight of the period is more uniformly successful; masculinisation is not produced by the small doses used by Bishop. In any case this side-effect may be completely eliminated by the use of a newer non-virilising androgen such as ’Androstolone.’ This therapy combined with premenstrual ammonium chloride will relieve a great majority of cases. A point of considerable interest from the theoretical point of view is that these patients rarely complain of spasmodic dysmenorrhoea, and their intra-uterine pressure during the flow is never high. Both these facts substantiate Morton’s work on the diminished progestational influence which is probably the cause of the condition. ALBERT DAVIS. London, W.1. as
.
MONILIASIS DURING ANTIBIOTIC THERAPY
SiR,-As you stated in your annotation of July 25, Candida albicans is present in the gastro-intestinal tract of most normal people and, being resistant to all common antibiotics, will increase when concomitant bacteria are
eliminated by antibiotic therapy. I should like to add that the elimination of bacterial competitors for food-supply is certainly not the only factor involved in this increase of C. albicans, since it has been reported that some antibiotics have, at least in vitro, a direct or indirect stimulating effect on the growth of C. albicans. It has been shown by Moore,l by Pappenfort and Schnall,2 and more recently by Huppert et al.that aureomycin exerts a direct stimulation on the growth of C. albicans in Sabouraud’s broth, in Sabouraud’s agar, and in a semi-
broth. On the other hand, I had observed an indirect effect of penicillin on C. albicans (1947, unpublished). When cultivated
synthetic ,
in Schopfer’s entirely synthetic medium, this fungus requires biotin as the only essential growth factor. When biotin is present in the medium at an optimal concentration, penicillin, even in la-rge amounts, has no effect on the yield of C. albicans. But- when biotin is added in insufficient quantity to the synthetic medium, then the presence of penicillin (about 100 units per ml.) has a significant enhancing effect on the growth of C. albicans, as if it acted in synergism with biotin. When penicillin is present alone in the medium, without biotin, C. albicans does not grow at all-a fact which eliminates the possibility of penicillin containing, as an impurity, some growth-promoting factor.
In
the course of antibiotic therapy, elimination of some of the intestinal bacteria necessary for the synthesis of vitamins and other metabolites should have some adverse effect not only on the patient’s economy but also on C. albicans itself, which requires at least one of these metabolites, biotin. However, if the phenomenon 1. Moore, M. J. Lab. clin. Med. 1951, 37, 703. 2. Pappenfort, R. B., Schuall, E. S. Arch. intern. Med. 1951, 88, 729. 3. Huppert, M., MacPherson, D. A., Cazin, J. J. Bact, 1953, 65, 171.
described above also takes place in vivo, the presence of aureomycin or of penicillin might, at the same time, provide a way by which the fungus could overcome this deficiency and proliferate. Evidently, such observations do not yield any informa. tion as to whether C. albicans is actually responsible for the disturbances following antibiotic therapy. The abundance of C. albicans in the stools of patients with sprue or pernicious anffimia may suggest that, in all these cases, some definite change in the metabolic environment in the gastro-intestinal tract is the common cause of the fungus’s proliferation. New York State Medical Center, GEORGES H. WERNER. New York
City, U.S.A.
TOBACCO-SMOKING SiR,ŇA leisurely investigation into the psychology of tobacco-smoking in average people, which I made over a considerable number of years, .leaves me in no doubt that, contrary to what Dr. H. Pullar-Strecker (Sept. 12) maintains, tobacco is very much a drug of addiction. Precisely the same fundamental psychic attitudes shown by, for example, the morphine addict to morphine are also, on close scrutiny, plainly demonstrable to a greater or lesser extent in the addict to tobacco. Certain things, however, tend to obscure the kinship between these two addictions. The chief thing is that the textbook picture of the (for example, morphine, opium, hashish) addict, while true of addicts who have fallen into medical hands, is not a correct picture of addicts taken en masse. For instance, from conversations I have had with people who have been in the East and who have had opportunities of paying particular attention to the subject, it is evident that the vast majority of addicts are not miserable, depraved creatures whose one and only thought is to get hold of their daily supply : nor, again, do they require increasing doses to secure the effect of the drug. On the contrary, they are average, everyday people who go successfully about their everyday affairs-just like tobacco addicts in this country, provided they are assured of their 10-15 cigarettes a day. However, take away the supply of the tobacco addict and a very different picture presents itself-e.g., the child who will steal and then sell a typewriter to get money to buy cigarettes. Equivalent reactions are revealed by many adults who will spend more annually on cigarettes than would supply a much-needed annual holiday, a stair carpet, or an educational endowment policy for their children’s education. This point can be made still more plainly by considering how, in 1952, the people of this country spent far more on tobacco (jE823 million) than on the National Health Service. The amount we spend on tobacco and alcoholic drinks is almost a of what we spend on foodstuffs. Surely such figures betoken " an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means," and justify us in concluding that the W.H.O. distinction between drugs liable to produce addiction and habit-forming- drugs is mere
quarter
hairsplitting. The definition to which Dr. Pullar-Strecker refers is
unsatisfactory in that it mixes up psychological, moralistic, and social aspects, thereby unnecessarily confusing the issue. I would suggest, instead, the following
tentative definition of A
an
addiction :
psychiatric abnormality the psycho-economics of which is to effect a psychic equilibrium by means of repeated dependent behaviour directed towards an external and usually inanimate object which is eventually incorporated into the body which develops tolerance to the physical effects of the incorporation on the basic psychic relations with that object being at an oral level of libidinal development, and the dependence being such that equally satisfying substitute relations with other objects cannot be established, with, consequently, the production of withdrawal and
677
attempted substitute symptoms gratification is removed.
when the
physical
source
of
the
Such a definition holds even in those cases where the drug is taken by injection ; for, in addition to the invariable oral psychic symptoms revealed on investigation, other psychiatric symptoms deriving from other levels of libidinal development also enter into an addiction and may, superficially, obscure the basic clinical picture. Such a definition, also, would not only cover the " malignant " addictions, as Glover calls them, but also include very interesting " benign addictions not mentioned in textbooks. These include excessive milk-drinking in adults (the least complicated form of addiction) and barley-chewing and turnipchewing, cases of which have been referred to me by practitioners because of the chronic, compulsive, absorbing, and inordinate extent of such activities. R. GOOD. Shotts, Lanarkshire. "
OCCUPATIONAL HEALTH SERVICE SiR,-Dr. Parker, in his letter last week, recognises the danger of setting up a separate occupational health clinical service, with all the duplication and waste which that would entail. So far in this country we have only touched the fringe of occupational health. In the coming years we shall see a growing realisation that the health of a man or woman must be considered in relation to his or her total environment ; this need applies as strongly to shops, offices, shipyards, and farms as it does to factories. An occupational health service is necessary in order to increase both the health and the wealth of the
community. Such a service, however well organised at the top, cannot become a reality until the family doctor is enabled to consider the patient in relation to all the circumstances of his life. The present contribution which the 18,000 British doctors make to occupational health is equivalent to the employment of not more than 200 whole-time doctors, if as many. The 10% of G.1-.8 who play some small part in industrial work must be raised to 70% or more. This can be done only if there is an efficient regional organisation for occupational health to which the G.P. can look for advice and training. The Medical Practitioners’ Union recently published The most important a memorandum on this subject. conclusion reached was that an occupational health service must become an integral part of the National Health Service and not merely be coordinated with it. This could be well achieved by transferring the Factory Department to the Ministry of Health, thus keeping the experience of the Factory Department and ensuring its integration with the other health services. The organisation of an occupational health service at regional level raises a more controversial issue. Various reasons (which I have no space to give) impelled us to the conclusion that the local health authority (county or county borough) was the only practicable body for the purpose. Each M.o.H. would then have an additional assistant M.o.H. in charge of occupational health. The function of the latter would be to train, advise, and integrate the work of the G.P.S in the area in so far as occupational health was concerned. In the larger areas several whole-time doctors would be needed ; communal studies on morbidity would be undertaken and research work initiated. Only with some such regional organisation will G.P.S be enabled to play a full part in occupational health work. No cadre of experts can replace them. When I expressed this view to the T.U.C. conference recently I was asked whether the G.P. was going to learn occupational health at the expense of the patient. The speaker did not appreciate that sound clinical knowledge is the basis of occupational health work and that no theoretical training can possibly fit a doctor to enter any kind of
factory and deal with all its problems. He must learn on the job. Ihope that the medical profession will insist that a unified health service is the only one capable of producing true " occupational health." Medical Practitioners’ Union, 55, Russell Square, London, W.C.1.
BRUCE CARDEW General secretary.
PHENYLBUTAZONE SiR,ŅDuring the course of an investigation into the correlation of therapeutic effects with blood-levels in phenylbutazone therapy, we have noticed in recent months a diminution in the clinical response with a corresponding fall in the serum-phenylbutazone levels, sometimes to blank values, on a dose of 600 mg. daily. We have reason to believe this is due to a change in the coating of the tablet with consequent reduction of absorption of the drug. It has been possible by splitting the tablet before ingestion to obtain therapeutic effects and serum concentrations similar to those previously obtained, without any increase in the incidence of gastric disturbance. ENA BRUCK Rheumatism Department, M. E. FEARNLEY West London Hospital. I. MEANOCK. MALARIA IN SERVICEMEN of cases of malaria have been found number SiR,ŅA in Servicemen who have returned from abroad.12 Last year, at the Military Hospital, Tidworth,3 we saw 102 cases which were diagnosed by finding Plasmodium vivax in the blood. Of these 102 patients, 69 were having a first attack (suppressed primary cases), and 33 had had one or more previous attacks. All these patients had returned from service in Korea, Malaya, or Hong-Kong. While stationed overseas all patients had been on suppressive proguanil (’Paludrine’) 100 mg. daily, which was stopped some time during the voyage home. The distribution of cases was as follows :
Clinically the patients presented with fever, sometimes a rigor, and some with general malaise, headache, anorexia, and upper respiratory symptoms. Only 34 had palpable spleens. All patients responded rapidly to treatment with quinine gr. 10 and pamaquin. 10 mg. thrice daily for 14 days. Bed rest was enforced during
with
treatment, and
no serious toxic effects were noted. A follow-up of these cases 6 months to a year after treatment revealed 6 proven cases of relapse, and 4 in which there had been undiagnosed short-term fevers ; 4 patients could not be traced. This accords with the usual relapse-rate on such treatment. The possibility of a subclinical parasitaemia preceding clinical manifestations was investigated by blood . films taken from 84 fit men of the Gloucestershire Regiment approximately 6 months after proguanil was discontinued. There was only 1 positive result-in a man who had already had two recent attacks treated with quinine Of the apparently normal men in this group alone. 2 subsequently had attacks, one 4 days after the test and one a month later. There thus appeared to be no obvious subclinical parasitaemia. The use of proguanil as a suppressive agent is now well established, even though drug resistance arises in some strains of P. vivax and P. falciparum. The latent period
1. Macdonald, G. Lancet, 1952, ii, 45. 2. Adams, A. R. D., Seaton, D. R. Ibid. 3. See MacFarlane, R. G. Ibid, p. 288.
-
improvements
Smith-Clarke,
as
were
PREMENSTRUAL TENSION SiR,-May I comment on your leading
article of
Sept. 12 ? In the first place premenstrual tension is not as rare you suggest, for it was the main source of complaint in 3% of 2000 hospital patients. Secondly, your suggestion that progesterone treatment is highly successful is not borne out in my experience, for though it is true that about half the cases are adequately relieved there is little result in the remainder. On the contrary, most patients find ethisterone in large doses nauseating, and the common delay in the appearance of the next menstrual period is a source of anxiety to the majority of patients. Inhibition of ovulation by androgen therapy during the first fortnight of the period is more uniformly successful; masculinisation is not produced by the small doses used by Bishop. In any case this side-effect may be completely eliminated by the use of a newer non-virilising androgen such as ’Androstolone.’ This therapy combined with premenstrual ammonium chloride will relieve a great majority of cases. A point of considerable interest from the theoretical point of view is that these patients rarely complain of spasmodic dysmenorrhoea, and their intra-uterine pressure during the flow is never high. Both these facts substantiate Morton’s work on the diminished progestational influence which is probably the cause of the condition. ALBERT DAVIS. London, W.1. as
.
MONILIASIS DURING ANTIBIOTIC THERAPY
SiR,-As you stated in your annotation of July 25, Candida albicans is present in the gastro-intestinal tract of most normal people and, being resistant to all common antibiotics, will increase when concomitant bacteria are
eliminated by antibiotic therapy. I should like to add that the elimination of bacterial competitors for food-supply is certainly not the only factor involved in this increase of C. albicans, since it has been reported that some antibiotics have, at least in vitro, a direct or indirect stimulating effect on the growth of C. albicans. It has been shown by Moore,l by Pappenfort and Schnall,2 and more recently by Huppert et al.that aureomycin exerts a direct stimulation on the growth of C. albicans in Sabouraud’s broth, in Sabouraud’s agar, and in a semi-
broth. On the other hand, I had observed an indirect effect of penicillin on C. albicans (1947, unpublished). When cultivated
synthetic ,
in Schopfer’s entirely synthetic medium, this fungus requires biotin as the only essential growth factor. When biotin is present in the medium at an optimal concentration, penicillin, even in la-rge amounts, has no effect on the yield of C. albicans. But- when biotin is added in insufficient quantity to the synthetic medium, then the presence of penicillin (about 100 units per ml.) has a significant enhancing effect on the growth of C. albicans, as if it acted in synergism with biotin. When penicillin is present alone in the medium, without biotin, C. albicans does not grow at all-a fact which eliminates the possibility of penicillin containing, as an impurity, some growth-promoting factor.
In
the course of antibiotic therapy, elimination of some of the intestinal bacteria necessary for the synthesis of vitamins and other metabolites should have some adverse effect not only on the patient’s economy but also on C. albicans itself, which requires at least one of these metabolites, biotin. However, if the phenomenon 1. Moore, M. J. Lab. clin. Med. 1951, 37, 703. 2. Pappenfort, R. B., Schuall, E. S. Arch. intern. Med. 1951, 88, 729. 3. Huppert, M., MacPherson, D. A., Cazin, J. J. Bact, 1953, 65, 171.
described above also takes place in vivo, the presence of aureomycin or of penicillin might, at the same time, provide a way by which the fungus could overcome this deficiency and proliferate. Evidently, such observations do not yield any informa. tion as to whether C. albicans is actually responsible for the disturbances following antibiotic therapy. The abundance of C. albicans in the stools of patients with sprue or pernicious anffimia may suggest that, in all these cases, some definite change in the metabolic environment in the gastro-intestinal tract is the common cause of the fungus’s proliferation. New York State Medical Center, GEORGES H. WERNER. New York
City, U.S.A.
TOBACCO-SMOKING SiR,ŇA leisurely investigation into the psychology of tobacco-smoking in average people, which I made over a considerable number of years, .leaves me in no doubt that, contrary to what Dr. H. Pullar-Strecker (Sept. 12) maintains, tobacco is very much a drug of addiction. Precisely the same fundamental psychic attitudes shown by, for example, the morphine addict to morphine are also, on close scrutiny, plainly demonstrable to a greater or lesser extent in the addict to tobacco. Certain things, however, tend to obscure the kinship between these two addictions. The chief thing is that the textbook picture of the (for example, morphine, opium, hashish) addict, while true of addicts who have fallen into medical hands, is not a correct picture of addicts taken en masse. For instance, from conversations I have had with people who have been in the East and who have had opportunities of paying particular attention to the subject, it is evident that the vast majority of addicts are not miserable, depraved creatures whose one and only thought is to get hold of their daily supply : nor, again, do they require increasing doses to secure the effect of the drug. On the contrary, they are average, everyday people who go successfully about their everyday affairs-just like tobacco addicts in this country, provided they are assured of their 10-15 cigarettes a day. However, take away the supply of the tobacco addict and a very different picture presents itself-e.g., the child who will steal and then sell a typewriter to get money to buy cigarettes. Equivalent reactions are revealed by many adults who will spend more annually on cigarettes than would supply a much-needed annual holiday, a stair carpet, or an educational endowment policy for their children’s education. This point can be made still more plainly by considering how, in 1952, the people of this country spent far more on tobacco (jE823 million) than on the National Health Service. The amount we spend on tobacco and alcoholic drinks is almost a of what we spend on foodstuffs. Surely such figures betoken " an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means," and justify us in concluding that the W.H.O. distinction between drugs liable to produce addiction and habit-forming- drugs is mere
quarter
hairsplitting. The definition to which Dr. Pullar-Strecker refers is
unsatisfactory in that it mixes up psychological, moralistic, and social aspects, thereby unnecessarily confusing the issue. I would suggest, instead, the following
tentative definition of A
an
addiction :
psychiatric abnormality the psycho-economics of which is to effect a psychic equilibrium by means of repeated dependent behaviour directed towards an external and usually inanimate object which is eventually incorporated into the body which develops tolerance to the physical effects of the incorporation on the basic psychic relations with that object being at an oral level of libidinal development, and the dependence being such that equally satisfying substitute relations with other objects cannot be established, with, consequently, the production of withdrawal and
677
attempted substitute symptoms gratification is removed.
when the
physical
source
of
the
Such a definition holds even in those cases where the drug is taken by injection ; for, in addition to the invariable oral psychic symptoms revealed on investigation, other psychiatric symptoms deriving from other levels of libidinal development also enter into an addiction and may, superficially, obscure the basic clinical picture. Such a definition, also, would not only cover the " malignant " addictions, as Glover calls them, but also include very interesting " benign addictions not mentioned in textbooks. These include excessive milk-drinking in adults (the least complicated form of addiction) and barley-chewing and turnipchewing, cases of which have been referred to me by practitioners because of the chronic, compulsive, absorbing, and inordinate extent of such activities. R. GOOD. Shotts, Lanarkshire. "
OCCUPATIONAL HEALTH SERVICE SiR,-Dr. Parker, in his letter last week, recognises the danger of setting up a separate occupational health clinical service, with all the duplication and waste which that would entail. So far in this country we have only touched the fringe of occupational health. In the coming years we shall see a growing realisation that the health of a man or woman must be considered in relation to his or her total environment ; this need applies as strongly to shops, offices, shipyards, and farms as it does to factories. An occupational health service is necessary in order to increase both the health and the wealth of the
community. Such a service, however well organised at the top, cannot become a reality until the family doctor is enabled to consider the patient in relation to all the circumstances of his life. The present contribution which the 18,000 British doctors make to occupational health is equivalent to the employment of not more than 200 whole-time doctors, if as many. The 10% of G.1-.8 who play some small part in industrial work must be raised to 70% or more. This can be done only if there is an efficient regional organisation for occupational health to which the G.P. can look for advice and training. The Medical Practitioners’ Union recently published The most important a memorandum on this subject. conclusion reached was that an occupational health service must become an integral part of the National Health Service and not merely be coordinated with it. This could be well achieved by transferring the Factory Department to the Ministry of Health, thus keeping the experience of the Factory Department and ensuring its integration with the other health services. The organisation of an occupational health service at regional level raises a more controversial issue. Various reasons (which I have no space to give) impelled us to the conclusion that the local health authority (county or county borough) was the only practicable body for the purpose. Each M.o.H. would then have an additional assistant M.o.H. in charge of occupational health. The function of the latter would be to train, advise, and integrate the work of the G.P.S in the area in so far as occupational health was concerned. In the larger areas several whole-time doctors would be needed ; communal studies on morbidity would be undertaken and research work initiated. Only with some such regional organisation will G.P.S be enabled to play a full part in occupational health work. No cadre of experts can replace them. When I expressed this view to the T.U.C. conference recently I was asked whether the G.P. was going to learn occupational health at the expense of the patient. The speaker did not appreciate that sound clinical knowledge is the basis of occupational health work and that no theoretical training can possibly fit a doctor to enter any kind of
factory and deal with all its problems. He must learn on the job. Ihope that the medical profession will insist that a unified health service is the only one capable of producing true " occupational health." Medical Practitioners’ Union, 55, Russell Square, London, W.C.1.
BRUCE CARDEW General secretary.
PHENYLBUTAZONE SiR,ŅDuring the course of an investigation into the correlation of therapeutic effects with blood-levels in phenylbutazone therapy, we have noticed in recent months a diminution in the clinical response with a corresponding fall in the serum-phenylbutazone levels, sometimes to blank values, on a dose of 600 mg. daily. We have reason to believe this is due to a change in the coating of the tablet with consequent reduction of absorption of the drug. It has been possible by splitting the tablet before ingestion to obtain therapeutic effects and serum concentrations similar to those previously obtained, without any increase in the incidence of gastric disturbance. ENA BRUCK Rheumatism Department, M. E. FEARNLEY West London Hospital. I. MEANOCK. MALARIA IN SERVICEMEN of cases of malaria have been found number SiR,ŅA in Servicemen who have returned from abroad.12 Last year, at the Military Hospital, Tidworth,3 we saw 102 cases which were diagnosed by finding Plasmodium vivax in the blood. Of these 102 patients, 69 were having a first attack (suppressed primary cases), and 33 had had one or more previous attacks. All these patients had returned from service in Korea, Malaya, or Hong-Kong. While stationed overseas all patients had been on suppressive proguanil (’Paludrine’) 100 mg. daily, which was stopped some time during the voyage home. The distribution of cases was as follows :
Clinically the patients presented with fever, sometimes a rigor, and some with general malaise, headache, anorexia, and upper respiratory symptoms. Only 34 had palpable spleens. All patients responded rapidly to treatment with quinine gr. 10 and pamaquin. 10 mg. thrice daily for 14 days. Bed rest was enforced during
with
treatment, and
no serious toxic effects were noted. A follow-up of these cases 6 months to a year after treatment revealed 6 proven cases of relapse, and 4 in which there had been undiagnosed short-term fevers ; 4 patients could not be traced. This accords with the usual relapse-rate on such treatment. The possibility of a subclinical parasitaemia preceding clinical manifestations was investigated by blood . films taken from 84 fit men of the Gloucestershire Regiment approximately 6 months after proguanil was discontinued. There was only 1 positive result-in a man who had already had two recent attacks treated with quinine Of the apparently normal men in this group alone. 2 subsequently had attacks, one 4 days after the test and one a month later. There thus appeared to be no obvious subclinical parasitaemia. The use of proguanil as a suppressive agent is now well established, even though drug resistance arises in some strains of P. vivax and P. falciparum. The latent period
1. Macdonald, G. Lancet, 1952, ii, 45. 2. Adams, A. R. D., Seaton, D. R. Ibid. 3. See MacFarlane, R. G. Ibid, p. 288.
-