- Email: [email protected]
WHAT OF GENERAL PRACTICE?
640
fully inflated, and mucus was aspirated from the several occasions. Nikethamide 2 ml. and picrotoxin 3 mg. produced no response.
dilator
lungs
was
on
Whole-blood cholinesterase levels in these patients and in five others who responded normally to succinylcholine (i.e., about 5 minutes’ apnoea) gave the following results : Case no. Cholinesterase * Response to succinylcholine 1 94 Delayed (75 min. apnosa) 2 91 Delayed (75 min. apnoea) A Normal 125 B 115 Normal C Normal 113 D 124 Normal E 114 Normal * The cholinesterase number was determined by the Michel electrometric method,3 and should be considered with reference to the normal range of 80-129. ..
..
..
..
..
..
,
..
.
..
v.
CARDIOSPASM
SIR,—In the interests of accuracy I should like to point out that Ryle’s patient with cardiospasm was not cured by the laying-on of hands. His symptoms were completely relieved and he was able to take part in vigorous athletics, but X-ray examination showed that the dilatation of the oesophagus and the hold-up at the cardia remained unchanged. The Radcliffe Infirmary, L. J. WITTS. Oxford.
WHAT OF GENERAL PRACTICE?
..
..
..
..
The
ACHALASIA
..
differences
in cholinesterase number between normal and those with delayed response are thus not so great as the differences cited ,by Bourne et al. ; but the simplicity of the Michel method makes it very suitable for screening cases in which the use of succinylcholine is proposed. We hope to carry out further work to ascertain whether plasma or erythrocyte levels would show a wider divergence bv this techniaue. J. E. REID Royal Victoria Hospital, D. W. NEILL. Belfast.
patients with
AVERSION TO ALCOHOL
SIR,—Dr. Pullar-Strecker refers (Sept. 13) to aversion to alcohol in Hodgkin’s disease. I have suffered from Hodgkin’s disease for five years at least. Very early on I became aware that about ten minutes after the ingestion of alcohol I had a pain at the site of the lesion. I have told this to many doctors, and most of them have, I suspect, thought that it was a psychoneurotic symptom but that I must be humoured. One professor, however, told me that it was a well-known phenomenon and that I must be absolutely teetotal. Another very famous physician said : " Well, alcohol is a vasodilator, so why not ? " The radiotherapist who has successfully treated me has found another patient who volunteered the same information ; so I am convinced that this is real. The sensation is so unpleasant that I have not persevered in experiments into its cause, but it seems that it might be worth investigating in our search for the cause and cure of this baffling disease. AN ON.
CANADIAN UNIVERSITY APPOINTMENTS SIR,—I note in your issue of Aug. 16 an advertisement for an assistant or associate professor of anatomy in a Canadian university at$4600 per annum. May I make this the occasion of some general observations on the state of affairs in Canada ?’? In the first place, your readers should be aware that Canadian universities rarely advertise for staff for medical schools, and that almost the only appointments advertised are those which Canadian doctors will not consider because they regard the salary as too low. Canada is the richest country in the Commonwealth and soon will be the richest country in the world. Correspondingly, the cost of living is high, and in the city where this associate professor of anatomy is to live it is higher than in most parts of the United States. My own estimate is that to have the same standard of living as a reader in anatomy in the United Kingdom, an associate professor here would require at least$8000 per annum. Commencing salaries are maximum salaries. The Canadian medical profession, in my view, ought not to tolerate a situation whereby few (or no) Canadians will accept preclinical posts in their medical schools. And until the Canadian Medical Association lays down a salary scale for all hospital and medical school appointments, intending candidates for Canadian posts should exercise due caution. TEACHER. Canada. 3. Aldridge, W. N.,
Davies, D. R.
Brit. med. J. 1952, i, 945.
SIR,—It seems a just summary of the discussion in your columns to say that since the demise of unspecialised consultant physicians the G.P. is the only comprehensive doctor left. As such he is the only one with the practical experience necessary to gain an over-all view of medicine. It would now seem high time he concerned himself with the subjugation of this unruly machinery of hospital and " scientific " medicine to the needs of his patients. That the machine is in part human must be allowed for, but this complication of evolutionary regression, by which a proportion of his colleagues have become cardinals of the machinery, must not distract the G.r.’s attention in his over-all view of the mechanism. As in all similar modern devices, the man-the whole man-must be master, or nothing but ill will come of it. B. M. O’SULLIVAN. London, S.W.I 0. -
-
SIR,—It has been suggested that a part of my letter of Sept. 20 might be interpreted as a criticism of certain services in this area. If this is so, may I quickly state that the general practitioners of Shropshire are fortunate in having access to an excellent and comprehensive pathological service. It is this happy experience which makes me feel that such an arrangement should be universal, and that it ought to be possible to provide access to X-ray departments in a similar way. JOHN C. RYLE. Shrewsbury. SALT-LOSING NEPHRITIS
SIR,—We are grateful to Dr. McGowan (Sept. 20) for drawing attention to an error in our paper on salt-losing nephritis (Sept. 6). We would point out, however, that the inistake was not one of biochemical estimation. The figures for serum-chlorides given in the table for case 2 actually represent chlorides as sodium chloride and should have been written and calculated as such. Thus the correct milliequivalent values for chlorides in this case lie between 610 and 79-0, levels which are quite compatible with the low serum-sodium figures and with a diagnosis of marked salt depletion. The suggestion of Dr. Atkinson and Dr. Prankerd (Sept. 13) that in 2 of our patients the state of salt loss might have been secondary to tuberculosis is interesting but, we think, untenable. In the first place, as they point out, the cases of Westwater et al. showed no obvious renal damage to account for their low serum-sodium levels ; our cases, on the other hand, all showed gross disorganisation of the kidneys. Secondly, we do not consider that our cases (the one with a small unilateral apical lesion and the other with healed miliary disease) are comparable with a group of patients who were seriously ill or dying from their pulmonary tuberculosis, for it was among such a group that Westwater et al. found the low levels of serum-sodium. Thirdly, no less than 9 out of 24 of their patients who died showed unequivocal proof of adrenal injury," evidence whioh was sought but not found in our cases, though the adrenalB were not, it is true, actually cultured for tubercle bacilli. As regards case 1 we had, as we admitted, no biochemical evidence of salt depletion in life. Since the publication of our paper, however, we have received information about the sodium chloride content of the "
fully inflated, and mucus was aspirated from the several occasions. Nikethamide 2 ml. and picrotoxin 3 mg. produced no response.
dilator
lungs
was
on
Whole-blood cholinesterase levels in these patients and in five others who responded normally to succinylcholine (i.e., about 5 minutes’ apnoea) gave the following results : Case no. Cholinesterase * Response to succinylcholine 1 94 Delayed (75 min. apnosa) 2 91 Delayed (75 min. apnoea) A Normal 125 B 115 Normal C Normal 113 D 124 Normal E 114 Normal * The cholinesterase number was determined by the Michel electrometric method,3 and should be considered with reference to the normal range of 80-129. ..
..
..
..
..
..
,
..
.
..
v.
CARDIOSPASM
SIR,—In the interests of accuracy I should like to point out that Ryle’s patient with cardiospasm was not cured by the laying-on of hands. His symptoms were completely relieved and he was able to take part in vigorous athletics, but X-ray examination showed that the dilatation of the oesophagus and the hold-up at the cardia remained unchanged. The Radcliffe Infirmary, L. J. WITTS. Oxford.
WHAT OF GENERAL PRACTICE?
..
..
..
..
The
ACHALASIA
..
differences
in cholinesterase number between normal and those with delayed response are thus not so great as the differences cited ,by Bourne et al. ; but the simplicity of the Michel method makes it very suitable for screening cases in which the use of succinylcholine is proposed. We hope to carry out further work to ascertain whether plasma or erythrocyte levels would show a wider divergence bv this techniaue. J. E. REID Royal Victoria Hospital, D. W. NEILL. Belfast.
patients with
AVERSION TO ALCOHOL
SIR,—Dr. Pullar-Strecker refers (Sept. 13) to aversion to alcohol in Hodgkin’s disease. I have suffered from Hodgkin’s disease for five years at least. Very early on I became aware that about ten minutes after the ingestion of alcohol I had a pain at the site of the lesion. I have told this to many doctors, and most of them have, I suspect, thought that it was a psychoneurotic symptom but that I must be humoured. One professor, however, told me that it was a well-known phenomenon and that I must be absolutely teetotal. Another very famous physician said : " Well, alcohol is a vasodilator, so why not ? " The radiotherapist who has successfully treated me has found another patient who volunteered the same information ; so I am convinced that this is real. The sensation is so unpleasant that I have not persevered in experiments into its cause, but it seems that it might be worth investigating in our search for the cause and cure of this baffling disease. AN ON.
CANADIAN UNIVERSITY APPOINTMENTS SIR,—I note in your issue of Aug. 16 an advertisement for an assistant or associate professor of anatomy in a Canadian university at$4600 per annum. May I make this the occasion of some general observations on the state of affairs in Canada ?’? In the first place, your readers should be aware that Canadian universities rarely advertise for staff for medical schools, and that almost the only appointments advertised are those which Canadian doctors will not consider because they regard the salary as too low. Canada is the richest country in the Commonwealth and soon will be the richest country in the world. Correspondingly, the cost of living is high, and in the city where this associate professor of anatomy is to live it is higher than in most parts of the United States. My own estimate is that to have the same standard of living as a reader in anatomy in the United Kingdom, an associate professor here would require at least$8000 per annum. Commencing salaries are maximum salaries. The Canadian medical profession, in my view, ought not to tolerate a situation whereby few (or no) Canadians will accept preclinical posts in their medical schools. And until the Canadian Medical Association lays down a salary scale for all hospital and medical school appointments, intending candidates for Canadian posts should exercise due caution. TEACHER. Canada. 3. Aldridge, W. N.,
Davies, D. R.
Brit. med. J. 1952, i, 945.
SIR,—It seems a just summary of the discussion in your columns to say that since the demise of unspecialised consultant physicians the G.P. is the only comprehensive doctor left. As such he is the only one with the practical experience necessary to gain an over-all view of medicine. It would now seem high time he concerned himself with the subjugation of this unruly machinery of hospital and " scientific " medicine to the needs of his patients. That the machine is in part human must be allowed for, but this complication of evolutionary regression, by which a proportion of his colleagues have become cardinals of the machinery, must not distract the G.r.’s attention in his over-all view of the mechanism. As in all similar modern devices, the man-the whole man-must be master, or nothing but ill will come of it. B. M. O’SULLIVAN. London, S.W.I 0. -
-
SIR,—It has been suggested that a part of my letter of Sept. 20 might be interpreted as a criticism of certain services in this area. If this is so, may I quickly state that the general practitioners of Shropshire are fortunate in having access to an excellent and comprehensive pathological service. It is this happy experience which makes me feel that such an arrangement should be universal, and that it ought to be possible to provide access to X-ray departments in a similar way. JOHN C. RYLE. Shrewsbury. SALT-LOSING NEPHRITIS
SIR,—We are grateful to Dr. McGowan (Sept. 20) for drawing attention to an error in our paper on salt-losing nephritis (Sept. 6). We would point out, however, that the inistake was not one of biochemical estimation. The figures for serum-chlorides given in the table for case 2 actually represent chlorides as sodium chloride and should have been written and calculated as such. Thus the correct milliequivalent values for chlorides in this case lie between 610 and 79-0, levels which are quite compatible with the low serum-sodium figures and with a diagnosis of marked salt depletion. The suggestion of Dr. Atkinson and Dr. Prankerd (Sept. 13) that in 2 of our patients the state of salt loss might have been secondary to tuberculosis is interesting but, we think, untenable. In the first place, as they point out, the cases of Westwater et al. showed no obvious renal damage to account for their low serum-sodium levels ; our cases, on the other hand, all showed gross disorganisation of the kidneys. Secondly, we do not consider that our cases (the one with a small unilateral apical lesion and the other with healed miliary disease) are comparable with a group of patients who were seriously ill or dying from their pulmonary tuberculosis, for it was among such a group that Westwater et al. found the low levels of serum-sodium. Thirdly, no less than 9 out of 24 of their patients who died showed unequivocal proof of adrenal injury," evidence whioh was sought but not found in our cases, though the adrenalB were not, it is true, actually cultured for tubercle bacilli. As regards case 1 we had, as we admitted, no biochemical evidence of salt depletion in life. Since the publication of our paper, however, we have received information about the sodium chloride content of the "