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WHO OUGHT TO SEE A PSYCHIATRIST?
93 to
primitive
Man’s diet would be in the form of insects and
small birds. I venture to suggest that the diet of primitive Man consisted of fruits, berries, and nuts primarily, with animal additions of insects and eggs, and small birds if he could catch them. Even so, this alternative diet still supports the second sentence in Professor Yudkin’s third proposition-namely, that the foods which early Man found most palatable gave him a diet poor in carbohydrate and richer in protein and fat. This is of fundamental importance and I cannot stress it too much, because it points to the correct balance in the diet we are trying to define-the diet to which the body is already adapted and which therefore is a good one and will maintain good health and will not predispose to or even cause disease. Ever since Man’s brain became large enough to enable him to have logical thought, he has considered himself apart from all other animals; but in evolutionary terms it is only yesterday that we descended from the trees to become actively bipedal. We shall do well not to forget our animal heritage-particularly in the study of nutrition. Levenshulme, Manchester, 19.
S. G.
JEFFS.
THE COMPLEAT PHYSICIAN
SIR,—I thank you for enabling me to read last week Dr. Rae Gilchrist’s Harveian Oration. I was interested in the list of ten qualities which 1400 teachers considered important in the boy intending to be a doctor: loyalty, perseverance, poise, conscientiousness,
Shock is not uncommon after snake-bite, and its familiar features are usually present. The explanation of their absence in this case may rest in the nature of the venom, since no drugs were given before admission. P. A. VARDY Department of Pædiatrics, The Government Hospital, R. ROUBENOFF. Ashkelon, Israel. WHO OUGHT TO SEE A PSYCHIATRIST? SIR,-Une has no quarrel with Dr. Kessel’sgeneral
conclusions in his survey (May 18) of why patients are referred to psychiatrists. But he touches only by implication on an important aspect of the referral process-namely, the interpersonal relationship between the referring doctor and the patient. In my experience this has often been of significance, especially if one makes some assessment of this feature of the situation when the patient is referred. A gross example is provided by the patient who falls in love with her doctor. The latter is plagued by a series of night calls for trivial complaints. Although no objective assessment of the presence of a psychoneurosis has been made, referral is resorted to, invariably quite justifiably. Fluctuations in the pressure of work may also influence the referral-rate by general practitioners. Thus, an epidemic of infectious illness may limit the time he has available to deal with neurotic patients and his referral-rate increases. Dr. Kessel’s article will help to bring more objectivity into the situation, but the human equation remains basic. Port Elizabeth, South Africa.
resourcefulness, sympathy, patience, compassion, gentleness, imagination. But are not all these attributes essential for success in any walk of life above the menial few ? From this, I would deduce that there are no special characteristics required in a doctor. Except, of course, the basic two: to be human and humane. LEON M. SHIRLAW.
HYPOTENSION WITHOUT SHOCK
SIR,-It may be of interest to record an additional case of hypotension without the familiar clinical features of shock. In this instance, it followed a snake-bite. Dr. Barraclough and Professor Sharpey-Schaferdraw attention to the loss of circulatory reflexes after the use of depressants of the central nervbus system or after cerebrovascular accidents. The condition is characterised by severe hypotension, but with warm skin, of normal colour, a relatively slow pulse-rate, and venous distension (i.e., a clinical situation quite different from the usual state of shock). ’
A boy aged 10 years was admitted 3 hours after being bitten the heel by a snake which was identified as Vipera palestinensis. On admission his blood-pressure was unrecordable and no pulse was felt at the wrist. His state of consciousness was clouded, but his skin was warm and dry and to our surprise he had heart sounds of excellent quality and a rate of 100 per min. with occasional extrasystoles. An intravenous infusion of noradrenaline was started immediately, but the response was delayed and his blood-pressure rose only after a total of 4 mg. of noradrenaline had been given over 15 minutes in 500 ml. of 5% glucose. His blood-pressure remained normal thereafter, and after further treatment with intravenous hydrocortisone, anti-venom, and blood, the child made a full recovery. on
It should be noted that this
was not a severe
snake-bite,
in view of the absence of hxmolysis and the rapid recovery. 1.
Lancet, 1963, i, 1121.
TERENCE E. LYNCH.
SALICYLATE ACTION AND THYROIDAL AUTONOMY IN HYPERTHYROIDISM
SIR,-We were most interested to read the paper by Mr. Myhill and Dr. Hales (April 13) in which reference is made to previous work from this laboratory.l22 The authors confirm our findings indicating a depression of T.S.H. secretion in normal subjects. In hyperthyroidism and Hales studies in carried out secretion-rate Myhill four patients, with no change in two, increase in one, and a possible slowing in the other. In our studies, following therapy doses of 1311, a definite slowing has now been observed in four out of eight cases. The mechanism of this effect of salicylate is fully discussed in our previous paper with reference to the possibility of displacement of thyroid hormones from binding plasma-proteins.2 Subsequent studies in man and rats in this laboratory indicate that, despite the fall in plasma protein-bound iodine (P.B.I.), there is an increase in circulating free thyroxine in vivo after administration of salicylate, and in rats this rise is associated with a fall in plasma-T.s.H. levels.3 Hence the fall in secretion-rate in the thyrotoxic patients suggests susceptibility to a fall in circulating T.S.H. levels in some cases of thyrotoxicosis. Recently we have shown that the circulating iodoamino-acid 4 pattern characteristic of thyrotoxicosis can be reproduced by The thyrotoxic T.S.H. administration to normal subjects.5 pattern is also occasionally seen in normal subjects with plasma These P.B.I. levels at the upper limit of the normal range. from the normal to the transition findings suggest gradual hyperthyroid state.6 The use of the word " autonomous " to describe the behaviour of the thyrotoxic gland is misleading, since the Hetzel, B. S., Good, B. F., Charnock, J. S., Welby, M. L. Lancet, 1960, i, 957. 2. Hetzel, B. S., Good, B. F., Wellby, N. L., Begg, M. W. Aust. Ann. Med. 1962, 11, 34. 3. Good, B. F., Hetzel, B. S. Unpublished data. 4. Wellby, M. L., Hetzel, B. S., Good, B. F. Brit med. J. 1963, i, 439. 5. Wellby, M. L., Hetzel, B. S. Nature, Lond. 1962, 193, 752. 6. Wellby, M. L., Hetzel, B. S., Isaachsen, M. L. Aust. Ann. Med. 1963, 12, 30. 1.
primitive
Man’s diet would be in the form of insects and
small birds. I venture to suggest that the diet of primitive Man consisted of fruits, berries, and nuts primarily, with animal additions of insects and eggs, and small birds if he could catch them. Even so, this alternative diet still supports the second sentence in Professor Yudkin’s third proposition-namely, that the foods which early Man found most palatable gave him a diet poor in carbohydrate and richer in protein and fat. This is of fundamental importance and I cannot stress it too much, because it points to the correct balance in the diet we are trying to define-the diet to which the body is already adapted and which therefore is a good one and will maintain good health and will not predispose to or even cause disease. Ever since Man’s brain became large enough to enable him to have logical thought, he has considered himself apart from all other animals; but in evolutionary terms it is only yesterday that we descended from the trees to become actively bipedal. We shall do well not to forget our animal heritage-particularly in the study of nutrition. Levenshulme, Manchester, 19.
S. G.
JEFFS.
THE COMPLEAT PHYSICIAN
SIR,—I thank you for enabling me to read last week Dr. Rae Gilchrist’s Harveian Oration. I was interested in the list of ten qualities which 1400 teachers considered important in the boy intending to be a doctor: loyalty, perseverance, poise, conscientiousness,
Shock is not uncommon after snake-bite, and its familiar features are usually present. The explanation of their absence in this case may rest in the nature of the venom, since no drugs were given before admission. P. A. VARDY Department of Pædiatrics, The Government Hospital, R. ROUBENOFF. Ashkelon, Israel. WHO OUGHT TO SEE A PSYCHIATRIST? SIR,-Une has no quarrel with Dr. Kessel’sgeneral
conclusions in his survey (May 18) of why patients are referred to psychiatrists. But he touches only by implication on an important aspect of the referral process-namely, the interpersonal relationship between the referring doctor and the patient. In my experience this has often been of significance, especially if one makes some assessment of this feature of the situation when the patient is referred. A gross example is provided by the patient who falls in love with her doctor. The latter is plagued by a series of night calls for trivial complaints. Although no objective assessment of the presence of a psychoneurosis has been made, referral is resorted to, invariably quite justifiably. Fluctuations in the pressure of work may also influence the referral-rate by general practitioners. Thus, an epidemic of infectious illness may limit the time he has available to deal with neurotic patients and his referral-rate increases. Dr. Kessel’s article will help to bring more objectivity into the situation, but the human equation remains basic. Port Elizabeth, South Africa.
resourcefulness, sympathy, patience, compassion, gentleness, imagination. But are not all these attributes essential for success in any walk of life above the menial few ? From this, I would deduce that there are no special characteristics required in a doctor. Except, of course, the basic two: to be human and humane. LEON M. SHIRLAW.
HYPOTENSION WITHOUT SHOCK
SIR,-It may be of interest to record an additional case of hypotension without the familiar clinical features of shock. In this instance, it followed a snake-bite. Dr. Barraclough and Professor Sharpey-Schaferdraw attention to the loss of circulatory reflexes after the use of depressants of the central nervbus system or after cerebrovascular accidents. The condition is characterised by severe hypotension, but with warm skin, of normal colour, a relatively slow pulse-rate, and venous distension (i.e., a clinical situation quite different from the usual state of shock). ’
A boy aged 10 years was admitted 3 hours after being bitten the heel by a snake which was identified as Vipera palestinensis. On admission his blood-pressure was unrecordable and no pulse was felt at the wrist. His state of consciousness was clouded, but his skin was warm and dry and to our surprise he had heart sounds of excellent quality and a rate of 100 per min. with occasional extrasystoles. An intravenous infusion of noradrenaline was started immediately, but the response was delayed and his blood-pressure rose only after a total of 4 mg. of noradrenaline had been given over 15 minutes in 500 ml. of 5% glucose. His blood-pressure remained normal thereafter, and after further treatment with intravenous hydrocortisone, anti-venom, and blood, the child made a full recovery. on
It should be noted that this
was not a severe
snake-bite,
in view of the absence of hxmolysis and the rapid recovery. 1.
Lancet, 1963, i, 1121.
TERENCE E. LYNCH.
SALICYLATE ACTION AND THYROIDAL AUTONOMY IN HYPERTHYROIDISM
SIR,-We were most interested to read the paper by Mr. Myhill and Dr. Hales (April 13) in which reference is made to previous work from this laboratory.l22 The authors confirm our findings indicating a depression of T.S.H. secretion in normal subjects. In hyperthyroidism and Hales studies in carried out secretion-rate Myhill four patients, with no change in two, increase in one, and a possible slowing in the other. In our studies, following therapy doses of 1311, a definite slowing has now been observed in four out of eight cases. The mechanism of this effect of salicylate is fully discussed in our previous paper with reference to the possibility of displacement of thyroid hormones from binding plasma-proteins.2 Subsequent studies in man and rats in this laboratory indicate that, despite the fall in plasma protein-bound iodine (P.B.I.), there is an increase in circulating free thyroxine in vivo after administration of salicylate, and in rats this rise is associated with a fall in plasma-T.s.H. levels.3 Hence the fall in secretion-rate in the thyrotoxic patients suggests susceptibility to a fall in circulating T.S.H. levels in some cases of thyrotoxicosis. Recently we have shown that the circulating iodoamino-acid 4 pattern characteristic of thyrotoxicosis can be reproduced by The thyrotoxic T.S.H. administration to normal subjects.5 pattern is also occasionally seen in normal subjects with plasma These P.B.I. levels at the upper limit of the normal range. from the normal to the transition findings suggest gradual hyperthyroid state.6 The use of the word " autonomous " to describe the behaviour of the thyrotoxic gland is misleading, since the Hetzel, B. S., Good, B. F., Charnock, J. S., Welby, M. L. Lancet, 1960, i, 957. 2. Hetzel, B. S., Good, B. F., Wellby, N. L., Begg, M. W. Aust. Ann. Med. 1962, 11, 34. 3. Good, B. F., Hetzel, B. S. Unpublished data. 4. Wellby, M. L., Hetzel, B. S., Good, B. F. Brit med. J. 1963, i, 439. 5. Wellby, M. L., Hetzel, B. S. Nature, Lond. 1962, 193, 752. 6. Wellby, M. L., Hetzel, B. S., Isaachsen, M. L. Aust. Ann. Med. 1963, 12, 30. 1.