grouping 3.8litres (standardised to mean height) shown in the table certainly reflects high-normal lung function. The table shows that in each F.E.v.l class, the yearly incidence of hard C.H.D. was related to lifetime total number of cigarettes smoked (current cigarette smoking showed clearly the same relationship); in the high-normal F.E.V.! class, the increased incidence with heavier smoking was highly significant. A multivariate analysis of risk factors, making use of an exponential model which takes account of differences in follow-up,4 revealed that number of cigarettes (t=4.5, P<0.0001), cholesterol (t=4.3, P<0.0001), and systolic bloodwere significantly related to incipressure (t=2.3, P<0.05) dence of hard C.H.D. whereas F.E.v., (t=0.1) was not. Another study5-which reported an association between lung function and hard C.H.D. dealt with subjects aged .24-84, some with other chronic diseases including angina pectoris, but cigarette smoking was still a more important risk factor. It seems clear that, in the context of at least one important disease associated with cigarette smoking, the direct effect of smoking is more significant than any indirect effect via reduced lung function. This conclusion may not hold in older subjects where cigarette smoking has not been found to be strongly related to C.H.D. deaths.6 This work was supported by le Groupe d’Etude sur 1’Epidemiologie de l’Athérosc1érose a joint venture of l’Institut National de la Sante et de la Recherche Médicale (INSERM) and the Prefecture de Paris, with a grant from the French Ministrv of Health. -
INSERM Unit 169, 94800 Villejuif, France
"A LITTLE SOMETHING BETWEEN MEALS": MASKED ADDICTION NOT LOW BLOOD-SUGAR
Marks and Rose’ call attention to the "vague symptoms of discomfort, irritability, tenseness, mental vagueness and inability to concentrate, which are frequently expressed, even by normal a meal, particularly afternoon tea or people when they miss " morning ’elevenses.’ These symptoms, "though not generally recognizable as being due to hunger, are relieved by food". They are not properly termed "hypoglycaemic", since "the concentration of glucose in the blood is not abnormally low at a time when symptoms are present, nor like hunger, are they relieved by intravenously administered glucose", and "there is at present no satisfactory explanation". This mystery may be solved by reference to the literature on food allergy-specifically, Rinkel’s concept of masked food allergy2 and Randolph’s concept of stimulatory and withdrawal levels of ecological disturbance.3 Masked addiction to commonly and frequently ingested foods may be suspected when similar symptoms occur upon failure to consume them regularly. Moreover, the foods most usually consumed at tea and for "elevenses"-milk, white flour, coffee, tea, and sugar-are amongst those most often found to cause masked addictions. The symptoms described by Marks and Rose represent various (- to - - - in Randolph’s terminology) withdrawal levels of response in ecologically maladapted individuals, and the "lift" which constitutes one of people’s main motivations to partake of mid-meal breaks represents a + level stimulatory reaction following re-exposure to the addictant(s).
SIR,-In their classic monograph
Lellouch, J., Rakotovao, R. Rev. Epidémiol. Santé publ. 1976, 24, 123. Friedman, G. D., Klatsky, A. L., Siegelaub, A. B. New Engl. J. Med. 1976, 294, 1071. 6 Gordon, T., Castelli, W. P., Hjortland, M. C., Kannel, W. B., Dawber, T. R. J. Am. med. Ass. 1977, 238, 497. 1. Marks, V., Rose, F. C. Hypoglycæmia. Oxford, 1965. 4. 5.
THE ENGLISH-SPEAKING WORLD
SiR,—In 1972 the Conference of Surgical Colleges met in Cape Town, and later in Ottawa and Chicago. These meetings remarkable. For the first time the American College of Surgeons, represented by its President, joined the Colleges of England, Edinburgh, Glasgow, Ireland, Australasia, Canada, and South Africa and played a full part in the discussions and decisions, the main topic being training for a career in surgery. Not only was there a very great measure of agreement upon all important matters but also the future appeared bright, with the representatives from all Colleges speaking of the value of unity and looking forward to an increasing measure of intercollegiate cooperation. For several years afterwards the pattern had been set and the wish of the Colleges to work together governed educational debates and the designing of training were
programmes and examinations. But now-what has gone wrong? What has happened to all these good intentions? Everywhere one looks, the spectacle of this surgical college or that taking a decision in isolation, even at times in defiance, of the views of other colleges catches the eye: "do it our way" is the cry on all sides "or let us abandon
unity as an objective". Another meeting of the Conference of Surgical Colleges is planned for October of this year. We urge those who represent their Colleges to attend it determined to find again that earlier spirit of unity which, if not lost, has at least been temporarily mislaid. The combined wisdom and experience of the Colleges represented can lead the surgical world, provided the influence of the Conference is exercised as a single unit and that the Colleges of which it is composed are seen to be in cooperation rather than competition. HEDLEY ATKINS, Past-president, R.C.S. England JOHN MCAULIFFE CURTIN, Past-president, R.C.S.I. FRANK DUFF, Past-president, R.C.S.I.
J. ENGLEBERT DUNPHY, Past-president, A.C.S.
EDWARD HUGHES, Past-president, R.A.C.S. WILLIAM LONGMIRE, Past-president, A.C.S.
Past-president, R.C.P.S. Canada GEORGE DUNLOP, Past-president, A.C.S. D. J. DUPLESSIS, Past-president, College of Medicine, South Africa ANDREW WATT
Past-president, R.C.P.S. Glasgow
JANNIE LOUW, Past-president, College of Medicine, South Africa
Past-president, R.C.S. England Past-president, R.C.P.S. Canada THOMAS HOLMES SELLORS, SMITH, Past-president, R.C.S. England Past-president, R.C.S. England CLAUDE WELCH, FRANK STINCHFIELD, Past-president, A.C.S. Past-president, A.C.S. ROBERT WRIGHT, Past-president, R.C.P.S. Glasgow
GENERAL PRACTITIONER AS GENERAL PHYSICIAN
Department of Psychology, Institute of Psychiatry, London, SE5 8AF.
2. Rinkel, H. J. Ann. Allergy, 1944, 2, 115. 3. Randolph, T. G. in Clinical Ecology (edited by
COOPERATION AMONG SURGICAL COLLEGES IN
SIR The iconclasm of Dr Lefever (May 26, p. 1133) makes me feel like saying that if he wishes to see lots of major illness for a low income, there are plenty of mission hospitals in the Third World where he could do just that. Equally it may be that he hankers after North American general practice where patients with British type minor illnesses get the hospital type works-for the doctor’s protection and to make a large fee seem worthwhile. However, many doctors in the U.K. still have an altruistic attitude, and Lefever is not alone in
being recurrently embarrassed when our remuneration is publicly discussed; but at least the Review Body has removed much of the public haggling which used to take place, and the independent Review Body is supposed to give the profession what it deserves. I suspect that Lefever’s reaction to general practice is due to the "mass of trivia" which makes some G.P.s so unhappy; but it is only at the end of the consultation that one can classify the triviality of an illness. Perhaps patients with cancer or myocardial infarction should be treated in hospital, but how will they get there? Someone, sometime has to decide. The Western World has decided, I believe rightly, that first contact should be with a doctor, and if primary contact with a doctor is right for the rich and private patient, then this is what should apply in the National Health Service. I am surprised that some more senior G.P. has not replied to Professor Jennett’s thesis that a superior specialist should have someone between him and the family doctor (March 17, p. 594). Does he too feel so overwhelmed by a mass of trivia that some barrier should be erected? Sir James McKenzie waded through a mass of trivia in Burnley, and became a founding father of cardiology and good general practice. Lefever undoubtedly could promote the health of his obese patients with their trivial complaint by improving his 10-year cure-rate for obesity, which I suspect is poorer than that for malignant cerebral tumours in Jennett’s unit; and one of the recurring problems of general, and no doubt neurosurgical, practice is the trivial question "When is a headache a headache and not a cerebral tumour"? Unfortunately the truly general physician is largely a thing of the past, now that most physicians have their special interests. It is probably true to say that 10% of practising doctors in general practice and hospital are excellent, 10% are poor, and the other 80% are hard working and willing to learn; this major group in general practice should surely be the area where centres of excellence should be working to educate the primary-care doctor to fill the role left by the demise of the general physician. And "welfare" may not be part of scientific health care, but it most certainly is part of the compassion which ought to be a feature of medical practice. Lefever’s May 26 article immediately followed one by Professor Kessel on reassurance. Patients go to G.P.S for reassurance ; and are referred to specialists so that both patient and G.P. can have reassurance. These results would be more difficult to achieve if further layers were to be interposed in the nresent structure.
Way, Norham, Berwick upon Tweed, Northumberland
G. A. C. BINNIE
MANIPULATION, OSTEOPATHY, AND BACK PAIN
SIR,-Dr Robertson, president of the British Association of Medical Manipulation, (June 2, p. 1190) fails to understand the recommendations of the Working Group on Back Pain, chaired by Prof. A. L. Cochrane. Robertson says: "there is no need to go outside the medical profession to evaluate manipulative medicine". In this he may well be right, since nobody outside the medical profession would want to claim that he or she is practising "manipulative medicine". The Working Group on Back Pain recognised, however, that many patients do go outside the medical profession for treatment, and they claim to derive benefit from the services of osteopaths, chiropractors, and others. The working party rightly took the view that it is first necessary to test whether such practitioners really do offer effective treatment. If they do, then is the time to assess the nature of this therapy and whether it can or should be equated with manipulative medicine. Much of osteopathy, incidentally, does not fit into the medical definition of manipulation, and to imply, as Robertson
does, that heterodox practices such as osteopathy and chiropractice are to be equated with "manipulative medicine" is indefensible. Whereas the established puncture professions have
osteopathic, chiropractic, and acuagreed to cooperate in setting up comparative trials-although, in contradistinction to their patients, they have nothing whatever to gain from working with doctors inside or outside the National Health Serviceinterested groups within medicine already seem to wish to close ranks to deny the public the opportunity to get at the answers to those fundamental questions which the working-group has realised must be answered before there can be any hope of improving the service to the many back-pain sufferers with whom the medical profession on its own cannot cope. General Council and 16 Buckingham Gate, London SW1.
C. I. DOVE Registrar
AMIODARONE AND THE THYROID
SIR, : Your editorial ot March 17 (p. 599) and Dr Chung’ss letter (April 7, p. 785) refer to the question of thyroid function in patients on amiodarone therapy. The setting-up of specific and direct micromethods for radioimmunoassay of free fractions of thyroid hormones’ permits a more thorough study. We have investigated an 8-year-old boy (weight 22 kg) who since 1974 had had attacks of paroxysmal reciprocating tachycardia due to anomalous retrograde conduction in the atrioventricular node. Several antiarrhythmic drugs had had no effect; only amiodarone 200 mg daily, taken with digitalis, beginning 18 months previously had had good clinical results. After 15 months, however, arrhythmic attacks returned at increasing frequency. Withdrawal of amiodarone reversed the negative symptoms. The data shown in the table refer to the last three months of therapy and to the month after withdrawal of the drug. The main results are the constant decrease in total T3 and free T 3’ an increase in total T4 and in free T4, an increase in reverse T3, and no variation in T.B.G. and T.S.H. After the patient had been off the drug for a month all values had returned to normal. The increase in free T4 may have been responsible for the recurring arrhythmic attacks and for slight clinical symptoms of hyperthyroidism. In view of the conflicting results of previous data, which point to a "low T syndrome"3 we would stress that only with direct and accurate measurement of free fractions were we able to account for the changes induced by amiodarone. Institute
of Radiology, University of Ferrara, 44100 Ferrara, Italy Division of
ADRIANO PIFFANELLI DARIO PELIZZOLA LUCIANO RICCI
LUCIANO CODECÁ ANTONIO MASONI PIER BRUNO ROMELLI
Pennisi, F., Romelli, P. B., Vanchieri, L. J. endocr. Invest. 1979, 2, 25. Burger, A., and others J. clin. Invest. 1978, 58, 255. 3. Jonckheer, M. H., and others. Clin. Endocr. 1978, 9, 27.
(SEPT., OCT., NOV.) AND AFTER ITS WITHDRAWAL (DEC.)
THYROID FUNCTION UNDER AMIODARONE THERAPY