Metric
Mystique
poll by the Gallup organization (released Nov 24, stated that "the metric system is failing to make its way 1977) the into everyday thinking of the average American." This conclusion was founded on a survey demonstrating that though approximately three Americans in four (74%) have heard of the metric system, fewer than one in four (24%) would like to see it adopted. This reluctance probably is not based as much on the metric system's undeniable advantages in science, technology, and international trade as it is on resistance to change, the very human aversion to departing from the comfortable rut, and the misgivings over conversion arithmetic. Despite increasing (though seldom highly visible) efforts by government agencies and educational institutions, the survey points out that more than 75% of the persons interviewed could not, or would not, even guess how many liters were the equivalent of a gallon, how many inches would go into a meter, or how to convert miles to kilometers. Yet the metric system is far easier to use than our present conglomerate of odd units, for it is based, like our monetary system, on the simple principle of decimal steps. Those of us who traveled to Great Britain when 20 shillings equaled a pound sterling, and 12 pence gave you a shilling (let alone the headaches of fretting over farthings and guineas) are only too thankful that the British, too, have adopted decimal currency. Monetary system aside, metrics are creeping into our lives: There are 100-mm cigarettes with 5 mg of tar, 1-liter soft drink bottles, 100-meter dashes, 1.4-liter engines, and so on. Science already is fully metricated, and medicine is well on the way by now. Rarely are drugs prescribed in units other than metric, thanks to educational efforts by the medical schools and by medical journals, including The Journal.' Perhaps the greatest opposition of all to metrication will come from the home. Housewives, understandably, will see little reason in, and thus have little incentive to, baking at 177 °C rather than at 350 °F, or to using 475 ml of water rather than 1 pint. Yet, even in the kitchen change is closer at hand than appreciated generally. Look at packaged foods nowadays, and you will see metric measurements alongside pounds, inches, and pints. It has been The Journal's editorial policy for some years to use metric units for length, weight, volume, and temperature, with the corresponding customary units shown in parentheses where appropriate.2 With that transition policy in force for some years, readers now will soon encounter the next phase: metric units standing alone without the crutch of accompa¬ nying parenthesized "old" units. Eventually, we shall switch to A
New Requirements for Authors.—Congress recently passed The Copyright Revision Act of 1976, which affects JAMA's procedure for acceptance of manuscripts. Please
recent
refer to the "Instructions for Authors" page for details.
the international system of units (SI), which retains many of the familiar units such as meter, kilogram, and second, but adds new and largely unfamiliar (to physicians) names such as Pa (pascal) to replace mm Hg, J (joule) instead of cal, and mol/L rather than g/dl.' We shall keep our readers posted on these matters, and from time to time provide brief fillers that will explain medically important SI units, and tabulate appropriate conversion
factors.
Rudolph H.
de
Jong,
MD
1. Vaisrub S: Lost in metrication. JAMA 238:2532, 1977. 2. Barclay WR: Standardizing units of measurements. JAMA 236:1981, 1977. 3. The International System of Units (SI), special publication 330. National Bureau of Standards, US Government Printing Office, 1977.
A
Glimpse at Medicine Abroad
In these
days of supersonic air transport and satellite communioften are reminded of John Donne's admonition, cations, we
island, entire of itself." headline that the international heroin syndicate Newspapers has established new import routes into our country. Nightly news reports alert us to a contagion dubbed the "Russian flu." No doubt we all feel a sense of relief as the World Health Organization proclaims that variola major has been eradicated from the earth. Yet if foreign lands have their dangers, they also have their delights. Certainly one of travel's pleasures is observing how the necessities of life are handled in new and diverse ways. Can one forget how delicious a simple snack of bread and cheese tasted along a French roadside? Or how graceful a sarong-clad figure looked in the South Pacific? The pleasures of a caseta on a warm afternoon in Lima? Food, clothing, shelter\p=m-\allare done differently from Lapland to Cape Horn; yet, no one way is right "No
or
man
is
an
wrong.
And so it is with health care. Recently a delegation from the American Medical Association and a separate task force from the US Department of Health, Education, and Welfare jour¬ neyed to Great Britain to survey its National Health Service. We applaud these and similar efforts to sift and winnow the strengths and weaknesses of other health care systems. America
Address editorial communications to the Editor, 535 N Dearborn St, Chicago, IL 60610.
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/09/2015
has no monopoly on good ideas and while we have much to offer other nations, we also have much to learn. With the demands of clinical practice and patient care, however, it is difficult for most physicians to find time for foreign travel and study. Fortunately for the past several years, readers of The Journal have been advised of new medical
developments abroad through the section of The Journal edited
international comments
by
Zenonas Danilevicius,
MD.
Beginning with this issue, international comments will feature a special once-a-month series on medical care and medical education throughout the world. E. Grey Dimond, MD, leads off the entire effort with a fascinating glimpse of Chinese medical education several years after the "cultural revolution." This is Dr Dimond's fifth visit to the People's Republic of China, and he makes a strong case for physicians to travel abroad. If foreign travel is not possible personally, however, we hope our readers will take a different tack and follow The Journal's armchair wanderings through the medical care systems of the world in the months to come. Bon voyage! Jeffrey Kunz,
Pickwickian
Syndrome?
MD
The Dickens!
The link between Charles Dickens and the syndrome that relates to one of his characters was first mentioned 60 years ago by William Osier, MD, who noted that "a remarkable phenomenon associated with excessive fat in young persons is an uncontrollable tendency to sleep\p=m-\likethe fat boy in Pickwick." The Dickensian connection, which was missed or ignored by Auchincloss et al1 who first described a typical case, was picked up by Burwell et al2 in 1956 when they labeled the syndrome Pickwickian. They ascribed the somnolence, cyanosis, polycythemia, alveolar hypoventilation, and right ventricular failure, which characterize the syndrome, to obesity with its attendant increase in the work of breathing. As is often the case with eponymous syndromes, the monolithic structure of the Pickwickian syndrome soon began to crack. Gastaut et al3 (1965) split off a syndrome that does not conform to type. Its genesis is not in the daytime somnolence induced by the increased work of breathing, but in the nocturnal disturbance of sleep caused by intermittent upperairway obstruction secondary to a variety of causes. As a result of the obstruction, the patient experiences periods of apnea followed by restless awakenings that are accompanied by sonorous snoring. The sleep apnea may recur hundreds of times during the night. Although his respiration is normal during the day, the victim of sleep apnea is, nevertheless, handicapped by daytime somno¬ lence, which can be mistaken for narcolepsy, and by physio¬ logic and psychologic disturbances. Among the often noted clinical features are a short, thick neck and large jowls,
paranoia, depression or hostility, transient pulmonary and systemic hypertension, and moderate hypercarbia, which is not as pronounced as in the typical Pickwickian syndrome. Obesity is a common but not invariable characteris¬ Symptoms of
tic. More serious,
however, are the cardiac arrhythmias that often complicate sleep apnea. Tilkian et al4 observed disorders of
rhythm, some of a serious life-threatening nature, in 14 of 15 of their patients. Such arrhythmias, usually observed during sleep, may be responsible for the sudden death that sometimes strikes patients with sleep apnea during the night. It has also been suggested by some and disputed by others that sudden infant death is precipitated by this syndrome.
The mechanism of the cardiovascular complications has not been fully clarified. Tilkian and his associates believe that the primary dysfunction resides in the CNS, as suggested by the abnormal atony of the hypoglossus often observed during the apneic intervals. They derive further support for this opinion from their reported case in the February issue of the Archives of Internal Medicine. The patient had an unusual combination of autonomie insufficiency (Shy-Drager syndrome) and sleep apnea. The latter, however, was not associated with the expected hypertension or cardiac arrhythmias, presumably because of the ablation of CNS influences, as corroborated by multiple areas of degenerations in the CNS outside the medul¬ lary centers found during autopsy. Involvement of the CNS is also suggested by the occasional persistence of apnea after tracheostomy.' Whether central apnea, which often accompanies periodic sleep apnea, can occur independently is still a moot point. Was the fat boy in Pickwick a true Pickwickian or was he the victim of sleep apnea? Dickens provides no clues. Let us then leave the original syndrome to Pickwick and find another eponym for the obstructive sleep apnea. We can choose the name of Gastaut who first described it. Alternatively we may borrow Ondine's name from the respiratory disorders to which it has been loosely appended. What could be more fittingly commemorative of the beautiful water nymph who punished her mortal husband by depriving him of the ability to breathe automatically? Without the benefit of tracheostomy, the poor wretch, having forgotten how to breathe, died in his sleep—a victim of "Ondine's curse." 1.
of
a
Samuel Vaisrub, MD Auchincloss JH, Cook E, Renzetti AD: Clinical and physiological aspects case of obesity, polycythemia, and hypoventilation. J Clin Invest 34:1537,
1955. 2. Burwell CS, Robin ED, Whaley RD, et al: Extreme obesity associated with alveolar hypoventilation\p=m-\pickwickiansyndrome. Am J Med 21:811-818, 1956. 3. Gastaut H, Tassinari CA, Duron B: Polygraphic study of the episodic diurnal and nocturnal manifestations of the Pickwick syndrome. Brain Res
2:167, 1966.
et al: Sleep-induced apnea of cardiac arrhythmias and their reversal after tracheostomy. Am J Med 63:348-358, 1977. 5. Sackner MA, Landa J, Forrest T, et al: Periodic sleep apnea: Chronic sleep deprivation related to intermittent upper airway obstruction and central nervous system disturbance. Chest 67:164-171, 1975.
4. Tilkian
AG, Guilleminault C, Schroeder J,
syndrome prevalence
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/09/2015
Mystique
poll by the Gallup organization (released Nov 24, stated that "the metric system is failing to make its way 1977) the into everyday thinking of the average American." This conclusion was founded on a survey demonstrating that though approximately three Americans in four (74%) have heard of the metric system, fewer than one in four (24%) would like to see it adopted. This reluctance probably is not based as much on the metric system's undeniable advantages in science, technology, and international trade as it is on resistance to change, the very human aversion to departing from the comfortable rut, and the misgivings over conversion arithmetic. Despite increasing (though seldom highly visible) efforts by government agencies and educational institutions, the survey points out that more than 75% of the persons interviewed could not, or would not, even guess how many liters were the equivalent of a gallon, how many inches would go into a meter, or how to convert miles to kilometers. Yet the metric system is far easier to use than our present conglomerate of odd units, for it is based, like our monetary system, on the simple principle of decimal steps. Those of us who traveled to Great Britain when 20 shillings equaled a pound sterling, and 12 pence gave you a shilling (let alone the headaches of fretting over farthings and guineas) are only too thankful that the British, too, have adopted decimal currency. Monetary system aside, metrics are creeping into our lives: There are 100-mm cigarettes with 5 mg of tar, 1-liter soft drink bottles, 100-meter dashes, 1.4-liter engines, and so on. Science already is fully metricated, and medicine is well on the way by now. Rarely are drugs prescribed in units other than metric, thanks to educational efforts by the medical schools and by medical journals, including The Journal.' Perhaps the greatest opposition of all to metrication will come from the home. Housewives, understandably, will see little reason in, and thus have little incentive to, baking at 177 °C rather than at 350 °F, or to using 475 ml of water rather than 1 pint. Yet, even in the kitchen change is closer at hand than appreciated generally. Look at packaged foods nowadays, and you will see metric measurements alongside pounds, inches, and pints. It has been The Journal's editorial policy for some years to use metric units for length, weight, volume, and temperature, with the corresponding customary units shown in parentheses where appropriate.2 With that transition policy in force for some years, readers now will soon encounter the next phase: metric units standing alone without the crutch of accompa¬ nying parenthesized "old" units. Eventually, we shall switch to A
New Requirements for Authors.—Congress recently passed The Copyright Revision Act of 1976, which affects JAMA's procedure for acceptance of manuscripts. Please
recent
refer to the "Instructions for Authors" page for details.
the international system of units (SI), which retains many of the familiar units such as meter, kilogram, and second, but adds new and largely unfamiliar (to physicians) names such as Pa (pascal) to replace mm Hg, J (joule) instead of cal, and mol/L rather than g/dl.' We shall keep our readers posted on these matters, and from time to time provide brief fillers that will explain medically important SI units, and tabulate appropriate conversion
factors.
Rudolph H.
de
Jong,
MD
1. Vaisrub S: Lost in metrication. JAMA 238:2532, 1977. 2. Barclay WR: Standardizing units of measurements. JAMA 236:1981, 1977. 3. The International System of Units (SI), special publication 330. National Bureau of Standards, US Government Printing Office, 1977.
A
Glimpse at Medicine Abroad
In these
days of supersonic air transport and satellite communioften are reminded of John Donne's admonition, cations, we
island, entire of itself." headline that the international heroin syndicate Newspapers has established new import routes into our country. Nightly news reports alert us to a contagion dubbed the "Russian flu." No doubt we all feel a sense of relief as the World Health Organization proclaims that variola major has been eradicated from the earth. Yet if foreign lands have their dangers, they also have their delights. Certainly one of travel's pleasures is observing how the necessities of life are handled in new and diverse ways. Can one forget how delicious a simple snack of bread and cheese tasted along a French roadside? Or how graceful a sarong-clad figure looked in the South Pacific? The pleasures of a caseta on a warm afternoon in Lima? Food, clothing, shelter\p=m-\allare done differently from Lapland to Cape Horn; yet, no one way is right "No
or
man
is
an
wrong.
And so it is with health care. Recently a delegation from the American Medical Association and a separate task force from the US Department of Health, Education, and Welfare jour¬ neyed to Great Britain to survey its National Health Service. We applaud these and similar efforts to sift and winnow the strengths and weaknesses of other health care systems. America
Address editorial communications to the Editor, 535 N Dearborn St, Chicago, IL 60610.
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/09/2015
has no monopoly on good ideas and while we have much to offer other nations, we also have much to learn. With the demands of clinical practice and patient care, however, it is difficult for most physicians to find time for foreign travel and study. Fortunately for the past several years, readers of The Journal have been advised of new medical
developments abroad through the section of The Journal edited
international comments
by
Zenonas Danilevicius,
MD.
Beginning with this issue, international comments will feature a special once-a-month series on medical care and medical education throughout the world. E. Grey Dimond, MD, leads off the entire effort with a fascinating glimpse of Chinese medical education several years after the "cultural revolution." This is Dr Dimond's fifth visit to the People's Republic of China, and he makes a strong case for physicians to travel abroad. If foreign travel is not possible personally, however, we hope our readers will take a different tack and follow The Journal's armchair wanderings through the medical care systems of the world in the months to come. Bon voyage! Jeffrey Kunz,
Pickwickian
Syndrome?
MD
The Dickens!
The link between Charles Dickens and the syndrome that relates to one of his characters was first mentioned 60 years ago by William Osier, MD, who noted that "a remarkable phenomenon associated with excessive fat in young persons is an uncontrollable tendency to sleep\p=m-\likethe fat boy in Pickwick." The Dickensian connection, which was missed or ignored by Auchincloss et al1 who first described a typical case, was picked up by Burwell et al2 in 1956 when they labeled the syndrome Pickwickian. They ascribed the somnolence, cyanosis, polycythemia, alveolar hypoventilation, and right ventricular failure, which characterize the syndrome, to obesity with its attendant increase in the work of breathing. As is often the case with eponymous syndromes, the monolithic structure of the Pickwickian syndrome soon began to crack. Gastaut et al3 (1965) split off a syndrome that does not conform to type. Its genesis is not in the daytime somnolence induced by the increased work of breathing, but in the nocturnal disturbance of sleep caused by intermittent upperairway obstruction secondary to a variety of causes. As a result of the obstruction, the patient experiences periods of apnea followed by restless awakenings that are accompanied by sonorous snoring. The sleep apnea may recur hundreds of times during the night. Although his respiration is normal during the day, the victim of sleep apnea is, nevertheless, handicapped by daytime somno¬ lence, which can be mistaken for narcolepsy, and by physio¬ logic and psychologic disturbances. Among the often noted clinical features are a short, thick neck and large jowls,
paranoia, depression or hostility, transient pulmonary and systemic hypertension, and moderate hypercarbia, which is not as pronounced as in the typical Pickwickian syndrome. Obesity is a common but not invariable characteris¬ Symptoms of
tic. More serious,
however, are the cardiac arrhythmias that often complicate sleep apnea. Tilkian et al4 observed disorders of
rhythm, some of a serious life-threatening nature, in 14 of 15 of their patients. Such arrhythmias, usually observed during sleep, may be responsible for the sudden death that sometimes strikes patients with sleep apnea during the night. It has also been suggested by some and disputed by others that sudden infant death is precipitated by this syndrome.
The mechanism of the cardiovascular complications has not been fully clarified. Tilkian and his associates believe that the primary dysfunction resides in the CNS, as suggested by the abnormal atony of the hypoglossus often observed during the apneic intervals. They derive further support for this opinion from their reported case in the February issue of the Archives of Internal Medicine. The patient had an unusual combination of autonomie insufficiency (Shy-Drager syndrome) and sleep apnea. The latter, however, was not associated with the expected hypertension or cardiac arrhythmias, presumably because of the ablation of CNS influences, as corroborated by multiple areas of degenerations in the CNS outside the medul¬ lary centers found during autopsy. Involvement of the CNS is also suggested by the occasional persistence of apnea after tracheostomy.' Whether central apnea, which often accompanies periodic sleep apnea, can occur independently is still a moot point. Was the fat boy in Pickwick a true Pickwickian or was he the victim of sleep apnea? Dickens provides no clues. Let us then leave the original syndrome to Pickwick and find another eponym for the obstructive sleep apnea. We can choose the name of Gastaut who first described it. Alternatively we may borrow Ondine's name from the respiratory disorders to which it has been loosely appended. What could be more fittingly commemorative of the beautiful water nymph who punished her mortal husband by depriving him of the ability to breathe automatically? Without the benefit of tracheostomy, the poor wretch, having forgotten how to breathe, died in his sleep—a victim of "Ondine's curse." 1.
of
a
Samuel Vaisrub, MD Auchincloss JH, Cook E, Renzetti AD: Clinical and physiological aspects case of obesity, polycythemia, and hypoventilation. J Clin Invest 34:1537,
1955. 2. Burwell CS, Robin ED, Whaley RD, et al: Extreme obesity associated with alveolar hypoventilation\p=m-\pickwickiansyndrome. Am J Med 21:811-818, 1956. 3. Gastaut H, Tassinari CA, Duron B: Polygraphic study of the episodic diurnal and nocturnal manifestations of the Pickwick syndrome. Brain Res
2:167, 1966.
et al: Sleep-induced apnea of cardiac arrhythmias and their reversal after tracheostomy. Am J Med 63:348-358, 1977. 5. Sackner MA, Landa J, Forrest T, et al: Periodic sleep apnea: Chronic sleep deprivation related to intermittent upper airway obstruction and central nervous system disturbance. Chest 67:164-171, 1975.
4. Tilkian
AG, Guilleminault C, Schroeder J,
syndrome prevalence
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/09/2015
