1352
A zero value had been found in all cases before tamoxifen treatment, but after tamoxifen the index regularly increased to values between 10 and 300%, reaching 500% or more in four cases and 800 in one. This effect has not previously been described in humans. The smears returned to an atrophic pattern within two months after tamoxifen withdrawal. Overall, 32 % of the patients responded favourably to tamoxifen, showing an objective tumour regression. No sure relationship has been evidenced between the post-treatment rise in KPI and the response of cancer to tamoxifen treatment. As in some animal models, the drug seems to have an oestrogen-like effect on the vaginal epithelium. It is still not clear whether the tumour may also react to tamoxifen as if it was an oestrogen. E FERRAZZI G CARTEI R MATTARAZZO M FIORENTINO Department of Medical Oncology, Regional General Hospital, Padua, Italy
Clarke, J H, Peck, E, jun, and Anderson, J N, Nature, 1974, 251, 446. 2 Harper, H J K, and Walpole, A L, Nature, 1967, 87, 212. Jordan, V C, European J7ournal of Cancer, 1976, 12, 419. 4Skidmore, J, Walpole, A L, and Woodburn, J, J7ournal of Endocrinology, 1972, 52, 289. 5 Weid, G L, Acta Cytologica, 1957, 1, 75.
Royal College of Physicians and fluoridation SIR,-The selective use of research material from studies by Dr Robert Weaver quoted by the authors of the Royal College of Physicians' report Fluoride, Teeth and Health' is surprising and merits explanation. On p 9 of their report they refer to a paper published by Dr Weaver2 showing that 5-yearold children in South Shields with naturally fluoridated water at 14 ppm had on average 3-9 decayed, missing, or filled (DMF) teeth compared with 6-6 in children in North Shields with 0-25 ppm fluoride in the drinking water. Moreover, says the report, "at the age of 12 the number of DMF teeth in South Shields was 56,0 of that in North Shields." In Weaver's second study' evidence was given "which suggests that fluorine is a caries-postponing rather than a caries-preventing factor." Table III of this paper shows that by the age of 15 years children from South Shields had an average of 4-4 DMF teeth compared with 4-3 at the age of 12 years in North Shields. By the age of 17 those in the high-fluoride areas had 6-5 DMF teeth compared with 7-2 in the low-fluoride areas, a difference of about half a decayed tooth on average and a difference which steadily lessens with increasing age. A survey to discover if the effects of water-borne fluorides continued into adulthood showed that young South Shields mothers had a dental advantage of about five years, but for the over-30s the difference was negligible. Dr Weaver's third paper,4 also unmentioned in the RCP's report, contains his final and considered conclusions in which it was shown that "only a limited effect could be expected from the ingestion of fluoride in drinking water." Weaver remarked that if the protection given by fluorine in South Shields had not been shown to be of brief duration the dental profession would have been faced with an
BRITISH MEDICAL JOURNAL
embarrassing question, which would have been, "If the incidence of dental caries in South Shields is so very much less than in North Shields, why is it that the population of South Shields is no healthier than that of North Shields ? The answer is that the figure of 560,) which I have given in connection with the findings in 12-year-old children is misleading. There is no very striking difference in the incidence of caries in the two towns." Perhaps the authors of Fluoride, Teeth and Health would care to explain why they omitted these important statements and conclusions from one of their own references. RONALD V MUMMERY St Helier, Jersey, CI
Royal College of Physicians of London, Fluoride, Teeth and Health. London, Pitman, 1976. 2 Weaver, R, British Dental Journal, 1944, 76, 29. Weaver, R, British Dental,Journal, 1944, 77, 185. 'Weaver, R, Proceedlings of the Royal Society of Medicine, 1948, 41, 284.
Academics and scientists SIR,-It appears that Dr W B Hepburn chose to use the rather inappropriate medium of a book review (9 April, p 966) to air his individual prejudices. It is particularly difficult to understand why he felt it necessary to introduce an unrecognisable character sketch of the late Professor H A Harris into a review of a series of biographies which did not include him. The strength of H A Harris's personality
would have demanded deference, whatever had been his academic status, and I am sure that there can be few who knew him who would find "quaint" an appropriate descriptive adjective. While far from a midget in physical stature H A Harris was of a mental stature such as to inspire the respect, admiration, and eventually affection of many of his students and staff. Without the very real inspiration provided by him and his department the current shortage of medically qualified anatomists would have been even more desperate than it is. Among all the positive features of H A Harris's character it is regrettable that Dr Hepburn chose only to select two of his antipathies-whistling and undergraduate arrogance. DAVID BULMER Medical and Biological Sciences Building University of Southampton
Parascending: a safer alternative to hang gliding
SIR,-Dr G M Youill's presentation of the risks of hang gliding (26 March, p 823) complements Kirby's report on parachuting from aircraft.' The purpose of this letter is to draw attention to the existence of a third, much less dangerous aerial sport called parascending (parasailing in the USA). It is probably the simplest, cheapest, and safest way for the individual to get into the air. The parascender puts on the parachute harness with the canopy laid out behind him. A tow-line (usually 460 m (500 yards) long for the trained club member) from the harness is hitched to a Land Rover, which moves off at a speed appropriate to the wind conditions and the weight of the parascender. The parachute, held open by two wing-tip holders,
21 MAY 1977
inflates and the parascender goes up like a glider. At the desired height of 250-300 m (800-1000 feet) the parascender releases himself from the tow-line, steers his course, and makes his landing. The flight and landing techniques are the same as in parachuting from aircraft, but the risks of exit and of canopy maldevelopment are abolished; the parascender is not towed up if any fault appears when the canopy is opened on the ground. The British Association of Parascending Clubs is the national body concerned with the licensing of instructors and national aspects of the sport. It is closely concerned with all matters of safety. The injury rate for 50 807 flights in the USA was reported to be about 0-5 %,2 but we consider the risk to be smaller. The injuries we encounter are abrasions, bruises, sprains, and minor undisplaced fractures which do not keep members off work, and even these are unusual outside the competitions which tempt a parascender to go for the target instead of landing defensively. From four club seasons with over 2000 flights two members have been admitted to hospital: one suffered acute pain from a known and previously disabling lumbar disc lesion and the other had a grand mal attack. This information is presented because we believe that parascending should be dealt with in its own right by insurance underwriters and not classed with hang gliding or parachuting from aircraft. A J MACAULAY Chief Instructor
P G F NIXON London W8
2
President, Charing Cross Hospital Parascending Club
Kirby, N G, Proceedings of the Royal Society of M2?dicine, 1974, 67, 17. Hall, G W, Aviation, Space and Environmiental Medicine, 1977, 48, 164.
Night visiting rates by general practitioners SIR,-I wish to comment on the article on this subject by Mr M J Buxton and others from the Centre for Social Studies (26 March, p 827) and Dr I C Gilchrist's letter (7 May; p 1217). Mr Buxton and his colleagues record an increase of approximately 135 % in the night visiting rate per 1000 patients between 1967-8 and 1975-6 for the country as a whole. In this group practice of four, by contrast, our night visiting rate in 11 years to 1976 dropped by 15 2°,. We recorded our night calls (11 pm to 8 am) for six years, 1 January 196031 December 1965,' and again 11 years later, for 1976. The night call rate for the six years 1960-5 averaged 6 6 and this compares with 5 6 per 1000 patients in 1976 (64 night calls for our list of 11 440). We considered that only three (4-1 %) of these calls were unnecessary. The authors speculate on whether the number of night calls has risen since 1967, after which general practitioners began to be paid for these night calls. In this practice they have fallen. They also point out that deputising services and a high proportion of social class V patients increase the night visiting rate. In Farnborough we have our own rota for calls and the number of social class V patients is low. The figures provided by Mr Buxton and his colleagues also tend to confirm what other
BRITISH MEDICAL JOURNAL
21
MAY
1977
1353
observers have noted, that night visiting rates producing severe oedema in elderly patients are higher in the north of England and in who are on a high dosage schedule, as was the Scotland.2 -4 case with the patient reported. Finally, while congratulating Mr Buxton and his colleagues on their excellent paper, I D L F DUNLEAVY consider their last paragraph to be mistaken. University Department of Psychiatry, Each doctor must decide, and then take Royal Victoria Infirmary, responsibility for, any action following a Newcastle upon Tyne request for a night call. This will depend on Kelly, D, et al, British3rournal of Psychiatry, 1970, 116, his knowledge of the patient and the circum387. stances, and not on any 'consensus' of explicit 2Rees, L, and Davies, B, Journal of Mental Science, 1961, 107, 560. criteria. 3 Dunleavy, D L F, MD thesis, National University of J N A PRITCHARD Ireland. Cooper, A J, and Ashcroft, G, Diabetes, 1967, 16, 272.
Farnborough, Hants 'Pritchard, J N A, British MedlicalJournal, 1966, 1, 614. 2Brotherson, J H F, et al, British Medical Journal, 1959, 2, 1169. 3Webster, G L, et al, British Medical Journal, 1965, 1, 1369. 4Pritchard, J N A, Journal of the Royal College of General Practitioners, 1976, 26, 166 and 357.
Mucocutaneous lymph node syndrome SIR,-I was interested in the recent reports of cases of mucocutaneous lymph node syndrome (Kawasaki disease) occurring in England (19 February, p 511; 2 April, p 883). This is probably not a new disease to Britain or anywhere else. In 1960 Forbes and Bradley described in your columns' a 9-year-old boy with an aneurysm of his left coronary artery. Thye did not know the aetiology then but their case was almost identical with one seen in Canada in 1976.2 Subsequent to the Japanese descriptions these cases appeared to have been rare fatal examples of Kawasaki disease. PAUL WENTWORTH Clinical Laboratories, Brantford General Hospital,
Brantford, Ontario
Forbes, G, and Bradley, A, British Medi-cal Journal, 1960, 2, 1344. 2Wentworth, P, and Silver, M D, Canadian Medical Association Journal, 1976, 115, 299.
Phenelzine and oedema
SIR,-Drs A Goonewardene and P J Toghill (2 April, p 879) describe a case of gross oedema during treatment for depression with a monoamine oxidase inhibitor (phenelzine) and a benzodiazepine (diazepam). They question whether phenelzine alone could have been responsible for this side effect. In a series of phobic patients undergoing treatment with phenelzine ankle oedema was found to be common in adults,' and in a controlled drug trial with depressed patients two out of 20 developed oedema. In a personal series3 of 22 patients with endogenous depression receiving phenelzine in varying daily dosage of 60, 75, and 90 mg severe ankle oedema was noted in four. These four subjects were all women, over 50 years of age, and receiving 90 mg of phenelzine daily. No electrolyte or other blood abnormalities were noted and the oedema did not respond to concurrent use of diuretics, subsiding only when the drug was withdrawn or its dosage reduced. Some of the weight gain in the case reported may have been due to other factors. It has long been known that monoamine oxidase inhibitors can induce hypoglycaemia,' and Kelly et al in their series' reported excessive weight gain due to a craving for carbohydrates in a number of patients. The available evidence, therefore, would suggest that phenelzine is indeed capable of
Reduced DNA synthesis in non-responsive coeliac disease SIR,-I have read the paper by Drs P E Jones and T J Peters on DNA synthesis by the jejunal mucosa in responsive and nonresponsive coeliac disease (30 April, p 1130) with great interest and would like to suggest a reason for the low DNA synthesis found in non-responsive patients. We have reported' six patients with non-responsive coeliac disease with very low serum zinc values (5 7+1 2 cLmol/l (37 0+7 5 1jg/10O ml)). These patients showed a marked response to zinc therapy. As zinc is necessary for the incorporation of :H-thymidine into DNA,2 I would like to know the zinc status of Drs Jones and Peters's non-responsive patients. If non-response to gluten withdrawal, low DNA synthesis, and low plasma zinc are all part of the same syndrome the estimation of plasma or serum zinc should be a quicker and cheaper method of detecting non-responders than mucosal culture and 3H-thymidine incorporation studies, valuable though these are in understanding the mechanism of coeliac disease. MARGARET ELMES Departmen-t of Pathology,
Welsh National School of Medicine, Cardiff
'Elmes, M, Golden, M K, and Love, A H G, Quarterly J'ournal of Medicine, 1976, 180, 696. Williams, R B, and Chesters, J K, in Trace Element Metabolism in Animals, ed C F Mills, p 164. Edinburgh, Livingstone, 1970.
A case of dysphagia
SIR,-"Clinics in General Practice" is a series which should provide insights into how general practitioners and specialists can best interact with a particular clinical problem. Comment should be informed, instructive, and to the point. "A case of dysphagia" (30 April, p 1139) failed to show this interaction to have been in the best long-term interests of the patient. Dr A G Donald presented the trainee's problem patient, who at 30 was unmarried and during three months with the practice consulted excessively and received two specialist referrals. She had a past history involving three specialties with largely insignificant findings. She presented her new doctor with a new symptom, dysphagia, and demanded an ENT opinion. The trainee made an initial diagnosis of a functional illness and the trainer suggested that physical causes should be excluded. But that is tiot enough. For a diagnosis of hysterical psychoneurosis there must be positive signs of hysterical illness and, preferably, understandable gain.' Mr J D K Dawes, misjudging his forum,
gave a political account of the NHS and private practice covering 10 column inches, leaving only a few inches to make such comments as, "If . . . the patient demands it referral is essential." He agreed that "this patient is obviously under emotional stress" and that if no abnormality is found "the dysphagia for solid foods may be . . . hysterical." In the postscript sense at first prevails. The patient saw an ENT specialist twice who listened to her, and her symptoms evaporated without resort to any potentially dangerous procedures. But the trainee, having had his hypothesis "validated against an ENT opinion," did not take the logical step of psychiatric referral. Referral to a psychiatric department in a general hospital would permit liaison with other specialties when, as would almost certainly happen, she produced further symptoms. She was referred to two further specialists before she finally left. Running away is one way of coping. With psychiatric help she might have discovered more adaptive ways of coping. Hysterical patients are classically demanding and will continue to demand physical explanations to psychological problems, running the risk of further referrals and consequently more and potentially dangerous investigative procedures. It seems important to consider how differently this patient might have been treated if this series is to be of educational value. IAN PULLEN Department of Psychiatry, Western General Hospital, Edinburgh
Reed, J L, British Jotrnal of Hospital Medicine, 1971, 5, 237.
Alcoholic liver disease in women SIR,-Dr A N Hamlyn, in discussing why women could be more susceptible than men to the development of alcoholic cirrhosis (23 April, p 1085), suggests that female alcoholics could be more likely to underestimate the amount of alcohol consumed. Other factors besides average daily alcohol consumption may be important. For example, for a given weekly alcohol intake women tend to drink on more occasions than men.' Thus the total time that blood ethanol levels are elevated above some "threshold" value rather than peak levels might determine the development of severe liver disease in alcoholic patients, and clearly this possibility should be considered in future surveys. G NICHOLSON Ninewells Hospital, Dundee Dight, S E, Scottish HMSO, 1976.
Drinking Habits. London,
Gluten-free diet in dermatitis herpetiformis SIR,-I enjoyed the paper by Drs Christine I Harrington and N W Read (2 April, p 872) on the immunological consequences of gluten withdrawal in dermatitis herpetiformis (DH). It appears that in three of the 10 patients studied there was disappearance of IgAcontaining cells from the lamina propria of the jejunal mucosa following gluten withdrawal. This is a surprising finding which is at variance with our early observations' and those of Lancaster Smith et al2 that jejunal
A zero value had been found in all cases before tamoxifen treatment, but after tamoxifen the index regularly increased to values between 10 and 300%, reaching 500% or more in four cases and 800 in one. This effect has not previously been described in humans. The smears returned to an atrophic pattern within two months after tamoxifen withdrawal. Overall, 32 % of the patients responded favourably to tamoxifen, showing an objective tumour regression. No sure relationship has been evidenced between the post-treatment rise in KPI and the response of cancer to tamoxifen treatment. As in some animal models, the drug seems to have an oestrogen-like effect on the vaginal epithelium. It is still not clear whether the tumour may also react to tamoxifen as if it was an oestrogen. E FERRAZZI G CARTEI R MATTARAZZO M FIORENTINO Department of Medical Oncology, Regional General Hospital, Padua, Italy
Clarke, J H, Peck, E, jun, and Anderson, J N, Nature, 1974, 251, 446. 2 Harper, H J K, and Walpole, A L, Nature, 1967, 87, 212. Jordan, V C, European J7ournal of Cancer, 1976, 12, 419. 4Skidmore, J, Walpole, A L, and Woodburn, J, J7ournal of Endocrinology, 1972, 52, 289. 5 Weid, G L, Acta Cytologica, 1957, 1, 75.
Royal College of Physicians and fluoridation SIR,-The selective use of research material from studies by Dr Robert Weaver quoted by the authors of the Royal College of Physicians' report Fluoride, Teeth and Health' is surprising and merits explanation. On p 9 of their report they refer to a paper published by Dr Weaver2 showing that 5-yearold children in South Shields with naturally fluoridated water at 14 ppm had on average 3-9 decayed, missing, or filled (DMF) teeth compared with 6-6 in children in North Shields with 0-25 ppm fluoride in the drinking water. Moreover, says the report, "at the age of 12 the number of DMF teeth in South Shields was 56,0 of that in North Shields." In Weaver's second study' evidence was given "which suggests that fluorine is a caries-postponing rather than a caries-preventing factor." Table III of this paper shows that by the age of 15 years children from South Shields had an average of 4-4 DMF teeth compared with 4-3 at the age of 12 years in North Shields. By the age of 17 those in the high-fluoride areas had 6-5 DMF teeth compared with 7-2 in the low-fluoride areas, a difference of about half a decayed tooth on average and a difference which steadily lessens with increasing age. A survey to discover if the effects of water-borne fluorides continued into adulthood showed that young South Shields mothers had a dental advantage of about five years, but for the over-30s the difference was negligible. Dr Weaver's third paper,4 also unmentioned in the RCP's report, contains his final and considered conclusions in which it was shown that "only a limited effect could be expected from the ingestion of fluoride in drinking water." Weaver remarked that if the protection given by fluorine in South Shields had not been shown to be of brief duration the dental profession would have been faced with an
BRITISH MEDICAL JOURNAL
embarrassing question, which would have been, "If the incidence of dental caries in South Shields is so very much less than in North Shields, why is it that the population of South Shields is no healthier than that of North Shields ? The answer is that the figure of 560,) which I have given in connection with the findings in 12-year-old children is misleading. There is no very striking difference in the incidence of caries in the two towns." Perhaps the authors of Fluoride, Teeth and Health would care to explain why they omitted these important statements and conclusions from one of their own references. RONALD V MUMMERY St Helier, Jersey, CI
Royal College of Physicians of London, Fluoride, Teeth and Health. London, Pitman, 1976. 2 Weaver, R, British Dental Journal, 1944, 76, 29. Weaver, R, British Dental,Journal, 1944, 77, 185. 'Weaver, R, Proceedlings of the Royal Society of Medicine, 1948, 41, 284.
Academics and scientists SIR,-It appears that Dr W B Hepburn chose to use the rather inappropriate medium of a book review (9 April, p 966) to air his individual prejudices. It is particularly difficult to understand why he felt it necessary to introduce an unrecognisable character sketch of the late Professor H A Harris into a review of a series of biographies which did not include him. The strength of H A Harris's personality
would have demanded deference, whatever had been his academic status, and I am sure that there can be few who knew him who would find "quaint" an appropriate descriptive adjective. While far from a midget in physical stature H A Harris was of a mental stature such as to inspire the respect, admiration, and eventually affection of many of his students and staff. Without the very real inspiration provided by him and his department the current shortage of medically qualified anatomists would have been even more desperate than it is. Among all the positive features of H A Harris's character it is regrettable that Dr Hepburn chose only to select two of his antipathies-whistling and undergraduate arrogance. DAVID BULMER Medical and Biological Sciences Building University of Southampton
Parascending: a safer alternative to hang gliding
SIR,-Dr G M Youill's presentation of the risks of hang gliding (26 March, p 823) complements Kirby's report on parachuting from aircraft.' The purpose of this letter is to draw attention to the existence of a third, much less dangerous aerial sport called parascending (parasailing in the USA). It is probably the simplest, cheapest, and safest way for the individual to get into the air. The parascender puts on the parachute harness with the canopy laid out behind him. A tow-line (usually 460 m (500 yards) long for the trained club member) from the harness is hitched to a Land Rover, which moves off at a speed appropriate to the wind conditions and the weight of the parascender. The parachute, held open by two wing-tip holders,
21 MAY 1977
inflates and the parascender goes up like a glider. At the desired height of 250-300 m (800-1000 feet) the parascender releases himself from the tow-line, steers his course, and makes his landing. The flight and landing techniques are the same as in parachuting from aircraft, but the risks of exit and of canopy maldevelopment are abolished; the parascender is not towed up if any fault appears when the canopy is opened on the ground. The British Association of Parascending Clubs is the national body concerned with the licensing of instructors and national aspects of the sport. It is closely concerned with all matters of safety. The injury rate for 50 807 flights in the USA was reported to be about 0-5 %,2 but we consider the risk to be smaller. The injuries we encounter are abrasions, bruises, sprains, and minor undisplaced fractures which do not keep members off work, and even these are unusual outside the competitions which tempt a parascender to go for the target instead of landing defensively. From four club seasons with over 2000 flights two members have been admitted to hospital: one suffered acute pain from a known and previously disabling lumbar disc lesion and the other had a grand mal attack. This information is presented because we believe that parascending should be dealt with in its own right by insurance underwriters and not classed with hang gliding or parachuting from aircraft. A J MACAULAY Chief Instructor
P G F NIXON London W8
2
President, Charing Cross Hospital Parascending Club
Kirby, N G, Proceedings of the Royal Society of M2?dicine, 1974, 67, 17. Hall, G W, Aviation, Space and Environmiental Medicine, 1977, 48, 164.
Night visiting rates by general practitioners SIR,-I wish to comment on the article on this subject by Mr M J Buxton and others from the Centre for Social Studies (26 March, p 827) and Dr I C Gilchrist's letter (7 May; p 1217). Mr Buxton and his colleagues record an increase of approximately 135 % in the night visiting rate per 1000 patients between 1967-8 and 1975-6 for the country as a whole. In this group practice of four, by contrast, our night visiting rate in 11 years to 1976 dropped by 15 2°,. We recorded our night calls (11 pm to 8 am) for six years, 1 January 196031 December 1965,' and again 11 years later, for 1976. The night call rate for the six years 1960-5 averaged 6 6 and this compares with 5 6 per 1000 patients in 1976 (64 night calls for our list of 11 440). We considered that only three (4-1 %) of these calls were unnecessary. The authors speculate on whether the number of night calls has risen since 1967, after which general practitioners began to be paid for these night calls. In this practice they have fallen. They also point out that deputising services and a high proportion of social class V patients increase the night visiting rate. In Farnborough we have our own rota for calls and the number of social class V patients is low. The figures provided by Mr Buxton and his colleagues also tend to confirm what other
BRITISH MEDICAL JOURNAL
21
MAY
1977
1353
observers have noted, that night visiting rates producing severe oedema in elderly patients are higher in the north of England and in who are on a high dosage schedule, as was the Scotland.2 -4 case with the patient reported. Finally, while congratulating Mr Buxton and his colleagues on their excellent paper, I D L F DUNLEAVY consider their last paragraph to be mistaken. University Department of Psychiatry, Each doctor must decide, and then take Royal Victoria Infirmary, responsibility for, any action following a Newcastle upon Tyne request for a night call. This will depend on Kelly, D, et al, British3rournal of Psychiatry, 1970, 116, his knowledge of the patient and the circum387. stances, and not on any 'consensus' of explicit 2Rees, L, and Davies, B, Journal of Mental Science, 1961, 107, 560. criteria. 3 Dunleavy, D L F, MD thesis, National University of J N A PRITCHARD Ireland. Cooper, A J, and Ashcroft, G, Diabetes, 1967, 16, 272.
Farnborough, Hants 'Pritchard, J N A, British MedlicalJournal, 1966, 1, 614. 2Brotherson, J H F, et al, British Medical Journal, 1959, 2, 1169. 3Webster, G L, et al, British Medical Journal, 1965, 1, 1369. 4Pritchard, J N A, Journal of the Royal College of General Practitioners, 1976, 26, 166 and 357.
Mucocutaneous lymph node syndrome SIR,-I was interested in the recent reports of cases of mucocutaneous lymph node syndrome (Kawasaki disease) occurring in England (19 February, p 511; 2 April, p 883). This is probably not a new disease to Britain or anywhere else. In 1960 Forbes and Bradley described in your columns' a 9-year-old boy with an aneurysm of his left coronary artery. Thye did not know the aetiology then but their case was almost identical with one seen in Canada in 1976.2 Subsequent to the Japanese descriptions these cases appeared to have been rare fatal examples of Kawasaki disease. PAUL WENTWORTH Clinical Laboratories, Brantford General Hospital,
Brantford, Ontario
Forbes, G, and Bradley, A, British Medi-cal Journal, 1960, 2, 1344. 2Wentworth, P, and Silver, M D, Canadian Medical Association Journal, 1976, 115, 299.
Phenelzine and oedema
SIR,-Drs A Goonewardene and P J Toghill (2 April, p 879) describe a case of gross oedema during treatment for depression with a monoamine oxidase inhibitor (phenelzine) and a benzodiazepine (diazepam). They question whether phenelzine alone could have been responsible for this side effect. In a series of phobic patients undergoing treatment with phenelzine ankle oedema was found to be common in adults,' and in a controlled drug trial with depressed patients two out of 20 developed oedema. In a personal series3 of 22 patients with endogenous depression receiving phenelzine in varying daily dosage of 60, 75, and 90 mg severe ankle oedema was noted in four. These four subjects were all women, over 50 years of age, and receiving 90 mg of phenelzine daily. No electrolyte or other blood abnormalities were noted and the oedema did not respond to concurrent use of diuretics, subsiding only when the drug was withdrawn or its dosage reduced. Some of the weight gain in the case reported may have been due to other factors. It has long been known that monoamine oxidase inhibitors can induce hypoglycaemia,' and Kelly et al in their series' reported excessive weight gain due to a craving for carbohydrates in a number of patients. The available evidence, therefore, would suggest that phenelzine is indeed capable of
Reduced DNA synthesis in non-responsive coeliac disease SIR,-I have read the paper by Drs P E Jones and T J Peters on DNA synthesis by the jejunal mucosa in responsive and nonresponsive coeliac disease (30 April, p 1130) with great interest and would like to suggest a reason for the low DNA synthesis found in non-responsive patients. We have reported' six patients with non-responsive coeliac disease with very low serum zinc values (5 7+1 2 cLmol/l (37 0+7 5 1jg/10O ml)). These patients showed a marked response to zinc therapy. As zinc is necessary for the incorporation of :H-thymidine into DNA,2 I would like to know the zinc status of Drs Jones and Peters's non-responsive patients. If non-response to gluten withdrawal, low DNA synthesis, and low plasma zinc are all part of the same syndrome the estimation of plasma or serum zinc should be a quicker and cheaper method of detecting non-responders than mucosal culture and 3H-thymidine incorporation studies, valuable though these are in understanding the mechanism of coeliac disease. MARGARET ELMES Departmen-t of Pathology,
Welsh National School of Medicine, Cardiff
'Elmes, M, Golden, M K, and Love, A H G, Quarterly J'ournal of Medicine, 1976, 180, 696. Williams, R B, and Chesters, J K, in Trace Element Metabolism in Animals, ed C F Mills, p 164. Edinburgh, Livingstone, 1970.
A case of dysphagia
SIR,-"Clinics in General Practice" is a series which should provide insights into how general practitioners and specialists can best interact with a particular clinical problem. Comment should be informed, instructive, and to the point. "A case of dysphagia" (30 April, p 1139) failed to show this interaction to have been in the best long-term interests of the patient. Dr A G Donald presented the trainee's problem patient, who at 30 was unmarried and during three months with the practice consulted excessively and received two specialist referrals. She had a past history involving three specialties with largely insignificant findings. She presented her new doctor with a new symptom, dysphagia, and demanded an ENT opinion. The trainee made an initial diagnosis of a functional illness and the trainer suggested that physical causes should be excluded. But that is tiot enough. For a diagnosis of hysterical psychoneurosis there must be positive signs of hysterical illness and, preferably, understandable gain.' Mr J D K Dawes, misjudging his forum,
gave a political account of the NHS and private practice covering 10 column inches, leaving only a few inches to make such comments as, "If . . . the patient demands it referral is essential." He agreed that "this patient is obviously under emotional stress" and that if no abnormality is found "the dysphagia for solid foods may be . . . hysterical." In the postscript sense at first prevails. The patient saw an ENT specialist twice who listened to her, and her symptoms evaporated without resort to any potentially dangerous procedures. But the trainee, having had his hypothesis "validated against an ENT opinion," did not take the logical step of psychiatric referral. Referral to a psychiatric department in a general hospital would permit liaison with other specialties when, as would almost certainly happen, she produced further symptoms. She was referred to two further specialists before she finally left. Running away is one way of coping. With psychiatric help she might have discovered more adaptive ways of coping. Hysterical patients are classically demanding and will continue to demand physical explanations to psychological problems, running the risk of further referrals and consequently more and potentially dangerous investigative procedures. It seems important to consider how differently this patient might have been treated if this series is to be of educational value. IAN PULLEN Department of Psychiatry, Western General Hospital, Edinburgh
Reed, J L, British Jotrnal of Hospital Medicine, 1971, 5, 237.
Alcoholic liver disease in women SIR,-Dr A N Hamlyn, in discussing why women could be more susceptible than men to the development of alcoholic cirrhosis (23 April, p 1085), suggests that female alcoholics could be more likely to underestimate the amount of alcohol consumed. Other factors besides average daily alcohol consumption may be important. For example, for a given weekly alcohol intake women tend to drink on more occasions than men.' Thus the total time that blood ethanol levels are elevated above some "threshold" value rather than peak levels might determine the development of severe liver disease in alcoholic patients, and clearly this possibility should be considered in future surveys. G NICHOLSON Ninewells Hospital, Dundee Dight, S E, Scottish HMSO, 1976.
Drinking Habits. London,
Gluten-free diet in dermatitis herpetiformis SIR,-I enjoyed the paper by Drs Christine I Harrington and N W Read (2 April, p 872) on the immunological consequences of gluten withdrawal in dermatitis herpetiformis (DH). It appears that in three of the 10 patients studied there was disappearance of IgAcontaining cells from the lamina propria of the jejunal mucosa following gluten withdrawal. This is a surprising finding which is at variance with our early observations' and those of Lancaster Smith et al2 that jejunal
