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CARE OF DRUG ADDICTS

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Page 1: CARE OF DRUG ADDICTS

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systemic diseases which give rise to the symptoms of back-ache and which are not amenable to manipulative treatment.Disseminated sclerosis, some nutritional deficiencies, and mostneuropathies are amongst other cases in point. The crux ofthis matter is, of course, accurate diagnosis.Mr. Bremner’s statement that he applies manipulation for

backache with the idea of giving the patient " a good start "will cause the average osteopath to recoil in horror. As well

suggest the victim be given a bath as a helpful preliminary."Backache" is not a diagnosis, but a symptom. Nor is

manipulation an all-purpose procedure. Indeed, it would bepreferable to call it manipulative therapy, and when appliedin a case presenting the symptom of backache it should be

preceded by certain initial basic steps:Firstly, the patient must be clinically assessed, and an adequate

differential-diagnosis made. Selectivity is essential.Secondly, when manipulative therapy is applied it must have

specific objectives, work within well-defined limits, and never beused as a general procedure without definite reason.Thirdly, in manipulative techniques, it is necessary-to safeguard

the patient and the parts involved-that the operator conforms toscientifically based rules. Indiscriminate force is no more manipula-tion than a violent blow with a club on a ball is golf.

The trained osteopath claims that he uses his manipul-five therapy to attain specific and precise objectives in ahighly selective way. He further claims that to use

manipulative techniques, and the methods of diagnosisnecessary as a preliminary to them, one must be taught,and the period of training must be a long one. A crafts-man is much more than a man who just " knows how ".To his theory must be added a long and sometimesdifficult period of practical experience.

R. F. MILLERRegistrar,

London, S.W.I. General Council and Register of Osteopaths.

SIR,-Manipulative treatment presents us with a regu-larly repeatable and predictable series of events, and istherefore worthy of scientific study.A typical patient complains of pain of the " muscular rheu-

matism " type, and the appropriate manipulation of the appro-priate joint commonly produces an immediate cure. This is a

phenomenon I have observed several times a week for the pastten years. Although manipulation under anxsthesia is sometimesuseful, I do not use it myself in general practice. In any case,the question of anxsthesia is irrelevant to our present themeand is in fact confusing since it would be quite possible for ajoint to be manipulated accidentally while an anxsthetisedpatient was being lifted or moved (I am thinking of the painsin the right iliac fossa which disappear after the removal of anormal appendix). On the other hand, I have several times seenpatients whose pains have arisen from sustained, strained pos-tures under anxsthesia.Some regard the manipulable diseases as being psychological

in origin, and the treatment by manipulation as psychotherapy.On the contrary, my own evidence suggests that we are dealingwith a group of diseases of mechanical origin. They arise gen-erally either from a chronic postural strain (of external origin,such as those caused by sagging beds, pillows of the wrongheight, or unsuitable furniture, or of internal origin, such aspregnancy backache). Alternatively, they may arise from acutestrains, which may likewise be regarded as of external origin(such as backache after lifting) or of internal origin (such as post-partum backache, pain at the tips of the lower costal cartilagesafter coughing, or a " crick in the neck "). The change in thedegree of pain with movement in certain directions, and theusually successful mechanical treatment of such conditions bymanipulation or by exercises, is further evidence of a mechanicaldisease.

The precise nature of the changes in a joint which isbeing manipulated has not been certainly and clearlyestablished. I do not feel it is in any way disgraceful to

admit to ignorance even over such a crucial point as this.What we must all feel to be disgraceful is that ancientarguments about unregistered practitioners should havebeen allowed to obstruct the advance in knowledge of thispart of medicine for the best part of a century.

Lowestoft. N. B. EASTWOOD.

SiR,—I cannot understand how Dr. Barbor (Feb. 1)interpreted my letter of Jan. 25 as advocating manipula-tion of the spine as a placebo. There is nothing whateverin my letter to justify this interpretation.

R. F. MILLERRegistrar,

General Council and Register of Osteopaths.

N. B. EASTWOOD.

DAVID F. THOMAS.War Memorial Hospital,

Scunthorpe.

1. See Lancet, 1957, ii, 888.2. ibid. p. 929.3. Sims, W. H. ibid. p. 1076.4. Schindel, L. Unexpected Reactions to Modern Therapeutics: Anti-

biotics. London, 1957.5. Pierce, H. E., Jr. J. Nat. M.A. 1953, 45, 68.6. Feinberg, S. M., Feinberg, A. R. J. Amer. med. Ass. 1956, 160, 778.7. Blanton, W. B., Blanton, F. M. J. Allergy, 1953, 24, 405.8. Mayer, C. S., Mosco, M. M., Schutz, P. I., Osterman, F. A., Steen, L. H.,

Baker, L. A., J. Amer. med. Ass. 1952, 151, 351.9. Everett, R. ibid. 1951, 146, 1314.

PENICILLIN HYPERSENSITIVITY

LEO SCHINDEL.

SIR,-During the symposium on antibiotics and inyour leading article on penicillin hypersensitivity 2 men-tion was made repeatedly of anaphylactoid reactions follow-ing injections of penicillin. Dr. Sims 3 asked whether

anaphylactoid reactions to oily suspensions of procainepenicillin have been observed.Having dealt with the side-effects of antibiotics in a book,4

I should like to draw your attention to the fact that in the litera-ture it is stressed time and again that anaphylactoid reactionsafter penicillin depend neither on a special compound which isadministered, nor on the medium in which penicillin is dis-solved or suspended. Reactions have been reported after oraladministration of penicillin as well as after local adminis-tration. 6 Mayer et al. reported anaphylactoid reactions withfatal results due to inhalation of penicillin powder. Everett 9

reported acute anaphylactoid reactions after instillation intothe maxillary sinuses. Special mention has been made 6 ofanaphylactoid reactions after intramuscular injections of

procaine penicillin in oil with aluminium monostearate. Inone case, the patient died 20 minutes after the injection. Hereit is remarkable that the case-history did not indicate anyallergic reactions nor any previous treatment with penicillin.

Jerusalem, L SIsrael. LEO SCHINDEL.

CARE OF DRUG ADDICTS

SIR,—The report of a study group of the World HealthOrganisation on drug addiction (Jan. 11, p. 113) gives the’impression that victims of addiction to opium and itsderivatives can be readily treated by various techniques.This is quite contrary to the general experience of thosefamiliar with the problem.

It is misleading and unrealistic to refer to " easiest to treatand " harder to treat " and to suggest that addiction can betreated by mass methods (whatever that may mean) or by psy-chotherapy not essentially different from that employed in otherpersonality disorders.The unpleasant truth is that drug addiction occurs invariably

in psychopathic personalities, and is for all practical purposesincurable. There is no such thing as a slight case of addictionjust as there is no such entity as a slight case of pregnancy. Thecondition either exists or does not and the only circumstanceswhich can favourably influence the prognosis are its duration,the quality of the patient’s personality, and the nature of hisenvironment.

Residential treatment is absolutely essential in any attempt atcure and anything short of this is a waste of time, effort, andmoney. Furthermore, the addict will inevitably relapse after

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every treatment other than that carried out under residentialconditions, which means thatultimately a longer-standing addic-tion will have to be tackled and that any confidence which the

patient might have had in the efficacy of treatment will have be’-come seriously undermined.

It is still far too easy for addicts to obtain drugs. In mostcases they represent’ themselves to sympathetic (and possiblyinexperienced) practitioners as anxious to undertake treatmentbecause they can no longer afford the exorbitant prices de-manded by dope pedlars. Very often drugs are obtained bypeople who are not addicts at all and the supply changes handsat fifty or more times its cost.The only effective way of preventing abuses by ambulant

patients or tricksters is personally to administer drugs onlywhen there is clinical evidence of deprivation. Theyshould not be given a supply of the drug under any cir-cumstances but referred to hospital.

Until legislation is introduced to provide for the deten-tion of addicts in hospital on their own application for aminimum period of three months, their numbers will notdiminish and the cure of drug addiction will continue to belargely providential.London, N.W.I. ELLIS STUNGO.ELLIS STUNGO.

TREATMENT OF UNDULANT FEVER

E. E. LEHMANN.Hayim Yassky Hadassah Negew Hospital,Beer Sheba, Israel.

Sir,-With great interest I was reading Dr. TorresGost’s article of Jan. 25.

So many treatments have been tried for brucellosisbut none has been proved wholly satisfactory: it wouldbe very welcome if Cathomycin’ turned out to be thedrug of choice.

I had the opportunity to observe several outbreaks ofbrucellosis in the Negev district of Israel. The first epidemicbroke out some four years ago and we treated about 20 cases.In 1957, in a much bigger outbreak, we cared for well over100 cases (a report has not yet been published). We had, ofcourse, the opportunity to try several treatments. All patients,however, got streptomycin and chlortetracycline (aureomycin)or oxytetracycline (‘ Terramycin’) in different doses and fordifferent periods of time. The cases treated were all in anacute phase and showed the typical signs and symptoms ofbrucellosis in all varieties.With very few exceptions, the patients reacted satisfactorily

to this treatment: the temperature started to drop after aboutthree days and usually became normal on the fifth day. Allthe other symptoms and pathological laboratory findings dis-appeared during the treatment. The spleen got smaller butdid not return to normal. The treatment was usually continuedfor two to three weeks. I do not say that all the patients werecured during the course of treatment-several patients didhave relapses-but quite a number felt fit after treatment.The follow-up showed no further relapses and there was adefinite decline of the agglutination titre.

Dr. Torres Gost does not say anything about the follow-upof his patients, and I must confess his statement is not tooconvincing. One cannot yet say definitely whether cathomycinreally is the drug of choice in brucellosis. Dr. Torres Gostdoes not mention how long his patients were observed afterstopping treatment. It is known that patients with brucellosiscan relapse even after months of comparative wellbeing.I should think a period of at least one year should elapsebefore the patient is regarded as cured. During this period thepatient should feel well himself, the clinical and laboratoryfindings should remain normal, and the agglutination titreshould become normal or at least decline.

The trial period of cathomycin seems to me too shortto justify a final conclusion. Our experiences with

streptomycin and aureomycin (or terramycin) were

satisfactory as regards immediate reaction to treatmentbut not as regards complete cure after the first course of

treatment. Practically all cases were finally cured. Therewere no toxic or allergic reactions to the drugs used.

1. Lancet, 1957, ii, 850.2. ibid. p. 805.

TIME OF RECURRENCE OR CURE OF TUMOURSIN CHILDHOOD

M. W. PARTINGTON.Jenny Lind Hospital,Norwich.

SiR,ŃThe following case-report is of interest in viewof Dr. Knox and Dr. Kingsley Pillers’ paper (Jan. 25)on the prediction of a " period of risk " of tumourrecurrence after operation.A boy, born on March 14, 1953, appeared a normal child

until August, 1953, when a large tumour was found in theabdomen filling the left hypochondrium and extending intothe left inguinal fossa. On Aug. 26, at laparotomy, the tumourwas removed. It was found to arise from the lower pole of theleft kidney, and histological section showed that it was a

Wilms tumour. Postoperative progress was excellent and nodeep X-ray treatment was given. He was seen at 6-monthlyintervals in the outpatient department and on Jan. 18, 1955,was noted to be fit and well. In February, 1955, he had anattack of pneumonia treated at home. Soon after this he becameshort of breath, and on April 4, 1955, a chest radiograph showeda large secondary deposit in the right lung. Further treat-ment was refused; and he died on April 27, 1955.

In this case the estimated " period of risk " was 14months (5 months plus 9 months). This child survived14 months after operation and a further 6 months intothe " safe period " before a recurrence was found.Even if the attack of " pneumonia " is taken as the firstsign of recurrence, he lived some 4 months into the" safe period " apparently fit and well.As Dr. Knox and Dr. Kingsley Pillers point out, one

patient surviving far into the " safe period " with eventualrecurrence would seriously call in question the premiseon which the estimation of the " period of risk " is based.This boy could be such a case. On the other hand, it isconceivable that a large secondary tumour could have beenpresent in the chest for 6 months before it was actuallydiagnosed. Nevertheless, this patient’s recurrence wassufficiently late to warrant some caution in accepting Knoxand Kingsley Pillers’ estimate of the " period of risk ".

I should like to thank Mr. A. B. Birt for permission to publishthis case.

CORTISONE AND HYPOGLYCÆMIC SHOCK

SIR,-Dr. Kay, in his interesting remarks,! expressedthe opinion that in our experiments 2 insulin sensitivity wasdue to depression, by the previous large doses of cortisone,of the activity of the pituitary gland and the adrenal cortex.To explain the absence of hypoglycaemic shock duringcortisone treatment, he suggested that the stimulatingeffect of cortisone on the cerebral cortex was absent at

blood-sugar levels producing hypoglycxmic shock.In our opinion, other factors must also be taken into account.

The blood-sugar level at which insulin shock appears dependson the state of the organism. Under certain experimental con-ditions there is no shock at quite low blood-sugar levels, whileunder other circumstances shock may develop at comparativelyhigh levels. In diabetic patients hypoglycaemic shock sometimessets in at about 100 mg. per 100 ml., if, after insulin, the blood-sugar had fallen there from a high level.

In our animal experiments, when before insulin administra-tion the blood-sugar had been considerably above normal (inrabbits the blood-sugar may rise spontaneously on excitation),insulin shock at times developed at a level even higher than