1261

observations suggest that there is a hyperdynamicequilibrium of more synalbumin antagonist with morecirculating insulin during the latent and early phases ofdiabetes mellitus.12 Moreover, there is evidence thatthis antagonist, which was detected using muscle, doesnot affect insulin action on adipose tissue 10-theconversion of carbohydrate to fat is not impeded. Thesuggestion therefore was that " obese diabetics becomeobese because they are diabetic ".11 This idea is

strengthened by the findings of ALP and RECANT, 21who not only confirmed the original reports of thecontra-insulin action of albumin on muscle, thoughnot on fat, but also showed that albumin had a stimula-tory action on fat greater than that achieved by theinsulin carried with it.From examination of relatives of patients with

essential diabetes, it seems that many more people areconstituted as diabetics than ever develop carbohydrateintolerance.12 22 If this can be confirmed, it seems likelythat one probably not uncommon cause of obesity inthe " normal " population is the diabetic constitution.

Annotations

HOW WE TELL

DOCTORS can easily fall into a collective way of thinkingabout those who seek their services. And if it is true that

people lose half their humanity when they become patientsthey may lose the other half when they become patients inhospital. The hospital doctor is dealing with large num-bers of patients he knows only in the hospital context, andhe is encountering the same disorders time and time again.Everything encourages him to think in terms of casesrather than people, and the habit of authority engenderedby the hospital hierarchy may betray him into treating hispatients accordingly. The patient is, of course, unawareof the doctor’s difficulty. He feels himself unique andimportant, in hospital as elsewhere-individually sick,individually frightened, and individually in need of treat-ment, sympathy, and reassurance. And when everyexcuse has been made for the doctor, if he fails to recogniseand meet these needs he is seriously at fault.That he does fail periodically is again made apparent

by the letter on p. 1274. Our correspondent’s recollectionof what was said to her may be distorted by hindsight andher own distress; but that she should have left hospitalfeeling as she did about her treatment there is sufficientindication that she was mishandled. The surgeon in thisinstance apparently lacked common courtesy-a deficiencywe have noted before in the hospital attitude to patients.23To him, his words may not seem out of the ordinary; butthe patient remembered them, and not her operation,as the most unpleasant part of her experience.

Doctors in general are probably not sufficiently awareof the significance patients attach to what they say. Notall may have the gift of finding the right word for theright moment, but all can at least recognise the importanceof trying. That recognition is certainly not fostered in themedical schools. Students receive little guidance in thisaspect of their work, and their learning by experience20. Lowy, C., Blanshard, G., Phear, D. Lancet, 1961, i, 802.21. Alp, H., Recant, L. Metabolism, 1964, 13, 609.22. Vallance-Owen, J., Ashton, W. L. Diabetes, 1963, 12, 356.23. Lancet, Jan. 9, 1965, p. 93.

alone can be a damaging business. The sort of help theymight be given is illustrated by Genevieve Burton in abook 24 intended for nurses. She describes, very simply,the development of personality and its relation to the

patterns of behaviour that illness may evoke; and shesupplies anecdotes throughout to make her points. Herintention is to equip the nurse with a knowledge of whatis involved in her dealings with patients so that she maydevelop each new relationship to best advantage.Between many a doctor and his patient, however,

relationship is as near non-existent as the doctor can

manage. For lack of time or lack of confidence he mayfind distance expedient. But he cannot, while he prac-tises, absolve himself from the duty of choosing his wordswith care.

DYNAMIC OBSTRUCTION

OF THE LEFT VENTRICLE

OBSTRUCTION to emptying of the left ventricle, with asystolic pressure gradient across the outflow tract,25 may,it is now recognised, have causes other than disease of theaortic valve. Hypertrophy of ventricular muscle was aconstant feature of earlier cases,26 but similar harmo-dynamic changes have lately been produced in the

apparently normal heart by reduction in venous returninduced by the Valsalva manaeuvre 27 and bypasssequestration,28 and by drugs.

Isoprenaline can produce reversible obstruction of theventricular outflow tract in man and laboratoryanimals,28-30 and Krasnow et al. 29 postulated that the causewas shortening of cardiac muscle below the aortic valve.The importance of sympathetic activity was recognised byHoney et al.31 who suggested that in Fallot’s tetralogy oneof the causes of the fall in arterial oxygen saturation oneffort might be increased outflow-tract obstruction

resulting from sympathetic stimulation, and that this fallmight be reduced by pronethalol. They found that

pronethalol did in fact do that, thus demonstrating theimportance of increased P-adrenergic receptor stimulationin the enhancement of myocardial contractility duringexercise.Brock and his colleagues 32 have now described dynamic

obstruction produced by various agents which share theproperty of causing a more vigorous contraction of theheart. These were the naturally occurring catecholamines,adrenaline, noradrenaline, and isoprenaline, and the non-specific cardiac stimulants, aminophylline and calciumchloride. They studied 20 dogs, in 10 of which (the" reactors") they could produce a gradient of up to

200 mm. Hg with relatively small doses. In the other 10 itwas impossible to induce these hxmodynamic changeseither with the same or very much larger doses. Thereason for such a difference in response was not clear, forthe drugs had similar inotropic, chronotropic, andperipheral effects in the two groups, and there were noobvious anatomical differences between them.

The pressure gradient induced by catecholamines was24. Burton, G. Nurse and Patient. London: Tavistock Publications. 1965.

Pp. 212. 21s.25. Goodwin, J. F., Hollman, A., Cleland, W. P., Teare, D. Br. Heart J.

1960, 22, 403.26. Lancet, 1962, ii, 186.27. Braunwald, E., Oldham, H. N., Ross, J., Linhart, J. W., Mason, D. T.,

Fort, L. Circulation, 1964, 29, 422.28. Cross, C. E., Salisbury, R. F. Am. J. Cardiol. 1963, 12, 394.29. Krasnow, N., Rolett, E., Hood, W. B., Yurchak, P. M., Gorlin, R. ibid.

1963, 11, 1.30. Harrison, D. C., Glick, G., Goldblatt, A., Braunwald, E. Circulation,

1964, 29, 186.31. Honey, M., Chamberlain, D. A., Howard, J. ibid. 1964, 30, 501.32. deBono, A. H., Proctor, E., Brock, R. Guy’s Hosp. Rep. 1965, 114, 4.