bread

204

its full complement of nurses of both sexes and a waiting-list.None of us likes empirical treatments. We are -not

enamoured of electroplexy, insulin, or neurosurgery.Nevertheless, when employed witb discrimination in

every orthodox mental hospital, these methods produceremissions or recoveries. They are not used for adminis-trative purposes or as methods of restraint. The ever

increasing number of open wards, better atmosphere,and vastly increased freedom extant in such hospitalsshould be apparent to the meanest intelligence or mostcareless observer.

Finally, no nurse of ours polishes floors. Nurses ofboth sexes, if asked by Dr. Hunter, will inform him in nouncertain terms that the last two decades have broughtthem increased dignity, stature, and standing ratherthan the reverse.We realise that we still have far to travel in the field

of psychiatry, and we feel that its interests would bestbe subserved by balanced judgments and fewer sweepingassertions on the part of those practitioners in this spherenot immediately connected with mental hospitals.

Dr. Hunter would be well advised to pay a round ofvisits to representative mental hospitals wherein we areconvinced he will find nursing personnel with eruditionand dignity equal to his own.

H. C. BECCLEPhysician-superintendent

MORRIS MARKOWEDeputy Physician-superintendent.

Springfield Hospital,London, S.W.17.

1 Lancet. 1955, ii, 1284.2. Arch. Path. (Lab. Med.) 1954, 57, 288.

Chandler, G. N., Watkinson, G. Lancet, 1953, ii, 1170.

VENO-OCCLUSIVE DISEASE OF THE LIVER

G. BRAS.Pathology Department,

University College of the West Indies,Mona St. Andrew, Jamaica.

SiR,-Your annotation on this condition 1 does notrefer to our first article 2 in which the histology andpathogenesis-slightly misrepresented in your annotation-were fully described.

INTRAGASTRIC MILK DRIP IN TREATMENT OFUPPER GASTRO-INTESTINAL HÆMORRHAGE

G. N. CHANDLERG. WATKINSON.Department of Medicine,

University of Leeds.

SiR,-Dr. Dawson, in his article on the continuous

intragastric milk drip in the treatment of upper gastro-intestinal haemorrhage (Jan. 14), makes critical referenceto our observations 3 on the value of the indwellingtube in the management of hsematemesis. Our continuedexperience of the method, which now extends to 225

patients, has, if anything, increased our confidence inthe procedure.The recognition of further gastric haemorrhage formed

only a small part of the original study of 105 patients ;of equal value, and disregarded by Dr. Dawson, has beenthe information provided as to the site of ulcer by theassociation of clear aspiration specimens with clinicalevidence of continued bleeding, indicating a source ofhaemorrhage beyond the pylorus. These factors, in

conjunction with the gastric secretory patterns observedduring and after the acute stages of gastroduodenal hsemor-rhage, led to the correct recognition of the pathologicalcause of the bleeding in a significant proportion of thepatients studied. We suggest that the complete applica-tion of the method might have improved the resultsobtained, our mortality of 4.8% in 225 unselected

patients so investigated comparing favourably withDr. Dawson’s series (8 in 100 patients).We would agree with Dr. Dawson that the reappear-

ance or continuance of blood-staining of the gastriccontents does not necessarily herald a further massivehaemorrhage ; but its presence gives no grounds for

complacency, and, with other criteria, will lead to theearlier recognition and treatment of this complication.

We believe that a complete regard for all the points madein our paper can do much to stimulate awareness of the

diagnostic problem and to facilitate its earlier solution.From our further experience we see no reason to modifyout original conclusion that early gastric aspiration aidsmaterially in the management of haematemesis.

1. McCance, R. A., Widdowson, E. M. Lancet, 1955, ii, 205.2. Widdowson, E. M., McCance, R. A. Spec. Rep. Ser. med. Res.

Coun. Lond. no. 287. H.M. Stationery Office, 1954.3. Physiol. Rev. 1951, 31, 205.

BREAD

E. P. EVANS.Winnipeg, Manitoba,Canada.

SiR,—Professor McCance and Dr. Widdowson con-

cluded their article on Old Thoughts and New Work onBreads White and Brown 1 by saying :

" It is of course

always quite possible that little attention will be paid tothese experiments of ours...." I have just re-read theiroriginal report,2 which confirms the conclusion I first cameto that the experiments were vitiated by the fact that noconsideration had been given to the possibility that thechildren suffered from hypothyroidism, and that iodinewas the limiting factor in their inability to grow. On

seeing these undergrown children it is astonishing thatany clinician could have overlooked this, apart fromthe fact that Duisburg is, I believe, in a goitrous area.The effects of the secretion of the thyroid on protein,fat, carbohydrate, and calcium metabolism, on nerve-muscle function, on reproductive activity, and on resis-tance to infection are well known.3The following data from these experiments support

this contention :

At the start of the studies 5 children at Duisburg and 3 atVohwinkel had thyroid enlargement ; at the end 64 at Duis-burg (66%) and 27 at Vohwinkel (50%) had enlarged thyroids.The protein range at Duisburg was 61-73 g., at Vohwinkel51-53 g., and in both groups the weight increase in the sametime was the same, so that it can be seen that the lowerVohwinkel supply of protein was adequate for growth, theexcess protein at Duisburg merely going to supply energy andaccounting for the increased hypothyroidism in that group.This is the reason why the addition of milk was ineffectiveowing to the exhaustion of the available iodine and thecomment " cannot be improved by a milk supplement" ismeaningless.The delay in epiphyseal ossification is typical of hypo-

thyroidism, quite a different radiological picture to that ofrickets. The continued presence of skin infection supports thiscontention, as does the complete absence of puberty in boysof 14. Amongst British boys puberty may start at 10 or 11years. Iodine was given, and this in itself should have sug-gested the nature of the deficiency. The puzzling oedema isdue to the unbalanced vitamin supplement added to the 70%-extraction flour and causing a conditioned vitamin-B1 defici-ency. It is said that the children were so ravenous that theycleared every scrap of food and yet gave scraps of food to themonkeys in the zoo. This does not appear to have beenallowed for in the tables. One wonders what else the childrendid ?

It can be seen therefore that there are no grounds forProfessor McCance’s conclusions, as the question ofiodine being the limiting factor in failure of growth wasnot considered, and the internal evidence in the experi-ments strongly suggests that it was.

" Man cannot live by bread alone." It has never beenclaimed that man can subsist on wholemeal bread alone,but with other foods it enhances their combined nutri-tional value. It is astonishing that the claim should bemade that the experimental diets were nutritionallyadequate, when the subjects of the studies are shown atthe end to have enlarged thyroids, skin sepsis, delayedpuberty, bad teeth, and delayed epiphyseal ossification-and at an age well below that in which they will becalled upon to sustain all the vicissitudes of life.