304
Journal of the Royal Society of Medicine Volume 85 May 1992
Letters to the Editor Preference is given to letters commenting on contributions recently published in the JRSM. They should not exceed 300 words and should be typed double-spaced.
Low dose botulinum toxin for spasmodic torticollis In an open study, D'Costa and Abbott (November 1991 JRSM, p 650) treated patients with spasmodic torticollis (ST) using a 'low' dose of botulinum toxin (BT), and found that it was effective and had a lower incidence of side effects than the 'recommended' dose of 800-1000 mu (they quoted doses in ng, but the mouse unit is now the preferred measure as it is a unit of potency: 1 ng=40 mouse units). It is not clear how they decided the dose for each patient, as it ranged from 400 to 600 mu, nor whether patients had previously been treated with BT. The resulting improvement appeared comparable to that quoted in previous trials using higher doses. I have been treating patients with ST with the 'lower' dose over the last 4 years and would agree that it is effective. I routinely use 500 mu (= 12.5 ng) as a first dose and modify subsequent doses according to the observed response and reports from patients and relatives. After two or three treatments a reasonably stable compromise can usually be reached between benefit and side effects. Patients receive BT injections on average every 3 months. I have retrospectively analysed the dose of BT given to each of 79 patients with ST in my clinic during the 3 month period of July to October 1991. Each had received at least three previous treatments with BT and dosage was therefore likely to be stabilized. No patient was included twice. The mean dose given per patient was 545 mu (SD 120), the median dose was 500 mu (12.5 ng), and the range was 200-800 mu (5-20 ng). In my experience an initial dose of 500 mu results in few problems, but it should be considered as no more than a 'ranging shot'. The wide range of maintenance doses eventually used suggests that it is important to adjust the dose individually. The main determining factors are the degree of benefit and the severity and duration of side effects, particularly the main dose limiting side effect which is dysphagia. It should be noted that dysphagia may be played down by patients, who may be reluctant to forego the benefits of larger doses of toxin but who underestimate the danger of aspiration. A P MOORE
Department of Neurological Science Faculty of Medicine, University of Liverpool Walton Hospital, Liverpool L9 1AE
Polarization of art and science I read with great interest the editorial on the debate about the polarization of 'Art' and 'Science' (November 1991 JRSM, p 637). I was surprised by the statement in the editorial that such a debate 'never was applicable to medicine'.
The theory and practice of medicine today is a firm and irrefutable statement of science. From the origins ofthe germ theory to the discovery of genetic coding, the field of medicine is now purely a scientific pursuit. The art of healing has yielded to the science of technological wizardry. The reductionism of Newtonian physics has permeated the world of medicine to the extent that medical students now practise 'objective and scientific detachment' from the 'objects' of their enquiry. In such a technical world, health is a biophysical concept and medics are as removed from art as the neurophysiologist is from existential philosophy. In the 1980s, the debate has been referred to as that between 'Scientism' and 'Poetism' . Scientism is a belief that science knows, or will soon know all the answers. Poetism is the firm conviction in the validity of imaginatively produced hypothesis, considered true only because of their 'higher inspirational origin or an appeal to some mystic predilection of their authors'. Scientism in medicine allows us to brush aside phenomena like the 'placebo effect' in drug trials as an aberration in the scientific pursuit of chemical cures, deserving neither a cogent explanation nor further study. Poetism allows many in the general public to be swayed by various kinds of therapies from the different schools of alternative medicine, some dubious, a few deleterious, and many a waste of time and money. If medicine is to make such a debate irrelevant it is not a certain combination of 'A' levels that will achieve this. A totally new approach is required to conceptualize health and illness. Such a 'paradigm shift' has already occurred in the field of nuclear physics, the purest of the pure sciences2. Only such a paradigm shift in the field of medicine will allow a true combination of artistic vision and scientific excellence. S P SINGH
Department of Psychiatry University Hospital, Queen's Medical Centre Nottingham NG7 2UH
References 1 Medawar P. Pluto's Republic. London: Oxford University Press, 1982 2 Capra F. The Turning Point. London: Fontana Books, 1983
Subtotal colectomy following marathon running in a female patient I was most interested in reading the case report by Beaumont and Teare (July 1991 JRSM, p 439). In 1980 1 was involved with a runner who presented with bloody diarrhoea 24 h following a 23 mile fell race (the Yorkshire Three Peaks). This had been run on a hot day with the ground very hard underfoot. The individual had become very dehydrated and on the final few miles was somewhat disorientated. On account of shin soreness following the event a single dose of 100 mg flurbiprofen had been taken. As the bloody diarrhoea persisted for some weeks sigmoidoscopy and barium enema were undertaken, revealing an inflammatory proctitis. This necessitated treatment initially with Predsol enemas followed by Colifoam enemas and then Salazopyrin treatment. It was some months before symptoms came under control. It was considered by an eminent gastroenterologist that neither the activity nor the flurbiprofen was of
Journal of the Royal Society of Medicine Volume 85 April 1992
relevance to the pathology. It was recommended that Salazopyrin be taken life-long, but the runner withdrew this after 6 months and has had no further episodes. It is obvious that sincethat time there has been an increased awareness of lower gastrointestinal problems in runners. I ould suggest that the runner described by myself-had a' ailder reriodn of inflammatory bowel disease ;o that described in you Journal. WENDY N DODDS St Luke's Hospital Bradford, West Yorkshire BD5 ONA
Gut fermentation Eaton's paper on gut fermentation (tjpvember JRSM 1991, p 669) drew my memory back mauiy years. I think it was believed thait the condition -intestinal carbohydrate dyspepsia-was 'due to colonization of the small gut by coliforms foflowing a bout of' gastroenteritis. A high starch 'dlet maintained the abnormal bacterial population leading to abdominal distension, the production of excess flatus and, as months passed, increasing introspection, frustration and polysymptomatology in the patient. When I was serving in the RCAF in the mid-fifties a fighter pilot saw me with symptoms of intestinal carbohydrate dyspepsia to such' an extent that he could not tolerate high altitudte flying. He gave a typical history. I took'him off bread and other cereal based food, potatoes, and pUss for 3 days - he was then to fly again; he did so and was very much better. I kept him on the' same regimen for 2 weeks and then added firstly bread, then other cereals and finally potatoes over a further fortnight. He did naot consult me again. I have seen many patients with similar symptoms since then and they all did well. Patients were always told the reasons for the low starch regimen. I see fewer patients now, being partiallyr' retired and working in a different field, but if -IL saw a patient tomorrow with a bubbly distended gut following, even remotely, an attack of diarrhoea, I would ask for a stool cultare and mk roscopy and if these were normal I would advise the low starch regimen. Only if symptoms continued would I ask for further investigation. G MATHWS 47 Melbury Road
identified as an important factor in tierapeutic .' referring to a valuable 1979 evaluation publication2. Tuberculosis physicians were well aware, in the mid-196Os, of non-compliance of patients takingbulky, unpleasant PAS. In 1958 and 1962 I documnented the m of drugs, quoting genlroblem of self examples from other diseases and chemoprophylaxis and summarized our'findings from the Tuberculosis Research Unit, Madras, that the problem applied not only to PAS but to isoniazid, a drug given in small dosage, and even a placebo3'4. Compliance led the two-MRC tuberculosis units to develop intermittent regimens, 'making fully supervised chemotherapy possible, then to shortening the duration of chemotherapy and then to short duration fully intermittent -regimens. We have moved 'far beyond once daily dosage,.discussed by' Keen, to intermittency as infrequent as once weekly' in the continuation phase of treatment and MRC colleagues -have studied in depth the mechanisms of action of pulses of antituberculosis drugs. Physician com'pliance' remains another essential issue. Our,MRC view is problems of patient compliance are best solved by the -development of intermittent and depot regimens. WALLACE Fox 28 Mount Ararat Road Richmond, Surrey TWlO 6PG
'References 1 Nohl J. In: Clarke Cli, transL The black death. A chronicle of the plague. London: George Allen& Unwin Ltd, 1926:78 2 Hayes RB, Taylor DW, Sackett DL, eds. Compliance in health care. Baltimore: Johns Hopkins University Press, 1979 3 Fox W. The problem of self-administration ofdrugs; with parti,ular reference to pulmonary tuberculosis. Tubercle
1958;39:269-74 4 Fox W. Self-administration of medicaments: a review of published work and a study of the problems. Bull Int Union Tuberc 1962;32:307-31' 5 Mitchison DA, Dickinson JM. Laboratory aspects of intermittent drug therapy. Postgrad Med J 1971; 47:737-41 6 Fox W. Compliance of patients and physicians: experience and lessons from tuberculosis - I and II. BMJ 1983; 287:33-5, ,101-5
Holland Park, London W14 8AD
References 1 Scott RB. Price's textbook of th,e practice of medicine, 10th edn. London: Oxford University Press, 1966:524-5
What is the best dosage schedule for patients?, Peter Keen (November 199i JRSM, p 640) states 'non-compliance by patients is not'a new disovey...' quoting a perceptive and' witty Stephen Leacock reference. However, Hippocrates wrote that 'the physician should keep aware of 'the fact that the' patients often lie when they'state they have taken certain medicines'. In 1710, during a plague outbreak, a judicial edict was read from pulpits in a district of east Prussia that 'all those' would be' regarded as suicides and their corpses would be publlcly hanged who refused to take the prescribed medicines even if these proved to be of no avail'.1 Keen state's 'It was only about 20 years ago that compliance was fQrmally
Crohn's disease of the vulva The letter from Hossain and Bazaz (November 1991 JRSM, p 693) suggeists that if medical therapy fails for.Crohnss disease of the vulva, vulvectomy or debridempt therapy may be required. I suggest before resorting to surgery try local injection of triamcinolone as a susp-nsion into the vulval areas both intradermally and below any u-lcerated areas. I discussed this in 1985 at my Presidential Address to the Section of Coloproctology and I use this technique for perianal, peristomal Crohn's disease and pyodermal gangrenosum. I have only seen one mild Crobn's disease involvement of the vulva which did not require this therapy but I[would very strongly roeommend that it be tried before radical surgery. It does .Tquire general anaesthetic and up to 40 mg can be given at one time, Senior Consultant Surgeon, DOUGLAS IRLLAR Colchester District General Hospital, Essex
305
Journal of the Royal Society of Medicine Volume 85 May 1992
Letters to the Editor Preference is given to letters commenting on contributions recently published in the JRSM. They should not exceed 300 words and should be typed double-spaced.
Low dose botulinum toxin for spasmodic torticollis In an open study, D'Costa and Abbott (November 1991 JRSM, p 650) treated patients with spasmodic torticollis (ST) using a 'low' dose of botulinum toxin (BT), and found that it was effective and had a lower incidence of side effects than the 'recommended' dose of 800-1000 mu (they quoted doses in ng, but the mouse unit is now the preferred measure as it is a unit of potency: 1 ng=40 mouse units). It is not clear how they decided the dose for each patient, as it ranged from 400 to 600 mu, nor whether patients had previously been treated with BT. The resulting improvement appeared comparable to that quoted in previous trials using higher doses. I have been treating patients with ST with the 'lower' dose over the last 4 years and would agree that it is effective. I routinely use 500 mu (= 12.5 ng) as a first dose and modify subsequent doses according to the observed response and reports from patients and relatives. After two or three treatments a reasonably stable compromise can usually be reached between benefit and side effects. Patients receive BT injections on average every 3 months. I have retrospectively analysed the dose of BT given to each of 79 patients with ST in my clinic during the 3 month period of July to October 1991. Each had received at least three previous treatments with BT and dosage was therefore likely to be stabilized. No patient was included twice. The mean dose given per patient was 545 mu (SD 120), the median dose was 500 mu (12.5 ng), and the range was 200-800 mu (5-20 ng). In my experience an initial dose of 500 mu results in few problems, but it should be considered as no more than a 'ranging shot'. The wide range of maintenance doses eventually used suggests that it is important to adjust the dose individually. The main determining factors are the degree of benefit and the severity and duration of side effects, particularly the main dose limiting side effect which is dysphagia. It should be noted that dysphagia may be played down by patients, who may be reluctant to forego the benefits of larger doses of toxin but who underestimate the danger of aspiration. A P MOORE
Department of Neurological Science Faculty of Medicine, University of Liverpool Walton Hospital, Liverpool L9 1AE
Polarization of art and science I read with great interest the editorial on the debate about the polarization of 'Art' and 'Science' (November 1991 JRSM, p 637). I was surprised by the statement in the editorial that such a debate 'never was applicable to medicine'.
The theory and practice of medicine today is a firm and irrefutable statement of science. From the origins ofthe germ theory to the discovery of genetic coding, the field of medicine is now purely a scientific pursuit. The art of healing has yielded to the science of technological wizardry. The reductionism of Newtonian physics has permeated the world of medicine to the extent that medical students now practise 'objective and scientific detachment' from the 'objects' of their enquiry. In such a technical world, health is a biophysical concept and medics are as removed from art as the neurophysiologist is from existential philosophy. In the 1980s, the debate has been referred to as that between 'Scientism' and 'Poetism' . Scientism is a belief that science knows, or will soon know all the answers. Poetism is the firm conviction in the validity of imaginatively produced hypothesis, considered true only because of their 'higher inspirational origin or an appeal to some mystic predilection of their authors'. Scientism in medicine allows us to brush aside phenomena like the 'placebo effect' in drug trials as an aberration in the scientific pursuit of chemical cures, deserving neither a cogent explanation nor further study. Poetism allows many in the general public to be swayed by various kinds of therapies from the different schools of alternative medicine, some dubious, a few deleterious, and many a waste of time and money. If medicine is to make such a debate irrelevant it is not a certain combination of 'A' levels that will achieve this. A totally new approach is required to conceptualize health and illness. Such a 'paradigm shift' has already occurred in the field of nuclear physics, the purest of the pure sciences2. Only such a paradigm shift in the field of medicine will allow a true combination of artistic vision and scientific excellence. S P SINGH
Department of Psychiatry University Hospital, Queen's Medical Centre Nottingham NG7 2UH
References 1 Medawar P. Pluto's Republic. London: Oxford University Press, 1982 2 Capra F. The Turning Point. London: Fontana Books, 1983
Subtotal colectomy following marathon running in a female patient I was most interested in reading the case report by Beaumont and Teare (July 1991 JRSM, p 439). In 1980 1 was involved with a runner who presented with bloody diarrhoea 24 h following a 23 mile fell race (the Yorkshire Three Peaks). This had been run on a hot day with the ground very hard underfoot. The individual had become very dehydrated and on the final few miles was somewhat disorientated. On account of shin soreness following the event a single dose of 100 mg flurbiprofen had been taken. As the bloody diarrhoea persisted for some weeks sigmoidoscopy and barium enema were undertaken, revealing an inflammatory proctitis. This necessitated treatment initially with Predsol enemas followed by Colifoam enemas and then Salazopyrin treatment. It was some months before symptoms came under control. It was considered by an eminent gastroenterologist that neither the activity nor the flurbiprofen was of
Journal of the Royal Society of Medicine Volume 85 April 1992
relevance to the pathology. It was recommended that Salazopyrin be taken life-long, but the runner withdrew this after 6 months and has had no further episodes. It is obvious that sincethat time there has been an increased awareness of lower gastrointestinal problems in runners. I ould suggest that the runner described by myself-had a' ailder reriodn of inflammatory bowel disease ;o that described in you Journal. WENDY N DODDS St Luke's Hospital Bradford, West Yorkshire BD5 ONA
Gut fermentation Eaton's paper on gut fermentation (tjpvember JRSM 1991, p 669) drew my memory back mauiy years. I think it was believed thait the condition -intestinal carbohydrate dyspepsia-was 'due to colonization of the small gut by coliforms foflowing a bout of' gastroenteritis. A high starch 'dlet maintained the abnormal bacterial population leading to abdominal distension, the production of excess flatus and, as months passed, increasing introspection, frustration and polysymptomatology in the patient. When I was serving in the RCAF in the mid-fifties a fighter pilot saw me with symptoms of intestinal carbohydrate dyspepsia to such' an extent that he could not tolerate high altitudte flying. He gave a typical history. I took'him off bread and other cereal based food, potatoes, and pUss for 3 days - he was then to fly again; he did so and was very much better. I kept him on the' same regimen for 2 weeks and then added firstly bread, then other cereals and finally potatoes over a further fortnight. He did naot consult me again. I have seen many patients with similar symptoms since then and they all did well. Patients were always told the reasons for the low starch regimen. I see fewer patients now, being partiallyr' retired and working in a different field, but if -IL saw a patient tomorrow with a bubbly distended gut following, even remotely, an attack of diarrhoea, I would ask for a stool cultare and mk roscopy and if these were normal I would advise the low starch regimen. Only if symptoms continued would I ask for further investigation. G MATHWS 47 Melbury Road
identified as an important factor in tierapeutic .' referring to a valuable 1979 evaluation publication2. Tuberculosis physicians were well aware, in the mid-196Os, of non-compliance of patients takingbulky, unpleasant PAS. In 1958 and 1962 I documnented the m of drugs, quoting genlroblem of self examples from other diseases and chemoprophylaxis and summarized our'findings from the Tuberculosis Research Unit, Madras, that the problem applied not only to PAS but to isoniazid, a drug given in small dosage, and even a placebo3'4. Compliance led the two-MRC tuberculosis units to develop intermittent regimens, 'making fully supervised chemotherapy possible, then to shortening the duration of chemotherapy and then to short duration fully intermittent -regimens. We have moved 'far beyond once daily dosage,.discussed by' Keen, to intermittency as infrequent as once weekly' in the continuation phase of treatment and MRC colleagues -have studied in depth the mechanisms of action of pulses of antituberculosis drugs. Physician com'pliance' remains another essential issue. Our,MRC view is problems of patient compliance are best solved by the -development of intermittent and depot regimens. WALLACE Fox 28 Mount Ararat Road Richmond, Surrey TWlO 6PG
'References 1 Nohl J. In: Clarke Cli, transL The black death. A chronicle of the plague. London: George Allen& Unwin Ltd, 1926:78 2 Hayes RB, Taylor DW, Sackett DL, eds. Compliance in health care. Baltimore: Johns Hopkins University Press, 1979 3 Fox W. The problem of self-administration ofdrugs; with parti,ular reference to pulmonary tuberculosis. Tubercle
1958;39:269-74 4 Fox W. Self-administration of medicaments: a review of published work and a study of the problems. Bull Int Union Tuberc 1962;32:307-31' 5 Mitchison DA, Dickinson JM. Laboratory aspects of intermittent drug therapy. Postgrad Med J 1971; 47:737-41 6 Fox W. Compliance of patients and physicians: experience and lessons from tuberculosis - I and II. BMJ 1983; 287:33-5, ,101-5
Holland Park, London W14 8AD
References 1 Scott RB. Price's textbook of th,e practice of medicine, 10th edn. London: Oxford University Press, 1966:524-5
What is the best dosage schedule for patients?, Peter Keen (November 199i JRSM, p 640) states 'non-compliance by patients is not'a new disovey...' quoting a perceptive and' witty Stephen Leacock reference. However, Hippocrates wrote that 'the physician should keep aware of 'the fact that the' patients often lie when they'state they have taken certain medicines'. In 1710, during a plague outbreak, a judicial edict was read from pulpits in a district of east Prussia that 'all those' would be' regarded as suicides and their corpses would be publlcly hanged who refused to take the prescribed medicines even if these proved to be of no avail'.1 Keen state's 'It was only about 20 years ago that compliance was fQrmally
Crohn's disease of the vulva The letter from Hossain and Bazaz (November 1991 JRSM, p 693) suggeists that if medical therapy fails for.Crohnss disease of the vulva, vulvectomy or debridempt therapy may be required. I suggest before resorting to surgery try local injection of triamcinolone as a susp-nsion into the vulval areas both intradermally and below any u-lcerated areas. I discussed this in 1985 at my Presidential Address to the Section of Coloproctology and I use this technique for perianal, peristomal Crohn's disease and pyodermal gangrenosum. I have only seen one mild Crobn's disease involvement of the vulva which did not require this therapy but I[would very strongly roeommend that it be tried before radical surgery. It does .Tquire general anaesthetic and up to 40 mg can be given at one time, Senior Consultant Surgeon, DOUGLAS IRLLAR Colchester District General Hospital, Essex
305
