746

and this would introduce a bias to the series.Such points make it difficult to exclude completelyenvironmental and selective factors, but in generalthis interesting study adds to the cumulativelyconvincing evidence in support of hereditary factorsin the duration of life. We still lack an adequatemeasure of the strength of these factors andevidence as to the mechanism of such inheritance.

DINITROPHENOL COMPOUNDS IN OBESITY

DURING the last two years drugs of the nitro-phenol group have been widely used in the treat-ment of obesity, and it may now be opportune totake stock of the experience gained on both sidesof the Atlantic. It is clear that the nitrated

phenols are powerful and hence potentiallydangerous agents, their principal effect being asubstantial acceleration of the basal metabolic rate.Three deaths have so far been recorded, for whichdinitrophenol was responsible in two and dinitro-cresol in the third. The first fatality followed anenormous overdose taken, it seems, intentionally(J. C. GEIGER 1) ; the second occurred in a negresswho received rather large daily doses of nitrophenolover a period of two weeks 2 ; while the third,which formed the subject of a recent coroner’s

inquest in London, can also be attributed to over-dosage for which the patient was responsible.Apart from these deaths there is ample evidencethat more or less serious toxic symptoms are notuncommon. Some of this evidence has alreadybeen mentioned in these columns,3 and furtherinstances have more recently been described byJ. H. MASSERMAN and H. GOLDSMITH,2 who observedunpleasant reactions, notably a fall in blood

pressure, tachycardia, acidosis, and stupor in 4out of 18 psychotic patients treated with dinitro-phenol. Such drawbacks, however strongly theymay argue in favour of caution and rigid controlof the sale of the drugs, do not necessarily providereason for discarding them, for, as I. M. RABINO-wITCx and A. F. FOWLER 4 point out, some ofthe most useful drugs in the pharmacopoeia,

1 Jour. Amer. Med. Assoc., 1933, ci., 1333.2 Ibid., Feb. 17th, 1934, p. 523.

3 THE LANCET, 1933, ii., 1098, 1218.4 Canad. Med. Assoc. Jour., February, 1934, p. 128.

such as morphia and strychnine, are equallyopen to abuse. But this argument can be pushedtoo far. The first care of the physician is to dono harm to his patient. He does not prescribemorphia when aspirin will answer his purpose;neither should he use dinitrophenol until he issatisfied that safer remedies are not available.This elementary principle of therapeutics seems

in danger of being overlooked.It might be expected, with reason, that a drug

which stimulates metabolism would be valuable

mainly in treating conditions in which metabolismis depressed. The clearest example of such an

abnormality is myxoedema, but myxoedema ismore than a simple expression of slowed meta-bolism (DODDS and ROBERTSON,5 D. M. DUNLOF 6),and incidentally is not generally associated withconspicuous adiposity; so that nitrophenol isuseless as a substitute for thyroxine. In the vast

majority of cases of obesity the basal metabolicrate lies within normal limits and the excess fatmust in theory, and can in practice, be readilydispersed by simple restriction of diet and increasedphysical activity. It is true that nitrophenol byraising the basal metabolism will increase the totaloutput of heat from the body and will so permitthe self-indulgent to eat their cakes while preservingtheir figures. But this entails habitual use of thedrug ; and he would be a bold man who, mindfulof what was learnt about nitrated aromatic com-

pounds during the war, would ignore the possibilityof ultimate damage to the liver.To revert to more immediate dangers, two facts

may be emphasised: the first that, short of

periodic measurements of basal metabolism, whichare rarely practicable, there is no way of recognisingintoxication from overdosage or idiosyncrasy ingood time ; and the second that, once the meta-bolic fire has got out of control, the physician ishelpless, for as yet he has nothing with which toquench the flames. The question may be fairlystated thus : is it justifiable, in dealing with acondition which almost always responds readilyto a little wholesome discipline, to employ insteada drug of unquestioned potency but uncertain

toxicity ? 1 ---

5 THE LANCET, 1933, ii., 1197.6 Brit. Med. Jour., March 24th, 1934, p. 523.

ANNOTATIONS

COMPULSORY CONSULTATIONS

THE March number of St. Bartholomew’s HospitalJournal contains a rumour that the medical consul-tations held at the hospital are to be abolished. Letthem pass, the surgeon might say, for they are onlythings of yesterday, mere mushroom growths. Theold-time physicians rarely saw the patient; theyprescribed for him sitting in a coffee house, upon thereport of symptoms told them by the apothecary.They were far too individualistic to consult withanyone, least of all with a fellow physician, unless agreat nobleman had the gout or a royal personagewas about to die. It was far otherwise with thesurgeons.From the earliest times of which there is any record

in London the surgeons were the guardians of thepublic health and were held responsible for the cureof the sick and maimed. They were on duty at thecity gates to see that no grossly diseased person wasadmitted ; and as early as Feb. 2nd, 1369, the chief

f

officers of their gild were sworn to take charge of thehurt and wounded and to give true information tothe officers of the city about such persons " whetherthey be in danger of death or not." A few years laterwhen the barbers had become a company theyordained, in what would now be called their standingorders, that " no barber practising the surgical facultywithin the liberty of the city should presume to takeunder his charge any sick person in actual danger ofdeath or of permanent disability from injury withoutshowing him to the master and wardens." Should