CASE OF ANOREXIA NERVOSA RESPONDING TO ZINC SULPHATE
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350 MEDICINE AND THE MARKET SIR,-I cannot let Dr Owen’s Point of View (July 7, p 30) pass without comment. While American medicine is in an interesting state of change and the effect on a doctor’s freedom is hard to predict, I well remember this freedom during my years in the British NHS. During my surgical house job the waiting list for a cholecystectomy was two years and in my six months more people on the waiting-list for inguinal hernia repair died than had their operation. Later, when I was a registrar in a purpose-built cardiothoracic centre, cardiologists, cardiac surgeons, and anaesthetists fretted under a maximum of 400 open-heart cases per year imposed by bureaucratic diktat, while the waiting lists for valve replacement stretched to 18 months and for coronary surgery to 8 months-some freedom. I do not know where Owen obtained his figures for life expectancy in the United States but the death rate for people 25-64 years of age declined an average of less than 1% per year from 1950 to 1970, but fell by 2-3% per year during the 1970s.1 The bulk of this improvement was the result of a 28% fall in cardiac death rates. The over-65 figures are similar. In the UK heart disease death-rates are static. Owen himself was once in a position to influence preventive measures but I do not recall any effective measures to reduce cigarette consumption or to encourage seat-belt legislation during that period, policies which would have avoided much morbidity and early mortality. Certainly, epidemiology has a low place in American priorities and the popular notion that good health is something that comes out of a bottle prevails, but is this not also true in the UK? Cardiology Associates of Florence, PA, Pee Dee Medical Park Suite 204, 506 East Cheves Street, Florence, South Carolina 29501, USA PETER MARX 1. Kleinman JC, Fingerhut LA, Feldman JJ. Trends in mortality. In: Health United States (DHHS Pub 81-1232). Washington, DC: US Government Printing Office, 1981: 23, 139. CASE OF ANOREXIA NERVOSA RESPONDING TO ZINC SULPHATE SIR,-A 13-year-old girl presented weighing 37 kg, miserable and tearful. Her mother had noticed progressive loss of weight and increasing depression. Within a month the patient lost another 31/2 kg and she was referred to a consultant adolescent psychiatrist who confirmed anorexia nervosa. Two months later, despite counselling, her weight had fallen to 31 - 5 kg. Zinc deficiency was tentatively diagnosed when it was noted that the patient could not taste a 0 - 107o solution ofZnS04.7H2O in distilled water, whereas we and members of our families could taste it easily, with strong aversion in some instances. Hypogeusia is a common early symptom of zinc deficiency. 1 A zinc solution containing 15 mg Zn (provided by 66 mg ZnS04.7H20) in distilled water was then given orally three times per day with meals. When the patient was next seen, 2 weeks later, her appetite and demeanour had obviously improved. This was the first consultation during which she had not wept. Supplementation was continued at the higher level of 50 mg Zn three times daily in the form of ’Zincomed’ zinc sulphate capsules. After 4 months, her weight had increased by 13 kg to 44 - 5 kg, her appetite and demeanour were normal, and she could taste the O. 1% zinc sulphate solution. Zinc supplementation was discontinued, but after 10 months she showed signs of recurrence: her weight had fallen by 2 kg to 42-5 5 kg, she appeared somewhat depressed again, and responded only weakly to the "taste test". Zinc supplementation with zincomed was reintroduced at the previous dose level. Within 2 months her weight returned to 44 - 5 kg, she was cheerful again, and the taste test was strongly positive. There is a scientific rationale for the use of zinc in anorexia nervosa. We do not doubt that the reduced food intake initially results from social factors. However, starvation (in common with other stresses) paradoxically increases urinary zinc excretion,2 2 thereby exacerbating the effect of reduced dietary intake. As zinc status declines, impairment of zinc-dependent senses of taste and smelli may be expected to reduce further the desire for food. These considerations led us to the idea that zinc supplementation might be of value in anorexia nervosa.1,2 Dietary zinc deficiency may be quite common in the UK. A 1981 survey reported the zinc intake from an average diet to be about 10-5 5 mg daily, with risk of less for vegetarians. The US National Academy of Sciences recommends 15 mg, 20 mg, and 25 mg for normal adults, pregnant women, and lactating mothers, respectively.4 Department of Chemistry, University of Reading, Reading RG6 2AD D. BRYCE-SMITH R. I. D. SIMPSON Health Centre, Wayside Green, Woodcote, Reading 1. Aggett PJ, Harries JT. Current status of zinc in health and disease states. Arch Dis Child 1979; 54: 909-17. 2 Underwood EJ. Trace elements in human and animal nutrition, 4th ed. London Academic Press, 1977. 3 Ministry of Agriculture, Fisheries and Food. Survey of copper and zinc in food (Food Surveillance Paper no 5). London: HM Stationery Office, 1981. 4. Recommended dietary allowances, 8th ed. Washington, DC: National Academy of Sciences, 1974. CLINICS FOR HEAD-AND-NECK CANCER PATIENTS SiR,-Dr Sutton (June 9, p 1300) seems to think that if a tumour recurs it will be metastatic disease suitable only for palliation. Far from it. In head-and-neck cancer, for example, a local recurrence after radiotherapy is often cured by "salvage" surgery, and metastatic recurrence in the regional lymph nodes is curable by radical neck dissection.’ The early detection of a tumour recurrence can be difficult and, for nodal metastases, may be crucial for long- term survival. Moreover, the incidence of second primary tumours is about 15% in patients with head-and-neck cancer, most of which are metachronous. For these reasons, we believe that an informed and alert long-term follow-up on all head-and-neck cancer patients is essential. If the follow-up and review of patients is properly done, then efficacy of local treatment policies will be known, and formal treatment protocols for specified tumours can be laid down. This reduces the need for a "combined tumour clinic" to decide on treatment, but does not remove the need to retain the combined conference, where difficult or unusual cases are presented and discussed. Whatever the method for deciding "best treatment", the consultants from the different specialties must agree on the responsibility for the supervision of management and follow-up of any particular patient. Of course the patients must also know who the consultant is that is primarily concerned with their management, otherwise they may feel lost. A combined cancer clinic does have the advantage of bringing interested parties together so that arrangements concerning treatment can be finalised at a single meeting and the maintenance of a local tumour registry is made more simple. We have been striving for years to establish good combined cancer clinics and follow-up facilities. We find statements such as Sutton’s too general to be constructive or helpful. Department of Otolaryngology, Green Lane Hospital, Auckland 3, New Zealand Clinical Oncology Unit, Auckland Hospital R. P. MORTON C. S. BENJAMIN 1. Conley J. Radical neck dissection. Laryngoscope 1974; 84: 1344-52 2. Hordijk GJ, de Jong JMA. Synchronous and metachronous tumours in patients with head and neck cancer. J Laryngol Otol 1983; 97: 619-21. SIR,-We were sorry to see that Dr Sutton has had unfortunate experiences in running combined clinics and that he recommends that such clinics be disbanded. What he has to say may apply to many forms of cancer, but what he recommends would be very dangerous in head-and-neck cancer. He argues that joint clinics between surgeons and radiotherapists should be disbanded because
Transcript of CASE OF ANOREXIA NERVOSA RESPONDING TO ZINC SULPHATE
350
MEDICINE AND THE MARKET
SIR,-I cannot let Dr Owen’s Point of View (July 7, p 30) passwithout comment. While American medicine is in an interestingstate of change and the effect on a doctor’s freedom is hard topredict, I well remember this freedom during my years in the BritishNHS. During my surgical house job the waiting list for a
cholecystectomy was two years and in my six months more peopleon the waiting-list for inguinal hernia repair died than had theiroperation. Later, when I was a registrar in a purpose-builtcardiothoracic centre, cardiologists, cardiac surgeons, andanaesthetists fretted under a maximum of 400 open-heart cases peryear imposed by bureaucratic diktat, while the waiting lists for valvereplacement stretched to 18 months and for coronary surgery to 8months-some freedom.
I do not know where Owen obtained his figures for life expectancyin the United States but the death rate for people 25-64 years of agedeclined an average of less than 1% per year from 1950 to 1970, butfell by 2-3% per year during the 1970s.1 The bulk of thisimprovement was the result of a 28% fall in cardiac death rates. Theover-65 figures are similar. In the UK heart disease death-rates arestatic.Owen himself was once in a position to influence preventive
measures but I do not recall any effective measures to reduce
cigarette consumption or to encourage seat-belt legislation duringthat period, policies which would have avoided much morbidity andearly mortality. Certainly, epidemiology has a low place inAmerican priorities and the popular notion that good health issomething that comes out of a bottle prevails, but is this not also truein the UK?
Cardiology Associates of Florence, PA,Pee Dee Medical Park Suite 204,506 East Cheves Street,Florence, South Carolina 29501, USA PETER MARX
1. Kleinman JC, Fingerhut LA, Feldman JJ. Trends in mortality. In: Health UnitedStates (DHHS Pub 81-1232). Washington, DC: US Government Printing Office,1981: 23, 139.
CASE OF ANOREXIA NERVOSA RESPONDING TOZINC SULPHATE
SIR,-A 13-year-old girl presented weighing 37 kg, miserable andtearful. Her mother had noticed progressive loss of weight andincreasing depression. Within a month the patient lost another 31/2kg and she was referred to a consultant adolescent psychiatrist whoconfirmed anorexia nervosa. Two months later, despitecounselling, her weight had fallen to 31 - 5 kg. Zinc deficiency wastentatively diagnosed when it was noted that the patient could nottaste a 0 - 107o solution ofZnS04.7H2O in distilled water, whereas weand members of our families could taste it easily, with strongaversion in some instances. Hypogeusia is a common early symptomof zinc deficiency. 1A zinc solution containing 15 mg Zn (provided by 66 mg
ZnS04.7H20) in distilled water was then given orally three timesper day with meals. When the patient was next seen, 2 weeks later,her appetite and demeanour had obviously improved. This was thefirst consultation during which she had not wept. Supplementationwas continued at the higher level of 50 mg Zn three times daily in theform of ’Zincomed’ zinc sulphate capsules. After 4 months, herweight had increased by 13 kg to 44 - 5 kg, her appetite anddemeanour were normal, and she could taste the O. 1% zinc sulphatesolution. Zinc supplementation was discontinued, but after 10months she showed signs of recurrence: her weight had fallen by 2kg to 42-5 5 kg, she appeared somewhat depressed again, andresponded only weakly to the "taste test". Zinc supplementationwith zincomed was reintroduced at the previous dose level. Within 2months her weight returned to 44 - 5 kg, she was cheerful again, andthe taste test was strongly positive.There is a scientific rationale for the use of zinc in anorexia
nervosa. We do not doubt that the reduced food intake initiallyresults from social factors. However, starvation (in common withother stresses) paradoxically increases urinary zinc excretion,2 2
thereby exacerbating the effect of reduced dietary intake. As zinc
status declines, impairment of zinc-dependent senses of taste andsmelli may be expected to reduce further the desire for food. Theseconsiderations led us to the idea that zinc supplementation might beof value in anorexia nervosa.1,2Dietary zinc deficiency may be quite common in the UK. A 1981
survey reported the zinc intake from an average diet to be about10-5 5 mg daily, with risk of less for vegetarians. The US National
Academy of Sciences recommends 15 mg, 20 mg, and 25 mg fornormal adults, pregnant women, and lactating mothers,respectively.4Department of Chemistry,University of Reading,Reading RG6 2AD D. BRYCE-SMITH
R. I. D. SIMPSON
Health Centre,Wayside Green,Woodcote, Reading
1. Aggett PJ, Harries JT. Current status of zinc in health and disease states. Arch Dis Child1979; 54: 909-17.
2 Underwood EJ. Trace elements in human and animal nutrition, 4th ed. LondonAcademic Press, 1977.
3 Ministry of Agriculture, Fisheries and Food. Survey of copper and zinc in food (FoodSurveillance Paper no 5). London: HM Stationery Office, 1981.
4. Recommended dietary allowances, 8th ed. Washington, DC: National Academy ofSciences, 1974.
CLINICS FOR HEAD-AND-NECK CANCER PATIENTS
SiR,-Dr Sutton (June 9, p 1300) seems to think that if a tumourrecurs it will be metastatic disease suitable only for palliation. Farfrom it. In head-and-neck cancer, for example, a local recurrenceafter radiotherapy is often cured by "salvage" surgery, andmetastatic recurrence in the regional lymph nodes is curable byradical neck dissection.’ The early detection of a tumour recurrencecan be difficult and, for nodal metastases, may be crucial for long-term survival. Moreover, the incidence of second primary tumoursis about 15% in patients with head-and-neck cancer, most of whichare metachronous. For these reasons, we believe that an informedand alert long-term follow-up on all head-and-neck cancer patients isessential.
If the follow-up and review of patients is properly done, thenefficacy of local treatment policies will be known, and formaltreatment protocols for specified tumours can be laid down. Thisreduces the need for a "combined tumour clinic" to decide on
treatment, but does not remove the need to retain the combined
conference, where difficult or unusual cases are presented anddiscussed. Whatever the method for deciding "best treatment", theconsultants from the different specialties must agree on the
responsibility for the supervision of management and follow-up ofany particular patient. Of course the patients must also know whothe consultant is that is primarily concerned with their
management, otherwise they may feel lost.A combined cancer clinic does have the advantage of bringing
interested parties together so that arrangements concerningtreatment can be finalised at a single meeting and the maintenanceof a local tumour registry is made more simple.We have been striving for years to establish good combined cancer
clinics and follow-up facilities. We find statements such as Sutton’stoo general to be constructive or helpful.Department of Otolaryngology,Green Lane Hospital,Auckland 3, New Zealand
Clinical Oncology Unit,Auckland Hospital
R. P. MORTON
C. S. BENJAMIN
1. Conley J. Radical neck dissection. Laryngoscope 1974; 84: 1344-522. Hordijk GJ, de Jong JMA. Synchronous and metachronous tumours in patients with
head and neck cancer. J Laryngol Otol 1983; 97: 619-21.
SIR,-We were sorry to see that Dr Sutton has had unfortunateexperiences in running combined clinics and that he recommendsthat such clinics be disbanded. What he has to say may apply tomany forms of cancer, but what he recommends would be verydangerous in head-and-neck cancer. He argues that joint clinicsbetween surgeons and radiotherapists should be disbanded because
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