Oct 22, 1983 - Bebington, Wirral, Merseyside L63 4JY) writes: Mr M M Petersen and others .... the proposed amendments to the Police Bill and because of the ...
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medical colleagues will easily bow to the decisions of a chief executive, even if he is a consultant. It is precisely because doctors insist on always being consulted and that they will not trust others to make decisions for them (a feature of their clinical work) that there is such a proliferation of committees. Doctors complain about the time wasted by the number of meetings, but I believe that it is they who, unwittingly no doubt, are the cause of them. You can trust a chief executive and let him get on with the job and accept his decisions, or you can have a series of committees to keep an eye on him and see that he
Points Women in medicine Dr F LEFFORD (Department of Anatomy and Embryology, University College, London WC1E 6BT) writes: Professor Peter Richard's observation (24 September, p 898) that women have "great political power" cannot be allowed to pass without comment. The resistance to change inherent in most (if not all) institutions-of which the medical profession is one example-ensures that women never achieve political power unless they conform to the accepted and acceptable male model in both attitude and behaviour. The description of Mrs Margaret Thatcher as "the best man in the Cabinet" is not regarded as a joke by most professional women. Professor Richard's statement: "Married women have to decide how to combine home and family life with a career" is most revealing. Why only
married womnen ? What decisions does he think married men have to make? The tendency for doctors to marry doctors does not compound "the problem": it serves to clarify the central issuenamely, acceptance of equal responsibility for home and family life in all its aspects, which means child care as well as financial support, by both parents with equally demanding work commitments.
Solving medical manpower problems Dr G C MATHERS (Gloucester) writes: I have recently been considerably saddened by the experiences of colleagues who have been enormously disappointed because their sons and daughters are unable to get into medical school, despite what appear to be adequate qualifications. In the face of the tremendous demand for places that now exists, I have been further saddened to see that young doctors may not now be able to obtain preregistration posts after qualifying. May I suggest that, like the miners, doctors now be offered voluntary redundancy. This one move would solve "at a stroke" the medical manpower miseries of the moment.
Amputation of both legs in the elderly Dr SUNDAR MUTHU (Department of Health and Social Security, Artificial Limb and Appliance Centre, Bristol) writes: I was delighted to see Dr C P U Stewart's letter (17 September, p 840) contradicting Minerva's outrageous extrapolation of my paper' suggesting that all elderly bilateral amputees should be given wheelchairs and not artificial limbs. As pointed out in that letter, my paper referred only to bilateral above knee amputees. Since publication of my paper, however, there has been a paper on the energy cost of ambulation compared with that of wheelchair propulsion in elderly bilateral below knee amputees.2 In this study, mean oxygen consumption of bilateral below knee amputees was 123% higher than that of normal subjects during ambulation whereas there was no significant difference between the two groups when wheelchair propulsion was
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does not stray too far from what you believe to be acceptable. Fortunately, I believe there is no chance of having chief executives. Doctors would not stand for having power concentrated in this fashion, even if it is wielded by one of their own, and the other essential professions would not stand for it either. PHILIP RHODES University Faculty of Medicine, Southampton General Hospital, Southampton S09 4XY Department of Health and Social Security. Management arrangements for the reorganised National Health Service. London: HMSO, 1972.
hypercalcaemic, the serum concentration of immunoreactive parathyroid hormone, estimated in a good assay, is the only reliable way of making the diagnosis short of surgery. Mundy GR, Cove DH, Fisken RA. Primary hyperparathyroidism: changes in the pattern of clinical presentation. Lancet 1980;i:1317-20. Heath H III, Hodgson SF, Kennedy MA. Primary hyperparathyroidism: incidence, morbidity and potential economic impact on a community. N EnglJ Med 1980;302:189-93.
Tying shoelaces
Dr W S PARKER (Patcham, Brighton BNl 8TD) writes: Professor Philip Rhodes (10 September, p 747) and others convalescing after receiving hip replacements can be relieved of the need to ask others to tie their shoelaces. I replaced my conventional laces with 50 cm of coloured haberdashers' hat elastic, tied in the usual way on an used. This suggests that wheelchair propulsion is empty shoe and finished with a conventional bow. a more energy efficient mode of mobility than I can put on my shoes without help, using a long ambulation in the elderly bilateral below knee handled shoehorn. I find them suitable for house amputee just as much as his above knee counter- and town use but have to rely on firm conventional part. This has implications for both groups of laces for country walking. patients, especially as they are likely to have cardiovascular and respiratory systems that are compromised. If only energy and economic costs Effect of thalidomide on orogenital were involved, then Minerva's sweeping statement ulceration might well have held more than a grain of truth. There are, however, other factors-for example, restoration of body image and self esteem-which Professor W WALKER, Dr H B M LEWIS, and Dr F ALBERT-REcHT (Aberdeen Royal Infirmary, dictate limb prescription. Aberdeen AB9 2ZB) write: The report of Dr P W Muthu S. Limb fitting and survival in the dysvascular Bowers and Dr R J Powell (17 September, p 799) double above knee amputee. 7 R Coll Surg Edinb of the effect of thalidomide on orogenital ulceration 1983 ;28 :157-9. recalls an earlier attempt to use clinically the 2 DuBow LL, Witt PL, Kadaba MP, Reyes R, Cochran immunosuppressant action of this drug. At the GVB. Oxygen consumption of elderly persons with bilateral below knee amputations: ambulation vs Newcastle meeting of the British Society for wheelchair propulsion. Arch Phys Med Rehabil Haematology in 1968 we reported the successful 1983 ;64 :255-9. treatment with thalidomide of an elderly woman with severe cold haemagglutinin disease' in whom steroids and azathioprine had failed. Thalidomide Q fever was hard to come by, but two courses (which ended when the supply ran out) brought about Dr JAMEs F BOYD (Brownlee Laboratory, Ruchill each time a sharp fall in titre of the cold agglutinin Hospital, Glasgow G20 9NB) writes: Professor and in IgM concentration, with parallel diminution Alasdair M Geddes (1 October, p 927) provides a in the IgM paraprotein as shown by electrophoresis. useful review of Q fever, but there is one comment By courtesy of Dr K Hellman of the Imperial which I would like to qualify. Because tuberculosis Cancer Research Fund, whose experiments with and brucellosis have virtually been eradicated from skin homografts in mice had suggested this cattle in Scotland, England, and Wales it is com- treatment, we obtained enough thalidomide for a monly assumed that tuberculosis and brucellosis longer course of about eight months. This resulted have been eradicated from humans also. Clearly in complete clinical and haematological remission this is not so, although new cases of these infections with a return to normal range of cold agglutinin acquired by the alimentary route from cattle and a normal electrophoretic pattern. The drug sources should be minimal from now on. The was discontinued, but the remission lasted until existing infected population has its allotted three the patient died of disseminated malignant score years and ten ahead of it, with the possibility lymphoma eight years later. of reactivation of disease at any time. It occurred to us then that a wide range of severe and non-responsive immunological disorders would justify a trial of thalidomide, or perhaps a chemically related substance. But the tragedy was Parathyroid hormone and fresh in people's minds, and resistance to the 25-hydroxyvitamin D concentrations in suggestion prompt and strong. Besides, the danger elderly people of a nasty peripheral neuropathy, almost always irreversible, is a considerable deterrent. Dr ROGER A FISKEN (Clatterbridge Hospital, Bebington, Wirral, Merseyside L63 4JY) writes: 'Lewis HBM, Albert-Recht F, Walker W. Cold haemagglutination disease treated by thalidomide. Mr M M Petersen and others (20 August, p 521) BrJ7 Haematol 1968;2:322. seem to have used their interesting observations on parathyroid hormone and 25-hydroxyvitamin D concentrations in the elderly in support of an altogether erroneous conclusion, when they say in Latissimus dorsi reconstruction of the their last paragraph: "Excessive reliance should breast not be placed on serum immunoreactive parathyroid hormone concentrations in diagnosing Dr TREVOR J POWLES and Mr ANTHONY G NASH primary hyperparathyroidism in old people." Of (Royal Marsden Hospital, Sutton, Surrey SM2 course it would be wrong to make this diagnosis 5PT) write: Although we are in general agreement in anyone, young or old, on the basis of a raised with most of the leading article by Mr J Meirion concentration of immunoreactive parathyroid Thomas (27 August, p 569) we disagree with the hormone if, as in the case reported by Mr Petersen conclusion that there is no place for immediate and his colleagues, the serum calcium concentra- latissimus dorsi reconstruction after mastectomy. tions were normal. The whole point about both After treating 36 patients presenting to our joint our own survey' and that from the Mayo Clinic2 breast clinic with this procedure we consider that is that no subject was included unless he or she was it has an important place in treatment of central hypercalcaemic. Primary hyperparathyroidism is a tumours. The cosmetic results of wide excision disorder with protean manifestations, especially in of central tumours with or without removal of the the elderly, and provided that the patient is truly nipple followed by radiotherapy are generally poor.
1226 Similarly, we have found that mastectomy with immediate latissimus dorsi reconstruction is useful for treatment of recurrent carcinoma in a breast previously treated conservatively by primary excision and radiotherapy. We have found immediate latissimus dorsi reconstruction readily acceptable by our patients compared with standard mastectomy. In our opinion the cosmetic results are comparable to those for primary excision and radiotherapy with the added advantage of not requiring 4-6 weeks of treatment. It seems that direct evaluation of this procedure by randomised clinical trials is not possible until the ethical problems of such trials, particularly in relation to informed consent, are resolved.
Endocrine myopathies Dr DOUGLAS GOLDING (Princess Alexandra Hospital, Harlow, Essex CM20 1QX) writes: Dr P Kendall-Taylor and Dr D M Turnbull (10 September, p 705) mention mitochondrial abnormalities in steroid myopathy but do not emphasise that these represent the profound abnormalities often found in "muscle poisoning" by drugs, as opposed to the much less prominent changes seen in polymyositis complicating rheumatoid arthritis and other connective tissue disorders. When studying the ultrastructure of steroid myopathy we found the mitochondria very enlarged, irregular, and probably functionless, though some normal forms were seen adjacent to those myofibrils remaining intact.1 'Golding DN, Murray SM, Pearce GW, Thompson M. Corticosteroid myopathy. Annals of Physical Medicine 1961;6:171-7.
Allergy to Brazil nut Dr DOUGLAS G BLACK (Newark Hospital, Newark on Trent, Nottinghamshire NG24 1TG) writes: I am able to add a further case of allergy to Brazil nut in an atopic individual to the four cases reported by Dr David W Hide (24 September, p 900). I have had mild atopic eczema and asthma since infancy. I vividly recall being offered a Brazil nut to eat for the first time one Christmas when I was about 8 or 9. The inside of my mouth immediately began to itch intensely, and my tongue and lips became considerably swollen. The discomfort lasted for several hours. Since then I have inadvertently eaten Brazil nuts, usually in the form of chopped nuts within toffee, on several occasions, each of which has produced a similar brisk reaction. As far as I know I am not allergic to any other substance. For years I have claimed to be allergic only to Brazil nuts. Such a statement has usually been met with scorn, and I am therefore grateful to Dr Hide for easing my peace of mind.
Falciparum malaria resistant to chloroquine and Fansidar Dr DAVID STEVENSON (Department of International Community Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA) writes: Dr C Herzog and others (1 October, p 947) mention the problem of falciparum malaria resistant to chloroquine and Fansidar (pyrimethamine and sulfadoxine) in East Africa. Working in Malawi from 1958 to 1966 I encountered several cases of falciparum malaria that did not respond to treatment with chloroquine. In two cases (myself, and one of my Malawian staff) I tried treatment with proguanil hydrochloride (Paludrine), eight 100 mg tablets the first day and six 100 mg tablets the second and third days, after which we recovered. At the time I was using proguanil hydrochloride as a prophylactic drug, 100 mg daily, later increased to 200 mg. My impression was that proguanil gave a large measure of protection against malaria in Malawi and that, although one might occasionally develop malaria while taking a prophylactic dose, a larger dose could still be effective against the
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infection. Although proguanil is not normally recommended for treatment, it may be worth a trial if an infection does not respond to other antimalarials.
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figures given in The Medical Effects of Nuclear War are substantially accurate" since most of the figures are hypothetical speculations based on extrapolation from experimental results. Furthermore, at least one figure is wildly inaccurate. I refer to the statement on pages 3 to 9 of the report: "A well organised surgical team might be able to perform Traumatic neuropathy of second up to seven operations in a 12 hour period under cervical spinal nerves ideal conditions." Under far from ideal conditions in the western desert in 1943 the casualty clearing Dr SIMON BEHRMAN (London WIN IDA) writes: station to which my surgical team was attached In a recent paper (23 April, p 1312) I listed the dealt with 1394 casualties in 24 hours, the four topographies of pain of traumatic neuropathy of surgeons carrying out 137 operations, my own total the second cervical spinal nerve as follows: of 31 being below average. So, under ideal conipsilateral half of the scalp, periorbital temporal and ditions the figure should exceed 16. Admittedly, suboccipital regions, and locations around the ear these figures, while contradicting Mr Smith's use and the angle of the jaw. My recent personal of the word "all" do not necessarily affect the experience of herpes zoster affecting this nerve corrections of other assumptions but, since the leads me to conclude that the distribution of the figures I quote are easily obtainable, the correctness neuralgia is far more extensive than our anatomical of the other figures is at least questionable. notions would suggest. The principal locations of the pain were the region below the ramus of the mandible, infra and supra clavicular regions, the lobe of the ear, the entire deltoid region, and also Donation of cadaveric kidneys the nape of the neck. I believe it is important to bear in mind these aberrant areas of pain when Dr L HARVEY (Department of Pathology, Univerdealing with cases of traumatic neuropathy of the sity of Sheffield Medical School, Sheffield S 10 2RX) second cervical nerve. writes: Minerva (16 July, p 224) refers to the persistent problem of insufficient cadaveric organ donors in the United Kingdom.... To establish a realistic pool of donors seems to require active Computer security screening of the public without creating fears of Dr M J C BROWN (Hayes, Middlesex) writes: ulterior medical motives. A possible method may Confidentiality is the biggest problem confronting be an addition to the front sheet of each patient's medical computing, yet Mr J Payton and Dr A J record adjacent to the name and address-for Asbury (1 October, p 965) dismiss it by the example, a box for their initials or signature or computer experts' usual legerdemain of including insertion of a yes/no sticker giving permission (or confidentiality in the general scope of security, not) for their or their child's organs to be donated arguing that because computer records are secure after death. Each individual's visit to their general ipso facto they are confidential. Security guards practitioner's surgery thereby increases the populaagainst the abuse of unauthorised access to records, tion screened. The screening may be done-for but confidentiality is concerned with preventing example, on arrival at reception to minimise the the abuse of authorised access. The report of time taken during consultation. Permission to Ontario's Royal Commission on the Confidentiality donate could then be gained by access to the of Health Records,' a 1626 page inquiry into the patient's general practitioner/family practitioner abuse of computer medical records in Ontario, committee's records only after the diagnosis of found that the principal abuses of medical records brain death has been made and communicated to came from the state-for example, federal police, relatives. local police, and immigration authorities. Despite the proposed amendments to the Police Bill and because of the permissiveness of the Data Pro- Resuscitation services tection Bill, the state will have no difficulty in authorising itself to look at our medical records, Dr H ROBINSON (The Health Centre, Cobham, which belong to the Secretary of State. Surrey KTII IAE) writes: Dr Roger H Jones Krever H, chairman. Report of the Commission of quotes the London region as having no resuscitation Inquiry into the Confidentiality of Health Records. services. There are in fact seven cardiac ambuToronto: Government of the Province of Ontario, lances based at Cobham, Hersham, and Walton. Canada, 1980. These are equipped for intubation, infusion, and cardiac monitoring and defibrillation. £25 000 was raised by the community within a short period of Clinical experience with the oxygen time to equip these ambulances, and there was such concentrator good will that I am sure the other areas could easily emulate such schemes. Dr HIROSHI KAWANE (Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical School, Kurashiki City, Okayama 701-01, Japan) writes: In their article on the oxygen Cigarette smoking after myocardial concentrator (13 August, p 459) Dr T W Evans and infarction others did not comment on the noise of machines but this is an important consideration at night Dr KEITH BALL (Department of Community during sleep. Another type of home oxygen Medicine, Middlesex Hospital Medical School, concentrator which uses a "semipermeable Central Middlesex Hospital, London NWIO 7NS) membrane" is more popular in Japan. Although writes: In his reply to the question on the risk of output is limited to 40°O1 oxygen by this type, both relapse after a coronary attack Dr I M Graham (1 the noise and the size are smaller than those of a October 1982, p 971) underemphasises the import"molecular sieve" system. Since the Japanese live ance of continued cigarette smoking. This is in small houses, so called "rabbit hutches," noise- surprising since much work on this matter has been less and small concentrators may be preferred. reported from his group in Dublin. During 12 Moreover, the risk of oxygen-induced carbon different studies, including his own,' Mulcahy dioxide narcosis can be minimised by administering found that those who continued smoking had a greater risk of relapse, varying from one and a half low concentrations of oxygen. times to twice the risk of those who stopped. It should be more widely recognised that at present helping a patient to stop smoking is by far the most The medical effects of nuclear war effective means of secondary prevention after a Professor JOHN C WATTS (Hasketon, Nr Wood- coronary attack. bridge, Suffolk IP13 6JL) writes: I find it difficult Mulcahy R. Influence of cigarette smoking on to understand how the Reverend John Macdonald morbidity and mortality after myocardial infarction Smith (20 August, p 562) is able to state that "all Br Heart 1983;49:410-5.
