- Email: [email protected]
HAZARDS OF BARIUM-SULPHATE ENEMA
1034
the biochemist himself. What is clearly needed is a greater integration of the laboratory services, both within their own house and within the framework of the hospital as a whole. No hospital worker, be he physician, surgeon, histologist, or biochemist, can go it alone, even if the latter thinks he can do it all himself. It is, of course, platitudinous to say there is no place for the enthusiastic amateur in this modern scientific work; each specialist must overtly be trained as such, but he would be a fool indeed to suppose he alone has something to offer the patient, whatever the latter’s disease. Pathology is the study of disease: however Dr. Hendry may interpret biochemistry to himself, in clinical practice it is the application of chemistry to the study of human disease, and it must follow that even he is to some extent a pathologist. I personally would like the terms pathologist and pathology laboratory, as currently used, to be discontinued, in hospitals at least. Instead, the terms
bacteriologist, biochemist, biophysicist, haematologist, histologist, or virologist could be used according to taste: each worker should have an individual laboratory, but all should be contiguous and in one central building, so having common meeting and stamping grounds. Medicine and pathology have both suffered enough enthusiastic divisionists already without further chemical schizists. County Hospital, Lincoln. J. R. H. PINKERTON. HYDROCORTISONE AND CORTICOTROPHIN IN HERPES ZOSTER the SIR,-During past three months I have been using short courses of intensive hydrocortisone 10 mg. t.i.d. for four days in severe cases of herpes zoster-with dramatic
results. Severe pain is relieved in two days and herpetic vesicles scab and separate at an earlier period. This has been particularly noticeable in severe herpes of the ophthalmic division of the 5th nerve. This treatment has also been used for herpes involving cutaneous branches of the brachial plexus, again with dramatic improvement. I do not seem to have seen this reported elsewhere. The same improvement has been seen with the use of corticotrophin long-acting gel (40 units six-hourly for three days). seem to
J. A. WAKES MILLER. VIRUS INFECTIONS DURING PREGNANCY SIR,—Iread your leader of Oct. 8 with much interest, because it fell to me to review this topic at the First
International Conference on Congenital Malformations held in London in July, 1960. May I take this opportunity to encourage those readers who may be continuing to investigate the outcome of rubella in pregnancy to arrange for the assistance of a laboratory where virus diagnostic tests can be performed ? Although the rubella virus has not yet been isolatedand we have had many negative results in Toronto-the Echo viruses that may cause a similar clinical syndrome can be readily grown in tissue culture. Work done on the Echo viruses in Canada and many other parts of the world has convinced me that a diagnosis of " rubella " or " german measles " obtained from a patient must be considered unreliable. Even a physician may mistake infection with an Echo virus (especially type 9) for rubella. In differentiation, it is important to note the short incubation period of Echo infections
(3-5 days). Epidemiological studies such as those commented on in your editorial have produced substantial results. Such
studies may, however, prove even more rewarding in the future when epidemiological techniques are correlated with the more precise laboratory techniques of the modern medical virologist. School of Hygiene, University of Toronto.
A.
J. RHODES.
FATAL RESPIRATORY OBSTRUCTION DUE TO FAULTY ENDOTRACHEAL TUBE have encountered this phenomenon of respiraSIR,—I
tory obstruction due to faulty endotracheal tube on three occasions. Simple deflation of the cuff has relieved the obstruction immediately, and the operation has been proceeded with. There is no need to change the tube. A few weeks after my first case our registrar encountered this mishap, and deflation of the cuff again reversed a potentially serious position. Morriston Hospital, Swansea.
J. M. LEWIS.
HAZARDS OF BARIUM-SULPHATE ENEMA
SIR,—Your annotation of Oct. 8 refers to bariumsulphate pulmonary embolism. The following case may therefore be of interest as a record of a further hazard in relation to this common diagnostic procedure. A fit man of 70 was referred from the outpatient department for barium enema. He complained of mucous diarrhoea.
Technically the enema was uneventful. On walking from the X-ray table he complained of sudden severe abdominal pain and collapsed to the floor. The radiologist reported that he was unconscious for some seconds. He was transferred immediately to a general medical ward. When examined he was conscious, complaining of generalised abdominal pain and mentioned a transient sharp left-sided chest pain. No peripheral pulses were detectable; bloodpressure was unrecordable and the jugular venous pressure was raised. It was then observed that a striking generalised erythema was developing: it reached a maximum some 45 minutes after completion of the enema, and faded gradually the next 6 hours. Immediate resuscitation was symptomatic, using oxygen, morphine, intravenous pressor agents, and intramuscular promethazine. Chest X-ray, plain X-ray of the abdomen, electrocardiogram, serum-transaminases, and urinary 5-hydroxyindole-acetic acid were all subsequently shown to be normal. The barium enema showed a few diverticula in the sigmoid colon but no other abnormality. The patient made an uneventful recovery and was discharged 10 days later. The cause of his abdominal pain remains obscure. In view of the negative findings and the clinical picture, this man may have had an acute hypersensitivity reaction The barium enema was made up in 1 % tannic acid and was preceded by colonic irrigation with tap-water followed by ’Veripaque’ enema. A similar investigation 4 months previously with the same preparation was entirely uneventful Skin tests using 1 % tannic acid were negative. over
Fatal
due
barium-sulphate pulreported.’ A second case in which this diagnosis seems highly probable, although necropsy was not allowed, has recently been recorded.2 Acute " water intoxication in the preparation of children for barium enema is now a well-recognised and some-
collapse
to
proven
monary embolism has now been
"
times fatal hazard.3-5 But the condition I have described does not seem to have been recorded previously. Over 1000 barium enemas are performed annually in this hospital; no member of the staff of the department of radiology has seen or heard of a similar case. Although, 1.
Truemner,
K.
M., Vanlandingham, H. J. Amer. med. Ass. 1960, 173,
1089.
2. 3. 4. 5.
Rosenberg, L. S., Fine, A. Radiology, 1959, 73, Hiatt, R. B. Ann. Surg. 1951, 133, 313. Jolleys, A. Brit. med. J. 1952, i, 693. Lancet, 1959, i, 559.
771.
1035
therefore, a most unusual event, its seriousness seems to warrant more general recognition. We are hoping to do further studies in an attempt to determine the nature and of this reaction. It would be interesting, meanwhile, to hear of any similar incident. I should like to thank Dr. G. D. Hadley for his advice and permission to publish this case. cause
Middlesex Hospital,
London, W.1.
B. R. WEBSTER.
ACUTE COPPER POISONING SIR, The paper by Professor Semple and his colleagues (Sept. 24) is very timely, especially because the possibility of toxic hazards from copper heating vessels does not seem to be generally appreciated.’ It may be of interest to recall that Dr. Harold Jacobziner, assistant commissioner of the New York City Department of Health, commented last year on the toxic hazards of copper as well as other metals in hot tap-water drawn from corroded lined by these metals. He said that he had in his files pipes " the report of an investigation of a case where several persons became ill due to excessive copper in water drawn from the bottom of a hot water tank ". Jacobziner was commenting on a paper 3 which had recommended the use of hot tap-water in the Dreoaration of infant feeds. Memorial
Hospital of Long Beach,
Long Beach, California.
GEORGE X. TRIMBLE.
normal values of hsemoglobin, red-cell counts, and packedcell volumes, so Dr. Mooney and Dr. Heathcote (Oct. 1) could again, on this evidence alone, question the scientific basis for using serum-vitamin-Bl2 levels as proof of adequate dosage. I submit however that, as a general concept of rational therapy, it is desirable to give a sufficient amount of the vitamin to maintain the serum level near the average normal mean-that is, about 400 {-L[.Lg. per ml. It therefore seems necessary, if oral treatment for pernicious anaemia is considered desirable for a particular patient, that over 200 .g. daily should be administered, whether the vitamin Bl2 is in a crystalline form or a
neotide comnlex. Coventry and Warwickshire Hospital, Coventry.
BROADER MEDICAL TEACHING SIR,-May I comment on your interesting annotation
Broader Medical Teaching (Oct. 22) ? On Oct. 23, 500 general practitioners attended our third Medical World Conference. One of the subjects was " Training for General Practice ". From the discussion, several attitudes became apparent: (a) The G.P.s agreed unanimously that their medical-school training had not fitted them for their work; (b) that, with few exceptions, hospital doctors who had trained them had little knowledge or understanding of the problems facing the G.P.; (c) that, despite a growing awareness of these deficiencies in training, the situation has not improved of recent years. laudable attempt to correct an unbalanced system of some universities and the College of General Practitioners have introduced schemes to allow medical students to see something of general practice during their training. Apart from local schemes which allow students to spend a few weeks with selected G.P.S, there are the Edinburgh and Manchester University schemes. On a more ambitious scale the Inverness Regional Hospital Board is providing rotating internships, which include attachment to G.P.s, and the Wessex scheme financed by one of the Nuffield Trusts is seeking to provide young G.P.S with a chance to see something of all three branches of the Service. No-one would wish to minimise these efforts. Yet surely they leave the main problem unsolved. The hospital teacher who will continue to form the minds of new generations of students is still out of touch with the problem of general practice. How can this be otherwise when the career structure in the hospital field demands that the young trainee consultant should unremittingly follow the narrow lines of his specialty ? I suggested at our conference that the problem could be partly solved if every future teacher in the hospital service had to spend a period in general practice-a proposal which was warmly welcomed. The time to do so would be between the registrar and senior-registrar appointmentsi.e., before the young specialist sets his foot on the ladder from which he dare not fall off. If the time spent in general practice were made a condition of appointment to In
ORAL TREATMENT OF PERNICIOUS ANÆMIA WITH LOW DOSES OF H.P.P./1 SIR,-Dr. Varadi (Oct. 15) must realise how increasingly
difficult it has now become for us to assess the significance of his findings, faced as we are with three differing descriptions of the treatment given, and the responses obtained, from the same ten cases. It is also "a matter of some surprise to find that he classifies a case as relapsed " (Sept. 17) when, in fact, the patient did not suffer a deterioration in the blood-picture at all, but merely a fall in the serum-B12 level when the daily dose was reduced from 300 g. to 100 {-Lg. of B12. Finally, it is a little disappointing that Dr. Varadi has still declined to explain the scientific basis of his interpretation of serum-B12 levels, when applied to this particular form of therapy. We do not doubt that the estimation may be of some value in confirming a diagnosis in the untreated case of pernicious ansemia, but we would like to know what evidence he has for the conclusion in the penultimate paragraph of his letter of Sept. 17, that serum-B12 levels also reflect the degree of intestinal absorotion. on this varticular form of theravv. F. S. MOONEY St. Helens Hospital. J. G. HEATHCOTE.
SIR,-Like Dr. Varadi and Mr. Elwis (Sept. 17) I have been investigating the serum-vitamin-B12 levels of
patients with pernicious anxmia in relapse who have been treated with vitamin-B12/peptide (’ Distivit’). In 8 such patients receiving 200 {-Lg. daily or less, followed for periods of three to eighteen months, the serum-B12 concentration rose above 200 {-L{-Lg. per ml. in 1 case only. A further 2 patients given 500 pLg. daily for a period of eighteen months maintained serum levels around 400 {-L{-Lg. per ml. These results are broadly similar to those previously reportedusing oral crystalline vitamin B12. With the exception of 1 patient receiving 100 u.g. daily, all these cases reached and maintained 1. 2. 3. 4.
J. Amer. med. Ass. 1960, 174, 550. Jacobziner, H. J. Pediat. 1959, 55, 797. Fischer, C., Whitman, M. ibid. p. 116. Marshall Chalmers, J. N., Shinton, N. K. Lancet, 1958, ii, 1298.
N. K. SHINTON.
a
training,
senior-registrar post, no-one would gain an unfair advantage. Unlike the G.P. trainees, these young aspiring specialists would not have to be taught general practice by selected good G.P.S. Their need is to see the realities of practice in all its forms. They could be attached to four different types of practice for six weeks each, and could learn quickly some of the problems facing the industrial, semia
urban, rural, and seaside G.P. In all, this would occupy only six months of their working lives, yet it could have a and beneficial effect on the future training of the medical student-and, indeed, on British medicine. BRUCE CARDEW
profound
Editor, Medical World.
the biochemist himself. What is clearly needed is a greater integration of the laboratory services, both within their own house and within the framework of the hospital as a whole. No hospital worker, be he physician, surgeon, histologist, or biochemist, can go it alone, even if the latter thinks he can do it all himself. It is, of course, platitudinous to say there is no place for the enthusiastic amateur in this modern scientific work; each specialist must overtly be trained as such, but he would be a fool indeed to suppose he alone has something to offer the patient, whatever the latter’s disease. Pathology is the study of disease: however Dr. Hendry may interpret biochemistry to himself, in clinical practice it is the application of chemistry to the study of human disease, and it must follow that even he is to some extent a pathologist. I personally would like the terms pathologist and pathology laboratory, as currently used, to be discontinued, in hospitals at least. Instead, the terms
bacteriologist, biochemist, biophysicist, haematologist, histologist, or virologist could be used according to taste: each worker should have an individual laboratory, but all should be contiguous and in one central building, so having common meeting and stamping grounds. Medicine and pathology have both suffered enough enthusiastic divisionists already without further chemical schizists. County Hospital, Lincoln. J. R. H. PINKERTON. HYDROCORTISONE AND CORTICOTROPHIN IN HERPES ZOSTER the SIR,-During past three months I have been using short courses of intensive hydrocortisone 10 mg. t.i.d. for four days in severe cases of herpes zoster-with dramatic
results. Severe pain is relieved in two days and herpetic vesicles scab and separate at an earlier period. This has been particularly noticeable in severe herpes of the ophthalmic division of the 5th nerve. This treatment has also been used for herpes involving cutaneous branches of the brachial plexus, again with dramatic improvement. I do not seem to have seen this reported elsewhere. The same improvement has been seen with the use of corticotrophin long-acting gel (40 units six-hourly for three days). seem to
J. A. WAKES MILLER. VIRUS INFECTIONS DURING PREGNANCY SIR,—Iread your leader of Oct. 8 with much interest, because it fell to me to review this topic at the First
International Conference on Congenital Malformations held in London in July, 1960. May I take this opportunity to encourage those readers who may be continuing to investigate the outcome of rubella in pregnancy to arrange for the assistance of a laboratory where virus diagnostic tests can be performed ? Although the rubella virus has not yet been isolatedand we have had many negative results in Toronto-the Echo viruses that may cause a similar clinical syndrome can be readily grown in tissue culture. Work done on the Echo viruses in Canada and many other parts of the world has convinced me that a diagnosis of " rubella " or " german measles " obtained from a patient must be considered unreliable. Even a physician may mistake infection with an Echo virus (especially type 9) for rubella. In differentiation, it is important to note the short incubation period of Echo infections
(3-5 days). Epidemiological studies such as those commented on in your editorial have produced substantial results. Such
studies may, however, prove even more rewarding in the future when epidemiological techniques are correlated with the more precise laboratory techniques of the modern medical virologist. School of Hygiene, University of Toronto.
A.
J. RHODES.
FATAL RESPIRATORY OBSTRUCTION DUE TO FAULTY ENDOTRACHEAL TUBE have encountered this phenomenon of respiraSIR,—I
tory obstruction due to faulty endotracheal tube on three occasions. Simple deflation of the cuff has relieved the obstruction immediately, and the operation has been proceeded with. There is no need to change the tube. A few weeks after my first case our registrar encountered this mishap, and deflation of the cuff again reversed a potentially serious position. Morriston Hospital, Swansea.
J. M. LEWIS.
HAZARDS OF BARIUM-SULPHATE ENEMA
SIR,—Your annotation of Oct. 8 refers to bariumsulphate pulmonary embolism. The following case may therefore be of interest as a record of a further hazard in relation to this common diagnostic procedure. A fit man of 70 was referred from the outpatient department for barium enema. He complained of mucous diarrhoea.
Technically the enema was uneventful. On walking from the X-ray table he complained of sudden severe abdominal pain and collapsed to the floor. The radiologist reported that he was unconscious for some seconds. He was transferred immediately to a general medical ward. When examined he was conscious, complaining of generalised abdominal pain and mentioned a transient sharp left-sided chest pain. No peripheral pulses were detectable; bloodpressure was unrecordable and the jugular venous pressure was raised. It was then observed that a striking generalised erythema was developing: it reached a maximum some 45 minutes after completion of the enema, and faded gradually the next 6 hours. Immediate resuscitation was symptomatic, using oxygen, morphine, intravenous pressor agents, and intramuscular promethazine. Chest X-ray, plain X-ray of the abdomen, electrocardiogram, serum-transaminases, and urinary 5-hydroxyindole-acetic acid were all subsequently shown to be normal. The barium enema showed a few diverticula in the sigmoid colon but no other abnormality. The patient made an uneventful recovery and was discharged 10 days later. The cause of his abdominal pain remains obscure. In view of the negative findings and the clinical picture, this man may have had an acute hypersensitivity reaction The barium enema was made up in 1 % tannic acid and was preceded by colonic irrigation with tap-water followed by ’Veripaque’ enema. A similar investigation 4 months previously with the same preparation was entirely uneventful Skin tests using 1 % tannic acid were negative. over
Fatal
due
barium-sulphate pulreported.’ A second case in which this diagnosis seems highly probable, although necropsy was not allowed, has recently been recorded.2 Acute " water intoxication in the preparation of children for barium enema is now a well-recognised and some-
collapse
to
proven
monary embolism has now been
"
times fatal hazard.3-5 But the condition I have described does not seem to have been recorded previously. Over 1000 barium enemas are performed annually in this hospital; no member of the staff of the department of radiology has seen or heard of a similar case. Although, 1.
Truemner,
K.
M., Vanlandingham, H. J. Amer. med. Ass. 1960, 173,
1089.
2. 3. 4. 5.
Rosenberg, L. S., Fine, A. Radiology, 1959, 73, Hiatt, R. B. Ann. Surg. 1951, 133, 313. Jolleys, A. Brit. med. J. 1952, i, 693. Lancet, 1959, i, 559.
771.
1035
therefore, a most unusual event, its seriousness seems to warrant more general recognition. We are hoping to do further studies in an attempt to determine the nature and of this reaction. It would be interesting, meanwhile, to hear of any similar incident. I should like to thank Dr. G. D. Hadley for his advice and permission to publish this case. cause
Middlesex Hospital,
London, W.1.
B. R. WEBSTER.
ACUTE COPPER POISONING SIR, The paper by Professor Semple and his colleagues (Sept. 24) is very timely, especially because the possibility of toxic hazards from copper heating vessels does not seem to be generally appreciated.’ It may be of interest to recall that Dr. Harold Jacobziner, assistant commissioner of the New York City Department of Health, commented last year on the toxic hazards of copper as well as other metals in hot tap-water drawn from corroded lined by these metals. He said that he had in his files pipes " the report of an investigation of a case where several persons became ill due to excessive copper in water drawn from the bottom of a hot water tank ". Jacobziner was commenting on a paper 3 which had recommended the use of hot tap-water in the Dreoaration of infant feeds. Memorial
Hospital of Long Beach,
Long Beach, California.
GEORGE X. TRIMBLE.
normal values of hsemoglobin, red-cell counts, and packedcell volumes, so Dr. Mooney and Dr. Heathcote (Oct. 1) could again, on this evidence alone, question the scientific basis for using serum-vitamin-Bl2 levels as proof of adequate dosage. I submit however that, as a general concept of rational therapy, it is desirable to give a sufficient amount of the vitamin to maintain the serum level near the average normal mean-that is, about 400 {-L[.Lg. per ml. It therefore seems necessary, if oral treatment for pernicious anaemia is considered desirable for a particular patient, that over 200 .g. daily should be administered, whether the vitamin Bl2 is in a crystalline form or a
neotide comnlex. Coventry and Warwickshire Hospital, Coventry.
BROADER MEDICAL TEACHING SIR,-May I comment on your interesting annotation
Broader Medical Teaching (Oct. 22) ? On Oct. 23, 500 general practitioners attended our third Medical World Conference. One of the subjects was " Training for General Practice ". From the discussion, several attitudes became apparent: (a) The G.P.s agreed unanimously that their medical-school training had not fitted them for their work; (b) that, with few exceptions, hospital doctors who had trained them had little knowledge or understanding of the problems facing the G.P.; (c) that, despite a growing awareness of these deficiencies in training, the situation has not improved of recent years. laudable attempt to correct an unbalanced system of some universities and the College of General Practitioners have introduced schemes to allow medical students to see something of general practice during their training. Apart from local schemes which allow students to spend a few weeks with selected G.P.S, there are the Edinburgh and Manchester University schemes. On a more ambitious scale the Inverness Regional Hospital Board is providing rotating internships, which include attachment to G.P.s, and the Wessex scheme financed by one of the Nuffield Trusts is seeking to provide young G.P.S with a chance to see something of all three branches of the Service. No-one would wish to minimise these efforts. Yet surely they leave the main problem unsolved. The hospital teacher who will continue to form the minds of new generations of students is still out of touch with the problem of general practice. How can this be otherwise when the career structure in the hospital field demands that the young trainee consultant should unremittingly follow the narrow lines of his specialty ? I suggested at our conference that the problem could be partly solved if every future teacher in the hospital service had to spend a period in general practice-a proposal which was warmly welcomed. The time to do so would be between the registrar and senior-registrar appointmentsi.e., before the young specialist sets his foot on the ladder from which he dare not fall off. If the time spent in general practice were made a condition of appointment to In
ORAL TREATMENT OF PERNICIOUS ANÆMIA WITH LOW DOSES OF H.P.P./1 SIR,-Dr. Varadi (Oct. 15) must realise how increasingly
difficult it has now become for us to assess the significance of his findings, faced as we are with three differing descriptions of the treatment given, and the responses obtained, from the same ten cases. It is also "a matter of some surprise to find that he classifies a case as relapsed " (Sept. 17) when, in fact, the patient did not suffer a deterioration in the blood-picture at all, but merely a fall in the serum-B12 level when the daily dose was reduced from 300 g. to 100 {-Lg. of B12. Finally, it is a little disappointing that Dr. Varadi has still declined to explain the scientific basis of his interpretation of serum-B12 levels, when applied to this particular form of therapy. We do not doubt that the estimation may be of some value in confirming a diagnosis in the untreated case of pernicious ansemia, but we would like to know what evidence he has for the conclusion in the penultimate paragraph of his letter of Sept. 17, that serum-B12 levels also reflect the degree of intestinal absorotion. on this varticular form of theravv. F. S. MOONEY St. Helens Hospital. J. G. HEATHCOTE.
SIR,-Like Dr. Varadi and Mr. Elwis (Sept. 17) I have been investigating the serum-vitamin-B12 levels of
patients with pernicious anxmia in relapse who have been treated with vitamin-B12/peptide (’ Distivit’). In 8 such patients receiving 200 {-Lg. daily or less, followed for periods of three to eighteen months, the serum-B12 concentration rose above 200 {-L{-Lg. per ml. in 1 case only. A further 2 patients given 500 pLg. daily for a period of eighteen months maintained serum levels around 400 {-L{-Lg. per ml. These results are broadly similar to those previously reportedusing oral crystalline vitamin B12. With the exception of 1 patient receiving 100 u.g. daily, all these cases reached and maintained 1. 2. 3. 4.
J. Amer. med. Ass. 1960, 174, 550. Jacobziner, H. J. Pediat. 1959, 55, 797. Fischer, C., Whitman, M. ibid. p. 116. Marshall Chalmers, J. N., Shinton, N. K. Lancet, 1958, ii, 1298.
N. K. SHINTON.
a
training,
senior-registrar post, no-one would gain an unfair advantage. Unlike the G.P. trainees, these young aspiring specialists would not have to be taught general practice by selected good G.P.S. Their need is to see the realities of practice in all its forms. They could be attached to four different types of practice for six weeks each, and could learn quickly some of the problems facing the industrial, semia
urban, rural, and seaside G.P. In all, this would occupy only six months of their working lives, yet it could have a and beneficial effect on the future training of the medical student-and, indeed, on British medicine. BRUCE CARDEW
profound
Editor, Medical World.