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HOSPITAL MEDICAL RECORDS
684
Letters to the Editor FŒTAL AND NEONATAL ANOXIA
SIR,—While agreeing with almost all you say in your leader of March 16, I am unable to see the logic of your statement that the fact of infants being able to survive long periods of asphyxia without damage to the nervous system is " an encouragement to those who plead for more active resuscitation of the newborn." Presumably " more active " refers to positive-pressure oxygen. We can all agree that if there is evidence of obstruction which cannot be relieved by posturing and nasopharyngeal suction, it is logical to pass a tracheal tube under direct vision and apply controlled suction. But these cases do not require artificial respiration ; the baby is capable of breathing, but breathing is obstructed. The cases which are controversial are those in which intranatal factors (prolonged labour, low haemoglobin in the mother, haemorrhage, anaesthetics, analgesics, &c.) have caused anoxic injury to the midbrain with failure of respiratory activity. The baby is suffering from " white asphyxia." It is limp, pale, or cyanosed, and makes no respiratory effort. In such cases it is doubtful whether the lungs can be made to expand and take up oxygen by positive pressures which do not also rupture the lung. I have seen one case recently with bilateral pneumothorax following positive-pressure oxygen ; this infant did not survive. No doubt this problem of the anoxic infant will become less urgent as all possible measures are taken to secure physiological parturition, but we are very far from this position at present and in the meantime it astonishes me that there is not universal acceptance of the value of intragastric oxygen. Here is a method which is safe, which is available to any midwife if she is given the necessary equipment, and which secures oxygenation of the blood (enough to abolish clinical cyanosis) in perhaps 3 out of 4 such cases. It is a reasonable assumption that this degree of oxygenation will prevent further cerebral damage and put the infant in the best position for Some spontaneous recovery of respiratory function. experienced operators consider that there are times when intragastric oxygen fails to produce, or perhaps to maintain, a good colour in the baby, and when intubation will allow bronchial absorption of oxygen enough to save life ; for this, relatively low pressures of oxygen are required. This may well be the case, but laryngoscopy and intubation can be carried out only by someone medically qualified, with the necessary training and equipment. More than three-quarters of all deliveries are by midwives alone. Farnborough Hospital, Kent.
D. G. LEYS.
BRONCHIAL CARCINOMA
SIR,—We deplore the complacency of recent letters and wish to support Mr. Vernon Thompson’s plea (Feb. 23) for a greater sense of urgency in the diagnosis of bronchial carcinoma and a greater awareness of its possibility in any doubtful respiratory illness. Too often procrastination in actively making a diagnosis removes the chance of successful surgery. Experience in Birmingham of 4103 cases recently reviewed1 has shown that a successful excision of the growth by pneumonectomy or lobectomy offers a 21 % chance of surviving five years, but only 12.2% had a resection. This deplorably low figure was largely due to the fact that 63% of cases had inoperable growths or metastases when first seen at hospital. Up to some point in their history, all growths must be essentially resectable. Hence early recognition is vitally necessary. 1. United Birmingham vol. 2.
Hospitals Annual Cancer Report, 1954,
Most, eases come to be examined on account of symp. toms. In 10% their first symptom has been of an inoperable nature (neurological, metastasis, swelling of the The others demand an X-ray of the chest, neck, &c.). since most (73%) are referable to the lungs. That is where the " wait and see" policy, the " review in 6 weeks," the " unresolved pneumonia," and other futile reports spell death to the patient. In a disease so common and with such prominence in the mind these days, it is extraordinary to us how reluctant radiologists and physicians are to consider the possibility of cancer. There is no time to be lost--analysis of 1592 cases in 1950showed in untreated cases an average time from first symptom to diagnosis of 4.4 months and of life after diagnosis of 4-0 months. Surgeons can hardly expect to cure their patients if they .arrive only in the last stage of their illness. A. L. D’ABREU
A. BRIAN TAYLOR. HOSPITAL MEDICAL RECORDS SIR,—I wish to refer to a problem of some urgency regarding the fate of medical records in National Health
Service
hospitals. Hospital medical staffs of the National Health Service have recently been, or are likely soon to be, asked by their management committees to advise them on the question of keeping or destroying medical records. This advice should be given with circumspection. Medical records-i.e., case-papers, reports, X rays, like other hospital records, Public Records, &c.-are, within the meaning of the Public Records Office Acts. This means that their preservation or destruction is subject to legal limitations and not to local or individual caprice. In 1954 the Ministry of Health issued a circular (H.M.54/47) to management committees informing them that at that time no records could be destroyed until definite permissive regulations had been issued. These regulations issued by the Ministry of Health with the Public Records Otfice appeared in December, 1956 (H.M.56/103), comprising a circular and a schedule of a list and particulars of certain classes of documents accruing in hospitals and offices of hospital authorities not considered of sufficient public value to justify their preservation in the Public Records Office. This deals with all manner of medical and hospital records, many not of medical character. Under the terms of this last circular and the accompanying schedule, it is now permissible for management committees to destroy medical records of patients six years after their last attendance at the hospital in question except in the case of mental hospitals. In the case of patients who died, the notes may be destroyed three years after their death. Both circulars explain that this legislation is permissive and suggest that the records should in fact be kept for the longest possible time. This point deserves great emphasis. The period of six years that is employed is probably inspired by legal considerations and from the medical viewpoint seems very short. This is obviously so in relation to the life time of a child patient, or in respect of a disease liable to recurrence-for example, rheumatic fever. It is also short in respect of a disease like disseminated sclerosis, which has a long extension in time. Aside from the welfare of the individual patient, however, a considerable amount of genetic, statistical, and large-scale social medical research must involve consulting records extending over a longer time than this, Moreover, it is at least a tenable proposition that patients are entitled not to have their records destroyed at all. Almost certainly they have no such right at present, but whether they should not have one is worth considera2.
Taylor, A. B., Waterhouse, J. A. H. Thorax, 1950, 5, 257.
685 tion. The provision of a medical dossier for all patients be a proper and valuable feature of the National Health Service. Perhaps a National Medical Archive Office storing microfilm copies of records is not an
might
of keeping patients’ the of around revolves records question the space required for their storage. The ideal way of keeping records is probably in their original and complete form. Less satisfactory is to employ some selection of types of records to be conserved. Microfilm records obviously save an enormous amount of space, but the initial cost of the apparatus, as well as the continual employment of extra staff to operate it, represents a formidable financial burden, and such a solution might be more suitable to a Central Medical Archive Office than to smaller units such
hospital
groups. In my view, it is better that case-papers be kept intact and indefinitely and in their original form until some further consideration be given to this problem on a national scale. It seems unsatisfactory that the fate of patients’ records should be decided at the level of local hospital management committees whose practice will
certainlv
varv.
Lewisham Hospital, London, S.E.13.
M. 0. SKELTON.
INSULIN TREATMENT OF SCHIZOPHRENIA SIR,—I should like to congratulate Dr. Ackner, Dr. Harris, and Dr. Oldham on their controlled study, a masterpiece of planning and execution, described in your last issue (p. 607). Whether we like it or not, we shall have to accept their conclusion that insulin is not the therapeutic agent of the coma regime. However, this need not sadden the old hands ; it simply confirms that for getting there’in medicine there is nothing like the prescription : Sweat makes good mortar. H. PULLAR-STRECKER HEBERDEN SOCIETY SIR,—Your report of March 16 (p. 565) of the papers read at the meeting of the Heberden Society on Feb. 22 contains a number of inaccuracies which we would be grateful if you would correct. First, with regard to the electrodiagnostic changes in polymyositis, no evidence of spontaneous lower-motorneurone activity was found and it was the association of a high rheobase with an intensity-duration curve characteristic of denervated muscle that was of significance. The characteristic electromyographic change was a predominance on volition of the short duration and polyphasic motor unit potentials typical of a myopathy with, in half the cases, the coexisting features of a neuropathic lesion-i.e., long duration polyphasic motor unit potentials with occasional fibrillation potentials and positive
potentials. the electrophoresis of serumyou report, to glycoproteins," but to mucoproteins," the fractions wrl and M2 of which forma part only of the &agr;1 and &agr;2 glycoproteins respectively. Therefore, mucoprotein wrl or M2 should be read for &agr;1 or &agr;2 glycoproteins throughout your report. While the shapes indicative of fraction micro-heterogeneity were obtained after two dimensional electrophoresis, semi-quantitative estimation of the two mucoprotein fractions were, in fact, based on a single electrophoretic analysis at pH 4.5. Finally, in the paper on sheep-cell agglutination tests, the figures you report-e.g., positive results in 48% of cases of lupus erythematosus—relate to those quoted from the world literature and were not the results obtained at this hospital upon which the paper was based. More important, however, is the fact that not all of our lupus cases with positive agglutination with the super-
Second, the paper referred not,
proteins
"
spot
on
as
a
Finally,
impracticable suggestion. Meanwhile, the practical problem
as
a positive result with the precipitate and as method of distinguishing between rheumatoid arthritis and lupus erythematosus, it was apparently reliable in the event of a positive agglutination with the supernatant.
natant had
"
it
was
the
cases
of
systemic lupus erythematosus
without joint involvement that appeared to have a higher incidence of false positive Wassermann tests (especially the cardiolipin test) and it was in two cases, not one, of systemic lupus with positive agglutination tests that the activity lay in the &bgr;-globulin zone. A. T. RICHARDSON J. H. JACOBS Department of Physical Medicine and Rheumatology, R. L. MARKHAM Royal Free Hospital, E. V. HESS. London, W.C.1. CIGARETTE SMOKING AT SCHOOL SIR,—I was most interested in the article by Dr. Parry Jones in your issue of March 23. I notice that he thinks his results might be abnormally high. I am at present conducting an investigation into the smoking habits of school-children in this county. This is being carried out by means of an anonymous questionnaire, following an explanatory talk to the pupils. The eventual total number involved will be in the region of 9500 children between the ages of 11and 16 and attending all types of school. Several months will elapse before the survey has been completed and analysed, but preliminary results indicate that Dr. Parry Jones’s findings are not in any way abnormal, and, in fact, some of my earlier findings show that the incidence of smoking is higher than he has quoted. Health Department, Oxfordshire County Council, Oxford.
P. W. BOTHWELL Deputy County Medical Officer.
RHEUMATOID ARTHRITIS WITH CHRONIC LEG ULCERATION
SIR,—It was not at all our intention, in our article of Feb. 9, to suggest that varicose ulceration may not coexist with rheumatoid arthritis. It would indeed be significant if two such common disorders were not often seen in the same patient. We are naturally familiar with cases like the one Dr. Rivlin mentions (March 9) in which, as he says, the ulcer obviously results from venous stasis. Our point is that in the cases we described we could decide that the ulcers did not so originate. We need hardly detail the bed rest and ancillary treatment we gave for these ulcers except to emphasise that the methods we used were those by which we regularly heal stasis ulcers and that failure of these cases to heal was striking and at first unexpected. We agree with Dr. Laine and Dr. Vainio (March 23) that the L.E.-cell phenomenon is not specific, but we had Because of the clinical simimore evidence than this. skin ulceration with of the all cases, showing larity rheumatoid arthritis in the absence of vascular stasis, we thought it right to group them together, and it then is seen that among six patients four had shown drug sensitivity, all had serum abnormalities, four showed the L.E.-cell phenomenon, and there were many other features which taken together can all be covered by the diagnosis of disseminated lupus erythematosus and by no other ,
single diagnosis. In describing these cases as " rheumatoid arthritis with chronic leg ulceration " we were careful to avoid calling them " disseminated lupus erythematosus with leg ulceration," and in our discussion we indicated the contrast between these cases and the more acute case in which the diagnosis of disseminated lupus erythematosus is more acceptable. In general the diagnostic criteria of disseminated lupus erythematosus cannot be precisely laid down. If, therefore, we put these cases into the category of disseminated
Letters to the Editor FŒTAL AND NEONATAL ANOXIA
SIR,—While agreeing with almost all you say in your leader of March 16, I am unable to see the logic of your statement that the fact of infants being able to survive long periods of asphyxia without damage to the nervous system is " an encouragement to those who plead for more active resuscitation of the newborn." Presumably " more active " refers to positive-pressure oxygen. We can all agree that if there is evidence of obstruction which cannot be relieved by posturing and nasopharyngeal suction, it is logical to pass a tracheal tube under direct vision and apply controlled suction. But these cases do not require artificial respiration ; the baby is capable of breathing, but breathing is obstructed. The cases which are controversial are those in which intranatal factors (prolonged labour, low haemoglobin in the mother, haemorrhage, anaesthetics, analgesics, &c.) have caused anoxic injury to the midbrain with failure of respiratory activity. The baby is suffering from " white asphyxia." It is limp, pale, or cyanosed, and makes no respiratory effort. In such cases it is doubtful whether the lungs can be made to expand and take up oxygen by positive pressures which do not also rupture the lung. I have seen one case recently with bilateral pneumothorax following positive-pressure oxygen ; this infant did not survive. No doubt this problem of the anoxic infant will become less urgent as all possible measures are taken to secure physiological parturition, but we are very far from this position at present and in the meantime it astonishes me that there is not universal acceptance of the value of intragastric oxygen. Here is a method which is safe, which is available to any midwife if she is given the necessary equipment, and which secures oxygenation of the blood (enough to abolish clinical cyanosis) in perhaps 3 out of 4 such cases. It is a reasonable assumption that this degree of oxygenation will prevent further cerebral damage and put the infant in the best position for Some spontaneous recovery of respiratory function. experienced operators consider that there are times when intragastric oxygen fails to produce, or perhaps to maintain, a good colour in the baby, and when intubation will allow bronchial absorption of oxygen enough to save life ; for this, relatively low pressures of oxygen are required. This may well be the case, but laryngoscopy and intubation can be carried out only by someone medically qualified, with the necessary training and equipment. More than three-quarters of all deliveries are by midwives alone. Farnborough Hospital, Kent.
D. G. LEYS.
BRONCHIAL CARCINOMA
SIR,—We deplore the complacency of recent letters and wish to support Mr. Vernon Thompson’s plea (Feb. 23) for a greater sense of urgency in the diagnosis of bronchial carcinoma and a greater awareness of its possibility in any doubtful respiratory illness. Too often procrastination in actively making a diagnosis removes the chance of successful surgery. Experience in Birmingham of 4103 cases recently reviewed1 has shown that a successful excision of the growth by pneumonectomy or lobectomy offers a 21 % chance of surviving five years, but only 12.2% had a resection. This deplorably low figure was largely due to the fact that 63% of cases had inoperable growths or metastases when first seen at hospital. Up to some point in their history, all growths must be essentially resectable. Hence early recognition is vitally necessary. 1. United Birmingham vol. 2.
Hospitals Annual Cancer Report, 1954,
Most, eases come to be examined on account of symp. toms. In 10% their first symptom has been of an inoperable nature (neurological, metastasis, swelling of the The others demand an X-ray of the chest, neck, &c.). since most (73%) are referable to the lungs. That is where the " wait and see" policy, the " review in 6 weeks," the " unresolved pneumonia," and other futile reports spell death to the patient. In a disease so common and with such prominence in the mind these days, it is extraordinary to us how reluctant radiologists and physicians are to consider the possibility of cancer. There is no time to be lost--analysis of 1592 cases in 1950showed in untreated cases an average time from first symptom to diagnosis of 4.4 months and of life after diagnosis of 4-0 months. Surgeons can hardly expect to cure their patients if they .arrive only in the last stage of their illness. A. L. D’ABREU
A. BRIAN TAYLOR. HOSPITAL MEDICAL RECORDS SIR,—I wish to refer to a problem of some urgency regarding the fate of medical records in National Health
Service
hospitals. Hospital medical staffs of the National Health Service have recently been, or are likely soon to be, asked by their management committees to advise them on the question of keeping or destroying medical records. This advice should be given with circumspection. Medical records-i.e., case-papers, reports, X rays, like other hospital records, Public Records, &c.-are, within the meaning of the Public Records Office Acts. This means that their preservation or destruction is subject to legal limitations and not to local or individual caprice. In 1954 the Ministry of Health issued a circular (H.M.54/47) to management committees informing them that at that time no records could be destroyed until definite permissive regulations had been issued. These regulations issued by the Ministry of Health with the Public Records Otfice appeared in December, 1956 (H.M.56/103), comprising a circular and a schedule of a list and particulars of certain classes of documents accruing in hospitals and offices of hospital authorities not considered of sufficient public value to justify their preservation in the Public Records Office. This deals with all manner of medical and hospital records, many not of medical character. Under the terms of this last circular and the accompanying schedule, it is now permissible for management committees to destroy medical records of patients six years after their last attendance at the hospital in question except in the case of mental hospitals. In the case of patients who died, the notes may be destroyed three years after their death. Both circulars explain that this legislation is permissive and suggest that the records should in fact be kept for the longest possible time. This point deserves great emphasis. The period of six years that is employed is probably inspired by legal considerations and from the medical viewpoint seems very short. This is obviously so in relation to the life time of a child patient, or in respect of a disease liable to recurrence-for example, rheumatic fever. It is also short in respect of a disease like disseminated sclerosis, which has a long extension in time. Aside from the welfare of the individual patient, however, a considerable amount of genetic, statistical, and large-scale social medical research must involve consulting records extending over a longer time than this, Moreover, it is at least a tenable proposition that patients are entitled not to have their records destroyed at all. Almost certainly they have no such right at present, but whether they should not have one is worth considera2.
Taylor, A. B., Waterhouse, J. A. H. Thorax, 1950, 5, 257.
685 tion. The provision of a medical dossier for all patients be a proper and valuable feature of the National Health Service. Perhaps a National Medical Archive Office storing microfilm copies of records is not an
might
of keeping patients’ the of around revolves records question the space required for their storage. The ideal way of keeping records is probably in their original and complete form. Less satisfactory is to employ some selection of types of records to be conserved. Microfilm records obviously save an enormous amount of space, but the initial cost of the apparatus, as well as the continual employment of extra staff to operate it, represents a formidable financial burden, and such a solution might be more suitable to a Central Medical Archive Office than to smaller units such
hospital
groups. In my view, it is better that case-papers be kept intact and indefinitely and in their original form until some further consideration be given to this problem on a national scale. It seems unsatisfactory that the fate of patients’ records should be decided at the level of local hospital management committees whose practice will
certainlv
varv.
Lewisham Hospital, London, S.E.13.
M. 0. SKELTON.
INSULIN TREATMENT OF SCHIZOPHRENIA SIR,—I should like to congratulate Dr. Ackner, Dr. Harris, and Dr. Oldham on their controlled study, a masterpiece of planning and execution, described in your last issue (p. 607). Whether we like it or not, we shall have to accept their conclusion that insulin is not the therapeutic agent of the coma regime. However, this need not sadden the old hands ; it simply confirms that for getting there’in medicine there is nothing like the prescription : Sweat makes good mortar. H. PULLAR-STRECKER HEBERDEN SOCIETY SIR,—Your report of March 16 (p. 565) of the papers read at the meeting of the Heberden Society on Feb. 22 contains a number of inaccuracies which we would be grateful if you would correct. First, with regard to the electrodiagnostic changes in polymyositis, no evidence of spontaneous lower-motorneurone activity was found and it was the association of a high rheobase with an intensity-duration curve characteristic of denervated muscle that was of significance. The characteristic electromyographic change was a predominance on volition of the short duration and polyphasic motor unit potentials typical of a myopathy with, in half the cases, the coexisting features of a neuropathic lesion-i.e., long duration polyphasic motor unit potentials with occasional fibrillation potentials and positive
potentials. the electrophoresis of serumyou report, to glycoproteins," but to mucoproteins," the fractions wrl and M2 of which forma part only of the &agr;1 and &agr;2 glycoproteins respectively. Therefore, mucoprotein wrl or M2 should be read for &agr;1 or &agr;2 glycoproteins throughout your report. While the shapes indicative of fraction micro-heterogeneity were obtained after two dimensional electrophoresis, semi-quantitative estimation of the two mucoprotein fractions were, in fact, based on a single electrophoretic analysis at pH 4.5. Finally, in the paper on sheep-cell agglutination tests, the figures you report-e.g., positive results in 48% of cases of lupus erythematosus—relate to those quoted from the world literature and were not the results obtained at this hospital upon which the paper was based. More important, however, is the fact that not all of our lupus cases with positive agglutination with the super-
Second, the paper referred not,
proteins
"
spot
on
as
a
Finally,
impracticable suggestion. Meanwhile, the practical problem
as
a positive result with the precipitate and as method of distinguishing between rheumatoid arthritis and lupus erythematosus, it was apparently reliable in the event of a positive agglutination with the supernatant.
natant had
"
it
was
the
cases
of
systemic lupus erythematosus
without joint involvement that appeared to have a higher incidence of false positive Wassermann tests (especially the cardiolipin test) and it was in two cases, not one, of systemic lupus with positive agglutination tests that the activity lay in the &bgr;-globulin zone. A. T. RICHARDSON J. H. JACOBS Department of Physical Medicine and Rheumatology, R. L. MARKHAM Royal Free Hospital, E. V. HESS. London, W.C.1. CIGARETTE SMOKING AT SCHOOL SIR,—I was most interested in the article by Dr. Parry Jones in your issue of March 23. I notice that he thinks his results might be abnormally high. I am at present conducting an investigation into the smoking habits of school-children in this county. This is being carried out by means of an anonymous questionnaire, following an explanatory talk to the pupils. The eventual total number involved will be in the region of 9500 children between the ages of 11and 16 and attending all types of school. Several months will elapse before the survey has been completed and analysed, but preliminary results indicate that Dr. Parry Jones’s findings are not in any way abnormal, and, in fact, some of my earlier findings show that the incidence of smoking is higher than he has quoted. Health Department, Oxfordshire County Council, Oxford.
P. W. BOTHWELL Deputy County Medical Officer.
RHEUMATOID ARTHRITIS WITH CHRONIC LEG ULCERATION
SIR,—It was not at all our intention, in our article of Feb. 9, to suggest that varicose ulceration may not coexist with rheumatoid arthritis. It would indeed be significant if two such common disorders were not often seen in the same patient. We are naturally familiar with cases like the one Dr. Rivlin mentions (March 9) in which, as he says, the ulcer obviously results from venous stasis. Our point is that in the cases we described we could decide that the ulcers did not so originate. We need hardly detail the bed rest and ancillary treatment we gave for these ulcers except to emphasise that the methods we used were those by which we regularly heal stasis ulcers and that failure of these cases to heal was striking and at first unexpected. We agree with Dr. Laine and Dr. Vainio (March 23) that the L.E.-cell phenomenon is not specific, but we had Because of the clinical simimore evidence than this. skin ulceration with of the all cases, showing larity rheumatoid arthritis in the absence of vascular stasis, we thought it right to group them together, and it then is seen that among six patients four had shown drug sensitivity, all had serum abnormalities, four showed the L.E.-cell phenomenon, and there were many other features which taken together can all be covered by the diagnosis of disseminated lupus erythematosus and by no other ,
single diagnosis. In describing these cases as " rheumatoid arthritis with chronic leg ulceration " we were careful to avoid calling them " disseminated lupus erythematosus with leg ulceration," and in our discussion we indicated the contrast between these cases and the more acute case in which the diagnosis of disseminated lupus erythematosus is more acceptable. In general the diagnostic criteria of disseminated lupus erythematosus cannot be precisely laid down. If, therefore, we put these cases into the category of disseminated