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ELECTROLYTE DISTURBANCES IN BEER DRINKERS
1088 MISUSE OF MEDICAL WOMANPOWER
ELECTROLYTE DISTURBANCES IN BEER DRINKERS
SIR,-Dr. Forster’s point (Oct. 25, p. 818) that married doctors live predominantly in the South-East is not borne out in practice, at least for senior trainees in psychiatry. As part of a recent postal survey I ascertained the place of residence of 27 senior registrars who were restricted as to where they could apply for consultant posts, usually because of family reasons. 4 were from Greater London, 3 each from Glasgow and Manchester, and 1 each from Edinburgh, Lancawomen
shire, Cambridge, Warwick, Nottingham, Leeds, Stafford, Northampton, Norwich, Sheffield, Portsmouth, Bristol, Birmingham, Abingdon, Doncaster, Newcastle, and Northern Ireland. Until proved otherwise, it must be assumed that this group is likely to be representative of all married women doctors. From this it follows that the assumption of a heavy concentration in the South-East is unfounded and therefore this should not be a factor in determining the issue of the feasibility of supernumerary posts.
Warley Hospital, Brentwood, Essex CM14 5HQ.
C. P. B. BROOK
MEDICAL TECHNOLOGY
SIR,-Dr Mahler, Director-General of the World Health Organisation, states (Nov. 1, p. 829) that the health professions place "a gross restriction in the information available" the public on health matters and that this obscurity causes "an unnecessary but inevitable dependency of the population upon the holders of these mysteries". The truth is that information and discussion on medical matters is constantly laid before the whole population by newspapers and their medical editors, health journals, radio and television talks and discussions, and the posters and literature of the Council for Health Education. The principal medical journals are available in the public reference libraries, and associations of lay and medical members exist for the care of sufferers from many disabilities like blindness, deafness, handicap in children, diabetes, arthritis, chest and heart disease, epilepsy, and spasticity.
to
p.
SIR,- The report by Dr Hilden and Dr Svendsen (Aug. 9, 245) of a specific hypo-osmolality* syndrome in beer
by us (Sept. 6, p. 455) because given and alternative explanations not excluded. We feel that these criticisms stand, despite the proponents’ reply (Oct. 25, p. 822) and that the concept, although plausible, remains unproven. Dr Demanet suggested (Sept. 6, p. 455) that he had earlier’ noted the syndrome in 4 patients, but seems to have forgotten that case 7 fulfilled the criteria for inappropriate secretion of antidiuretic hormone (A.D.H.), cases 6, 11, and 12 were anorectic and malnourished, all cases had suffered from diarrhoea or vomiting, cases 6, 7, and 11 were hypokalasmic, case 6 had cirrhosis, case 11 had emphysema, and case 12 had some evidence of renal impairment (a raised blood-urea concentration). Hyponatrxmia has drinkers
If the doctor is doing all he can to relieve the patient of his disabilities and their resultant anxiety he will want to use all the techniques of diagnosis and treatment indicated. For this reason, it is wrong for Dr Mahler to decry medical technology in a wholesale way; it is needed for discovering new preventive and curative methods and for applying them where they are needed. While decrying technology, Dr Mahler asks for the assign"of health resources within a country on a problem-solvbasis". Much of the resources spent on medical matters in ing Britain are given to solving problems already, but the answers to problems must be applied to groups of people or to individuals in a way that also needs much expenditure. ment
Dr Mahler criticises the number of references of patients by general practitioners to specialists and puts forward, as a fair comparison, of what should be, his many air journeys, when he does not expect to "be flown by a professor of aeronautical engineering rather than an experienced pilot". The analogy is wrong, because Dr Mahler flies in highly standardised and
carefully tested and maintained aircraft, not analogous to human beings with infinitely variable defects which it is the aim of the health professions to mitigate. 8 West Hill Court,
Millfield Lane, London N6.
J. M. ALSTON
commented
on
was not
been described in association with all these situations. The patient of Dr Banks and Dr Lecky (Sept. 20, p. 559) cannot be fully assessed because of therapy with bendroflumethiazide and propranolol, the high potassium intake, management by fluid restriction and sodium administration, and the lack of information on the initial urinary osmolar excretion and osmolality. Overall, it seems more likely that the patient had a sodium depletion than a water-excess syndrome, but even in the latter case diuretic therapy, hypokalxmia intrinsic renal disease,4 "appropriate",’ or inappropriate activity of A.D.H.6 could be responsible. We agree that hypo-osmolality syndromes are common in beer drinkers, but many causes are possible. We would therefore suggest that the minimal criteria for diagnosis of the proposed specific syndrome include: the formal exclusion of a misleading result, sodium depletion, and other causes of water excess, and the presence of a low urinary osmolality and a low osmolar excretion. Division of Clinical Chemistry, Institute of Medical and Veterinary Science, Frome Road, Adelaide, South Australia.
I agree with Dr Mahler that there should be the constant effort to communicate fully between patient and doctor, but he does not record that there is seldom enough time for this and that differences between races are a barrier for many of the
population.
was
positive evidence
P. J. PHILLIPS R. W. PAIN
HEPATITIS-B VIRUS INFECTION OF CHILDREN BORN TO MOTHERS WITH SEVERE HEPATITIS
SIR,-We observed 2 children born by caesarean section to mothers with severe hepatitis-B (HB) viral hepatitis. Tests for HBsAg and HBsAb were performed by counter-immunoelectrophoresis, microcomplement fixation, inhibition of passive haemagglutination, and radioimmunoassay. The mothers had severe HBs-positive hepatitis with high transaminase levels, low clotting factors, and neurological manifestations with coma (stages II and iv). Delivery was performed by cxsarean section after 7zand 8 months’ gestation. In both cases no HBsAg was found in cord blood, amniotic fluid, or placenta. HBsAg in the latter was sought by indirect and direct immunofluorescence, using human and goat antiHBsAb as well as human and chimpanzee anti-HBcAb (Dr J. Hoofnagle, National Institutes of Health, Bethesda). Both children developed HBs antigenaemia at 50 and 60 days of age. After 10 months, one child was still HBsAg positive. The second child, however, developed a mild clinical and 1.
Demanet, J. C., Bonnyns, M., Bleiberg, H., Stevens-Rocmans, C. Lancet, 1971, ii, 1115. 2. Martin, E. W., Alexander, S. F., Farage, D. J., Hassan, W. E., Martin, R D. Hazards of Medication; p. 752. Philadelphia, 1971. 3. Fichman, M. P., Vorherr, H., Kleeman, C. R., Telfer, N. Ann. intern. Med 1971, 75, 853. 4. Marcus, F. I. Am. J. Med. 1975, 58, 452. 5. Phillips, P. J. Aust. N.Z. Jl Med. 1975, 5, 287. 6. Shalhoub, R. J., Antoniou, L. D. Ann. intern. Med. 1969, 70, 943. *The correct term for the measurement of the osmotic activity of a solution is osmolality (mosm/kg of solvent) and not osmotantv (mosm/1 of solution). The numerical difference is, however, small.
ELECTROLYTE DISTURBANCES IN BEER DRINKERS
SIR,-Dr. Forster’s point (Oct. 25, p. 818) that married doctors live predominantly in the South-East is not borne out in practice, at least for senior trainees in psychiatry. As part of a recent postal survey I ascertained the place of residence of 27 senior registrars who were restricted as to where they could apply for consultant posts, usually because of family reasons. 4 were from Greater London, 3 each from Glasgow and Manchester, and 1 each from Edinburgh, Lancawomen
shire, Cambridge, Warwick, Nottingham, Leeds, Stafford, Northampton, Norwich, Sheffield, Portsmouth, Bristol, Birmingham, Abingdon, Doncaster, Newcastle, and Northern Ireland. Until proved otherwise, it must be assumed that this group is likely to be representative of all married women doctors. From this it follows that the assumption of a heavy concentration in the South-East is unfounded and therefore this should not be a factor in determining the issue of the feasibility of supernumerary posts.
Warley Hospital, Brentwood, Essex CM14 5HQ.
C. P. B. BROOK
MEDICAL TECHNOLOGY
SIR,-Dr Mahler, Director-General of the World Health Organisation, states (Nov. 1, p. 829) that the health professions place "a gross restriction in the information available" the public on health matters and that this obscurity causes "an unnecessary but inevitable dependency of the population upon the holders of these mysteries". The truth is that information and discussion on medical matters is constantly laid before the whole population by newspapers and their medical editors, health journals, radio and television talks and discussions, and the posters and literature of the Council for Health Education. The principal medical journals are available in the public reference libraries, and associations of lay and medical members exist for the care of sufferers from many disabilities like blindness, deafness, handicap in children, diabetes, arthritis, chest and heart disease, epilepsy, and spasticity.
to
p.
SIR,- The report by Dr Hilden and Dr Svendsen (Aug. 9, 245) of a specific hypo-osmolality* syndrome in beer
by us (Sept. 6, p. 455) because given and alternative explanations not excluded. We feel that these criticisms stand, despite the proponents’ reply (Oct. 25, p. 822) and that the concept, although plausible, remains unproven. Dr Demanet suggested (Sept. 6, p. 455) that he had earlier’ noted the syndrome in 4 patients, but seems to have forgotten that case 7 fulfilled the criteria for inappropriate secretion of antidiuretic hormone (A.D.H.), cases 6, 11, and 12 were anorectic and malnourished, all cases had suffered from diarrhoea or vomiting, cases 6, 7, and 11 were hypokalasmic, case 6 had cirrhosis, case 11 had emphysema, and case 12 had some evidence of renal impairment (a raised blood-urea concentration). Hyponatrxmia has drinkers
If the doctor is doing all he can to relieve the patient of his disabilities and their resultant anxiety he will want to use all the techniques of diagnosis and treatment indicated. For this reason, it is wrong for Dr Mahler to decry medical technology in a wholesale way; it is needed for discovering new preventive and curative methods and for applying them where they are needed. While decrying technology, Dr Mahler asks for the assign"of health resources within a country on a problem-solvbasis". Much of the resources spent on medical matters in ing Britain are given to solving problems already, but the answers to problems must be applied to groups of people or to individuals in a way that also needs much expenditure. ment
Dr Mahler criticises the number of references of patients by general practitioners to specialists and puts forward, as a fair comparison, of what should be, his many air journeys, when he does not expect to "be flown by a professor of aeronautical engineering rather than an experienced pilot". The analogy is wrong, because Dr Mahler flies in highly standardised and
carefully tested and maintained aircraft, not analogous to human beings with infinitely variable defects which it is the aim of the health professions to mitigate. 8 West Hill Court,
Millfield Lane, London N6.
J. M. ALSTON
commented
on
was not
been described in association with all these situations. The patient of Dr Banks and Dr Lecky (Sept. 20, p. 559) cannot be fully assessed because of therapy with bendroflumethiazide and propranolol, the high potassium intake, management by fluid restriction and sodium administration, and the lack of information on the initial urinary osmolar excretion and osmolality. Overall, it seems more likely that the patient had a sodium depletion than a water-excess syndrome, but even in the latter case diuretic therapy, hypokalxmia intrinsic renal disease,4 "appropriate",’ or inappropriate activity of A.D.H.6 could be responsible. We agree that hypo-osmolality syndromes are common in beer drinkers, but many causes are possible. We would therefore suggest that the minimal criteria for diagnosis of the proposed specific syndrome include: the formal exclusion of a misleading result, sodium depletion, and other causes of water excess, and the presence of a low urinary osmolality and a low osmolar excretion. Division of Clinical Chemistry, Institute of Medical and Veterinary Science, Frome Road, Adelaide, South Australia.
I agree with Dr Mahler that there should be the constant effort to communicate fully between patient and doctor, but he does not record that there is seldom enough time for this and that differences between races are a barrier for many of the
population.
was
positive evidence
P. J. PHILLIPS R. W. PAIN
HEPATITIS-B VIRUS INFECTION OF CHILDREN BORN TO MOTHERS WITH SEVERE HEPATITIS
SIR,-We observed 2 children born by caesarean section to mothers with severe hepatitis-B (HB) viral hepatitis. Tests for HBsAg and HBsAb were performed by counter-immunoelectrophoresis, microcomplement fixation, inhibition of passive haemagglutination, and radioimmunoassay. The mothers had severe HBs-positive hepatitis with high transaminase levels, low clotting factors, and neurological manifestations with coma (stages II and iv). Delivery was performed by cxsarean section after 7zand 8 months’ gestation. In both cases no HBsAg was found in cord blood, amniotic fluid, or placenta. HBsAg in the latter was sought by indirect and direct immunofluorescence, using human and goat antiHBsAb as well as human and chimpanzee anti-HBcAb (Dr J. Hoofnagle, National Institutes of Health, Bethesda). Both children developed HBs antigenaemia at 50 and 60 days of age. After 10 months, one child was still HBsAg positive. The second child, however, developed a mild clinical and 1.
Demanet, J. C., Bonnyns, M., Bleiberg, H., Stevens-Rocmans, C. Lancet, 1971, ii, 1115. 2. Martin, E. W., Alexander, S. F., Farage, D. J., Hassan, W. E., Martin, R D. Hazards of Medication; p. 752. Philadelphia, 1971. 3. Fichman, M. P., Vorherr, H., Kleeman, C. R., Telfer, N. Ann. intern. Med 1971, 75, 853. 4. Marcus, F. I. Am. J. Med. 1975, 58, 452. 5. Phillips, P. J. Aust. N.Z. Jl Med. 1975, 5, 287. 6. Shalhoub, R. J., Antoniou, L. D. Ann. intern. Med. 1969, 70, 943. *The correct term for the measurement of the osmotic activity of a solution is osmolality (mosm/kg of solvent) and not osmotantv (mosm/1 of solution). The numerical difference is, however, small.