- Email: [email protected]
PRIVACY FOR A HANDICAPPED CHILD
1081 time.Cost equations are complex and often cannot take account of all factors. Heavy advertising of medicines may lead to larger sales without necessarily decreasing the doctor’s work load which should be directed to the more serious cases. There must also be considerations of safety, efficacy, promotional responsibility, and health education. Not only must OTC drugs be safe, but also they should not displace other essential aspects of treatment, nor be promoted with exaggerated claims. Loperamide does not completely fulfil these criteria. It is not free from side-effects, especially in small children.2,3 It is an opioid analogue, and the decrease in bowel
motility may be socially convenient, but it also slows the elimination of pathogens.’-’ What is potentially more dangerous is that giving medicines often displaces and detracts from the more important therapeutic measure of replacing water and electrolytes.6 The heavy sales of loperamide may be mainly due to fears of holiday diarrhoea and to heavy promotion. Under the heading "Montezuma’s revenge" an advertisement for ’Arret’ (loperamide) claims that the drug "... works fast. In fact in some patients diarrhoea is stopped in less than one hour". Most antidiarrhoeal drugs are promoted and prescribed without reference to either oral rehydration therapy or health education to prevent further episodes. The privilege of selling potent medicines OTC should carry the responsibility of giving warnings and providing health education. Department of Child Life and Health, University of Edinburgh, Edinburgh EH9 1UW
WILLIAM A. M. CUTTING
Yule B. The economics of switching drugs from prescription-only to over-the-counter availability discussion paper no 02/88. Health Economics Research Unit, University of Aberdeen, 1988. 2 Minton NA, Smith PGD. Loperamide toxicity in a child after a single dose. Br Med J 1.
Ryan M,
3.
von
1987; 294: 1383. Muhlendahl KE, Bunjes R, Krienke EG. Loperamide induced ileus. Lancet 1980,
i: 209.
Portnoy BL, DuPont HL, Pruitt D, Abdo JA, Rodriguez JT. Antidiarrheal agents in the treatment of acute diarrhea in children. JAMA 1976; 236; 844-46. 5. Vesikari T, Isolauri E. A comparative trial of cholestryamine and loperamide for acute diarrhoea in infants treated as outpatients. Acta Paediatr Scand 1985; 74: 650-54. 6. Kirkpatrick M. Management of dysentery by community health workers. Lancet 1988; 4.
ii: 1425.
BRITISH DIPLOMAS AND LIMITED REGISTRATION
SiR,—Doctors who have attended one year diploma courses in the UK and have been awarded a diploma by a British university will find that the one year mandatory training period does not count as clinical experience in the eyes of the General Medical Council (GMC). Such doctors are not even granted registration limited to the subspecialty in which they obtained the diploma. Diploma holders are not given any preference in overseas sponsorship schemes run by the Royal Colleges. This policy is unjust. Is it sensible that one academic year of training in, say, cardiology at the National Heart and Brompton Hospitals in London should not be accepted as clinical experience for sitting the GMC’s Professional and Linguistics Assessment Board (PLAB) tests for overseas doctors, whereas a dubious certificate from a hospital in equatorial Africa is accepted? The universities should not hide under the pretext that these diplomas are academic qualifications and that it is not their job to get them recognised for limited registration purposes by the GMC. If this argument were valid, why are higher university degrees (MD and MS) and a pass in part I of the MRCPath and FRCR accepted? Perhaps one should also ask the Royal College of Physicians why part I in the MRCP is not treated like the MRCPath and FRCR. The diploma courses are held at UK teaching hospitals and the examination standard is high, but when it comes to overseas sponsorship schemes the diplomas are ignored and places go to those whose seniors can write to a British chum to say that "Dr X is suitable, so take him". This is no service to British patients and it is an insult to British diploma examiners. It is the expansion of sponsorship schemes that has led the British diploma holders to feel the injustice. This system of exemption from the PLAB may lead to a cosy relationship between overseas and British consultants but there will be fewer jobs through the PLAB as a result and fewer doctors will be able to come to UK from India, Pakistan, and Bangladesh, including some who pass high in the PLAB. House No 1, Street No 76, Sector G 6/4, Islamabad, Pakistan
A. ILAHI
ORIGINS OF INTRAVENOUS FLUID THERAPY
SIR,-Dr Cosnett’s article (April 8, p 768) was enjoyable. O’Shaughnessy’s observation and conclusions, and Latta’s use of intravenous fluids for the treatment of cholera during the 1831-32 epidemic, were indeed remarkable, but these doctors were not alone in attempting to apply reason and science to the treatment of the blue cholera. Over a year before O’Shaughnessy’s observation, Jaenichen, a German physician, facing the same tidal wave of cholera in Russia, had also concluded that the primary problem in cholera was loss of fluid from the bowep.2 So in 1830 he infused a saline-like solution intravenously into a cholera patient. Needless to say, his attempt, like those of O’Shaughnessy and Latta, was condemned severely by his peers. In Russia, as in Britain and later in the United States, the traditionalists of the day prevailed and emetics and cathartics continued to be prescribed as a more rational therapy. Further, their use was defended by such notables as Payne, Austin-Flint, and Osler.3 Almost three-quarters of a century was to pass before Leonard Rogers showed that intravenous fluids were capable of reducing the mortality rate in cholera patients in Calcutta from 70% to around 20%.4
PRIVACY FOR A HANDICAPPED CHILD
SIR,-Dr Galloway (April 22, p 907) describes a severely disabled 6-year-old whose parents do not want anything done which might jeopardise their child’s life: the family receives several allowances related to the child’s disability. Galloway asks: "Is it ethical for a child to be used in this way?" His letter does indeed raise ethical issues, but not the ones he identifies. The family described is identifiable from this letter. The child is not being denied treatment which would be likely to improve the quality of her life. Perhaps then he feels that the child is being "inappropriately kept going"? He seems distressed that this child "is bringing in almost z200 a week, enabling the family to maintain their own house, run a car, and feed and clothe themselves". How ethical is it for Galloway to speculate in this way about a patient under his care, and should The Lancet publish such speculation? Social Paediatric and Obstetric Research Unit, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ
HELEN ROBERTS
Department of Medicine, School of Medicine,
University of Alabama at Birmingham, Birmingham, Alabama 35294, USA 1.
T. W. SHEEHY
Jaenichen Dr Die cholera in Moscau mit kritischen Bermerkugen zu emem Aufsatz von Herrn Leimedicus Dr. v. Loder uber diese Epidemia. Wissenschaft Ann Gesamt Heilk 1831; 19: 385. 2. Jaenichen Dr. Memoire sur le cholera. morbus qui regne en Russie. Gaz Méd Paris 1830-31, 1-2: 85. 3 Osler W. Principles and practices of medicine, 8th ed. New York: Appleton, 1915:137. 4. Rogers LE. Bowel diseases in the tropics London: Froude, Hodder and Stoughton, 1921.
WHEN LASER VAPORISATION FOR CIN WHAT NEXT?
FAILS,
SiR,—Mr Cullimore and colleagues (March 11, p 561) reinforce the results of our study in Sheffield in 1986.’ Women who have residual or recurrent disease after local ablative therapy treated by further ablative therapy (laser vaporisation) have a very low success rate. Our conclusion at that time was that such patients should undergo an excisional form of treatment. However, the vast majority of such patients may be treated by a laser excision cone
motility may be socially convenient, but it also slows the elimination of pathogens.’-’ What is potentially more dangerous is that giving medicines often displaces and detracts from the more important therapeutic measure of replacing water and electrolytes.6 The heavy sales of loperamide may be mainly due to fears of holiday diarrhoea and to heavy promotion. Under the heading "Montezuma’s revenge" an advertisement for ’Arret’ (loperamide) claims that the drug "... works fast. In fact in some patients diarrhoea is stopped in less than one hour". Most antidiarrhoeal drugs are promoted and prescribed without reference to either oral rehydration therapy or health education to prevent further episodes. The privilege of selling potent medicines OTC should carry the responsibility of giving warnings and providing health education. Department of Child Life and Health, University of Edinburgh, Edinburgh EH9 1UW
WILLIAM A. M. CUTTING
Yule B. The economics of switching drugs from prescription-only to over-the-counter availability discussion paper no 02/88. Health Economics Research Unit, University of Aberdeen, 1988. 2 Minton NA, Smith PGD. Loperamide toxicity in a child after a single dose. Br Med J 1.
Ryan M,
3.
von
1987; 294: 1383. Muhlendahl KE, Bunjes R, Krienke EG. Loperamide induced ileus. Lancet 1980,
i: 209.
Portnoy BL, DuPont HL, Pruitt D, Abdo JA, Rodriguez JT. Antidiarrheal agents in the treatment of acute diarrhea in children. JAMA 1976; 236; 844-46. 5. Vesikari T, Isolauri E. A comparative trial of cholestryamine and loperamide for acute diarrhoea in infants treated as outpatients. Acta Paediatr Scand 1985; 74: 650-54. 6. Kirkpatrick M. Management of dysentery by community health workers. Lancet 1988; 4.
ii: 1425.
BRITISH DIPLOMAS AND LIMITED REGISTRATION
SiR,—Doctors who have attended one year diploma courses in the UK and have been awarded a diploma by a British university will find that the one year mandatory training period does not count as clinical experience in the eyes of the General Medical Council (GMC). Such doctors are not even granted registration limited to the subspecialty in which they obtained the diploma. Diploma holders are not given any preference in overseas sponsorship schemes run by the Royal Colleges. This policy is unjust. Is it sensible that one academic year of training in, say, cardiology at the National Heart and Brompton Hospitals in London should not be accepted as clinical experience for sitting the GMC’s Professional and Linguistics Assessment Board (PLAB) tests for overseas doctors, whereas a dubious certificate from a hospital in equatorial Africa is accepted? The universities should not hide under the pretext that these diplomas are academic qualifications and that it is not their job to get them recognised for limited registration purposes by the GMC. If this argument were valid, why are higher university degrees (MD and MS) and a pass in part I of the MRCPath and FRCR accepted? Perhaps one should also ask the Royal College of Physicians why part I in the MRCP is not treated like the MRCPath and FRCR. The diploma courses are held at UK teaching hospitals and the examination standard is high, but when it comes to overseas sponsorship schemes the diplomas are ignored and places go to those whose seniors can write to a British chum to say that "Dr X is suitable, so take him". This is no service to British patients and it is an insult to British diploma examiners. It is the expansion of sponsorship schemes that has led the British diploma holders to feel the injustice. This system of exemption from the PLAB may lead to a cosy relationship between overseas and British consultants but there will be fewer jobs through the PLAB as a result and fewer doctors will be able to come to UK from India, Pakistan, and Bangladesh, including some who pass high in the PLAB. House No 1, Street No 76, Sector G 6/4, Islamabad, Pakistan
A. ILAHI
ORIGINS OF INTRAVENOUS FLUID THERAPY
SIR,-Dr Cosnett’s article (April 8, p 768) was enjoyable. O’Shaughnessy’s observation and conclusions, and Latta’s use of intravenous fluids for the treatment of cholera during the 1831-32 epidemic, were indeed remarkable, but these doctors were not alone in attempting to apply reason and science to the treatment of the blue cholera. Over a year before O’Shaughnessy’s observation, Jaenichen, a German physician, facing the same tidal wave of cholera in Russia, had also concluded that the primary problem in cholera was loss of fluid from the bowep.2 So in 1830 he infused a saline-like solution intravenously into a cholera patient. Needless to say, his attempt, like those of O’Shaughnessy and Latta, was condemned severely by his peers. In Russia, as in Britain and later in the United States, the traditionalists of the day prevailed and emetics and cathartics continued to be prescribed as a more rational therapy. Further, their use was defended by such notables as Payne, Austin-Flint, and Osler.3 Almost three-quarters of a century was to pass before Leonard Rogers showed that intravenous fluids were capable of reducing the mortality rate in cholera patients in Calcutta from 70% to around 20%.4
PRIVACY FOR A HANDICAPPED CHILD
SIR,-Dr Galloway (April 22, p 907) describes a severely disabled 6-year-old whose parents do not want anything done which might jeopardise their child’s life: the family receives several allowances related to the child’s disability. Galloway asks: "Is it ethical for a child to be used in this way?" His letter does indeed raise ethical issues, but not the ones he identifies. The family described is identifiable from this letter. The child is not being denied treatment which would be likely to improve the quality of her life. Perhaps then he feels that the child is being "inappropriately kept going"? He seems distressed that this child "is bringing in almost z200 a week, enabling the family to maintain their own house, run a car, and feed and clothe themselves". How ethical is it for Galloway to speculate in this way about a patient under his care, and should The Lancet publish such speculation? Social Paediatric and Obstetric Research Unit, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ
HELEN ROBERTS
Department of Medicine, School of Medicine,
University of Alabama at Birmingham, Birmingham, Alabama 35294, USA 1.
T. W. SHEEHY
Jaenichen Dr Die cholera in Moscau mit kritischen Bermerkugen zu emem Aufsatz von Herrn Leimedicus Dr. v. Loder uber diese Epidemia. Wissenschaft Ann Gesamt Heilk 1831; 19: 385. 2. Jaenichen Dr. Memoire sur le cholera. morbus qui regne en Russie. Gaz Méd Paris 1830-31, 1-2: 85. 3 Osler W. Principles and practices of medicine, 8th ed. New York: Appleton, 1915:137. 4. Rogers LE. Bowel diseases in the tropics London: Froude, Hodder and Stoughton, 1921.
WHEN LASER VAPORISATION FOR CIN WHAT NEXT?
FAILS,
SiR,—Mr Cullimore and colleagues (March 11, p 561) reinforce the results of our study in Sheffield in 1986.’ Women who have residual or recurrent disease after local ablative therapy treated by further ablative therapy (laser vaporisation) have a very low success rate. Our conclusion at that time was that such patients should undergo an excisional form of treatment. However, the vast majority of such patients may be treated by a laser excision cone