- Email: [email protected]
Soranus of Ephesus on migraine
CORRESPONDENCE
care. Even if an overestimate, it is a small percentage of a very large sum of money. Anaesthetists working in the UK, and it is unlikely to be different for the specialty in the USA, are exhorted by management to use cheaper drugs that alter the cost of a hospital stay by a far smaller percentage. Levinsky contends that savings would have to come from denying common treatments, such as penicillin. Why not just think more carefully about to which elderly patients penicillin is given? Levinsky’s weakest evidence is to use the USA’s experience of renal replacement therapy to reject the ethical argument that rationing by age is just. The social bias in obtaining dialysis was eliminated when Medicare started to pay for everyone, and Levinsky argues that limiting availability by age will reintroduce that bias: the well off and well spoken will still get treatment whatever their age. Levinsky is correct, but the well off already get better treatment. The division between the well off and worst off is even wider when the comparison is made across, rather than within, countries, and is getting wider. Any limit to treatment, whether or not age is a criterion in deciding the limit, can be overcome by some individuals. Levinsky takes issue with the ethicists for suggesting an ideal world, but himself suggests a world that cannot exist: Medicare cannot extend from paying for dialysis to paying for everything possible. Some medical treatments will be denied to the majority, but paid for by those who can afford them. Rationing of health care, on whatever basis, is neither uniformly logical nor uniformly just. But rationing is more just at the end of a natural life than before its end. Neville W Goodman Department of Anasethesia, Southmead Hospital, Bristol BS10 5NB, UK (e-mail: [email protected]) 1
Levinsky NG. Can we afford medical care for Alice C? Lancet 1998; 352: 1849–51.
Pagers to test vibratory sense Sir—Sody Naimer (Dec 12, p 1942)1 describes the adverse effects of a vibrating pager; however, this technology is also being used to diagnose illness. Impairments of vibratory sense often reflect posterior column disorders, and traditionally tuning forks of 128 or 256 Hz are used to test for such deficits. We were surprised on rounds to see a medical resident use the vibration mode of a pager to test vibratory sense
678
and wondered how frequently pagers were used for this purpose. A selfadministered, anonymous survey was distributed at inpatient and outpatient morning report and to ambulatory care staff at the Denver VA Medical Center. There were 66 responses: ten from medical students, 17 from interns, 27 from residents, eight from staff physicians, and four from nurse practitioners. 64 respondents carried pagers, and 33 respondents reported using a pager to test vibratory sense. None of the medical students reported ever using a pager for this purpose, whereas 31 interns and residents have used it for this purpose. Only two of the staff physicians used the pager for this test and none of the nurse practitioners ever used a pager for this purpose. This difference was significant: 31 (71%) residents used pagers at least occasionally compared with only 9% of non-residents (p=0·0001). 15 (23%) respondents used a pager either frequently or always to test vibratory sense. A review of ten British and American physical diagnosis tests found only one that mentioned this technique,2 and a Medline literature search did not reveal any citations on the accuracy or reliability of pagers for vibratory testing. Pagers are commonly used to test for vibratory sense at our institution, despite absence of data on their reliability and accuracy. The ubiquitous availability of pagers makes them attractive for testing, but it is not known whether pagers are an adequate tool since the frequency is lower than typical tuning forks (usually 91 Hz), the vibration amplitude does not decay, it is applied over a wider area than the base of tuning fork, and the stimulus may lessen in intensity with increased battery age. We wonder if the use of pagers for vibratory testing among residents reflects a transient adaptation to the rigors of residency or a behaviour that will continue once in practice. Vibrating pagers may be a double-edged sword: if they prove to be an accurate testing device, then patients with problems such as B12 deficiency may be identified. If not, then a new generation of doctors could be deluding themselves that they have appropriately tested vibratory sense. *Allan V Prochazka, Connor McBryde Ambulatory Care, Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver, CO 80220, USA 1 2
Naimer S. The vibrating pager. Lancet 1998; 352: 1942. Novey DW. Rapid access guide to physical examination, 2nd edn. St Louis: Mosby Inc, 1998: 502–04.
Soranus of Ephesus on migraine Sir—The earlier the better is essential in aborting migraine attacks, because gastric stasis inhibits drug absorption. But migraineurs without an aura, over 80%, complain they cannot tell “whether it is the start of a migraine or my normal headache”. I have frequently mentioned this dilemma in talks on migraine to general practitioners. After one lecture a doctor told me of his personal discovery: if shaking his head rapidly from side to side several times increased the pain, then a migraine had begun. A few months later, I was fascinated to read in a brilliant article on the migraine aura by Alvarez1 that not only was Soranus of Ephesus aware of this problem 1800 years ago, but also gave a solution: “A good way of telling whether or not a headache is going to be migrainous is to sit with the head down below the knees. If the head starts to throb, it is a migraine.” Increased pain is probably adequate to distinguish the intracranial pain of migraine,2 from an extracranial muscle or psychogenic tension headache. Patients told of the above two manoeuvres are delighted because it prevents unnecessary medication which can, in some, provoke analgesic dependency. Emmanouil Galanakis’ review (Dec 19/26, p 2012)3 indicates the breadth and depth of Soranus’ knowledge, aided by his listening to patients. We can therefore add to “Listen to the patient he is telling you the diagnosis”, that he or she may also be telling you the treatment, and at times provide clues to mechanisms underlying the condition. J N Blau The Private Consulting Rooms, The National Hospital, London WC1N 3BG, UK 1
2
3
Alvarez WC. The migrainous scotoma as studied in 618 persons. Am J Ophthalmol 1960; 49: 489–504. Blau JN, Dexter SL. The site of pain origin during migraine attacks. Cephalalgia 1981; 1: 143–47. Galanakis E. Apgar score and Soranus of Ephesus. Lancet 1998; 352: 2012–13.
DEPARTMENT OF ERROR Randomised double-blind placebo-controlled study of interferon β-1a in relapsing-remitting multiple sclerosis—In this article by the PRISMS study group (Nov 7, 1998, p 1498–504) the acknowledgment section was incorrect. Professor L Kappos received payments from Ares-Serono International SA (Geneva, Switzerland) exclusively for funding of research in his department and not for private purposes. Also, A McDougall and J Frith from the University of Sydney, Sydney, Australia, should have been included as members of the PRISMS study group.
THE LANCET • Vol 353 • February 20, 1999
care. Even if an overestimate, it is a small percentage of a very large sum of money. Anaesthetists working in the UK, and it is unlikely to be different for the specialty in the USA, are exhorted by management to use cheaper drugs that alter the cost of a hospital stay by a far smaller percentage. Levinsky contends that savings would have to come from denying common treatments, such as penicillin. Why not just think more carefully about to which elderly patients penicillin is given? Levinsky’s weakest evidence is to use the USA’s experience of renal replacement therapy to reject the ethical argument that rationing by age is just. The social bias in obtaining dialysis was eliminated when Medicare started to pay for everyone, and Levinsky argues that limiting availability by age will reintroduce that bias: the well off and well spoken will still get treatment whatever their age. Levinsky is correct, but the well off already get better treatment. The division between the well off and worst off is even wider when the comparison is made across, rather than within, countries, and is getting wider. Any limit to treatment, whether or not age is a criterion in deciding the limit, can be overcome by some individuals. Levinsky takes issue with the ethicists for suggesting an ideal world, but himself suggests a world that cannot exist: Medicare cannot extend from paying for dialysis to paying for everything possible. Some medical treatments will be denied to the majority, but paid for by those who can afford them. Rationing of health care, on whatever basis, is neither uniformly logical nor uniformly just. But rationing is more just at the end of a natural life than before its end. Neville W Goodman Department of Anasethesia, Southmead Hospital, Bristol BS10 5NB, UK (e-mail: [email protected]) 1
Levinsky NG. Can we afford medical care for Alice C? Lancet 1998; 352: 1849–51.
Pagers to test vibratory sense Sir—Sody Naimer (Dec 12, p 1942)1 describes the adverse effects of a vibrating pager; however, this technology is also being used to diagnose illness. Impairments of vibratory sense often reflect posterior column disorders, and traditionally tuning forks of 128 or 256 Hz are used to test for such deficits. We were surprised on rounds to see a medical resident use the vibration mode of a pager to test vibratory sense
678
and wondered how frequently pagers were used for this purpose. A selfadministered, anonymous survey was distributed at inpatient and outpatient morning report and to ambulatory care staff at the Denver VA Medical Center. There were 66 responses: ten from medical students, 17 from interns, 27 from residents, eight from staff physicians, and four from nurse practitioners. 64 respondents carried pagers, and 33 respondents reported using a pager to test vibratory sense. None of the medical students reported ever using a pager for this purpose, whereas 31 interns and residents have used it for this purpose. Only two of the staff physicians used the pager for this test and none of the nurse practitioners ever used a pager for this purpose. This difference was significant: 31 (71%) residents used pagers at least occasionally compared with only 9% of non-residents (p=0·0001). 15 (23%) respondents used a pager either frequently or always to test vibratory sense. A review of ten British and American physical diagnosis tests found only one that mentioned this technique,2 and a Medline literature search did not reveal any citations on the accuracy or reliability of pagers for vibratory testing. Pagers are commonly used to test for vibratory sense at our institution, despite absence of data on their reliability and accuracy. The ubiquitous availability of pagers makes them attractive for testing, but it is not known whether pagers are an adequate tool since the frequency is lower than typical tuning forks (usually 91 Hz), the vibration amplitude does not decay, it is applied over a wider area than the base of tuning fork, and the stimulus may lessen in intensity with increased battery age. We wonder if the use of pagers for vibratory testing among residents reflects a transient adaptation to the rigors of residency or a behaviour that will continue once in practice. Vibrating pagers may be a double-edged sword: if they prove to be an accurate testing device, then patients with problems such as B12 deficiency may be identified. If not, then a new generation of doctors could be deluding themselves that they have appropriately tested vibratory sense. *Allan V Prochazka, Connor McBryde Ambulatory Care, Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver, CO 80220, USA 1 2
Naimer S. The vibrating pager. Lancet 1998; 352: 1942. Novey DW. Rapid access guide to physical examination, 2nd edn. St Louis: Mosby Inc, 1998: 502–04.
Soranus of Ephesus on migraine Sir—The earlier the better is essential in aborting migraine attacks, because gastric stasis inhibits drug absorption. But migraineurs without an aura, over 80%, complain they cannot tell “whether it is the start of a migraine or my normal headache”. I have frequently mentioned this dilemma in talks on migraine to general practitioners. After one lecture a doctor told me of his personal discovery: if shaking his head rapidly from side to side several times increased the pain, then a migraine had begun. A few months later, I was fascinated to read in a brilliant article on the migraine aura by Alvarez1 that not only was Soranus of Ephesus aware of this problem 1800 years ago, but also gave a solution: “A good way of telling whether or not a headache is going to be migrainous is to sit with the head down below the knees. If the head starts to throb, it is a migraine.” Increased pain is probably adequate to distinguish the intracranial pain of migraine,2 from an extracranial muscle or psychogenic tension headache. Patients told of the above two manoeuvres are delighted because it prevents unnecessary medication which can, in some, provoke analgesic dependency. Emmanouil Galanakis’ review (Dec 19/26, p 2012)3 indicates the breadth and depth of Soranus’ knowledge, aided by his listening to patients. We can therefore add to “Listen to the patient he is telling you the diagnosis”, that he or she may also be telling you the treatment, and at times provide clues to mechanisms underlying the condition. J N Blau The Private Consulting Rooms, The National Hospital, London WC1N 3BG, UK 1
2
3
Alvarez WC. The migrainous scotoma as studied in 618 persons. Am J Ophthalmol 1960; 49: 489–504. Blau JN, Dexter SL. The site of pain origin during migraine attacks. Cephalalgia 1981; 1: 143–47. Galanakis E. Apgar score and Soranus of Ephesus. Lancet 1998; 352: 2012–13.
DEPARTMENT OF ERROR Randomised double-blind placebo-controlled study of interferon β-1a in relapsing-remitting multiple sclerosis—In this article by the PRISMS study group (Nov 7, 1998, p 1498–504) the acknowledgment section was incorrect. Professor L Kappos received payments from Ares-Serono International SA (Geneva, Switzerland) exclusively for funding of research in his department and not for private purposes. Also, A McDougall and J Frith from the University of Sydney, Sydney, Australia, should have been included as members of the PRISMS study group.
THE LANCET • Vol 353 • February 20, 1999