THE MYSTIQUE OF THE BARIUM MEAL

208 were difficult conditions in some psychiatric and geriatric hospitals, due to unsatisfactory buildings, overcrowding, or shortage of staff. That was one reason more for paying tribute to the staff who gave devoted care to patients while having to work in those conditions.

that there

Sexual Offences Bill Mr. LEO ABSE’s Bill was introduced in the House of Lords by the Earl of ARRAN who moved the second reading on July 13. The motion was carried by 111 votes to 48.

QUESTION

TIME

Centres for Drug Addicts Lord SANDFORD asked the Government what arrangements they had in mind for ensuring that rehabilitation centres for drug addicts were provided to match the treatment centres called for in Hospital Memorandum (67) 16 and to state what scale of grant they would offer to voluntary bodies willing to undertake such provision in respect of capital expenditure and running costs.-Lord BESWICK, the parliamentary UnderSecretary of State for Commonwealth Affairs, replied: There is no ready-made proven system of rehabilitation and it is a question of deciding what are the most promising ways of improving existing facilities. The Minister of Health arranged two conferences-of psychiatrists, medical officers of health, and voluntary bodies-and the results have been placed before the Advisory Committee on Drug Dependence, which has set up a subcommittee on rehabilitation. Guidance on this subject, including the coordination of statutory and voluntary services, will be issued when recommendations have been received from the advisory committee. Lord NEWTON: Can the noble Lord give us an absolute assurance that the Government will not bring into effect the provisions of the Dangerous Drugs Bill until they are absolutely satisfied that enough rehabilitation centres are effectively working or have been set up ?-Lord BESWICK: I cannot give that assurance, nor do I think it should be given. Facilities for rehabilitation are already provided by hospitals and by the local authorities, as well as excellent voluntary organisations. Moreover, it is now possible for local health authorities to give grants to voluntary organisations. The only question to be decided is which of the various facilities ought to be encouraged further by a grant. Lord SANDFORD asked H.M. Government how many hospitals had indicated that they have inpatient and outpatient treatment centres in operation by the end of this year; and what number of addicts it was expected to be able to treat in them.-Lord BESWICK replied: All hospital boards who were asked to do so have replied to this memorandum. By about the end of this year inpatient treatment in the London area for heroin addiction is expected to be available at 10 hospitals and outpatient treatment at 14 hospitals. Detailed arrangements, including the precise number of addicts who will be able to be treated, are being discussed with the hospital authorities concerned. Outside London treatment will be available, if required, at most mental hospitals. Lord SANDFORD: How many hospitals have outlined the plans they are making to expand their existing services when the Bill becomes law ?-Lord BESWICK: Discussions are now taking place with the hospital boards and there are many details to be settled. But I think the answer I have given shows that the hospital boards have been forthcoming in their replies to the inquiries. Lord AMULREE: Will the clinics be available for patients on more than one or two days a week, and for what length of time during the day ?-Lord BESWICK: This is precisely the kind of detail which has to be discussed. There are many unknowns in this matter and at the moment it is quite impossible to give details of that kind.

Capital Expenditure

on

Hospitals

Actual and estimated capital expenditure on N.H.S. hospitals between the years 1965-66 and 1967-68 was f,227 million. Between October, 1964, and September, 1966, 8198 hospital beds were completed through new building or conversion schemes.

Letters

to

the Editor

TREATMENT CENTRES FOR DRUG ADDICTS SIR,-In the past so much has been talked about treatment centres for drug addicts and yet so little has been done that it is worth asking why. When referring to these centres our official rulers in medical matters seem to put on solemn faces as if such centres have to be housed in special buildings needing much time, money, and forethought. The truth is that a treatment centre is just a place where addicts are dealt with in whatever way seems proper at the time. Several have been in existence for years, run by so-called Junkie doctors, of whom I have the doubtful honour of being one. As we Junkie doctors are general practitioners, our treatment centres have consisted of what the ordinary general practitioner has to offer-stripped to the barest essentials, a consulting and waiting room and the usual clinical paraphernalia. These simple things and the doctor himself are all that is needed. The doctor who treats addicts under the National Health Service must be a certain type. He must have a certain amount of dedication, and he must have interest and toughness. He must be prepared to lose quite a lot of money, for addicts are the greatest time consumers of all patients. About my colleagues who treat addicts for payment I say

nothing. It is surely useless to pretend that a hospital-any hospitalcannot provide as good a service as the general practitioner. The service really consists of a simplified casualty department. The doctor is not on full-time duty, but he must be available any time of the day or night. So let us have done with the nonsense that any hospital whatever cannot provide a couple of rooms and the work shared among the junior staff-say, half an hour a day apiece. If ordinary G.P.s have been doing it for years, then any hospital in the country can do as well and better. There are one or two other points. It is utterly useless to offer addicts clinics two or three times a week, as if these were medical or surgical clinics. Addicts cannot keep regular hours. They are all emergencies, or if they are not now they will be in a few hours when they are deprived. To tell an addict that the clinic is full and he must come back in a week is just farcical. Next, the Ministry of Health, in its rather nebulous plans, proposes to establish clinics in outer London, and then protests that no addicts have applied for treatment, so it is no use extending them. Of course it isn’t. Junkies haunt Central London. To expect them to make a two-hour journey to the suburbs would be just as fatuous as to ask the same thing of a man who had been run over by a bus. I am sure that if the Ministry opened an addicts’ clinic in John o’ Groats perfect peace would reign. The only Central London hospital which takes addicts is already giving them appointments weeks ahead. In conclusion, I see not the slightest reason why addict clinics should not be set up in every hospital in London and all large cities-and that within a week. The trimmings can come later. A. J. HAWES. London W.1.

THE

MYSTIQUE OF THE BARIUM MEAL SIR,-The heading under which Dr. Nelson’s article (July 8, p. 92) appears seems particularly apt, since it is followed by nearly two pages of dogmatic statements, most of which are open to dispute. Naturally we welcome any help in our constant reappraisal of the techniques of radiological investigation of the upper alimentary tract. However, Dr. Nelson merely makes a series of claims, many of which are demonstrably inaccurate, and criticisms of procedures which have been of purely historical interest for some time. It is not possible to discuss all the matters raised in this article, but several points invite immediate comment. Dr. Nelson does not describe the precise details of his

209

technique and we are not told the relative diagnostic importance that he attaches to fluoroscopic and radiographic findings. The merits of these two methods and the changing emphasis on each pose fundamental questions which must be answered before any intelligent discussion of technical details is possible. It has been suggested elsewhere that with a small-field intensifier and an optimal optical system it is possible to establish the diagnosis by screening alone.1 The reduction that occurs in the quality of the screen image when large-field intensifiers and television are used inevitably demands that radiography is used for accurate diagnosis. Unlike Dr. Nelson, we firmly believe that under these circumstances it is the less reliable diagnostician who accepts anything but the best

possible films. We do not understand the distinction between films of adequate " diagnostic quality and films of best possible quality ". We understand that Dr. Nelson advocates buying expensive apparatus but not providing enough cubicles. Even though he cannot wait for the patient to undress he has time to follow the examination through to the colon. We are intrigued by his implication that the colon can be demonstrated adequately with 2 oz. of barium given by mouth. Surely the barium meal is designed to examine the alimentary tract from mouth to duodenojejunal flexure with modifications to suit each clinical problem as it presents. For example, cine fluorography, far from being a gimmick, is an invaluable method of investigating the mechanism of swallowing, because every detail can be studied at length in the developed film. Such an examination can be made physiologically only in the erect position. "

"

We cannot accept that it is inevitable to perpetuate the mystique of screening in the dark. While we agree that all radiologists in training should learn to use the conventional screen, we are sure that they should become skilled in the use of all forms of apparatus, and, most of all, develop an attitude of mind that will enable them to make the best use of any further technical advances. In fact, we are unaware of any training department in which this is not the custom. If any radiologist still uses a pint of barium routinely and is responsible for producing skin erythema on the back of the patient, then there is some justification for Dr. Nelson’s comments on these points. Unfortunately this mythical figure would be unlikely to read the current medical literature

regularly. University Department of Radiodiagnosis, Medical School, University Walk, Bristol 8, and

SIR,-As practising radiologists, very keen to dispute dogma whenever possible, we read the paper by Dr. Nelson with The first principle in disputing dogma great interest. must surely be to avoid replacing one dogma with another. This necessitates proving one’s case, which we suggest that Dr. Nelson has failed to do.

Should the necessary we shall look

proof of Dr. Nelson’s assertions be available, forward

to

its publication in The Lancet.

W. DAVIDSON S. M. HALE W. SIMPSON

Department of Radiology, Newcastle General Hospital,

W.

Westgate Road,

URQUHART

J. R. YOUNG.

Newcastle upon Tyne, 4.

BENT BACKS IN BRITTANY

SIR,-Bent backs

are

very

common

amongst the

elderly

female population of Brittany, and are perhaps the rule in the Crozon peninsula. The local women are said to do a lot of

backbending and/or lifting 1.

in the

course

factor ? Lewisham Hospital, London S.E.13.

L. V. ROBERTS.

ICE-CREAM-VAN ACCIDENTS SiR,ŁYour correspondentsmay be interested to know that towards the end of my recent six years in paediatric hospital and general practice in Western Australia I found these accidents an ever-increasing problem. Childhood mortality in the large busy city of Perth, in particular, was so high for this type of accident that a public outcry resulted in the compulsory flying of a red danger flag by the many ice-cream vans in use. This was lettered clearly, and projected at right-angles horizontally on the traffic-side of the van; whenever the driver stopped this flag was automatically raised for display. Oncoming cardrivers were able to exercise extra caution in adequate time on this clear warning, even if the children did forget their seeing " kerb drill ". Though I cannot now refer to actual statistics, I was very impressed at the time with the results, which appeared to drastically curtail the needless loss of child health and life. British Medical

Team,

Luang Prabang, Boite Postale 317, Laos.

ALAN GOODWIN.

SIR,-Dr. Briggs and Dr. Potter1 of Oxford express an interest in data about children injured by passing vehicles in the vicinity of ice-cream vans to or from which they were hurrying in connection with an ice-cream purchase. Dr. A. L. Lloyd of Birmingham in 1964 presented a resolution to the Council of the British Medical Association requesting consideration of the hazard posed by "ice-cream vending vehicles equipped with amplified chimes 11.2 In support of his resolution Dr. Lloyd provided some regional statistics on the number of accidents to children in which ice-cream vans were involved. The hazard is illustrated by the following paragraph in the Long Beach (California) Press-Telegram of May 2, 1966: "

JOHN ROYLANCE RHYS DAVIES.

Bristol Royal Infirmary, Bristol 2.

which must subject their backs to multiple strains, doubtless aggravated by postmenopausal osteoporosis. But is this an adequate explanation? Perhaps there is some more basic upset of mineralisation. The atmosphere is laden with iodine. Can diminished production of thyrocalcitonin be a

of their

Roylance, J. Br. J. Radiol. 1962, 35,

409.

daily duties,

A 9-year-old-girl running home with an ice-cream bar was killed Sunday when struck by a car as she darted into its path from in front

of the halted ice-cream truck." Catholic Hospitals Medical Education Foundation, 101 Memorial Drive, Kansas City, Missouri 64108.

GEORGE X. TRIMBLE.

SELF-TREATMENT SIR,-Dr. Cargill’s proposal to institute self-treatment with oxytetracycline3 is most interesting, and, as he points out, has much to recommend it. To the possible objections to the scheme which he mentions, he provides reasonable answers. However, he fails to mention one criticism which has come to my mind, which leads me to believe that the programme which he has proposed is, rather than being too broad, not broad

enough. Dr. Cargill proposes to educate the public in the use of broad-spectrum antibiotics through the mass media and specific instructions given with the medications. Unfortunately, these methods have been shown to be rather poor for informing the public on health matters. Examples are well known: Briggs, M., Potter, J. M. Lancet, July 1, 1967, p. 41. Hails, F. G. ibid. July 8, 1967, p. 103. 2. Br. med. J. 1964, ii, suppl. p. 100. 3. Cargill, D. Lancet, 1967, i, 1377. 1.