- Email: [email protected]
TO BE TAKEN AS DIRECTED
747 closer to the patient’s family. Since the requireof section 60 were fulfilled in respect of the appellant an order for her admission and detention at Talgarth would be in
Letters
an area
to
the Editor
ments
made. Court of Appeal, Criminal Division. Sachs, L.J., Cantley and Cusack, J.y. March 25, 1968. Counsel and solicitors: Colin Sara (Kingsley, Napley & Co.); John Newey (solicitor, Ministry of Health). R.
Marsden.
v.
L. NORMAN WILLIAMS Barrister-at-Law.
HOSPITAL MEDICAL-STAFF STRUCTURE SIR,-Mr. Hendry’s views (March 16, p. 586), on hospital staffing are both refreshingly original and very welcome. "... the point of transition from supervised to unsupervised work " is indeed the crux of the matter. No self-respecting doctor wants to be supervised " for the whole of his career, even though such supervision is often purely nominal or nonexistent in practice. Many general practitioners in posts governed by section 10(b) of the terms and conditions of service of hospital staff are in just this position. Although there are some 4000 of them, the equivalent of some 800 full-time hospital doctors, they receive little consideration from any quarter. For example, neither the report of the working-party on medical work in hospitals,l nor the reports2 on the negotiations between the Health Departments and representatives of hospital doctors even mention their existence. It is also too often forgotten that not all hospital work is specialist " work. Indeed in a recent survey by the SouthEast England Faculty of the Royal College of General Practitioners it was estimated that as many as 53-9% of patients admitted to hospitals in that region could have been cared for by their general practitioner, who could have dealt with 11% of all admissions without consultant help.3 Mr. Hendry says " we should be trying to move towards a system that encourages doctors in hospital to see one another as professional colleagues ...." In supporting this may I go further and suggest that there is a place both for the generalist in the hospital and for the specialist in the community services ? "
In A
England Now
Running Commentary by Peripatetic Correspondents
It is not every day one is called before the Lord Chief Justice. Down the Strand to the threshold of Fleet Street where, in a long pseudo-Gothic cathedral, the Law (though not necessarily Truth, alas) is worshipped. Robed and wigged priests flit reverently to and fro in its service, and a few from the ignorant masses gaze open-mouthed in wonder. Stone-work ornate and dirty, smoking and photography forbidden. Incense, only, is
lacking. In
a remote corner
is the
Justice’s Court, inscribed
Holy
of Holies, the Lord Chief
by the door. Scarlet clad a learned Lord of Law on either side, he pondered the fate of a sad lad who had found the sexual side of marriage hard going and, in a mood of bleak despair, had taken it out on local haystacks in a big way with a box of matches. At the trial he had been given a short prison sentence which, in the face of uncontested medical evidence, seemed inappropriate. Now, with care and patience, the Appeal Court set the matter right. The psychiatric view was pondered carefully and long with more courtesy and sympathy than I have experienced in many a year of expert witnessing. Books from floor to ceiling gazed dustily down on the deliberations. Justice was done, and in the nicest way. Respect for the Law was enhanced-and it needed to be. Five wasted months, banged up in purgatory, had made the therapeutic task harder. A man innocent of the ways of crime had learned already where to buy guns, how to crack safes, and where, once outside, to find the frail friendship of the chronically crooked. No blame for that to the Lord Chief Justice and his Lords on either hand. But a pity just the same. When
we
dropped
out
as
such
spring-cleaned the cellar last week a paper of the back of a cupboard. It was an invitation to attend the 1818 annual general meeting of subscribers to the town dispensary, and a report on the finances and work done during 1817-a neatly printed balance-sheet of charitable and clinical detail, a glimpse at the way general practice was settling down again in the second year after the battle of Waterloo. The townsfolk who could not afford to buy their own medicines had to seek a letter of recommendation from a subscriber or the overseer of the poor and attend the dispensary at 9 A.M. in summer or 10 A.M. in winter, or, if incapable, be visited at home by a surgeon or the apothecary. On one side of the balance-sheet the 4 duty surgeons subscribed half-a-guinea apiece. On the other side they received no fees. Only the apothecary got E80 salary a year. Medicines cost E148, and the total expenses for the year were E237 14s. 8d. 1638 patients are on the list, with 1452 written off cured, 47 relieved, 62 dead, and only 77 carried forward to next year. The clinical material was varied: 248 cases of cowpox and only 55 of smallpox; 218 simple fevers against 73 typhus, 43 scarlets, and 5 choleras; 118 bothered with itch and 97 with worms. Interesting causes of death included mortification of the toes in the workhouse. The detailed diagnostic analysis under 75 heads must have been designed to impress the lay subscribers. I can only hope that the cost accountants of the Ministry of Health, or the clerk of the executive council, or the statisticians of the Royal College of General Practitioners never get hold of this document. I am not sure whose Waterloo it would be.
"
Stratford-on-Avon, Warwickshire.
E. O. EVANS.
TO BE TAKEN AS DIRECTED
SIR,-At a recent domiciliary visit six bottles of tablets were produced, of which three were labelled " To be taken as directed ". One of these bottles contained tablets offrusemide, which the doctor intended the patient to take in a dosage of one tablet per week. The others could have contained vitamins, chlorpromazine, digitalis, or potassium chloride, to be taken in ones or twos up to three or four times a day. The patient was very ill and mentally confused; neither she, nor her mentally defective daughter, nor her doctor or myself could say which tablet was which. The doctor had prescribed three sets of tablets Modo dicto usendum, abbreviated as usual to m.d.u., under the impression that the pharmacist would sort
things
out.
The roots of this problem go deep. I have seen the same clinical condition develop when oral-diuretic tablets were correctly labelled. In patients with congestive heart-failure an attack of bronchitis or a minor trauma can precipitate cerebral anoxia, and nobody may be able to tell which tablet or how many of them the mentally confused patient has taken. When I do a domiciliary visit without the doctor I am often asked by the elderly amnesic living alone which tablet she should take and how often. There is really no point in prescribing dangerous drugs for this type of patient to take home. As likely as not she will take the vitamin pill once a week, the barbiturate in the morning, the digitalis at night, and the oral diuretic three times a day after meals. For the treatment of congestive heart-failure in the elderly patient at home I would recommend the doctor to personally administer 1-5 mg. digoxin in a single dose at the time of his visit on two successive days (or the district nurse might administer the digoxin on the second day). Despite all adver1. First Report of the Joint Working Party on the Organisation of Medical Work in Hospitals. H.M. Stationery Office, 1967. See Lancet, 1967, ii, 975. 2. Br. med. J. March 16, 1968, suppl. p. 73. 3. Jl R. Coll. gen. Practnrs, 1967, 14, 294.
748 "
the contrary there is no maintenance " dose of digitalis. Those doctors who believe that oral diuretics are of benefit should administer the tablet personally or get the district nurse to administer it once a week. Weekly weighing provides an excellent check on the efficacy of treatment and costs almost nothing. Elderly folk are presbyopic as well as presbyophrenic. Hence all tablets should be dispensed in large rather than small containers. The directions should be printed in letters as large as the label can possibly accommodate. When tablets are toxic -and most of them are-the directions should be printed in red. For those who like to garnish their prescriptions with a bit of Latin might I suggest the signature, Calligraphia rubra et magna, for all those containing oral diuretics ? Abbreviated in the usual way it will help to remind the doctor that these drugs have some undesirable side-effects. Manor Park Hospital, WILLIAM HUGHES. Fishponds, Bristol.
tisements
to
HYPOMAGNESÆMIA IN NEPHROSIS
SiR,—The ability to excrete magnesium may be severely impaired, and serum-levels may rise, in patients with chronic renal disease with azotmmia. However, little is known on magnesium metabolism in patients with the nephrotic syndrome. In my laboratory serum-magnesium levels have been measured in patients with idiopathic nephrotic syndrome before and after steroid therapy. I have studied one female and eight male, hitherto untreated, patients with idiopathic nephrosis, aged 8 months to 13 years at the onset of the disease. There was no history of antecedent renal parenchymal diseases. (Edema, hypoproteinsemia with reversal of the albumin/globulin ratio, and hypercholesterolmniia were uniformly present at the onset of the disease. The blood-urea nitrogen was normal. Haematuria and pyuria were absent. The patients received glucocorticoids (prednisolone, dexamethasone, or betamethasone) only, daily or on alternate days; all were steroid-responsive, and had complete remissions while on this therapy. Protein disappeared from the urine within 2 weeks of starting the steroid therapy in all, and the steroid dose was then gradually decreased. Two patients with
protein-losing enteropathy, with hypoproteineemia (3-2 and 3-4 g. per 100 ml.) and generalised oedema, served as controls. Serum-magnesium concentrations were measured by a modification of the fluorometric method of Schachterwith 1.
Schachter, D. J. Lab. clin. Med. 1961, 58, 495.
’
Multiplier Fluorescence Meter, model 540 ’ (Photovolt Corporation, 1115 Broadway, New York 10).2 The mean level of serum-magnesium in six of the patients who were untreated and had generalised cedema was 1-67 meq. per litre (S.D. 0-14), which was significantly reduced by the standard of this laboratory3 (p < 0-01). Further reduction of serum-magnesium levels occurred in three patients within 2 weeks of starting therapy. Thereafter, the serum-magnesium
gradually to the normal range as the disease improved (see figure). Serially determined levels of serummagnesium in all nine patients were plotted against the levels of serum-total-protein, albumin/globulin ratio, «2-globulin, and levels increased
total cholesterol. Serum-magnesium levels showed direct correlations with serum-protein levels (r=+0-644, P<0-01), and with albumin/globulin ratio of the serum (r=+0-783, On the other hand, serum-magnesium levels were P<0-01). inversely correlated with oc2-globulin levels (r=-0-628, p < 0-05), and with total cholesterol levels (r= --0-772, P < 0-01). The two patients with protein-losing enteropathy had low serum-magnesium levels (1-80 and 1-44 meq. per litre). Hypomagnesasmia in nephrosis and protein-losing enteropathy may be partly due to secondary hyperaldosteronism, which is thought to develop in patients with generalised oedema, and partly to urinary or intestinal loss of protein-bound magnesium. The further reduction of serum-magnesium level, which occurred in three nephrotics within 2 weeks of starting steroid therapy, was probably due to increased glomerularfiltration rate caused by the steroid therapy and/or to increased secretion of aldosterone produced by dietary salt restriction. Department of Pædiatrics, University of Tokyo, AKIO KOBAYASHI. Tokyo, Japan.
MEASUREMENT OF BLOOD-GLUCOSE LEVELS SiRj—Your leading article (Feb. 24, p. 405) quite correctly points out that there are a large number of methods extant for measuring blood-glucose levels and that results from these methods may vary considerably from one another. An additional source of confusion is introduced by the multiplicity of specimens which are conventionally used for this procedure. Although in the past glucose has traditionally been estimated on whole blood, the source of the blood has in different areas or even in the same area at different times been venous or capillary. It is well known that capillary blood can have a glucose concentration higher than venous blood by an amount which may vary from 0 to 50 mg. per 100 ml., depending on the level of the bloodsugar and the time since the previous meal. We are on the verge of adding still another complication with the introduction of multiphasic screening. The endeavour to perform many determinations simultaneously and
automatically on specimen to
a
single specimen requires
that
be serum. Therefore we are already seeing, and will in the future see even more, glucose determinations on serum rather than whole blood. Serum-concentrations of glucose are about 10% higher than wholeblood concentrations, because of the higher water content of serum as acompared with red cells, and this difference depends upon the hmmatocrit. There is now probably a good argument for abandoning the use of whole blood in biochemical investigation, unless one is specifically interested in the red-cell concentrations. For such determinations as blood urea-nitrogen and glucose, the use of whole blood not only introduces an uncertainty because of varying hasmatocrit but 2. 3.
Kobayashi, A., Shiraki, K. Archs Dis. Childh. 1967, 42, 615. Kobayashi, A. Lancet, 1967, ii, 100.
Letters
an area
to
the Editor
ments
made. Court of Appeal, Criminal Division. Sachs, L.J., Cantley and Cusack, J.y. March 25, 1968. Counsel and solicitors: Colin Sara (Kingsley, Napley & Co.); John Newey (solicitor, Ministry of Health). R.
Marsden.
v.
L. NORMAN WILLIAMS Barrister-at-Law.
HOSPITAL MEDICAL-STAFF STRUCTURE SIR,-Mr. Hendry’s views (March 16, p. 586), on hospital staffing are both refreshingly original and very welcome. "... the point of transition from supervised to unsupervised work " is indeed the crux of the matter. No self-respecting doctor wants to be supervised " for the whole of his career, even though such supervision is often purely nominal or nonexistent in practice. Many general practitioners in posts governed by section 10(b) of the terms and conditions of service of hospital staff are in just this position. Although there are some 4000 of them, the equivalent of some 800 full-time hospital doctors, they receive little consideration from any quarter. For example, neither the report of the working-party on medical work in hospitals,l nor the reports2 on the negotiations between the Health Departments and representatives of hospital doctors even mention their existence. It is also too often forgotten that not all hospital work is specialist " work. Indeed in a recent survey by the SouthEast England Faculty of the Royal College of General Practitioners it was estimated that as many as 53-9% of patients admitted to hospitals in that region could have been cared for by their general practitioner, who could have dealt with 11% of all admissions without consultant help.3 Mr. Hendry says " we should be trying to move towards a system that encourages doctors in hospital to see one another as professional colleagues ...." In supporting this may I go further and suggest that there is a place both for the generalist in the hospital and for the specialist in the community services ? "
In A
England Now
Running Commentary by Peripatetic Correspondents
It is not every day one is called before the Lord Chief Justice. Down the Strand to the threshold of Fleet Street where, in a long pseudo-Gothic cathedral, the Law (though not necessarily Truth, alas) is worshipped. Robed and wigged priests flit reverently to and fro in its service, and a few from the ignorant masses gaze open-mouthed in wonder. Stone-work ornate and dirty, smoking and photography forbidden. Incense, only, is
lacking. In
a remote corner
is the
Justice’s Court, inscribed
Holy
of Holies, the Lord Chief
by the door. Scarlet clad a learned Lord of Law on either side, he pondered the fate of a sad lad who had found the sexual side of marriage hard going and, in a mood of bleak despair, had taken it out on local haystacks in a big way with a box of matches. At the trial he had been given a short prison sentence which, in the face of uncontested medical evidence, seemed inappropriate. Now, with care and patience, the Appeal Court set the matter right. The psychiatric view was pondered carefully and long with more courtesy and sympathy than I have experienced in many a year of expert witnessing. Books from floor to ceiling gazed dustily down on the deliberations. Justice was done, and in the nicest way. Respect for the Law was enhanced-and it needed to be. Five wasted months, banged up in purgatory, had made the therapeutic task harder. A man innocent of the ways of crime had learned already where to buy guns, how to crack safes, and where, once outside, to find the frail friendship of the chronically crooked. No blame for that to the Lord Chief Justice and his Lords on either hand. But a pity just the same. When
we
dropped
out
as
such
spring-cleaned the cellar last week a paper of the back of a cupboard. It was an invitation to attend the 1818 annual general meeting of subscribers to the town dispensary, and a report on the finances and work done during 1817-a neatly printed balance-sheet of charitable and clinical detail, a glimpse at the way general practice was settling down again in the second year after the battle of Waterloo. The townsfolk who could not afford to buy their own medicines had to seek a letter of recommendation from a subscriber or the overseer of the poor and attend the dispensary at 9 A.M. in summer or 10 A.M. in winter, or, if incapable, be visited at home by a surgeon or the apothecary. On one side of the balance-sheet the 4 duty surgeons subscribed half-a-guinea apiece. On the other side they received no fees. Only the apothecary got E80 salary a year. Medicines cost E148, and the total expenses for the year were E237 14s. 8d. 1638 patients are on the list, with 1452 written off cured, 47 relieved, 62 dead, and only 77 carried forward to next year. The clinical material was varied: 248 cases of cowpox and only 55 of smallpox; 218 simple fevers against 73 typhus, 43 scarlets, and 5 choleras; 118 bothered with itch and 97 with worms. Interesting causes of death included mortification of the toes in the workhouse. The detailed diagnostic analysis under 75 heads must have been designed to impress the lay subscribers. I can only hope that the cost accountants of the Ministry of Health, or the clerk of the executive council, or the statisticians of the Royal College of General Practitioners never get hold of this document. I am not sure whose Waterloo it would be.
"
Stratford-on-Avon, Warwickshire.
E. O. EVANS.
TO BE TAKEN AS DIRECTED
SIR,-At a recent domiciliary visit six bottles of tablets were produced, of which three were labelled " To be taken as directed ". One of these bottles contained tablets offrusemide, which the doctor intended the patient to take in a dosage of one tablet per week. The others could have contained vitamins, chlorpromazine, digitalis, or potassium chloride, to be taken in ones or twos up to three or four times a day. The patient was very ill and mentally confused; neither she, nor her mentally defective daughter, nor her doctor or myself could say which tablet was which. The doctor had prescribed three sets of tablets Modo dicto usendum, abbreviated as usual to m.d.u., under the impression that the pharmacist would sort
things
out.
The roots of this problem go deep. I have seen the same clinical condition develop when oral-diuretic tablets were correctly labelled. In patients with congestive heart-failure an attack of bronchitis or a minor trauma can precipitate cerebral anoxia, and nobody may be able to tell which tablet or how many of them the mentally confused patient has taken. When I do a domiciliary visit without the doctor I am often asked by the elderly amnesic living alone which tablet she should take and how often. There is really no point in prescribing dangerous drugs for this type of patient to take home. As likely as not she will take the vitamin pill once a week, the barbiturate in the morning, the digitalis at night, and the oral diuretic three times a day after meals. For the treatment of congestive heart-failure in the elderly patient at home I would recommend the doctor to personally administer 1-5 mg. digoxin in a single dose at the time of his visit on two successive days (or the district nurse might administer the digoxin on the second day). Despite all adver1. First Report of the Joint Working Party on the Organisation of Medical Work in Hospitals. H.M. Stationery Office, 1967. See Lancet, 1967, ii, 975. 2. Br. med. J. March 16, 1968, suppl. p. 73. 3. Jl R. Coll. gen. Practnrs, 1967, 14, 294.
748 "
the contrary there is no maintenance " dose of digitalis. Those doctors who believe that oral diuretics are of benefit should administer the tablet personally or get the district nurse to administer it once a week. Weekly weighing provides an excellent check on the efficacy of treatment and costs almost nothing. Elderly folk are presbyopic as well as presbyophrenic. Hence all tablets should be dispensed in large rather than small containers. The directions should be printed in letters as large as the label can possibly accommodate. When tablets are toxic -and most of them are-the directions should be printed in red. For those who like to garnish their prescriptions with a bit of Latin might I suggest the signature, Calligraphia rubra et magna, for all those containing oral diuretics ? Abbreviated in the usual way it will help to remind the doctor that these drugs have some undesirable side-effects. Manor Park Hospital, WILLIAM HUGHES. Fishponds, Bristol.
tisements
to
HYPOMAGNESÆMIA IN NEPHROSIS
SiR,—The ability to excrete magnesium may be severely impaired, and serum-levels may rise, in patients with chronic renal disease with azotmmia. However, little is known on magnesium metabolism in patients with the nephrotic syndrome. In my laboratory serum-magnesium levels have been measured in patients with idiopathic nephrotic syndrome before and after steroid therapy. I have studied one female and eight male, hitherto untreated, patients with idiopathic nephrosis, aged 8 months to 13 years at the onset of the disease. There was no history of antecedent renal parenchymal diseases. (Edema, hypoproteinsemia with reversal of the albumin/globulin ratio, and hypercholesterolmniia were uniformly present at the onset of the disease. The blood-urea nitrogen was normal. Haematuria and pyuria were absent. The patients received glucocorticoids (prednisolone, dexamethasone, or betamethasone) only, daily or on alternate days; all were steroid-responsive, and had complete remissions while on this therapy. Protein disappeared from the urine within 2 weeks of starting the steroid therapy in all, and the steroid dose was then gradually decreased. Two patients with
protein-losing enteropathy, with hypoproteineemia (3-2 and 3-4 g. per 100 ml.) and generalised oedema, served as controls. Serum-magnesium concentrations were measured by a modification of the fluorometric method of Schachterwith 1.
Schachter, D. J. Lab. clin. Med. 1961, 58, 495.
’
Multiplier Fluorescence Meter, model 540 ’ (Photovolt Corporation, 1115 Broadway, New York 10).2 The mean level of serum-magnesium in six of the patients who were untreated and had generalised cedema was 1-67 meq. per litre (S.D. 0-14), which was significantly reduced by the standard of this laboratory3 (p < 0-01). Further reduction of serum-magnesium levels occurred in three patients within 2 weeks of starting therapy. Thereafter, the serum-magnesium
gradually to the normal range as the disease improved (see figure). Serially determined levels of serummagnesium in all nine patients were plotted against the levels of serum-total-protein, albumin/globulin ratio, «2-globulin, and levels increased
total cholesterol. Serum-magnesium levels showed direct correlations with serum-protein levels (r=+0-644, P<0-01), and with albumin/globulin ratio of the serum (r=+0-783, On the other hand, serum-magnesium levels were P<0-01). inversely correlated with oc2-globulin levels (r=-0-628, p < 0-05), and with total cholesterol levels (r= --0-772, P < 0-01). The two patients with protein-losing enteropathy had low serum-magnesium levels (1-80 and 1-44 meq. per litre). Hypomagnesasmia in nephrosis and protein-losing enteropathy may be partly due to secondary hyperaldosteronism, which is thought to develop in patients with generalised oedema, and partly to urinary or intestinal loss of protein-bound magnesium. The further reduction of serum-magnesium level, which occurred in three nephrotics within 2 weeks of starting steroid therapy, was probably due to increased glomerularfiltration rate caused by the steroid therapy and/or to increased secretion of aldosterone produced by dietary salt restriction. Department of Pædiatrics, University of Tokyo, AKIO KOBAYASHI. Tokyo, Japan.
MEASUREMENT OF BLOOD-GLUCOSE LEVELS SiRj—Your leading article (Feb. 24, p. 405) quite correctly points out that there are a large number of methods extant for measuring blood-glucose levels and that results from these methods may vary considerably from one another. An additional source of confusion is introduced by the multiplicity of specimens which are conventionally used for this procedure. Although in the past glucose has traditionally been estimated on whole blood, the source of the blood has in different areas or even in the same area at different times been venous or capillary. It is well known that capillary blood can have a glucose concentration higher than venous blood by an amount which may vary from 0 to 50 mg. per 100 ml., depending on the level of the bloodsugar and the time since the previous meal. We are on the verge of adding still another complication with the introduction of multiphasic screening. The endeavour to perform many determinations simultaneously and
automatically on specimen to
a
single specimen requires
that
be serum. Therefore we are already seeing, and will in the future see even more, glucose determinations on serum rather than whole blood. Serum-concentrations of glucose are about 10% higher than wholeblood concentrations, because of the higher water content of serum as acompared with red cells, and this difference depends upon the hmmatocrit. There is now probably a good argument for abandoning the use of whole blood in biochemical investigation, unless one is specifically interested in the red-cell concentrations. For such determinations as blood urea-nitrogen and glucose, the use of whole blood not only introduces an uncertainty because of varying hasmatocrit but 2. 3.
Kobayashi, A., Shiraki, K. Archs Dis. Childh. 1967, 42, 615. Kobayashi, A. Lancet, 1967, ii, 100.