- Email: [email protected]
TOWARDS RESPONSIBLE PARENTHOOD
285
altogether, for there will always be some who realise after qualification that their vocation lies exclusively in the laboratory. No department, as far as I am aware, has yet taken the novel and courageous but inevitable step of creating a combined chemical-pathology/clinical-chemistry department staffed by medical and non-medical personnel of equal standing and status, which would be a model for such departments in nonteaching hospitals, for which there is an even greater need. Area Laboratory, West Park Hospital, VINCENT MARKS. Epsom, Surrey. never cease
RETENTION OF MEDICAL RECORDS SiR,-An increasingly acute problem of storage of medical records has developed in recent years in hospitals in the United Kingdom. Since the 1939-45 war case-records have"tended to get larger and larger, and together with this so-called information explosion " there has been the widespread adoption of the unit system of filing case-records. In many hospitals storage space is now nearly exhausted, both for the records themselves and for the master indexes of these records, and yet there is no general agreement among physicians and surgeons as to how long it is either desirable or necessary to keep old case-records. There are several ways of dealing with the problem: one is utterly to destroy old records, another is to transfer them to microfilm, and a third is to transfer the important data within them to special summaries or abstracts. This third method has many advocates, who see in it opportunities for computerising certain data for statistical evaluation, but this is really something of a " red herring " as far as the main issue is concerned. How long should previous case-records of patients be retained after their last attendance, and is microfilm storage a satisfactory solution of the problem ? There are of course certain categories of disease in which many would advocate keeping of the case-records at least until the death of the patients, and these categories certainly include all forms of malignant disease. Medical Records Research Group (Nuffield Provincial Hospitals Trust), Western Infirmary, Glasgow W.1
J. H. MITCHELL.
TOWARDS RESPONSIBLE PARENTHOOD
SIR,-Sir Theodore Fox in his article last week dismisses
morality on the grounds that it would not be to the community if the members were to work it out for themselves from first principles, and that its traditional religious basis has now been largely dismissed. He does, however, mention that two Communist nations, China and Russia, conform to this, and that they have shown " that adolescent sexual immorality can be almost abolished by a chaperonage of girls and the further segregation of the traditional sexual
freely acceptable
"
sexes ", but he says that these nations have had to pay heavy price for this ". He does not say what this price is
"
a
or
whether its cost in adolescence is recouped in married life. At present, our women are paying an enormous price for sexual freedom in unwanted pregnancies, abortions, forced marriages, veneral disease, and personal humiliation, but no d0ubt Sir Theodore feels that these dangers can be avoided by education. He mentions that for some " intercourse is indissolubly associated with the desire for children and a permanent home’.This point is the most important factor in responsible pa-enthood. The sexual act cannot be divorced from an urge for companionship, home-making, and later childbirth, without the partners losing a sense of their personal values, and their "1.1,2 to integrate in family units and into society. Adequate measures can never be effective unless a " nest and some security are provided. This may well mean earlier marriage and more contraceptive education, but more promiscuity only result in irresponsible parenthood.
With regard to the discussion whether married people should take other partners, unless human nature changes it is impossible to say how this will not conflict with Sir Theodore’s criterion that a " child’s best preparation for marriage is to livein a home made successful by both parents". In saying, My own feeling is that we are apt to take the sexual act itself too seriously; for often it is no more than a physiological incident, soon forgotten ", he is stating a masculine attitude which was commonly heard before sexual education made its impact over the past fifteen years. I believe that young people today are much more serious-minded and responsible. "
Powick Hospital, nr. Worcester.
G. I. TEWFIK.
TREATMENT OF STATUS ASTHMATICUS
SIR,-The syndrome of status asthmaticus, the treatment of which is discussed by Mr. Marchand and Dr. van Hasselt (Jan. 29), is not uncommon; their description and your annotation (Jan. 29) raise several important clinical and physiological points which cannot be left undisputed. Dr. Grant (Feb. 12) takes up some of these points, and rightly questions the attribution of the favourable results obtained to intermittent positive-pressure (i.p.p.) ventilation, or l.p.p. breathing assisted during inspiration (i.p.p.B.l.) as it is known in the United States. From my experience in many parts of the world, I do wonder about the frequency with which Mr. Marchand and Dr. van Hasselt have used artificial ventilation. In such acute conditions when so many medications are administered it is very difficult to emphasise the results as being due to one
specific measure. While it is not appropriate to go into the pathophysiological of status asthmaticus here, it should be stressed that in the acute syndrome the stage is very similar to acute ventilatory failure seen in any chronic obstructive pulmonary diseaseoften described as chronic bronchitis in Britain and emphysema in the U.S. In status asthmaticus bacterial infection may not be a predominant factor. This might explain the relative dryness of the respiratory tract in such patients. In the U.S. during the past 20 years very large experience has been gathered of the treatment of acute ventilatory failure in such patients, and only recently is the problem beginning to be understood. Jones et aLl worked on a model and simulated varying degrees of respiratory obstruction. They found that with mild and moderate expiratory obstruction there was an improvement in ventilation and blood-gases with i.p.p.i3.i. But there was actually decrease in alveolar ventilation despite an increase in minute ventilation, and deterioration in the blood-gas picture, with severe obstruction.1 Cullen et al. have already seen clinical evidence of this. My group did some planned studies to sort out this problem of the value of I.P.P.B.I. without bronchodilators in severely obstructed patients.3 It was concluded that in most of these patients I.P.P.B.i. did not prove beneficial. This treatment’s value cannot be assessed by reporting favourable outcomes in acutely ill patients; it has to be evaluated when the patients are on the way to recovery, by extensive studies with sophisticated analyses of pulmonary mechanics. Sukumalchantra et al. have found increased physiological dead-space ventilation with I.P.P.B.I. This did not lead to an improvement in blood-gases on 16 of 27 occasions in thirteen patients. The first report of the use of I.P.P.B.I. in Britain in status asthmaticus was by Broom,5 but was based on small experience. Mr. Marchand and Dr. van Hasselt also administered high doses of sedatives, which might have evoked muscular relaxation. Whether I.P.P.B.I. is effective in respiratory
picture
Jones, R. H., MacNamara, J., Gaersler, E. A. Am. Rev. resp. Dis. 1960, 82, 164. 2. Cullen, J. H., Brum, V. C., Reidt., W. U. Am. Rev. Tuberc. pulm. Dis. 1957, 76, 33. 3. Kamat, S. R., Dulfano, M. J., Segal, M. S. Am. Rev. resp. Dis. 1962, 86, 360. 4. Sukumalchantra, Y., Park., S. S., Williams, M. H. ibid. 1965, 92, 885. 5. Broom, B. Lancet, 1960, i, 899. 1.
altogether, for there will always be some who realise after qualification that their vocation lies exclusively in the laboratory. No department, as far as I am aware, has yet taken the novel and courageous but inevitable step of creating a combined chemical-pathology/clinical-chemistry department staffed by medical and non-medical personnel of equal standing and status, which would be a model for such departments in nonteaching hospitals, for which there is an even greater need. Area Laboratory, West Park Hospital, VINCENT MARKS. Epsom, Surrey. never cease
RETENTION OF MEDICAL RECORDS SiR,-An increasingly acute problem of storage of medical records has developed in recent years in hospitals in the United Kingdom. Since the 1939-45 war case-records have"tended to get larger and larger, and together with this so-called information explosion " there has been the widespread adoption of the unit system of filing case-records. In many hospitals storage space is now nearly exhausted, both for the records themselves and for the master indexes of these records, and yet there is no general agreement among physicians and surgeons as to how long it is either desirable or necessary to keep old case-records. There are several ways of dealing with the problem: one is utterly to destroy old records, another is to transfer them to microfilm, and a third is to transfer the important data within them to special summaries or abstracts. This third method has many advocates, who see in it opportunities for computerising certain data for statistical evaluation, but this is really something of a " red herring " as far as the main issue is concerned. How long should previous case-records of patients be retained after their last attendance, and is microfilm storage a satisfactory solution of the problem ? There are of course certain categories of disease in which many would advocate keeping of the case-records at least until the death of the patients, and these categories certainly include all forms of malignant disease. Medical Records Research Group (Nuffield Provincial Hospitals Trust), Western Infirmary, Glasgow W.1
J. H. MITCHELL.
TOWARDS RESPONSIBLE PARENTHOOD
SIR,-Sir Theodore Fox in his article last week dismisses
morality on the grounds that it would not be to the community if the members were to work it out for themselves from first principles, and that its traditional religious basis has now been largely dismissed. He does, however, mention that two Communist nations, China and Russia, conform to this, and that they have shown " that adolescent sexual immorality can be almost abolished by a chaperonage of girls and the further segregation of the traditional sexual
freely acceptable
"
sexes ", but he says that these nations have had to pay heavy price for this ". He does not say what this price is
"
a
or
whether its cost in adolescence is recouped in married life. At present, our women are paying an enormous price for sexual freedom in unwanted pregnancies, abortions, forced marriages, veneral disease, and personal humiliation, but no d0ubt Sir Theodore feels that these dangers can be avoided by education. He mentions that for some " intercourse is indissolubly associated with the desire for children and a permanent home’.This point is the most important factor in responsible pa-enthood. The sexual act cannot be divorced from an urge for companionship, home-making, and later childbirth, without the partners losing a sense of their personal values, and their "1.1,2 to integrate in family units and into society. Adequate measures can never be effective unless a " nest and some security are provided. This may well mean earlier marriage and more contraceptive education, but more promiscuity only result in irresponsible parenthood.
With regard to the discussion whether married people should take other partners, unless human nature changes it is impossible to say how this will not conflict with Sir Theodore’s criterion that a " child’s best preparation for marriage is to livein a home made successful by both parents". In saying, My own feeling is that we are apt to take the sexual act itself too seriously; for often it is no more than a physiological incident, soon forgotten ", he is stating a masculine attitude which was commonly heard before sexual education made its impact over the past fifteen years. I believe that young people today are much more serious-minded and responsible. "
Powick Hospital, nr. Worcester.
G. I. TEWFIK.
TREATMENT OF STATUS ASTHMATICUS
SIR,-The syndrome of status asthmaticus, the treatment of which is discussed by Mr. Marchand and Dr. van Hasselt (Jan. 29), is not uncommon; their description and your annotation (Jan. 29) raise several important clinical and physiological points which cannot be left undisputed. Dr. Grant (Feb. 12) takes up some of these points, and rightly questions the attribution of the favourable results obtained to intermittent positive-pressure (i.p.p.) ventilation, or l.p.p. breathing assisted during inspiration (i.p.p.B.l.) as it is known in the United States. From my experience in many parts of the world, I do wonder about the frequency with which Mr. Marchand and Dr. van Hasselt have used artificial ventilation. In such acute conditions when so many medications are administered it is very difficult to emphasise the results as being due to one
specific measure. While it is not appropriate to go into the pathophysiological of status asthmaticus here, it should be stressed that in the acute syndrome the stage is very similar to acute ventilatory failure seen in any chronic obstructive pulmonary diseaseoften described as chronic bronchitis in Britain and emphysema in the U.S. In status asthmaticus bacterial infection may not be a predominant factor. This might explain the relative dryness of the respiratory tract in such patients. In the U.S. during the past 20 years very large experience has been gathered of the treatment of acute ventilatory failure in such patients, and only recently is the problem beginning to be understood. Jones et aLl worked on a model and simulated varying degrees of respiratory obstruction. They found that with mild and moderate expiratory obstruction there was an improvement in ventilation and blood-gases with i.p.p.i3.i. But there was actually decrease in alveolar ventilation despite an increase in minute ventilation, and deterioration in the blood-gas picture, with severe obstruction.1 Cullen et al. have already seen clinical evidence of this. My group did some planned studies to sort out this problem of the value of I.P.P.B.I. without bronchodilators in severely obstructed patients.3 It was concluded that in most of these patients I.P.P.B.i. did not prove beneficial. This treatment’s value cannot be assessed by reporting favourable outcomes in acutely ill patients; it has to be evaluated when the patients are on the way to recovery, by extensive studies with sophisticated analyses of pulmonary mechanics. Sukumalchantra et al. have found increased physiological dead-space ventilation with I.P.P.B.I. This did not lead to an improvement in blood-gases on 16 of 27 occasions in thirteen patients. The first report of the use of I.P.P.B.I. in Britain in status asthmaticus was by Broom,5 but was based on small experience. Mr. Marchand and Dr. van Hasselt also administered high doses of sedatives, which might have evoked muscular relaxation. Whether I.P.P.B.I. is effective in respiratory
picture
Jones, R. H., MacNamara, J., Gaersler, E. A. Am. Rev. resp. Dis. 1960, 82, 164. 2. Cullen, J. H., Brum, V. C., Reidt., W. U. Am. Rev. Tuberc. pulm. Dis. 1957, 76, 33. 3. Kamat, S. R., Dulfano, M. J., Segal, M. S. Am. Rev. resp. Dis. 1962, 86, 360. 4. Sukumalchantra, Y., Park., S. S., Williams, M. H. ibid. 1965, 92, 885. 5. Broom, B. Lancet, 1960, i, 899. 1.