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UNNECESSARY INVESTIGATIONS
1006 I realise that this requires ruthless elimination of many papers, but can anybody think that a bad thing who has studied programmes of congresses ? Only too often does it seem as if papers are read because the organising committee wished to be courteous to a country and not exclude its speaker or speakers, although their contribution may be minimal. I hope that steps like these may reduce the number of people attending a congress ; and who except statisticians of congresses or hotel-keepers would regard this as a bad thing ? St. John’s Hospital,
S. L. LAST.
Stone, Aylesbury.
l-NORADRENALINE IN MYOCARDIAL INFARCTION
SiR,-A study of the effects
the
electrocardiogram of 1--noradrenaline in hypotensive oligaemia in the dog, shortly to be published, confirms the findings of Dr. on
Littler and Dr. McKendrick (Oct. 26). The overall survival-rate of dogs made oligaemic and hypotensive is not improved by elevation of blood-pressure with l-noradrenaline, as compared with untreated control animals 1; the time of their deaths, however, is differenttreated animals often dying with heart-block or vèntricular fibrillation during actual administration of the drug. Atropine might, as Professor Maegraith (Nov. 2) suggests, lead to significant improvement in similar circumstances. Unfortunately, it has been found that, in experimental oligaemic hypotension, the gross abnormality in cardiac carbohydrate metabolism is not reversed towards normal by l-noradrenaline as it is by blood-transfusion. Furthermore, l-noradrenaline in the heparinised hypotensive dog regularly leads to extensive subendocardial haemorrhages. Knowing the great capacity of vital organs to increase their extraction of essential metabolites from the reduced volume of blood reaching them in shock states, one wonders whether patients with hypotension who are given l-noradrenaline and recover do so in spite of this t.hera.Dv a,nl not because of it. University Department of Surgery, The Royal Infirmary, Sheffield.
B. N. CATCHPOLE.
OVER THE HILLS FROM WINDSCALE
SiR,-After reading the article by Dr. Madge (Nov. 9) is left wondering how much of it is directed towards restoring the loss of public confidence he deplores. Much has been made of lack of cooperation between the United Kingdom Atomic Energy Authority and the public-health authorities. As medical officer of the district in which the Windscale incident occurred, I can say quite firmly that this hare was not started in Cumberland. From the outset the county medical officer and myself were constantly in touch with the Atomic Energy Authority and the ministerial and regional representatives of the Ministry of Agriculture, Fisheries and Food, who were promptly on the scene. I believe I am not the first to suggest that the " grave disquiet " referred to was inversely proportional to proximity to the reactor. Locally the event was simply a sensation, and the population was spared the panic which might well follow the advocated use of warning sirens. Radioactivity in the area never approached a level at which people might have been advised to take protective measures for themselves. Data in support of this were made available at Windscale, and it is difficult to reconcile with this the implication that information was hard to one
come
by.
That information of course was basic material on which any doctor with a fair knowledge of radioactive hazards could form a reasonable judgment. One now has to ask if access to highly technical detail, which is presumably what Dr. Madge desires, is of material value to medical officers of health. Most would be loth, on the 1. Catchpole, B. N., Hackel, D. B., Simeone, F. A. Ann. 142, 372.
Surg. 1955,
basis of their own interpretation of such esoteric facts, to advise any action contrary to the readily available advice of the Ministry of Health, Medical Research Council, and Atomic Energy Authority. We are, after all, accustomed to relying on much expert advice and information. Is it going to become necessary for doctors to verify by personally conducted investigation the safety, for example, of poliomyelitis vaccine ?‘ To tangle risks to unborn generations with a reported high incidence of congenital malformants in South Westmorland is surely treading shaky ground. Till congenital malformations and their causes, where known, are made notifiable there will remain notable gaps in our statistical
knowledge. When, in time to come, the whole affair can be viewed in perspective it is more likely that the invisible vapour from the Windscale chimney will be found to have caused no ill health other than a minor degree of neurosis in the few. Meanwhile the nation daily regards with unwonted complacency the emissions from our industrial stacks, visible reminders of a staggering morbidity due simply to good old-fashioned smoke. Is not the situation Gilbertian ?g J. N. DOBSON Medical officer of health, Ennerdale Rural District Council.
" MUNCHAUSEN’S SYNDROME "
SzR,-We should like to report another so-called Munchausen’s
case
of the
syndrome.
A woman in her thirties goes under the name of Joyce A. She is about 4 ft. 8 in. tall and very obese, weighing over She gives a history of having tuberculous sixteen stone. peritonitis in 1942, for which she was drained via a laparotomy nine times in Colchester Military Hospital. She says that she is married but separated from her husband, and that she has no children. Her complaint is either of renal colic or of diffuse abdominal pain, mimicking obstruction. She is apt to request pethidine, and when this is withheld she discharges herself from hospital.
We understand that in the
past week she has gone
through four hospitals in North-West London, and we are drawing attention to her in the hope that she will be recognised in the casualty department, and not needlesslv admitted to hosnital. Whittington Hospital, London, N.19.
. B. H. BASS M. G. SELSON.
UNNECESSARY INVE STIG ATIONS
SiR -Your
peripatetic correspondent (Nov. 2) treats jocular manner what has become one of the more pressing and depressing problems of our hospital service -the ordering of unnecessary investigations. He realises that some of the pathological investigations he orders in
are
a
of
no
value, but has he considered how many useless
X-ray examinations are requestedI Does the average pneumonia need to be radiographed more often than once for diagnosis and a second time at an outpatientdepartment follow-up six -weeks laterHas it not been shown that once the duodenal cap is deformed further barium meals are of no value unless a fresh lesion is suspected as well as the chronic duodenal ulcer ?Why are barium enemas done before sigmoidoscopy ? The preparation is unpleasant for the patient and may take the nurse 1-2 hours. Is any useful purpose served by radiographs of the lumbar spine in the vast numbers of cases of occasional recurrent low-back pain ’? This list could be considerably extended. If only those X-rays which are clinically justified were ordered, there would be less. difficulty in X-ray departments, most of which nowadays are understaffed; and unnecessary radiation, which we are told may be dangerous, would be avoided. G. OSBORNE.
S. L. LAST.
Stone, Aylesbury.
l-NORADRENALINE IN MYOCARDIAL INFARCTION
SiR,-A study of the effects
the
electrocardiogram of 1--noradrenaline in hypotensive oligaemia in the dog, shortly to be published, confirms the findings of Dr. on
Littler and Dr. McKendrick (Oct. 26). The overall survival-rate of dogs made oligaemic and hypotensive is not improved by elevation of blood-pressure with l-noradrenaline, as compared with untreated control animals 1; the time of their deaths, however, is differenttreated animals often dying with heart-block or vèntricular fibrillation during actual administration of the drug. Atropine might, as Professor Maegraith (Nov. 2) suggests, lead to significant improvement in similar circumstances. Unfortunately, it has been found that, in experimental oligaemic hypotension, the gross abnormality in cardiac carbohydrate metabolism is not reversed towards normal by l-noradrenaline as it is by blood-transfusion. Furthermore, l-noradrenaline in the heparinised hypotensive dog regularly leads to extensive subendocardial haemorrhages. Knowing the great capacity of vital organs to increase their extraction of essential metabolites from the reduced volume of blood reaching them in shock states, one wonders whether patients with hypotension who are given l-noradrenaline and recover do so in spite of this t.hera.Dv a,nl not because of it. University Department of Surgery, The Royal Infirmary, Sheffield.
B. N. CATCHPOLE.
OVER THE HILLS FROM WINDSCALE
SiR,-After reading the article by Dr. Madge (Nov. 9) is left wondering how much of it is directed towards restoring the loss of public confidence he deplores. Much has been made of lack of cooperation between the United Kingdom Atomic Energy Authority and the public-health authorities. As medical officer of the district in which the Windscale incident occurred, I can say quite firmly that this hare was not started in Cumberland. From the outset the county medical officer and myself were constantly in touch with the Atomic Energy Authority and the ministerial and regional representatives of the Ministry of Agriculture, Fisheries and Food, who were promptly on the scene. I believe I am not the first to suggest that the " grave disquiet " referred to was inversely proportional to proximity to the reactor. Locally the event was simply a sensation, and the population was spared the panic which might well follow the advocated use of warning sirens. Radioactivity in the area never approached a level at which people might have been advised to take protective measures for themselves. Data in support of this were made available at Windscale, and it is difficult to reconcile with this the implication that information was hard to one
come
by.
That information of course was basic material on which any doctor with a fair knowledge of radioactive hazards could form a reasonable judgment. One now has to ask if access to highly technical detail, which is presumably what Dr. Madge desires, is of material value to medical officers of health. Most would be loth, on the 1. Catchpole, B. N., Hackel, D. B., Simeone, F. A. Ann. 142, 372.
Surg. 1955,
basis of their own interpretation of such esoteric facts, to advise any action contrary to the readily available advice of the Ministry of Health, Medical Research Council, and Atomic Energy Authority. We are, after all, accustomed to relying on much expert advice and information. Is it going to become necessary for doctors to verify by personally conducted investigation the safety, for example, of poliomyelitis vaccine ?‘ To tangle risks to unborn generations with a reported high incidence of congenital malformants in South Westmorland is surely treading shaky ground. Till congenital malformations and their causes, where known, are made notifiable there will remain notable gaps in our statistical
knowledge. When, in time to come, the whole affair can be viewed in perspective it is more likely that the invisible vapour from the Windscale chimney will be found to have caused no ill health other than a minor degree of neurosis in the few. Meanwhile the nation daily regards with unwonted complacency the emissions from our industrial stacks, visible reminders of a staggering morbidity due simply to good old-fashioned smoke. Is not the situation Gilbertian ?g J. N. DOBSON Medical officer of health, Ennerdale Rural District Council.
" MUNCHAUSEN’S SYNDROME "
SzR,-We should like to report another so-called Munchausen’s
case
of the
syndrome.
A woman in her thirties goes under the name of Joyce A. She is about 4 ft. 8 in. tall and very obese, weighing over She gives a history of having tuberculous sixteen stone. peritonitis in 1942, for which she was drained via a laparotomy nine times in Colchester Military Hospital. She says that she is married but separated from her husband, and that she has no children. Her complaint is either of renal colic or of diffuse abdominal pain, mimicking obstruction. She is apt to request pethidine, and when this is withheld she discharges herself from hospital.
We understand that in the
past week she has gone
through four hospitals in North-West London, and we are drawing attention to her in the hope that she will be recognised in the casualty department, and not needlesslv admitted to hosnital. Whittington Hospital, London, N.19.
. B. H. BASS M. G. SELSON.
UNNECESSARY INVE STIG ATIONS
SiR -Your
peripatetic correspondent (Nov. 2) treats jocular manner what has become one of the more pressing and depressing problems of our hospital service -the ordering of unnecessary investigations. He realises that some of the pathological investigations he orders in
are
a
of
no
value, but has he considered how many useless
X-ray examinations are requestedI Does the average pneumonia need to be radiographed more often than once for diagnosis and a second time at an outpatientdepartment follow-up six -weeks laterHas it not been shown that once the duodenal cap is deformed further barium meals are of no value unless a fresh lesion is suspected as well as the chronic duodenal ulcer ?Why are barium enemas done before sigmoidoscopy ? The preparation is unpleasant for the patient and may take the nurse 1-2 hours. Is any useful purpose served by radiographs of the lumbar spine in the vast numbers of cases of occasional recurrent low-back pain ’? This list could be considerably extended. If only those X-rays which are clinically justified were ordered, there would be less. difficulty in X-ray departments, most of which nowadays are understaffed; and unnecessary radiation, which we are told may be dangerous, would be avoided. G. OSBORNE.