THE LANC ET, OCT O BE R
25, 1975
819
BETA-BLOCKADE WITHDRAWAL SIR,-Your editorial (Sept. 27, p. 592) commenting on the work of Miller and his colleagues I emphasises the serious dangers of sudden withdrawal of beta-blockers in patients with ischremic heart-disease and concludes that these drugs should not be withdrawn abruptly. Although there are a number of possible explanation s, the most likely occurrence is sympathetic overactivity following release of beta-blockade with a resultant increase in heart -rate, cardiac contracility, and myocardial oxygen consumption; furthermore, the increase in sympathetic activity may lead to [ifethreatening ectopic arrhythmias. In support of thi s I would like to draw attention to the occurrence of a withdrawal syndrome in three patients following the sudden cessation of propranolol which was being admini stered in high doses (2000 mg, 1440 mg, and 960 mg daily) for the treatment of hypertension. 2 The syndrome, which was in man y respect s indistinguishable from florid thyrotoxicosis, was characterised by distress of such severity as to make the patient seek hospital attention-tenseness, anxiety, palpitations, and excessive perspiration. On examination the patients were anxious, restle ss, and worried, and there was a tachycardia and tremor of the outstretched hands which were warm and moist. These symptoms occurred within a week of stopping propranolol and were relieved within 24 hours by as little as a quarter of the original dose. These manifestations can only have been caused by sympathetic overactivity, and if this were to occur-even in a less dramatic form because of lower dosage--in patient s with ischremic heart-disease the effects on a diseased myocardium might well be catastrophic. I strongly endorse your plea for gradual withdrawal of all beta-adrenergic blocking drugs, and I am tempted to suggest that gradual withdrawal of drugs should be a general pharmacological principle. 18 Ely Place, Dublin 2, Eire.
EOIN
T.
O'BRIEN
PATHOLOGICAL SPECIMENS IN THE POST SJR,-The Post Office welcomes the concern expre ssed by Dr Simpson and Professor Zuckerman (Oct. 11, p. 70 1) about poor packaging of pathological specimens sent through the post. They echo misgivings which have been voiced to the Department of Health and Social Security and other bodies about the casual way some medical, veterinary, and other scientific workers despatch potentially dangerous sub stances. To avoid risk to the people who handle the se packages, the British Post Office has stringent requirements-and there are equally strict international regulations--for the posting and packaging of such materials. Perhaps I may remind your readers of what they are. First, pathological specimens may not normally be sent by post, unless they are sent for examination or analysis to a recognised medical authority or laboratory, or to a med ical or dental practitioner or veterinary surgeon. T hey ma y only be sent by first-class letter post and the y have to be packaged and labelled in a prescribed manner. Any packet found in the parcel post, or found in the letter post not properly packed and labelled, will be destroyed with all wrappings and enclosures. Persons who send dangerous liquids or substances by post without complying with the requirements for packaging and labelling are liable to prosecution. Requirements for packaging pathological specimens are : The liquid or substance must be enclosed in a container which is hermetically sealed or otherwise securely closed. The container must be placedin a strong wooden or metal case (any I. Miller. R. R., Olsen, H. G., Amsterdam. E. A., Ma son, D. T. Ne ws En g l. ] .Med. 1975,293, 4t6. . 2. O'Brien, E. T ., MacK inn on, J. Br. H eart]. 1972,34,1042.
other case must be approved by the Post Office before use) in such a way that it cannot shift about. The container must be surrounded by enough absorbent materialsawdust or Callan wool-Io prevent any leakage from the package if the container became damaged. The outside of the package must be marked "Fra gile With Care" and "Pathological Specimen" . Any organisation in the United Kingdom intending to send pathological specimens through the post should first send samples of the containers they propose to use to Postal Headquarters (PMkl ), St Martin's Ie Grand, London ECIA IHQ, to confirm that they are acceptable. Organisations in other countries should consult their own postal authority. Finally, if laboratories do receive packages of this kind which have been damaged in transit, we ask them to try to preserve them as far as they are able in as near as possible the condition in which the y arrive, and inform their local Head Postmaster. This will help the Post Office in its efforts to stop dangerous materials being sent by post in a way which could harm others. Postal Head qu art er s, St j\1a rtin's Ie G rand, London EC IA IHQ.
J. C. JEFFR EY Principal Medical Officer (Posts)
FAMILY-PLANNING SERVICES SJR,-With reference to your editorial of Oct. 11 (p.694 ), we should like to point out that the Government had no need "to win, by a touch of gold .. . the cooperation of . . . tho se hospital consultants who are concerned with contraception and sterilisation" . Contraception and sterilisation are alread y widely available in the Health Service . In the Grampian Health Board Area in 1974, 1500 sterilisations were performed mostly on social grounds, and it will cost the Board at least £40 000 to remunerate doctors for performing a similar number next year. There is no question of extra work being involved, and for the profession's negotiators to pretend that there is, is dishonest . We believe the situation 10 be similar in many other parts of Britain. This scheme is, therefore, a catastrophic waste of money which the Health Ser vice can ill afford. In addition, this scheme will have man y damaging effects: firstly, women ma y not receive the objective counselling the y have the right to expect in matters of family planning if some of the alternatives which a doctor may suggest involve a large personal fee for him; secondly, item-of-service payments of this magnitude will certainly prove divisive within the medical profession with ill-feeling and dissension about the administration of the scheme between units and within units; also, man y more arduous, time-consuming, or highly skilled aspects of our work will remain unrewarded and may suffer as a result; there will be a trend towards performance of sterilisation (and reversal), operations in clinical situations where inadequate facilities or expertise are available; the teaching of medical students and nurses that fertility control is an integral part of medical care will be made difficult , if contraception and sterilisation are adm inistratively considered matters for which special payments must be made. It seems especially inappropriate that this ridiculous scheme has been negotiated at the very time when the Health Service has been reorganised to tr y to pro vide integrated med ical care for the public . We are absolutel y opposed to any item-of-service payment for family-plann ing services, and hope that the scheme will be reconsidered. Aberdeen Maternity Hospital . Corn hill Road. Aberdeen. AB9 2ZA.
MARI ON H. HAL L ALLANTEMPLETON
SIR,-Your annotation gives a fa ir summary of the new item-of-service extras negotiated for hospital doctors. In common with several of my colleagues in this department I
820
THE LANCET, OCTOBER
shared a conviction that these payments should be refused on the grounds that they would have to be made out of district funds to the detriment of other services and that they would represent payment for work which was already being done. I have now been assured that part of the £600 million allocated to the Health Service took into account the extra cost to the N.H.S. of former F.P.A. work and that these payments were to be made for new work done in addition to that already carried out on present operating-lists. Remunerable operations will therefore be done either on new operating-lists or after normal lists have been completed. This being so the objections no longer stand but I doubt if "silencing by gold" will prove to be a very accurate description of the deal. Department of Anesthetics, Southampton General Hospital, Southampton.
P.
J. HORSEY
SIR,-I cannot see how the present free contraceptive service can be fully effective and reach all patients unless the cooperation of doctors is achieved: extending family-planning clinics, as you suggested is not enough. The Government has discovered it takes "a touch of gold" to interest doctors in this scheme: rather than consider this as a "money-spinner", it must surely be the best-ever investment for a crowded, ailing country such as Britain. My regret is that it was not introduced years ago, when thousands of unwanted children and their ensuing problems or terminations might have been prevented. What a tragedy if discontent at the Government's means prevent the end being achieved. 42, Dreghorn Loan, Edinburgh EHI3 ODE.
PENELOPE A. WATSON
SI UNITS SIR,-I read with morbid delight the article by Dr Clark and Dr Sheldon on SI units (Oct. 11, p. 700). What skill the D.H.S.S. displays in firing off diversionary volleys at a time when all our attention should be focused on the grave and very real problems that beset the N.H.S. The D. H. S. S. has carefully ordered a change which actually has some benefits and which was certain to rouse our conservative doctors. They have thus been able to sit back and enjoy watching furious clinicians battering the beleaguered biochemists. Churchill would have been proud of the physicians of Sussex standing in their last ditch on Brighton beach resisting to the end the invasion by the dread SI units. Sadly their ditch has already-to use their analogy-been flattened by the steam roller; the mole has burrowed to the very heart of the system. I would also ask our clinical colleagues to be charitable to the humble biochemist. Considered rationally the SI unit is at worst harmless, although a waste of money, and at best an advance in communication. Scientists have already invaded many of the bastions of clinical medicine and it is perhaps even sensible to talk to them in the same language. Think, too, of the joy that SI has brought to the clinical biochemist. Up and down the country committees of biochemists have sat for weeks, if not months, in total ecstasy compiling conversion tables, wall charts, booklets, new tables of normal values, and making myriads of new rules. A new spotlight has, if briefly, focused on the clinical chemist as posters round the hospitals announce the coming of SI, like a new Messiah. What joy. In hospitals where the change has already taken place there have been few problems. There are even advantages like the greater ease in calculating plasma osmolality. Think of the chaos that could ensue if we now stick halfway with half our hospitals working in the new and half in the old units. The fait has already been accompli. Perhaps it would be wise if we followed the advice of the disciple of Confucius who said: "When rape is inevitable, lie back and enjoy it". By and large the coming of the SI unit is a major non-event.
25,1975
There are many more serious problems to worry about. Laboratory services will contract and clinical care deteriorate unless more funds become available immediately. Let us avoid the smoke screens, ignore the minutiee of SI, forget private practice, and be patient over our contracts. The profession must unite to ensure that adequate finance is available for the real business of medicine--that is, providing the best possible care for our patients. University Department of Chemical Pathology, General Hospital, Southampton S094XY.
K. G. M. M. ALBERTI
SIR,-There is only one thing to be done about the directive from the Department of Health concerning SI units, and that is to ignore it. If clinicians and pathologists refuse to use this system, a deal of trouble and much paper will be saved. It would help, Sir, if you and other editors of medical journals would also refuse to use SI, and say so forthwith. 57 Egerton Crescent, London SW3 2ED.
NORMAN A. PUNT
MENTAL HEALTH ACT 1959 SIR,-For some time it has been apparent that the Mental Health Act 1959 is not working as well as it might be, and now two more cases have given rise to further doubt. The first case concerned a married woman who killed two of her children and was detained under Section 60 of the Mental Health Act 1959. As there was no restriction order, the responsible medical officer was entitled to discharge her when he saw fit. The second case concerned a patient from Broadmoor who was allowed out for the day with a social worker. The social worker and patient went to London, separated, and arranged to meet again at a specific time and place; not surprisingly, the patient failed to turn up. However, the Department of Health issued an assurance that the patient was perfectly harmless; this being so, one wonders why he was detained at Broadmoor. Where the safety of the public is involved, I feel the decision to discharge a patient from hospital should not be that of the responsible medical officer alone. Such a decision should be taken by an independent body, such as a mental health tribunal. The most simple way to deal with this problem would be to abolish Section 60 and to apply Section 65 in all cases. This would mean extra work for the mental health tribunals, but would go far towards alleviating public anxiety. Claypenny Hospital, Easingwold, Yorks. Y06 3PR.
J. NEWCOMBE
PILES: THEIR NATURE AND MANAGEMENT SIR,-The point of view of Mr Thomson concerning the modern management of piles (Sept. 13, p. 494) was already enunciated in the 12th century by Moses Maimonides in his Treatise on Hemorrhoids. I This work was written for a nobleman, as Maimonides describes in the introduction-probably a member of the Sultan's family. There are seven chapters dealing with normal digestion, foods harmful to patients with hsernorrhoids, beneficial foods, and general and local therapeutic measures such as sitz baths, oils, and fumigations. Maimonides disapproves of blood-letting or surgery for harnorrhoids except in very severe cases. His whole approach to the problem seems to bespeak a modern medical trend. Maimonides states: "Because this illness [i.e., hremorrhoids] recurred many times, the patient considered having them extirpated in order to uproot this malady from its source so that it not return again. I informed him of 1. Rosner, F., Muntoer, S. The Medical Writings of Moses Maimonidcs. Vol. Ill. Treatise on Hemorrhoids & Responsa. Philadelphia, 1969.
25, 1975
819
BETA-BLOCKADE WITHDRAWAL SIR,-Your editorial (Sept. 27, p. 592) commenting on the work of Miller and his colleagues I emphasises the serious dangers of sudden withdrawal of beta-blockers in patients with ischremic heart-disease and concludes that these drugs should not be withdrawn abruptly. Although there are a number of possible explanation s, the most likely occurrence is sympathetic overactivity following release of beta-blockade with a resultant increase in heart -rate, cardiac contracility, and myocardial oxygen consumption; furthermore, the increase in sympathetic activity may lead to [ifethreatening ectopic arrhythmias. In support of thi s I would like to draw attention to the occurrence of a withdrawal syndrome in three patients following the sudden cessation of propranolol which was being admini stered in high doses (2000 mg, 1440 mg, and 960 mg daily) for the treatment of hypertension. 2 The syndrome, which was in man y respect s indistinguishable from florid thyrotoxicosis, was characterised by distress of such severity as to make the patient seek hospital attention-tenseness, anxiety, palpitations, and excessive perspiration. On examination the patients were anxious, restle ss, and worried, and there was a tachycardia and tremor of the outstretched hands which were warm and moist. These symptoms occurred within a week of stopping propranolol and were relieved within 24 hours by as little as a quarter of the original dose. These manifestations can only have been caused by sympathetic overactivity, and if this were to occur-even in a less dramatic form because of lower dosage--in patient s with ischremic heart-disease the effects on a diseased myocardium might well be catastrophic. I strongly endorse your plea for gradual withdrawal of all beta-adrenergic blocking drugs, and I am tempted to suggest that gradual withdrawal of drugs should be a general pharmacological principle. 18 Ely Place, Dublin 2, Eire.
EOIN
T.
O'BRIEN
PATHOLOGICAL SPECIMENS IN THE POST SJR,-The Post Office welcomes the concern expre ssed by Dr Simpson and Professor Zuckerman (Oct. 11, p. 70 1) about poor packaging of pathological specimens sent through the post. They echo misgivings which have been voiced to the Department of Health and Social Security and other bodies about the casual way some medical, veterinary, and other scientific workers despatch potentially dangerous sub stances. To avoid risk to the people who handle the se packages, the British Post Office has stringent requirements-and there are equally strict international regulations--for the posting and packaging of such materials. Perhaps I may remind your readers of what they are. First, pathological specimens may not normally be sent by post, unless they are sent for examination or analysis to a recognised medical authority or laboratory, or to a med ical or dental practitioner or veterinary surgeon. T hey ma y only be sent by first-class letter post and the y have to be packaged and labelled in a prescribed manner. Any packet found in the parcel post, or found in the letter post not properly packed and labelled, will be destroyed with all wrappings and enclosures. Persons who send dangerous liquids or substances by post without complying with the requirements for packaging and labelling are liable to prosecution. Requirements for packaging pathological specimens are : The liquid or substance must be enclosed in a container which is hermetically sealed or otherwise securely closed. The container must be placedin a strong wooden or metal case (any I. Miller. R. R., Olsen, H. G., Amsterdam. E. A., Ma son, D. T. Ne ws En g l. ] .Med. 1975,293, 4t6. . 2. O'Brien, E. T ., MacK inn on, J. Br. H eart]. 1972,34,1042.
other case must be approved by the Post Office before use) in such a way that it cannot shift about. The container must be surrounded by enough absorbent materialsawdust or Callan wool-Io prevent any leakage from the package if the container became damaged. The outside of the package must be marked "Fra gile With Care" and "Pathological Specimen" . Any organisation in the United Kingdom intending to send pathological specimens through the post should first send samples of the containers they propose to use to Postal Headquarters (PMkl ), St Martin's Ie Grand, London ECIA IHQ, to confirm that they are acceptable. Organisations in other countries should consult their own postal authority. Finally, if laboratories do receive packages of this kind which have been damaged in transit, we ask them to try to preserve them as far as they are able in as near as possible the condition in which the y arrive, and inform their local Head Postmaster. This will help the Post Office in its efforts to stop dangerous materials being sent by post in a way which could harm others. Postal Head qu art er s, St j\1a rtin's Ie G rand, London EC IA IHQ.
J. C. JEFFR EY Principal Medical Officer (Posts)
FAMILY-PLANNING SERVICES SJR,-With reference to your editorial of Oct. 11 (p.694 ), we should like to point out that the Government had no need "to win, by a touch of gold .. . the cooperation of . . . tho se hospital consultants who are concerned with contraception and sterilisation" . Contraception and sterilisation are alread y widely available in the Health Service . In the Grampian Health Board Area in 1974, 1500 sterilisations were performed mostly on social grounds, and it will cost the Board at least £40 000 to remunerate doctors for performing a similar number next year. There is no question of extra work being involved, and for the profession's negotiators to pretend that there is, is dishonest . We believe the situation 10 be similar in many other parts of Britain. This scheme is, therefore, a catastrophic waste of money which the Health Ser vice can ill afford. In addition, this scheme will have man y damaging effects: firstly, women ma y not receive the objective counselling the y have the right to expect in matters of family planning if some of the alternatives which a doctor may suggest involve a large personal fee for him; secondly, item-of-service payments of this magnitude will certainly prove divisive within the medical profession with ill-feeling and dissension about the administration of the scheme between units and within units; also, man y more arduous, time-consuming, or highly skilled aspects of our work will remain unrewarded and may suffer as a result; there will be a trend towards performance of sterilisation (and reversal), operations in clinical situations where inadequate facilities or expertise are available; the teaching of medical students and nurses that fertility control is an integral part of medical care will be made difficult , if contraception and sterilisation are adm inistratively considered matters for which special payments must be made. It seems especially inappropriate that this ridiculous scheme has been negotiated at the very time when the Health Service has been reorganised to tr y to pro vide integrated med ical care for the public . We are absolutel y opposed to any item-of-service payment for family-plann ing services, and hope that the scheme will be reconsidered. Aberdeen Maternity Hospital . Corn hill Road. Aberdeen. AB9 2ZA.
MARI ON H. HAL L ALLANTEMPLETON
SIR,-Your annotation gives a fa ir summary of the new item-of-service extras negotiated for hospital doctors. In common with several of my colleagues in this department I
820
THE LANCET, OCTOBER
shared a conviction that these payments should be refused on the grounds that they would have to be made out of district funds to the detriment of other services and that they would represent payment for work which was already being done. I have now been assured that part of the £600 million allocated to the Health Service took into account the extra cost to the N.H.S. of former F.P.A. work and that these payments were to be made for new work done in addition to that already carried out on present operating-lists. Remunerable operations will therefore be done either on new operating-lists or after normal lists have been completed. This being so the objections no longer stand but I doubt if "silencing by gold" will prove to be a very accurate description of the deal. Department of Anesthetics, Southampton General Hospital, Southampton.
P.
J. HORSEY
SIR,-I cannot see how the present free contraceptive service can be fully effective and reach all patients unless the cooperation of doctors is achieved: extending family-planning clinics, as you suggested is not enough. The Government has discovered it takes "a touch of gold" to interest doctors in this scheme: rather than consider this as a "money-spinner", it must surely be the best-ever investment for a crowded, ailing country such as Britain. My regret is that it was not introduced years ago, when thousands of unwanted children and their ensuing problems or terminations might have been prevented. What a tragedy if discontent at the Government's means prevent the end being achieved. 42, Dreghorn Loan, Edinburgh EHI3 ODE.
PENELOPE A. WATSON
SI UNITS SIR,-I read with morbid delight the article by Dr Clark and Dr Sheldon on SI units (Oct. 11, p. 700). What skill the D.H.S.S. displays in firing off diversionary volleys at a time when all our attention should be focused on the grave and very real problems that beset the N.H.S. The D. H. S. S. has carefully ordered a change which actually has some benefits and which was certain to rouse our conservative doctors. They have thus been able to sit back and enjoy watching furious clinicians battering the beleaguered biochemists. Churchill would have been proud of the physicians of Sussex standing in their last ditch on Brighton beach resisting to the end the invasion by the dread SI units. Sadly their ditch has already-to use their analogy-been flattened by the steam roller; the mole has burrowed to the very heart of the system. I would also ask our clinical colleagues to be charitable to the humble biochemist. Considered rationally the SI unit is at worst harmless, although a waste of money, and at best an advance in communication. Scientists have already invaded many of the bastions of clinical medicine and it is perhaps even sensible to talk to them in the same language. Think, too, of the joy that SI has brought to the clinical biochemist. Up and down the country committees of biochemists have sat for weeks, if not months, in total ecstasy compiling conversion tables, wall charts, booklets, new tables of normal values, and making myriads of new rules. A new spotlight has, if briefly, focused on the clinical chemist as posters round the hospitals announce the coming of SI, like a new Messiah. What joy. In hospitals where the change has already taken place there have been few problems. There are even advantages like the greater ease in calculating plasma osmolality. Think of the chaos that could ensue if we now stick halfway with half our hospitals working in the new and half in the old units. The fait has already been accompli. Perhaps it would be wise if we followed the advice of the disciple of Confucius who said: "When rape is inevitable, lie back and enjoy it". By and large the coming of the SI unit is a major non-event.
25,1975
There are many more serious problems to worry about. Laboratory services will contract and clinical care deteriorate unless more funds become available immediately. Let us avoid the smoke screens, ignore the minutiee of SI, forget private practice, and be patient over our contracts. The profession must unite to ensure that adequate finance is available for the real business of medicine--that is, providing the best possible care for our patients. University Department of Chemical Pathology, General Hospital, Southampton S094XY.
K. G. M. M. ALBERTI
SIR,-There is only one thing to be done about the directive from the Department of Health concerning SI units, and that is to ignore it. If clinicians and pathologists refuse to use this system, a deal of trouble and much paper will be saved. It would help, Sir, if you and other editors of medical journals would also refuse to use SI, and say so forthwith. 57 Egerton Crescent, London SW3 2ED.
NORMAN A. PUNT
MENTAL HEALTH ACT 1959 SIR,-For some time it has been apparent that the Mental Health Act 1959 is not working as well as it might be, and now two more cases have given rise to further doubt. The first case concerned a married woman who killed two of her children and was detained under Section 60 of the Mental Health Act 1959. As there was no restriction order, the responsible medical officer was entitled to discharge her when he saw fit. The second case concerned a patient from Broadmoor who was allowed out for the day with a social worker. The social worker and patient went to London, separated, and arranged to meet again at a specific time and place; not surprisingly, the patient failed to turn up. However, the Department of Health issued an assurance that the patient was perfectly harmless; this being so, one wonders why he was detained at Broadmoor. Where the safety of the public is involved, I feel the decision to discharge a patient from hospital should not be that of the responsible medical officer alone. Such a decision should be taken by an independent body, such as a mental health tribunal. The most simple way to deal with this problem would be to abolish Section 60 and to apply Section 65 in all cases. This would mean extra work for the mental health tribunals, but would go far towards alleviating public anxiety. Claypenny Hospital, Easingwold, Yorks. Y06 3PR.
J. NEWCOMBE
PILES: THEIR NATURE AND MANAGEMENT SIR,-The point of view of Mr Thomson concerning the modern management of piles (Sept. 13, p. 494) was already enunciated in the 12th century by Moses Maimonides in his Treatise on Hemorrhoids. I This work was written for a nobleman, as Maimonides describes in the introduction-probably a member of the Sultan's family. There are seven chapters dealing with normal digestion, foods harmful to patients with hsernorrhoids, beneficial foods, and general and local therapeutic measures such as sitz baths, oils, and fumigations. Maimonides disapproves of blood-letting or surgery for harnorrhoids except in very severe cases. His whole approach to the problem seems to bespeak a modern medical trend. Maimonides states: "Because this illness [i.e., hremorrhoids] recurred many times, the patient considered having them extirpated in order to uproot this malady from its source so that it not return again. I informed him of 1. Rosner, F., Muntoer, S. The Medical Writings of Moses Maimonidcs. Vol. Ill. Treatise on Hemorrhoids & Responsa. Philadelphia, 1969.
