BRITISH MEDICAL JOURNAL
1157
30 APRIL 1977
should not now be extended to all independent schools. A rapid survey of those members of the Medical Officers of Schools Association who are responsible for girls in independent schools indicates new grounds for concern that adequate rubella immunity will not be achieved in women of childbearing age. In the present climate of alarm about all immunisation procedures there is evidence that many more parents in social classes I and II are withholding consent for rubella vaccination despite informed advice from school doctors. It is misleading to suggest that the low uptake in girls of professional families is because they are "more likely to attend independent schools and therefore to be excluded from the vaccination programme" and unjust to the many medical officers of independent schools who maintain the highest standards of preventive medicine. T W HOSKINS Honorary Secretary, Medical Officers of Schools Association Christ's Hospital, Horsham, Sussex
SIR,-In a recent article about rubella vaccination of schoolgirls (19 March, p 760) we are told that in 1969 prior to the introduction of this programme some 80-90% of women of childbearing age had a naturally acquired immunity. It was noted that significantly fewer girls from professional families were vaccinated and suggested that this could be due to lack of immunisation programmes in independent schools. I wonder if another explanation could be that professional families are more likely to appreciate that natural immunity is to be preferred and that a girl's chance of acquiring this will be seriously reduced by vaccination. They may wonder whether an injection at the age of 12 will continue to give adequate protection after 20 or more years. Perhaps the girl may decide to wait until she is contemplating having a child before being vaccinated if she is not immune. The authors state that if the present programme is to be successful almost 100% of girls must be vaccinated. It is unrealistic to hope for this in 12-year-old girls. This programme will certainly lower the proportion of childbearing women who are naturally immune to rubella. It will produce a group of women who will have dubious immunity in their thirties. I believe its long-term result will be to increase the incidence of fetal abnormalities due to congenital rubella. It should be replaced by a programmne of selective vaccination of susceptible women before they start childbearing. The great majority of women manage to plan their first pregnancy responsibly. It is disgraceful to prejudice their chances of bearing a normal child for the sake of those few who cannot. J F WOOD Enfield, Middlesex
Stillbirth, grief, and medical education SIR,-The Rev Alan Swinton's letter (9 April, p 971) is beguiling in its good sense, its humanity, and its appreciation of his colleagues; but it just won't do. He is right to protect patients from medical people who may believe they always know what is best, and the
quotation from Lewis's paper' could possibly be misread that way, being rather condensed as well as psychologically sophisticated. Lewis, jolly, and Morris have collaborated for some years to develop an ambience in which problems like stillbirth can be thought about and Lewis's paper discussed some useful approaches and reflections from which colleagues elsewhere can learn. In considering whether or how to encourage parents to handle a stillborn baby and attend the funeral it is essential to grasp that here is a syndrome in which the compulsive, even overwhelming, aversion of professional attention is an integral part. This is not a moral proposition for existential philosophy but a clinical sign to be faced and recognised and studied, like ketosis on the breath of a diabetic. The syndromes around stillbirth include the feature of extraordinary medical resistance to publishing anything about it. Lewis and I are preparing a separate paper on this curious phenomenon and have accumulated quite a dossier on it. Until my own paper,2 stumbling upon the subject of reactions to stillbirth, I was not able to find a single article on it nor any mention of the topic in any index in the English language, even though more must presumably exist since the problem should be obvious to a blind man. Even now we have still found only one earlier reference, in an American nursing journal.3 It followed logically and inexorably for the paper to be rejected by the Lancet and BMJ with the entrancing explanation that enough had already been published on the subject although some better work was, allegedly, on the way. Yet, courage, convention, and imagination are not at all the issues since, if I may mention it, the BMJ has published a number of thornier papers4-6 in which I have had a hand and even gave skilled editorial help with them generally. The next thing to grasp is that the danger lies not in the grief and distress; the danger is in bypassing it, thereby promoting a variety of severe psychological complications. Moreover, the danger is not merely to the mother but also to her husband, her surviving children, and, worst of all, to the next baby. To be the surviving twin of a stillbirth can sometimes be a special catastrophe. Whereas grief is relatively understandable and obvious, these other dangers are complex; their management and prevention are very hard. To approach this difficult territory in bland optimism, trusting to a bit of native humanity and ordinary good sense, is just silly. We teach doctors about the theory of bacteriology and train them in the use of aseptic techniques; we do not merely rely on their good upbringing and hope they will wash behind their ears. Syndromes and remedies in medicine require initial description with delineation of detail, and some of this has begun7'-l regarding stillbirth reactions. I am sorry to find a priest giving support to the amateurism in psychosocial matters that usually passes for medical education, with its breathtaking illiteracy in the behavioural sciences and the catastrophic pharmaceutical prescribing that is its counterpart. The clergy are often more attuned than doctors, but an attitude of Christian charity to medical blind spots, double vision, and despair" is becoming as disastrous as "forgiving" dirty hands in the operating theatre would be. It seems'2 1" we now have well over 100 000 emergency admissions each year due to overdoses of drugs, mostly prescribed by doctors. The
current increase will fill all emergency beds by 1984. Is it still seriously to be proposed that we can rely on the general good sense of doctors? Let's at least get our heads down and look at a few problems. Stillbirth is one. Thank heaven for the lay press in giving us a bit of a lead'4 15 and thanks, however belatedly, for the recent response in the chief medical journals. Psychiatrists, of course, have yet to catch up. I think it quite interesting that certain paediatricians have been quickest off the mark. Perhaps they have the sharpest sense of the children who failed to live. S BOURNE Tavistock Clinic, London NW3
Lewis, E, Lancet, 1976, 2, 619. 2Bourne, S, Journal of the Royal College of General Practitioners, 1968, 16, 103. 3Newton, N, and Newton, M, Journal of the American Medical Association, 1962, 181, 206. Bourne, S, and Bruggen, P, British Medical Journal, 1975, 1, 162. Bruggen, P, and Bourne, S, British Medical Journal, 1976, 1, 536. Bruggen, P, and Bourne, S, British Medical Journal, 1977, 1, 462. 7Lewis, E, in Proceedings of the Third International Congress of Psychosomatic Medicine in Obstetrics and Gynecology, ed Norman Morris, p 323. Basel, Karger, 1971. Lewis, E, and Page, A, British Journal of Medical Psychology, in press. Jolly, H, Proceedings of the Royal Society of Medicine, 1976, 69, 835. Morris, D, Proceedings of the Royal Society of Medicine, 1976, 69, 837. Bourne, S, and Lewis, E, Journal of the Royal College of General Practitioners, 1977, 27, 37. 12 Jones, D I R, British Medical Journal, 1977, 1, 28. 13 Ghodse, A H, British Medical Journal, 1977, 1, 805. 14Jolly, H, The Times, 3 December, 1975. " Mooney, B, Guardian, 8 January 1976.
Localised airway obstruction SIR,-Your leading article (12 March, p 669) ends with the statement: "Whenever the possibility [of localised airway obstruction] is suspected flow volume curves should give the answer." This conclusion appears to be largely based on the work of Harrison,' who reported 16 patients with upper airway obstruction and claimed that respiratory function tests, in particular the flow volume loop, play an essential part in the recognition and management of this problem. In fact, the cause of the obstruction in most of Harrison's patients was fairly obvious (tracheal stricture after tracheostomy and lesions of the larynx, pharynx, and tongue). Only in one case, a patient with a benign tracheal tumour, was there not a cogent reason for suspecting localised airway obstruction, and even in that particular case it would have been difficult to ignore the diagnostic implication of the expectoration of a lump of pink material followed by haemoptysis.
The use of flow volume loops to investigate these patients, although of considerable academic interest, can have contributed very little in practical terms to their diagnosis and management, and it is unfortunate that you should have placed so much emphasis on the value of a procedure which requires fairly sophisticated equipment unlikely to be available outside major teaching centres. Leaving aside lesions of the larynx and pharynx, which seldom present serious diagnostic problems, the important causes of localised airway obstruction are tracheal stricture following tracheostomy, benign lesions of the trachea-for example, cylindroma-and malignant tumours involving the tracheal bifurcation. All these lesions may present with symptoms resembling chronic asthma, they
1158
BRITISH MEDICAL JOURNAL
are all amenable to appropriate treatment, and in every case the diagnosis can be made rapidly and reliably by endoscopic examination. Endoscopy is mentioned in the article, but almost casually, and the reader is left with the impression that physiological investigations, particularly the flow volume curve, are of much greater importance. The article would, in my view, have served a more useful purpose if it had included a short account of the indications for endoscopic examination in the type of case in which localised obstructive lesions of the trachea and main bronchi are apt to be mistaken for asthma. Stridor is, of course, a characteristic feature in such cases (it was present in all but one of Harrison's 16 patients), but physicians are often slow to distinguish it from wheeze and perhaps need reminding that it is accentuated by coughing. This is indeed always the case with inspiratory stridor, which is by far the most common type. It will seldom be missed if the patient takes a few deep inspirations with the mouth open, and is then asked to cough. Laryngoscopy and bronchoscopy should be carried out immediately on every patient with stridor. Although advanced diffuse airways obstruction
occasionally produces
apparently
typical
stridor, the number of such patients who may be unnecessarily subjected to endoscopic examination will be extremely small. Finally, it must be emphasised that tracheal stricture is a not uncommon complication of tracheostomy, particularly in patients who require artificial ventilation via a cuffed tube for several weeks, and this possibility should always be considered when dyspnoea and "wheeze" develop for the first time within six months of removal of the tracheostomy tube. There are still a few situations in medical practice where a direct diagnostic approach has much to commend it, and this, pace the respiratory physiologists, is surely one of them.
30 APRIL 1977
insects and sexual contact, factors more difficult to control. What are the risks of repeated injections of human immunoglobulin ? American practice is to give injections at six-monthly intervals, although the passive immunity gained after each injection is probably only of a high order for three months. Has any attempt been made to investigate the large numbers of individuals injected repeatedly over many years in pursua,nce of this policy? F W BEST
is simple. Charge a "hotel-fee" daily for all in hospital and increase the number of highly remunerative private beds, these funds to be used locally where they are earned to finance more consultant staff and more convalescent beds. Also encourage local voluntary subscription, which would quickly provide a sterile-air operating tent in the existing theatre. Meanwhile invite those so long and patiently waiting sufferers to come elsewhere.
Imperial Chemical Industries Ltd,
Boylestone, Derbyshire
London
SWI
***Official guidance is scanty simply because hard data are just not available. On theoretical grounds, however, it is certainly likely that technical personnel employed in field work in underdeveloped areas are in greater need of protection than executives who do not stray far from their modern hotels. The precautions which can be taken are alluded to in Dr Best's letter. With regard to the risks of repeated injections of human immunoglobulin, this seems to be small, although reactions have been described. The report of the MRC Working Party on Hypogammaglobulinaemial describes one death in a 27-year-old man with hypogammaglobulinaemia who had been receiving weekly injections of immunoglobulin for four years and some occasional generalised but nonfatal reactions in other patients treated in a similar way. It is unlikely, however, that repeated injections to prevent viral hepatitis (which would have to be given every four months to provide complete protection) would give rise to anything moi,e serious than local pain.-ED, BMJ. Medical Research Council, Hypogammaglobulinaemia in the United Kingdom. Special Report Series No 310. London, HMSO, 1971.
R LUNT
***Mr Lunt sent a copy of this letter to Professor J A Scott, regional medical officer to the Trent RHA, whose reply is printed below.-ED, BM7. SIR,-So long as the Trent RHA is underresourced it will have to select particular services for improvement and inevitably some parts of the population it serves will have to wait for the developments which no one doubts are necessary. A great deal of capital development has already been undertaken in Lincolnshire, and while most of this has been at Boston, Lincoln itself has benefited through the construction of new geriatric and younger disabled units at St George's Hospital and a new general operating theatre at the County Hospital. New geriatric wards have also been built at Gainsborough and an upgraded accident department is under construction at the Lincoln County Hospital. It is very easy to criticise the inadequacies of the National Health Service, but fundamentally they are not of its making. J A SCOTT Trent Regional Health Authority,
Sheffield
IAN W B GRANT Orthopaedic services in Lincoln
Respiratory Diseases Unit, Northern General Hospital, Edinburgh Harrison, B D W, Quarterly 1976, 45, 625.
J7ournal
of Medicine,
Tourist hepatitis SIR,-With reference to your leading article (22 January, p 189), as one with some responsibility for the health of a large number of people travelling to and living in overseas territories I have found it difficult to formulate a rational policy for prophylaxis of hepatitis. Official guidance is scanty. During 1976 the Department of Health and Social Security advocated gammaglobulin injections for those travelling to Ecuador and Iran. Now the advice offered is more general. Taiwan, Indonesia, and "South America" (Dr F Morgan, 5 March, p 646) are territories with an allegedly high level of prevalence. It would seem that a great part of the assessment of risk is anecdotal (vide Dr Morgan's letter) and furthermore no attempt is made to relate risk to mode of living. The executive living in a hotel is less vulnerable than his technical colleague investigating the efficacy of a pesticide in an underdeveloped rural area. Elementary precautions, like eating only cooked food while it remains hot and avoiding all dubious sources of water, may help prevent infection with hepatitis A virus. Hepatitis B appears to be capable of transmission by biting
SIR,-A recent six-week locumship spent in Lincoln as consultant orthopaedic surgeona capacity in which I served Derby for 25 years-filled me with the gravest concern for both the folk of Lincoln and its surroundings, for which the Trent Regional Health Authority is responsible, and for my two colleagues who are flogging themselves to death in the effort to meet the clinical demands. That there should be a 4-5-year waiting list for such a cost-effective and pain-relieving operation as the installation of an artificial hip is atrocious; that it requires to be done in an unprotected theatre shared with other cases of an infected nature is wrong-both for this and many other orthopaedic cases involving large implants. A shortage of "second-stage" or convalescent beds is clogging the top-grade surgical wards and a waiting period of some 8-10 weeks for outpatient consultation fills in a sorry picture which might well sustain litigation by the folk of Lincoln against the regional health authority, who are clearly not doing their duty. However, the action would simply call forth the defence of lack of funds and be as destructively wasteful for the country as the "strikes" have been. Nevertheless, this state of affairs does draw painful attention to the even more fearful shortage of funds suffered by our armed services. The solution for Lincoln, and for the many similarly deprived areas throughout the NHS,
Responsibility and management in pathology laboratories
SIR,-It has been brought to the attention of the Wolverhampton Consultants' Committee that evidence has been submitted to the Royal Commission on the National Health Service by the Institute of Medical Laboratory Sciences in which the opinion was expressed that the managerial head of the medical laboratory service in each health district should be a medical laboratory scientist (technician) accountable to the district management team for all medical laboratory investigations performed in the district. This opinion was unacceptable to the committee, which considered that the only appropriate person to be the head of a laboratory is a consultant
pathologist. This matter has recently been ventilated in your journal and I am instructed by the committee to say that we have written to the presidents of the royal colleges recommending that recognition for postgraduate training for their examinations should be withdrawn from all establishments where laboratory services are not headed by a consultant pathologist or in certain cases by a scientific officer of equivalent standing. J A MACDOUGALL Chairman, Consultants' Committee, Wolverhampton Area Health Authority
New Cross Hospital, Wolverhampton
1157
30 APRIL 1977
should not now be extended to all independent schools. A rapid survey of those members of the Medical Officers of Schools Association who are responsible for girls in independent schools indicates new grounds for concern that adequate rubella immunity will not be achieved in women of childbearing age. In the present climate of alarm about all immunisation procedures there is evidence that many more parents in social classes I and II are withholding consent for rubella vaccination despite informed advice from school doctors. It is misleading to suggest that the low uptake in girls of professional families is because they are "more likely to attend independent schools and therefore to be excluded from the vaccination programme" and unjust to the many medical officers of independent schools who maintain the highest standards of preventive medicine. T W HOSKINS Honorary Secretary, Medical Officers of Schools Association Christ's Hospital, Horsham, Sussex
SIR,-In a recent article about rubella vaccination of schoolgirls (19 March, p 760) we are told that in 1969 prior to the introduction of this programme some 80-90% of women of childbearing age had a naturally acquired immunity. It was noted that significantly fewer girls from professional families were vaccinated and suggested that this could be due to lack of immunisation programmes in independent schools. I wonder if another explanation could be that professional families are more likely to appreciate that natural immunity is to be preferred and that a girl's chance of acquiring this will be seriously reduced by vaccination. They may wonder whether an injection at the age of 12 will continue to give adequate protection after 20 or more years. Perhaps the girl may decide to wait until she is contemplating having a child before being vaccinated if she is not immune. The authors state that if the present programme is to be successful almost 100% of girls must be vaccinated. It is unrealistic to hope for this in 12-year-old girls. This programme will certainly lower the proportion of childbearing women who are naturally immune to rubella. It will produce a group of women who will have dubious immunity in their thirties. I believe its long-term result will be to increase the incidence of fetal abnormalities due to congenital rubella. It should be replaced by a programmne of selective vaccination of susceptible women before they start childbearing. The great majority of women manage to plan their first pregnancy responsibly. It is disgraceful to prejudice their chances of bearing a normal child for the sake of those few who cannot. J F WOOD Enfield, Middlesex
Stillbirth, grief, and medical education SIR,-The Rev Alan Swinton's letter (9 April, p 971) is beguiling in its good sense, its humanity, and its appreciation of his colleagues; but it just won't do. He is right to protect patients from medical people who may believe they always know what is best, and the
quotation from Lewis's paper' could possibly be misread that way, being rather condensed as well as psychologically sophisticated. Lewis, jolly, and Morris have collaborated for some years to develop an ambience in which problems like stillbirth can be thought about and Lewis's paper discussed some useful approaches and reflections from which colleagues elsewhere can learn. In considering whether or how to encourage parents to handle a stillborn baby and attend the funeral it is essential to grasp that here is a syndrome in which the compulsive, even overwhelming, aversion of professional attention is an integral part. This is not a moral proposition for existential philosophy but a clinical sign to be faced and recognised and studied, like ketosis on the breath of a diabetic. The syndromes around stillbirth include the feature of extraordinary medical resistance to publishing anything about it. Lewis and I are preparing a separate paper on this curious phenomenon and have accumulated quite a dossier on it. Until my own paper,2 stumbling upon the subject of reactions to stillbirth, I was not able to find a single article on it nor any mention of the topic in any index in the English language, even though more must presumably exist since the problem should be obvious to a blind man. Even now we have still found only one earlier reference, in an American nursing journal.3 It followed logically and inexorably for the paper to be rejected by the Lancet and BMJ with the entrancing explanation that enough had already been published on the subject although some better work was, allegedly, on the way. Yet, courage, convention, and imagination are not at all the issues since, if I may mention it, the BMJ has published a number of thornier papers4-6 in which I have had a hand and even gave skilled editorial help with them generally. The next thing to grasp is that the danger lies not in the grief and distress; the danger is in bypassing it, thereby promoting a variety of severe psychological complications. Moreover, the danger is not merely to the mother but also to her husband, her surviving children, and, worst of all, to the next baby. To be the surviving twin of a stillbirth can sometimes be a special catastrophe. Whereas grief is relatively understandable and obvious, these other dangers are complex; their management and prevention are very hard. To approach this difficult territory in bland optimism, trusting to a bit of native humanity and ordinary good sense, is just silly. We teach doctors about the theory of bacteriology and train them in the use of aseptic techniques; we do not merely rely on their good upbringing and hope they will wash behind their ears. Syndromes and remedies in medicine require initial description with delineation of detail, and some of this has begun7'-l regarding stillbirth reactions. I am sorry to find a priest giving support to the amateurism in psychosocial matters that usually passes for medical education, with its breathtaking illiteracy in the behavioural sciences and the catastrophic pharmaceutical prescribing that is its counterpart. The clergy are often more attuned than doctors, but an attitude of Christian charity to medical blind spots, double vision, and despair" is becoming as disastrous as "forgiving" dirty hands in the operating theatre would be. It seems'2 1" we now have well over 100 000 emergency admissions each year due to overdoses of drugs, mostly prescribed by doctors. The
current increase will fill all emergency beds by 1984. Is it still seriously to be proposed that we can rely on the general good sense of doctors? Let's at least get our heads down and look at a few problems. Stillbirth is one. Thank heaven for the lay press in giving us a bit of a lead'4 15 and thanks, however belatedly, for the recent response in the chief medical journals. Psychiatrists, of course, have yet to catch up. I think it quite interesting that certain paediatricians have been quickest off the mark. Perhaps they have the sharpest sense of the children who failed to live. S BOURNE Tavistock Clinic, London NW3
Lewis, E, Lancet, 1976, 2, 619. 2Bourne, S, Journal of the Royal College of General Practitioners, 1968, 16, 103. 3Newton, N, and Newton, M, Journal of the American Medical Association, 1962, 181, 206. Bourne, S, and Bruggen, P, British Medical Journal, 1975, 1, 162. Bruggen, P, and Bourne, S, British Medical Journal, 1976, 1, 536. Bruggen, P, and Bourne, S, British Medical Journal, 1977, 1, 462. 7Lewis, E, in Proceedings of the Third International Congress of Psychosomatic Medicine in Obstetrics and Gynecology, ed Norman Morris, p 323. Basel, Karger, 1971. Lewis, E, and Page, A, British Journal of Medical Psychology, in press. Jolly, H, Proceedings of the Royal Society of Medicine, 1976, 69, 835. Morris, D, Proceedings of the Royal Society of Medicine, 1976, 69, 837. Bourne, S, and Lewis, E, Journal of the Royal College of General Practitioners, 1977, 27, 37. 12 Jones, D I R, British Medical Journal, 1977, 1, 28. 13 Ghodse, A H, British Medical Journal, 1977, 1, 805. 14Jolly, H, The Times, 3 December, 1975. " Mooney, B, Guardian, 8 January 1976.
Localised airway obstruction SIR,-Your leading article (12 March, p 669) ends with the statement: "Whenever the possibility [of localised airway obstruction] is suspected flow volume curves should give the answer." This conclusion appears to be largely based on the work of Harrison,' who reported 16 patients with upper airway obstruction and claimed that respiratory function tests, in particular the flow volume loop, play an essential part in the recognition and management of this problem. In fact, the cause of the obstruction in most of Harrison's patients was fairly obvious (tracheal stricture after tracheostomy and lesions of the larynx, pharynx, and tongue). Only in one case, a patient with a benign tracheal tumour, was there not a cogent reason for suspecting localised airway obstruction, and even in that particular case it would have been difficult to ignore the diagnostic implication of the expectoration of a lump of pink material followed by haemoptysis.
The use of flow volume loops to investigate these patients, although of considerable academic interest, can have contributed very little in practical terms to their diagnosis and management, and it is unfortunate that you should have placed so much emphasis on the value of a procedure which requires fairly sophisticated equipment unlikely to be available outside major teaching centres. Leaving aside lesions of the larynx and pharynx, which seldom present serious diagnostic problems, the important causes of localised airway obstruction are tracheal stricture following tracheostomy, benign lesions of the trachea-for example, cylindroma-and malignant tumours involving the tracheal bifurcation. All these lesions may present with symptoms resembling chronic asthma, they
1158
BRITISH MEDICAL JOURNAL
are all amenable to appropriate treatment, and in every case the diagnosis can be made rapidly and reliably by endoscopic examination. Endoscopy is mentioned in the article, but almost casually, and the reader is left with the impression that physiological investigations, particularly the flow volume curve, are of much greater importance. The article would, in my view, have served a more useful purpose if it had included a short account of the indications for endoscopic examination in the type of case in which localised obstructive lesions of the trachea and main bronchi are apt to be mistaken for asthma. Stridor is, of course, a characteristic feature in such cases (it was present in all but one of Harrison's 16 patients), but physicians are often slow to distinguish it from wheeze and perhaps need reminding that it is accentuated by coughing. This is indeed always the case with inspiratory stridor, which is by far the most common type. It will seldom be missed if the patient takes a few deep inspirations with the mouth open, and is then asked to cough. Laryngoscopy and bronchoscopy should be carried out immediately on every patient with stridor. Although advanced diffuse airways obstruction
occasionally produces
apparently
typical
stridor, the number of such patients who may be unnecessarily subjected to endoscopic examination will be extremely small. Finally, it must be emphasised that tracheal stricture is a not uncommon complication of tracheostomy, particularly in patients who require artificial ventilation via a cuffed tube for several weeks, and this possibility should always be considered when dyspnoea and "wheeze" develop for the first time within six months of removal of the tracheostomy tube. There are still a few situations in medical practice where a direct diagnostic approach has much to commend it, and this, pace the respiratory physiologists, is surely one of them.
30 APRIL 1977
insects and sexual contact, factors more difficult to control. What are the risks of repeated injections of human immunoglobulin ? American practice is to give injections at six-monthly intervals, although the passive immunity gained after each injection is probably only of a high order for three months. Has any attempt been made to investigate the large numbers of individuals injected repeatedly over many years in pursua,nce of this policy? F W BEST
is simple. Charge a "hotel-fee" daily for all in hospital and increase the number of highly remunerative private beds, these funds to be used locally where they are earned to finance more consultant staff and more convalescent beds. Also encourage local voluntary subscription, which would quickly provide a sterile-air operating tent in the existing theatre. Meanwhile invite those so long and patiently waiting sufferers to come elsewhere.
Imperial Chemical Industries Ltd,
Boylestone, Derbyshire
London
SWI
***Official guidance is scanty simply because hard data are just not available. On theoretical grounds, however, it is certainly likely that technical personnel employed in field work in underdeveloped areas are in greater need of protection than executives who do not stray far from their modern hotels. The precautions which can be taken are alluded to in Dr Best's letter. With regard to the risks of repeated injections of human immunoglobulin, this seems to be small, although reactions have been described. The report of the MRC Working Party on Hypogammaglobulinaemial describes one death in a 27-year-old man with hypogammaglobulinaemia who had been receiving weekly injections of immunoglobulin for four years and some occasional generalised but nonfatal reactions in other patients treated in a similar way. It is unlikely, however, that repeated injections to prevent viral hepatitis (which would have to be given every four months to provide complete protection) would give rise to anything moi,e serious than local pain.-ED, BMJ. Medical Research Council, Hypogammaglobulinaemia in the United Kingdom. Special Report Series No 310. London, HMSO, 1971.
R LUNT
***Mr Lunt sent a copy of this letter to Professor J A Scott, regional medical officer to the Trent RHA, whose reply is printed below.-ED, BM7. SIR,-So long as the Trent RHA is underresourced it will have to select particular services for improvement and inevitably some parts of the population it serves will have to wait for the developments which no one doubts are necessary. A great deal of capital development has already been undertaken in Lincolnshire, and while most of this has been at Boston, Lincoln itself has benefited through the construction of new geriatric and younger disabled units at St George's Hospital and a new general operating theatre at the County Hospital. New geriatric wards have also been built at Gainsborough and an upgraded accident department is under construction at the Lincoln County Hospital. It is very easy to criticise the inadequacies of the National Health Service, but fundamentally they are not of its making. J A SCOTT Trent Regional Health Authority,
Sheffield
IAN W B GRANT Orthopaedic services in Lincoln
Respiratory Diseases Unit, Northern General Hospital, Edinburgh Harrison, B D W, Quarterly 1976, 45, 625.
J7ournal
of Medicine,
Tourist hepatitis SIR,-With reference to your leading article (22 January, p 189), as one with some responsibility for the health of a large number of people travelling to and living in overseas territories I have found it difficult to formulate a rational policy for prophylaxis of hepatitis. Official guidance is scanty. During 1976 the Department of Health and Social Security advocated gammaglobulin injections for those travelling to Ecuador and Iran. Now the advice offered is more general. Taiwan, Indonesia, and "South America" (Dr F Morgan, 5 March, p 646) are territories with an allegedly high level of prevalence. It would seem that a great part of the assessment of risk is anecdotal (vide Dr Morgan's letter) and furthermore no attempt is made to relate risk to mode of living. The executive living in a hotel is less vulnerable than his technical colleague investigating the efficacy of a pesticide in an underdeveloped rural area. Elementary precautions, like eating only cooked food while it remains hot and avoiding all dubious sources of water, may help prevent infection with hepatitis A virus. Hepatitis B appears to be capable of transmission by biting
SIR,-A recent six-week locumship spent in Lincoln as consultant orthopaedic surgeona capacity in which I served Derby for 25 years-filled me with the gravest concern for both the folk of Lincoln and its surroundings, for which the Trent Regional Health Authority is responsible, and for my two colleagues who are flogging themselves to death in the effort to meet the clinical demands. That there should be a 4-5-year waiting list for such a cost-effective and pain-relieving operation as the installation of an artificial hip is atrocious; that it requires to be done in an unprotected theatre shared with other cases of an infected nature is wrong-both for this and many other orthopaedic cases involving large implants. A shortage of "second-stage" or convalescent beds is clogging the top-grade surgical wards and a waiting period of some 8-10 weeks for outpatient consultation fills in a sorry picture which might well sustain litigation by the folk of Lincoln against the regional health authority, who are clearly not doing their duty. However, the action would simply call forth the defence of lack of funds and be as destructively wasteful for the country as the "strikes" have been. Nevertheless, this state of affairs does draw painful attention to the even more fearful shortage of funds suffered by our armed services. The solution for Lincoln, and for the many similarly deprived areas throughout the NHS,
Responsibility and management in pathology laboratories
SIR,-It has been brought to the attention of the Wolverhampton Consultants' Committee that evidence has been submitted to the Royal Commission on the National Health Service by the Institute of Medical Laboratory Sciences in which the opinion was expressed that the managerial head of the medical laboratory service in each health district should be a medical laboratory scientist (technician) accountable to the district management team for all medical laboratory investigations performed in the district. This opinion was unacceptable to the committee, which considered that the only appropriate person to be the head of a laboratory is a consultant
pathologist. This matter has recently been ventilated in your journal and I am instructed by the committee to say that we have written to the presidents of the royal colleges recommending that recognition for postgraduate training for their examinations should be withdrawn from all establishments where laboratory services are not headed by a consultant pathologist or in certain cases by a scientific officer of equivalent standing. J A MACDOUGALL Chairman, Consultants' Committee, Wolverhampton Area Health Authority
New Cross Hospital, Wolverhampton
