the proper management of toxemia are hydralazine and magnesium sulfate. Our experience in managing all hyper¬ tensive pregnancies over the last six years with this philosophy has resulted in a perinatal mortality equal to that of our general population.3 We would strongly discourage other modes of therapy, which are not compatible with the proper respect for, as Keith rightly states, "the overwhelming danger to the fetus." .
.
.
Richard P. Perkins, MD
University
of Colorado
Medical Center
Denver 1. Perkins RP: Diazoxide in treatment of severe pre-
eclampsia and hypertensive encephalopathy. Am J Obstet Gynecol 126:296, 1976. 2. Lindheimer MD, Katz AI: Sodium and diuretics in pregnancy. N Engl J Med 288:891, 1973. 3. Perkins RP: The conservative management of toxemia. Obstet Gynecol 49:498, 1977.
Old Picture Needed To the Editor.\p=m-\An ancestor of mine, named Confucius, said many years ago that one picture is worth 10,000 words. General Patton, my commanding general in World War II when I was a P-38 reconnaissance pilot, said that one look is worth a hundred reports. This all came to mind recently when my wife's Uncle Rufus had a suspicious shadow on his chest x-ray film. Not disregarding the clinical data that Uncle Rufus had smoked for 50 years and had a severe cough, the diagnosis of this chest mass was still in doubt. The chest roentgenogram was taken by our local radiologist, who sent a report that it was normal. When I saw the film before I received the report, I thought the patient had a lung tumor. I showed the film to another radiologist, and he said that the patient had a mass in the lung. Another radiologist said that he read the film as normal. A fourth radiologist interpreted the film as showing a lung tumor. The score is now two radiologists interpreting the film as showing a lung tumor and two reading the film as normal. My inter¬ pretation does not count. "So," you say, "does he have any old films? Let's see what they look like." "Yes," I answered, "he was in this hospital ten years ago, and films were taken then and reported normal." Surprise or no surprise, all x-ray films are thrown out after three years. Uncle Rufus' films were taken out seven years ago and turned into silver bullion, worth 8 cents. The films were
long gone. Why do
we throw out chest x-ray films? "We don't have the space," answered everyone. Everyone means the record
room, which needs space for microfilm machines. It includes the social service department, which needs space for psychological reports on parents of patients with enuresis. The special service department needs room to display hanging baskets and athletic trophies. The board room needs space to display portraits of board members, past and present. We must have room for recreational therapy, said the head of the department of, you guessed it, recreational therapy. As I was escorted through the gigantic hospital and shown the large library, the voluminous medical rec¬ ords, the whirlpools, the gymnasium, the spacious desks of the public rela¬ tions department, the beautiful cafe¬ teria, the ornate chapel, and the marble halls of the lobby, I quietly thought that Uncle Rufus could cer¬ tainly benefit from one look at his chest x-ray film of ten years ago to compare it with the film taken last
week. We would gladly trade for one (x-ray) picture.
10,000 words J. MarDock, MD Dallas
Enuresis To the Editor. \p=m-\Iwas recently challenged in my medical practice to devise a treatment for a 16-year-old boy with
intractable case of nocturnal enuresis. For as long as the patient could remember, he had always been a bed wetter. He had gone through the standard regimens of limiting his fluids before bedtime, the use of drugs such as imipramine hydrochloride (Tofranil), and being awakened by a bell when his voided urine completed an electric circuit, all of these were unsuccessful. The boy was becoming, in the meanwhile, increasingly concerned about his lack of bladder control. He was living in a boys' home where his peers were shaming him and his classmates would not associate with him if he had not showered before leaving for school. Girls his own age wanted nothing to do with him. In the office he was obviously embarrassed and very anxious that he would never have a "dry" night. To allay his anxiety, I gave him a condom catheter and drainage bag and ex¬ plained that he would now neither wet the bed nor smell badly in the morning. He then went home and experienced his first dry night, and he began to have others. He was gradually weaned from the bag and at last visit reported his bed-wetting to be cured. I offer this method for boys as a an
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/05/2015
practical way of breaking the bed-wet¬ ting cycle, which is primarily the fear
of humiliation from parents and friends for continuing to wet the bed and its sequela. Sanford J. Brown, MD McCornack Center for the Healing Arts
Mendocino, Calif
Malpractice To the Editor.\p=m-\The commentary by James M. Vaccarino, JD, (238:861, 1977) should be memorized by every practicing physician and should be enshrined on a plaque next to or slightly above the Hippocratic oath. As a plaintiff's attorney, I sit every day across the desk from people voicing all of the complaints set forth by Dr Vaccarino. Most are eliminated. It just happens that the complaints in a meritorious case and the complaint in a nonmeritorious case are identical to begin with. It is only by looking at a valid, well-kept record that the two types of cases can be separated and many nonmeritorious suits avoided. Walter C. Ward, MD, JD Miami
To the Editor.\p=m-\Vaccarino's article contains a sensible and well reasoned approach to the problem of malpractice. It should be mandatory reading for all physicians. Thomas C. Hullverson Missouri Association of Trial Attorneys Jefferson
City,
Mo
Occupational Hazard Rate.\p=m-\ In the Aug 29 issue of The Journal (238:955-959, 1977), the ORIGINAL
CONTRIBUTION "Occupational Hazards for Operating Room-Based Physicians: Analysis of Data From the United States and the United Kingdom" contained an error in Table 2. In the last column ("Congenital Abnormalities/Live-Born Children, %") and row 11 ("Control male physicians, United States"), the number 0.9\m=+-\0.4should be corrected to read 3.9 \m=+-\0.4.
Carlos II.\p=m-\ In the Sept 12 issue of The Journal (238:1169-1174, 1977), Fig 1 of the SPECIAL COMMUNICATION "A Medical History of the Spanish Habsburgs: As Traced in Portraits" incorrectly showed Carlos III instead of Carlos II as the last ruler of five
generations of Spanish Habsburgs.
.
.
Richard P. Perkins, MD
University
of Colorado
Medical Center
Denver 1. Perkins RP: Diazoxide in treatment of severe pre-
eclampsia and hypertensive encephalopathy. Am J Obstet Gynecol 126:296, 1976. 2. Lindheimer MD, Katz AI: Sodium and diuretics in pregnancy. N Engl J Med 288:891, 1973. 3. Perkins RP: The conservative management of toxemia. Obstet Gynecol 49:498, 1977.
Old Picture Needed To the Editor.\p=m-\An ancestor of mine, named Confucius, said many years ago that one picture is worth 10,000 words. General Patton, my commanding general in World War II when I was a P-38 reconnaissance pilot, said that one look is worth a hundred reports. This all came to mind recently when my wife's Uncle Rufus had a suspicious shadow on his chest x-ray film. Not disregarding the clinical data that Uncle Rufus had smoked for 50 years and had a severe cough, the diagnosis of this chest mass was still in doubt. The chest roentgenogram was taken by our local radiologist, who sent a report that it was normal. When I saw the film before I received the report, I thought the patient had a lung tumor. I showed the film to another radiologist, and he said that the patient had a mass in the lung. Another radiologist said that he read the film as normal. A fourth radiologist interpreted the film as showing a lung tumor. The score is now two radiologists interpreting the film as showing a lung tumor and two reading the film as normal. My inter¬ pretation does not count. "So," you say, "does he have any old films? Let's see what they look like." "Yes," I answered, "he was in this hospital ten years ago, and films were taken then and reported normal." Surprise or no surprise, all x-ray films are thrown out after three years. Uncle Rufus' films were taken out seven years ago and turned into silver bullion, worth 8 cents. The films were
long gone. Why do
we throw out chest x-ray films? "We don't have the space," answered everyone. Everyone means the record
room, which needs space for microfilm machines. It includes the social service department, which needs space for psychological reports on parents of patients with enuresis. The special service department needs room to display hanging baskets and athletic trophies. The board room needs space to display portraits of board members, past and present. We must have room for recreational therapy, said the head of the department of, you guessed it, recreational therapy. As I was escorted through the gigantic hospital and shown the large library, the voluminous medical rec¬ ords, the whirlpools, the gymnasium, the spacious desks of the public rela¬ tions department, the beautiful cafe¬ teria, the ornate chapel, and the marble halls of the lobby, I quietly thought that Uncle Rufus could cer¬ tainly benefit from one look at his chest x-ray film of ten years ago to compare it with the film taken last
week. We would gladly trade for one (x-ray) picture.
10,000 words J. MarDock, MD Dallas
Enuresis To the Editor. \p=m-\Iwas recently challenged in my medical practice to devise a treatment for a 16-year-old boy with
intractable case of nocturnal enuresis. For as long as the patient could remember, he had always been a bed wetter. He had gone through the standard regimens of limiting his fluids before bedtime, the use of drugs such as imipramine hydrochloride (Tofranil), and being awakened by a bell when his voided urine completed an electric circuit, all of these were unsuccessful. The boy was becoming, in the meanwhile, increasingly concerned about his lack of bladder control. He was living in a boys' home where his peers were shaming him and his classmates would not associate with him if he had not showered before leaving for school. Girls his own age wanted nothing to do with him. In the office he was obviously embarrassed and very anxious that he would never have a "dry" night. To allay his anxiety, I gave him a condom catheter and drainage bag and ex¬ plained that he would now neither wet the bed nor smell badly in the morning. He then went home and experienced his first dry night, and he began to have others. He was gradually weaned from the bag and at last visit reported his bed-wetting to be cured. I offer this method for boys as a an
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/05/2015
practical way of breaking the bed-wet¬ ting cycle, which is primarily the fear
of humiliation from parents and friends for continuing to wet the bed and its sequela. Sanford J. Brown, MD McCornack Center for the Healing Arts
Mendocino, Calif
Malpractice To the Editor.\p=m-\The commentary by James M. Vaccarino, JD, (238:861, 1977) should be memorized by every practicing physician and should be enshrined on a plaque next to or slightly above the Hippocratic oath. As a plaintiff's attorney, I sit every day across the desk from people voicing all of the complaints set forth by Dr Vaccarino. Most are eliminated. It just happens that the complaints in a meritorious case and the complaint in a nonmeritorious case are identical to begin with. It is only by looking at a valid, well-kept record that the two types of cases can be separated and many nonmeritorious suits avoided. Walter C. Ward, MD, JD Miami
To the Editor.\p=m-\Vaccarino's article contains a sensible and well reasoned approach to the problem of malpractice. It should be mandatory reading for all physicians. Thomas C. Hullverson Missouri Association of Trial Attorneys Jefferson
City,
Mo
Occupational Hazard Rate.\p=m-\ In the Aug 29 issue of The Journal (238:955-959, 1977), the ORIGINAL
CONTRIBUTION "Occupational Hazards for Operating Room-Based Physicians: Analysis of Data From the United States and the United Kingdom" contained an error in Table 2. In the last column ("Congenital Abnormalities/Live-Born Children, %") and row 11 ("Control male physicians, United States"), the number 0.9\m=+-\0.4should be corrected to read 3.9 \m=+-\0.4.
Carlos II.\p=m-\ In the Sept 12 issue of The Journal (238:1169-1174, 1977), Fig 1 of the SPECIAL COMMUNICATION "A Medical History of the Spanish Habsburgs: As Traced in Portraits" incorrectly showed Carlos III instead of Carlos II as the last ruler of five
generations of Spanish Habsburgs.
