712
Journal of the Royal Society of Medicine Volume 85 November 1992
Letters to the Editor Preference is given to letters commenting on contributions recently published in the JRSMi They should not exceed 300 words and should be typed double-spaced.
Hazards of metered dose inhalers for asthma The article about inhalation therapy for asthma by di Benedetto and Clarke (January 1992 JRSM, p 3) together with the ensuing correspondence prompts me to report an unusual hazard of metered dose inhalers that I have recently encountered. An asthmatic Australian plumber presented complaining of a sensation of a foreign body having entered his airway after using his inhaler. A bronchoscopy was performed and a plastic lug used to prevent central heating radiators from vibrating was retrieved from the right main bronchus. This had become inadvertently lodged in the mouthpiece of the inhaler which he carried in his overall pocket (Figure 1). The patient was not at all surprised since he recalled having inhaled a spider in similar circumstances previously.
Figure 1.
The cap of the inhaler must be kept firmly in position and patients also needto be aware that a small creature might creep down the side ofthe metal insert and become trapped if it is given the opportunity. PETER PRINSLEY
ENT Department Royal Free Hospital London NW3
HIV and the elderly The cases of acquired immunodeficiency in the elderly reported by McBride et aL (April 1992 JRSM, p 240) add weight to previous reports calling for vigilance for HIV infection in elderly patients1'2. However, it is not enough to demand that HIV be considered: it is equally important- that doctors are aware of widespread ageist attitudes in the medical profession which assume that the elderly are not sexually active. In our own case, a 73-year-old patient had freely volunteered information about his- homosexuality to a medical team. This information was neither recorded in the notes nor considered clinically relevant, despite a history of general physical decline1. There is now abundant evidence of heterosexual3 and homosexual4 activity among older people, and clinics for sexually transmited diseases have
reported their experiences with their older patients5. It is important that our medical training should emphasize that sexual activity is maintained in very many older patients and that attention should be paid to the sexual history in all patients, irrespective of their age. Medical students have been shown to display a positive attitude towards sexually active older patients6, and this should encourage a change in attitudes. D O'NEILL
Department of Geriatric Medicine,
Selly Oak Hospital, Birmingham B29 6JD References 1 O'Neill D, O'Neill J, Walsh JB, Coakley D. HIV seropositivity in a geriatric medical unit. Postgrad Med J 1988;64:832 2 Walsh DA. Lengthy incubation for homosexual transmission of acquired immunodeficiency syndrome in a 79 year old man. Postgrad Med J 1989;65:959 3 Busse EW, Pfeiffer E. Behaviour and adaptation in late life. Boston: Little Brown Co., -1977 4 Benn KC, Thompson NL. Social and psychological functioning of the ageing male homosexual. Br J Psychiatry 1980;137:361-70 5 Rogstad K, Bignell CJ. Sex and the elderly. BMJ
1989;29:1279 6 Damrosch SP, Fischmann SH. Medical students' attitudes towards sexually active older people. J Am Geriatr Soc 1985;33:852-5
Medical reports for compensation claims I congratulate Drs Cornes and Aitken on their valuable addition to the dearth of literature on medical reports (June 1992 JRSM, p 329-333). It may not be as easy for those compiling the medical reports to make as complete a report as one might hope. Insurance companies requiring medical reports may request the exclusion of certain information from the main report. A leading firm of solicitors appears to instruct its clients not to discuss with the examining doctor any of the circumstances surrounding their accident, their treatment and their past medical history. Inevitably the doctor compiling the medical report is acting for one side or the other- either the plaintiff or the defendant. The first duty of the insurance company acting for the defendant is to limit their shareholders' liability. The prime interest of the plaintiff- often backed by the resources of a trade union legal department - is to secure the highest award for damages. The difference in view expressed in medical reports on the same patient produced by the opposing sides may occasionally be so at variance that it is difficult to believe the medical experts are describing the same patient. The most unfortunate problem with this adversarial system I have witnessed in the High Court on several occasions when the judge has found either for or against the plaintiff in contiradiction to the overwhelming weight of expert medical opinion. The suggestion of appropriate training courses for those compiling medical reports is a good one. The obvious parties to fund and organize such courses would be the insurance companies representing the defendant and the trades unions representing the plaintiff. For one side alone to supervise such a course might prejudice credibility for the reasons mentioned above. Working together there would be benefit for all
Journal of the Royal Society of Medicine Volume 85 November 1992
concerned, particularly those poor human beings around whom the all too often protracted, firustrating and bewildering medico-legal process presently revolves. R A WARREN 152 Harley Strbet London W1N 4iH
Another look at holistic medicine I appear to have inadvertently trodden on an holistic toe (May 1992 JRSM, p 307). Ofcourse6, the late Lord Horder was quite right in his quoted teaching, but was he not referring to medicarpractice as a whole? And I fail to see the relevance of General Smuts to this question, philosopher or no. Taking issue with me regarding the unpredictability of outcome in most musculoskeletal therapies, Dr Bourne says, ... . most of the "thirty therapies inDr Paterson's trial (my italics) gave results that were not much better than the 33% expected from placebos.' While 20 years ago I did conduct a trial on well over 1000 patients, this waA for a,number of reasotis not statistically significant, which-was-why it was NOT included among the 1000or more references to the. textbook I DID quote', arid why I did -NoT quote my early trial in the previous correspondence; so how he justifies his comment on my results-- escapes me. Prediction of outcome of any therapy is more likely to prove accurate if it is, (in part) based on the independently confirmed experience ofmany observers, rather than on that of few. Of course, we welcome contrary evidence which is valid and of relevance, as this is the very stuff of scientific adv.ance, but meanwhile prediction in this field remai a 'highrisk' exercise, to be undertaken only by the intrepid. J K PATERSON
Llot, Lee Fitayes, 13640 La Roque d'Anth6ron, France
Reference 1 Burn L, Paterson JK. Musculoskeletal medicine, the spine. London: Kluwer Academic, 1990
The plague of Athens Dr J M H Hopper (June 1992 JRSM, p 350) suggests a possible solution to one of medical history's greatest puzzles. Of all the diseases proposedso far as likely causes for the Plag,ue of Athens - bubonic plague, ergotism, measles, smallpox, typhus,' dengue', scarlet fever2, meningococcal disease, influenza3, Marburg and Ebola fevers4, and toxic shock s'yndiome5 - none has been exact enough hiatch for unequivocal acceptance. Hopper has made a g6od case fTor Lassa fever, but the case for epidemic inhalation an'thrax' is as strong, if not stronger. Anthrax appears in chapter'9 of Eiodus-as the 5th and 6th plagues of Egypt, -and'in Virgil's 3rd Georgic as the murrain of NoricuiA. Inhalation anthrax has an incubation period of-between one and 5 days, presents initially as a febril-e ilfness with influenzatype symptoms, and thlen progresses rapidly to respiratory distress and circulatory collapse as secondary pneumonia, septicaemia, and seeding to meninges, spleen and bowel'occur7. Precise diagnosis of the Plague of Athens is likely to remain an elusive chimera, never to be realized, its search a self-indulgent parlour game for classical scholars and medical historians alike. It was an extraordinary event and its understanding must
surely require some stretching of our collective imagination if we are to explain it in present day terms. Itscause may have -been the product of a random mutation rendered extinct by-. its own virulence, or some special population -characteristic may -have made the Athenians vulnerable to an atypical form of a disease still with us today. JA S M- SHERRY Profesor of Family Medicine Ross KILPATRICK
and of Psychology Professor of Classics
Queen's University,
Kingston, Canada K7L 3N6
References 1 Longrigg J. The great plague of Athens. Htst Sci 1980;xviii:209-25 2 Shrewsiury JFD. The plagiue of Athens. Bull Hist Med 1950;24:10-25 3 Kobert R. Ueber die Pest des-Thucydides. Janus 1899; 4:240-51, 289-99 4 Scarrow GD. The Atheaian plague: a possible diagnosis. Anc Hist Bull 1988;2(l):4.-7 r AD, Wortlie TD, Solomon J, Ray CG, Petersen ,5 L E. The Thucydides syn4rome: a new hypothesis for the cause of the plague of Athens. N Engl J Med 1985; 313:1027-30 -6 Cbhistie AB. The clinical aspects of anthrax. Postgrad Med J 1973;,49:565-70 7 Tuazon CU. Gram-positive pneurnnias. Med Clin NAm 1980;64:343-61
The-importance of combining xylene cleervance and immunohistochemistry in the accurate taging. of colorectal- carcinoma We read Haboubi et aL's article with interest (July, 1992. JRSM, p 386) but feel that their review of the literature has been less than complete. In 1989 we described' the technique of initial dissectiofr after fixation and histological examination ofthe examined nodes; we then followed this with fat cle-arance and further dissection of the mesoc6lon. We showed that not only was there a greatdr harvest of nodes but five patients out of 58 initially reported as being of Dukes B status were in fact DWkEs, C that is 8.6% -were under reported. We have now followed these.patients for 5 years and 4 of these 5 patients have. died of carcinomatosis (report in preparation). R GRACE The Royal Hospital Wolverhampton WV2 1BT K E M ScYw Reference 1 Scott, KWM, Grace RH. Detection of lymph node setastases in colorestal carcinoma before and after fat : clearancp. Br J Surg 1989;76:1165-7
Pathogenesis of multiple sclerosis: a blood-brgu barrier disease ?Profesor Hughes in his editorial (July 1992 JRSM, p'373) states that it is d4Bcult to determine whether the earliest event in multiple sclerosis (MS) is damage to myelin or vascular inflation, dCespite acknowledging that vascular lesions occur. in the brain outside areas of demyelination and in the retina, where there is no myelin. This proves that the bloodbrain barrier disturbance in MS is primary. MRI with gadolinium DTPA has shown that disturbance can precede the demyelination by several days or weeks'. Following blood-brain barrier damage demyelination
713
Journal of the Royal Society of Medicine Volume 85 November 1992
Letters to the Editor Preference is given to letters commenting on contributions recently published in the JRSMi They should not exceed 300 words and should be typed double-spaced.
Hazards of metered dose inhalers for asthma The article about inhalation therapy for asthma by di Benedetto and Clarke (January 1992 JRSM, p 3) together with the ensuing correspondence prompts me to report an unusual hazard of metered dose inhalers that I have recently encountered. An asthmatic Australian plumber presented complaining of a sensation of a foreign body having entered his airway after using his inhaler. A bronchoscopy was performed and a plastic lug used to prevent central heating radiators from vibrating was retrieved from the right main bronchus. This had become inadvertently lodged in the mouthpiece of the inhaler which he carried in his overall pocket (Figure 1). The patient was not at all surprised since he recalled having inhaled a spider in similar circumstances previously.
Figure 1.
The cap of the inhaler must be kept firmly in position and patients also needto be aware that a small creature might creep down the side ofthe metal insert and become trapped if it is given the opportunity. PETER PRINSLEY
ENT Department Royal Free Hospital London NW3
HIV and the elderly The cases of acquired immunodeficiency in the elderly reported by McBride et aL (April 1992 JRSM, p 240) add weight to previous reports calling for vigilance for HIV infection in elderly patients1'2. However, it is not enough to demand that HIV be considered: it is equally important- that doctors are aware of widespread ageist attitudes in the medical profession which assume that the elderly are not sexually active. In our own case, a 73-year-old patient had freely volunteered information about his- homosexuality to a medical team. This information was neither recorded in the notes nor considered clinically relevant, despite a history of general physical decline1. There is now abundant evidence of heterosexual3 and homosexual4 activity among older people, and clinics for sexually transmited diseases have
reported their experiences with their older patients5. It is important that our medical training should emphasize that sexual activity is maintained in very many older patients and that attention should be paid to the sexual history in all patients, irrespective of their age. Medical students have been shown to display a positive attitude towards sexually active older patients6, and this should encourage a change in attitudes. D O'NEILL
Department of Geriatric Medicine,
Selly Oak Hospital, Birmingham B29 6JD References 1 O'Neill D, O'Neill J, Walsh JB, Coakley D. HIV seropositivity in a geriatric medical unit. Postgrad Med J 1988;64:832 2 Walsh DA. Lengthy incubation for homosexual transmission of acquired immunodeficiency syndrome in a 79 year old man. Postgrad Med J 1989;65:959 3 Busse EW, Pfeiffer E. Behaviour and adaptation in late life. Boston: Little Brown Co., -1977 4 Benn KC, Thompson NL. Social and psychological functioning of the ageing male homosexual. Br J Psychiatry 1980;137:361-70 5 Rogstad K, Bignell CJ. Sex and the elderly. BMJ
1989;29:1279 6 Damrosch SP, Fischmann SH. Medical students' attitudes towards sexually active older people. J Am Geriatr Soc 1985;33:852-5
Medical reports for compensation claims I congratulate Drs Cornes and Aitken on their valuable addition to the dearth of literature on medical reports (June 1992 JRSM, p 329-333). It may not be as easy for those compiling the medical reports to make as complete a report as one might hope. Insurance companies requiring medical reports may request the exclusion of certain information from the main report. A leading firm of solicitors appears to instruct its clients not to discuss with the examining doctor any of the circumstances surrounding their accident, their treatment and their past medical history. Inevitably the doctor compiling the medical report is acting for one side or the other- either the plaintiff or the defendant. The first duty of the insurance company acting for the defendant is to limit their shareholders' liability. The prime interest of the plaintiff- often backed by the resources of a trade union legal department - is to secure the highest award for damages. The difference in view expressed in medical reports on the same patient produced by the opposing sides may occasionally be so at variance that it is difficult to believe the medical experts are describing the same patient. The most unfortunate problem with this adversarial system I have witnessed in the High Court on several occasions when the judge has found either for or against the plaintiff in contiradiction to the overwhelming weight of expert medical opinion. The suggestion of appropriate training courses for those compiling medical reports is a good one. The obvious parties to fund and organize such courses would be the insurance companies representing the defendant and the trades unions representing the plaintiff. For one side alone to supervise such a course might prejudice credibility for the reasons mentioned above. Working together there would be benefit for all
Journal of the Royal Society of Medicine Volume 85 November 1992
concerned, particularly those poor human beings around whom the all too often protracted, firustrating and bewildering medico-legal process presently revolves. R A WARREN 152 Harley Strbet London W1N 4iH
Another look at holistic medicine I appear to have inadvertently trodden on an holistic toe (May 1992 JRSM, p 307). Ofcourse6, the late Lord Horder was quite right in his quoted teaching, but was he not referring to medicarpractice as a whole? And I fail to see the relevance of General Smuts to this question, philosopher or no. Taking issue with me regarding the unpredictability of outcome in most musculoskeletal therapies, Dr Bourne says, ... . most of the "thirty therapies inDr Paterson's trial (my italics) gave results that were not much better than the 33% expected from placebos.' While 20 years ago I did conduct a trial on well over 1000 patients, this waA for a,number of reasotis not statistically significant, which-was-why it was NOT included among the 1000or more references to the. textbook I DID quote', arid why I did -NoT quote my early trial in the previous correspondence; so how he justifies his comment on my results-- escapes me. Prediction of outcome of any therapy is more likely to prove accurate if it is, (in part) based on the independently confirmed experience ofmany observers, rather than on that of few. Of course, we welcome contrary evidence which is valid and of relevance, as this is the very stuff of scientific adv.ance, but meanwhile prediction in this field remai a 'highrisk' exercise, to be undertaken only by the intrepid. J K PATERSON
Llot, Lee Fitayes, 13640 La Roque d'Anth6ron, France
Reference 1 Burn L, Paterson JK. Musculoskeletal medicine, the spine. London: Kluwer Academic, 1990
The plague of Athens Dr J M H Hopper (June 1992 JRSM, p 350) suggests a possible solution to one of medical history's greatest puzzles. Of all the diseases proposedso far as likely causes for the Plag,ue of Athens - bubonic plague, ergotism, measles, smallpox, typhus,' dengue', scarlet fever2, meningococcal disease, influenza3, Marburg and Ebola fevers4, and toxic shock s'yndiome5 - none has been exact enough hiatch for unequivocal acceptance. Hopper has made a g6od case fTor Lassa fever, but the case for epidemic inhalation an'thrax' is as strong, if not stronger. Anthrax appears in chapter'9 of Eiodus-as the 5th and 6th plagues of Egypt, -and'in Virgil's 3rd Georgic as the murrain of NoricuiA. Inhalation anthrax has an incubation period of-between one and 5 days, presents initially as a febril-e ilfness with influenzatype symptoms, and thlen progresses rapidly to respiratory distress and circulatory collapse as secondary pneumonia, septicaemia, and seeding to meninges, spleen and bowel'occur7. Precise diagnosis of the Plague of Athens is likely to remain an elusive chimera, never to be realized, its search a self-indulgent parlour game for classical scholars and medical historians alike. It was an extraordinary event and its understanding must
surely require some stretching of our collective imagination if we are to explain it in present day terms. Itscause may have -been the product of a random mutation rendered extinct by-. its own virulence, or some special population -characteristic may -have made the Athenians vulnerable to an atypical form of a disease still with us today. JA S M- SHERRY Profesor of Family Medicine Ross KILPATRICK
and of Psychology Professor of Classics
Queen's University,
Kingston, Canada K7L 3N6
References 1 Longrigg J. The great plague of Athens. Htst Sci 1980;xviii:209-25 2 Shrewsiury JFD. The plagiue of Athens. Bull Hist Med 1950;24:10-25 3 Kobert R. Ueber die Pest des-Thucydides. Janus 1899; 4:240-51, 289-99 4 Scarrow GD. The Atheaian plague: a possible diagnosis. Anc Hist Bull 1988;2(l):4.-7 r AD, Wortlie TD, Solomon J, Ray CG, Petersen ,5 L E. The Thucydides syn4rome: a new hypothesis for the cause of the plague of Athens. N Engl J Med 1985; 313:1027-30 -6 Cbhistie AB. The clinical aspects of anthrax. Postgrad Med J 1973;,49:565-70 7 Tuazon CU. Gram-positive pneurnnias. Med Clin NAm 1980;64:343-61
The-importance of combining xylene cleervance and immunohistochemistry in the accurate taging. of colorectal- carcinoma We read Haboubi et aL's article with interest (July, 1992. JRSM, p 386) but feel that their review of the literature has been less than complete. In 1989 we described' the technique of initial dissectiofr after fixation and histological examination ofthe examined nodes; we then followed this with fat cle-arance and further dissection of the mesoc6lon. We showed that not only was there a greatdr harvest of nodes but five patients out of 58 initially reported as being of Dukes B status were in fact DWkEs, C that is 8.6% -were under reported. We have now followed these.patients for 5 years and 4 of these 5 patients have. died of carcinomatosis (report in preparation). R GRACE The Royal Hospital Wolverhampton WV2 1BT K E M ScYw Reference 1 Scott, KWM, Grace RH. Detection of lymph node setastases in colorestal carcinoma before and after fat : clearancp. Br J Surg 1989;76:1165-7
Pathogenesis of multiple sclerosis: a blood-brgu barrier disease ?Profesor Hughes in his editorial (July 1992 JRSM, p'373) states that it is d4Bcult to determine whether the earliest event in multiple sclerosis (MS) is damage to myelin or vascular inflation, dCespite acknowledging that vascular lesions occur. in the brain outside areas of demyelination and in the retina, where there is no myelin. This proves that the bloodbrain barrier disturbance in MS is primary. MRI with gadolinium DTPA has shown that disturbance can precede the demyelination by several days or weeks'. Following blood-brain barrier damage demyelination
713
