Sep 5, 1981 - I have found this system-exemplified in the Polyglot. Medical Questionnaire'-of great value over many years. Otherwise good interpreters may.
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Management of alcohol withdrawal symptoms SIR,-Having read the letter by M A Gillman and F J Lichtigfeld (4 July, p 64) on the management of alcohol withdrawal symptoms, in which they report on the good results of continuous nitrous oxide and oxygen therapy, I would be interested to know what proportions of the gas mixtures were used, for how long treatment was maintained, and if they encountered any difficulty with bone marrow suppression-the latter being a problem when these gas mixtures were used for the long-term ventilation of patients in intensive care units. This would be relevant as their patients may well be already suffering some degree of immune deficiency owing to their chronic addiction and poor nutrition. R D WALTON
follow-up of such cases, so that they will not be missed. The hydrocephalus which follows subarachnoid space obstruction by blood or fibrin is not of the normal-pressure type as stated, but is high-pressure communicating hydrocephalus. This fact can be confirmed by measuring lumbar cerebrospinal fluid pressure, which is frequently recorded above 20 cm H2O in these cases. They are therefore to be regarded as quite distinct from the normalpressure syndrome of Adams et al,3 in which the precise aetiology remains obscure. This point is well illustrated by the authors themselves, who present a computed tomography scan showing a good example of anterior periventricular oedema due to high-pressure hydrocephalus following haemorrhage. These comments are intended as a constructive supplement to a lesson which was well taught but deserved better homework.
Department of Experimental and Clinical Pharmacology, University of the Witwatersrand Medical School, Johannesburg, South Africa
'Langa H. Relative analgesia in dental practice. 2nd ed. Philadelphia: WB Saunders, 1976. 2 Anonymous. Lancet 1978;ii:613-4.
HUGH COAKHAM Department of Neurosurgery, Frenchay Hospital, Bristol BS16 ILE ' Vassilouthis J, Richardson AE. J Neurosurg 1979;51: 341-51. 2Drake CG. Stroke 1981;12:273-83. 3Adams RD, Fisher CM, Hakim S, Ojemann RG, Sweet WH. N EnglJ Med 1965;273:117-26.
Cephaloridine encephalopathy SIR,-One point not mentioned by Dr R Taylor and his colleagues (8 August, p 409) is that the dose of cephaloridine infused into the patient they described was much greater than that recommended by the manufacturers. I was partially responsible for a similar but not so severe event in a younger patient.' In 95 out of 96 cases of acute renal failure associated with cephaloridine administration either the dose was too large or the antibiotic had been given with frusemide, which potentiates the nephrotoxicity, or both.2 Correctly used, cephaloridine is a valuable antibiotic. ROGER GABRIEL Department of Renal Medicine, St Mary's Hospital, London W2 lNY 1 Gabriel R, Foord RD, Joekes AM. Br Med J 1970; iv :283-4. 2Foord RD. J Antimicrob chemnotherap 1975;1, suppl 3: 119-32.
***We sent this letter to the authors, who ** *We sent this letter to the authors, who reply below.-ED, BM7. reply below.-ED,
BM_'.
Hydrocephalus after subarachnoid haemorrhage
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Communicating with non-Englishspeaking patients
SIR,-Mr Pash Bal's article (1 August, p 368) on communicating with non-English-speaking patients contained much useful information. He did not refer to the excellent system of words or questions in two or more languages, printed in lists, with a common number referring to the word or question. I have found this system-exemplified in the Polyglot Medical Questionnaire'-of great value over many years. Otherwise good interpreters may have difficulties with medical words, and this system can help to find the correct word quickly. The Red Cross also publishes useful language cards based on this system for simple communication between patient and doctor or doctor and patient. A WARD GARDNER Esso Medical Centre,
Fawley, Southampton S04 lTX
Harrogate District Hospital, Harrogate HG2 7SX
SIR,-At no point in our brief description of our technique (4 July, p 64), did we indicate that the nitrous oxide-oxygen mixtures were administered on a continuous basis. The technique used was that advocated by Langa,' who has treated many hundreds of dental patients without untoward side effects. Usually, one 20-minute period of treatment with analgesic concentrations of nitrous oxide was sufficient to obtain a therapeutic effect. In a minority of cases this 20-minute treatment was repeated not more than twice more within the next 48 hours. All cases were given 20 minutes of 100% oxygen prior to and also after the nitrous oxide. Previous experience has indicated that the degree of exposure to nitrous oxide used in our studies does not result in bone marrow depression; in fact, the point has been made that "nitrous oxide given for up to 48 hours is unlikely to be harmful."2 A full description of this work has been accepted for publication in the South African Medical Journal. M A GILLMAN F J LICHTIGFELD
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SIR,-We are grateful to Dr Gabriel for his comments. The major point that we wished to make was that overdosage with cephaloridine may induce an encephalopathy. In the case we reported the dose administered (6 grams daily) exceeded that recommended for adults during the 48 hour period after surgery (4 g daily). Moreover, the drug was given as a continuous intravenous infusion, not as intermittent injections as advised by the manufacturers. The case serves to re-emphasise the importance of observing the manufacturer's advice on
SIR,-The majority of patients who have suffered subarachnoid haemorrhage develop a temporary degree of hydrocephalus revealed by computed tomography. In 7-10% of cases this progresses to become neurologically manifest, often after two weeks,1 2 and it can then be rapidly reversed by cerebrospinal fluid diversion. This complication is watched for by neurosurgeons as a matter of routine. The "Lesson of the week" by Ms Sarah dosage and mode of administration. Robinson and Dr G Holdstock (15 August, Roy TAYLOR p 479) serves to emphasise the fact that the M K WARD duty lies with those familiar with this conof Medicine, Department dition to educate and inform the referring Royal Victoria Infirmary, doctors, or to liaise appropriately over the Newcastle upon Tyne NEI 4LP
Parry SC. The polyglot medical questionnaire. London: H K Lewis, 1953.
Dealing with epileptics SIR,-It was with enthusiasm that we noted the commitment by the BMJ to the International Year of Disabled People and the resulting series of articles entitled "Dealing with the Disadvantaged." This has prompted us to report some of our findings from a study of patients with epilepsy. Despite the considerable amount of work directed towards defining community attitudes,' patients' attitudes towards their condition and its management have received very little attention. As part of a larger study, 53 patients with epilepsy, referred from a random sample of 50 Sydney general practitioners,2 were asked to identify the "most important" therapist in the management of their epilepsy and to indicate the level of satisfaction with the service provided. If a therapist generated dissatisfaction reasons for this were sought, as were suggestions for the possible upgrading of patient care. Of the 53 patients interviewed, 18 selected their GP as the "most important" therapist, 18 identified their neurologist, 10 claimed that no one fulfilled this role, and six cited "others" (including themselves). Nineteen patients criticised the neurologist while only four expressed dissatisfaction with their GP. The source of dissatisfaction with specialists related to their demeanour and a failure of communication rather than any criticism of their technical expertise. Comments included "Scornful manner"; "I can't talk to him"; "He doesn't explain anything"; or "Very rude and arrogant." Thirty-six of the 53 respondents offered suggestions for improving the care of people with epilepsy. These suggestions included a desire for better education of patients and a need for an awareness by doctors of the very real psychosocial needs of their patients. From the one-third of respondents who felt that the medical profession was not meeting their needs and a further one-third who criticised neurologists in their doctorpatient relationships, it was apparent that in the International Year of Disabled People there is reason for concern and a need for re-evaluation of the service provided for patients with a chronic condition such as epilepsy. While one-third of the 53 patients criticised their specialists only four patients
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admonished their GP. This provided strong indication of a need for specialists, the acknowledged experts in their technical field, to re-evaluate their approach to patients and by doing so include a more open exploration of the psychosocial issues which cause patients concern. We believe that these findings are most relevant to "dealing with the disadvantaged," who, it would appear, may feel inhibited in their encounters with the medical profession, especially those at consultant level. Roy BERAN CAROLINE SUTTON School of Community Medicine, University of New South Wales, Kensington, New South Wales 2033, Australia
Smoking, coal, asbestos, and the lungs SIR,-Your admirable analysis of the contributions of smoking and of occupational dust exposure to disease of the airways (15 August, p 457) teaches us two important lessons. Let us hope that they are heeded not only in Britain but also in the third world. The first lesson is that both society and individuals should weigh against the benefits of any industrial process the costs of its associated mortality and morbidity. We can do this only on the basis of the evidence from research into the association between exposure to respirable dust and the risks of pulmonary disease. Such epidemiological inquiry is sadly neglected in many tropical countries where monitoring of neither the health of coalminers nor the level of dust exposure is standard practice. In a recent study' of 675 men representing some 3000 employees in the only colliery in West Africa, evidence of impaired ventilatory capacity had to be interpreted in the absence of serial radiographs and of any information about dust exposure. The second lesson is that smoking adds a further insult to the lungs of men already exposed to dust-an insult which might be quantifiable from an analysis of the relative exposures to dust and cigarette smoke. In Britain dust is being reduced by effective control measures while smoking remains at epidemic proportions. In tropical Africa the opposite is true at the moment. There may yet be time to collect valuable data about the epidemiology of chronic lung disease from populations with a different mix of predisposing factors before smoking, "the coming epidemic,"2 redresses the balance and we lose the chance to learn and the chance to educate in time. J M PATRICK Department of Physiology and Pharmacology, Medical School, Nottingham NE7 2UH ' Jain BL, Patrick JM. Br J Ind Med 1981;38:275-80. 2Taha A, Ball K. Br Med3' 1980;280:991-3.
Drug treatment of premature labour SIR,-Your leading article (8 August, p 395) is a timely reminder of the uncertainties still evident in the drug treatment of premature labour. Despite the fact that the use of drugs, and in particular the ,-sympathomimetic agents, has not been matched with improved rates of perinatal survival, many hundreds of
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pregnant women and their fetuses throughout the world are still being exposed to such treatment, the risks of which are by no means insignificant. The decision as to whether to prescribe these potentially harmful drugs for patients admitted to hospital with a history that is compatible with premature labour is often made hurriedly and with a misdirected sense of urgency, which is conveyed to an already anxious mother. Nevertheless, until we have methods which allow us to distinguish between true and false labour, most obstetricians often prefer quite naturally to err on the side of overdiagnosis. The diagnosis presents no problems when painful uterine contractions are combined with dilatation of the cervix, but commonly the overall picture is less than clearcut. It should be remembered that the diagnosis of labour is made initially by the patient, who presents herself on the labour ward with the belief that she may be in labour. That this belief may be mistaken should come as no surprise, especially in primigravidas who have had no previous experience. In these circumstances there is usually plenty of time for observation with external tocography to monitor uterine activity and, more importantly, with a second vaginal examination to determine changes in cervical effacement and dilatation. It is the latter parameters and not the frequency and duration of uterine contractions which provide the objective and conclusive evidence that labour is in progress. Some obstetricians are wary of performing repeat vaginal examinations for fear of introducing infection, and because digital examination of the cervix possibly elevates circulating prostaglandins.1 Surely the information to be gained from such assessments outweighs these theoretical risks, and I remain to be convinced that a gentle, competent, and aseptic vaginal examination alters prostaglandin levels sufficiently to have any bearing on the outcome of labour, whether it is established or not. Because of the lingering doubts concerning the wisdom of the continued unselected use of P-sympathomimetic drugs in premature labour, and because their use is limited by the significant incidence of unpleasant side effects, the search must continue for therapeutic alternatives. In this regard your article omitted to mention the calcium antagonists, which have been shown to be effective inhibitors of spontaneous and induced contractile activity in myometrium, both in vitro2 and in vivo in patients with dysmenorrhoea.3 These may well prove to be agents with promising potential in the treatment of premature labour if preliminary reports4 5 are confirmed. As yet there has not been a study that has compared all the different modes of therapy available (including bed rest alone) in the management of premature labour. As you rightly emphasise, such a trial would have to be a multicentre one, and perhaps this could be co-ordinated by the Royal College of Obstetricians and Gynaecologists.
675 4Andersson K-E. In: Anderson A, Beard R, Brudenell JM, Dunn PM, eds. Preterm labour. Proceedings of the 5th study group. London: Royal College of Obstetricians and Gynaecologists, 1977;101-14. Ulmsten U, Andersson K-E, Wingerup L. Arch Gynecol 1980;229:1-5.
Medical manpower help to Third-world countries
SIR,-Many young doctors from the United Kingdom in postgraduate training who from compassion or other considerations give their medical services to the Third world often go back home and find they have lost their place in the hierarchical queue. At the mandatory retiring age of 65 (in the UK) many hospital doctors are still quite healthy, very active, and children have grown up. Organised positive encouragement should be given to these people to do a few years in their specialties in the Third-world countries, to the mutual benefit of the host country and the doctors, before they retire to ruminate, grow roses, and paint. DOZIE IKEDIFE Ikedife Hospital, Nnewi, Nigeria
Too few vocational training schemes
SIR,-Your correspondents (18 July, p 236 and 15 August, p 504) complain that there is a shortage of vocational training schemes for general practice, a serious matter now that training is mandatory. In this region, for the August half-yearly intake 343 fully registered doctors made 734 applications in response to advertisements for 46 places. Probably another 30-40 applicants would have been able to arrange their own self-structured scheme. As a result the number of trainees commencing training during the year just about equalled the regional annual GP recruitment. Therefore 70% of the doctors making application for vocational training in this region in either "A" or "B" programmes did not find training posts within it. Some may well be in training in other regions, so that any authoritative statement about disparity between applicants and posts requires a national survey. By next summer there may be a freeze on the SHO establishment as well as the implementation of an edict by the GMC that doctors with limited registration must be trained in educationally approved posts only. Consequently, all doctors, newly arrived or already here, with limited registration will be seeking posts within an establishment reduced by the exclusion of unapproved posts. If it is now argued that there should be more vocational training schemes, which require educationally approved posts for prescribed experience, then there will be fewer available posts for all the other disciplines. A vocational training scheme represents a providential arrangement whereby packages of SHO posts in a variety of major STEPHEN WEST specialties-as well as the guarantee of timely GP trainee posts-are offered only to those Department of Obstetrics and training for general practice. Appointment Gynaecology, confers three years' guaranteed continuous St Bartholomew's Hospital, London ECIA 7BE appropriate employment and consequent security. 'Mitchell MD, Kierse MJNC, Anderson ABM, The justification for presenting this training Turnbull AC. Br J Obstet Gynaecol 1974;81:35-8. 'Fleckenstein A, Grun G, Tritthart H, Byon K. facility-now training is mandatory-is to Klin Wochenschr 1971;49:32-41. 'Andersson K-E, Ulmsten U. Br J Obstet Gynaecol ensure that there will be training opportunities for a major proportion of the annual 1978;85:142-8.
