228 BRITISH MEDICAL JOURNAL 26 JULY 1975 notes the substantial benefit many children Motor Insurance and Ischaemic Heart in the affirmative form, has been the subject with moderate to severe chronic asthma Disease of discussion and agreement between insurers derive from the use of steroid aerosols. How- and the B.M.A.-I am, etc., SIR,-Some interesting points have been ever, it fails to emphasize the important Br Med J: first published as 10.1136/bmj.3.5977.228-a on 26 July 1975. Downloaded from place that regular use of bronchodilators has raised by Dr. G. J. Rockley (22 March, p. 679) concerning the R. C. W. BARDELL in management. underwriting of motor Secretary General, It is inferred that if adequate control of insurance where the medical condition of the British Insurance Association asthma is not achieved with regular pro- policy-holder is relevant. London E.C.4 phylactic disodium cromoglycate and Motor insurance contracts are governed by bronchodilator therapy given early in the the principle of utmost good faith-that is course of any acute wheezing attack steroid to say that there is a requirement on the therapy in one form or another should be part of the policy-holder to notify his in- Prophylaxis of Postoperative Deep Vein used. As about 05 % of children have surer of any fact which would materially Thrombosis chronic airways obstruction as a result of alter the risk. This would include any change in health affecting the ability to SIR,-We are obliged to Mr. F. S. A. Doran asthma' 2 and this is often inadequately con- (24 May, p. 442). He has done as much as trolled with regular disodium cromoglycate drive advised to the patient by his doctor. Insurers would always expect a doctor to anyone else to popularize electrical calf and intermittent bronchodilators, steroids muscle stimulation for the prevention of appear to be recommended for a large num- advise a patient on the extent and nature of his future activities relative to his medical postoperative deep vein thrombosis. We also ber of children. This is despite the well- thank Mr. J. A. Lewis (5 July, p. 41) for known complications of oral corticosteroids condition, whether his advice is sought specifically or not. It remains as a matter pointing out the superiority of random and the lack of information of the long-term number tables (which we now use). The effects of topical steroids on the human lung. for the patient's own conscience and com- mon sense as to whether he accepts or rejects method of randomization in the published In fact many children with moderate trial (22 March, p. 649) based on the month chronic asthma whose airways obstruction the doctor's advice. In the case of illness or some form of disability insurers must defer of birth of the patient produced an un- persists despite regular disodium cromo- fortunate excess of patients in the control glycate and intermittent bronchodilator to the opinion of a registered medical practi- tioner on the question of the policy-holder's group. This made the figures clumsily un- therapy will be adequately controlled with even but it can surely not be claimed that it regular bronchodilator therapy. The effec- ability and suitability to drive. In these circumstances it is vital for a was anything but strictly random or that the tiveness of regular oral theophylline in full method of prophylaxis used was determined therapeutic dosage is now well documented.3 patient to understand and appreciate the fact that if he fails to advise his insurers of a by our preference and not purely by chance. While the value of combining one of the Mr. Doran's labour in calculating x2 of newer 3-adrenergic stimulators either orally change in his medical condition then he would certainly run the risk of having a the stimulator group against the heparin or by inhalation with regular theophylline is group has been largely wasted. He has added not proved, we have used this combination claim for damage to property (including damage to his own car) repudiated. In so far together laparotomies for benign disease, for many years and have achieved very laparotomies for malignant disease, and adequate control in a substantial number of as personal injury claims are concerned the Road Traffic Act deals with this situation- operations on the bladder and prostate and children with rmoderate to severe chronic has produced a x2 of 4-924-favouring asthma without any apparent side effects.4 particularly section 148. When an insurer requires a report from heparin with a probability of over 95%. If Orciprenaline or salbutamol by inhalation he had taken laparotomies for benign disease using a hand nebulizer driven by small air a doctor concerning fitness to drive, it is normally expected that the report will come alone and compared the two groups he compressor pump as described in detail else- would have found a x2 of 0-875 (no sig- where5 is particularly valuable both for the from the patient's general practitioner, and it would be assumed that the G.P. would be nificant advantage of heparin over the control of persisting airways obstruction and stimulator). In the laparotomies for malignant for the rapid relief of acute exacerbations. in possession of all facts concerning the case. disease on the other hand x2 is 13-298 and http://www.bmj.com/ Certainly no child should be started on In the case of ischaemic heart disease, where fitness to drive may improve over the the chance that heparin is no better than corticosteroids, either by inhalation or orally, electrical stimulation is less than one in 1000. until it has been clearly demonstrated that months after clinical recovery, a certificate of fitness to drive would be required by the He makes another statistical mistake twice. the combination of regular disodium cromo- First, in comparing major deep vein throm- glycate, oral theophylline, and orciprenaline insurers from the patient's doctor stating that the condition had improved to the extent bosis (D.V.T.) between the two groups. The or salbutamol by inhalation has failed to give total number of cases of major D.V.T. in adequate control. The criteria for control where driving a vehicle would not be ab- normally hazardous. Equally, the insurers the stimulator group was five and in the outlined in your article are adequate, but in heparin group one. Add these together and older children objective evidence from pul- would be expected to be notified of any

divide by two and the total expected number on 1 October 2021 by guest. Protected copyright. monary function testing is also of consider- decline in the patient's condition which would affect fitness to drive. Insurers require is three. No statistician is prepared to apply able importance. Some parents of children the x2 test (or indeed any other test) when with chronic asthma fail to appreciate the only an affirmative opinion from a medical practitioner regarding the patient's ability to the expected number is less than four. severity of the condition and may report that Similarly, four haemorrhages in the heparin their child is normal whereas he has sub- drive. The extent to which a doctor feels it necessary to examine a patient and to con- group against none in the stimulator group stantial persisting airways obstruction. Con- gives an expected number of two and, again, versely there are a small number of children, sult with specialists, etc., is entirely a matter of opinion for the doctor in individual cases. cannot be analysed statistically. To put it usually from disturbed backgrounds, who on another way, if you toss a penny four times reporting by parents seem to be having a It follows from this that the fee which a doctor charges a patient for such a pro- there is a strong possibility that it will come great deal of trouble with their asthma, but down heads on each occasion. this is not supported by objective data. There fessional opinion would reflect the amount is a substantial risk of undertreating the of work, time, and consultation necessary for Twenty-two patients were withdrawn from the former group and overtreating the latter if him to produce such an opinion. trial. There were four deaths, two in the stimulator Because they have a duty- placed upon group, one in the control group, and one in the history alone is the guide to therapy.-I am, heparin group. Their details are as follows: etc., them to provide insurance cover for the motoring public insurers feel that they must (1) Stimulator. A man of 80 died two days after PETER D. PHELAN laparotomy, suture of a caecal perforation, and satisfy themselves at all times regarding the transverse colostomy for an obstructing carcinoma Department of Thoracic Medicine, level of fitness of a driver, and it is to this of sigmoid colon. Overwhelming sepsis. No Royal Children's Hospital, end that it is necessary for them to require Melbourne necropsy. (2) Stimulator. A man of 76 died two their policy-holders to seek medical advice. days after gastrectomy, splenectomy, and trans- 1 McNicod, K. N., and Williams, H. E., British In many cases, while insurers are prepared verse colectomy for advanced carcinoma of the Medical 7ournal, 1973, 4, 7. to provide insurance cover they may wish- stomach. Superior mesenteric artery occlusion. No 2 Hill, D. J., et al., Archives of Disease in Child- necropsy. (3) Control. A woman of 71 hood, 1972, 47, 874. and indeed they have the right-to impose died three 3 Weinberger, M. M., and Bronsky, E. A., 7ournal special terms and to charge higher than days after gastrectomy and transverse colectomy of Pediatrics, 1974, 84, 421. normal premiums. for gastric reticulosis. Cardiac and respiratory 4 Williams, H. E., and Phelan, P. D., Respiratory failure. No necropsy. (4) Heparin. A man of 74 Illness in Children, p. 116. Oxford, Blackwell With regard to the certificate of ability to Scientific, 1975. died four days after right hemicolectomy for a 5 Phelan, P. D., and Stocks, J. G., Archives of drive mentioned in Dr. Rockley's letter, may perforated carcinoma of the caecum. Uraemia and Disease in Childhood, 1974, 49, 143. I say that this certificate, which is couched bronchopneumonia. Necropsy showed no pul- BRITISH MEDICAL JOURNAL 26 JULY 1975 229 monary embolus and no more bleeding at the general hospitals and some teaching hos- buted to inhibition of cytochrome oxidase. operation site than would have been expected. pitals. Though I saw in the primary health In vitro 50% inhibition occurs at a con- Of the 14 patients withdrawn because of centres many examples of Indian doctors centration of 15 ,umol HCN/1.3 In vivo there failure to observe the protocol, one was in supplying a cheerful and unselfish service to will no doubt be a plasma/tissue concentra- Br Med J: first published as 10.1136/bmj.3.5977.228-a on 26 July 1975. Downloaded from the heparin group (the preoperative dose was their countrymen, the lack of even the tion gradient and so plasma levels at which forgotten) and the remaining 13 in the simplest equipment and the elementary inhibition would occur would be somewhat stimulator group: in seven of these the sur- nature of the procedures in these centres was higher. In dogs given a single intravenous geon omitted to use the machine and in six striking. In the district and general hospitals dose of 1 mg SNP/kg, resulting in peak the machine failed to function.-We are, etc., laboratory equipment was of the scantiest plasma levels of 3 Amol HCN/1, we have and in the teaching hospitals there was a found evidence for histotoxic hypoxia. I. LAWRENCE ROSENBERG conspicuous lack of the sort of modern Our studies in man have shown that St. James's Hospital, equipment one would have expected to find plasma HCN levels immediately following Leeds there. short-term infusions (over a period of two MARY EVANS In the hospitals the few laboratory tests hours or less) show a linear relationship to A. V. POLLOCK attempted were carried out usually in one the total dose of SNP. A plasma level of Scarborough Hospital, Scarborough, N. Yorks room and there was a grave lack of 3 ,umol HCN/1 would be reached by the adequately trained technical staff. I noticed infusion of about 1-5 mg SNP/kg. that doctors generally had a knowledge of Deaths have been reported4 following Survival after Postoperative Avascular only the simplest techniques such as blood SNP infusions in which doses of approxi- Necrosis of Lesser Curve of Stomach cell counting, examining malaria slides, or mately 4 mg/kg per two-hour period have examining faecal specimens for helminth ova, been given. It therefore seems reasonable to SIR,-I read with interest the paper by Dr. and while one could argue that medicine suggest that plasma HCN levels should not J. F. Halvorsen and others (14 June, p. 590) could possibly be practised in rural India be allowed to rise above 3 ,mol/l and the reporting the third death due to avascular without a knowledge of laboratory pro- maximum total dose of SNP be set at 15 necrosis of the lesser curve of the stomach cedures, such inadequately trained doctors mg/kg for hypotensive anaesthesia of rela- following highly selective vagotomy (H.S.V.) would not be suitable for participating in a tively short duration. In the event of un- for duodenal ulcer. I should like to describe highly technical hospital service such as toward symptoms attributable to SNP we a similar case in which the patient survived. Britain's. would certainly encourage the use of An otherwise healthy male patient aged 46 with a No doubt some graduates of the good hydroxocobalamin and sodium bicarbonate as long history of chronic duodenal ulceration under- Indian medical schools display a wider you suggest, and in addition sodium thio- went H.S.V. on 28 November 1974. His condition knowledge of medical practice, but those of sulphate.-We are, etc., remained satisfactory until the third postoperative us who know India well are aware that there CYRIL J. VESEY day, when he developed left lower chest pain asso- are a great number of doctors coming to PETER COLE ciated with fever, mild hypotension, and a pleural this country who are simply not well enough PETER SIMPSON friction rub. It was assumed that he had developed trained. It is absolutely imperative that there Department of Anaesthesia, a chest infection and he was treated accordingly be a sorting-out examination, and no matter St. Bartholomew's Hospital, with physiotherapy, systemic antibiotics, etc. London E.C.1 Several hours later his condition deteriorated: his how disappointing its results may be for blood pressure fell, abdomen became distended, some candidates an exacting standard must 1 Vesey, C. J., et al., British Medical Yournal, 1974, 2, 140. and bowel sounds were absent. An abdominal tap be maintained. 2 Sorbo, B., in Proceedings of the First International was performed and the fluid obtained was mis- It would be futile to run a three-month Pharmacological Meeting, ed. B. B. Brodie, takenly thought to be blood. Intraperitoneal course (as has been suggested by an Indian et al., vol. 6, p. 21. London, Pergamon, 1962. 3 Schubert, J., and Brill, W. A., Yournal of haemorrhage was therefore diagnosed and appro- doctor on the radio from Birmingham) to Pharmacology and Experimental Therapeutics, priate resuscitation was carried out. Once a suitable prepare doctors who have arrived in the 1969, 162, 352. blood pressure was attained laparotomy was 4 Merrifield, A. J., and Blundell, M. D., British

U.K. to take the G.M.C. examination. How http://www.bmj.com/ carried out, when a large defect was found in the lournal of Anaesthesia, 1974, 46, 324. lesser curve and about 2 1 of blood-stained fluid, could a three-month habilitation course, mostly gastric contents, in the peritoneal cavity. especially for someone whose English is The defect was sutured and peritoneal toilet car- weak, make up for the deficiencies of several ried out. The patient's postoperative condition was years in an inferior medical school?-I am, Emigration of Doctors satisfactory but he subsequently developed a left etc., SIR,-Dr. M. P. White (7 June, p. 561) subphrenic abscess which required treatment with R. J. HENDERSON writes from his experience as a district drainage and antibiotics. He was discharged on Public Health Laboratory, 10 January 1975 and when last seen at the clinic in Royal Infirmary, medical officer, but many of us who have May 1975 he was very well, had no recurrence of Worcester served from the grass roots up to Ministry dyspepsia, and was prepared to go back to work. levels in many developing countries are un- on 1 October 2021 by guest. Protected copyright. This case also demonstrates the difficulty able to agree with his statements. There is in diagnosis of this rare condition, which Sodium Nitroprusside in Anaesthesia no such thing as tropical medicine; it is nonetheless should be thought of if de- the medical care of poverty, national and terioration occurs after H.S.V. SIR,-We should like to amplify your brief individual; and the paramedical and auxiliary statement (7 June, p. 524) on the metabolism cadres, urban and rural health centres, and I should like to thank Mr. G. E. Schofield for of sodium nitroprusside (SNP).' a permission to report this case which was under his reconsideration of medical student training care. In patients infused with SNP we have are all appearing in the so-called developed found that there was an increase in blood countries as they face up to the economic I am, etc., cyanide (HCN) levels, even with small doses problems of medical care. STUART W. BRODIE of the drug. Of this HCN, 98',' was present Dr. White specifically raises four points Law Hospital, Carluke, Lanarkshire in the red cells. Though /-mercaptopyruvate as some of the "certain facts .. . always sulphur transferase occurs in the red cells of ignored" by the protagonists of community the rat,' it has not yet been shown to play health care. G.M.C. and Indian Qualifications any significant role in the direct detoxication I agree that in the developing countries of HCN in human erythrocytes. The blood there is a decline of morale, discipline, and SIR,-Mr. A. K. Varshneya (5 July, p. 43) HCN is slowly detoxicated to thiocyanate output of the health services paralleling those writes that there is an increasing number of (SCN) by tissue rhodanese so that plasma of the U.K. But the root causes are very teaching schools in India with poorly SCN levels showed only a gradual rise. The different. In the developing countries the equipped departments and that the standard ratio SCN:HCN in body fluids is normally indigenous are now taught by indigenous of medical education has gone down in around 1000: 1 and so at the relatively low physicians and paramedicals who in turn recent years. I spent nearly 13 years in the levels of SCN attained during hypotensive were taught by expatriates. Thus the Indian Medical Service, so that I know the anaesthesia using SNP there would be in- indigenous -students continue to be taught an background, and I have been back twice, in significant formation of HCN from SCN by inappropriate medical care system. Indi- 1969-70 and 1972, touring the Indian states the ill-defined thiocyanate oxidase system. genous training in many areas is still not on behalf of the World Health Organization. You suggest a maximum SNP dose rate of orientated to a country's individual epidemi- During these tours I visited a large number 3 mg kg-' h-1, but this may be too high. ological and social needs and priorities. of primary health centres and district and Death due to cyanide poisoning is attri- Doctors and paramedicals soon discover this