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CORRESPONDENCE Pinning down the diagnosis in breast cancer .................. W W Park, MD ...... Which arm squeezes the bag? ............... H G Magill, MB ......... Photo-onycholysis caused by tetracyclines .................. H Baker, FRCP ...... .................. 516 MRCP .............. Barium meal in uncomplicated Accident or suicide? ................ 516 dyspepsia H H Pilling, MB ........ J R W Lyall, MRCP, and T E T West, MD.. Induction of labour and perinatal mortality R W Beard, FRCOG, and P J Steer, MB ...... 516 Chloroquine-induced involuntary Rubella vaccination during oral movements contraceptive care S Singhi, MD, and others ................ A J Rose, MRCGP, and K F Mole, MRCGP.... 517 Strawberry pickers' foot drop Late infection after total hip replacement P A M Weston, FRCS, and M L E Espir, FRCP J D Langdon, MB, FDSRCS; M Webley, Paternity testing MRCP, and M L Snaith, MD .............. 517 A Usher, FRCPATH ...................... Comparison of treatment with fast metabolism in the elderly Drug neutrons and photons D J Smithard, MRCP, and M J S Langman, Mary Catterall, FRCR, and others .......... 518 FRCP ................................ Evolution of poliovirus since introduction The cowardice continues of attenuated vaccine ............. J E Caughey, FRCP ....... H V Wyatt, PHD ........................ 518 Prolactin in anorexia nervosa Running away from accidents A J Isaacs, MRCP, and others ............ .............. 518 P A Lawrence, MB ........ Starting on the pill Immersion and drowning in children Nancy B Loudon, MB .................. C D Auld, MB, and J N Norman, FRCSED.. 519 Geriatrics in isolation Entry to medicine N K Chakravorty, MRCPED .............. Anne-Marie Feeley; B A Bell, FRCSED ...... 519

Medical hazards of air travel I D Rennie, MD ........................ 515 Epilepsy and drowning in childhood S Livingston, MD, and others ............ 515 A case of intrinsic asthma I W B Grant, FRCPED; D Honeybourne,

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Correspondents are urged to write briefly so that readers may be offered as wide a selectiont of letters as possible. So many are being received that the omission of sonie is inevitable. Letters should be signed personally by all their authors. Medical hazards of air travel SIR,-Like Mr J G Callanan (4 June, p 1473) I seem to have an Ancient Mariner effect in jumbo jets. In December 1975, travelling from Chicago to San Francisco, I spent an hour or so looking after a middle-aged man with chest pains while fuel was jettisonned for an unscheduled stop in Denver to ship him off to hospital. In March 1976, flying directly from Honolulu to Chicago, I spent a yet more energetic two hours looking after a 60-year-old woman with severe angina and tachycardia. She told me (but had not previously told the airline) that she had just taken her discharge from hospital against medical advice and was flying to the mid-West for cardiac investigation. Once again an unscheduled stop, this time in San Francisco. Getting a history was difficult-she had a recurrent laryngeal palsy after thyroidectomy. Six weeks after this I went to O'Hare to meet a British physician arriving from London. Meet him I did: he was returning from a nearby hospital whither he had accompanied the body of the co-pilot, he having spent two hours performing cardiac massage en route. Several points arise. Firstly, I would endorse Dr Callanan's suggestion that we start to put together a screening system for high-risk passengers, such as the second patient above, but the co-pilot had presumably been thoroughly screened by his employers already, so the chances of success here are small. Secondly, it seems to me that no one can call himself a physician who is not prepared to help in such an emergency (which is terrifying to patient, fellow passengers, and crew), though legally he does not have to and is indeed advised not to. The doctor's mere presence and

authority have a dramatic calming effect on all. As important as this is the attitude of the airlines. My inquiries elicited the fact that such incidents were vanishingly rare (one airline physician told me, "one death for every three million passengers": I wonder whether this statistic is correct). On none of these occasions was any medical equipment, diagnostic or therapeutic, available apart from oxygen and a trivial first-aid box. I was told by one airline that no general agreement had been reached about adequate medical equipment largely because the airlines were afraid that a physician-volunteer would not be able to use the equipment if it was presented to him and there would be important legal implications if the volunteer could not cope. They gave as an example an ophthalmologist suddenly faced with a tracheostomy. This is a silly argument and of small comfort to the reasonably competent physician who would like to pass a laryngeal tube, relieve pain, or even use a stethoscope. On the second of the two incidents mentioned above passengers were asked if they had any drugs which might be suitable. Trinitrin was produced by a tourist and it relieved the patient's pain. A very large amount of diazepam was also collected from numerous passengers; presumably it would have effectively sedated me. It certainly gave me food for sociological thought. It was pointed out to me that it was hard for the airlines to identify any volunteer as indeed being a physician (I was able to give numerous evidences of this in the shape of medical licences and so on and would not have thought it hard for others to do so). They also pointed

Erythromycin in renal failure M St G Wheeley, MB .................. Prevention and health Norma B Batley, SRN .................. Maintenance digoxin after an episode of heart failure R J Dobbs, MRCP, and others ............ Sterilisation reversal requests Marion Gillett, MB .................... Genital yeast infections A B Maclean, MB ...................... Poisoning with antidepressants C L Brewer, MRCPSYCH ................ How effective is measles immunisation? W M Jordan, BM ...................... Postgraduate training in environmental health A D C S Cameron, MFCM ................ Need part time be second-rate? J M Kerry Bluglass, MRCPSYCH, and R S

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Bluglass, FRCPSYCH .................... 524 Health centre running costs A Elliott, FRCGP ........................ 524 How many medical students? T D Brogan, FRCPATH .................. 524 A gross exaggeration T J Millin, FRCS ...................... 524 out the problem of carrying any form of drugs around on planes, especially those making international flights, partly because of the threat of theft. This can scarcely apply to such drugs as trinitrin. It would not be difficult to devise a system for securing an adequately stocked drug and instrument chest. Certainly the doctor flying as a paying passenger cannot afford the weight or space to carry his own emergency bag: such threatening instruments would be confiscated at the airport and the doctor probably imprisoned while the authorities decided whether to press drug charges in addition. Clearly the airlines and regulatory agencies should get together soon to sort out these problems. I DRUMMOND RENNIE Section of Nephrology, Rush-Presbyterian-St Lukes Medical Center, Chicago, Illinois

Epilepsy and drowning in childhood

SIR,-Unfortunately, many physicians still restrict the participation of epileptic children in physical activities, particularly body contact sports and swimming. We were therefore very pleased to note that analysis of the data relative to water immersion accidents in 149 cases led Dr J H Pearn (11 June, p 1510) to conclude that "with effective supervision . . . epileptic children may swim with confidence." Our experience over 41 years in managing approximately 20 000 epileptic children, thousands of whom have engaged in swimming under supervised circumstances, supports his findings. Although some of our patients experienced a convulsion while swimming, none, as in Dr Pearn's series, drowned. Our experience is also consistent with Dr Pearn's finding that "seizures occurring in the bathtub . . . may be life-threatening," and in

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our series, as in his, water immersion fatalities were limited to the bathtub. In each of our fatal cases the patient had bathed alone in a tub that was almost filled with water. We therefore advise that older epileptics bathe alone only in tubs containing generally no more than 5-7 5 cm of water. Young children, whether epileptic or not, should not be permitted to bathe alone in a bathtub. An alternative method of cleansing consists of showering while seated on the floor of the bathtub, with the drain open so that the water flows out constantly. We prefer that the patient use a handheld showering instrument in the bathtub rather than the overhead, wall-implanted type because the former immediately ceases operation on release of finger pressure. Contrary to Dr Pearn's recommendation, however, we do not advise that epileptics be allowed to shower alone, at least not in a standing position and especially not in glass or plastic enclosed stalls. Several of our patients who experienced a convulsion while showering fell through glass enclosures and severely injured themselves. In addition, two of our patients who had seizures in a shower stall fell against the tap that regulates the hot water flow and suffered extensive burns. Finally, some of our patients sustained serious bruises and lacerations in association with seizures occurring while showering in the upright position. In environments that include only a wall shower and in cases where the individual insists on bathing in a shower stall we recommend that the patient be seated on an appropriate type of chair or bench during the entire

costeroid, such as prednisolone, for the first few days. Although it is true that sodium cromoglycate is seldom effective in elderly asthmatics, it is not correct to say that this drug is of ?zo value in intrinsic asthma, since this is a controversial issue which has not yet been resolved. I would strongly dispute the final conclusion that the most important point is "to educate the patients in the dangers of overdosing themselves with any inhaled 3agonist." It is equally important, if not more so, to warn patients that if they fail to obtain the usual degree of relief from the use of a bronchodilator aerosol they are in a potentially dangerous situation and should seek medical help immediately. IAN W B GRANT Respiratory Unit, Northern General Hospital, Edinburgh

SIR,-In the article by Dr G M Bell and Professor M D Rawlins on "A case of intrinsic asthma" (23 July, p 250) Professor Rawlins makes the mistake of dismissing sodium cromoglycate (SCG) as being "of no value for intrinsic asthma." This is at variance with the findings of the MRC collaborative trials reported from London in 1972' and jointly from London and Edinburgh in 1976.2 Using the FEV, as an index of improvement the latter paper showed that those patients receiving SCG derived very similar benefit whether their asthma was of extrinsic or intrinsic type. Indeed, none of the patients with intrinsic shower. asthma on placebo continued successfully for SAMUEL LIVINGSTON the first 52 weeks of the trial, whereas 600, of LYDIA L PAULI those with the same type of asthma on SCG IRVING PRUCE (with or without isoprenaline) were still on Samuel Livingston Epilepsy this treatment after 52 weeks with an imDiagnostic and Treatment proved FEV,. In view of the benign nature of Center, Baltimore, Maryland SCG in terms of side effects (no adrenal suppression or oropharyngeal candidiasis), it is a pity to dismiss its use for intrinsic asthma in A case of intrinsic asthma the presence of good evidence of the converse. SIR,-I find it a little difficult to understand DAVID HONEYBOURNE why this simple and straightforward case London SE18 report (23 July, p 250) should have been Brompton Hospital MRC Collaborative Trial, British published under the inappropriate and granMedical Jozurnal, 1972, 4, 383. diose title of "Community Clinics in Clinical 'Northern General Hospital Brompton Hospital MRC Collaborative Trial, British Medical Joutrnal, 1976, Pharmacology," but I hope you will permit a 1, 361. practising clinician to voice his disquiet over some of the views expressed in the article. In the case history reference is made to Accident or suicide? treatment with "intravenous aminophylline and hydrocortisone," which suggests that this SIR,-I was very interested to read your was the only treatment the patient received for leading article on this subject (23 July, p 212) his episodes of acute status asthmaticus. I but feel that certain fundamental considerathink it should have been made clear in the tions, if not ignored, have at least been left Advice section that if an attack of asthma is unmentioned. In the first place a coroner's verdict is based ever sufficiently severe to warrant these forms of intravenous therapy it should always be upon legal rather than medical reasoning and followed up by a course of oral corticosteroids. to that extent official suicide rates so far as It is stated that the patient's symptoms were England and Wales are concerned are quite due to "intrinsic asthma," but this diagnosis useless for the purpose of medical statistics. One can approach the facts in any given case cannot be made without skin sensitivity tests, along one or two legal paths. In the first one of which there is no mention in the report. Since the patient had a peak expiratory flow adopts a presumption against suicide (analogof only 80 1/min his asthma must have been ous to the presumption of innocence in a quite severe and he therefore ought to have criminal trial-the law never having fully been given an initial course of treatment with accepted that suicide is not a crime) and, in an oral corticosteroid preparation to bring the absence of any express or implied intention his symptoms under control before beginning to end life by the deceased, one must conclude maintenance treatment with a corticosteroid that the death was accidental. The second aerosol. As all respiratory physicians know, approach does not make any presumption but severe asthma cannot be controlled by a asks whether (a) in ending his or her own life corticosteroid aerosol and it is vital in these the deceased must have intended to do so, or circumstances to prescribe an oral corti- (b) whether he or she may have had an expec-

20 AUGUST 1977

tation of merely inflicting serious damage or illness while accepting the possibility of death (especially in self-poisoning) or (c) whether he or she could have suffered the damage entirely inadvertently. In the first case the verdict must be suicide, but in the second and third the evidence of intention falls short of suicide and results in open verdicts. In this approach the verdict of accidental death is reserved for those cases in which there is overwhelming evidence of inadvertence. A history of mental illness or previous attempts to end life are of minor importance legally in reaching a verdict; indeed, one could argue that it is improper even to consider them since they are analogous to previous convictions in a criminal trial and the verdict in any death must be reached only on the basis of the pathological and circumstantial evidence immediately surrounding the death. Those who are mentally disturbed usually have problems of concentration and it could be argued that they are more accident-prone than those not so disturbed and that the mental condition would therefore equally favour an accidental death in some circumstances. Furthermore, by the rules of chance alone a proportion of depressed persons, alcoholics, drug-dependents, and schizophrenics must be involved in accidents to which they have made only an inadvertent contribution. Within the near future coroners hope to be freed from some of the rules which at present govern their inquiries. At present when death is unnatural they are bound to hold an inquest, but it is to be hoped that in the future the distinction between the non-inquest and the inquest case may depend on whether or not a second party is directly involved in causing the death. This would be a more useful distinction and it could even be accompanied by a reclassification of deaths in which all self-induced deaths were put into a single category. The present classification of unnatural deaths has to some extent outlived its usefulness from a legal point of view. The responsibility of deciding what is suicide would then fall on the Office of Population Censuses and Surveys, if they still wished to draw a distinction, and their findings would no doubt be more acceptable to the psychiatrists who are interested in this problem. HERBERT H PILLING HM Coroner for South Yorkshire

(West District)

Medico-Legal Centre, Sheffield

Induction of labour and perinatal mortality SIR,-We would like to continue the discussion started by the paper of Dr Margaret B McNay and others (5 February, p 347), which essentially advocates routine induction of labour as a means of avoiding deaths of "unknown aetiology" among mature babiesthat is, 38 weeks (266 days) or more. Our concern is that the benefits of such a practice in terms of perinatal salvage may be outweighed by the recognised morbidity that accompanies routine induction due to failed induction, an increase in neonatal jaundice,' and hypoxia from excessive oxytocin infusion.', Unquestionably the occurrence of mature unknown (MU) stillbirths and neonatal deaths represents obstetric failure; but we suggest that techniques other than induction are now available for dealing with this problem.

Epilepsy and drowning in childhood.

BRITISH MEDICAL JOURNAL 515 20 AUGUST 1977 CORRESPONDENCE Pinning down the diagnosis in breast cancer .................. W W Park, MD ...... Which...
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