BRITISH MEDICAL JOURNAL

6 NOVEMBER 1976

1133

infarction will recover or not. I do a large number of post-mortem examinations and it is quite obvious that many, many people, often dying from unrelated conditions, have had previous extensive myocardial infarction which has completely healed without the patient having made any serious complaints or Ciba Foundation Guest Symposium, Thorax, 1959, requiring treatment. 14, 286. 2 D'Souza, M F, et al, Clinical Allergy, 1973, 3, 177. It seems to me, therefore, that in the light 3McAllen, M A, Assem, E S K, and Maunsell, K, of our present proved knowledge Dr Davies's British Medical Journal, 1970, 1, 501. opinion is the only reasonable one and, indeed, 4Skinner, C, and Palmer, K N V, Thorax, 1974, 29, 574. Endocrine Department, Pride, N B, British Journal of Diseases of the Chest, Mater Misericordiae Hospital, the only humane one. There is something Dublin 1971, 65, 135. rather objectionable about a government 'R0nnov-Jessen, V, and Kirkegaard, C, British Medical department using the whole of its weight to Journal, 1973, 1, 41. sweep aside the claim of a widow whose 2 Gordon, D L, et al, American J7ournal of the Medical husband probably died as the result of working Risk of venepuncture Sciences, 1974, 263, 31. 3 Baxter, J D, and Bondy, P K, Annals of Internal and at the same time hastening to distribute Medicine, 1966, 65, 429. SIR,-We have recently had a peculiar com- 4 Rose, E, and Boles, R S, Medical Clinics of North money to drug addicts and the like. America, 1953, 37, 1715. A antecubital venepuncture. of plication Twycross, R G, and Marks, V, British Medical G S ANDREWS 67-year-old man was admitted because of J7ournal, 1969, 2, 701. P S, and Osborne, Hughes, R, British Medical Department of Pathology, suspected pulmonary emboli. He received 6Harper, Journal, 1970, 1, 213. Royal Gwent Hospital, intravenous heparin intermittently. On the 7Guyer, P B, British Medical Jrournal, 1965, 1, 169. A J, Postgraduate Medical Journal, 1970, Newport, Gwent sixth day of therapy, after an antecubital 8Richards, 46, 440. venepuncture for diagnostic purposes, a Adams, P H, et al, Quarterly Journal of Medicine, 1967, 36, 1. hematoma of 6 x 8 cm developed, and he Professional standards began to complain of severe pain with median distribution. In two weeks he presented a surgeon in a district clear-cut carpal-tunnel syndrome without any SIR,-I wonder if the vomiting described by SIR,-As a practising becoming increasingly myself signs of bleeding in this region. After six Dr F D Rosenthal and others (24 July, p 209) hospital I find weeks he was operated on and the nerve was might be due to too rapid ingestion of large concerned about the professional standards colleagues. I get the found to be compressed by a tiny blood clot. amounts of food. I have observed this mechan- of my recently qualified undergraduate training impression that their in with ism one patient gross thyrotoxicosis. His state improved but permanent damage remained. It must be assumed that this small Treatment with carbimazole resulted in more has concentrated on the "scientific" rather amount of blood wandered along the nerve leisurely eating pari passu with cessation of than the clinical and practical aspects of medicine. Many do not appear to have learnt from the antecubital region to the carpal vomiting. how to take a proper history, how to perform B I CHAZAN tunnel, where it coagulated and showed its a proper clinical examination, and most have General Hospital, adverse effect. virtually no experience of practical procedures. DAVID KOHN Sunderland Perhaps even more serious is their lack of ASIA BUSH I do not refer solely to the "professionalism." ISIDOR KESSLER matter of dress and address of colleagues (and Coronary artery disease and Kaplan Hospital, Rehovot, other staff) in front of patients, but mainly Israel coalworkers' pneumoconiosis to their attitude towards their job and patients. SIR,-I write to support Dr Dewi Davies Too often they seem to lack interest, inquisiand a sense of personal responsibility Thyrotoxic vomiting (16 October, p 925). It seems that the DHSS tiveness, have drawn sweeping conclusions from the to patients under their care, even if their SIR,-I wish to dispel two myths regarding articles quoted, which are by no means contact with the patient is of brief duration. vomiting in thyrotoxicosis. proved. Even the authors themselves only Many do not understand that every doctor has Firstly, it would appear from the paper by postulate certain possible explanations. Un- a legal responsibility to take "due care" within Dr F D Rosenthal and others (24 July, p 209) fortunately the DHSS loftily expresses its views the limit of his knowledge and competence: do not appear to have been taught what and from the subsequent correspondence that as based on "authoritative opinions," they "due care." vomiting in patients with thyrotoxicosis is rare. suggesting that nobody else has any authority constitutes The of medicine is based on compractice This is not so. Ronnov-Jessen and Kirkegaard1 or is worth considering, and by incorporating passion and caring; all possible and foreseeable reported vomiting in seven out of 28 patients these in "case law" wrongly turns a theory into risk to the patient-not the doctor-should over 60 years of age. Gordon et al2 in a a proved fact, failing to realise that one of the is practical. In other prospective study found thyrotoxic vomiting conclusions which could be drawn from the be eliminated so far inasthe word professionalwords, as is implied in 35 of 121 patients. The omission from articles quoted is that death from coronary for, even if we cannot textbooks of any mention of vomiting as a thrombosis can be avoided by tying a ligature ism, we must striveWe cannot condone any symptom of thyrotoxicosis is to be blamed for around one's neck to obstruct the airway and achieve, perfection. the general unawareness of this symptom, then arranging to die from something else at fall in the standard of care given to our patients. There is only one yardstick by which such since diagnosis is based on mental processes the earliest possible moment. We do not know all about the cause of care should be measured. Would we like to trying to find the closest match between the chronic bronchitis or emphysema or why some be on the receiving end ? patient and the textbook "disease." The second point, touched upon by Dr P H cases of pneumoconiosis progress to progressive M C T MoRRISON Sanderson (4 September, p 584), is the associa- massive fibrosis. We do not know the cause of Margaret Hospital, tion of thyrotoxic hypercalcaemia with vomit- coronary atheroma or why some cases develop Princess Swindon ing. Although hypercalcaemia in thyrotoxicosis thrombosis which may or may not lead to is as common as in sarcoidosis (about 170%),2 3 myocardial infarction. How, in the midst of all it has had the reputation of a rare complication this ignorance, can we produce "authoritative for the same reasons as for vomiting. Rose and statements" on the interaction of the two Traumatic rupture of ear drum Boles4 and Twycross and Marks5 each conditions ? In practice these statistical surveys mean SIR,-Recently I saw an overseas student who reported three patients with thyrotoxic hypercalcaemia, and all six patients also had little. One is faced with the problem of a patient had just sustained a traumatic rupture of his vomiting. Single cases of combined hyper- who has in fact developed both myocardial ear drum from a cause I have not met before. calcaemia and vomiting in thyrotoxicosis were infarction and pneumoconiosis and died. I do His girl friend had inserted her tongue into described by Harper and Hughes,6 Guyer,7 not think that anybody can say that pneumo- his auditory meatus for his delight and when and Richards. 8 While both hypercalcaemia and coniosis did not play some part in the cause of she removed it he experienced a sharp pain vomiting in thyrotoxicosis are unrelated to the death or that it did not have any effect on the which had persisted. Examination showed a severity of the disease,2 39 vomiting may also heart because I do not believe that anybody traumatic perforation of the drum with be a symptom of hypercalcaemia. Thus we can say whether a patient with myocardial haemorrhage. Presumably the tongue had

The complete analysis of the results consists of 27 tables, but obviously a selection had to be made for our paper. JOHN GADDIE C SKINNER K N V PALMER

should distinguish vomiting due to thyrotoxic hypercalcaemia, vomiting due to thyrotoxicosis per se, and their coincidences. In the series of Gordon et a12 vomiting was found with equal frequency in both normocalcaemic and hypercalcaemic groups (about 300%' each). In fact, the only distinguishing symptoms of the hypercalcaemic group were apathy and constipation. PETR SKRABANEK

Professional standards.

BRITISH MEDICAL JOURNAL 6 NOVEMBER 1976 1133 infarction will recover or not. I do a large number of post-mortem examinations and it is quite obviou...
282KB Sizes 0 Downloads 0 Views