BRITISH MEDICAL JOURNAL 30 APRIL 1977
Br Med J: first published as 10.1136/bmj.1.6069.1157-b on 30 April 1977. Downloaded from http://www.bmj.com/ on 26 October 2020 at Auckland University Technology. Protected by copyright.
should not now be extended to all independent
schools.
A rapid survey of those members of the
Medical Officers of Schools Association who
are responsible for girls in independent
schools indicates new grounds for concern
that adequate rubella immunity will not be
achieved in women of childbearing age. In the
present climate of alarm about all immunisation
procedures there is evidence that many more
parents in social classes I and II are with-
holding consent for rubella vaccination despite
informed advice from school doctors. It is
misleading to suggest that the low uptake in
girls of professional families is because they
are "more likely to attend independent schools
and therefore to be excluded from the
vaccination programme" and unjust to the
many medical officers of independent schools
who maintain the highest standards of
preventive medicine.
T W HOSKINS
Honorary Secretary,
Medical Officers of Schools Association
Christ's Hospital,
Horsham, Sussex
SIR,-In a recent article about rubella vaccina-
tion of schoolgirls (19 March, p 760) we are
told that in 1969 prior to the introduction of
this programme some 80-90% of women of
childbearing age had a naturally acquired
immunity. It was noted that significantly fewer
girls from professional families were vacci-
nated and suggested that this could be due to
lack of immunisation programmes in inde-
pendent schools.
I wonder if another explanation could be
that professional families are more likely to
appreciate that natural immunity is to be pre-
ferred and that a girl's chance of acquiring this
will be seriously reduced by vaccination. They
may wonder whether an injection at the age of
12 will continue to give adequate protection
after 20 or more years. Perhaps the girl may
decide to wait until she is contemplating
having a child before being vaccinated if she
is not immune.
The authors state that if the present pro-
gramme is to be successful almost 100% of
girls must be vaccinated. It is unrealistic to
hope for this in 12-year-old girls. This pro-
gramme will certainly lower the proportion of
childbearing women who are naturally im-
mune to rubella. It will produce a group of
women who will have dubious immunity in
their thirties. I believe its long-term result
will be to increase the incidence of fetal
abnormalities due to congenital rubella. It
should be replaced by a programmne of selective
vaccination of susceptible women before they
start childbearing.
The great majority of women manage to
plan their first pregnancy responsibly. It is
disgraceful to prejudice their chances of bear-
ing a normal child for the sake of those few
who cannot.
J F WOOD
Enfield,
Middlesex
Stillbirth, grief, and medical education
SIR,-The Rev Alan Swinton's letter (9 April,
p 971) is beguiling in its good sense, its
humanity, and its appreciation of his col-
leagues; but it just won't do. He is right to
protect patients from medical people who may
believe they always know what is best, and the
quotation from Lewis's paper' could possibly
be misread that way, being rather condensed
as well as psychologically sophisticated. Lewis,
jolly, and Morris have collaborated for some
years to develop an ambience in which prob-
lems like stillbirth can be thought about and
Lewis's paper discussed some useful approaches
and reflections from which colleagues else-
where can learn.
In considering whether or how to encourage
parents to handle a stillborn baby and attend
the funeral it is essential to grasp that here is a
syndrome in which the compulsive, even
overwhelming, aversion of professional atten-
tion is an integral part. This is not a moral
proposition for existential philosophy but a
clinical sign to be faced and recognised and
studied, like ketosis on the breath of a diabetic.
The syndromes around stillbirth include the
feature of extraordinary medical resistance to
publishing anything about it. Lewis and I are
preparing a separate paper on this curious
phenomenon and have accumulated quite a
dossier on it. Until my own paper,2 stumbling
upon the subject of reactions to stillbirth, I
was not able to find a single article on it nor
any mention of the topic in any index in the
English language, even though more must
presumably exist since the problem should be
obvious to a blind man. Even now we have
still found only one earlier reference, in an
American nursing journal.3 It followed
logically and inexorably for the paper to be
rejected by the Lancet and BMJ with the
entrancing explanation that enough had
already been published on the subject although
some better work was, allegedly, on the way.
Yet, courage, convention, and imagination
are not at all the issues since, if I may mention
it, the BMJ has published a number of
thornier papers4-6 in which I have had a hand
and even gave skilled editorial help with them
generally.
The next thing to grasp is that the danger
lies not in the grief and distress; the danger is in
bypassing it, thereby promoting a variety of
severe psychological complications. Moreover,
the danger is not merely to the mother but
also to her husband, her surviving children,
and, worst of all, to the next baby. To be the
surviving twin of a stillbirth can sometimes
be a special catastrophe. Whereas grief is
relatively understandable and obvious, these
other dangers are complex; their management
and prevention are very hard.
To approach this difficult territory in bland
optimism, trusting to a bit of native humanity
and ordinary good sense, is just silly. We
teach doctors about the theory of bacteriology
and train them in the use of aseptic techniques;
we do not merely rely on their good upbringing
and hope they will wash behind their ears.
Syndromes and remedies in medicine require
initial description with delineation of detail,
and some of this has begun7'-l regarding
stillbirth reactions.
I am sorry to find a priest giving support
to the amateurism in psychosocial matters
that usually passes for medical education, with
its breathtaking illiteracy in the behavioural
sciences and the catastrophic pharmaceutical
prescribing that is its counterpart. The clergy
are often more attuned than doctors, but an
attitude of Christian charity to medical blind
spots, double vision, and despair" is becoming
as disastrous as "forgiving" dirty hands in the
operating theatre would be. It seems'2 1" we
now have well over 100 000 emergency
admissions each year due to overdoses of
drugs, mostly prescribed by doctors. The
1157
current increase will fill all emergency beds
by 1984. Is it still seriously to be proposed
that we can rely on the general good sense of
doctors? Let's at least get our heads down
and look at a few problems. Stillbirth is one.
Thank heaven for the lay press in giving us
a bit of a lead'4 15 and thanks, however
belatedly, for the recent response in the chief
medical journals. Psychiatrists, of course, have
yet to catch up. I think it quite interesting that
certain paediatricians have been quickest off
the mark. Perhaps they have the sharpest
sense of the children who failed to live.
S BOURNE
Tavistock Clinic,
London NW3
Lewis, E, Lancet, 1976, 2, 619.
2Bourne, S, Journal of the Royal College of General
Practitioners, 1968, 16, 103.
3Newton, N, and Newton, M, Journal of the American
Medical Association, 1962, 181, 206.
Bourne, S, and Bruggen, P, British Medical Journal,
1975, 1, 162.
Bruggen, P, and Bourne, S, British Medical Journal,
1976, 1, 536.
Bruggen, P, and Bourne, S, British Medical Journal,
1977, 1, 462.
7Lewis, E, in Proceedings of the Third International
Congress of Psychosomatic Medicine in Obstetrics and
Gynecology, ed Norman Morris, p 323. Basel,
Karger, 1971.
Lewis, E, and Page, A, British Journal of Medical
Psychology, in press.
Jolly, H, Proceedings of the Royal Society of Medicine,
1976, 69, 835.
Morris, D, Proceedings of the Royal Society of Medicine,
1976, 69, 837.
Bourne, S, and Lewis, E, Journal of the Royal College
of General Practitioners, 1977, 27, 37.
12 Jones, D I R, British Medical Journal, 1977, 1, 28.
13 Ghodse, A H, British Medical Journal, 1977, 1, 805.
14Jolly, H, The Times, 3 December, 1975.
" Mooney, B, Guardian, 8 January 1976.
Localised airway obstruction
SIR,-Your leading article (12 March, p 669)
ends with the statement: "Whenever the
possibility [of localised airway obstruction] is
suspected flow volume curves should give the
answer." This conclusion appears to be largely
based on the work of Harrison,' who reported
16 patients with upper airway obstruction and
claimed that respiratory function tests, in
particular the flow volume loop, play an
essential part in the recognition and manage-
ment of this problem. In fact, the cause of the
obstruction in most of Harrison's patients was
fairly obvious (tracheal stricture after tracheos-
tomy and lesions of the larynx, pharynx, and
tongue). Only in one case, a patient with a
benign tracheal tumour, was there not a
cogent reason for suspecting localised airway
obstruction, and even in that particular case it
would have been difficult to ignore the
diagnostic implication of the expectoration of
a lump of pink material followed by haemopty-
sis.
The use of flow volume loops to investigate
these patients, although of considerable
academic interest, can have contributed very
little in practical terms to their diagnosis and
management, and it is unfortunate that you
should have placed so much emphasis on the
value of a procedure which requires fairly
sophisticated equipment unlikely to be
available outside major teaching centres.
Leaving aside lesions of the larynx and pharynx,
which seldom present serious diagnostic
problems, the important causes of localised
airway obstruction are tracheal stricture
following tracheostomy, benign lesions of the
trachea-for example, cylindroma-and malig-
nant tumours involving the tracheal
bifurcation. All these lesions may present with
symptoms resembling chronic asthma, they

1158
are all amenable to appropriate treatment, and
in every case the diagnosis can be made rapidly
and reliably by endoscopic examination.
Endoscopy is mentioned in the article, but
almost casually, and the reader is left with the
impression that physiological investigations,
particularly the flow volume curve, are of
much greater importance. The article would,
in my view, have served a more useful purpose
if it had included a short account of the
indications for endoscopic examination in the
type of case in which localised obstructive
lesions of the trachea and main bronchi are apt
to be mistaken for asthma. Stridor is, of course,
a characteristic feature in such cases (it was
present in all but one of Harrison's 16 patients),
but physicians are often slow to distinguish it
from wheeze and perhaps need reminding
that it is accentuated by coughing. This is
indeed always the case with inspiratory stridor,
which is by far the most common type. It will
seldom be missed if the patient takes a few
deep inspirations with the mouth open, and is
then asked to cough. Laryngoscopy and
bronchoscopy should be carried out
immediately on every patient with stridor.
Although advanced diffuse airways obstruction
occasionally produces apparently typical
stridor, the number of such patients who may
be unnecessarily subjected to endoscopic
examination will be extremely small. Finally,
it must be emphasised that tracheal stricture
is a not uncommon complication of tracheos-
tomy, particularly in patients who require
artificial ventilation via a cuffed tube for
several weeks, and this possibility should
always be considered when dyspnoea and
"wheeze" develop for the first time within six
months of removal of the tracheostomy tube.
There are still a few situations in medical
practice where a direct diagnostic approach has
much to commend it, and this, pace the
respiratory physiologists, is surely one of them.
IAN W B GRANT
Respiratory Diseases Unit,
Northern General Hospital,
Edinburgh
Harrison, B D W, Quarterly J7ournal of Medicine,
1976, 45, 625.
Tourist hepatitis
SIR,-With reference to your leading article
(22 January, p 189), as one with some respon-
sibility for the health of a large number of
people travelling to and living in overseas
territories I have found it difficult to formulate
a rational policy for prophylaxis of hepatitis.
Official guidance is scanty. During 1976 the
Department of Health and Social Security
advocated gammaglobulin injections for those
travelling to Ecuador and Iran. Now the
advice offered is more general. Taiwan,
Indonesia, and "South America" (Dr F
Morgan, 5 March, p 646) are territories with
an allegedly high level of prevalence. It would
seem that a great part of the assessment of risk
is anecdotal (vide Dr Morgan's letter) and
furthermore no attempt is made to relate risk
to mode of living. The executive living in a
hotel is less vulnerable than his technical
colleague investigating the efficacy of a
pesticide in an underdeveloped rural area.
Elementary precautions, like eating only cooked
food while it remains hot and avoiding all
dubious sources of water, may help prevent
infection with hepatitis A virus. Hepatitis B
appears to be capable of transmission by biting
BRITISH MEDICAL JOURNAL
insects and sexual contact, factors more
difficult to control.
What are the risks of repeated injections of
human immunoglobulin ? American practice is
to give injections at six-monthly intervals,
although the passive immunity gained after
each injection is probably only of a high order
for three months. Has any attempt been made
to investigate the large numbers of individuals
injected repeatedly over many years in
pursua,nce of this policy?
F W BEST
Imperial Chemical Industries Ltd,
London SWI
***Official guidance is scanty simply because
hard data are just not available. On theoretical
grounds, however, it is certainly likely that
technical personnel employed in field work in
underdeveloped areas are in greater need of
protection than executives who do not stray
far from their modern hotels. The precautions
which can be taken are alluded to in Dr
Best's letter.
With regard to the risks of repeated injec-
tions of human immunoglobulin, this seems to
be small, although reactions have been
described. The report of the MRC Working
Party on Hypogammaglobulinaemial describes
one death in a 27-year-old man with hypo-
gammaglobulinaemia who had been receiving
weekly injections of immunoglobulin for four
years and some occasional generalised but non-
fatal reactions in other patients treated in a
similar way. It is unlikely, however, that
repeated injections to prevent viral hepatitis
(which would have to be given every four
months to provide complete protection)
would give rise to anything moi,e serious than
local pain.-ED, BMJ.
Medical Research Council, Hypogammaglobulinaemia
in the United Kingdom. Special Report Series No
310. London, HMSO, 1971.
Orthopaedic services in Lincoln
SIR,-A recent six-week locumship spent in
Lincoln as consultant orthopaedic surgeon-
a capacity in which I served Derby for 25
years-filled me with the gravest concern for
both the folk of Lincoln and its surroundings,
for which the Trent Regional Health Authority
is responsible, and for my two colleagues who
are flogging themselves to death in the effort
to meet the clinical demands.
That there should be a 4-5-year waiting list
for such a cost-effective and pain-relieving
operation as the installation of an artificial
hip is atrocious; that it requires to be done
in an unprotected theatre shared with other
cases of an infected nature is wrong-both
for this and many other orthopaedic cases
involving large implants.
A shortage of "second-stage" or convales-
cent beds is clogging the top-grade surgical
wards and a waiting period of some 8-10 weeks
for outpatient consultation fills in a sorry
picture which might well sustain litigation by
the folk of Lincoln against the regional
health authority, who are clearly not doing
their duty. However, the action would simply
call forth the defence of lack of funds and
be as destructively wasteful for the country
as the "strikes" have been. Nevertheless, this
state of affairs does draw painful attention to
the even more fearful shortage of funds suf-
fered by our armed services.
The solution for Lincoln, and for the many
similarly deprived areas throughout the NHS,
Br Med J: first published as 10.1136/bmj.1.6069.1157-b on 30 April 1977. Downloaded from http://www.bmj.com/ on 26 October 2020 at Auckland University Technology. Protected by copyright.
30 APRIL 1977
is simple. Charge a "hotel-fee" daily for all in
hospital and increase the number of highly
remunerative private beds, these funds to be
used locally where they are earned to finance
more consultant staff and more convalescent
beds. Also encourage local voluntary subscrip-
tion, which would quickly provide a sterile-air
operating tent in the existing theatre.
Meanwhile invite those so long and patiently
waiting sufferers to come elsewhere.
R LUNT
Boylestone,
Derbyshire
***Mr Lunt sent a copy of this letter to
Professor J A Scott, regional medical officer
to the Trent RHA, whose reply is printed
below.-ED, BM7.
SIR,-So long as the Trent RHA is under-
resourced it will have to select particular
services for improvement and inevitably some
parts of the population it serves will have to
wait for the developments which no one
doubts are necessary. A great deal of capital
development has already been undertaken in
Lincolnshire, and while most of this has been
at Boston, Lincoln itself has benefited through
the construction of new geriatric and younger
disabled units at St George's Hospital and a
new general operating theatre at the County
Hospital. New geriatric wards have also been
built at Gainsborough and an upgraded
accident department is under construction at
the Lincoln County Hospital.
It is very easy to criticise the inadequacies
of the National Health Service, but funda-
mentally they are not of its making.
J A SCOTT
Trent Regional Health Authority,
Sheffield
Responsibility and management in
pathology laboratories
SIR,-It has been brought to the attention of
the Wolverhampton Consultants' Committee
that evidence has been submitted to the Royal
Commission on the National Health Service
by the Institute of Medical Laboratory
Sciences in which the opinion was expressed
that the managerial head of the medical
laboratory service in each health district should
be a medical laboratory scientist (technician)
accountable to the district management team
for all medical laboratory investigations per-
formed in the district. This opinion was
unacceptable to the committee, which con-
sidered that the only appropriate person to be
the head of a laboratory is a consultant
pathologist.
This matter has recently been ventilated
in your journal and I am instructed by the
committee to say that we have written to the
presidents of the royal colleges recommending
that recognition for postgraduate training for
their examinations should be withdrawn from
all establishments where laboratory services
are not headed by a consultant pathologist or
in certain cases by a scientific officer of
equivalent standing.
J A MACDOUGALL
Chairman,
Consultants' Committee,
Wolverhampton Area Health Authority
New Cross Hospital,
Wolverhampton