The BMJ’s Nuremberg issue

Many people are still uncomfortable withthe topic of Nazi medicine

Editor—The BMJ’s issue commemoratingthe Nuremberg doctors’ trial1 is a coura-geous attempt to address an uneasy topic,for which the editor deserves praise. The fol-lowing short account may show just howbrave it is.

Having a longstanding interest in uncov-ering Nazi medical atrocities, I decided towrite a four part series on the subject andsuggested the idea to the Journal of PhysicalMedicine and Rehabilitation. Being one of twoeditors in chief of this journal, I did not wantto exert any pressure and accepted withoutfurther comment that the Belgian coeditorin chief rejected my offer. The RoyalBelgium Society of Physical Medicine andRehabilitation, which is officially affiliated tothe journal, apparently heard of my planand its rejection and was outraged by thenotion of the journal touching the subject.When I mentioned medicine during theThird Reich in a recent editorial in thejournal2 the secretary general of the society

Advice to authorsWe receive more letters than we can publish: wecan currently accept only about one third. Weprefer short letters that relate to articlespublished within the past four weeks. We alsopublish some “out of the blue” letters, whichusually relate to matters of public policy.

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reacted by demanding from the journal’spublisher, Blackwell, that I immediatelyresign from my position as editor in chief:“With great dismay we read Professor Ernst’seditorial and paper on Nazi medicine ... and... demand Professor Ernst’s resignation aseditor in chief, otherwise the society willwithdraw from the journal in 1997.”Blackwell stood behind me in this matter,and the journal is now dissociating from theBelgian society. I should add that my verybrief mention of Nazi medicine was in thecontext of a historical account of homoeo-pathy in Germany and that my original fourpapers relating to the Nuremberg doctors’tribunal are currently being published inWiener Medizinische Wochenschrift, which isalso published by Blackwell.3

This anecdote illustrates how uncom-fortable many people are with the topic ofNazi medicine. The BMJ and WienerMedizinische Wochenschrift show that the con-cern for important ethical issues shouldoverride other interests with a view tobenefiting the medical community.E Ernst DirectorDepartment of Complementary Medicine,Postgraduate Medical School, University of Exeter,Exeter EX2 4NT

1 Leaning J. War crimes and medical science. BMJ1996;313:1413-5. (7 December.)

2 Ernst E. Similia similibus curentur: 200 years ofhomoeopathy. Eur J Phys Med Rehab 1996;6:133.

3 Ernst E. 50 years ago: the Nuremberg doctors’ tribunal.Part 1: The descent towards medicalised murder. WienMed Wochenschr 1996;146:574-6. [Parts 2, 3, and 4 are inpress.]

Abortion and euthanasia evoke thoughtsof Nazi Germany

Editor—The concern about doctors andfascism reported in a news article is rightand proper.1 We are living in a society basedon the survival of the fittest—a culture thatincreasingly considers it legitimate to pickoff the weak and dispose of the inconven-ient. In Nazi Germany psychiatric patientswere considered to be inconvenient, andthousands were put to death. It was donelegally, it was done behind closed doors, andit was done with the cooperation of the doc-tors of the day.

Now it is unwanted children who are“inconvenient,” and 170 000 are put to deathin England and Wales each year. It is donelegally, it is done behind closed doors, and itis done by the medical profession. And, too,doctors sit back as euthanasia is debated in

the media—legalised disposal of expensiveand troublesome elderly people. What next?Hugh J Thomson Consultant surgeonBirmingham Heartlands Hospital, BirminghamB9 5SS

1 Woods D. Lessons still need to be learned fromNuremberg. BMJ 1996;313:1422. (7 December.)

College oath requires physicians to doeverything for the welfare of the state

Editor—Hartmut M Hanauske-Abel showshow German doctors embraced subservi-ence to the Nazis as early as 1933: “To servethis State must be the sole objective of themedical profession,” as one of them wrote.1

From this all the rest—forced sterilisations,involuntary euthanasia, and medical“experiments”—duly followed.

It is surprising, then, that the Royal Col-lege of Physicians requires as a condition ofadmission to the fellowship the completionof a “form of faith,” in which the doctorpromises to “do everything ... to the honourof the College and welfare of the State”without mention of responsibilities toindividual patients. Doubtless most doctorswould hold that their primary obligation wasto their patients; and, in so far as the stateserves to protect the interests of its citizens,the welfare of the state and the welfare ofpatients may coincide. It is not difficult, how-ever, to conceive of situations in which con-flict might arise, and it seems remarkablethat such a form of faith has survived andfound signatories in the post-Nurembergera.Geoffrey Nicholson Consultant physician99 Broadbottom Road, Mottram, Near Hyde,Cheshire SK14 6JA

1 Hanauske-Abel HM. Not a slippery slope or sudden sub-version: German medicine and national socialism in1933. BMJ 1996;313:1453-63. (7 December.)

Photographs exploited their subjects

Editor—I have no doubt that both HartmutM Hanauske-Abel and the BMJ’s staff gave agreat deal of thought to the inclusion ofphotographs showing experiments on pris-oners in Dachau concentration camp.1 I alsorealise the conflict between “never forget-ting” what happened and exploitation, butfor me these photographs were a furtherabuse of those who were unwilling partici-pants in the first place.K Osborne Senior scientist in epidemiology1A Boothby Road, London N19 4AA

1 Hanauske-Abel HM. Not a slippery slope or sudden sub-version: German medicine and national socialism in1933. BMJ 1996;313:1453-63. (7 December.)

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Nobody died during experiments onvitamin C and vitamin A intakes inSheffield

Editor—The important issue commemorat-ing the Nuremberg doctors’ trial contains anarticle by Paul Weindling reporting thepresence of a BMJ correspondent at thetrial.1 Weindling mentions research carriedout in Sheffield on human volunteers whowere conscientious objectors in the secondworld war and writes that “a volunteerreceiving a depleted intake of vitamin C haddied of a heart attack.” This is not true.

I was a member of the research team(which was directed by Sir Hans Krebs) andwas responsible for the clinical aspects of theexperiment, which was designed to deter-mine the human requirements for vitaminC. It was reported fully in 1953.2

None of the volunteers died in either thevitamin C deprivation experiment or the vita-min A deprivation experiment that precededit, although one man, Milburn, came close todeath in the vitamin C experiment. Afterspending 229 days on a diet as deficient invitamin C as we could make it he had clearevidence of scurvy, including bleeding gumsand haemorrhages round the hair follicles ofthe legs. One night, after these signs hadappeared, he developed all the majorsymptoms of coronary thrombosis. He wastreated at once with intravenous vitamin Cand recovered completely. Haemorrhage intothe heart or pericardium was diagnosed.

All 10 volunteers on the vitamin C freediet developed clinical scurvy, of whom one,Drake, had considerable bleeding into aknee joint after a bicycle ride. The experi-ment confirmed that in scurvy, in addition tobleeding into the gums and skin, bleedingmay occur anywhere, sometimes with seri-ous results. It enabled us to suggest aminimum daily human requirement of 30mg of vitamin C.

Other experiments were carried out onthese volunteers, including experiments intothe transmission of scabies, the effects oftotal deprivation of water for three days (the“shipwreck experiment”), and the effects ofliving on a diet from which vitamin A wasexcluded for nearly two years.

The informed consent of the volunteerswas always obtained in the experiments inSheffield. These volunteers played an impor-tant part in making measurements andrecording data, and they asked that theirnames be recorded in the Medical ResearchCouncil’s reports when these were published;this was done. In the course of theexperiments they often suffered considerablediscomfort and in some cases quite seriousillness. They helped to make some importantcontributions to medical knowledge, and theyshould be remembered in medical history.John Pemberton Emeritus professor of social andpreventive medicineIona, Cannon Fields, Hathersage, SheffieldS30 1AG

1 Weindling P. Human guinea pigs and the ethics ofexperimentation: the BMJ’s correspondent at theNuremberg medical trial. BMJ 1996;313:1467-70. (7December.)

2 Bartley W, Krebs HA, O’Brien JRP. Vitamin C requirementof human adults: a report by the vitamin C subcommittee of theAccessory Food Factors Committee and others. London: Medi-cal Research Committee, 1953.

Compulsory sterilisation of defectivepeople was legal in several countriesbesides Germany

Editor—In the BMJ’s splendid Nazi issueHartmut M Hanauske-Abel explains thatcompulsory sterilisation of defective peoplein Germany was inspired by pre-Nazi medicaleugenicists.1 However, this policy was firstimplemented in the United States, in Indiana,in 1907 “to prevent procreation of confirmedcriminals, idiots, imbeciles and rapists.”2

By 1913 such sterilisation was legalisedin 12 states, and more than 60 000 peoplewere sterilised between 1907 and the 1970s,especially in California. Moreover, such laws,conceived and carefully drafted by doctors,were upheld by the United States SupremeCourt in 1927 and were still valid in 1985 in19 states. These laws were useful models forlegislation elsewhere, not only by the Nazisin 1933 but also in Alberta and Denmark(1928), Norway and Sweden (1934), andFinland (1935).J H Baron Honorary professorial lecturerGastrointestinal Division, Mount Sinai School ofMedicine, New York, NY 10029-6574, USA

1 Hanauske-Abel HM. Not a slippery slope or sudden sub-version: German medicine and national socialism in1933. BMJ 1996;313:1453-63. (7 December.)

2 Reilly PR. The surgical solution: a history of involuntary steri-lisation in the USA. Baltimore: Johns Hopkins UniversityPress, 1991.

Use of Nazi material during medicaltraining left an uncomfortable feeling

Editor—I read with interest the articlescommemorating the anniversary of theNuremberg doctors’ trials.1 They remindedme of an incident during my undergraduateteaching at Cambridge University asrecently as 1981. We were given a physiologylecture on respiration and, to illustrate themovements of the respiratory muscles, wereshown film that, we were told, had beentaken in a Nazi concentration camp. Thefilm lasted several minutes and showed themovements of the diaphragm and othermuscles involved in breathing in a boy whohad been exposed to a much higher dose ofx rays than was known to be safe.

I remember that our lecturer’s justifica-tion for using this material was thatsomething positive could come out of such adreadful time. I also remember feelinguncomfortable about the film, but, to myshame, I said nothing, nor did I discuss itwith other students afterwards. I would beinterested to know if contemporaries ofmine recall this incident and whether theuniversity continues to use the material.Margaret Hannah Consultant in public healthFife Health Board, Cupar, Fife KY15 5UP

1 Leaning J. War crimes and medical science. BMJ1996;313:1413-5. (7 December.)

Is enough enough?

Editor—The BMJ is important not onlybecause of the medical articles it publishes—

other journals do that too—but because of itscommitment to culture: the fearless desire toeducate, to stimulate, and to amuse its read-ers. The recent Nuremberg issue was literallyastonishing.

Those of us who are not “historicalrevisionists” are well aware of the barbarismof the Nazi era perpetrated by not onlyGermans. But I, along with the many, hadalways assumed that most of the population,including the medical profession, were con-verted either via “the slippery slope” orthrough “sudden subversion.” But theremarkable paper by Hartmut M Harnauske-Abel shows that this was not so, and I wasshocked by the extraordinary cover up subse-quently by the German authorities and medi-cal establishment and by the drastic conse-quences for him.1 This tends to confirmGoldhagen’s controversial assertion thatthere was no sudden forced subversion of thewillingly anti-Semitic Germanic population.2

And then I thought: why should a medi-cal journal thrust these issues before uswhen historical journals have not, by andlarge, produced any of this direct, shockingmaterial—even the direct report of Hitler’sprewar diatribe? Will the general press orjournals republish or comment on thisissue’s articles? Why should an organ of aninstinctively conservative profession (amedical journal) risk causing controversyand possible friction with its peer Europeanjournals? Why now? What purpose does itserve to hound these perpetrators for thewhole of their lives; is enough enough,particularly after this length of time? Shouldthe Christian ethic of forgiveness be themotto of a largely non-Christian world,especially when that world watched theBalkan Christians showing that Europeanbarbarity is alive and well?

As someone who has a legacy ofmid-century “European culture” and whohas never known grandparents or aunts oruncles, I found these questions springing upas I read these brave, distressing articles.Harry Preston Medical practitioner838 Doncaster Road, Doncaster, Victoria 3108,Australia

1 Hanauske-Abel HM. Not a slippery slope or sudden sub-version: German medicine and national socialism in1933. BMJ 1996;313:1453-63. (7 December.)

2 Goldhagen DJ. Hitler’s willing executioners. London: Little,Brown, 1996.

Access to computedtomography in British accidentand emergency departmentsEditor—Julien Bogousslavsky highlights theneed for further trials of thrombolysis inpatients presenting soon after the onset ofacute ischaemic stroke.1 However, beforerandomisation the patient must have com-puted tomography to exclude intracranialhaemorrhage as the cause of the stroke.Computed tomography has not been widelyavailable in the United Kingdom.2 Accidentand emergency departments are well placedto perform the initial triage and assessment

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of patients presenting with acute stroke, buta selective audit suggested that access tocomputed tomography in these depart-ments was patchy.3 We therefore conducteda comprehensive survey of the access tocomputed tomography in British accidentand emergency departments.

We posted questionnaires to all theaccident and emergency departments listedin the 1996 directory of the British Associ-ation for Accident and Emergency Medicine.4

All questionnaires were accompanied by aletter explaining the purpose of the study anda reply paid envelope. The questionnairesand accompanying letters were addressed tothe consultant in charge. Reminder letterswere sent to all non-respondents two weeksafter the initial posting. Thereafter, non-respondents were sent one further reminder.

Two hundred and thirty two of the 273general, adult, main accident and emergencydepartments responded (response rate85%). The non-responding departmentshad similar rates of annual attendance tothose of the responders. Of the respondents,205 departments had onsite computed tom-ography. Departments in hospitals withoutscanners for computed tomography hadsignificantly lower mean annual attendances(32 044 v 53 487, P < 0.05). In 142 of theresponding departments the scanner wassited either adjacent to or within theaccident and emergency unit itself. Access tourgent computed tomography is shown intable 1. Four fifths of responding consultants(185) were interested in receiving furtherinformation about a proposed future ran-domised controlled trial of thrombolysis inpatients with acute ischaemic stroke.

The Audit Commission recently sug-gested that 24 hour computed tomography isan essential support service for all main acci-dent and emergency departments.3 We foundthat almost all of the main departments havea scanner in their hospital. A surprisinglyhigh proportion of these scanners werelocated within (or adjacent to) the accidentand emergency unit itself. Although the avail-ability of computed tomography seems to bebetter than suggested by the Audit Commis-sion’s report,3 urgent computed tomographyoutside normal working hours for patientswith stroke was not readily available in asignificant proportion of departments. Nonethe less, computed tomography is nowavailable in sufficient British accident andemergency departments for further trials ofthrombolysis within a few hours of onset of

ischaemic stroke to be undertaken in theUnited Kingdom.Paul Dorman Medical Research Council clinicaltraining fellowPeter Sandercock Reader in neurologyNeurosciences Trials Unit, Department of ClinicalNeurosciences, University of Edinburgh, WesternGeneral Hospital, Edinburgh EH4 2XU

1 Bogousslavsky J. Thrombolysis in acute stroke. BMJ1996;313:640-1. (14 September.)

2 Langton Hewer R, Wood VA. Availability of computedtomography of the brain in the United Kingdom. BMJ1989;298:1219-20.

3 Audit Commission. By accident or design: improving A&Eservices in England and Wales. London: HMSO, 1996.

4 British Association for Accident and Emergency Medi-cine. Directory 1996. Lavenham, Suffolk: Lavenham Press,1996.

Who should talk to patientswith cancer about genetics?Editor—Mutations in the recently identifiedBRCA1, BRCA2, MLH1, and MSH2 genesare associated with high risk of developingcommon cancers—namely, of the breast,ovary, and colorectum.1 2 As the generalpublic is already informed in the popularpress about the increased risk of cancer it isnot surprising that the demand for genetictesting is increasing.3 The organisation, staff-ing, and funding of specialist breast andovarian cancer clinics is a topical issue.

Stoll stated that oncology nurses shouldstaff specialist breast and ovarian clinics,3

whereas Campbell et al preferred theappointment of specialist genetic nurseswith training in oncology.4

However, doctors and nurses in allspecialties caring for patients with cancerwill be required to give information. Weinvestigated how this group of healthprofessionals responds to patients’ inquiriesabout familial cancer by circulating aconfidential questionnaire to 19 senior doc-tors and 14 nurses. The questionnaire wasdesigned to obtain information on theirgeneral knowledge about cancer genetics,the clinical application, and their views onissues concerning genetic testing.

Twenty questionnaires were returnedfrom 10 doctors and nurses. On averageeach practitioner saw 150 patients with can-cer a year. The survey showed an obviousdichotomy between wanting to provideinformation on genetics and further man-agement and their inability to do so. Familyhistory of cancer was not discussed routinelybecause of lack of time. Criteria for genetictesting or screening were not used. Inaddition, staff did not appreciate theassociated issues surrounding genetic test-ing (impact on individual patients and theirfamilies and the need for confidentiality).

Genetic units can and should providecontinuing education and guidance onprotocols for genetic testing and collaboratewith specialties to formulate screening proto-cols. The organisation of a local multidiscipli-nary team to set up studies to evaluate genetictesting and outcomes of clinical managementfunded by the NHS research and develop-ment programme would ensure that each

specialty’s skills are used. Cancer genetic serv-ices will then become an integral part of clini-cal practice, as requested by the respondentsto our questionnaire.

The quality of information giving oncancer and genetics is directly related to theknowledge of professionals and their abilityto communicate this to a patient regardlessof their specialty. If they do not know theanswer to a question they must be able torefer the patient to someone who does.Wendy Chorley Macmillan genetic nurse specialistKay MacDermot Senior lecturer in clinical geneticsClinical Genetic Department, Royal Free Hospital,London NW3 2QG

1 Easton DF, Ford D, Bishop DT, Breast Cancer LinkageConsortium. Breast and ovarian cancer incidence inBRCA1-mutation carriers. Am J Hum Genet 1995;56:265-71.

2 Liu B, Parsons R, Papadopoulos N, Nicolaides NC, LynchHT, Watson P, et al. Analysis of mismatch repair genes inhereditary non-polyposis colorectal cancer patients.Nature Med 1996;2:169-74.

3 Stoll B. Specialist breast and ovarian cancer clinics shouldbe staffed by oncologist nurses. BMJ 1996;312:913.

4 Campbell H, Mackay J, Porteous M. The future of breastand ovarian cancer clinics—no longer just research, now aclinical need. BMJ 1995;311:1584.

Registering a fetus papyraceus

Registration is important for researchinto cerebral palsy

Editor—R F Heys questions the need toregister a fetus papyraceus as a stillbirthwhen the cotwin survives, pointing out thedistress it causes to the parents.1 We believe,however, that limiting the registration ofstillbirths to those weighing ≥ 500 g, asrecommended by the World HealthOrganisation, would be a retrograde step.

It is well recognised that, in a twin preg-nancy, if one twin dies in utero the cotwinhas a high risk of cerebral palsy, particularlyif the twins were monochorionic. In twopopulation based series the risk of cerebralpalsy in a surviving twin when the cotwindied in utero was about 1 in 10.2 3

The Mersey cerebral palsy register hasdetails of 18 twin pregnancies in which onetwin was recorded as dying in utero in theobstetric notes and the surviving cotwin hadcerebral palsy. These 18 twin pregnancieshave been traced through the birth anddeath registrations of the Office for NationalStatistics, and in six the fetal death was notregistered, although it was a legal require-ment to do so. This has led to the hypothesisthat the spastic form of cerebral palsy is dueto the death of one twin early in gestation—that is, apparently singleton infants with cer-ebral palsy were one of twins in which thecotwin died early in gestation and was notrecognised. We have proposed that cerebralpalsy is predominantly the result of the van-ishing twin phenomenon.4 If this hypothesisis not refuted it will be extremely importantfor parental counselling not only that a fetuspapyraceus should be registered but that theeven earlier death of a twin diagnosed byultrasonography should be noted andfollowed up.

Heys is also concerned that upholdingthe legal requirement could seriously distort

Table 1 Numbers of accident and emergencydepartments in the United Kingdom with access tourgent computed tomography (n=232)

Easyaccess

Access withdifficulty

Access for urgent cases:

During normal working hours 195 11

Out of hours 156 31

Access for acute stroke*:

During normal working hours 121 71

Out of hours 59 102

*If thrombolysis was being considered.

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the stillbirth statistics of hospitals undertak-ing selective termination. Surely allowancecan be made for this when stillbirth rates arecompared. Being a slave to numerical datacan be counterproductive; what is needed isthe reason for the stillbirth, whether it ispreventable, and what its consequences are.If parents find it distressing to have to regis-ter a “barely recognisable scrap of human-ity” as a stillborn child and go through thetrauma of funeral arrangements there mustbe a better way of dealing with the problemthan leaving them in ignorance.

Incidently, the evidence suggests thatonly monochorionic twins are at risk if onedies in utero. Treatment for infertility resultsin multiple zygosity, and selective termina-tion will not increase the risk of cerebralpalsy if the proposed hypothesis is correct.P O D Pharoah Professor of public healthR W I Cooke Professor of child healthUniversity of Liverpool, Liverpool L69 3BX

1 Heys RF. Selective abortion. BMJ 1996;313:1004. (19October.)

2 Grether JK, Nelson KB, Cummins SK. Twinning andcerebral palsy: experience in four northern Califor-nian counties, births, 1983 through 1985. Pediatrics1993;92:854-8.

3 Pharoah POD, Cooke T. Cerebral palsy and multiplebirths. Arch Dis Child (in press).

4 Pharoah POD, Cooke RWI. A hypothesis for theaetiology of spastic cerebral palsy: the vanishing twin. DevMed Child Neurol (in press).

Health professionals can exercisediscretion

Editor—R F Heys’s letter about the require-ment to register all “births” of a fetuspapyraceus highlights the confusion amongmidwives, obstetricians, and registrars ofbirths and deaths on this issue.1 In 1995 Ilooked after a woman who was known to havehad a first trimester death of one of her twotwins. I issued instructions that the birth wasto be recorded and registered as a singleton.Soon after the birth I was informed by one ofour senior midwives that the local registrarhad previously advised that such birthsshould be recorded as multiple births, with astillbirth being registered. Having discussedthe matter with the local registrar—whorepeated this advice—I took it up with thenational office and subsequently wrote to thesecretary of state for health for clarification.The matter was dealt with by G Hughes, thehead of branch, general register office, Officeof Population Censuses and Surveys (now theOffice for National Statistics). His responsewas that, while the law did technically requireregistration of a stillbirth, “in practice it iscomparatively rare for a papyraceus fetus tobe brought to the attention of the registrar,either by health professionals or by theparent(s). Moreover ... it is not usual practiceto chase up the non-attendance of suchevents.” This seems to give licence to obstetri-cians, midwives, and other health profession-als to exercise discretion in such cases.Malcolm Griffiths Consultant obstetricianLuton and Dunstable Hospital NHS Trust, LutonLU4 0DZ

1 Heys RF. Selective abortion. BMJ 1996;313:1004. (19October.)

Purchasers should requireproviders to set standards forpain reliefEditor—The sad tale by Matthew Juniper, ayoung rugby player, about the six weeks hespent in hospital after he injured his legshows the continuing lack of adequateknowledge of pain relief.1 Undergraduateand postgraduate education in pain reliefremains inadequate, and it is time that we setstandards.

The book Clinical Audit in Palliative Caredescribes a set of standards for palliativecare,2 which are readily adaptable for themanagement of pain. There are four corestandard statements.

Standard 1 (pain control)—All patientshave their pain and associated symptomscontrolled to a degree that is acceptable tothem, and achievable within current knowl-edge.

Standard 2 (collaboration)—There is effec-tive collaboration between nurses, doctors,and other professionals to provide supportfor patients in pain.

Standard 3 (patient information)—Thepatient has the information that he or sheseeks relating to the cause of the pain andthe options for treatment to enable him orher to make informed choices.

Standard 4 (education)—All professionalstaff have access to up to date knowledge onthe principles and practice of pain relief andcan show an appropriate level of skill fortheir area of work.

I invite all purchasers to require this oftheir providers (and, if they refuse, toprovide justification for their refusal). Per-haps the colleges and other authoritativebodies in medicine and nursing should signup as well. At the end of the 20th century itis a sobering thought that the first account ofopiate analgesia was given by Theophrastussome 2300 years ago.William G Notcutt Consultant anaesthetistJames Paget Hospital, Great Yarmouth NR31 6LA

1 Juniper M. The tale of two wards. BMJ 1996;313:1152. (2November.)

2 Higginson I, ed. Clinical audit in palliative care. Oxford:Radcliffe, 1993.

Diagnosing death

Start resuscitation first

Editor—The subtitle of Rodger Charlton’seditorial on diagnosing death—Getting itright if vital opportunities for resuscitationare not to be missed—misleads readers.1 Itdoes not emphasise the common need tostart resuscitation when the diagnosis is indoubt, which in practice is often while infor-mation is still being gathered from attend-ants. Only when the clinician has decidednot to try resuscitation does the thoroughexamination proposed by Charlton becomerelevant. Before making this decision respi-ration should not be checked until theairway is opened, and a pulse should not besought until effective ventilation has been

provided. Although we acknowledge the dif-ficulties posed by diagnosing death in thecommunity, the logical sequence of currentresuscitation guidelines2 3 must be followedunless (or until) a positive decision not toresuscitate has been made. Furthermore, inthe case of drowning these guidelines(including those referenced by Charlton) donot propose the Heimlich manoeuvre toexpel water from the lungs but amplydescribe the reasons for not doing so.Simon Mardel MSc student in public health andhealth services researchAberdeen AB24 3HXColin Thomas Practitioner in resuscitation medicineResuscitation Department, Hereford HospitalsNHS Trust, County Hospital, Hereford HR1 2ER

1 Charlton R. Diagnosing death. BMJ 1986;313:956-7. (19October.)

2 Handley AJ, Swain A, eds. Advanced life support manual.Resuscitation Council (UK). 2nd ed. London: ResuscitationCouncil (UK), 1994.

3 Advanced Life Support Working Party of the EuropeanResuscitation Council. Guidelines for advanced lifesupport. Resuscitation 1992;24:111-21.

Death after electric shock and lightningstrike is more clear cut than suggested

Editor—Some of Rodger Charlton’s asser-tions about death from environmentalcauses are faulty.1 He says that death shouldnot be confirmed after immersion untilwater has been expelled from the lungs by aHeimlich manoeuvre and that death shouldbe confirmed with extreme caution afterlightning strike, electric shock, and airwayobstruction. There is little, if any, evidencefor these statements.

Heimlich evaluated the manoeuvrenamed after him in animal experiments inwhich anaesthetised beagles had the larynxobstructed by a plugged endotracheal tubeand then by a meat bolus.2 In both cases theHeimlich manoeuvre dislodged the obstruc-tion from the upper airway. There was nosimulation of drowning in this work, andthere is no good evidence that the manoeu-vre is effective in expelling water from thelower airways.

Drowning without aspiration of fluidaccounts for 10-20% of deaths by drowning.There is a consensus that the amount ofwater obtained during attempts to emptythe lungs when it has been tried does notjustify the inherent delay in airway manage-ment and ventilation.3 In addition, theperformance of the Heimlich manoeuvre onvictims of immersion may exacerbate acervical spine injury or expel swallowedwater from the stomach, leading to aspira-tion. Attempts to empty the lungs denycasualties the more important interventionof cardiopulmonary resuscitation.

The inference that cardiopulmonaryarrest after lightning strike is particularlyamenable to successful resuscitation withprolonged cardiopulmonary resuscitationhas no substance in fact. It stems from a casereport in 19614 that was misinterpreted in aclassic article.5 There is no reason todistinguish apparent death from electricshock or lightning strike from otherarrhythmia related deaths such as ventricu-lar fibrillation. In the original case report the

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period of cardiac arrest was uncertain butwas at most 12 minutes from loss of pulse toreturn of spontaneous circulation.

The suggestion that death from upperairway obstruction requires an unusuallyprolonged resuscitation is illogical. Cardiacarrest from upper airway obstruction is pre-ceded by profound hypoxia and hypercarbiaand consequently results in a poor outcomefrom resuscitation efforts. We agree that thediagnosis of death in a domiciliary setting isbeset with pitfalls. The specific instances wehave detailed, however, are more clear cutthan Charlton asserts.Gregor Campbell-Hewson Specialist registrar,accident and emergency medicineConor V Egleston Senior registrar, accident andemergency medicineSusan M Robinson Consultant, accident andemergency medicineAddenbrooke’s NHS Trust, Cambridge CB2 2QQ

1 Charlton R. Diagnosing death. BMJ 1996;313:956-7. (19October.)

2 Heimlich HJ. Pop goes the cafe coronary. Emerg Med1974;6:154-5.

3 Handley AJ, Swain A, eds. Advanced life support manual.Resuscitation Council (UK). 2nd ed. London: ResuscitationCouncil (UK), 1994.

4 Ravitch MM, Lane R, Safar P, Steichen FM, Knowles P.Lightning stroke. Report of a case with recoveryfollowing prolonged artificial respiration. N Engl J Med1961;264:36-8.

5 Taussig HB. “Death” from lightning and the possibility ofliving again. Ann Intern Med 1968;68:1345-53.

Death of the brain stem means death ofthe individual

Editor—Rodger Charlton says in his edito-rial on diagnosing death that “complete ces-sation of circulation to the normothermicadult brain for more than 10 minutes isincompatible with survival of brain tissue.” 1

This implies that shorter periods arecompatible with recovery of the brain,whereas it is well known that the safe periodof normothermic circulatory arrest does notexceed 3 minutes. He also suggests that anisoelectric electroencephalogram is one ofthe criteria for diagnosing brain death,whereas this is not so in Britain.

Of more importance is the obfuscationintroduced by concepts such as somaticdeath and molecular death. There is onlyone kind of human death and that is theirreversible loss of the capacity for con-sciousness, combined with the irreversibleloss of the capacity to breathe (and hence tosustain a spontaneous heart beat). Hencethe importance of clearly defining the crite-ria for the diagnosis of brain stem death,which were issued by the medical royalcolleges in 19762 and which led to theacceptance that death of the brain stem wasthe necessary and sufficient condition ofdeath of the brain as a whole and that deathof the brain means death of the individual.Terence English MasterSt Catharine’s College, Cambridge CB2 1RL

1 Charlton R. Diagnosing death. BMJ 1996;313:956-7. (19October.)

2 Diagnosis of brain death. Statement issued by the honor-ary secretary of the Conference of the Medical RoyalColleges and their Faculties in the United Kingdom on11 October 1976. BMJ 1976; ii:1187-8.

Author’s reply

Editor—I thank the correspondents fortheir remarks and the additional infor-mation given. In reply to Simon Mardel andColin Thomas, I would strongly affirm, as Ihope my editorial does, that when the diag-nosis of death is in doubt resuscitationshould be started while vital information isgathered from attendants.

In reply to Gregor Campbell-Hewsonand colleagues, the unfortunate circum-stance of apparent death may indeed occuras a result of lightning strike. Two recentcase reports vividly describe patients whosuffered lightning strike and were reportedas “comatose at the scene, with dilated non-reactive pupils and circulatory arrest.”Through aggressive and prolonged resusci-tation these two patients were revived.1 Asimilar argument may be made for cardiacarrest as a result of electric shock.2

The diagnosis of death is not alwaysstraightforward, and it is coincidental thatanother paper on this subject recentlyreiterated two questions posed by myeditorial.3 Firstly, although the heart mayhave stopped and respiration ceased, the tis-sues retain the “vital principle of life” forsome time. During this period of somatic orsystemic death (cessation of vital processes)and lingering vitality can death truly be con-firmed? Secondly, are we to wait for molecu-lar death (the progressive and irreversibledisintegration of the body tissues) beforedeath can be pronounced with absolute cer-tainty but at the risk of considerable distressto attendants? Thus, in reply to Sir TerenceEnglish, the use of the concepts, somaticdeath and molecular death are not to obfus-cate but rather to clarify that death is a proc-ess rather than an event.

These philosophical concerns about thedefinition of death highlight that dilemmasremain about the scientific criteria currentlyused to diagnose and predict death. Thisargument is borne out by the criteria used todiagnose brain stem death, which inAmerica include an isoelectric electroen-cephalogram but in Britain do not.4 Simi-larly, when outcome after resuscitation isconsidered, views on the likelihood of goodneurological recovery as a result of cerebralanoxia are diverse, the upper limit varyingbetween articles; a recent paper suggested atime limit of up to 5 minutes.5 Evidently, achallenge exists to refine consensus guide-lines to diagnose death.Rodger Charlton Senior lecturer in primary healthcareSchool of Postgraduate Medicine, Keele University,Stoke on Trent ST4 7QB

1 Graber J, Ummenhofer W, Herion H. Lightning accidentwith eight victims: case report and brief review of the lit-erature. J Trauma 1996;40:288-90.

2 Fontanarosa PB. Electrical shock and lightning strike.Ann Emerg Med 1993;22:378-85.

3 Powner DJ, Ackerman BM, Grenvik A. Medical diagnosisof death in adults: historical contributions to current con-troversies. Lancet 1996;348:1219-23.

4 Evans DW. Brain stem death. J R Coll Phys Lond1996;30:88.

5 Quan L. Drowning issues in resuscitation. Ann Emerg Med1993;22:366-9.

Office for National Statisticsneither conceals nor puts spinon statisticsEditor—Richard Smith accuses the Officefor National Statistics of burying differencesin death rates between rich and poor men inEngland and Wales.1 Nothing could befurther from the truth. The office isindependent and makes no value judgmentas to whether figures are good or bad. Itcertainly is not in the business of concealingor putting a spin on its statistics.

A stream of articles on this subject hasbeen published in recent editions of Popula-tion Trends. This year will see a majorpublication devoted to socioeconomic dif-ferences in mortality. When PopulationTrends was published in December I chaireda press briefing, to which the BMJ wasinvited. The conference lasted almost oneand a half hours, and these statistics werediscussed extensively.

In Smith’s analysis of subsequent presscoverage he fails to mention the PressAssociation, whose material is available tomedia outlets nationwide. It led with thisstory, with the headline “Poor die at threetimes rate of rich.”John Fox Chief medical statisticianOffice for National Statistics, London SW1V 2QQ

1 Smith R. Keeping the bad news from journalists. BMJ1997;314:81. (4 January.)

Moderate alcohol consumptionhas been shown previously toimprove insulin sensitivity inmenEditor—Stefan Kiechl and colleagues claimthat their study is the first to show a relationbetween alcohol consumption and plasmainsulin concentrations in men.1 This isuntrue. Over a year ago we published dataon the relation between alcohol consump-tion and plasma insulin and lipoproteinconcentrations in a large cross sectionalstudy of men.2

Altogether 729 men aged 40-69 (75% ofa stratified random sample) were recruitedfrom general practitioners’ lists in east Bris-tol, England. They comprised 354 men aged40-49, 205 aged 50-59, and 170 aged 60-69.Our findings differed from those of Kiechland colleagues. Increases in alcohol con-sumption were associated with increases inhigh density lipoprotein, high density lipo-protein-2 cholesterol, and high density lipo-protein-3 cholesterol concentrations anddecreases in low density lipoprotein choles-terol concentrations and the total:highdensity lipoprotein cholesterol ratio (table1). With insulin, however, there was a Ushaped relation, with moderate drinkers(21-30 g/day) having the lowest concentra-tions. This was confirmed when a quadraticterm was introduced into the analysis ofcovariance (P = 0.04).

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Compared with non-drinkers, moderatedrinkers had a lower plasma insulin concen-tration (by 1.2 mU/l, P = 0.04), low densitylipoprotein cholesterol concentration (by0.4 mmol/l, P = 0.0001), and total:high den-sity lipoprotein cholesterol ratio (by 0.9,P = 0.0001) but a higher high densitylipoprotein cholesterol concentration (by0.1 mmol/l, P = 0.02). Conversely, comparedwith moderate drinkers, heavy drinkers ( > 40g/day) had a higher plasma insulin concen-tration (by 1.5 mU/l, P = 0.01) and highdensity lipoprotein cholesterol concentra-tion (by 0.16 mmol/l, P = 0.0001). In thisanalysis the P value was derived from oneway analysis of covariance after adjustmentfor age, smoking habits, body mass index,waist:hip ratio, and use of antihypertensivedrugs.

Our data support Kiechl and colleagues’conclusion that moderate alcohol consump-tion improves insulin sensitivity, and thismight at least partly explain its cardioprotec-tive effect. We do not agree, however, thathigher intakes have the same benefit. Wealso question whether up to 50 g/dayshould be called a low intake and up to 99g/day a moderate intake.George Razay Lecturer in geriatric medicineCentre For Education and Research on Ageing,Concord G Hospital, Concord, NSW 2139,AustraliaK W Heaton Reader in medicineUniversity Department of Medicine, Bristol RoyalInfirmary, Bristol BS2 8HW

1 Kiechl S, Willeit J, Poewe W, Egger G, Overhollenzer F,Muggeo M, et al. Insulin sensitivity and regular alcoholconsumption: large, prospective, cross sectional popula-tion study (Bruneck study). BMJ 1996;313:1040-4. (26October.)

2 Razay G, Heaton KW. Alcohol consumption and cardio-vascular risk factors in middle aged men. CardiovascularRisk Factors, an International Journal 1995;5:200-5.

CS gas has been used aschemical restraint in mentallyill personEditor—An event that occurred recentlywhile I was on call as a senior registrar inpsychiatry in Leeds has prompted me tobecome concerned about the use of CS gasby the police. An inpatient on a neurologyward in a general hospital had become sud-denly and unexpectedly violent, causinginjuries to hospital staff. The episode could

not be contained on the ward, and so thepolice were called. The patient was taken toa nearby police station, and I was asked toassess his fitness to be detained in the cells.

In my experience it is usual, as a safetyprecaution, for the psychiatrist to be accom-panied by police officers when circum-stances dictate that an assessment must bemade in the cell. If the patient is aggressiveor violent the police will physically restrainhim or her, and this had always beensuccessful in cases in which I had beeninvolved previously. On this occasion, how-ever, the police instructed me to be ready tomove out of the way if the patient becameviolent “so that we can spray him with theCS gas.” In the event, although he wasaggressive, no restraint was necessary at thatstage.

After my assessment, arrangements weremade for the patient to be transferred (byambulance with two police officers to escorthim) to the secure ward of a local psychiatrichospital. On past occasions the police havetended to transport such patients with theirhands behind their backs in wrist restraints,sometimes being held face down on anambulance trolley. Again, I have not knownof any problems occurring in any such casesin which I have been involved.

In this case, however, I was telephonedlater by the police and told that the patienthad attacked the ambulance driver and that“the two officers could not restrain him sothey sprayed him in the face with the CSgas.” I am concerned about the commentsmade in the cells and the subsequent events.The police were readier to use CS gas than Iexpected.

To my knowledge, this is the firstreported case of CS gas being used torestrain a mentally ill person in policecustody in Britain. It raises important issuesabout the welfare of such people who comein contact with the police. If other, similar,cases are reported then the use of CS gasmay need to be addressed by the BMA’s eth-ics committee, perhaps with representationsbeing made to a body such as theAssociation of Chief Police Officers.

Peter Trigwell Senior registrar in psychiatryDepartment of Liaison Psychiatry, Leeds GeneralInfirmary, Leeds LS1 3EX

Paramedic skills

Data collected on paramedic care neednational standardisation

Editor—Howard K Simpson and Gary BSmith recommend national standards forthe evaluation of paramedic skills and raisethe possibility of opportunistic research(based on the differences between regions)to assess the benefit of interventions byparamedics.1 If these objectives are to beachieved, however, systems that allow thecollection of consistent, universally repro-ducible, data need to be implemented.

We conducted a survey of ambulanceservices to assess their methods of collectingdata; we sent out a questionnaire andrequest for the present paramedic reportform. We received 47 replies (100%) to thequestionnaire and 43 (91%) report forms.

Use of the patient report form wasuniversal. Twenty eight services said thatthey collected data on a computer database,with a further five intending to upgrade tothis in the near future. Seven services usedoptical scanners to collect data, with afurther 13 intending to upgrade to this.Ambulance services seem to be developingthe equipment to make extensive clinicalaudit and research possible.

Data collected on the patient reportform showed a similar degree of variabilityto that of the skills surveyed by Simpson andSmith. Recording of the Glasgow comascore (41 of the 43 forms) and systolic bloodpressure (all 43 forms) was almost universal,but recording of oxygen saturation (27forms), blood glucose result (12) and peakflow rate (14) reflected the variable trainingin these subjects. Trauma scoring was identi-fied on 27 forms: 25 services using therevised trauma score, while two used theCRAMS field triage scale3 (a scoring systembased on the five physiological or anatomi-cal variables of circulation, respiration,abdomen, movement, and speech). Assess-ment of prehospital trauma care mandatesthe recording of uniform physiological data.

Performance of paramedic skills wasrecorded with similar variability: 27 servicesrecorded the use of bag and mask ventila-tion, 42 the use of endotracheal intubation,and 42 the use of intravenous cannulation.Only 21 and 24 services, respectively,recorded failed attempts at intubation andcannulation. Drug use was recorded on achart by 34 services and with tick boxes byseven. Two forms had no dedicated space torecord the administration of drugs.

The development of a national ambu-lance report form, as proposed by the JointRoyal Colleges Ambulance Service LiaisonCommittee,2 would allow the collection ofuniform data on paramedic practice. Thesedata could then be used to allow analysis ofthe performance of ambulance services inthe ways that Simpson and Smith suggest.S Goodacre Specialist registrar in accident andemergencyA Gray Research registrar in accident and emergencyA McGowan Consultant in accident and emergencySt James’s University Hospital, Leeds LS9 7TF

Table 1 Mean lipoprotein and insulin concentrations(mmol/l) according to daily alcohol consumption,adjusted for age, body mass index, smoking, and use of antihypertensive drugs

Alcohol consumption (g/day)

P value0 1-20 21-30 31-40 >40

No of men 85 375 101 55 113

Mean alcohol intake (g/day) 0 8.6 24.8 35.3 64.9

HDL 1.08 1.12 1.18 1.30 1.34 0.001

HDL2 cholesterol 0.37 0.36 0.40 0.49 0.47 0.002

HDL3 cholesterol 0.74 0.79 0.82 0.84 0.87 0.02

Low density lipoprotein 3.9 3.6 3.4 3.5 3.4 0.001

Total/HDL ratio 5.8 5.3 4.8 4.6 4.5 0.0001

Insulin (mU/l) 6.2 6.1 5.1 5.9 6.8 0.06

HDL = High density lipoprotein.

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1 Simpson HK, Smith GB. Survey of paramedic skills in theUnited Kingdom and Channel Islands. BMJ1996;313:1052-3. (26 October.)

2 Audit Subcommittee of the Joint Royal CollegesAmbulance Service Liaison Committee. National ambu-lance service patient report form. London: Joint RoyalColleges Ambulance Service Liaison Committee, RoyalCollege of Physicians, 1995.

3 Gormican SP. CRAMS scale: field triage of traumavictims. Ann Emerg Med 1982;11:132-5.

Two tier system of advanced life supportand basic life support ambulances isneeded

Editor—Howard Simpson and Gary Smithreport that the skills taught to ambulanceservice paramedics in Britain vary widely.1

We suggest that this wide variability is aresult of the lack of evidence to support theuse of skills in advanced life support beforethe patient reaches hospital. We should beconsidering not simply which advanced lifesupport skills are taught but how, when, andif they should be used. In most ambulanceservices covering Britain the transport timeswhile the patient is taken to hospital areshort—shorter even than the time necessaryto establish venous access. Many patients,however, spend a long time at the scene towhich the ambulance has been called whileparamedics practise their advanced life sup-port skills. We should advocate the teachingand use of advanced life support skills in theprehospital environment only if the skillshave been shown to improve clinicaloutcome. At present this has been estab-lished only for defibrillation.2

In Britain most 999 calls do not result inthe use of advanced life support procedures,yet a paramedic is always sent. This results ina dilution of exposure to critically illpatients, deskilling, poor compliance withprotocols, and long times until the patientsreach hospital.3 4 A two tier system ofadvanced life support and basic life supportambulances is needed. This would give para-medics in advanced life support ambulancesregular exposure to critically ill patients.Clinical skills and judgment increase withexperience, and this perhaps explains whytwo tier systems have shown benefits inpatient outcome.2 5

If experience was concentrated amongfewer paramedics, delivery of care woulddoubtless improve. Only then would propos-als to teach the management of relatively rareemergencies, such as neonatal paediatric andobstetric resuscitation,1 be appropriate.Simon Carley Hillsborough research fellow, RoyalCollege of Surgeons of EnglandPolly Terry Clinical fellow in emergency medicineManchester Royal Infirmary, Manchester M13 9WL

1 Simpson HK, Smith GB. Survey of paramedic skills in theUnited Kingdom and Channel Islands. BMJ 1996;313:1052-3. (26 October.)

2 Callaham M, Madsden CD. Relationship of timeliness ofparamedic advanced life support interventions tooutcome in out-of-hospital cardiac arrest treated by firstresponders with defibrillators. Ann Emerg Med 1996;27:638-48.

3 Hodgetts TJ, Brown T, Driscoll P, Hanson J. Prehospitalcardiac arrest room for improvement. Resuscitation1995;29:47-54.

4 Lillis KA, Jaffe DM. Prehospital intravenous access inchildren. Ann Emerg Med 1992;21:1430-4.

5 Nichol G, Detsky AS, Stiell IG, O’Rourke K, Wells G,Laupacis A. Effectiveness of emergency medical servicesfor victims of out-of hospital cardiac arrest: a meta-analysis. Ann Emerg Med 1996;27:700-10.

Meta-analysis of risk ofgastrointestinal complicationswith NSAIDs

Authors should not have included datafrom one study

Editor—I wish to draw attention to animportant omission in the report of a meta-analysis of observational studies of seriousgastrointestinal complications of non-steroidal anti-inflammatory drugs.1 Thepaper was based on both published andunpublished data, and this process wasassisted by a workshop held in September1993 in Newcastle, Australia. This wasattended by many of the authors of theoriginal studies. Among those attending wasDr David Kaufman, from the Slone Epide-miology Unit at Boston University School ofMedicine.

Kaufman and his colleagues had previ-ously published an international study onmajor gastrointestinal complications ofnon-steroidal anti-inflammatory drugs.2 Atthe workshop Kaufman presented unpub-lished data from a follow up of their originalstudy. Kaufman and his colleagues were notprepared to be coauthors of the report aris-ing from the workshop because theyobjected to the use of meta-analysis duringsystematic reviews of non-randomised stud-ies. However, they agreed to provide accessto their data on the understanding that theywould write a commentary to accompanythe final report, which would outline theirconcerns. I undertook to facilitate this, butduring a protracted and complicated analy-sis and publication process I forgot theundertaking that I had made, and the finalreport appeared with no opportunity forKaufman and colleagues to write a com-mentary. Effectively, I included the unpub-lished data from the Slone EpidemiologyUnit without the final approval of theauthors. I sincerely regret this oversight andwish to apologise publicly for it.

The unpublished data from the SloneEpidemiology Unit made a significantcontribution to the overall analysis. In theiroriginal paper Kaufman et al analysed theresults in 574 cases of gastrointestinal bleed-ing. The report of the meta-analysisincluded details of 1004 cases. The unpub-lished data of Kaufman et al related to 430 ofa total of 9677 cases that were included inthe overview. These data contributed sub-stantially to the investigations of the relationbetween dose and risk, for which there werefewer studies overall.

The study in question was a high qualitycase-control study, and the data werereported accurately, so that their inclusionhas not introduced any error into the paper.The incorporation of the data, however, wasa breach of faith, which I regret.David Henry Senior lecturer in clinical pharmacologyFaculty of Medicine and Health Sciences, Disciplineof Clinical Pharmacology, University of Newcastle,Callaghan, Waratah, NSW 2308, Australia

1 Henry D, Lim LL-Y, Garcia Rodriguez LA, PerezGutthann S, Carson JL, Griffin M, et al. Variability in risk

of gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a collabora-tive meta-analysis. BMJ 1996;312:1563-6. (22 June.)

2 Kaufman DW, Kelly JP, Sheehan JE, Lasglo A, WiholmBE, Alfredsson L, et al. Non-steroidal anti-inflammatorydrug use in relation to major upper gastrointestinalbleeding. Clin Pharmacol Ther 1993;53:485-94.

Narrative review should have been used

Editor—We are glad to have theopportunity to put our view about DavidHenry and colleagues’ meta-analysis.1 Weagree with the overall conclusions of theanalysis, but they would have been reachedin a narrative review. We take issue with themeta-analysis because it included studiesthat differed in important respects and com-bined unlike things.

Exposure—The definitions of exposureranged from any prescription for a non-steroidal anti-inflammatory drug recordedby a pharmacy within one month to anyexposure recorded at interview within oneweek of the onset of the illness. Such hetero-geneous definitions should not be com-bined; indeed, some definitions includedexposures that were not aetiologicallyrelevant (for example, use of a drug stoppedweeks previously).

Dose—As acknowledged,1 doses weredefined differently among the studies, withdifferent cut off points, yet the meta-analysiscombined them without regard for thedifferences.

Outcome—Different studies evaluated dif-ferent outcomes, including gastric ulcer,duodenal ulcer, any upper gastrointestinalbleeding (including stools positive on occultblood testing), major bleeding only, andperforation, either singly or in differentcombinations. In some studies the diagnoseswere validated from medical records; in oth-ers they were not. Some studies includedonly the first occurrences of disease; othersincluded incident and recurrent cases.

Quality—Certain studies were excludedbecause they “did not show the associationwith gastrointestinal damage.” Unless therewere additional reasons for exclusion, themeta-analysis was biased. Although thestudies were assessed for quality, this assess-ment does not seem to have been taken intoaccount in the analysis, and we questionwhether it could have been. For example, insome studies detection bias could haveoccurred if users of non-steroidal anti-inflammatory drugs were tested more com-monly than non-users for stool occult blood:such bias cannot be measured or controlledfor. With regard to confounding, the phar-macy based studies lacked information onuse of over the counter aspirin, and itsconcomitant use with prescription non-steroidal anti-inflammatory drugs was notcontrolled. To give another example, peoplewith peptic ulcer or a history of uppergastrointestinal bleeding tend to avoid non-steroidal anti-inflammatory drugs; some stud-ies did not control for or even record theprevious occurrence of these conditions.Much the same considerations apply to otherconfounders such as cigarettes and alcohol.

Heterogeneity—Random effects modelswere used, presumably because the pooled

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results were heterogeneous. Such modelsmay be statistically valid, but they do notmake biological or clinical sense,2 and someadvocates of meta-analysis reject them.3

When several well conducted studiesidentify strong and generally similar effects,as in the present case, the conclusionsreached in a meta-analysis are likely toresemble those reached in a narrativereview. A meta-analysis does not contributefurther information. By contrast, a goodnarrative review can convey the weight,breadth, limitations, and subtlety of theevidence from the different studies moreclearly. Variation among studies is inevitablein observational research, and individualevaluations are essential.

If a narrative review and a meta-analysisreach the same broad conclusions whydisqualify the meta-analysis? A dangerinherent in the use of meta-analysis toevaluate large effects is that its seeminglegitimacy, because it comes up with the“right” answer, can be interpreted as confer-ring legitimacy to the meta-analysis of smalleffects. For small effects it may readily lead tospurious conclusions,2 4 and it is in theevaluation of small effects that meta-analysisis now most commonly being used.David W Kaufman Professor of epidemiologySamuel Shapiro Professor of epidemiologySlone Epidemiology Unit, Boston UniversitySchool of Medicine, Brookline, MA 02146, USA

1 Henry D, Lim LL-Y, Garcia Rodriguez LA, PerezGutthann S, Carson JL, Griffin M, et al. Variability in riskof gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a collabora-tive meta-analysis. BMJ 1996;312:1563-6. (22 June.)

2 Shapiro S. Meta-analysis/shmeta-analysis. Am J Epidemiol1994;140:771-7.

3 Greenland S. Can meta-analysis be salvaged? Am J Epide-miol 1994;140:783-7.

4 Shapiro S. Is meta-analysis a valid approach to the evalu-ation of small effects? J Clin Epidemiol (in press).

Self administered tampons canbe used to diagnose sexuallytransmitted diseasesEditor—Lars Østergaard and colleagueshighlight the importance of self adminis-tered techniques for diagnosing and screen-ing for chlamydial infection in women.1

They used the combined results from threesamples (first void urine, midstream urine,and a sample obtained with a 5 ml vaginalpipette) but were concerned about whetherwomen in the general community wouldcomply with this method.

We have used a tampon method admin-istered by patients to detect several genitalinfections, including infection with Chlamy-dia trachomatis, Neisseria gonorrhoeae, Tricho-monas vaginalis, and human papillomavirus,and found it to be highly acceptable. Womenare asked to insert and immediately removea commercially available tampon, which isthen placed in phosphate buffer in a sterilecontainer and sent to a centralised referencelaboratory for processing by the polymerasechain reaction.

The tampon technique has advantagesover the sampling method described by

Østergaard and colleagues because it relieson a procedure that most women performroutinely each month and that can beperformed at any time. The tampon collectsat least three times more DNA than a cervi-cal scrape2 and perhaps 100 times morethan a urine or vaginal minidouche speci-men, thus allowing multiple assays to beperformed with the polymerase chainreaction. The samples are robust and can betransported for processing many thousandsof kilometres away.

We have used the technique in urban,rural, and remote settings in both Aborigi-nal and non-Aboriginal women (includingin a study of over 1300 women living in thetop end of the Northern Territory ofAustralia). It has been shown to beacceptable ( > 95% of women agree toparticipate) and to be highly sensitive andspecific for each organism (FJB et al, 7thinternational congress for infectious dis-eases, Hong Kong, June 1996).3

In the future we will extend the poly-merase chain reaction mix to include prim-ers for herpes simplex type 1 and 2, syphilis,granuloma inguinale, and group B strepto-coccus. Primers for chancroid could be in-cluded in areas where the disease is prevalent.

The control of sexually transmitteddiseases in populations reduces the inci-dence of HIV infection,4 but effectiveprogrammes in such diseases require thedetection of asymptomatic infections, a factnot addressed by the “syndromic-treatment”approach. We have found the tampon tech-nique to be a valuable tool in the detectionof asymptomatic disease in a geographicallyand culturally heterogeneous population.Francis J Bowden HeadAIDS/Sexually Transmitted Diseases Unit, DiseaseControl, Territory Health Services, Darwin, NT,AustraliaBarbara A Paterson Research officerMenzies School of Health Research, DarwinSuzanne M Garland Director

Sepehr Tabrizi Senior research officerDepartment of Microbiology, Royal Women’sHospital, Melbourne, Victoria, AustraliaChristopher K Fairley Senior lecturerDepartment of Epidemiology and PreventiveMedicine, Monash University, Prahran, Victoria

1 Østergaard L, Møller JK, Andersen B, Olesen F. Diagno-sis of urogenital Chlamydia trachomatis infection inwomen based on mailed samples obtained at home:multipractice comparative study. BMJ 1996;313:1186-9.(9 November.)

2 Fairley CK, Chen S, Quinn M, McNeill JJ, Garland SM. Anovel method for the assessment of human papilloma-virus infection. J Infect Dis 1992;165:1103-6.

3 Tabrizi SN, Chen S, Borg AJ, Lees Ml, Fairley CK,Migliorini G, et al. Patient administered tampon collectedgenital cells in the assessment of Chlamydia trachomatisinfection using polymerase chain reaction. Sex Transm Dis(in press).

4 Grosskurth H, Mosha F, Todd J, Mwijarubi E, Klokke A.Impact of improved treatment of sexually transmitteddiseases on HlV infection in rural Tanzania: randomisedcontrolled trial. Lancet 1995;346:530-6.

Sailing makes use of tobaccosponsorshipEditor—When I visited the Boat Show inLondon recently my first view of Earls Courtafter I arrived by underground was a hugemock up of a yacht made out of hardboard(fig 1). This completely dwarfed theentrance. The chief medical officer’s statu-tory notice was just visible on the ground.The whole thing was an advertisement forSilk Cut cigarettes.

On looking through the official guide tothe show I found no mention of Silk Cutamong the numerous advertisements fromthe sailing world. However, an advertise-ment for a competition for “Silk Cut Sailingfor Britain” fell out of the guide, and this saidthat the yacht Silk Cut is participating in theWhitbread round the world race. Appar-ently Silk Cut had a stand in the exhibition,but I did not see it.

Sailing seems to be yet another sportthat depends on sponsorship from thetobacco industry.H M White Retired general practitioner7 Marlborough Avenue, Bromsgrove B60 2PG

Fig 1 Silk Cut and seven members of its crew, who hope to win the Whitbread round the world race

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