795
Healing rituals and sacred serpents SIR,-Dr Angeletti and colleagues’ (July 25, p 223) work on epidermal growth factor (EGF) of the Elaphe quatuorlineata is very interesting, but we are inclined not to agree with their speculation about the role of this factor in the healing rituals at ancient Asclepieia. They put forward three arguments to support their theory. First, the snakes E longissima and E quatuorlineata, associated with the Greek god of healing (Asclepios), are very common in Greece and Italy. These species contain considerable amounts of EGF in their saliva. Against Angeletti’s argument, is the fact that snakes have been associated with healing gods in several other parts of the world, where the above mentioned species are not common, and in quite different chronological periods. We refer to the well-known votive soapstone vase with two engraved intertwined snakes, offered to the Mesopotamian healing god Ningishida, made around 2000 BC.’ Generally, there is not one religion or mythology without its sacred snake, associated with life and death, and usually coiled around a tree or a rod.2.3The snake around the Tree of Knowledge in Paradise, the snake guarding the Hesperides’ apple tree in the Labours of Hercules, and the snake and rod of Asclepios are merely three such examples of the role of the snake as a totem.4 However, E longissima (Asclepios snake) is the most common snake in Greece, where it is called saita (arrow) because of its agility. Second, there are archaeological data from the marble carvings (pinakes) at the Asclepieion of Epidavros, proving the use of the close contact with the snake’s oral cavity to treat skin lesions. However, from an analysis of these marble slabs at Epidavross,6 the frequency of diseases cured by the intervention of the god/snake is: general internal medical disorders 18%, general surgical 16%,
gynaecological 14%, neurological 10%, ophthalmological 18%, dermatological 7%, and non-medical conditions 17%. The very low percentage of superficial lesions treated at the Asclepieion is an archaeological fact against, and not in favour of, any role for EGF. Third, there is experimental evidence of the beneficial action of EGF on skin lesions. Any such action would require some time of contact with the patient’s damaged tissue, and several applications. The example that Angeletti et al describe (and other similar reports) of instant cure of a "malignant sore" after a few seconds’ licking by a snakes’ tongue is beyond any rational scientific explanation. The attempt to explain ritualistic treatments with immunobiological explanations is very difficult. It reminds us somewhat of the efforts of 19th century theologians, trying to prove the existence of God with chemical
or
mathematical
International Hippocratic Foundation of Kos, National University of Athens School of Medicine, 10675 Athens. Greece 1
terms.
A. DIAMANDOPOULOS D. A. KOUTRAS S. G. MARKETOS
per year, if both variables are greater than zero, the total benefits of the disease eradication effort will be infinite, if calculated with a zero discount rate. Since disease eradication efforts are the only health projects with permanent benefits and finite costs, if a zero discount rate is applied, all disease eradication projects, no matter how inconsequential the disease, will have higher benefit/ cost ratios than all other health projects. Furthermore, this conclusion holds true, irrespective of the probability of success of the eradication effort, provided that probability is greater than zero. Thus, any cost-benefit analysis that uses a zero discount rate to compare alternative health investments would conclude that all eradication projects should be funded, before any funds are allocated to any other health investment. The lack of an adequate cost-benefit analysis with an appropriate, greater than zero, discount rate is one factor that has contributed to the decision by several Latin American countries to initiate a costly poorly timed effort to eliminate, not merely control, measles, while other, less permanent and inexpensive but nonetheless critical lifesaving health interventions are starved of resources. Economic analyses should clearly state the discount rate used and should show the sensitivity of the conclusions to reasonable changes in that rate. A zero discount rate, however, applied to further benefit always overstates the value of those benefits relative to similar present benefits, and should be avoided. cases occur
Management Sciences for Health, Institucion Sin Fines de Lucro, 3377 Tegucigalpa, Honduras
Demand for
PETER N. CROSS
hospital delivery services in Ireland
SiR,—Although the House of Commons Select Committee Report on Maternity Services refers only to the UK, I would like to comment from an Irish perspective on Ms Conti’s views on this document (Aug 22, p 489). In this country there has been a tradition of keeping private maternity fees a lot lower than in the UK with the result that many more patients can afford private treatment and can choose their hospital for delivery. While accepting that domiciliary delivery is an option that is rarely available, it is still noteworthy that patients are willing to travel long distances to deliver in units with high technology and high intervention rates, especially for epidural anaesthesia. Perhaps the Select Committee was unduly influenced by evidence from vocal pressure groups who may not represent the true majority of pregnant women. Institute of Obstetricians and 6 Kildare Street, Dublin 2, Ireland
Gynaecologists,
C.
J. CARR
Lyons A, Petrucelli R. Medecine. an illustrated history New York: HN Abrams, 1987;
65. 2 Schouten J. The rod and serpent of Asklepios New York: Elsevier, 1967. 3. Diamandopoulos A. The rod and the snake: the deeper symbolism of the medical emblem. Materia Medica Greca 1992; 20: 207. 4. Frazer JG. The golden bough. London, 1920 5 Aravantinos A. In: Dragoulinos B, ed Asclepios and Asclepieia. Germany: Leipsing, 1907. 6. Diamandopoulou AH, Diamandopoulos A, Marketos S. Representation of opthalmological cures m hagiographies Abstract book, 17th Panhellenic Medical Meeting, Athens, 1991.
Discounting SIR,-Your July
18 editorial
health
care
valuable warning to of whom are health professionals and not economists, not only about the sensitivity of cost-effectiveness analyses to the economic discount rate used, but also about the lack of an objective method for selecting an appropriate rate. Your editorial could, however, discourage the use of an essential analytical tool, and the recommendation to always present a calculation of benefits based on a zero discount rate could lead to serious policy errors, as illustrated by the following example. Any successful disease eradication programme yields so-called permanent, never-ending benefits. In this instance, no matter how small a monetary value is ascribed to each case avoided or how few
provides
health-care planners and policy makers,
a
most
Fuzzy logic and waiting lists SiR,—The principles of the mathematical theory, fuzzy logic, are being applied to the chip-controlled regulation of camcorders, vacuum-cleaners, air-conditioners, and so on. Fuzzy set theory was invented by Prof Lotfi A. Zadeh in 1965 in the USA. His theory now
takes into account "neither ... nor" and "both" approaches, and expresses numerically the answers to questions such as "is a door left ajar open or closed?"-scoring 00 for totally wrong and 1 ’0 for truly correct. Thus this door might earn 07 for closed and 0-4 for open, and the fuzzy logic theory may thus allow precise conclusions about possibility. Fuzzy logic may be appropriate in the evaluation of waiting lists. We have examined our orthopaedic waiting list in these terms. In 4 female) July, 1992, 42 patients were awaiting operations (38 for an average of 10 months (range 3-19, SD 4 35). Diagnoses were osteoarthritis of the hip (7 patients), supraspinatus impingement (6), arthroscopy of large joints (5), toe deformities (4), exostoses (3), rotator cuff ruptures (3), spondylolisthesis (2), hip dysplasia (2), loosened total hip replacement (1), Baker’s cyst (1), Perthes disease (1), anterior cruciate ligament rupture (1), frozen shoulder (1), removal of metal (1), shoulder instability (1), loose bodies (1), avascular necrosis of the hip (1), and low back pain (1). Information
male,
Healing rituals and sacred serpents SIR,-Dr Angeletti and colleagues’ (July 25, p 223) work on epidermal growth factor (EGF) of the Elaphe quatuorlineata is very interesting, but we are inclined not to agree with their speculation about the role of this factor in the healing rituals at ancient Asclepieia. They put forward three arguments to support their theory. First, the snakes E longissima and E quatuorlineata, associated with the Greek god of healing (Asclepios), are very common in Greece and Italy. These species contain considerable amounts of EGF in their saliva. Against Angeletti’s argument, is the fact that snakes have been associated with healing gods in several other parts of the world, where the above mentioned species are not common, and in quite different chronological periods. We refer to the well-known votive soapstone vase with two engraved intertwined snakes, offered to the Mesopotamian healing god Ningishida, made around 2000 BC.’ Generally, there is not one religion or mythology without its sacred snake, associated with life and death, and usually coiled around a tree or a rod.2.3The snake around the Tree of Knowledge in Paradise, the snake guarding the Hesperides’ apple tree in the Labours of Hercules, and the snake and rod of Asclepios are merely three such examples of the role of the snake as a totem.4 However, E longissima (Asclepios snake) is the most common snake in Greece, where it is called saita (arrow) because of its agility. Second, there are archaeological data from the marble carvings (pinakes) at the Asclepieion of Epidavros, proving the use of the close contact with the snake’s oral cavity to treat skin lesions. However, from an analysis of these marble slabs at Epidavross,6 the frequency of diseases cured by the intervention of the god/snake is: general internal medical disorders 18%, general surgical 16%,
gynaecological 14%, neurological 10%, ophthalmological 18%, dermatological 7%, and non-medical conditions 17%. The very low percentage of superficial lesions treated at the Asclepieion is an archaeological fact against, and not in favour of, any role for EGF. Third, there is experimental evidence of the beneficial action of EGF on skin lesions. Any such action would require some time of contact with the patient’s damaged tissue, and several applications. The example that Angeletti et al describe (and other similar reports) of instant cure of a "malignant sore" after a few seconds’ licking by a snakes’ tongue is beyond any rational scientific explanation. The attempt to explain ritualistic treatments with immunobiological explanations is very difficult. It reminds us somewhat of the efforts of 19th century theologians, trying to prove the existence of God with chemical
or
mathematical
International Hippocratic Foundation of Kos, National University of Athens School of Medicine, 10675 Athens. Greece 1
terms.
A. DIAMANDOPOULOS D. A. KOUTRAS S. G. MARKETOS
per year, if both variables are greater than zero, the total benefits of the disease eradication effort will be infinite, if calculated with a zero discount rate. Since disease eradication efforts are the only health projects with permanent benefits and finite costs, if a zero discount rate is applied, all disease eradication projects, no matter how inconsequential the disease, will have higher benefit/ cost ratios than all other health projects. Furthermore, this conclusion holds true, irrespective of the probability of success of the eradication effort, provided that probability is greater than zero. Thus, any cost-benefit analysis that uses a zero discount rate to compare alternative health investments would conclude that all eradication projects should be funded, before any funds are allocated to any other health investment. The lack of an adequate cost-benefit analysis with an appropriate, greater than zero, discount rate is one factor that has contributed to the decision by several Latin American countries to initiate a costly poorly timed effort to eliminate, not merely control, measles, while other, less permanent and inexpensive but nonetheless critical lifesaving health interventions are starved of resources. Economic analyses should clearly state the discount rate used and should show the sensitivity of the conclusions to reasonable changes in that rate. A zero discount rate, however, applied to further benefit always overstates the value of those benefits relative to similar present benefits, and should be avoided. cases occur
Management Sciences for Health, Institucion Sin Fines de Lucro, 3377 Tegucigalpa, Honduras
Demand for
PETER N. CROSS
hospital delivery services in Ireland
SiR,—Although the House of Commons Select Committee Report on Maternity Services refers only to the UK, I would like to comment from an Irish perspective on Ms Conti’s views on this document (Aug 22, p 489). In this country there has been a tradition of keeping private maternity fees a lot lower than in the UK with the result that many more patients can afford private treatment and can choose their hospital for delivery. While accepting that domiciliary delivery is an option that is rarely available, it is still noteworthy that patients are willing to travel long distances to deliver in units with high technology and high intervention rates, especially for epidural anaesthesia. Perhaps the Select Committee was unduly influenced by evidence from vocal pressure groups who may not represent the true majority of pregnant women. Institute of Obstetricians and 6 Kildare Street, Dublin 2, Ireland
Gynaecologists,
C.
J. CARR
Lyons A, Petrucelli R. Medecine. an illustrated history New York: HN Abrams, 1987;
65. 2 Schouten J. The rod and serpent of Asklepios New York: Elsevier, 1967. 3. Diamandopoulos A. The rod and the snake: the deeper symbolism of the medical emblem. Materia Medica Greca 1992; 20: 207. 4. Frazer JG. The golden bough. London, 1920 5 Aravantinos A. In: Dragoulinos B, ed Asclepios and Asclepieia. Germany: Leipsing, 1907. 6. Diamandopoulou AH, Diamandopoulos A, Marketos S. Representation of opthalmological cures m hagiographies Abstract book, 17th Panhellenic Medical Meeting, Athens, 1991.
Discounting SIR,-Your July
18 editorial
health
care
valuable warning to of whom are health professionals and not economists, not only about the sensitivity of cost-effectiveness analyses to the economic discount rate used, but also about the lack of an objective method for selecting an appropriate rate. Your editorial could, however, discourage the use of an essential analytical tool, and the recommendation to always present a calculation of benefits based on a zero discount rate could lead to serious policy errors, as illustrated by the following example. Any successful disease eradication programme yields so-called permanent, never-ending benefits. In this instance, no matter how small a monetary value is ascribed to each case avoided or how few
provides
health-care planners and policy makers,
a
most
Fuzzy logic and waiting lists SiR,—The principles of the mathematical theory, fuzzy logic, are being applied to the chip-controlled regulation of camcorders, vacuum-cleaners, air-conditioners, and so on. Fuzzy set theory was invented by Prof Lotfi A. Zadeh in 1965 in the USA. His theory now
takes into account "neither ... nor" and "both" approaches, and expresses numerically the answers to questions such as "is a door left ajar open or closed?"-scoring 00 for totally wrong and 1 ’0 for truly correct. Thus this door might earn 07 for closed and 0-4 for open, and the fuzzy logic theory may thus allow precise conclusions about possibility. Fuzzy logic may be appropriate in the evaluation of waiting lists. We have examined our orthopaedic waiting list in these terms. In 4 female) July, 1992, 42 patients were awaiting operations (38 for an average of 10 months (range 3-19, SD 4 35). Diagnoses were osteoarthritis of the hip (7 patients), supraspinatus impingement (6), arthroscopy of large joints (5), toe deformities (4), exostoses (3), rotator cuff ruptures (3), spondylolisthesis (2), hip dysplasia (2), loosened total hip replacement (1), Baker’s cyst (1), Perthes disease (1), anterior cruciate ligament rupture (1), frozen shoulder (1), removal of metal (1), shoulder instability (1), loose bodies (1), avascular necrosis of the hip (1), and low back pain (1). Information
male,
