19 :
I
effects can be lessened by senna.3 Addition of millers’ bran to the diet enabled patients who had been constipated to defxcate without effort and to empty their bowels completely 6-without lowering any lavatory seats. If bran achieves the desired effect, the design of our plumbing need not be changed. This point will only be settled when the mechanics of defaecation has been investigated further.
NOTTINGHAM NOW
ONLY two medical schools in Britain, Nottingham and Southampton, have had the chance to experiment, from the outset, with the new ideas in medical education. The first doctors graduated from Nottingham this week. What is the state of play in Nottingham, and what has been the experience of the first cohort ? 1975 sees the medical school, with its annual intake of 48 (to be doubled in October), settling into definitive accommodation on the site of the massive university hospital under construction. 14 professorial chairs have been established over the past eight years, and the academic side has 150 clinical teachers, among whom are a committed group of general practitioners and all hospital consultants in Nottingham with some from adjacent centres. Most of the hospital-based clinical teaching is divided between the two main hospitals in the city. The aim in theory behind Nottingham’s five-year is a merging of basic scientific and clinical disciplines, so that from the first week students are put into live clinical situations and given a chance to identify with their eventual role as doctors. However, the first three years of the curriculum are described as basic medical sciences, leading to the B.MED.SCI., and just over two years are allowed for essentially The basic-sciences component is clinical work. imaginatively oriented towards three broad themes(A) the cell, (B) man, and (C) the community-in an attempt to cut across the artificial packaging of knowledge encouraged by competing disciplines. As examples, human morphology, biochemistry, and pathology are taught in theme A, physiology and behavioural sciences in theme B, and theme C includes social science and community health. course
Not surprisingly there are many stumbling-blocks to integration. There is a tendency to identify specific disciplines with themes, and academic demarcation disputes persist. The rigid assessment system and the highly competitive selection procedure encourage compulsive achievers and impose their own logic. In fact, the first two years turn out not to be at all that different from the traditional second M.B., the major innovations being the greater emphasis on project teaching, small-group work, the demonstration of the relevance of structure to function, the inclusion of behavioural issues and the context of man in society, and a population-based approach to health and disease. The third year of the honours course is probably the most successful educational experience-an elective 6.
Painter, N. S., Almeida, A. Z., Colebourne, K. W. 1972, i, 137.
Br. med.
J.
in a chosen subject leading to an original dissertation, several of which have been up to mastership standard. The clinical years in contrast look remarkably traditional, with rotations between specialist firms and a heavy hospital emphasis (except for a month in general practice and an enterprising community follow-up scheme). Outpatient contact is limited. There is not nearly enough involvement with local communities; and there is no shared learning with other members of the health-care team. Faced with the fundamental issue of how relevant this education is to people’s needs, Nottingham has come down on the side of the scientist rather than the humanist. Beside McMaster or Case Western, Nottingham looks pretty staid, but its first graduates are very competent clinicians and the seeds of the new educational ideas may well be germinating within them. The real test is what sort of medicine these doctors will be practising ten years hence.
AINHUM one of the minor but of tropical medicine-and permysterious problems a minor one in Nigeria. Cole1 studied not such haps 1000 individuals in Ibadan who were not complaining of their feet and found 22 with evidence of past or present ainhum, a percentage far higher than the usual figures. The process starts in the cleft between the fourth and little toes, involving usually the skin-groove
AiNHUM continues to be
at the toe is
plantar/digital junction; and ultimately the encircled, with resultant autoamputation.1-3
110 or so years after this curious disease was described from South America the pathogenesis remains puzzling. Most sufferers have been Black, in the Old World1 and the New,3 and the fibrogenetic tendency of Blacks was long a suspected factor till this was disproved by Kean and his colleagues. 3,4 The condition has been described in Whitesin Polynesians,6 and in Indians7 with or without some metabolic or associated dermatological disorder. In some cases considerable fibrosis6 and vascular changeshave been described, though often the changes seem secondary to the local lesion.i Possibly there may be two types of ainhum: one could be secondary to a skin disease, with a fibrous constricting band; the other might be a primary disease with no fibrosis, only a deepening and extending groove with, in its early stages, gross thickening of the stratum corneum, calcification of ducts and sweatglands, and no evidence of parasites or infection. Ulcerated areas may become infected later, giving a picture of chronic inflammation deep to hyperkeratotic epithelium, with normal vessels, normal nerves, and sterile bone absorption. It is the groove, not fibrous tissue, that constricts. The absence 4 of specific 1. Cole, G. J. J. Bone Jt Surg. 1965, 47B, 43. 2. Spinzig, E. W. Am. J. Roentg. 1939, 42, 246. 3. Kean, B. H., Tucker, H. A., Miller, W. C. Trans. R. Soc. trop. Med. Hyg. 1946, 39, 331. 4. Kean, B. H., Tucker, H. A. Archs Path. 1946, 41, 639. 5. Shaffer, L. J. O. ibid. 1947, 43, 170. 6. Browne, S. G. Ann. trop. Med. Parasitol. 1961, 55, 314. 7. Aggarwal, N. D., Singh, H.J. Bone Jt Surg. 1963, 45B, 376. 8. Davies, J. N. P., Hewer, T. F. Trans. R. Soc. trop. Med. Hyg. 1941, 35, 125.
20
epithelial, vascular, nerve, or gland changes, and of any consistent metabolic or infective condition makes the pathogenesis hard to discern. What, then, could be the cause, and why should the little toe be singled out ? The bilaterality and the affected site suggested that epidermophytosis, athlete’s foot, might be a factor,8 but such infection has never been identified. Some nervous disorder has been suggested, and McKnight9 claimed improvement after lumbar sympathectomy. Vascular disease, leprosy, yaws, keloid formation, and sickle-cell diseaseseem to have been ruled out, and we are left with a pathological process that seems to start with changes in a small group of basal cells in the epidermis of the cleft of the little toe. It does affect shoe-wearers, but probably most victims have gone shoeless for part of their lives. It is particularly common in agricultural workers, and for a long time it was believed to be overwhelmingly a male disorder.3 But 46% of Cole’s cases were females, and Daynes 10 reported from Transkei, where the disease is common, that females are six times more often affected than males. In the Transkei phocomelia is also frequent, and Daynes wondered whether phocomelia and ainhum might be caused by the same factor, possibly something of plant origin. This suggestion is worthy of exploration.
LESS OF A
BUILDING, MORE OF
A LIFE
OVER the years, the International Hospital Federation has not flinched from placing on the programmes for its biennial congresses some tricky, even touchy, subjects. This year’s meeting gathered last month in Zagreb (a place renowned in the record of international health for, among other of the city’s feats, the achievements of its former professor of hygiene, Andrija Stampar, who became president of the first World Health Assembly in 1948); and one of the areas for debate was the interplay (or the discord perhaps) between psychiatry and architecture. This was a difficult one: not so much for lack of forceful opinions or copious information but of proven facts-plus an occasional uneasiness in communication and understanding between psychiatrists, architects, environmental psychologists, and administrators (who perhaps have the toughest task of all, because they must somehow coordinate and realise the plans which others devise for the care of the mentally ill). Few in Zagreb went so far as to declare that it was monstrous urban living conditions created by modern architects which provided psychiatrists with many of their patients; but the thought was in the air. Mr N. E. Bank-Mikkelsen (director of services for the mentally retarded, National Board of Social Welfare, Copenhagen) was convinced, however, that the handicapped needed to live as other human beings did, no matter how much that way of life might be criticised: to be
accepted as belonging to society, even a very imperfect society, was of the utmost importance to them. In 9. 10.
McKnight, R. B. N. Carolina med. J. 1940, 1, Daynes, W. G. S. Afr. med. J. 1973, 47, 320.
the end, effective services and congenial surroundings had to be provided for everybody, not just for the
handicapped. that the human than environment was more important the physical one; and that, when some form of special building was needed to provide a home for the handicapped, small units, with ready access to the outside world, were cheaper to build and to run and more effective than large and isolated ones. An optimistic note was sounded in the increasing recognition of a more sympathetic attitude, especially among the young, Less immediately towards handicapped people. cheerful was the talk of disenchantment with proprofessional opinions and decisions: results might be better in this sector of health care, as elsewhere, if the responsibilities lay with a combination of lay and fessional opinions and decisions: results might be and interests. As for the mentally handicapped child, the view that even severe handicap should not mean certain entry to some large institution has lately been fortified by further British " non-professional Two recurrent messages
were
1
opinions.
The congress might have learned less than it expected about the actual mechanics of architecture, design, and building, as applied to the support of the mentally handicapped or ill. Indeed, it was not always clear what kind of illness was being pictured as best treated in a particular environment; the passive or the hyperactive ? ; the externally tranquil depression or the openly destructive psychosis ? A French view, from Dr Roger Amiel, illustrated a broader Gallic range of choices for psychiatric patients, a choice of extremes-solitude and communal life, dependence and autonomy-between which they were encouraged to alternate. Certainly, as Mr Kenneth Bayes, an architect, put it, there should be a scope for choice, to fulfil " the need to be different "-a fundamental human right, not to be denied to minority and deviant groups. From elsewhere in the congress discussion groups, news emerged that the application of computer techniques in health care had taken a beating from the
iconoclasts (" a decade of overpromise and underachievement ") who pointed severely to overambitious schemes which had failed. But the consensus seemed to be that the follies of youth should be forgotten and that, in another ten years, effective health care in many lands would be indissolubly wedded to computerism. The do-able things should be done first; and more adequate training in computer work should be offered at all levels, especially to medical graduates. The control of health-care cost in an uncontrolled environment " is a long phrase for a short and sharp dilemma facing many rich and inflation-struck communities: short, because unless it is resolved speedily, the standards which the majority of citizens may expect from their health services will wither. Under this title, the congress had a lively visit from Dr Thomas McCarthy and his colleagues from the United States, who addressed themselves to this little matter as it affected their country (see p. 26). "
76. 1. See
Lancet, June 14, 1975, p. 1326.
I
effects can be lessened by senna.3 Addition of millers’ bran to the diet enabled patients who had been constipated to defxcate without effort and to empty their bowels completely 6-without lowering any lavatory seats. If bran achieves the desired effect, the design of our plumbing need not be changed. This point will only be settled when the mechanics of defaecation has been investigated further.
NOTTINGHAM NOW
ONLY two medical schools in Britain, Nottingham and Southampton, have had the chance to experiment, from the outset, with the new ideas in medical education. The first doctors graduated from Nottingham this week. What is the state of play in Nottingham, and what has been the experience of the first cohort ? 1975 sees the medical school, with its annual intake of 48 (to be doubled in October), settling into definitive accommodation on the site of the massive university hospital under construction. 14 professorial chairs have been established over the past eight years, and the academic side has 150 clinical teachers, among whom are a committed group of general practitioners and all hospital consultants in Nottingham with some from adjacent centres. Most of the hospital-based clinical teaching is divided between the two main hospitals in the city. The aim in theory behind Nottingham’s five-year is a merging of basic scientific and clinical disciplines, so that from the first week students are put into live clinical situations and given a chance to identify with their eventual role as doctors. However, the first three years of the curriculum are described as basic medical sciences, leading to the B.MED.SCI., and just over two years are allowed for essentially The basic-sciences component is clinical work. imaginatively oriented towards three broad themes(A) the cell, (B) man, and (C) the community-in an attempt to cut across the artificial packaging of knowledge encouraged by competing disciplines. As examples, human morphology, biochemistry, and pathology are taught in theme A, physiology and behavioural sciences in theme B, and theme C includes social science and community health. course
Not surprisingly there are many stumbling-blocks to integration. There is a tendency to identify specific disciplines with themes, and academic demarcation disputes persist. The rigid assessment system and the highly competitive selection procedure encourage compulsive achievers and impose their own logic. In fact, the first two years turn out not to be at all that different from the traditional second M.B., the major innovations being the greater emphasis on project teaching, small-group work, the demonstration of the relevance of structure to function, the inclusion of behavioural issues and the context of man in society, and a population-based approach to health and disease. The third year of the honours course is probably the most successful educational experience-an elective 6.
Painter, N. S., Almeida, A. Z., Colebourne, K. W. 1972, i, 137.
Br. med.
J.
in a chosen subject leading to an original dissertation, several of which have been up to mastership standard. The clinical years in contrast look remarkably traditional, with rotations between specialist firms and a heavy hospital emphasis (except for a month in general practice and an enterprising community follow-up scheme). Outpatient contact is limited. There is not nearly enough involvement with local communities; and there is no shared learning with other members of the health-care team. Faced with the fundamental issue of how relevant this education is to people’s needs, Nottingham has come down on the side of the scientist rather than the humanist. Beside McMaster or Case Western, Nottingham looks pretty staid, but its first graduates are very competent clinicians and the seeds of the new educational ideas may well be germinating within them. The real test is what sort of medicine these doctors will be practising ten years hence.
AINHUM one of the minor but of tropical medicine-and permysterious problems a minor one in Nigeria. Cole1 studied not such haps 1000 individuals in Ibadan who were not complaining of their feet and found 22 with evidence of past or present ainhum, a percentage far higher than the usual figures. The process starts in the cleft between the fourth and little toes, involving usually the skin-groove
AiNHUM continues to be
at the toe is
plantar/digital junction; and ultimately the encircled, with resultant autoamputation.1-3
110 or so years after this curious disease was described from South America the pathogenesis remains puzzling. Most sufferers have been Black, in the Old World1 and the New,3 and the fibrogenetic tendency of Blacks was long a suspected factor till this was disproved by Kean and his colleagues. 3,4 The condition has been described in Whitesin Polynesians,6 and in Indians7 with or without some metabolic or associated dermatological disorder. In some cases considerable fibrosis6 and vascular changeshave been described, though often the changes seem secondary to the local lesion.i Possibly there may be two types of ainhum: one could be secondary to a skin disease, with a fibrous constricting band; the other might be a primary disease with no fibrosis, only a deepening and extending groove with, in its early stages, gross thickening of the stratum corneum, calcification of ducts and sweatglands, and no evidence of parasites or infection. Ulcerated areas may become infected later, giving a picture of chronic inflammation deep to hyperkeratotic epithelium, with normal vessels, normal nerves, and sterile bone absorption. It is the groove, not fibrous tissue, that constricts. The absence 4 of specific 1. Cole, G. J. J. Bone Jt Surg. 1965, 47B, 43. 2. Spinzig, E. W. Am. J. Roentg. 1939, 42, 246. 3. Kean, B. H., Tucker, H. A., Miller, W. C. Trans. R. Soc. trop. Med. Hyg. 1946, 39, 331. 4. Kean, B. H., Tucker, H. A. Archs Path. 1946, 41, 639. 5. Shaffer, L. J. O. ibid. 1947, 43, 170. 6. Browne, S. G. Ann. trop. Med. Parasitol. 1961, 55, 314. 7. Aggarwal, N. D., Singh, H.J. Bone Jt Surg. 1963, 45B, 376. 8. Davies, J. N. P., Hewer, T. F. Trans. R. Soc. trop. Med. Hyg. 1941, 35, 125.
20
epithelial, vascular, nerve, or gland changes, and of any consistent metabolic or infective condition makes the pathogenesis hard to discern. What, then, could be the cause, and why should the little toe be singled out ? The bilaterality and the affected site suggested that epidermophytosis, athlete’s foot, might be a factor,8 but such infection has never been identified. Some nervous disorder has been suggested, and McKnight9 claimed improvement after lumbar sympathectomy. Vascular disease, leprosy, yaws, keloid formation, and sickle-cell diseaseseem to have been ruled out, and we are left with a pathological process that seems to start with changes in a small group of basal cells in the epidermis of the cleft of the little toe. It does affect shoe-wearers, but probably most victims have gone shoeless for part of their lives. It is particularly common in agricultural workers, and for a long time it was believed to be overwhelmingly a male disorder.3 But 46% of Cole’s cases were females, and Daynes 10 reported from Transkei, where the disease is common, that females are six times more often affected than males. In the Transkei phocomelia is also frequent, and Daynes wondered whether phocomelia and ainhum might be caused by the same factor, possibly something of plant origin. This suggestion is worthy of exploration.
LESS OF A
BUILDING, MORE OF
A LIFE
OVER the years, the International Hospital Federation has not flinched from placing on the programmes for its biennial congresses some tricky, even touchy, subjects. This year’s meeting gathered last month in Zagreb (a place renowned in the record of international health for, among other of the city’s feats, the achievements of its former professor of hygiene, Andrija Stampar, who became president of the first World Health Assembly in 1948); and one of the areas for debate was the interplay (or the discord perhaps) between psychiatry and architecture. This was a difficult one: not so much for lack of forceful opinions or copious information but of proven facts-plus an occasional uneasiness in communication and understanding between psychiatrists, architects, environmental psychologists, and administrators (who perhaps have the toughest task of all, because they must somehow coordinate and realise the plans which others devise for the care of the mentally ill). Few in Zagreb went so far as to declare that it was monstrous urban living conditions created by modern architects which provided psychiatrists with many of their patients; but the thought was in the air. Mr N. E. Bank-Mikkelsen (director of services for the mentally retarded, National Board of Social Welfare, Copenhagen) was convinced, however, that the handicapped needed to live as other human beings did, no matter how much that way of life might be criticised: to be
accepted as belonging to society, even a very imperfect society, was of the utmost importance to them. In 9. 10.
McKnight, R. B. N. Carolina med. J. 1940, 1, Daynes, W. G. S. Afr. med. J. 1973, 47, 320.
the end, effective services and congenial surroundings had to be provided for everybody, not just for the
handicapped. that the human than environment was more important the physical one; and that, when some form of special building was needed to provide a home for the handicapped, small units, with ready access to the outside world, were cheaper to build and to run and more effective than large and isolated ones. An optimistic note was sounded in the increasing recognition of a more sympathetic attitude, especially among the young, Less immediately towards handicapped people. cheerful was the talk of disenchantment with proprofessional opinions and decisions: results might be better in this sector of health care, as elsewhere, if the responsibilities lay with a combination of lay and fessional opinions and decisions: results might be and interests. As for the mentally handicapped child, the view that even severe handicap should not mean certain entry to some large institution has lately been fortified by further British " non-professional Two recurrent messages
were
1
opinions.
The congress might have learned less than it expected about the actual mechanics of architecture, design, and building, as applied to the support of the mentally handicapped or ill. Indeed, it was not always clear what kind of illness was being pictured as best treated in a particular environment; the passive or the hyperactive ? ; the externally tranquil depression or the openly destructive psychosis ? A French view, from Dr Roger Amiel, illustrated a broader Gallic range of choices for psychiatric patients, a choice of extremes-solitude and communal life, dependence and autonomy-between which they were encouraged to alternate. Certainly, as Mr Kenneth Bayes, an architect, put it, there should be a scope for choice, to fulfil " the need to be different "-a fundamental human right, not to be denied to minority and deviant groups. From elsewhere in the congress discussion groups, news emerged that the application of computer techniques in health care had taken a beating from the
iconoclasts (" a decade of overpromise and underachievement ") who pointed severely to overambitious schemes which had failed. But the consensus seemed to be that the follies of youth should be forgotten and that, in another ten years, effective health care in many lands would be indissolubly wedded to computerism. The do-able things should be done first; and more adequate training in computer work should be offered at all levels, especially to medical graduates. The control of health-care cost in an uncontrolled environment " is a long phrase for a short and sharp dilemma facing many rich and inflation-struck communities: short, because unless it is resolved speedily, the standards which the majority of citizens may expect from their health services will wither. Under this title, the congress had a lively visit from Dr Thomas McCarthy and his colleagues from the United States, who addressed themselves to this little matter as it affected their country (see p. 26). "
76. 1. See
Lancet, June 14, 1975, p. 1326.
