116 is notoriously elusive; and some regard colonic mucus taken from a swab at sigmoidoscopy and examined immediately as more helpful than the fresh " warm stool. But, when the stool is fluid, mucus may be obtain at sigmoidoscopy, and mucosal impossible to " is in amoebiasis as in Crohn’s as hit-or-miss biopsy disease. So amoebiasis may slip through the diagnostic net-a serious matter, for the large bowel has sometimes been removed on the false assumption of ulcerative or Crohn’s colitis (though in none of Tucker’s patients). Lest it be thought that small-intestinal ulceration gives rise to less misunderstanding, other conditions of the small intestine may beguile the unwary into diagnosing Crohn’s disease. In Europe lymphoma is a rare example of such a condition, but in the Middle East has to be borne continuously in mind. In the U.K. the immigrant population is reintroducing physicians to ileocaecal tuberculosis, under which guise Crohn’s ileitis went unseen until Crohn, Ginsburg, and Oppenheimer 22 placed it on the nosological lists. Many are unaware that that common condition, the appendix abscess, can occasionally add to the confusion : when this abscess persists and lies in juxtaposition to the terminal ileum the patient can present with diarrhoea, a mass in the right iliac fossa simulating Crohn’s involvement, and a barium progress meal which shows the ileum to be narrowed because it is stretched out over the limit of the abscess. A close look at the X-rays will reveal the narrowed ileum to be placed in a curve as it describes the sector of the abscess circumference. So all may not be as it seems when Crohn’s disease is diagnosed. Diagnostic laparotomy sometimes has a place, despite the risk that operation may encourage a fistula if the disorder proves in fact to be Crohn’s disease. "
"
GIVING UP SMOKING
THE dust is clearing from the third World Conference on Smoking and Health, held this June in New York. What the conference chairman, Sir George Godber, described as the commonest self-inflicted injury today" is still very much with us. The evidence that smoking is dangerous is thoroughly documented 23-25 and is now generally accepted. Despite this, and a substantial effort to help people to stop smoking, very little has been achieved. A great many smokers want to give up but find they cannot. McKennell and Thomas 2reported in 1967 that three-quarters of current smokers either wished to stop smoking or had tried to stop and that only 2% of smokers were able to limit themselves to intermittent or occasional smoking. By one estimate, over a two-year period only 10% of smokers were able to give up spontaneously. 27 Clinical psychologists "
Crohn, B. B., Ginsburg, L., Oppenheimer, C. D.J. Am. med. Ass. 1932, 99, 1323. 23. Royal College of Physicians. Smoking and Health Now. London,
22.
1971. 24. Smoking and Health. Washington, 1964. 25. Smoking and its Effects on Health. Tech. Rep. Ser. Wld Hlth Org. 1975, no. 568. 26. McKennell, A. C., Thomas, R. K. Adults’ and Adolescents’ Smoking Habits and Attitudes. H.M. Stationery Office, 1967. 27. Eisinger, R. A. Soc. Sci. Med. 1972, 6, 137.
confirm
the
difficulty of permanently changing people’s smoking habits. 28-31 Hunt and enormous
Matarazzo 32looked at the results of 87 withdrawal studies for alcohol, heroin, or tobacco, and found an almost identical pattern of outcome for all three substances. About two-thirds of those who completed treatment relapsed in the subsequent three months. One year after treatment only 25% were still abstinent, and this probably overestimates the success-rate since the figure excludes patients who dropped out during treatment. Smoking-withdrawal clinics in Sweden 33 and Norway 34 report similar results. In treatment psychoanalysis, group therapy, drug therapy, and In unbehavioural therapy have all been tried. controlled studies hypnosis has looked promising, but this promise has not yet been tested by controlled Of the behavioural approaches investigation. 35 Lichtenstein’s rapid-smoking method seems the most effective. In two carefully controlled investigations abstinence-rates of 64% 36 and 52 % 37 were found six months after treatment. The main drawback to the method is a possible risk of excessive nicotine intoxication, and patients with cardiovascular disease have to be excluded. McKennell and Thomas’s figures suggest that Britain alone has about 10 million smokers who would like to give up smoking.3sThe U.K. has some ten withdrawal clinics, which cannot possibly cope with all potential attenders. Various strategies might improve the lot of those who continue to smoke. One approach is to abandon the goal of non-smoking and attempt to make smoking safer. 39 Another is to ban all tobacco advertising and promotion, and counteract its accumulated effect with anti-smoking advertising aimed at stressing the negative aspects of smoking. One way of under" lining the negative side would be to recognise compulsive tobacco smoking " as a diagnosis-a move proposed by Dr Jerome Jaffe at the New York conference. Yet another approach is to reduce consumption by increased taxation. 40 Finally, doctors and other health workers can make an important contribution. In one study 62% of a group of survivors of myocardial infarction were persuaded to stop smoking and were still abstinent a year later. 41This study relied heavily on the help of a community nurse who followed up the doctor’s anti-smoking advice by visiting the patients and their families at home. The elimination of smoking may be a pipe dream. For some the pace of modem life is apparently too great to tolerate without drugs such as alcohol and 28.
29. 30. 31. 32. 33. 34. 35.
Keutzer, C. S., Lichtenstein, E., Mees, H. L. Psychol. Bull. 1968, 70, 520. Bernstein, D. A. ibid. 1969, 71, 418. Lichtenstein, E., Keutzer, C. S. In Advances in Behaviour Therapy (edited by R. D. Rubin). New York, 1971. Bernstein, D. A., McAlister, A.J. addict. Behav. (in the press). Hunt, W. A., Matarazzo, J. D. J. abnorm. Psychol. 1973, 81, 107. Ejrup, B. Ca, 1963, 13, 183. Berglund, E. L. Tobacco Withdrawal Clinics. Oslo, 1969. Raw, M. Unpublished M.PHIL. dissertation, London University, 1974.
36.
37. 38. 39. 40. 41.
Schmahl, D. P., Lichtenstein, E., Harris, D. E. J. consult, clin. Psychol. 1972, 38, 105. Lichtenstein, E., Harris, D. E., Birchler, G. B., Wahl, J. M., Schmahl, D. P. ibid. 1973, 40, 92. Raw, M. Behav. Res. Ther. (in the press). Russell, M. A. H. Lancet, 1974, i, 254. Russell, M. A. H. Br. J. prev. Soc. Med. 1973, 27, 1. Burt, A., Thornley, P., Illingworth, D., White, P., Shaw, T. R. D., Turner, R. Lancet, 1974, i, 304.
117
nicotine. When the drugs themselves lead to further suffering, we find ourselves in a new paradox which we are unable or unwilling to solve.
NOMENCLATURE OF CONGENITAL LIMB DEFICIENCIES AFTER the thalidomide tragedy, closer attention to congenital malformations of the limbs revealed considerable confusion in terminology. Words such as meromelia or ectromelia do not always have the same meaning to those who use them and are incomprehensible to many others. Attempts to improve methods of classification, such as those by Frantz and O’Rahilly1 and Swanson2 in the United States and by Henkel and Willert3 in Germany, have helped to increase understanding of the congenital limb deficiencies, but the multiplicity of modifications and revisions in use throughout the world creates difficulties in discussing and comparing scientific work from different centres. A multinational working-group, sponsored by the International Society for Prosthetics and Orthotics, has now agreed on a new terminology,4 which makes it possible to classify these malformations simply and precisely. Every skeletal limb deficiency is considered as either transverse or longitudinal and further described in terms of the bones involved and the extent of their deficiency. The proposed system has been subjected to exhaustive field trials in many centres in the United States, the United Kingdom, and elsewhere in Europe. Among 400 cases none was encountered which could not be classified under the new system, which is now recommended for general use. Terms such as amelia and phocomelia are so well established in ordinary clinical practice in the U.K. that they are unlikely to be dropped immediately. Nevertheless, universal adoption of the new system of classification in case records and reports would go a long way to promote international understanding of skeletal limb deficiencies and of all that can be done to help those who suffer from them.
INFLATION AND THE N.H.S.
ON
11 the Government published the whiteThe Attack on Inflation, and, on the same day, paper, Mrs Barbara Castle, Secretary of State for Social Services, described the financial prospects for the National Health Service as bleak. We would be very lucky, she told the first annual meeting of the National Association of Health Authorities, if in the next three or four years we saw any real growth whatever in the N.H.S. The steady annual growth of the Service, which had enabled it to cope not only with the extra demands arising from demographic factors (notably the increase in the elderly population), and with the extra costs of new drugs and new kinds of treatment, but also to make real progress in development, could not now be maintained. It was not possible to say 1. 2. 3. 4.
July
Frantz, C. H., O’Rahilly, R. J. Bone Jt Surg. 1961, 43A, 1202. Swanson, A. B. Interclin. Inf. Bull. 1966, 6, 1. Henkel, H., Willert, H. J. Bone Jt Surg. 1969, 51B, 399. Proposed International Terminology for the Classification of Congenital Limb Deficiencies. Dev. Med. Child Neurol. 1975, 17, suppl. 34.
yet what the exact limit to growth would be, and Mrs Castle denied rumours that the N.H.S. would be inflation-proofed only up to a ceiling of 10%. Whatever the figure turned out to be, the money available should be spent as effectively as possible. In achieving savings, Mrs Castle would, she said, be utterly dependent on the professions and the health authorities to show what could be done, but she thought that administrative costs should be reduced (if possible to pre-reorganisation levels), that duplication of function between the Department, the regions, and the areas should be avoided, and that there should be some sharing of planning and financing of services between the health and local authorities. Mrs Castle is also planning to publish before the end of the year a document for discussion on priorities in the health and personal social services, but she has turned down the request from representatives of the British Medical Association, the Royal College of Nursing, the British Dental Association, the Royal College of Midwives, and the Joint Consultants Committee for an independent inquiry into the financing of the N.H.S. In a letter to Mr Walpole Lewin, chairman of the five groups, Mrs Castle declared that, with no extra money in the kitty for the N.H.S., such an inquiry would be irresponsible, and would fail to exert any influence on the Government’s decisions concerning the allocation of resources. She maintained that, in its first year of office, the present Government had raised the percentage of the gross national product devoted to the N.H.S. from 4-9%, which was the level of the previous two years, to, as provisionally assessed, 5-4% of the G.N.P. from April, 1974, to April, 1975-the largest single increase in expenditure devoted to the N.H.S. in any year since 1948. Nonetheless, Mrs Castle was quite willing to admit, in her speech of July 11, that the Health Service did not benefit as much as it should do (and as the Education Service certainly did) from effective pressure groups capable of influencing the Government’s decisions on spending priorities. In order to promote the growth of pressure groups and responsible local opinion in the N.H.S., Mrs Castle is going ahead with plans for the further democratisation of the Health Service as outlined in the consultation paper, Democracy in the N.H.S. The numbers of local-authority members on area and regional health authorities is to be increased to one-third of the total, and provision is to be made for the inclusion on health authorities of two members representing workers in the N.H.S. apart from doctors and nurses. Community health councils will be entitled to send one of their members to attend meetings of their area health authority with speaking, but not voting, rights. Meanwhile, the doctors, who are usually capable of making their views known and exerting pressure when required, are to seek a very early meeting with Mrs Castle to discuss the implications for the Health Service of the measures announced in the white-paper on inflation. They will be wanting to point out that large numbers of general practitioners, consultants, and senior registrars will be affected by the E8500 cut-off limit for pay increases, and that junior and Armed Forces doctors and medical teachers all have pay increases outstanding.
"
GIVING UP SMOKING
THE dust is clearing from the third World Conference on Smoking and Health, held this June in New York. What the conference chairman, Sir George Godber, described as the commonest self-inflicted injury today" is still very much with us. The evidence that smoking is dangerous is thoroughly documented 23-25 and is now generally accepted. Despite this, and a substantial effort to help people to stop smoking, very little has been achieved. A great many smokers want to give up but find they cannot. McKennell and Thomas 2reported in 1967 that three-quarters of current smokers either wished to stop smoking or had tried to stop and that only 2% of smokers were able to limit themselves to intermittent or occasional smoking. By one estimate, over a two-year period only 10% of smokers were able to give up spontaneously. 27 Clinical psychologists "
Crohn, B. B., Ginsburg, L., Oppenheimer, C. D.J. Am. med. Ass. 1932, 99, 1323. 23. Royal College of Physicians. Smoking and Health Now. London,
22.
1971. 24. Smoking and Health. Washington, 1964. 25. Smoking and its Effects on Health. Tech. Rep. Ser. Wld Hlth Org. 1975, no. 568. 26. McKennell, A. C., Thomas, R. K. Adults’ and Adolescents’ Smoking Habits and Attitudes. H.M. Stationery Office, 1967. 27. Eisinger, R. A. Soc. Sci. Med. 1972, 6, 137.
confirm
the
difficulty of permanently changing people’s smoking habits. 28-31 Hunt and enormous
Matarazzo 32looked at the results of 87 withdrawal studies for alcohol, heroin, or tobacco, and found an almost identical pattern of outcome for all three substances. About two-thirds of those who completed treatment relapsed in the subsequent three months. One year after treatment only 25% were still abstinent, and this probably overestimates the success-rate since the figure excludes patients who dropped out during treatment. Smoking-withdrawal clinics in Sweden 33 and Norway 34 report similar results. In treatment psychoanalysis, group therapy, drug therapy, and In unbehavioural therapy have all been tried. controlled studies hypnosis has looked promising, but this promise has not yet been tested by controlled Of the behavioural approaches investigation. 35 Lichtenstein’s rapid-smoking method seems the most effective. In two carefully controlled investigations abstinence-rates of 64% 36 and 52 % 37 were found six months after treatment. The main drawback to the method is a possible risk of excessive nicotine intoxication, and patients with cardiovascular disease have to be excluded. McKennell and Thomas’s figures suggest that Britain alone has about 10 million smokers who would like to give up smoking.3sThe U.K. has some ten withdrawal clinics, which cannot possibly cope with all potential attenders. Various strategies might improve the lot of those who continue to smoke. One approach is to abandon the goal of non-smoking and attempt to make smoking safer. 39 Another is to ban all tobacco advertising and promotion, and counteract its accumulated effect with anti-smoking advertising aimed at stressing the negative aspects of smoking. One way of under" lining the negative side would be to recognise compulsive tobacco smoking " as a diagnosis-a move proposed by Dr Jerome Jaffe at the New York conference. Yet another approach is to reduce consumption by increased taxation. 40 Finally, doctors and other health workers can make an important contribution. In one study 62% of a group of survivors of myocardial infarction were persuaded to stop smoking and were still abstinent a year later. 41This study relied heavily on the help of a community nurse who followed up the doctor’s anti-smoking advice by visiting the patients and their families at home. The elimination of smoking may be a pipe dream. For some the pace of modem life is apparently too great to tolerate without drugs such as alcohol and 28.
29. 30. 31. 32. 33. 34. 35.
Keutzer, C. S., Lichtenstein, E., Mees, H. L. Psychol. Bull. 1968, 70, 520. Bernstein, D. A. ibid. 1969, 71, 418. Lichtenstein, E., Keutzer, C. S. In Advances in Behaviour Therapy (edited by R. D. Rubin). New York, 1971. Bernstein, D. A., McAlister, A.J. addict. Behav. (in the press). Hunt, W. A., Matarazzo, J. D. J. abnorm. Psychol. 1973, 81, 107. Ejrup, B. Ca, 1963, 13, 183. Berglund, E. L. Tobacco Withdrawal Clinics. Oslo, 1969. Raw, M. Unpublished M.PHIL. dissertation, London University, 1974.
36.
37. 38. 39. 40. 41.
Schmahl, D. P., Lichtenstein, E., Harris, D. E. J. consult, clin. Psychol. 1972, 38, 105. Lichtenstein, E., Harris, D. E., Birchler, G. B., Wahl, J. M., Schmahl, D. P. ibid. 1973, 40, 92. Raw, M. Behav. Res. Ther. (in the press). Russell, M. A. H. Lancet, 1974, i, 254. Russell, M. A. H. Br. J. prev. Soc. Med. 1973, 27, 1. Burt, A., Thornley, P., Illingworth, D., White, P., Shaw, T. R. D., Turner, R. Lancet, 1974, i, 304.
117
nicotine. When the drugs themselves lead to further suffering, we find ourselves in a new paradox which we are unable or unwilling to solve.
NOMENCLATURE OF CONGENITAL LIMB DEFICIENCIES AFTER the thalidomide tragedy, closer attention to congenital malformations of the limbs revealed considerable confusion in terminology. Words such as meromelia or ectromelia do not always have the same meaning to those who use them and are incomprehensible to many others. Attempts to improve methods of classification, such as those by Frantz and O’Rahilly1 and Swanson2 in the United States and by Henkel and Willert3 in Germany, have helped to increase understanding of the congenital limb deficiencies, but the multiplicity of modifications and revisions in use throughout the world creates difficulties in discussing and comparing scientific work from different centres. A multinational working-group, sponsored by the International Society for Prosthetics and Orthotics, has now agreed on a new terminology,4 which makes it possible to classify these malformations simply and precisely. Every skeletal limb deficiency is considered as either transverse or longitudinal and further described in terms of the bones involved and the extent of their deficiency. The proposed system has been subjected to exhaustive field trials in many centres in the United States, the United Kingdom, and elsewhere in Europe. Among 400 cases none was encountered which could not be classified under the new system, which is now recommended for general use. Terms such as amelia and phocomelia are so well established in ordinary clinical practice in the U.K. that they are unlikely to be dropped immediately. Nevertheless, universal adoption of the new system of classification in case records and reports would go a long way to promote international understanding of skeletal limb deficiencies and of all that can be done to help those who suffer from them.
INFLATION AND THE N.H.S.
ON
11 the Government published the whiteThe Attack on Inflation, and, on the same day, paper, Mrs Barbara Castle, Secretary of State for Social Services, described the financial prospects for the National Health Service as bleak. We would be very lucky, she told the first annual meeting of the National Association of Health Authorities, if in the next three or four years we saw any real growth whatever in the N.H.S. The steady annual growth of the Service, which had enabled it to cope not only with the extra demands arising from demographic factors (notably the increase in the elderly population), and with the extra costs of new drugs and new kinds of treatment, but also to make real progress in development, could not now be maintained. It was not possible to say 1. 2. 3. 4.
July
Frantz, C. H., O’Rahilly, R. J. Bone Jt Surg. 1961, 43A, 1202. Swanson, A. B. Interclin. Inf. Bull. 1966, 6, 1. Henkel, H., Willert, H. J. Bone Jt Surg. 1969, 51B, 399. Proposed International Terminology for the Classification of Congenital Limb Deficiencies. Dev. Med. Child Neurol. 1975, 17, suppl. 34.
yet what the exact limit to growth would be, and Mrs Castle denied rumours that the N.H.S. would be inflation-proofed only up to a ceiling of 10%. Whatever the figure turned out to be, the money available should be spent as effectively as possible. In achieving savings, Mrs Castle would, she said, be utterly dependent on the professions and the health authorities to show what could be done, but she thought that administrative costs should be reduced (if possible to pre-reorganisation levels), that duplication of function between the Department, the regions, and the areas should be avoided, and that there should be some sharing of planning and financing of services between the health and local authorities. Mrs Castle is also planning to publish before the end of the year a document for discussion on priorities in the health and personal social services, but she has turned down the request from representatives of the British Medical Association, the Royal College of Nursing, the British Dental Association, the Royal College of Midwives, and the Joint Consultants Committee for an independent inquiry into the financing of the N.H.S. In a letter to Mr Walpole Lewin, chairman of the five groups, Mrs Castle declared that, with no extra money in the kitty for the N.H.S., such an inquiry would be irresponsible, and would fail to exert any influence on the Government’s decisions concerning the allocation of resources. She maintained that, in its first year of office, the present Government had raised the percentage of the gross national product devoted to the N.H.S. from 4-9%, which was the level of the previous two years, to, as provisionally assessed, 5-4% of the G.N.P. from April, 1974, to April, 1975-the largest single increase in expenditure devoted to the N.H.S. in any year since 1948. Nonetheless, Mrs Castle was quite willing to admit, in her speech of July 11, that the Health Service did not benefit as much as it should do (and as the Education Service certainly did) from effective pressure groups capable of influencing the Government’s decisions on spending priorities. In order to promote the growth of pressure groups and responsible local opinion in the N.H.S., Mrs Castle is going ahead with plans for the further democratisation of the Health Service as outlined in the consultation paper, Democracy in the N.H.S. The numbers of local-authority members on area and regional health authorities is to be increased to one-third of the total, and provision is to be made for the inclusion on health authorities of two members representing workers in the N.H.S. apart from doctors and nurses. Community health councils will be entitled to send one of their members to attend meetings of their area health authority with speaking, but not voting, rights. Meanwhile, the doctors, who are usually capable of making their views known and exerting pressure when required, are to seek a very early meeting with Mrs Castle to discuss the implications for the Health Service of the measures announced in the white-paper on inflation. They will be wanting to point out that large numbers of general practitioners, consultants, and senior registrars will be affected by the E8500 cut-off limit for pay increases, and that junior and Armed Forces doctors and medical teachers all have pay increases outstanding.
