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29 MARcH 1975

in improperly maintained apparatus, especially in the nebulising chamber. In Britain vaporisers are not yet in widespread use, in the home, without medical and nursing supervision; nor is the "inhalation therapist" a distinct entity as in North America. This recent report points out that there might be hazards from any trend in that direction. 1

R.,Jlournal

of Allergy and Clinical Immunology, 1974, 54, 222. Solomon, W. 2Anderson, A. A., Journal of Bacteriology, 1958, 76, 471. 3 Pierce, A. K., et al., New England J'ournal of Medicine, 1970, 282, 528. 4 Covelli, H. D., et al., American Review of Respiratory Diseases, 1973, 108, 698.

Eyes, Joints, and Intestines Inflammatory lesions of the eye occur in a number of rheumatic conditions, of which the best known are Still's disease, ankylosing spondylitis, and Reiter's syndrome. The most common is anterior uveitis, but conjunctivitis, keratitis, and episcleritis may also be found, especially in Reiter's syndrome and rheumatoid arthritis. In addition there may be a posterior uveitis, particularly with the collagen diseases-though it is doubtful whether division of uveitis into two types is either desirable or possible: sarcoidosis for example commonly causes iridocyclitis but retinal lesions are being recognized with increasing frequency. Ulcerative colitis may also be accompanied by anterior uveitis, the incidence in two large series1 2being 2% and 3-6% compared with 0.1% in the general population. An association with regional enteritis is less well known, but a recent survey of 322 patients in Leeds3 showed 21 (6.3%) to have eye complaints, of which anterior uveitis in 8 (2.4%) was the commonest; among others were episcleritis, keratitis, conjunctivitis, and macular haemorrhage. Patients with continuous bowel disease were 20 times and those with intermittent symptoms 10 times as likely to develop eye trouble as those in remission, but the site and extent of the bowel lesion did not play any part. The eye lesions rapidly resolved in 2 patients once their enteritis was brought under control with medical treatment; the other 19 patients were treated surgically, but in 5 this did not prevent further eye trouble. An association between chronic inflammatory bowel disease and arthropathy, particularly ankylosing spondylitis, is well recognized-it occurs in approximately 6% of patients4and there is a close correlation between arthropathy and anterior uveitis in these circumstances. In one series of 144 patients with ulcerative colitis,' 13 ofthe 25 with ankylosing spondylitis also had uveitis, and nearly half the Leeds patients with eye disease had some form of arthropathy, though the nature of the joint disease was not specified. Moreover, other "systemic" complications such as iron deficiency anaemia and skin and mouth lesions were common in the latter group. It is difficult to explain the occurrence of uveitis or indeed any other systemic manifestations in chronic inflammatory bowel disease; Wright et al.1 suggested that they might result from release ofbacterial antigens from the damaged bowel. The known association with arthropathy and the occurrence of uveitis in rheumatic syndromes and sarcoidosis have prompted the search for a common link. It is known that the majority of patients with ankylosing spondylitis possess the histocompatibility antigen, HL-A 27 (W27), and the same antigen is frequently present in Reiter's syndrome and in patients who develop arthropathy after gonococcal, dysenteric, and yersinia infections.5 So far no convincing relationship between HL-A

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27 and either ulcerative colitis or Crohn's disease alone has been established, but 13 out of 18 patients with ulcerative colitis and ankylosing spondylitis4 were positive for HL-A 27. In contrast, however, only 3 of 21 patients with sacroileitis or ankylosing spondylitis accompanying regional enteritis were positive,6 though this figure may be falsely low because of inclusion of "possible" cases, and other series should be tested. In another study of 100 patients with anterior uveitis no fewer than 27 out of 30 patients with associated rheumatic syndromes7 were positive for HL-A 27, while of the other 70 patients in whom there were no associated disorders only 27 were positive. Ten of the latter were among the 13 women in the series who were under 35, so perhaps this variety of uveitis is the female counterpart of Reiter's syndrome. Clearly there is a complex relationship between chronic inflammatory bowel disease, arthropathy, and uveitis. There is a need for further studies of patients showing various combinations of these features, with particular emphasis on accurate identification of the lesion and its site. Wright, R., et al., Quarterly Journal of Medicine, 1965, 34, 229. Billson, F. A., et al., Gut, 1967, 8, 102. 3 Hopkins, D. J., et al., British Journal of Ophthalmology, 1974, 58, 732. 4Brewerton, D. A., et al., Lancet, 1974, 1, 956. 5Aho, K., et al., Lancet, 1973, 2, 157. 6 Deuxchaisnes, C. N. de, et al., Lancet, 1974, 1, 1238. 7 Brewerton, D. A., et al., Lancet, 1974, 1, 464. 1

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Plastic Patients Clinical teachers who want to demonstrate physical signs have to limit their choice of subjects to the patients currendy available. This creates problems with signs that are either transient or relatively uncommon or that are associated with diseases which do not require admission to hospital. As a substitute for the real thing dermatologists and ophthalmologists can use photographs. Cardiologists have used gramophone records or tapes, and more recently a phonocardiosimulator has been developed to introduce students to what for many are the mysteries of cardiac auscultation.' It is a logical extension of such ideas that fundus photographs could be viewed through an aperture in a model eye2 and that cardiac noises could be heard by applying a stethoscope to an artificial chest. Recently a female pelvis has been constructed to allow students to practise vaginal examination. The most exotic developments to date are computercontrolled manikins which allow simulation of much more complicated pathophysiological states. These give the results of appropriate laboratory investigations as well as permitting direct examination for the detection of physical signs. Denson and Abrahamson3 introduced "Sim 1" for use in the teaching of anaesthetics, and more recently Gordon4 has described an animated manikin which will simulate about 50 cardiovascular diseases. Its computer will provide an account of the clinical history as well as electrocardiographic, radiological, and haemodynamic information; data from physical examination may be gained by exam iing the model. The student can assess the general appearance of the model (pallor, cyanosis), arterial and venous pulsation, the cardiac impulse, auscultatory signs, the blood pressure, and fundal appearances. Gordon points out that his model has many advantagesunlike real patients the manikin is never tired, worried, or abused, and instructive "patients" can be summoned at the

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touch of a button. It will allow follow-up experience to be gained very rapidly by compressing into seconds a natural history which might normally have a span of many years. The system is designed as a self-instructional tool, and there may be saving of teachers' time; certainly the student will need to be involved and to remain attentive, and the immediate feedback obtained on diagnostic and management decisions should help him to learn more effectively. Such a manikin clearly has great potential, but so far the system is experimental-no reliable true prototype has been completed. There may well be snags in the widespread use of this model. No estimate has been given of the costs, nor has there been any assessment of the logistics of the use of such a machine in a large teaching hospital, where the demands for its time may be vast. Sceptics will argue that a manikin, no matter how technically refined, is no substitute for real patients when learning about clinical aspects of cardiovascular disease. To counter this argument Gordon and his collaborators will have to show that skills learned on their machine are transferable to real clinical situations or show that time spent using it will shorten the period of patient-based training required to reach a predetermined level of clinical competence. Those attracted by Gordon's idea will be disappointed that the evaluation to be used at the end of training on the manikin is to be an oral and written examination. The failure to test a student's skills in physical examination seems an unfortunate oversight: after all it is the body of the manikin and its simulation of heart sounds which make the system unique. The experiment will be watched with interest, but its educational role will have to be critically evaluated to ensure that it adds something to clinical education and that it is not just a very expensive, albeit entertaining, gimmick. Aberg,

H., Johansson, R., and Michaa1sson, M., British Journal of Medical Education, 1974, 8, 262 Penta, F. B., and Kofman, S.,Journal of Medical Education, 1973, 48, 442. 3 Denson, J. S., and Abrahamson, S., Journal of the American Medical Association, 1969, 208, 504. 4 Gordon, M. S., American J'ournal of Cardiology, 1974, 34, 350. 2

An Easy Death Anyone who questions the value to society of the academic study of philosophy should read the report' on euthanasia produced by the Church of England's Board for Social Responsibility; this difficult subject has been analysed with rare clarity of thought. The report was prepared by a working party of doctors, philosophers, and priests, and confined itself to voluntary euthanasia-a request for death by a patient to his or her doctor. Problems such as the treatment of seriously handicapped infants were not considered. Though the word euthanasia means "easy death," in the sense considered by the working party it has come to mean killing. It is misleading to confuse euthanasia with a decision by a doctor to cease active efforts to treat disease. Good medical care of a patient should include recognition of the moment when it is time to allow him to die; and he should then be given as good a death as possible. "There is a clear distinction to be drawn," says the report, "between rendering

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29 MARcH 1975

someone unconscious at risk of killing him and killing him in order to render him unconscious." Case histories are given in the report which at first sight might suggest that there were circumstances in which a patient's request for a quick death should be granted. However, closer examination shows that almost always the circumstances could have been changed had better use been made of methods of controlling pain, vomiting, anxiety, and depression. Efforts should be concentrated on improving the care of the dying, says the report; and it suggests that ignorance and mistaken ideas are bigger obstacles than shortage of money or staff. Certainly, the report admits, there may be rare cases in which killing is morally justified-emergencies or accidents in war or in the jungle where medical care is lacking; but they do not provide arguments for a change in the law. Such a change could be justified only if it would clearly remove greater evils than it would cause. Legalisation of euthanasia would weaken the confidence of patients in their doctors; and it would create a new form of distress for old, sick individuals who would ask themselves whether they should prolong the burden on their families and attendants. The crucial objection, however, is the change in attitudes it would produce. Care of the dying has been improved in recent years, but it can and should be improved much further. Making euthanasia legal could reduce the incentive to improve the quality of terminal care and put in its place the concept of assisted suicide. On Dying Well. An Anglican Contribution to the Debate on Euthanasia. London, Church Information Office, 1975, price 95p. Copies may be obtained from C.I.O., Church House, Dean's Yard, London SWIP 3NZ.

Leeds Meeting Not many doctors can nowadays claim to be so isolated that there are no postgraduate lectures or demonstrations within easy distance of their homes-and in many areas the postgraduate medical centre is in effect the local doctors' club. This welcome change has reduced the value of long, formal medical meetings such as the traditional B.M.A. Annual Scientific Meeting, originally designed to take news of scientific developments to all parts of the country. Few doctors attending the Annual Representative Meeting now have the time or inclination to stay on for another four or five days to attend scientific sessions, and few outside the immediate area of the meeting want to travel, find locums, and book hotels when they can bring themselves up-to-date at their local postgraduate centre. For the Leeds meeting (22 March, p. 692), therefore, the Board of Science has adopted a new, simpler pattern. The A.R.M. will be held from Monday to Friday, 7-11 July; and there will be two formal scientific sessions on Wednesday and Thursday afternoons-symposia on "Primary Care and the Elderly" and "Arthritis and Its Treatment". In addition each day of the meeting short clinical visits have been arranged to the Leeds General Infirmary and the St. James's Hospital. Representatives and other doctors who attend the A.R.M. should find the new combined, streamlined meeting an economic and logistic success.

Editorial: Plastic patients.

BRITISH MEDICAL JOURNAL 29 MARcH 1975 in improperly maintained apparatus, especially in the nebulising chamber. In Britain vaporisers are not yet in...
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