279
Suppositories containing prostaglandin-synthetase
inhibi-
may prove better than tablets for the treatment of primary dysmenorrhoea. Local absorption may be more rapid and result in higher blood levels of anti-prostaglandins in the pelvic organs compared with oral administration. We are now comparing oral and rectal naproxen. OLAVI YLIKORKALA Department of Obstetrics and Gynæcology, ANTTI KAUPPILA University of Oulu, SF-90220 Oulu 22, Finland JUKKA PUOLAKKA tors
adult homozygote with only fetal haemoglobin within his vessels was the "C.A." of table n in an earlier paper9 where we showed clearly that there was imbalance of globin-chain synthesis. Ghana Institute of Clinical Genetics, Korle Bu Teaching Hospital, P.O. Box 150, Korle Bu, Ghana
F. I. D. KONOTEY-AHULU
"SEE IT DOESN’T HURT ..." ENTERITIS NECROTICANS IN NEPAL
SiR,-During a recent W.H.O. consultancy in Nepal on another matter, I was able to make some observations and inquiries about the possibility of enteritis necroticans being endemic there. The topography, terrain, and environment are very similar to those of the highlands of Papua New Guinea where the disease known as "pig-bel" is endemic. 1-3 The condition is caused by infection with Clostridium type C, present in the normal environment. This organism flourishes under changed ecological conditions.4-6 Its beta toxin, rapidly detoxified in the normal gut, penetrates the mucosa causing necrosis. The pathogenic outcome depends on the balance between the production and destruction of beta toxin. The disease is now preventable by vaccination (see p. 227). In the village setting in Nepal, the same ecological determinants exist as in Papua New Guinea. Protein deprivation in children (7%), ascaris infestation, faecal pollution of the environment, domestic pigs reared and cared for by lower caste Hindus, and seasonal gastroenteritis outbreaks following religious festivals with dietary change to meat and occasional consumption of sweet potato. Auxiliary health workers at several health posts, when questioned about the clinical features of acute pig-bel disease, agreed that they see cases. Surgeons at the Bir Hospital in Kathmandu recognise jejunal volvulus, usually associated with ascaris infestation, as the commonest cause of small-bowel obstruction met at laparotomy and recognise that cases appear to occur seasonally. It will be interesting to determine whether C. perfringens typeC is as widespread in the Nepali environment as it is in Papua New Guinea. Now that control by vaccination is feasible a search for undiagnosed cases of enteritis necroticans in other Asian, South East Asian, and Western Pacific countries where environments are similar might be useful. Department of Community Medicine, University of Adelaide, Adelaide, South Australia 5001
T. G. C. MURRELL
HOMOZYGOSITY FOR HEREDITARY PERSISTENCE OF FETAL HAEMOGLOBIN
SIR,-My attention has been drawn by Prof. Hermann Leh(Cambridge) and Prof. David Weatherall (Oxford) to an
mann
interpretation’ of the non-alpha/alpha chain ratio in the case of a blood-donor footballer who was homozygous for hereditary persistence of fetal hoemoglobin. The statement that there was no imbalance of globin-chain synthesis was incorrect, and we regret giving the opposite meaning while comparing our ratio with that of Charache et a1.8 who pointed out that "the Negro variety of hereditary persistence of fetal hxmoglobin" was a mild form of thalassaemia. Our error in our
(0.51)
1 Murrell, T. G. C., Roth, L. Med. J. Aust. 1963, i, 61. 2 Murrell, T. G. C., and others. Lancet, 1966, i, 127. 3 Murrell, T. G. C., and others. J. Hyg. Camb. 1966, 64, 375. 4. Egerton, J. R, Walker, P. D. J. Path. Bact. 1964, 88, 275. 5. Lawrence, G., Walker, P. D. Lancet, 1976,i, 125. 6 Walker, P. D., Murrell, T. G. C. J. Path. Bact. (in the press). 7 Acquaye, C. T. A., Oldham, J. H., Konotey-Ahulu, F. I. D. Lancet,
1977,
i, 796. 8
Charache, S , Clegg, J. B., Weatherall, D. Br.J. Hœmat. 1976, 34, 527.
Our peripatetic correspondent (Dec. 23/30, p. 1369) writes: "Dr May (Jan. 13, p. 103) has not read between the lines of my piece in In England Now. Neither Willie nor we would have dreamed of dissembling. Children are not fools; they easily saw through the ploy, but it still worked. Indeed, that was the beauty of it. Is not permissible pride a human emotion, too? And one that is not only to be encouraged, but productive of courage?"
9.
T. A., Oldham, J. H., Konotey-Ahulu, F. I. D. Yawson, G., Sukumaran, P. K., Schroeder, W. A., Huisman, T. H. J. Biochem. Genet. 1977, 15, 1083.
Ringelhann, B., Acquaye, C.
Commentary from Westminster From
Parliamentary Correspondent Conflicting Views on Cannabis our
PROPOSALS to liberalise the law on cannabis are being considered by the Home Secretary, Mr Merlyn Rees. They have been recommended to him by the Government’s Advisory Council on the Misuse of Drugs, which has just completed a review of the classification of controlled drugs and the penalties laid down. Its report, which has yet to be published, recommends that cannabis and cannabis resin should be downgraded to a lower category of drugs and that the penalties for unlawful possession should be relaxed. However, as Sir Robert Bradlaw, chairman of the Council, says in a letter to Mr Rees, the issue provoked "a marked division of opinion within the Council". Members were unanimous that the use of cannabis and cannabis resin should not be legalised and that a deterrent to their use was still needed. They rejected the idea of "decriminalisation" as adopted by several states in the U.S. There was also general agreement that any question of liberalising the present law should be approached with caution. Members were anxious that, whatever their recommendations, they should not lead to an increased use of the drug or to an increase in trafficking. The conflict of view arose over the harmfulness or otherwise of cannabis. The Council’s technical subcommittee, chaired by Prof. J. D. P. Graham, professor of pharmacology in the University of Wales, believed that lower penalties for unlawful possession could be contemplated without undue concern that this would encourage increased use and possible risk to public health. Its conclusion was "that there was no compelling evidence that occasional moderate use of cannabis was likely to have detrimental physical effects on individual users. The acute effect was one of intoxication and was dose related, temporary and reversible". After referring to evidence from America that the use of herbal cannabis (marihuana) impairs driving ability and that heavy use
280
impairs lung function in the same way as cigarette smoking, the committee said: "The available reports on the effects on the health of the individual of what is deemed to be long-continued (a matter of years) heavy use (daily consumption of several ’joints’) of cannabis contain no evidence of consequential harmful effects on physical health and contradictory reports on the mental state and intellectual capacities of the subjects examined. The subcommittee concluded that a causal relation between chronic use of cannabis and mental impairment was by no means proven and that there appeared to be many compounding factors involved". But this view was described as "unacceptable" to other working groups of the Council, who were not satisfied that enough was known to recommend an action which would be widely regarded as implying that the risks of using cannabis were less serious than was believed and which would encourage increased use. "In their opinion cannabis could undoubtedly cause an acute psychotic reaction and the question of possible long-term psychotic reaction was my no means finally settled. Hitherto unsuspected hazards were also certainly coming to light and there were leads from laboratory research which were at present difficult to interpret and in need of much further investigation. Whether cannabis was free from dependence potential was now open to debate. But influence on vehicle driving had to be taken seriously. The scientific evidence could not be pushed to a premature verdict, and the risks to the population of long-term exposure to cannabis, possibly at dose levels with which we are now in the Western world unfamiliar, remained an open but worrying question". The Council eventually decided by 21 votes to 6 to recommend transferring cannabis and cannabis resin from class B to class C, the least dangerous of the controlled drugs listed. By 16 votes to 11 it voted for reducing the penalties for unlawful possession of class-C drugs, abolishing the power of magistrates to impose prison sentences, and making the maximum penalty on summary conviction a fine of;200. A New Drive
on
249 votes to 139. The Departments of Transport and Health are firm believers in the need for legislation. They cite evidence that in accidents where safety belts are worn serious injuries are reduced by half. Their estimate is that if all front-seat drivers and passengers wore belts about 1000 lives would be saved and 10 000 serious injuries prevented each year, a possible saving of up to ,rV 50 million. The seat-belt wearing rate has been raised to around 30%. But it is argued that the voluntary approach, which has cost more than k5million so far, cannot achieve a higher rate. Italy and the United Kingdom are now the only countries in the Common Market where seat-belt wearing is not compulsory-compulsion began in the Irish Republic this week-and all foreign experience shows that compulsion can lead to wearing rates of over 80% without exceptional enforcement effort. The British Medical Association has written to all 635 M.p.s urging support for the Bill. But there is bound to be strong vocal opposition from a minority in Parliament arguing that the legislation represents an infringement of personal liberty.
by
y
Compensation for the Vaccine Damaged Another Bill published last week was the measure to provide for a scheme of payments to those people damaged as a result of vaccination. Under the legislation a payment of jlO 000 will be made to anyone who has suffered severe damage as a result of vaccination or of contact with someone who has been vaccinated, since the beginning of the N.H.S. on July 5, 1948. Payment will not be made where the death of a vaccine-damaged person occurred before May 9 last year when the scheme was announced. Claims will be considered by the Secretary of State and if he is not satisfied the matter will be referred to an independent medical tribunal whose decision will be conclusive. The legislation, which is expected to affect some 600 people, will not prejudice
anyone’s right to
institute
subsequent proceedings
in
re-
spect of disablement, although the payments could be taken into account if damages are awarded.
Seat Belts
The battle lines are already being drawn up for the latest attempt to legislate for the compulsory wearing of car seat belts. The Government’s Road Traffic (Seat Belts) Bill, published last week, would require drivers and front-seat passengers to wear belts in cars registered since 1965 and in light vans registered since 1967. The maximum penalty for non-wearing would be a fine of 50. The regulations would be subject to exemptions, which the Government would discuss with medical and transport bodies. But Mr William Rodgers, Secretary of State for Transport, has said he intends to draw the exemptions more narrowly than has previously been the case. He does not, for instance, propose to exempt children. But there will be exemptions for those with certain physical and mental conditions. The new Bill is the fifth attempt in six years to legislate on this controversial issue. Previous attempts have failed through lack of time and robust Parliamentary opposition. But Ministers are convinced there is a Parliamentary majority for the Bill, although there will be a free vote on both sides of the Commons. The last seatbelts Bill introduced in 1976 received its second reading
Parliament QUESTION TIME Hospital Waiting-lists On March 31, 1978, there were 603 240 patients awaiting admission to the National Health Service hospitals in England. 41 236 patients were classified as urgent, 64.7% of whom waited for more than one month. On June 30, 1974, there were 508 390 patients awaiting admission to N.H.S. hospitals in England.
Staff of the National Health Service On Sept. 30, 1977, 99 036 whole-time equivalent administrative and clerical staff were employed in the National Health Service in England. The ratio of administrative and clerical staff to medical staff was 1 - 8/1. Fluoridation MR CLEMENT FREUD (Lib, Isle of Ely) asked the Secretary of State for Social Services whether he would publish the evidence on the detrimental effect of fluoridation, in particular the evidence offered in the recent case in the court of common
Suppositories containing prostaglandin-synthetase
inhibi-
may prove better than tablets for the treatment of primary dysmenorrhoea. Local absorption may be more rapid and result in higher blood levels of anti-prostaglandins in the pelvic organs compared with oral administration. We are now comparing oral and rectal naproxen. OLAVI YLIKORKALA Department of Obstetrics and Gynæcology, ANTTI KAUPPILA University of Oulu, SF-90220 Oulu 22, Finland JUKKA PUOLAKKA tors
adult homozygote with only fetal haemoglobin within his vessels was the "C.A." of table n in an earlier paper9 where we showed clearly that there was imbalance of globin-chain synthesis. Ghana Institute of Clinical Genetics, Korle Bu Teaching Hospital, P.O. Box 150, Korle Bu, Ghana
F. I. D. KONOTEY-AHULU
"SEE IT DOESN’T HURT ..." ENTERITIS NECROTICANS IN NEPAL
SiR,-During a recent W.H.O. consultancy in Nepal on another matter, I was able to make some observations and inquiries about the possibility of enteritis necroticans being endemic there. The topography, terrain, and environment are very similar to those of the highlands of Papua New Guinea where the disease known as "pig-bel" is endemic. 1-3 The condition is caused by infection with Clostridium type C, present in the normal environment. This organism flourishes under changed ecological conditions.4-6 Its beta toxin, rapidly detoxified in the normal gut, penetrates the mucosa causing necrosis. The pathogenic outcome depends on the balance between the production and destruction of beta toxin. The disease is now preventable by vaccination (see p. 227). In the village setting in Nepal, the same ecological determinants exist as in Papua New Guinea. Protein deprivation in children (7%), ascaris infestation, faecal pollution of the environment, domestic pigs reared and cared for by lower caste Hindus, and seasonal gastroenteritis outbreaks following religious festivals with dietary change to meat and occasional consumption of sweet potato. Auxiliary health workers at several health posts, when questioned about the clinical features of acute pig-bel disease, agreed that they see cases. Surgeons at the Bir Hospital in Kathmandu recognise jejunal volvulus, usually associated with ascaris infestation, as the commonest cause of small-bowel obstruction met at laparotomy and recognise that cases appear to occur seasonally. It will be interesting to determine whether C. perfringens typeC is as widespread in the Nepali environment as it is in Papua New Guinea. Now that control by vaccination is feasible a search for undiagnosed cases of enteritis necroticans in other Asian, South East Asian, and Western Pacific countries where environments are similar might be useful. Department of Community Medicine, University of Adelaide, Adelaide, South Australia 5001
T. G. C. MURRELL
HOMOZYGOSITY FOR HEREDITARY PERSISTENCE OF FETAL HAEMOGLOBIN
SIR,-My attention has been drawn by Prof. Hermann Leh(Cambridge) and Prof. David Weatherall (Oxford) to an
mann
interpretation’ of the non-alpha/alpha chain ratio in the case of a blood-donor footballer who was homozygous for hereditary persistence of fetal hoemoglobin. The statement that there was no imbalance of globin-chain synthesis was incorrect, and we regret giving the opposite meaning while comparing our ratio with that of Charache et a1.8 who pointed out that "the Negro variety of hereditary persistence of fetal hxmoglobin" was a mild form of thalassaemia. Our error in our
(0.51)
1 Murrell, T. G. C., Roth, L. Med. J. Aust. 1963, i, 61. 2 Murrell, T. G. C., and others. Lancet, 1966, i, 127. 3 Murrell, T. G. C., and others. J. Hyg. Camb. 1966, 64, 375. 4. Egerton, J. R, Walker, P. D. J. Path. Bact. 1964, 88, 275. 5. Lawrence, G., Walker, P. D. Lancet, 1976,i, 125. 6 Walker, P. D., Murrell, T. G. C. J. Path. Bact. (in the press). 7 Acquaye, C. T. A., Oldham, J. H., Konotey-Ahulu, F. I. D. Lancet,
1977,
i, 796. 8
Charache, S , Clegg, J. B., Weatherall, D. Br.J. Hœmat. 1976, 34, 527.
Our peripatetic correspondent (Dec. 23/30, p. 1369) writes: "Dr May (Jan. 13, p. 103) has not read between the lines of my piece in In England Now. Neither Willie nor we would have dreamed of dissembling. Children are not fools; they easily saw through the ploy, but it still worked. Indeed, that was the beauty of it. Is not permissible pride a human emotion, too? And one that is not only to be encouraged, but productive of courage?"
9.
T. A., Oldham, J. H., Konotey-Ahulu, F. I. D. Yawson, G., Sukumaran, P. K., Schroeder, W. A., Huisman, T. H. J. Biochem. Genet. 1977, 15, 1083.
Ringelhann, B., Acquaye, C.
Commentary from Westminster From
Parliamentary Correspondent Conflicting Views on Cannabis our
PROPOSALS to liberalise the law on cannabis are being considered by the Home Secretary, Mr Merlyn Rees. They have been recommended to him by the Government’s Advisory Council on the Misuse of Drugs, which has just completed a review of the classification of controlled drugs and the penalties laid down. Its report, which has yet to be published, recommends that cannabis and cannabis resin should be downgraded to a lower category of drugs and that the penalties for unlawful possession should be relaxed. However, as Sir Robert Bradlaw, chairman of the Council, says in a letter to Mr Rees, the issue provoked "a marked division of opinion within the Council". Members were unanimous that the use of cannabis and cannabis resin should not be legalised and that a deterrent to their use was still needed. They rejected the idea of "decriminalisation" as adopted by several states in the U.S. There was also general agreement that any question of liberalising the present law should be approached with caution. Members were anxious that, whatever their recommendations, they should not lead to an increased use of the drug or to an increase in trafficking. The conflict of view arose over the harmfulness or otherwise of cannabis. The Council’s technical subcommittee, chaired by Prof. J. D. P. Graham, professor of pharmacology in the University of Wales, believed that lower penalties for unlawful possession could be contemplated without undue concern that this would encourage increased use and possible risk to public health. Its conclusion was "that there was no compelling evidence that occasional moderate use of cannabis was likely to have detrimental physical effects on individual users. The acute effect was one of intoxication and was dose related, temporary and reversible". After referring to evidence from America that the use of herbal cannabis (marihuana) impairs driving ability and that heavy use
280
impairs lung function in the same way as cigarette smoking, the committee said: "The available reports on the effects on the health of the individual of what is deemed to be long-continued (a matter of years) heavy use (daily consumption of several ’joints’) of cannabis contain no evidence of consequential harmful effects on physical health and contradictory reports on the mental state and intellectual capacities of the subjects examined. The subcommittee concluded that a causal relation between chronic use of cannabis and mental impairment was by no means proven and that there appeared to be many compounding factors involved". But this view was described as "unacceptable" to other working groups of the Council, who were not satisfied that enough was known to recommend an action which would be widely regarded as implying that the risks of using cannabis were less serious than was believed and which would encourage increased use. "In their opinion cannabis could undoubtedly cause an acute psychotic reaction and the question of possible long-term psychotic reaction was my no means finally settled. Hitherto unsuspected hazards were also certainly coming to light and there were leads from laboratory research which were at present difficult to interpret and in need of much further investigation. Whether cannabis was free from dependence potential was now open to debate. But influence on vehicle driving had to be taken seriously. The scientific evidence could not be pushed to a premature verdict, and the risks to the population of long-term exposure to cannabis, possibly at dose levels with which we are now in the Western world unfamiliar, remained an open but worrying question". The Council eventually decided by 21 votes to 6 to recommend transferring cannabis and cannabis resin from class B to class C, the least dangerous of the controlled drugs listed. By 16 votes to 11 it voted for reducing the penalties for unlawful possession of class-C drugs, abolishing the power of magistrates to impose prison sentences, and making the maximum penalty on summary conviction a fine of;200. A New Drive
on
249 votes to 139. The Departments of Transport and Health are firm believers in the need for legislation. They cite evidence that in accidents where safety belts are worn serious injuries are reduced by half. Their estimate is that if all front-seat drivers and passengers wore belts about 1000 lives would be saved and 10 000 serious injuries prevented each year, a possible saving of up to ,rV 50 million. The seat-belt wearing rate has been raised to around 30%. But it is argued that the voluntary approach, which has cost more than k5million so far, cannot achieve a higher rate. Italy and the United Kingdom are now the only countries in the Common Market where seat-belt wearing is not compulsory-compulsion began in the Irish Republic this week-and all foreign experience shows that compulsion can lead to wearing rates of over 80% without exceptional enforcement effort. The British Medical Association has written to all 635 M.p.s urging support for the Bill. But there is bound to be strong vocal opposition from a minority in Parliament arguing that the legislation represents an infringement of personal liberty.
by
y
Compensation for the Vaccine Damaged Another Bill published last week was the measure to provide for a scheme of payments to those people damaged as a result of vaccination. Under the legislation a payment of jlO 000 will be made to anyone who has suffered severe damage as a result of vaccination or of contact with someone who has been vaccinated, since the beginning of the N.H.S. on July 5, 1948. Payment will not be made where the death of a vaccine-damaged person occurred before May 9 last year when the scheme was announced. Claims will be considered by the Secretary of State and if he is not satisfied the matter will be referred to an independent medical tribunal whose decision will be conclusive. The legislation, which is expected to affect some 600 people, will not prejudice
anyone’s right to
institute
subsequent proceedings
in
re-
spect of disablement, although the payments could be taken into account if damages are awarded.
Seat Belts
The battle lines are already being drawn up for the latest attempt to legislate for the compulsory wearing of car seat belts. The Government’s Road Traffic (Seat Belts) Bill, published last week, would require drivers and front-seat passengers to wear belts in cars registered since 1965 and in light vans registered since 1967. The maximum penalty for non-wearing would be a fine of 50. The regulations would be subject to exemptions, which the Government would discuss with medical and transport bodies. But Mr William Rodgers, Secretary of State for Transport, has said he intends to draw the exemptions more narrowly than has previously been the case. He does not, for instance, propose to exempt children. But there will be exemptions for those with certain physical and mental conditions. The new Bill is the fifth attempt in six years to legislate on this controversial issue. Previous attempts have failed through lack of time and robust Parliamentary opposition. But Ministers are convinced there is a Parliamentary majority for the Bill, although there will be a free vote on both sides of the Commons. The last seatbelts Bill introduced in 1976 received its second reading
Parliament QUESTION TIME Hospital Waiting-lists On March 31, 1978, there were 603 240 patients awaiting admission to the National Health Service hospitals in England. 41 236 patients were classified as urgent, 64.7% of whom waited for more than one month. On June 30, 1974, there were 508 390 patients awaiting admission to N.H.S. hospitals in England.
Staff of the National Health Service On Sept. 30, 1977, 99 036 whole-time equivalent administrative and clerical staff were employed in the National Health Service in England. The ratio of administrative and clerical staff to medical staff was 1 - 8/1. Fluoridation MR CLEMENT FREUD (Lib, Isle of Ely) asked the Secretary of State for Social Services whether he would publish the evidence on the detrimental effect of fluoridation, in particular the evidence offered in the recent case in the court of common
