730
(20%) said yes and swab-touching test. positive test and
all except 3 also had a positive Of the 40 patients with both a an
affirmative
questionnaire
response, 9 denied that their vestibular tenderness was
sufficient to influence tampon use or sexual activity. For the remaining 31 patients (15% of the 210) the term "clinical vestibulitis" (after Friedrich 2) was applied to denote their vulvar disorder. The diagnostic criteria described by Friedrich for the vulvar vestibulitis syndrome included, in addition to pain on attempted vaginal entry and local tenderness, some degree of vestibular erythema. Using all these criteria for diagnosis, Furlonge et al3 undertook intensive investigations in 24 patients who, after numerous visits to general practitioner surgeries and gynaecology clinics, had found their way to the department of genitourinary medicine at St Thomas’s Hospital, London. All patients had a dermatological examination and a cervical smear test and swabs were taken from the vagina, urethra, and endocervix. A superficial excision biopsy was done of the area of maximum vestibular tenderness. The commonest microbiological finding was Candida, but in only 6 patients; Chlamydia trachomatis was isolated in 1 patient. All cervical smear tests were negative. In 11 patients there were histological features of non-
specific epithelial hyperplasia accompanied by an chronic inflamatory cell infiltrate of the lamina propria; the researchers do not attach much importance to these findings. 1 patient had an inflamed condyloma acuminata; 6 showed evidence of dysplasia (3 with koilocytosis), and in 2 patients there was koilocytosis alone. Caucasians predominated in both studies. Most women were between 20 and 30 years, although the age span was four decades. The American study showed a preponderance of nulliparous patients but in some women the symptoms had appeared post partum. All but 3 of the London patients belonged to social classes I and II. Some of Goetsch’s patients wondered if they might have an aversion to sex and some had female partners. Patients’ relationships in the British study were mainly monogamous and stable. A tender vestibule is unlikely to be conducive to promiscuity. No convincing explanation for the vulvar vestibulitis syndrome is forthcoming from these two studies. As Wa1cotr complained after scouring the acute or
rain forests for the graces of life, "There is too much nothing here." One is left with a chronic skin condition-in the American study the average duration of symptoms in non-postpartum patients was 10 years-and a name. Mere provision of a name for the disorder may help patients to cope with it; and in this case they can take additional comfort from knowing that their condition is not only recognised but also respectable. prevalence and historic features in a general gynecologic practice population. Am J Obstet Gynecol 1991;
1. Goetsch MF. Vulvar vestibulitis:
164: 1609-16.
2. Friedrich EG. Vulvar vestibulitis syndrome. J Reprod Med 1987; 32: 110-14. 3. Furlonge CB, Thin RN, Evans BE, McKee PH. Vulvar vestibulitis syndrome: a clinico-pathological study. Br J Obstet Gynaecol 1991; 98:
703-06. 4. Walcott D. Air. Collected poems. 1948-1984. New York: Noonday Press, 1990: 113.
Excimer laser 1991 Use of lasers in medicine is governed by two unwritten rules. First, lasers are at their best when there is no conventional treatment for a condition. Second (this rule is a corollary of the first), if there is a good conventional treatment then the onus of proof that the laser is better rests with the user, preferably by means of a randomised controlled trial. Introduction of excimer lasers into two areas of clinical practice illustrates both tenets. The excimer laser is a gas laser that relies on electronic transitions in excited states of noble gases and halogens to produce ultraviolet light at several wavelengths, depending on the mix of gas in the chamber. Because of a short pulse length, a wavelength that is highly absorbed by tissue, and a high photon energy, this laser can cut remarkably precise craters in tissue.33 Considerable practical experience of the excimer laser has accrued since The Lancet reviewed the subject in 1986.4 A xenon and chlorine mix gives an output at 308 mn-a wavelength that will pass down a quartz optical fibre if the pulse length of the laser is stretched (from 14-20 ns to about 180 ns) to reduce damage at the proximal end of the fibre. This laser has been used for coronary angioplasty, usually for stenoses rather than occlusions, in over 1000 patients57 and is supplied by three manufacturers. The delivery device consists of an over-the-wire multifibre ring catheter. The procedure is safe, with a primary success rate of over 85%, but the restenosis rate is much the same as with balloon angioplasty. There is some doubt about whether the bulk of the fibre produces an effect via simple dilatation with very little tissue vaporisation.There have been no controlled clinical comparisons of the device with balloon
angioplasty. An argon and fluorine gas mix gives an output at 193 nm, deep in the ultraviolet. The light is absorbed very heavily in transparent tissue such as the cornea and cannot be transmitted down any existing optical fibre to a useful extent. The short pulses of light are highly energetic and cut extremely sharp craters with hardly any surrounding tissue damage and no obvious potential for malignant transformation.9 Ophthalmologists have been at the forefront of medical laser research, the main reason being that there are no non-invasive alternatives to lasers for retinal and other intraocular surgery. The main ophthalmic application of the excimer laser at 193 nm is anterior corneal surgery, for which fibreoptic delivery is not required; the two most interesting uses are again subject to the general rules of medical laser
731
application. Radial keratotomy is a procedure for myopia in which the combination of a diamond knife and computer mapping10 has never been compared in a
controlled trial with the excimer laser." This
technique is controversial because it involves invasive manipulation of an eye which is essentially normal. Moreover, some researchers believe that laser cuts in the cornea heal less well than knife cuts Use of the laser for therapeutic keratectomy is far more likely to become established because there is no real alternative for the treatment of keratopathies apart from superficial mechanical abrasion. Gartry et al 13 lately used an ablative liquid to protect the normal areas of anterior cornea so that damaged areas could be removed selectively, thereby reducing the pain associated with hypertrophic corneal conditions and also improving acuity and reducing flare. Another possible application is for corneal sculpting for refractive purposes (photorefractive keratectomy), a procedure that remains largely unproven, with or without a laser.14,15 In the USA this technique is still subject to Food and Drug Administration (FDA) constraints and there are concerns about safety; the potential use of this approach by optometrists rather than ophthalmologists has been tested in the American courts.l6 FDA approval for the sale of excimer lasers does not necessarily mean that indications for their use have been fully evaluated. Until research has yielded clear guidelines for application of the excimer laser, the device still cannot be recommended for general use. 1. Phillips R. Sources and applications of ultraviolet radiation. London: Academic Press, 1983. 2. Cross FW, Bowker TJ. The physical properties of tissue ablation with excimer lasers. Med Instrument 1987; 21: 226-30. 3. Linsker R, Srinivasan R, Wynne JJ, Alonso DR. Far-ultraviolet laser ablation of atherosclerotic lesions. Lasers Surg Med 1984; 4: 201-06. 4. Editorial. Medical applications of the excimer laser. Lancet 1986; ii: 82-83.
5. Sanborn TA, Bittl JA, Hershman RA, Siegel RM. Percutaneous coronary excimer laser-assisted angioplasty: initial multicenter experience in 141 patients. JACC 1991; 17: 169B-73B. 6. Werner G, Buchwald A, Unterberg C, Voth E, Kreuzer H, Wiegand V. Excimer laser angioplasty in coronary artery disease. Eur Heart J 1991; 12: 24-29. 7. Cook SL, Eigler N, Goldenberg T, Forrester JS, Grundfest WS, Litvack F. Angiographic determinants of successful excimer laser angioplasty. Circulation 1990; 82 (suppl 3): 671. 8. Ischinger T, Coppenratl K, Pesarini A, Unsöld E, Delius W. Angioscopic findings after excimer laser angioplasty: laser or "Dotter" effects. Circulation 1990; 82 (suppl 3): 671. 9. Gebhardt BM, Salmeron B, McDonald MB. Effect of excimer laser energy on the growth potential of corneal keratocytes. Cornea 1990; 9: 205-10. 10. Binder PS. Radial keratotomy in the 1990s and the PERK study.
JAMA
1990; 263: 1127. 11. Seile T, Bender T, Wolensack J, Trockel S. Excimer laser keratotomy for correction of astigmatism. Am J Ophthalmol 1988; 105: 117-24. 12. Gipson IK, Cintron C, Binder PS. Corneal epithelial and stromal reactions to excimer laser photorefractive keratotomy. Arch Ophthalmol 1990; 108: 1539-42. 13. Gartry D, Kerr Muir M, Marshall J. Excimer laser treatment of corneal surface pathology: a laboratory and clinical study. Br J Ophthalmol 1991; 75: 258-69. 14. McDonald MB, Frantz JM, Klyce SD, et al. Central photorefractive keratectomy for myopia. Arch Ophthalmol 1990; 108: 799-808. 15. Rice N. Excimer laser for anterior cornea. Br J Ophthalmol 1991; 75: 257. 16. Knaub J. Excimer lasers—a place in optometry? Refract Corn Surg 1990; 6: 313-14.
Keeper of the public health Sir Donald Acheson, Chief Medical Officer at the Department of Health in London, retired earlier this week, a few days after presenting his eighth annual report, for the year 1990 (see p 751). When he forsook his post at Southampton eight years ago, many people wondered how this forthright academic would fit into the Whitehall scene. The timing turned out to be providential because he immediately applied his epidemiological and diplomatic skills to human immunodeficiency virus infection, then gathering pace in the cities. As the first CMO of the AIDS era he will be remembered for the way in which he championed strategies for prevention and control. He sought to raise public awareness early in the course of the epidemic and managed to convince ministers that taking on AIDS at that stage was not alarmism. Consequently, while many countries wavered Britain pressed ahead with a comprehensive and explicit publicity campaign that owed nothing to the nouveauVictorian values then espoused elsewhere by the Prime Minister and her colleagues. Nevertheless, Sir Donald clearly admired one stalwart figure of Victoria’s reign-Edwin Chadwick, who died in 1890 and whose work lay behind the creation of the post of CMO. When he gave the Edwin Chadwick centennial lecture last year1 he paid tribute to Chadwick’s farsightedness in recognising that environmental and social factors are linked to poverty and ill-health. Chadwick also features in Sir Donald’s final report, as does the theme of inequalities of health; at the press conference launching the report he declared bluntly "... there is a link, has been a link, and I suspect will continue to be a link between deprivation and ill health". It should come as no surprise that Sir Donald was instrumental in drafting the European Charter on Environment and Health that was approved at a ministerial conference in December, 1989.zEuropean governments, including that of the UK, duly agreed that "The health of individuals and communities should take clear precedence over considerations of economy and trade".3 In his 1988 inquiry4 he shaped the face of the new public health movements by proclaiming that public health is no less than "the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society"; and, in the subsequent reorganisation of the National Health Service, public health physicians found themselves suddenly influential again. Let us see how his successor Dr Kenneth Caiman, another erstwhile academic, matches this forceful performance. we live in. Lancet 1990; 336: 1482-85. 2. European Charter on Environment and Health. Copenhagen: WHO Regional Office for Europe, 1990. 3. Scott-Samuel A. European Charter on Environment and Health. Lancet
1. Acheson ED. Edwin Chadwick and the world
1990; 335: 980.
Department of Health. Public health in England (the Acheson Report). London: HM Stationery Office, 1988. 5. Editorial. What’s new in public health? Lancet 1991; 337: 1381-83.
4.
(20%) said yes and swab-touching test. positive test and
all except 3 also had a positive Of the 40 patients with both a an
affirmative
questionnaire
response, 9 denied that their vestibular tenderness was
sufficient to influence tampon use or sexual activity. For the remaining 31 patients (15% of the 210) the term "clinical vestibulitis" (after Friedrich 2) was applied to denote their vulvar disorder. The diagnostic criteria described by Friedrich for the vulvar vestibulitis syndrome included, in addition to pain on attempted vaginal entry and local tenderness, some degree of vestibular erythema. Using all these criteria for diagnosis, Furlonge et al3 undertook intensive investigations in 24 patients who, after numerous visits to general practitioner surgeries and gynaecology clinics, had found their way to the department of genitourinary medicine at St Thomas’s Hospital, London. All patients had a dermatological examination and a cervical smear test and swabs were taken from the vagina, urethra, and endocervix. A superficial excision biopsy was done of the area of maximum vestibular tenderness. The commonest microbiological finding was Candida, but in only 6 patients; Chlamydia trachomatis was isolated in 1 patient. All cervical smear tests were negative. In 11 patients there were histological features of non-
specific epithelial hyperplasia accompanied by an chronic inflamatory cell infiltrate of the lamina propria; the researchers do not attach much importance to these findings. 1 patient had an inflamed condyloma acuminata; 6 showed evidence of dysplasia (3 with koilocytosis), and in 2 patients there was koilocytosis alone. Caucasians predominated in both studies. Most women were between 20 and 30 years, although the age span was four decades. The American study showed a preponderance of nulliparous patients but in some women the symptoms had appeared post partum. All but 3 of the London patients belonged to social classes I and II. Some of Goetsch’s patients wondered if they might have an aversion to sex and some had female partners. Patients’ relationships in the British study were mainly monogamous and stable. A tender vestibule is unlikely to be conducive to promiscuity. No convincing explanation for the vulvar vestibulitis syndrome is forthcoming from these two studies. As Wa1cotr complained after scouring the acute or
rain forests for the graces of life, "There is too much nothing here." One is left with a chronic skin condition-in the American study the average duration of symptoms in non-postpartum patients was 10 years-and a name. Mere provision of a name for the disorder may help patients to cope with it; and in this case they can take additional comfort from knowing that their condition is not only recognised but also respectable. prevalence and historic features in a general gynecologic practice population. Am J Obstet Gynecol 1991;
1. Goetsch MF. Vulvar vestibulitis:
164: 1609-16.
2. Friedrich EG. Vulvar vestibulitis syndrome. J Reprod Med 1987; 32: 110-14. 3. Furlonge CB, Thin RN, Evans BE, McKee PH. Vulvar vestibulitis syndrome: a clinico-pathological study. Br J Obstet Gynaecol 1991; 98:
703-06. 4. Walcott D. Air. Collected poems. 1948-1984. New York: Noonday Press, 1990: 113.
Excimer laser 1991 Use of lasers in medicine is governed by two unwritten rules. First, lasers are at their best when there is no conventional treatment for a condition. Second (this rule is a corollary of the first), if there is a good conventional treatment then the onus of proof that the laser is better rests with the user, preferably by means of a randomised controlled trial. Introduction of excimer lasers into two areas of clinical practice illustrates both tenets. The excimer laser is a gas laser that relies on electronic transitions in excited states of noble gases and halogens to produce ultraviolet light at several wavelengths, depending on the mix of gas in the chamber. Because of a short pulse length, a wavelength that is highly absorbed by tissue, and a high photon energy, this laser can cut remarkably precise craters in tissue.33 Considerable practical experience of the excimer laser has accrued since The Lancet reviewed the subject in 1986.4 A xenon and chlorine mix gives an output at 308 mn-a wavelength that will pass down a quartz optical fibre if the pulse length of the laser is stretched (from 14-20 ns to about 180 ns) to reduce damage at the proximal end of the fibre. This laser has been used for coronary angioplasty, usually for stenoses rather than occlusions, in over 1000 patients57 and is supplied by three manufacturers. The delivery device consists of an over-the-wire multifibre ring catheter. The procedure is safe, with a primary success rate of over 85%, but the restenosis rate is much the same as with balloon angioplasty. There is some doubt about whether the bulk of the fibre produces an effect via simple dilatation with very little tissue vaporisation.There have been no controlled clinical comparisons of the device with balloon
angioplasty. An argon and fluorine gas mix gives an output at 193 nm, deep in the ultraviolet. The light is absorbed very heavily in transparent tissue such as the cornea and cannot be transmitted down any existing optical fibre to a useful extent. The short pulses of light are highly energetic and cut extremely sharp craters with hardly any surrounding tissue damage and no obvious potential for malignant transformation.9 Ophthalmologists have been at the forefront of medical laser research, the main reason being that there are no non-invasive alternatives to lasers for retinal and other intraocular surgery. The main ophthalmic application of the excimer laser at 193 nm is anterior corneal surgery, for which fibreoptic delivery is not required; the two most interesting uses are again subject to the general rules of medical laser
731
application. Radial keratotomy is a procedure for myopia in which the combination of a diamond knife and computer mapping10 has never been compared in a
controlled trial with the excimer laser." This
technique is controversial because it involves invasive manipulation of an eye which is essentially normal. Moreover, some researchers believe that laser cuts in the cornea heal less well than knife cuts Use of the laser for therapeutic keratectomy is far more likely to become established because there is no real alternative for the treatment of keratopathies apart from superficial mechanical abrasion. Gartry et al 13 lately used an ablative liquid to protect the normal areas of anterior cornea so that damaged areas could be removed selectively, thereby reducing the pain associated with hypertrophic corneal conditions and also improving acuity and reducing flare. Another possible application is for corneal sculpting for refractive purposes (photorefractive keratectomy), a procedure that remains largely unproven, with or without a laser.14,15 In the USA this technique is still subject to Food and Drug Administration (FDA) constraints and there are concerns about safety; the potential use of this approach by optometrists rather than ophthalmologists has been tested in the American courts.l6 FDA approval for the sale of excimer lasers does not necessarily mean that indications for their use have been fully evaluated. Until research has yielded clear guidelines for application of the excimer laser, the device still cannot be recommended for general use. 1. Phillips R. Sources and applications of ultraviolet radiation. London: Academic Press, 1983. 2. Cross FW, Bowker TJ. The physical properties of tissue ablation with excimer lasers. Med Instrument 1987; 21: 226-30. 3. Linsker R, Srinivasan R, Wynne JJ, Alonso DR. Far-ultraviolet laser ablation of atherosclerotic lesions. Lasers Surg Med 1984; 4: 201-06. 4. Editorial. Medical applications of the excimer laser. Lancet 1986; ii: 82-83.
5. Sanborn TA, Bittl JA, Hershman RA, Siegel RM. Percutaneous coronary excimer laser-assisted angioplasty: initial multicenter experience in 141 patients. JACC 1991; 17: 169B-73B. 6. Werner G, Buchwald A, Unterberg C, Voth E, Kreuzer H, Wiegand V. Excimer laser angioplasty in coronary artery disease. Eur Heart J 1991; 12: 24-29. 7. Cook SL, Eigler N, Goldenberg T, Forrester JS, Grundfest WS, Litvack F. Angiographic determinants of successful excimer laser angioplasty. Circulation 1990; 82 (suppl 3): 671. 8. Ischinger T, Coppenratl K, Pesarini A, Unsöld E, Delius W. Angioscopic findings after excimer laser angioplasty: laser or "Dotter" effects. Circulation 1990; 82 (suppl 3): 671. 9. Gebhardt BM, Salmeron B, McDonald MB. Effect of excimer laser energy on the growth potential of corneal keratocytes. Cornea 1990; 9: 205-10. 10. Binder PS. Radial keratotomy in the 1990s and the PERK study.
JAMA
1990; 263: 1127. 11. Seile T, Bender T, Wolensack J, Trockel S. Excimer laser keratotomy for correction of astigmatism. Am J Ophthalmol 1988; 105: 117-24. 12. Gipson IK, Cintron C, Binder PS. Corneal epithelial and stromal reactions to excimer laser photorefractive keratotomy. Arch Ophthalmol 1990; 108: 1539-42. 13. Gartry D, Kerr Muir M, Marshall J. Excimer laser treatment of corneal surface pathology: a laboratory and clinical study. Br J Ophthalmol 1991; 75: 258-69. 14. McDonald MB, Frantz JM, Klyce SD, et al. Central photorefractive keratectomy for myopia. Arch Ophthalmol 1990; 108: 799-808. 15. Rice N. Excimer laser for anterior cornea. Br J Ophthalmol 1991; 75: 257. 16. Knaub J. Excimer lasers—a place in optometry? Refract Corn Surg 1990; 6: 313-14.
Keeper of the public health Sir Donald Acheson, Chief Medical Officer at the Department of Health in London, retired earlier this week, a few days after presenting his eighth annual report, for the year 1990 (see p 751). When he forsook his post at Southampton eight years ago, many people wondered how this forthright academic would fit into the Whitehall scene. The timing turned out to be providential because he immediately applied his epidemiological and diplomatic skills to human immunodeficiency virus infection, then gathering pace in the cities. As the first CMO of the AIDS era he will be remembered for the way in which he championed strategies for prevention and control. He sought to raise public awareness early in the course of the epidemic and managed to convince ministers that taking on AIDS at that stage was not alarmism. Consequently, while many countries wavered Britain pressed ahead with a comprehensive and explicit publicity campaign that owed nothing to the nouveauVictorian values then espoused elsewhere by the Prime Minister and her colleagues. Nevertheless, Sir Donald clearly admired one stalwart figure of Victoria’s reign-Edwin Chadwick, who died in 1890 and whose work lay behind the creation of the post of CMO. When he gave the Edwin Chadwick centennial lecture last year1 he paid tribute to Chadwick’s farsightedness in recognising that environmental and social factors are linked to poverty and ill-health. Chadwick also features in Sir Donald’s final report, as does the theme of inequalities of health; at the press conference launching the report he declared bluntly "... there is a link, has been a link, and I suspect will continue to be a link between deprivation and ill health". It should come as no surprise that Sir Donald was instrumental in drafting the European Charter on Environment and Health that was approved at a ministerial conference in December, 1989.zEuropean governments, including that of the UK, duly agreed that "The health of individuals and communities should take clear precedence over considerations of economy and trade".3 In his 1988 inquiry4 he shaped the face of the new public health movements by proclaiming that public health is no less than "the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society"; and, in the subsequent reorganisation of the National Health Service, public health physicians found themselves suddenly influential again. Let us see how his successor Dr Kenneth Caiman, another erstwhile academic, matches this forceful performance. we live in. Lancet 1990; 336: 1482-85. 2. European Charter on Environment and Health. Copenhagen: WHO Regional Office for Europe, 1990. 3. Scott-Samuel A. European Charter on Environment and Health. Lancet
1. Acheson ED. Edwin Chadwick and the world
1990; 335: 980.
Department of Health. Public health in England (the Acheson Report). London: HM Stationery Office, 1988. 5. Editorial. What’s new in public health? Lancet 1991; 337: 1381-83.
4.
