677
off. The results are laconically described in a recently issued Congressional survey of Social Security, Medicare, and other Government benefits, Overview of Entitlement Programs: 1990 Green Book, compiled by the House of Representatives Ways and Means Committee. (The volume, 1445 pages of demographic and financial data, is available for$33, plus 25% for international orders, from the Superintendent of Documents, US Government
Printing Office, Washington, DC 20402. Specify GPO
052-070-066-60-1.) Noting that 147 000 beneficiaries are currently enrolled in the ESRD, at a cost in 1989 of$3’billion, the report states: "When the ESRD program was created, it was assumed that stock no.
the program enrollment would level out at about 90 000 enrollees by 1995. That mark was passed several years ago, and no indication exists that enrollment will stabilize soon". The report says that "new enrollment grew at an average annual rate of 10-1 percent from 1980 to 1985. Most of the growth in program participation is attributable to growth in the numbers of elderly people receiving services and growth in the numbers of more seriously ill people entering the program". The greatest rate of growth was in patients 75 years and older, from 1344 in 1980 to 3457 in 1985. "The rates of growth in older and sicker patients entering treatment for end-stage renal disease indicate a shift in physician practice patterns", the report continues. "In the past, most of these people would not have entered dialysis treatment because their age and severity of illness made successful treatment for renal failure less likely. Although the reasons that physicians have begun treating older and sicker patients are not precisely known, it is clear that these practice patterns have, and will continue, to result in steady increases in the numbers of patients enrolling in Medicare’s " end-stage renal program." Politicians and accountants can chip at the costs of this and other Medicare programmes. But short of economic calamity or a revolution in cultural values, Medicare spending is destined to boom.
Daniel S.
Greenberg
problems encountered in Vietnam; my guess is that it will be in the desert, too". An earlier lesson, actually from the desert, is also illustrative. I interviewed Col William A. Akers, a retired military physician who headed the US Army’s Vietnam dermatology research programme and is also familiar with what has happened to other armies in other wars. During the mid-1960s fighting in Yemen, Akers recounted, some 700 British paratroopers were flown to Aden and immediately marched to a destination 13 miles away. Though well trained and combat-ready, they were unused to desert conditions and their feet quickly became badly blistered. Fewer than a dozen completed the march fit to fight. Also likely in the Gulf, said Akers, is an epidemic of miliaria rubra, otherwise known as prickly heat. And it will be more likely yet if the troops have to wear occlusive suits for protection against the poison gas the Iraqis are known to have. Although rarely fatal, unless it progresses to miliaria profunda, prickly heat has two adverse impacts of which even many physicians are unaware. One is that sweat glands in the areas affected remain impaired for three to four weeks, despite the fact that the rash typically dissipates in a few days. The other, as was discovered in Vietnam, is that men with sweat glands shut down by miliaria rubra tend to expose themselves needlessly to enemy fire. Indeed, in studies he and a colleague did at the US Army’s Natick, Massachusetts, laboratory, Akers found that "if you have prickly heat on as little as 9% of your body surface, judgment is one of the first things to go". Two other skin disorders, minor at home, that reduced troop effectiveness in Vietnam and, Akers predicted, will do likewise in the Gulf are common acne (primarily seen in whites) and pseudofolliculitis barbae, a frequent complaint of African-Americans. In a hot environment, acne on the back easily becomes infected, the more so if rubbed by pack straps, map cases carried in rear pockets, canteens, and other irritants such as vehicle seat backs. Similarly, the curly facial hair of blacks, with its elliptical cross-section structure, renders these men vulnerable to infection if, as is required by military regulations, they have to shave often despite the heat. common
Judith Randal
Round the World Mexico: Juices, coffee enemas, and
USA: Desert dermatology Disorders of the skin may seem the most trivial of the threats US troops in Saudi Arabia face. But if the history of modem wars is any indication, they will be to blame for considerable unfitness for duty and no little suffering, even if the shooting never starts. During the Vietnam war alone, according to official military medical records, skin disorders were the single greatest cause of visits to Army outpatient facilities and, except for malaria and combat injuries, accounted for the most personnel evacuations as well. The Persian Gulf is, of course, far drier than southeast Asia. Still, heat is heat, whatever the humidity. "Besides," said Dr Stanford Lamberg, a Baltimore dermatologist who as a Navy physician did skin disorders research in Vietnam, "adry climate is no guarantee of low humidity if uniforms fit too tightly and are made of nonporous fabrics to discourage insect bites. Poorly ventilated clothing can itself create a hot humid environment around the body and so set the stage for intertrigo-friction, scalding, and maceration in places where skin meets skin. Intertrigo was one of the most
cancer
Cancer support centres and telephone advice services often receive inquiries about so-called dietary "cures" for cancer, mostly from desperate patients and their families, who are understandably willing to try unorthodox treatments when conventional therapy has failed. We recently visited the Gerson Clinic in northern Mexico to assess its dietary "cure" for cancer. Dr Max Gerson was born in 1881 in Wongrowitz, Germany, and while a student he discovered that he could control his migraine by following a low-salt diet rich in fresh fruit and vegetables. He later recommended the diet to his tuberculosis patients and noted an improvement in their disease. The diet formed the basis of the Gerson therapy, which in the latter stages of his career he applied to the treatment of cancer. He documented his work in a book, A Cancer Therapy: Results of Fifty Cases.1 Dr Gerson’s cancer therapy continues to be used at the Hospital of the Baja California in Tijuana, Mexico, one mile from the USA, where it is considered unacceptable by the medical establishment. However, the Gerson Institute,
678
PATIENTS WITH ASSESSABLE DISEASE
Psychological information was obtained from the patients present at the centre by interview and by completion of visual analogue scales. Despite a wide range of socioeconomic backgrounds the patients, most of whom had very poor prognoses, tended to agree on several points, including their dissatisfaction with their conventional therapy and doctors. They all rated very highly the support they received from their families resident with them and also the other patients, with whom many established close relationships. Another striking feature was the high degree of control the patients felt they had over their health and, perhaps as a consequence, their high ratings for mood and confidence. Particularly intriguing were the low pain scores and analgesic requirements for all the patients, despite the presence of extensive metastatic disease in many and the fact that several had been on opioid medication previously. We could find little objective evidence of an antitumour effect from the Gerson therapy, although most patients were not assessable because of concomitant conventional therapy. However, in a few patients definite tumour regression was documented. In view of the poor prognosis of most of the patients, perhaps it is more important that there was a subjective benefit both to them and to their families. There is evidence that a "fighting spirit" response is associated with a better prognosis,2 and Spiegel and co-workers3 have shown that patients with metastatic breast carcinoma treated with psychotherapy in addition to conventional chemotherapy had a significantly improved survival. Judged in this context, the improvement in the Gerson patients’ sense of wellbeing may take on a greater
importance. CR= complete
response,
PD=progressme disease,
SD= stable disease; N/A= not
assessable, Ca= carcinoma.
which
provides an patients interested
information and referral service for in the therapy, is based in Bonita,
California. The rigid
regimen includes an essentially vegan diet supplemented, ten times a day, with 8 oz juices made from crushed (not pulped) fruit and vegetables. The juices must be taken at intervals of exactly an hour and are always freshly prepared. Other fluids are kept to a minimum, and no tea, or oral coffee is allowed. Coffee is, however, considered to be a crucial part of the regimen, given in the form of four-hourly enemas. In addition, the patient may have soap and water enemas on alternate days. The patients also take a variety of medications throughout the day,
The nature of the therapy requires a positive contribution be made by the patient to his or her health and meets a need not satisfied by conventional therapy, in which the role of the patient is essentially passive. These approaches may suggest ways forward for oncologists in the management of desperate cancer patients and their families. to
Maudsley Hospital, London SE58AZ, UK
ALISON REED
Department of Clinical Oncology, Hammersmith Hospital, London W12 OHS
NICHOLAS JAMES KAROL SIKORA
alcohol,
including acid pepsin, potassium, Lugol’s solution, niacin, pancreatin, and extracts of thyroid and, until recently, liver. During our assessment we had free access to all the inpatients and their notes, and also a sample of notes gathered as examples of best responses. Out of a total of 3000 patients treated since 1974, 149 case histories were examined, having been selected by the Gerson Institute on the basis of replies to a postal questionnaire sent to patients the past two years. The commonest tumours were melanoma (24), breast carcinoma (29), colorectal cancer (21), prostate cancer (11), and lung cancer (15). Several factors account for the small numbers: many notes were destroyed in a fire in 1985, no systematic attempt was made at follow-up, and, furthermore, it is likely that most patients have died. Of those patients responding, 27 had independent documentation of their disease status from their "conventional" physicians and thus were assessable over
according to standard oncological criteria (see table).
1. Gerson M. A
cancer
therapy: results of fifty cases. Published by Gerson
Institute, Bonita, California, 1986. 2. Greer S, Morris T, Pettingale KW, Haybittle JL. Psychological response to breast cancer: 15 year outcome. Lancet 1990; 335: 49-50. 3. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on
survival of patients with metastatic breast
cancer.
Lancet
1989; ii: 888-91.
Nicaragua: The psychological impact of "low intensity" warfare The US backed struggle to topple the Sandinista government was based on so-called "low-intensity" warfare, defined by a colonel in the US Army Special Forces as "total war at grass roots level".1 Psychological warfare is a central element in this strategy and can be seen by the way the Contra guerillas sought through terrorisation to demoralise and paralyse the rural population and thereby pressurise central Government. Indeed some were given formal training in the psychology of terror, based on principles in US Central Intelligence Agency subversion manuals. Most of the 60 000 casualties were defenceless
off. The results are laconically described in a recently issued Congressional survey of Social Security, Medicare, and other Government benefits, Overview of Entitlement Programs: 1990 Green Book, compiled by the House of Representatives Ways and Means Committee. (The volume, 1445 pages of demographic and financial data, is available for$33, plus 25% for international orders, from the Superintendent of Documents, US Government
Printing Office, Washington, DC 20402. Specify GPO
052-070-066-60-1.) Noting that 147 000 beneficiaries are currently enrolled in the ESRD, at a cost in 1989 of$3’billion, the report states: "When the ESRD program was created, it was assumed that stock no.
the program enrollment would level out at about 90 000 enrollees by 1995. That mark was passed several years ago, and no indication exists that enrollment will stabilize soon". The report says that "new enrollment grew at an average annual rate of 10-1 percent from 1980 to 1985. Most of the growth in program participation is attributable to growth in the numbers of elderly people receiving services and growth in the numbers of more seriously ill people entering the program". The greatest rate of growth was in patients 75 years and older, from 1344 in 1980 to 3457 in 1985. "The rates of growth in older and sicker patients entering treatment for end-stage renal disease indicate a shift in physician practice patterns", the report continues. "In the past, most of these people would not have entered dialysis treatment because their age and severity of illness made successful treatment for renal failure less likely. Although the reasons that physicians have begun treating older and sicker patients are not precisely known, it is clear that these practice patterns have, and will continue, to result in steady increases in the numbers of patients enrolling in Medicare’s " end-stage renal program." Politicians and accountants can chip at the costs of this and other Medicare programmes. But short of economic calamity or a revolution in cultural values, Medicare spending is destined to boom.
Daniel S.
Greenberg
problems encountered in Vietnam; my guess is that it will be in the desert, too". An earlier lesson, actually from the desert, is also illustrative. I interviewed Col William A. Akers, a retired military physician who headed the US Army’s Vietnam dermatology research programme and is also familiar with what has happened to other armies in other wars. During the mid-1960s fighting in Yemen, Akers recounted, some 700 British paratroopers were flown to Aden and immediately marched to a destination 13 miles away. Though well trained and combat-ready, they were unused to desert conditions and their feet quickly became badly blistered. Fewer than a dozen completed the march fit to fight. Also likely in the Gulf, said Akers, is an epidemic of miliaria rubra, otherwise known as prickly heat. And it will be more likely yet if the troops have to wear occlusive suits for protection against the poison gas the Iraqis are known to have. Although rarely fatal, unless it progresses to miliaria profunda, prickly heat has two adverse impacts of which even many physicians are unaware. One is that sweat glands in the areas affected remain impaired for three to four weeks, despite the fact that the rash typically dissipates in a few days. The other, as was discovered in Vietnam, is that men with sweat glands shut down by miliaria rubra tend to expose themselves needlessly to enemy fire. Indeed, in studies he and a colleague did at the US Army’s Natick, Massachusetts, laboratory, Akers found that "if you have prickly heat on as little as 9% of your body surface, judgment is one of the first things to go". Two other skin disorders, minor at home, that reduced troop effectiveness in Vietnam and, Akers predicted, will do likewise in the Gulf are common acne (primarily seen in whites) and pseudofolliculitis barbae, a frequent complaint of African-Americans. In a hot environment, acne on the back easily becomes infected, the more so if rubbed by pack straps, map cases carried in rear pockets, canteens, and other irritants such as vehicle seat backs. Similarly, the curly facial hair of blacks, with its elliptical cross-section structure, renders these men vulnerable to infection if, as is required by military regulations, they have to shave often despite the heat. common
Judith Randal
Round the World Mexico: Juices, coffee enemas, and
USA: Desert dermatology Disorders of the skin may seem the most trivial of the threats US troops in Saudi Arabia face. But if the history of modem wars is any indication, they will be to blame for considerable unfitness for duty and no little suffering, even if the shooting never starts. During the Vietnam war alone, according to official military medical records, skin disorders were the single greatest cause of visits to Army outpatient facilities and, except for malaria and combat injuries, accounted for the most personnel evacuations as well. The Persian Gulf is, of course, far drier than southeast Asia. Still, heat is heat, whatever the humidity. "Besides," said Dr Stanford Lamberg, a Baltimore dermatologist who as a Navy physician did skin disorders research in Vietnam, "adry climate is no guarantee of low humidity if uniforms fit too tightly and are made of nonporous fabrics to discourage insect bites. Poorly ventilated clothing can itself create a hot humid environment around the body and so set the stage for intertrigo-friction, scalding, and maceration in places where skin meets skin. Intertrigo was one of the most
cancer
Cancer support centres and telephone advice services often receive inquiries about so-called dietary "cures" for cancer, mostly from desperate patients and their families, who are understandably willing to try unorthodox treatments when conventional therapy has failed. We recently visited the Gerson Clinic in northern Mexico to assess its dietary "cure" for cancer. Dr Max Gerson was born in 1881 in Wongrowitz, Germany, and while a student he discovered that he could control his migraine by following a low-salt diet rich in fresh fruit and vegetables. He later recommended the diet to his tuberculosis patients and noted an improvement in their disease. The diet formed the basis of the Gerson therapy, which in the latter stages of his career he applied to the treatment of cancer. He documented his work in a book, A Cancer Therapy: Results of Fifty Cases.1 Dr Gerson’s cancer therapy continues to be used at the Hospital of the Baja California in Tijuana, Mexico, one mile from the USA, where it is considered unacceptable by the medical establishment. However, the Gerson Institute,
678
PATIENTS WITH ASSESSABLE DISEASE
Psychological information was obtained from the patients present at the centre by interview and by completion of visual analogue scales. Despite a wide range of socioeconomic backgrounds the patients, most of whom had very poor prognoses, tended to agree on several points, including their dissatisfaction with their conventional therapy and doctors. They all rated very highly the support they received from their families resident with them and also the other patients, with whom many established close relationships. Another striking feature was the high degree of control the patients felt they had over their health and, perhaps as a consequence, their high ratings for mood and confidence. Particularly intriguing were the low pain scores and analgesic requirements for all the patients, despite the presence of extensive metastatic disease in many and the fact that several had been on opioid medication previously. We could find little objective evidence of an antitumour effect from the Gerson therapy, although most patients were not assessable because of concomitant conventional therapy. However, in a few patients definite tumour regression was documented. In view of the poor prognosis of most of the patients, perhaps it is more important that there was a subjective benefit both to them and to their families. There is evidence that a "fighting spirit" response is associated with a better prognosis,2 and Spiegel and co-workers3 have shown that patients with metastatic breast carcinoma treated with psychotherapy in addition to conventional chemotherapy had a significantly improved survival. Judged in this context, the improvement in the Gerson patients’ sense of wellbeing may take on a greater
importance. CR= complete
response,
PD=progressme disease,
SD= stable disease; N/A= not
assessable, Ca= carcinoma.
which
provides an patients interested
information and referral service for in the therapy, is based in Bonita,
California. The rigid
regimen includes an essentially vegan diet supplemented, ten times a day, with 8 oz juices made from crushed (not pulped) fruit and vegetables. The juices must be taken at intervals of exactly an hour and are always freshly prepared. Other fluids are kept to a minimum, and no tea, or oral coffee is allowed. Coffee is, however, considered to be a crucial part of the regimen, given in the form of four-hourly enemas. In addition, the patient may have soap and water enemas on alternate days. The patients also take a variety of medications throughout the day,
The nature of the therapy requires a positive contribution be made by the patient to his or her health and meets a need not satisfied by conventional therapy, in which the role of the patient is essentially passive. These approaches may suggest ways forward for oncologists in the management of desperate cancer patients and their families. to
Maudsley Hospital, London SE58AZ, UK
ALISON REED
Department of Clinical Oncology, Hammersmith Hospital, London W12 OHS
NICHOLAS JAMES KAROL SIKORA
alcohol,
including acid pepsin, potassium, Lugol’s solution, niacin, pancreatin, and extracts of thyroid and, until recently, liver. During our assessment we had free access to all the inpatients and their notes, and also a sample of notes gathered as examples of best responses. Out of a total of 3000 patients treated since 1974, 149 case histories were examined, having been selected by the Gerson Institute on the basis of replies to a postal questionnaire sent to patients the past two years. The commonest tumours were melanoma (24), breast carcinoma (29), colorectal cancer (21), prostate cancer (11), and lung cancer (15). Several factors account for the small numbers: many notes were destroyed in a fire in 1985, no systematic attempt was made at follow-up, and, furthermore, it is likely that most patients have died. Of those patients responding, 27 had independent documentation of their disease status from their "conventional" physicians and thus were assessable over
according to standard oncological criteria (see table).
1. Gerson M. A
cancer
therapy: results of fifty cases. Published by Gerson
Institute, Bonita, California, 1986. 2. Greer S, Morris T, Pettingale KW, Haybittle JL. Psychological response to breast cancer: 15 year outcome. Lancet 1990; 335: 49-50. 3. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on
survival of patients with metastatic breast
cancer.
Lancet
1989; ii: 888-91.
Nicaragua: The psychological impact of "low intensity" warfare The US backed struggle to topple the Sandinista government was based on so-called "low-intensity" warfare, defined by a colonel in the US Army Special Forces as "total war at grass roots level".1 Psychological warfare is a central element in this strategy and can be seen by the way the Contra guerillas sought through terrorisation to demoralise and paralyse the rural population and thereby pressurise central Government. Indeed some were given formal training in the psychology of terror, based on principles in US Central Intelligence Agency subversion manuals. Most of the 60 000 casualties were defenceless
