features may mimic the true disease depends on the sophistication of the patient and whether he or she has had
opportunity recently of observing the illness dein velop a friend or relative. Indigenous village practitioners may establish a considerable reputation through their cures of rabies hysteria. an
We thank Prof. G. M. Wilson and Dr B. Senewiratne for their encouragement and guidance; and St. John’s College, Cambridge and the trustees of the Sir Bartle Frere Fund for a grant to J. M. W. towards spending an elective period in Sri Lanka. Requests for reprints should be addressed to J. H. REFERENCES
1. 2. 3. 4. 5. 6. 7. 8.
Macrae, A. D. Lancet, 1969, ii, 1415. Times, July 11, 1975. Hole, N. H. Nature, 1969, 224, 244. Times, Jan. 16, 1975. Observer, July 13, 1975 Lancet, 1973, i, 89.
med. J. 1975, i, 221. Hattwick, M. A. W., Weis, T. T., Stechschulte, C. J., Baer, G. M., Gregg,
M. B. Ann. intern. Med. 1972, 76, 931. 9 Gardiner, A. M. N. Lancet, 1970, ii, 523. 10. Doege, T. C., Northrop, R. L ibid 1974, ii,
Round the World United States REMUNERATIVE THERAPY
Every national medical meeting in the U.S. these days has time set aside to allow those who attend the meeting to visit "the exhibits". These consist of a motley collection of medical equipment, new drugs, old drugs in new polypharmaceutical combinations, books ranging from the latest medical texts to the Encyclopcedia Britannica and the Kama Sutra, and material from various insurance companies willing to take away your money so that they can protect you against catastrophic medical illness, multiple pregnancy, and so on. The national meetings of chest physicians and anesthetists are slightly different, in that most of the exhibits are weird and wonderful Heath Robinson contraptions designed to help the patient "eliminate his secretions". On display will be seen 15 different brands of intermittent-positive-pressure-breathing (I.P.P.B.) machines, besides ultrasonic nebulisers, "cougholators", and sundry other gadgets. Representatives of the various companies who are pushing these devices exude enthusiasm and will give demonstrations of their wares, using live models who are almost invariably scantily clad nubile nymphs with urgent contours. A cult has grown up in the U.S. which subscribes to the notion that if a subject has chronic irreversible airways obstruction, then I.P.P.B. is benefical. Numerous studies have been done, only one of which purports to show any objective improvement following this mode of therapy. But non-mechanically inclined physicians are easily swayed by glib-talking salesmen and respiratory therapists, who speak of pressureflow relationships in smaller airways and of sputum viscosity. The mystique and impedimenta convince the practising physician that these experts know something of which they, the uninitiated, are unaware. In many hospitals routine I.P.P.B. is given to all patients before and after thoracic surgery, chest physiotherapists being almost unknown. Every accredited hospital has to have a director of respiratory therapy, at least according to the A.M.A. and A.H.A. accrediting bodies. Such directors are for the most part physicians who are paid a large salary by the hospital and who then also take a percentage from each treatment. All this adds up to big business, to the tune of a billion dollars annually. The evidence that i.P.P.B. and the other currently popular mechanical modes of respiratory therapy do any good is deficient. That routine I.P.P.B. and similar treatments are frequent causes of gram-negative lung infections and pneumothorax is well recognised. Since I.P.P.B. machines are usually driven by
containing between 40% and 100% oxygen, they frequently produce secondary hypoventilation in subjects with chronic respiratory failure. Although respiratory therapy is chronic remunerative medicine at its worst, most hospitals love it since it is a great generator of funds, patients like it because they feel something is being done for them, and the manufacturers of the equipment favour it for obvious reasons. In the circumstances, what chance is there for good sense and therapeutic objectivity? gas mixtures
HIGH INCOMES FROM MEDICAID
The U.S. Government recently published data showing that 207 physicians earned over$100 000 from Medicaid payments last year. The payments came from the treatment of low-income patients, Medicaid being a federal programme of subsidised medical care for needy oatients. The highest single figure for reimbursement ($451 156) went to a New York State physician. Most of the high earners came from California, New York, Texas, and the District of Columbia. In this connection it is also pertinent to bear in mind that Medicaid payments are not the physician’s only source of income. Departing from the usual practice, the Department of Health, Education, and Welfare has stated that it will publish the names of the high-earning physicians, but the purpose of such publicity is difficult to determine. It might be inferred that the Department is desirous of giving recognition to those physicians who are willing to devote so much of their time to the poor. This seems unlikely in view of the fact that most of the physicians concerned would have had to work a 72-hour day all year round without holidays in order to make time to see the patients and to carry out the procedures for which they are claiming compensation. The real reason for such publicity undoubtedly relates to the desire of the Government to reveal to the general public the names of those few members of the medical profession who are sailing too close to the wind. As a result, the high earners are likely to be audited and could well come unstuck, especially with the Internal Revenue Service. BUSING
In the early 1960s the wife of the then Governor of Massachusetts marched through the streets of Selma, Alabama, in an effort to hasten integration in Alabama’s public schools. It is more than a little ironic to realise that now, some 15 or 20 years later, it is the inhabitants of South Boston who are rioting because of a decision to bus vast numbers of Black pupils to predominantly White schools, and vice versa. Violence and racial riots, both in school and in the streets, are now commonplace in "the home of the bean and the cod", and there are many who, remembering the Bostonians holier-than-thou attitude, are finding it difficult to be sympathetic to them in their present predicament. However one looks at busing, it is a form of forced integration, and as such it has been an overall failure, in that it has produced exactly the opposite effect from what was intended. Thus, in 1960 in Memphis, Tennessee, there were 2000 pupils attending private schools. Following the institution of compulsory busing, the number of pupils in private schools in that city has increased to 20 000. Virtually all White pupils from the middle and upper class families who formerly attended Statesupported (public schools) now go to private schools. Only the children of the poor Whites continue to attend public schools, with the result that the standard in the formerly predominantly White schools has now declined to that of the worst schools in the Black ghetto. The recent unrest has caused Congress to hold further hearings, and some of the former enthusiasts for busing have openly stated that it has produced a situation that is the complete antithesis of what they had anticipated. Meanwhile, the general public have grown a little cynical in regard to those liberal Senators who so enthusiastically inflicted busing on their constituents, while at the same time sending their children to exclusive and expensive private schools in suburban