BRITISH MEDICAL JOURNAL

policy of the UK is out of step with the views of so many other countries. RICHARD TURNER University of Edinburgh

KEITH BALL Central Middlesex Hospital, London NWIO Joint Working Partv, J7ournal of the Royal College of Physicians of London, 1976, 10, 213. Department of Health and Social Security, Diet and Coronary Heart Disease. London, HMSO. 1974. 3 Den Hartog, C, Nutrition and Metabolism, 1974, 17, 193.

2

SIR,-Like many others, I have now received my second copy of Prevention of Coronary Heart Disease (CHD) by the joint working party of the Royal College of Physicians and the British Cardiac Society,' this time with benediction from the Chief Medical Officer. The law of diminishing returns applies to disease preventive campaigns involving community co-operation, so effort should be placed only where effect is likely, as in the prevention of much epidemic illness by hygiene and immunisation. In a sane society stopping smoking would have almost completely eliminated lung cancer, but the efforts at application of this firmly established relationship have been rather disappointing. Many people, however, have benefited from it, not only by prevention of lung cancer but also probably by the prevention of much other disease, including CHD, since it is the only risk factor the withdrawal of which in the general population has been shown to reduce CHD. Following the publication of the joint working party's report there has been a spate of publicity in the media, from which many intelligent lay people have formed the impression that we know that we can influence the incidence of CHD by altering the fat in our diet. Only two studies have been done on this, both quoted in the report; one produced no significant effect and the other was so badly designed that even the report recommends caution in its interpretation. To give pride of place and length to this unsubstantiated concept in the report is a distortion which was accentuated in its recommendations. The media have then greatly exaggerated this distortion. It arises from the assumption that associations are necessarily causative. Since such an assumption is insecure, it is essential that successful studies are completed demon-

strating such an effect before our limited public goodwill is used up in applying it. At present our publicity in this field should concentrate

represents at least 10 calories of edible carbohydrate in animal feed. They say that we should use nutritionally unnecessary quantities of vegetable oil, which would mainly be grown in developing countries which may be short of the really vital commodity-starch. There is no doubt that we "westernised" adults eat far more protein and fat than we need and more calories than are good for uschildren are different in their requirements. As responsible world citizens we should adopt lower-calorie, high-starch diets, with a higher proportion of our protein and fat of vegetable origin (and British farmers and agricultural researchers should learn to grow these here) and eat plenty of green vegetables to satisfy appetite. Most of us will eat some animal food, but if we keep it down to our requirements there will be no problem of animal fat if we eat the lot. Every calorie saved would save the world 10, it would do us no harm, and might even do us some good (for example, perhaps reduce CHD). Stopping smoking would do that, and would leave more land for food growing. That gets priorities into perspective -both scientific and moral. J F SOOTHILL London NW1l Joint Working Party, Journal of the Royal College of Physicians of London, 1976, 10, 213.

7 AUGUST 1976

The elderly mentally ill -whose responsibility?

SIR,-The article by Miss Pauline Pasker and others (17 July, p 164) discusses an important issue but greatly underestimates the gravity of the situation. The authors make the same mistake as the DHSS in considering only the changes in the over-65 population. In fact the most significant factor is the increase in the over-75s, because they use the services much more frequently than the 65-74-year-old age group. For example, in Oxfordshire they use the home help and district nursing service six times as frequently as the younger elderly. From the Government Actuary's figures' we can see that in the next 10 years there will be an increase of 132 000 people over the age of 65, but this hides an increase of nearly half a million people aged over 75 (table I). This is the most significant figure for looking at future services, especially for mentally ill people. TABLE i-Estimated and projected populations of England and Wales 1975-84 (in thousands)'

Men

65-74 over 7j5and

1975

1984

Changes

1922 778

1815 978 2304

-107 + 200

2551 {oe 65-74 75 and over 1705 Women

1991

-247

+ 286

Preoperative radiotherapy in rectal cancer

SIR,-In March 1976 a trial of preoperative radiotherapy in rectal cancer was begun under the auspices of the Medical Research Council. The trial is designed to compare a two-week regimen of preoperative radiotherapy similar to that used in a US Veterans Administration trial with low-dose x-ray treatment given in a single exposure. The Veterans Administration Surgical Co-operative Group trial1 published in 1973 showed that a radiation dose of about 2000 rads to the whole pelvis, delivered in 10 fractions over two weeks, significantly improved the survival of patients with Dukes stage-C tumours who were subjected to abdominoperineal resection. It was noted also that there was a statistically significant decrease in the number of patients found to have involved lymph nodes in the resected specimen in the group who received preoperative irradiation. At the present time 12 regions in the United Kingdom are collaborating in the Medical Research Council trial and over 250 patients were admitted to it in the first year. There has been no report of operative difficulties after irradiation and the operative morbidity and mortality have been found to be the same in the control and in the two irradiated groups. We would be grateful for the courtesy of your columns to bring this trial to the attention of other surgeons and radiotherapists to whom an invitation is extended to participate. Details of the trial and copies of the protocol and proforma may be obtained by writing to us.

on what is established-that all persons at special risk to CHD should stop smoking, as indeed everyone should. This is not the lesson which comes clearly from the report or from the ensuing publicity, and I feel that the joint working party is responsible for the latter as well as the former, since this effect could have been predicted. But that does not mean that diet is irrelevant, and individual doctors may recommend this in the management of individual patients. Indeed, the whole community should change its diet, but for other, valid reasons which shed doubts on the morality of the working party's Department of Radiotherapy, recommendations. At a time of disastrous world food shortage they say that we should Department of Surgery, avoid cream and top of the milk and cut off Western General Hospital, the fat from meat-and presumably throw it Edinburgh and the cream away. Every calorie of it Rowitt, B, et al, Radiology, 1973,

TABLE iI-Mental illness hospitals and units: agespecific admission rates per 100 000, 1964 and 1970-42 1964 All admissions First admissions

All admissions First admissions

1970

1971

1972

1973

178

490 172

479 167

733 393

724 371

710 348

Age 65-74 493 494 485

258

188

Age over 75

692 503

748 415

The hospital response to the ageing population with mental illness has been to admit fewer of them, as shown in table II. Obviously the problems are accumulating in the community and in old people's homes. There is a policy confusion in future planning for these problems. The DHSS makes its guesses from figures based on the over-65 population and changes in the total population, the latter estimate being no more than a guess because of the rapid changes in birth rates and the former, though more accurate, underestimating the extent of the problem. The keystone of DHSS policy is that half the elderly people who are severely mentally infirm should be in the community hospitals,3 though this is resisted by the general practitioners who must take day-to-day management of these hospitals, and the Wallingford Community Hospital Research Report, on which much of the DHSS thinking is based, specifically defines "grossly confused or disturbed patients" as a group not suitable for admission.4 The key to this lies in the future policy for old people's homes, and this is a policy vacuum. W DUNCAN The DHSS has issued a draft circular on the care of residents in old people's homes which ADAM N SMITH avoids the issue of their operational policy, and they are left having to admit all the cases that can no longer be maintained in the community, but which are not suitable for hospital -a motley collection of problems. 108, 389.

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7 AUGUST 1976

The increased number of over-75s is the main problem facing the Health Service. The only resource that will be available will be flexibility. The twin problems of policies to help elderly people with mental illness and to define the role of old people's homes must be tackled. The family practitioners, community nurses, volunteers, and neighbours of elderly people with mental illness can only do so much. A realistic residential policy must be worked out and the keystone of this must be the old people's homes J A MUIR GRAY J S RODGERS Oxfordshi re Area Health Authority (Teaching), Oxford Population Projections No 4 1973-2013, prepared by the Government Actuary. London, HMSO, 1974. 2Department of Health and Social Security, Health and Personal Social Services for England 1975. London, HMSO, 1976. 3Department of Health and Social Security, Community Hospitals: Their Role and Development in the National Health Service. London, DHSS, 1974. 4 Wallingford Community Hospital Research Project. Oxford, Oxford Regional Hospital Board, 1973.

What do community physicians do? SIR,-Dr A Roberts (17 July, p 178) was quite right in questioning whether I was not comparing the former medical officer of health (MOH) with the present community physician. My contention is that the problems are still there to be dealt with. The MOH in the past was the only professional to oversee the Victorian environment and the crude medicosocial problems of the day. As these were tackled and were held at bay a number of technicians had to be trained and later took on almost independent professional responsibilities regarding the environment, water, sewage, housing, cleansing, and the like. The same occurred in the personal services of domiciliary midwifery, health visiting, and mental health. The one essential in the provision of these municipal community services was the legal requirement to make them work, a mandatory situation which does not apply to clinical medicine, where, if everyone will speak truthfully, most of my colleagues unquestioningly and automatically apply our Hippocratic tradition, but some do not. It is this unique overall responsibility of the MOH to get things done in spite of everything which has disappeared.; There is nothing in its place to cope immediately and decisively with emergencies or to provide that background of comprehensive professional knowledge which is essential to medicosocial planning. This is why community physicians as successors of MOHs feel that their hands are tied behind their backs so that they are merely the spectators of situations which need their involvement. We have been translated into a defective, hospital-orientated, lay administrative system in which each section works like battery hens laying eggs at their own rate without regard to others, without any central communication or collation of information, without any feedback from other sections, and without spirit. The present system has no central registry or mechanism for the interpretation or co-ordination of the snowstorm of circulars from the DHSS (Elephant droppings) which confine our every action. Imagine the apoplexy of a surgeon if the rest of the team did their own thing in their own time or said they just didn't believe in

surgery anyway. This is the present position for community physicians, but we are still supposed to sort out anything and everything as well as being involved throughout the planning process. W S PARKER East Sussex Area Health Authority, Brighton Health District, Brighton, Sussex

Modified operation for ingrowing toenails

A 77-year-old hypertensive woman taking methyldopa 250 mg twice daily and cyclopenthiazide was admitted with acute gouty arthropathy. Cyclopenthiazide was discontinued without alteration in blood pressure control at 130/80 mm Hg, and allopurinol treatment was begun. After one week the blood urea remained elevated at 12-6 mmol/l (76 mg/100 ml) and it was considered that her blood pressure control might be excessive. Methyldopa was therefore withdrawn. Within a day her blood pressure had begun to rise, and 48 hours later, when it was 240/160 mm Hg, diazoxide 300 mg was given intravenously with immediate good effect. Satisfactory blood pressure control was later again obtained with methyldopa 250 mg twice daily. In view of the fact that this patient's hypertension was easily controlled, both before and after cessation of therapy, by a small dose of methyldopa we consider the acute hypertensive crisis to have been a demonstration of rebound precipitated by acute methyldopa withdrawal. This would support Drs Burden and Alexander's suggestion that rebound hypertension occurs with hypertensive drugs other than clonidine. J N SCOTT D G MCDEVITT

SIR,-Ingrowing toenails are one of the commonest conditions seen in surgical clinics. Operations, which tend to be left to junior staff, are frequently complicated by infection and later by nail regrowth due to an incompletely excised nail bed. We have, however, had very good results since using the following operation. It is usually performed under local anaesthesia, with a tourniquet. An elliptical segment, including the edge of the nail and the inflamed nail fold, is excised (see figure). The incisions are cut down to the bone so that a V-shaped segment of inflamed tissue is removed. This ensures that all the nail bed and all infected granulation tissue are completely removed. The wound is then cleaned with an antiseptic solution. Belfast City Hospital and

Department of Therapeutics and Pharmacology, Queen's University, Belfast

Short-term recovery of mental efficiency after anaesthesia SIR,-The paper by Mr J E P Simpson and others (26 June, p 1560) is a beautiful piece of scientific research and writing, but the results are meaningless. For day-case surgerv the aim is to produce adequate intraoperative anaesthesia and postoperative recovery of consciousness which is as rapid and complete as possible. Premedication is part of the total anaesthetic management of a patient, and though the anaesthetic techniques compared by Mr Simpson and his colleagues are standard, premedication for day-case surgery is normally restricted to nitrazepam or some quiet reassurance. (If early recovery of consciousness is vital anaesthesia may be induced with propanidid rather than thiopentone.) Patients given a premedication of papaveretum 20 mg and hyoscine 0-4 mg would probably require 7-9 hours to return to 600( of mental efficiency without any general anaesthetic. I hope Mr Simpson and his colleagues will repeat their excellent study with alternative and lighter premedication. E LL LLOYD

No sutures are used to close the defect; instead, a length of Steristrip - in (13 mm) is wrapped firmly around the toe. This produces very good approximation of the skin edges without leaving any open space beneath. A firm bandage is applied before the tourniquet is removed. This dressing is left undisturbed for eight days if possible. This operation has been performed on numerous occasions and has been characterised by being surprisingly pain free and Department of Anaesthetics, Royal Infirmary, having a low incidence of infection. Edinburgh

B V PALMER D LANG STEVENSON Whipps Cross Hospital, London ElI

Rebound hypertension after acute methyldopa withdrawal SIR,-We were interested in the report by Drs A C Burden and C T P Alexander (1 May, p 1056) of rebound hypertension after acute methyldopa withdrawal. Recently we observed a similar occurrence.

Propranolol in hypertension SIR,-I believe that the article by Dr D B Galloway and others (17 July, p 140) might be seriously misleading in that they have not given sufficient emphasis to the fact that their study deals only with patients who are mildly hypertensive and who are treated with propranolol alone. The so-called "law of the initial value''l 2suggests that the benefit of drugs may be proportionate to the severity of the condition treated, and my own experience

Letter: The elderly mentally ill--whose responsibility?

BRITISH MEDICAL JOURNAL policy of the UK is out of step with the views of so many other countries. RICHARD TURNER University of Edinburgh KEITH BALL...
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