BRITISH MEDICAL JOURNAL
2 DECEMBER 1978
tendency to regard impotent men as homogeneous from the endocrine, physiological, and psychological points of view. Our future research needs to pay more attention to their hormonal state and to the physiological nature of the dysfunction-failure of erection, ejaculation, or orgasm-and to the level of sexual interest or appetite.
Fran'ks, S, et al, Clinical Endocrinology, 1978, 8, 277. 2Thorner, M 0, and Besser, G M, in Prolactint and Human Reproduction, ed P G Crosignani and C Robyn, p 285. London, Academic Press, 1977. Bancroft, J H J, and Skakkebaek, N, Sex, Hormones and Behaviour, Ciba Fouindationz Symposiuzm No 62, March 1978. In press. Lawrence, D H, and Swyer, G I M, British Medical Journal, 1974, 1, 349. 5Raboch, J Mellan, J, and Starka, L, Archives of Sexuial Behaviour, 1975, 4, 541. Ismail, A A A, Davison, D W, and Loraine, J A, in Reproductive Endocrinology, ed W J Irvine, p 138. Edinburgh, Livingstone, 1970. 7Racey, P A, et al, Journal of Endocrinology, 1973, 59, 23. 8 Bruhl, E E, and Leslie, C H, Medical Record and Antnals, 1963, 56, 22. 9 Jakobovits, T, Fettility anid Sterility, 1970, 21, 32. ( Cooper, A J, et al, Irish Journal of Medical Scicnce, 1973, 142, 155. Carney, P A, Bancroft, J H J, and MatheNs, A M, British Journal of Psychiatry, 1978, 133, 339. ' Heller, C G, and Myers, G B, journal of the Amiierican Medical Association, 1944, 126, 472. 1 Vermeulen, A, Rubens, R, and Verdonck, L, Journal of Clinical Endocrinology and Metabolismi, 1972, 34, 730. Stearns, E L, et al, Amnerican Journal of Medicine, 1974, 57, 761. 1; Kinsey, A C, Pomeroy, W B, and Martin, C E, Sexuial Behaviour in the Human Male. Philadelphia, Saunders, 1948. Bancroft, J H J, and Coles, L, British Mcdical Journal, 1976, 1, 1575. Mortimer, C H, et al, British Medical Journal, 1974, 4, 617. 18 Benkert, 0, et al, Neuropsychobiology, 1975, 1, 203. 1 Davies, T F, et al, Clinical Endocrinology, 1976, 5, 601.
Renal complications of connective tissue disease Kidney damage contributes greatly to the illness and death associated with connective tissue diseases. Its frequency is difficult to assess, however, because estimates depend on the sensitivity of the criteria used for diagnosis, the specialty of the investigators, and the care taken to separate the effects of the disease from those of treatment. This was just one of the problems discussed at a recent meeting of rheumatologists and nephrologists dealing with renal complications in connective tissue disease, the proceedings of which will be published shortly as a supplement to the European Journal of Rheumatology. Estimates of deaths from renal complications in patients with rheumatoid disease varied from 4"() to 2200 and evidence of renal disease was reported in up to 70%0. The types of kidney damage included the amyloid deposition found in rheumatoid disease; the vasculitis that occurs in scleroderma and polyarteritis; the tubulointerstitial disease of Sj6gren's syndrome; and the immune complex deposition in glomeruli, seen most commonly in systemic lupus erythematosus. What causes immune complex glomerulonephritis? The size of the complexes, the IgG subclass and affinity of the antibody, and the capacity of the complexes to fix complement were some of the important factors discussed; and the meeting gave particular attention to the ability of the reticuloendothelial system to clear immune complexes. Renal amyloidosis secondary to rheumatoid disease usually progresses to kidney failure, though some spontaneous remissions do occur. The amyloid appears to be derived from serum protein amyloid A (AA), a soluble protein with a molecular weight of 12 500. The concentration of this protein
1517
is raised in chronic inflammatory diseases, including the connective tissue diseases. In the tissues of normal people serum protein amyloid A is degraded to small peptides, but in peripheral monocytes from patients with secondary amyloidosis serum protein amyloid A is only partially degraded-to the insoluble fibrillar protein amyloid A, which is the major component of amyloid. Long-term chlorambucil treatment of patients with juvenile rheumatoid arthritis may prevent death from renal amyloidosis, and the condition may even bring some benefit-renal transplantation in patients with secondary amyloidosis appears to be more often successful than in those with other forms of kidney disease. Should treatment with gold and penicillamine be stopped once proteinuria appears ? Although some rheumatologists took a more lenient view, nephrologists at the meeting argued that it should. In particular, patients who continue on penicillamine treatment despite proteinuria may develop a Goodpasture-like syndrome with crescentic glomerulonephritis and lung haemorrhages even though antibody to glomerular basement membrane is absent. The nephrotoxicity of analgesics and other non-steroidal anti-inflammatory drugs is a controversial subject. Whereas phenacetin-induced kidney damage is an established phenomenon, there is no incontrovertible evidence that non-steroidal anti-inflammatory drugs can damage the kidney. When sensitive indices of tubular damage, such as tubular cell excretion, N-acetyl glucosaminidase excretion, and lowmolecular-weight proteinuria, are used most if not all of these drugs can be shown to damage renal tubules. But how relevant is this to chronic renal damage after prolonged use? Only time can tell. Now that many new anti-inflammatory drugs are being introduced, rheumatologists should remember that the dangers of phenacetin were not recognised for some 50 years. Patients on long-term treatment with non-steroidal anti-inflammatory drugs should perhaps have regular checks on kidney function by serial creatinine measurements so that nephropathy is not overlooked. Meanwhile those with rheumatoid and other connective tissue diseases should not be denied the undoubted benefits of these highly effective drugs.
Nursing reform: shadow or substance? Doctors needed eight years and an independent inquiry to achieve reform of the General Medical Council. Nurses, midwives, and health visitors have just reached the Parliamentary stage in reforming their educational and registration procedures, eight years after the Briggs Committee1 started work "to review the role of the nurse and midwife in the hospital and the community and the education and training required for that role. . . ." The Briggs Report was comprehensive, with 75 recommendations that included setting up a central body responsible for professional standards of education and discipline in nursing and midwifery; education boards for England, Scotland, and Wales; an 18-month basic nursing practice course; and a call for nurses in training to be students rather than pairs of hands. Since the Committee on Nursing reported nurses have been urging the Government to act. Barbara Castle promised action in 1974. The Briggs Co-ordinating Committee, chaired by Mr Roland Moyle, Minister of State, was eventually set up
1518
by the DHSS in January 1977 to prepare the ground work for legislation, a Bill was half promised for the 1977-8 Parliamentary session, and, finally, on 2 November 1978 the Bill appeared. Like the original Medical Bill,2 the Nurses Midwives and Health Visitors Bill is slim. Indeed, in the second reading debate3 Mr Laurie Pavitt described it as "a skeleton of a Bill." Ministers were not pretending otherwise, for their aim was at producing enabling legislation, which would allow setting up of a United Kingdom Central Council for Nursing, Midwifery, and Health Visiting, with four national boards. Thus, the bulk of nursing reform, which most of the nursing profession agree is urgently needed, will have to await subsequent regulations. This may be convenient for Whitehall, but there are disadvantages: the Government can defer the real reforms until it can afford them-the early 1980s was Mr Moyle's tentative forecast, with the estimated cost (in 1977) at C32m-and important changes may never be debated in Parliament, for regulations commonly go through unopposed. With nursing standards under threat, as a recent RCN delegation bluntly told the Secretary of State,4 a wide-ranging Parliamentary debate on all aspects of nursing would give valuable publicity to a serious NHS problem. As it was, the debate on the second reading was disappointingly uninformative, with too much time spent on party points, other irrelevances, and, sadly, continuing differences of opinion among nurses, midwives, and health visitors. The delay can in part be attributed to these internal differences, for some midwives and health visitors fear that they might be swamped by their 400 000 or so nursing colleagues-the NHS has about 24 000 midwives and under 8000 health visitors. Further differences are now reported between union-orientated and profession-orientated nurses within the Briggs co-ordinating committee about the status of learners. The latter want full student status for learner nurses, but apparently the health union representatives are blocking this.5 Though understandable among such a large group of variously skilled individuals, such divisions will only cause further delays. Health visitors and midwives should be reassured by the example of the General Medical Council, which presides over a profession containing many specialties and a multitude of individualists. While nurses will prefer to settle for a slim Bill rather than no Bill at all, if they and their colleagues unite they might persuade MPs and Ministers to expand its provisions into legislation worthy of the Briggs Report. After all, the doctors managed this unusual feat in the last Parliamentary session.6 The estimated cost ought not to deter reform: indeed, the money should be found. Only if nurses are well trained and professionally satisfied will the NHS maintain-some would say revive-high standards of care for patients. Is the cost excessive when set beside the hundreds of millions the
BRITISH MEDICAL JOURNAL
2 DECEMBER 1978
taxpayer has bequeathed, for example, to Britain's unproductive car industry? The ailing NHS needs the substance of nursing reform today, not the shadow of a promise tomorrow. '
Report of the Committee on Nursing, Cmnd 5115. London, HMSO, 1972. Medical Bill. London, HMSO, 1977. 3Hansard. House of Commons, 13 November 1978, col 72. 4Royal College of Nursing, An Assessment of the State of Nursing in the National Health Service Since 1978. RCN, London, 1978. 5 Nursing Times, 1978, 74, 1870. 6British Medical Journal, 1978, 1, 532. 2
Image of a society The Normansfield Report' is more than another disclosure of particularly appalling practices at one hospital: it is an indictment that NHS reorganisation has failed to provide some of at least one group of patients, the mentally handicapped, with the sort of treatment that the citizens of a civilised society have a right to expect. The themes throughout (p 1560) are inertia, indifference, and a lack of willingness to take responsibilityand clearly no amount of health authorities, teams, multidisciplinary links, committees, councils, or officers can deal (either swiftly or deliberately) with the imperious, the opportunist, the feckless, the idle, and the incompetent. In some ways the problems at the hospital might be regarded not merely as the microcosm of many wrongs in the Health Service, but also of contemporary life. The report could not be published as a Command Paper because of an industrial dispute at the Stationery Office; it appeared on the day that strikers at the Ford Motor Company forced their way through the Government's pay policy; and on the next day, when the press conference was held by the regional health authority, many Londoners were prevented by an unofficial rail strike from getting to work and so creating more national wealth, some of which could have been spent on black spots such as Normansfield. Apart from the courageous behaviour of the chairman of the regional health authority, some of the junior nurses, teachers, patients' relatives, and hospital league of friends, there is one bright spot in this sorry episode. The report appeared while the Royal Commission on the National Health Service was still sitting. We hope that it will take to heart one lesson of the inquiry: that the whole cumbersome, expensive, and ineffectual administrative apparatus needs urgent reappraisal and change. Committee of Inquiry into Normansfield Hospital, Report. London, HMSO, 1978.
2 DECEMBER 1978
tendency to regard impotent men as homogeneous from the endocrine, physiological, and psychological points of view. Our future research needs to pay more attention to their hormonal state and to the physiological nature of the dysfunction-failure of erection, ejaculation, or orgasm-and to the level of sexual interest or appetite.
Fran'ks, S, et al, Clinical Endocrinology, 1978, 8, 277. 2Thorner, M 0, and Besser, G M, in Prolactint and Human Reproduction, ed P G Crosignani and C Robyn, p 285. London, Academic Press, 1977. Bancroft, J H J, and Skakkebaek, N, Sex, Hormones and Behaviour, Ciba Fouindationz Symposiuzm No 62, March 1978. In press. Lawrence, D H, and Swyer, G I M, British Medical Journal, 1974, 1, 349. 5Raboch, J Mellan, J, and Starka, L, Archives of Sexuial Behaviour, 1975, 4, 541. Ismail, A A A, Davison, D W, and Loraine, J A, in Reproductive Endocrinology, ed W J Irvine, p 138. Edinburgh, Livingstone, 1970. 7Racey, P A, et al, Journal of Endocrinology, 1973, 59, 23. 8 Bruhl, E E, and Leslie, C H, Medical Record and Antnals, 1963, 56, 22. 9 Jakobovits, T, Fettility anid Sterility, 1970, 21, 32. ( Cooper, A J, et al, Irish Journal of Medical Scicnce, 1973, 142, 155. Carney, P A, Bancroft, J H J, and MatheNs, A M, British Journal of Psychiatry, 1978, 133, 339. ' Heller, C G, and Myers, G B, journal of the Amiierican Medical Association, 1944, 126, 472. 1 Vermeulen, A, Rubens, R, and Verdonck, L, Journal of Clinical Endocrinology and Metabolismi, 1972, 34, 730. Stearns, E L, et al, Amnerican Journal of Medicine, 1974, 57, 761. 1; Kinsey, A C, Pomeroy, W B, and Martin, C E, Sexuial Behaviour in the Human Male. Philadelphia, Saunders, 1948. Bancroft, J H J, and Coles, L, British Mcdical Journal, 1976, 1, 1575. Mortimer, C H, et al, British Medical Journal, 1974, 4, 617. 18 Benkert, 0, et al, Neuropsychobiology, 1975, 1, 203. 1 Davies, T F, et al, Clinical Endocrinology, 1976, 5, 601.
Renal complications of connective tissue disease Kidney damage contributes greatly to the illness and death associated with connective tissue diseases. Its frequency is difficult to assess, however, because estimates depend on the sensitivity of the criteria used for diagnosis, the specialty of the investigators, and the care taken to separate the effects of the disease from those of treatment. This was just one of the problems discussed at a recent meeting of rheumatologists and nephrologists dealing with renal complications in connective tissue disease, the proceedings of which will be published shortly as a supplement to the European Journal of Rheumatology. Estimates of deaths from renal complications in patients with rheumatoid disease varied from 4"() to 2200 and evidence of renal disease was reported in up to 70%0. The types of kidney damage included the amyloid deposition found in rheumatoid disease; the vasculitis that occurs in scleroderma and polyarteritis; the tubulointerstitial disease of Sj6gren's syndrome; and the immune complex deposition in glomeruli, seen most commonly in systemic lupus erythematosus. What causes immune complex glomerulonephritis? The size of the complexes, the IgG subclass and affinity of the antibody, and the capacity of the complexes to fix complement were some of the important factors discussed; and the meeting gave particular attention to the ability of the reticuloendothelial system to clear immune complexes. Renal amyloidosis secondary to rheumatoid disease usually progresses to kidney failure, though some spontaneous remissions do occur. The amyloid appears to be derived from serum protein amyloid A (AA), a soluble protein with a molecular weight of 12 500. The concentration of this protein
1517
is raised in chronic inflammatory diseases, including the connective tissue diseases. In the tissues of normal people serum protein amyloid A is degraded to small peptides, but in peripheral monocytes from patients with secondary amyloidosis serum protein amyloid A is only partially degraded-to the insoluble fibrillar protein amyloid A, which is the major component of amyloid. Long-term chlorambucil treatment of patients with juvenile rheumatoid arthritis may prevent death from renal amyloidosis, and the condition may even bring some benefit-renal transplantation in patients with secondary amyloidosis appears to be more often successful than in those with other forms of kidney disease. Should treatment with gold and penicillamine be stopped once proteinuria appears ? Although some rheumatologists took a more lenient view, nephrologists at the meeting argued that it should. In particular, patients who continue on penicillamine treatment despite proteinuria may develop a Goodpasture-like syndrome with crescentic glomerulonephritis and lung haemorrhages even though antibody to glomerular basement membrane is absent. The nephrotoxicity of analgesics and other non-steroidal anti-inflammatory drugs is a controversial subject. Whereas phenacetin-induced kidney damage is an established phenomenon, there is no incontrovertible evidence that non-steroidal anti-inflammatory drugs can damage the kidney. When sensitive indices of tubular damage, such as tubular cell excretion, N-acetyl glucosaminidase excretion, and lowmolecular-weight proteinuria, are used most if not all of these drugs can be shown to damage renal tubules. But how relevant is this to chronic renal damage after prolonged use? Only time can tell. Now that many new anti-inflammatory drugs are being introduced, rheumatologists should remember that the dangers of phenacetin were not recognised for some 50 years. Patients on long-term treatment with non-steroidal anti-inflammatory drugs should perhaps have regular checks on kidney function by serial creatinine measurements so that nephropathy is not overlooked. Meanwhile those with rheumatoid and other connective tissue diseases should not be denied the undoubted benefits of these highly effective drugs.
Nursing reform: shadow or substance? Doctors needed eight years and an independent inquiry to achieve reform of the General Medical Council. Nurses, midwives, and health visitors have just reached the Parliamentary stage in reforming their educational and registration procedures, eight years after the Briggs Committee1 started work "to review the role of the nurse and midwife in the hospital and the community and the education and training required for that role. . . ." The Briggs Report was comprehensive, with 75 recommendations that included setting up a central body responsible for professional standards of education and discipline in nursing and midwifery; education boards for England, Scotland, and Wales; an 18-month basic nursing practice course; and a call for nurses in training to be students rather than pairs of hands. Since the Committee on Nursing reported nurses have been urging the Government to act. Barbara Castle promised action in 1974. The Briggs Co-ordinating Committee, chaired by Mr Roland Moyle, Minister of State, was eventually set up
1518
by the DHSS in January 1977 to prepare the ground work for legislation, a Bill was half promised for the 1977-8 Parliamentary session, and, finally, on 2 November 1978 the Bill appeared. Like the original Medical Bill,2 the Nurses Midwives and Health Visitors Bill is slim. Indeed, in the second reading debate3 Mr Laurie Pavitt described it as "a skeleton of a Bill." Ministers were not pretending otherwise, for their aim was at producing enabling legislation, which would allow setting up of a United Kingdom Central Council for Nursing, Midwifery, and Health Visiting, with four national boards. Thus, the bulk of nursing reform, which most of the nursing profession agree is urgently needed, will have to await subsequent regulations. This may be convenient for Whitehall, but there are disadvantages: the Government can defer the real reforms until it can afford them-the early 1980s was Mr Moyle's tentative forecast, with the estimated cost (in 1977) at C32m-and important changes may never be debated in Parliament, for regulations commonly go through unopposed. With nursing standards under threat, as a recent RCN delegation bluntly told the Secretary of State,4 a wide-ranging Parliamentary debate on all aspects of nursing would give valuable publicity to a serious NHS problem. As it was, the debate on the second reading was disappointingly uninformative, with too much time spent on party points, other irrelevances, and, sadly, continuing differences of opinion among nurses, midwives, and health visitors. The delay can in part be attributed to these internal differences, for some midwives and health visitors fear that they might be swamped by their 400 000 or so nursing colleagues-the NHS has about 24 000 midwives and under 8000 health visitors. Further differences are now reported between union-orientated and profession-orientated nurses within the Briggs co-ordinating committee about the status of learners. The latter want full student status for learner nurses, but apparently the health union representatives are blocking this.5 Though understandable among such a large group of variously skilled individuals, such divisions will only cause further delays. Health visitors and midwives should be reassured by the example of the General Medical Council, which presides over a profession containing many specialties and a multitude of individualists. While nurses will prefer to settle for a slim Bill rather than no Bill at all, if they and their colleagues unite they might persuade MPs and Ministers to expand its provisions into legislation worthy of the Briggs Report. After all, the doctors managed this unusual feat in the last Parliamentary session.6 The estimated cost ought not to deter reform: indeed, the money should be found. Only if nurses are well trained and professionally satisfied will the NHS maintain-some would say revive-high standards of care for patients. Is the cost excessive when set beside the hundreds of millions the
BRITISH MEDICAL JOURNAL
2 DECEMBER 1978
taxpayer has bequeathed, for example, to Britain's unproductive car industry? The ailing NHS needs the substance of nursing reform today, not the shadow of a promise tomorrow. '
Report of the Committee on Nursing, Cmnd 5115. London, HMSO, 1972. Medical Bill. London, HMSO, 1977. 3Hansard. House of Commons, 13 November 1978, col 72. 4Royal College of Nursing, An Assessment of the State of Nursing in the National Health Service Since 1978. RCN, London, 1978. 5 Nursing Times, 1978, 74, 1870. 6British Medical Journal, 1978, 1, 532. 2
Image of a society The Normansfield Report' is more than another disclosure of particularly appalling practices at one hospital: it is an indictment that NHS reorganisation has failed to provide some of at least one group of patients, the mentally handicapped, with the sort of treatment that the citizens of a civilised society have a right to expect. The themes throughout (p 1560) are inertia, indifference, and a lack of willingness to take responsibilityand clearly no amount of health authorities, teams, multidisciplinary links, committees, councils, or officers can deal (either swiftly or deliberately) with the imperious, the opportunist, the feckless, the idle, and the incompetent. In some ways the problems at the hospital might be regarded not merely as the microcosm of many wrongs in the Health Service, but also of contemporary life. The report could not be published as a Command Paper because of an industrial dispute at the Stationery Office; it appeared on the day that strikers at the Ford Motor Company forced their way through the Government's pay policy; and on the next day, when the press conference was held by the regional health authority, many Londoners were prevented by an unofficial rail strike from getting to work and so creating more national wealth, some of which could have been spent on black spots such as Normansfield. Apart from the courageous behaviour of the chairman of the regional health authority, some of the junior nurses, teachers, patients' relatives, and hospital league of friends, there is one bright spot in this sorry episode. The report appeared while the Royal Commission on the National Health Service was still sitting. We hope that it will take to heart one lesson of the inquiry: that the whole cumbersome, expensive, and ineffectual administrative apparatus needs urgent reappraisal and change. Committee of Inquiry into Normansfield Hospital, Report. London, HMSO, 1978.
