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Birch, C J, et al, omrnial of MVedical Virology, 1977, 1, 69. Middleton, P J, et al, _7otJoral of Clinical Pathology, 1976, 29, 191. Nastasi, IM C, Pringle, R C, and Gust, I D, Auistralian Jouirnal of Medical Technology, 1972, 3, 111. "Yolken, R H, et al, Lanicet, 1977, 2, 263. British Medical yournal, 1975, 3, 555. 12 Ryder, R W, et al, Latncet, 1976, 1, 659. Schoub, B D, et al, _oirnal of Hygiene, 1977, 78, 377. 14 De Groote, G, et al, Latncet, 1977, 1, 1263. 5 Madeley, C R, et al, j7ouirnzal of Hygiene, 1977, 78, 261.

Finger clubbing and hypertrophic pulmonary osteoarthropathy Every final-year medical student knows that clubbing of the fingers can be caused by intrathoracic sepsis, carcinoma of the lung, bacterial endocarditis, and cyanotic congenital heart disease; and honours candidates may add carcinoma of the thymus or thyroid, leiomyoma of the oesophagus, Hodgkin's disease of the thorax, disseminated chronic myeloid leukaemia, pleural mesothelioma or fibroma, achalasia or peptic ulceration of the oesophagus, cirrhosis of the liver, and ulcerative colitis. The small-print enthusiast can add cystic fibrosis,' pulmonary metastases2 from numerous sources including hypernephroma and melanoma,3 nasopharyngeal carcinoma,4 as a rarity in repeated pregnancies, and reversibly in purgative abuse.) This formidable list does not deny the diagnostic value of clubbing, particularly as suggestive of carcinoma of the bronchus, bacterial endocarditis, and intrathoracic suppuration, for these will account for most cases in everyday clinical practice. Hypertrophic pulmonary osteoarthropathy may complicate simple clubbing and present with periostitis with new bone formation in the limbs, possibly synovial hypertrophy with joint effusions, and abnormal sweating of the palms and soles. Some authorities have suggested that clubbing is not essential for the diagnosis of hypertrophic pulmonary osteoarthropathy," and the subtleties of early clubbing often evoke semantic debate at the bedside. The clinical hallmark of osteoarthropathy is painful periarticular or joint swellings over the wrists, knees, ankles, or elbows. The swelling and tenderness may be associated with morning stiffness and may mimic rheumatoid arthritis; the raised sedimentation rate may appear to confirm this suspicion, and it may be further reinforced by symptomatic relief from aspirin, indomethacin, or steroids, though the bony changes do not resolve. The typical radiological appearances of the periostitis of the long bones is usually diagnostic, but in unusual cases where joint features predominate the synovial fluid has been found to be "non-inflammatory" with a low leucocyte count and few neutrophils, serving to differentiate the condition from rheumatoid arthritis. Recent advances with radionuclide 99mTc phosphate complexes have helped to solve diagnostic confusion between hypertrophic osteoarthropathy and bone metastases in patients with carcinoma of the bronchus and may also allow the condition to be diagnosed with some certainty before the appearance of the characteristic radiological changes.7 Highquality radionuclide images show pericortical deposition in hypertrophic osteoarthropathy, in contrast to a central increase in concentration of the radiopharmaceutical in bony metastases. Though the mechanism of clubbing and hypertrophic pulmonary osteoarthropathy remains unknown, at least three theories have been advanced to explain the phenomenon. The

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neuronal theory proposes that afferent impulses travel by the vagus or intercostal nerves from the causative pulmonary focus, but the efferent pathway from the nervous system remains a mystery. Regression of the arthropathy after cervical or superior mediastinal vagotomy8' is advanced as evidence for this thesis. The hormonal theory, originating with Maric in 1890, currently advocates the production of a circulating agent capable of producing the clubbing and osteoarthropathy which is normally inactivated by passage through thc pulmonary circulation. This attractive hypothesis unfortunately has little experimental support: changes in neither oestrogen'l' nor human growth hormone11 are related to the syndrome.12 An extension of the hormonal theory invokes arteriovenous shunting across the lung, as in cyanotic congenital heart disease, which allows an unknown hormone-like substance to escape into the systemic circulation, but again this mysterious material has never been isolated. Studies using krypton clearance to measure blood flow have confirmed the earlier impression, based upon venous occlusion plethysmography, that the blood flow to the clubbed fingers is increased, " but this has been questioned in hypertrophic pulmonary osteoarthropathy.'4 A recent postmortem study1) also failed to find any consistent increase in the vascularity of the tissues of the nail bed in clubbed fingers, and there was also little difference in the mast cell counts in clubbed and control fingers. The pain of hypertrophic pulmonary osteoarthropathy has been relieved by vagotomy, hypophysectomy, intercostal nerve section, exploratory thoracotomy, or by radiotherapy to the causative lung lesion.'6 The vascularity of the joint lesions, as assessed by thermography, can also be reduced by combined alpha- and beta-adrenergic blockade. 17 It seems odd that despite this apparent plethora of clues the physiopathological mechanism underlying clubbing and hypertrophic osteoarthropathy remains an enigma. IMatthay, M A, et al, Thorax, 1976, 31, 572.

2Firooznia, H, et al, Radiology, 1975, 115, 269. 3Sonoda, T, and Krauss, S, J'ournal of the Tennessee Medical Association, 1975, 68, 716. 4Chio, K, Medical Journal of Malaysia, 1975, 30, 127. 5Silk, D B, Gibson, J A, and Murray, C R, Gastroenterology, 1975, 68, 790. 6 Schumacher, H R, Arthritis and Rheumatism, 1976, 19, 629. Rosenthall, L, and Kirsh, J, Radiology, 1976, 120, 359. 8 Flavell, G, Lancet, 1956, 1, 260. 9 Yacoub, M H, British Jfournal of Diseases of the Chest, 1965, 59, 28. Ginsberg, J, and Brown, J B, Lancet, 1961, 2, 1274. Steiner, H, Dahlback, 0, and Waldenstrom, J, Lancet, 1968, 1, 783. 12Riyami, A M, and Anderson, E G, British Journal of Diseases of the Chest, 1974, 68, 193. 3 Racoceanu, S N, et al, Annals of Internal Medicine, 1971, 75, 933. 14 Ginsberg, J, Quarterly Journal of Medicine, 1958, 27, 335. 15Marshall, R, American Review of Respiratory Diseases, 1976, 113, 395. 1" Steinfeld, A D, and Munzenrider, J E, Radiology, 1974, 113, 709. Reardon, G, Collins, A J, and Bacon, P A, Postgraduate Medical_Journal, 1976, 52, 170.

Obdurate politics When Mrs Barbara Castle introduced the DHSS consultative document on priorities' in March 1976 she undertook to modify the plan in the light of comments from health authorities, professional and staff associations, community health councils, and voluntary bodies. Her strategy-at a time when the nation's economic outlook was especially bleakwas to maintain a 1.800O rise in current NHS expenditure by cutting back the capital building programme. Her choice of priorities was equally clear: more resources were to be given

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to general practice, the community services, the old, and the mentally ill, and the money was to come from a cutback in maternity services and restricted growth in the acute specialties. The pressures that this policy put on acute hospital services were increased, in London at least, by the publication later the same year of plans for reallocation of resources between the regions.2 Even those intended to benefit from resource reallocation protested that the proposed restraints would lead to further deterioration in services to the patient; the four Thames regions, which were told to expect a progressive drop in their share of resources, saw no alternative but to plan hospital closures. The central criticism of the DHSS plans was that the acute sector could not maintain standards on a frozen budget; and there was no logic, we argued,3 in a decision to spend more money on the handicapped at the expense of acute services (and especially the maternity services) when these could, if improved further, reduce the amount of handicap in the community. The validity of those criticisms has been borne out by the strategic plans published by the NHS regions.4 Progress to the priority objectives will mean longer waiting times for hospital inpatients and outpatients, said the Southeast Thames region, and others echoed the impossibility of following the official guidelines. On the one hand, additional revenue costs have been generated by capital developments already under way; on the other, the effective freeze on new capital developments makes it impossible, for example, to replace large mental hospitals with acute units in district hospitals. The last 12 months have seen deterioration in the quality of hospital services, lengthening waiting lists, and a further drop in staff morale. Yet how has Mr David Ennals responded to the criticisms ? His "further discussion" of priorities published this week5 is obdurate in its refusal to admit any error in the DHSS strategy-though it does accept that "redeployment and rationalisation of acute services may require a more rapid increase in expenditure than was first thought." Overall, however, the emphasis remains on squeezing the acute hospital services still further, and on a whole range of economies. Highlighting day surgery, five-day wards, and programmed investigation units as if they were novelties, the document includes a long appendix of examples of ways of increasing hospital efficiency, ranging from campaigns to reduce waste in the use of bandages to advice on painting wood windows. What, in fact, the Government is doing is contracting the hospital service. Clearly the DHSS is proud of the 4 6°O( reduction in beds in acute hospitals in the past five years-and it also seems determined to attack excellence wherever it may be.6 Paradoxically, the only exception to this negative philosophy is a new, clear commitment to expand the medical school intake to reach 4000 places as soon as possible. The rationale of this policy (opposed by a growing sector of informed

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medical opinion7) is that more young doctors are needed to enable a higher proportion of posts in hospitals and in general practice to be filled with British graduates. Does the DHSS really believe that the answer to the problems of staffing unpopular specialties and decaying hospitals is simply to train more doctors? Such a solution cannot work while medical migration remains possible-and there is no way of shutting the door into Europe. Furthermore this is the only decision on manpower. The most glaring omission from the latest instalment in the priorities strategy is the continuing absence of any reference to economies in NHS staffing as a whole. "It is too soon," says the new discussion document, "to have expected manpower planning to have reached a high level, nationally or locally." Too soon ? Or is the problem too sensitive politically ? Mrs Castle's original strategy undertook to avoid redundancies, and the NHS unions were quick to call for consultations about any plans affecting their future. Yet 700 of the current expenditure of the DHSS is on staff, and in any other organisation looking for economies the most obvious step would be a detailed search for examples of overmanning as well as ways of making better use of skilled staff. While the plan talks of strategy, its horizons are as sadly limited as was the original. There is still no acknowledgment that regions might be able to innovate if given the encouragement to do so,4 or that alternative schemes might be tested in different parts of the country. Nor does the DHSS do more than pay lip service to the doctrine of prevention. Mr Ennals is going to publish a White Paper on prevention before long. But if the Government really gave prevention any priority it would have done more to promote immunisation in childhood, given full backing to the recent Bills to make wearing of seat belts compulsory, and made more use of taxation to discourage smoking and drinking. The biggest disappointment of this document, however, is the absence of any evidence that the DHSS has listened to its critics. The priorities policy and its modification by the RAWP proposals have been examined and debated in detail -and constructively-by NHS staff at all levels, yet their views seem to have been ignored or brushed aside as representing sectional interests. How can the DHSS expect cooperation in economies when its attitude is so autocratic? Dcpartment of Health and Social Services, Priorilties for Health and Personal Social Services in Etngland: a Consuiltative Document. London, HMSO, 1976. 2 Department of Health and Social Services, Sharing resources for health in Etngland: report of the Resource Allocation Working Party. London,

HMSO, 1976. British Medical Journal, 1976, 1, 1426. 4 British Medical_Journal, 1977, 2, 214. Department of Health and Social Security, Priorities in the Health and Social Services, The Way Forward. London, HMSO, 1977. 6 British Medical_Journal, 1976, 2, 779. British Medical Journal, 1977, 1, 465.

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Obdurate politics.

BRITISH MEDICAL JOURNAL 24 SEPTEMBER 1977 Birch, C J, et al, omrnial of MVedical Virology, 1977, 1, 69. Middleton, P J, et al, _7otJoral of Clinical...
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