1174 in W.H.O. Had this move succeeded, the United States would have withdrawn from the Organisation and the future of W.H.O. itself would have been in doubt. As it was, the danger was avoided by a combination of factors, not least of which was the impressive common sense and solidity of the Commonwealth countries, particularly the African countries. Calls to reason came from Kenya, Gambia, Nigeria, and Fiji. Another moderating influence was the use of the secret ballot, which allowed a vote by conscience to those who felt that W.H.O. should be concerned more with technical health matters than with transient and dangerous political issues (this is not, of course, to say that a health revolution does not need its own political support). This notable victory should not only have effects far into the future but also serve as an example to the rest of the United Nations system and support W.H.O.’s reputation. It should permit much greater concentration on the social goal which the Governments of the world have set themselves-"health for all by the year 2000." The Assembly also heard massive expressions of support for an agreed strategy towards this aim. It is now widely realised that the objectives in national terms are matters for each country to define for itself and that the global campaign must be the synthesis of the national plans, which must come first. The key to success will be the establishment of total cover by primary health-care services of a nature and quality relevant to health hazards, acceptable to the population served, and feasible within their resources. Countries which have not already done so must assess their objectives and then measure the resources required against those likely to be available. The difference in terms of money, experience, and training facilities will indicate what is required from international action and support. This support may be from the U.N. system as a whole, remembering that the real determinants of health reach far more widely than traditional health services-reduction of poverty, nutrition,
expulsion
education, agriculture, housing, and safe
water and countries must, of course, developed in role technical play a very important cooperation, either through W.H.O. or directly by bilateral cooperation with countries in need. W.H.O. has the constitutional duty to coordinate such international health flows in line with policies agreed by its member States in successive World Health Assemblies.
sanitation. The
During aspiration curettage a hollow metal cannula 3 mm in external diameter with an aperture at the end is passed into the uterus by gentle negotiation up the cervical canal. Since dilatation is not needed, paracervical anaesthesia is not required. At the proximal end of the cannula is a plastic collecting tube containing a sieve. The equipment is connected to an electrical vacuum pump so that, when the cannula is drawn gently down the uterine wall, endometrium is aspirated. This procedure is repeated a few times to explore the whole of the surface of the cavity, usually taking about a minute, and the plastic container is then detached from the cannula, filled with formol saline, and sent to the laboratory for histological examination. Usually the patient feels no pain at all; a few report discomfort of the sort associated with insertion of an intrauterine device or the preliminary part of a hysterosalpingogram. Very occasionally a patient reacts with a mild syncopal attack, but rapid recovery is usual. Most women are able to leave the couch immediately and go back to normal work the same or next day. The patient should be warned that there may be vaginal spotting of blood for a few days. Some may need oral analgesics for persistent discomfort reminiscent of mild dysmenorrhcea. Infection is rare and no serious hxmorrhage has been reported. A very large uterus or suspected pregnancy are among the few contraindications; aspiration curettage should not be regarded as definitive if an unsuspected large uterine cavity over 12 cm in length is encountered, if large polyps are suspected, or if the aspirate is scanty and there is doubt about proper exploration of the fundus.
Aspiration curettage is not new: Lorincz in 19342 desa method of diagnostic suction curettage that was investigated by Novak in 1935.3 In 1968 Jensen and Jensen4 compared Vabra suction with conventional curettage and showed that both completely evacuated endometrium from regular uterine cavities. Since then reports have appeared in the United Kingdom from Holt5 and Saunders and Rowland,6in Sweden from Lubbers,7 and now in Denmark from Haack-Sorensen et al. (a large series).8 Most workers reached the same conclusion-that outpatient curettage of the endometrium could replace an inpatient procedure in half to three-
cribed
quarters of cases. new surgical procedure is to be assessed older one, one compares efficacy, complications, and technical ease of the operations-in that order-and only then the costs. Several groups have reported that with Vabra aspiration curettage the yield of endometrium is as good as that achieved by conventional dilatation and curettage under general anæsthesia.4,6-8 Histological changes due to negative pressure have been described,6,8 but they are easy to distinguish and are seldom observed if tissue is fixed immediately. Holt5 found that the deeper layers of endometrium were relatively deficient after Vabra curettage but he did not
When
against OUTPATIENT UTERINE CURETTAGE THE uterus, though deep inside the body, is easily accessible for biopsy; but this usually means admission and curettage under general anaesthesia. In Britain curettage is one of the commonest operations for which patients are admitted to hospital and yet many women might be dealt with in the outpatients’ department, saving not just the cost of a hospital bed but also family upheaval, loss of work, and sometimes a long spell on the waiting-list. Most women prefer an outpatient procedure,l and any technique which allows acceptable biopsy of endometrium to be done in an outpatient deserves serious consideration. 1.
Falconer, G. P. Br. J. Hosp. Med. 1973, 9, 521.
a
an
2. Lorincz, B. Munch med. Wschr. 1934,81,215. 3. Novak, E.J.Am med.Ass. 1935,104,1497. 4. Jensen, J. A.,Jensen, J. G. Ugeskr. Lœg. 1968,130,2124. 5. Holt, E. M.J. Obstet. Gynœc. Br. Commonw. 1970,77,1043. 6. Saunders, P., Rowland, R. ibid. 1972,79, 168. 7. Lubbers, J. A. Acta. obstet. gynec. scand. 1977, suppl. 62, p.1 8. Haack-Sorensen, P. E., Starkluit, H., Aronsen, A., Kern Hangar, toffersen, K. Dan. med. Bull. 1979,26, 1.
M, Kris-
1175 this as a serious disadvantage. Malignant disease can be detected readily; only a large polyp might be missed by suction curettage which could have been picked up by the use of a pair of polypectomy forceps at the more formal operation. During the cervical-dilatation phase of conventional curettage there is a reported increase in pressure in the endometrial cavity of 30 to 100 mm Hg
see
theoretically might promote migration of potentially malignant cells up the fallopian tubes into the per itoneal cavity.’ This would not happen during Vabra curettage, for not only is no dilatation required but also the technique employs negative pressure for removing endometrium. Acceptability to patients ranges from 71%8 to 97%,4 and depends on selection of suitable patients and full explanations before the procedure, as well as on the dexterity of the gynoccologist; side-effects are few. So, if the technique is easy and rapid and the which
results similar to those of conventional curettages, what of cost? Cost-benefit analyses can be deceptive, but in this instance the advantage of the Vabra system can hardly be doubted: the procedure requires a small disposable piece of plastic costing a few pounds and takes a few minutes of outpatient time, while conventional dilatation and curettage demands a hospital bed and the additional costs of anaesthesia and operating-theatre. The Vabra method could be very useful in a busy gynaecological department. Infertility and dysfunctional uterine haemorrhage are conditions in which it has obvious attractions-to say nothing of postmenopausal women on hormone replacement therapy.,9 who should be monitored for endometrial carcinoma. 10
KEEP TAKING YOUR BRAN DIVERTICULAR disease of the colon seems to have been before the early part of this century.’ Although the pathological changes had been described many years before,2.3 the prevalence of the condition was not established until radiological examination of the large bowel was a regular procedure. In 1930,4 Mayo estimated that 5% of patients over the age of 40 had diverticular disease. The prevalence seems to have risen sharply over the past twenty years and the disease is now thought to affect 35% of English adults over the age of 60.5 This increase in prevalence has been related to a reduced consumption of food containing unprocessed fibre and an increased consumption of refined carbohydrates. Refining of flour and cereal and the change in diet date back to the last quarter of the nineteenth century, but if diverticular disease takes some 40 years to develop it rare
9 Studd, J. W., Thomas, M., Dische, F., Driver, M., Wade Evans, T., Wilhams, D. Br. med. J. 1979, i, 846. 10 Lancet. May 26,1979, p. 1121 1 Painter, N. S. Diverticular Disease of the Colon. London, 1975. 2 3 4
Rokitansky, C. A Manual of Pathological Anatomy. 1849. Habershon, S O. Observations on the Alimentary Canal. London, 1857. Mayo, W.JAnn. Surg. 1930,92,739.
5 Cleave., F. I. The Saccharine Disease. Bristol, 1974
is not difficult to understand why the prevalence has risen since 1920. In the past the disease was thought to be due to stagnation of fsces in the colon and treatment was aimed at keeping the colon as empty as possible by means of a low-residue diet and regular purgation. 6, However Painter and colleagues8 pointed out that characteristic features of the disease are raised intraluminal pressure in the colon, prolonged intestinal transit time, and reduced stool weight. They therefore recommended an increased intake of unrefined fibre both for prophylaxis and therapy-the very opposite of the standard treatment offered for so many years.9.10 This approach has now been generally accepted and there are many agents on offer which will increase stool bulk and alleviate symptoms. However, some doubt has lately been cast on the relation between the symptoms and the recognised pathophysiological features of the disease. Eastwood et al." compared the colonic motility, stool weight, and transit time in 60 patients with untreated diverticular disease with the same indices in a carefully matched control population." Surprisingly the stool weight and transit time in the patients with diverticular disease were similar to those of the controls. The motility index (derived from the amplitude and frequency of pressure waves) also varied widely. They postulated that patients with the so-called characteristic features of the disease probably represent a subgroup with chronic colonic obstruction or constipation and that the relief of symptoms by addition of bulking agents does not depend on the presence of these features. To test this hypothesis they compared the action of three different agents on colonic function in patients with diverticular disease.12 They chose coarse bran, ispaghula, and lactulose, all of which are thought to increase stool bulk and reduce transit time. Although all three agents did relieve symptoms their effects on colon function differed strikingly. Only ispaghula significantly increased stool weight and only bran significantly reduced transit time. The effects on colonic motility were equally surprising. Ispaghula significantly increased motility whereas bran and lactulose had no effect. These results were confirmed by giving twice the dose of ispaghula (four sachets a day). Thus, although all three agents reduced symptoms, there was no consistent relation to changes in motility, transit time, or stool weight, and the modus operandi is unclear. Agents which raise intraluminal pressure may, at least theoretically, lead to further hypertrophy of colonic musculature in patients with diverticular disease. From their investigations Eastwood and his co-workers conclude that coarse bran, which has a greater waterholding capacity than the fine variety,13 is the best agent for treating patients with this condition. Let us hope that a more palatable form will soon be devised.
6. Willard, J. H., Bockus, H. L. Am.J. dig. Dis. Nutr. 1936, 3, 580. 7. Edwards, H. C. Diverticula and Diverticulitis of the Intestine. Bristol, 1939. 8. Painter, N. S. Ann. R. Coll. Surg. Eng. 1964, 34, 98. 9. Painter, N. S., Burkitt, D. P. Br. med.J. 1971,ii,450. 10. Burkitt, D. P., Painter, N. S., Walker, A. R. P Lancet, 1972, ii, 1408. 11. Eastwood, M. A., Brydon, W. G., Smith, A. N., Pritchard, J. Lancet, 1978,
i, 1181. 12. Eastwood, M. A., Smith, A N., Brydon, W G., Pritchard, J. Gut, 1978, 19, 1144. 13. Kirwan, W. O., Smith, A. N., McConnell, A. A., Mitchell, W. D., Eastwood, M A Br. med J. 1974, iv, 187.
expulsion
education, agriculture, housing, and safe
water and countries must, of course, developed in role technical play a very important cooperation, either through W.H.O. or directly by bilateral cooperation with countries in need. W.H.O. has the constitutional duty to coordinate such international health flows in line with policies agreed by its member States in successive World Health Assemblies.
sanitation. The
During aspiration curettage a hollow metal cannula 3 mm in external diameter with an aperture at the end is passed into the uterus by gentle negotiation up the cervical canal. Since dilatation is not needed, paracervical anaesthesia is not required. At the proximal end of the cannula is a plastic collecting tube containing a sieve. The equipment is connected to an electrical vacuum pump so that, when the cannula is drawn gently down the uterine wall, endometrium is aspirated. This procedure is repeated a few times to explore the whole of the surface of the cavity, usually taking about a minute, and the plastic container is then detached from the cannula, filled with formol saline, and sent to the laboratory for histological examination. Usually the patient feels no pain at all; a few report discomfort of the sort associated with insertion of an intrauterine device or the preliminary part of a hysterosalpingogram. Very occasionally a patient reacts with a mild syncopal attack, but rapid recovery is usual. Most women are able to leave the couch immediately and go back to normal work the same or next day. The patient should be warned that there may be vaginal spotting of blood for a few days. Some may need oral analgesics for persistent discomfort reminiscent of mild dysmenorrhcea. Infection is rare and no serious hxmorrhage has been reported. A very large uterus or suspected pregnancy are among the few contraindications; aspiration curettage should not be regarded as definitive if an unsuspected large uterine cavity over 12 cm in length is encountered, if large polyps are suspected, or if the aspirate is scanty and there is doubt about proper exploration of the fundus.
Aspiration curettage is not new: Lorincz in 19342 desa method of diagnostic suction curettage that was investigated by Novak in 1935.3 In 1968 Jensen and Jensen4 compared Vabra suction with conventional curettage and showed that both completely evacuated endometrium from regular uterine cavities. Since then reports have appeared in the United Kingdom from Holt5 and Saunders and Rowland,6in Sweden from Lubbers,7 and now in Denmark from Haack-Sorensen et al. (a large series).8 Most workers reached the same conclusion-that outpatient curettage of the endometrium could replace an inpatient procedure in half to three-
cribed
quarters of cases. new surgical procedure is to be assessed older one, one compares efficacy, complications, and technical ease of the operations-in that order-and only then the costs. Several groups have reported that with Vabra aspiration curettage the yield of endometrium is as good as that achieved by conventional dilatation and curettage under general anæsthesia.4,6-8 Histological changes due to negative pressure have been described,6,8 but they are easy to distinguish and are seldom observed if tissue is fixed immediately. Holt5 found that the deeper layers of endometrium were relatively deficient after Vabra curettage but he did not
When
against OUTPATIENT UTERINE CURETTAGE THE uterus, though deep inside the body, is easily accessible for biopsy; but this usually means admission and curettage under general anaesthesia. In Britain curettage is one of the commonest operations for which patients are admitted to hospital and yet many women might be dealt with in the outpatients’ department, saving not just the cost of a hospital bed but also family upheaval, loss of work, and sometimes a long spell on the waiting-list. Most women prefer an outpatient procedure,l and any technique which allows acceptable biopsy of endometrium to be done in an outpatient deserves serious consideration. 1.
Falconer, G. P. Br. J. Hosp. Med. 1973, 9, 521.
a
an
2. Lorincz, B. Munch med. Wschr. 1934,81,215. 3. Novak, E.J.Am med.Ass. 1935,104,1497. 4. Jensen, J. A.,Jensen, J. G. Ugeskr. Lœg. 1968,130,2124. 5. Holt, E. M.J. Obstet. Gynœc. Br. Commonw. 1970,77,1043. 6. Saunders, P., Rowland, R. ibid. 1972,79, 168. 7. Lubbers, J. A. Acta. obstet. gynec. scand. 1977, suppl. 62, p.1 8. Haack-Sorensen, P. E., Starkluit, H., Aronsen, A., Kern Hangar, toffersen, K. Dan. med. Bull. 1979,26, 1.
M, Kris-
1175 this as a serious disadvantage. Malignant disease can be detected readily; only a large polyp might be missed by suction curettage which could have been picked up by the use of a pair of polypectomy forceps at the more formal operation. During the cervical-dilatation phase of conventional curettage there is a reported increase in pressure in the endometrial cavity of 30 to 100 mm Hg
see
theoretically might promote migration of potentially malignant cells up the fallopian tubes into the per itoneal cavity.’ This would not happen during Vabra curettage, for not only is no dilatation required but also the technique employs negative pressure for removing endometrium. Acceptability to patients ranges from 71%8 to 97%,4 and depends on selection of suitable patients and full explanations before the procedure, as well as on the dexterity of the gynoccologist; side-effects are few. So, if the technique is easy and rapid and the which
results similar to those of conventional curettages, what of cost? Cost-benefit analyses can be deceptive, but in this instance the advantage of the Vabra system can hardly be doubted: the procedure requires a small disposable piece of plastic costing a few pounds and takes a few minutes of outpatient time, while conventional dilatation and curettage demands a hospital bed and the additional costs of anaesthesia and operating-theatre. The Vabra method could be very useful in a busy gynaecological department. Infertility and dysfunctional uterine haemorrhage are conditions in which it has obvious attractions-to say nothing of postmenopausal women on hormone replacement therapy.,9 who should be monitored for endometrial carcinoma. 10
KEEP TAKING YOUR BRAN DIVERTICULAR disease of the colon seems to have been before the early part of this century.’ Although the pathological changes had been described many years before,2.3 the prevalence of the condition was not established until radiological examination of the large bowel was a regular procedure. In 1930,4 Mayo estimated that 5% of patients over the age of 40 had diverticular disease. The prevalence seems to have risen sharply over the past twenty years and the disease is now thought to affect 35% of English adults over the age of 60.5 This increase in prevalence has been related to a reduced consumption of food containing unprocessed fibre and an increased consumption of refined carbohydrates. Refining of flour and cereal and the change in diet date back to the last quarter of the nineteenth century, but if diverticular disease takes some 40 years to develop it rare
9 Studd, J. W., Thomas, M., Dische, F., Driver, M., Wade Evans, T., Wilhams, D. Br. med. J. 1979, i, 846. 10 Lancet. May 26,1979, p. 1121 1 Painter, N. S. Diverticular Disease of the Colon. London, 1975. 2 3 4
Rokitansky, C. A Manual of Pathological Anatomy. 1849. Habershon, S O. Observations on the Alimentary Canal. London, 1857. Mayo, W.JAnn. Surg. 1930,92,739.
5 Cleave., F. I. The Saccharine Disease. Bristol, 1974
is not difficult to understand why the prevalence has risen since 1920. In the past the disease was thought to be due to stagnation of fsces in the colon and treatment was aimed at keeping the colon as empty as possible by means of a low-residue diet and regular purgation. 6, However Painter and colleagues8 pointed out that characteristic features of the disease are raised intraluminal pressure in the colon, prolonged intestinal transit time, and reduced stool weight. They therefore recommended an increased intake of unrefined fibre both for prophylaxis and therapy-the very opposite of the standard treatment offered for so many years.9.10 This approach has now been generally accepted and there are many agents on offer which will increase stool bulk and alleviate symptoms. However, some doubt has lately been cast on the relation between the symptoms and the recognised pathophysiological features of the disease. Eastwood et al." compared the colonic motility, stool weight, and transit time in 60 patients with untreated diverticular disease with the same indices in a carefully matched control population." Surprisingly the stool weight and transit time in the patients with diverticular disease were similar to those of the controls. The motility index (derived from the amplitude and frequency of pressure waves) also varied widely. They postulated that patients with the so-called characteristic features of the disease probably represent a subgroup with chronic colonic obstruction or constipation and that the relief of symptoms by addition of bulking agents does not depend on the presence of these features. To test this hypothesis they compared the action of three different agents on colonic function in patients with diverticular disease.12 They chose coarse bran, ispaghula, and lactulose, all of which are thought to increase stool bulk and reduce transit time. Although all three agents did relieve symptoms their effects on colon function differed strikingly. Only ispaghula significantly increased stool weight and only bran significantly reduced transit time. The effects on colonic motility were equally surprising. Ispaghula significantly increased motility whereas bran and lactulose had no effect. These results were confirmed by giving twice the dose of ispaghula (four sachets a day). Thus, although all three agents reduced symptoms, there was no consistent relation to changes in motility, transit time, or stool weight, and the modus operandi is unclear. Agents which raise intraluminal pressure may, at least theoretically, lead to further hypertrophy of colonic musculature in patients with diverticular disease. From their investigations Eastwood and his co-workers conclude that coarse bran, which has a greater waterholding capacity than the fine variety,13 is the best agent for treating patients with this condition. Let us hope that a more palatable form will soon be devised.
6. Willard, J. H., Bockus, H. L. Am.J. dig. Dis. Nutr. 1936, 3, 580. 7. Edwards, H. C. Diverticula and Diverticulitis of the Intestine. Bristol, 1939. 8. Painter, N. S. Ann. R. Coll. Surg. Eng. 1964, 34, 98. 9. Painter, N. S., Burkitt, D. P. Br. med.J. 1971,ii,450. 10. Burkitt, D. P., Painter, N. S., Walker, A. R. P Lancet, 1972, ii, 1408. 11. Eastwood, M. A., Brydon, W. G., Smith, A. N., Pritchard, J. Lancet, 1978,
i, 1181. 12. Eastwood, M. A., Smith, A N., Brydon, W G., Pritchard, J. Gut, 1978, 19, 1144. 13. Kirwan, W. O., Smith, A. N., McConnell, A. A., Mitchell, W. D., Eastwood, M A Br. med J. 1974, iv, 187.
