832
Proc. roy. Soc. Med. Volume 70 December 1977
One can well understand the formidable problems of communication facing the drug regulatory authority described by Dr Harris. Although information appears to be fundamental to communication, more and better information does not solve the problem; on the contrary, the more the information the greater is the need for effective communication. Thus, in simply providing a mass of informative data the authority does not liquidate its responsibilities, for men hear only what they are capable of hearing. This is what makes communication from above downwards so difficult, unless the communicator knows what the recipient is capable of perceiving, which will be very different in the case of an Oxford don and that of a Beotian labourer. Success demands communication from below upwards as well as above downwards and it may be that drug regulatory authorities do not always take sufficient notice of the opinions of those to whom they attempt to communicate. In this connexion it may be significant to note that Dr Harris starts his address by quoting Dr Charles Fletcher's eight principles of communication but leaves out the last sentence of the eighth aphorism: 'effective communication between colleagues also demands willingness on the part of the giver to discover that more may be learnt than taught'. Undoubtedly, the presentation of any message must be sufficiently clear and unambiguous for the category of recipient for whom it is intended. Thus, perhaps the biggest problem facing drug regulatory authorities is their relationship with the media, for journalists and broadcasters are experts in communication and they reach individuals in their own homes giving a personal approach. Dr Charles Fletcher has done more than anyone to encourage communication in medicine, but it is doubtful if he is right when, in his Nuffield Provincial Trust monograph on the subject (Fletcher 1973), he adjures doctors 'to appreciate that journalists and broadcasters are no less responsible than they are themselves and are just as concerned with the good of the public'. It is not denied that the mass media have made outstanding contributions to preventive and therapeutic medicine, but there are very few doctors or scientifically qualified men on editorial staffs and it is doubtful if most journalists are as responsible as most doctors in being concerned with the good of the public. They have to earn their livings by pandering to the public taste for sensationalism, scandal, prurience and anything connected with sex - even the contraceptive pill. Dr Harris gave a very striking example of the harm that can be done when, in his address, he described the leak of information to the press about the cestrogenic content of the pill. Reporters who got hold of this confidential information gave it publicity before the circular had
reached doctors, declaring that there was a new risk of the contraceptive pill, rather than the actual discovery of how to reduce an already-known small risk of thromboembolism. In this area, much might be achieved by drug regulatory authorities if they were to improve their relationship with the media, perhaps by the incorporation of an able press-relations officer taking the media into his confidence. Manifestly it is difficult to establish such a relationship but, in lacking it, communication to the public about drugs is always going to be misunderstood and misinterpreted. A perusal of Dr Harris' most thought-provoking address impresses one with the fact that democracy is a very difficult form of government. We are all now aware of the disastrous results of the attempt to prohibit alcohol in the USA. In the same way, the apparently very necessary measures to control the prescription, use and production of modern medicines might possibly become the thin edge of the bureaucratic wedge to professional and industrial freedom. The trouble is that, although we nearly all maintain that freedom is good and restriction bad, when someone else's freedom of action becomes inconvenient we usually clamour for its restriction, a restriction which then seems essential in the public interest and based on the purest of motives. 'The Government must do something about it', we say. Such restrictions may be peculiarly undesirable when imposed hysterically to meet a crisis. DERRICK DUNLOP
Emeritus Professor of Therapeutics and Clinical Medicine University ofEdinburgh REFERENCES Fletcher C M (1973) Communication in Medicine. The Nuffield Provincial Hospitals Trust; p 93
Surgery of Congenital Urinary Tract Disease In pediatric urology, as in many branches of surgery, there is an increasing scope for the operative correction of disorders of form and function, but also a need for long-term supervision of surgical cases. Most problems relate to congenital urinary tract anomalies, though the surgery of stone and tumour is still of vital importance. Some of the anomalies are familiar from adult urological experience and are readily amenable to standard operative procedures; others are encountered in large numbers only in infancy and require some
Editorials specialized knowledge for successful treatment. The volume of work in pediatric urology will never approach that in the adult field, but its variety and intricacy are at least as great, so there will always be a place for specialists in this area playing their part, along with other pediatric physicians and surgeons, in children's hospitals where the difficult problems can be collected and intensively studied. The advances in surgical management concern particularly the infant, and it is clear that our best chances of securing normal or near normal function in congenital disorders of the urinary tract lie in early diagnosis and accurate correction. For the initial recognition of most urinary tract anomalies we must be dependent upon the hospital pediatrician who sees the infant soon after birth, and upon the community pidiatricians or general practitioners who are responsible for family care and infant welfare clinics. In spite of all that has been written on the subject, it is regrettable how often one sees children whose urinary tract infections in infancy have been missed or treated without investigation by short courses of chemotherapy. It is true, of course, that an extensive programme of investigation will not only show up those in urgent need of treatment, but will also distinguish the many minor abnormalities which are of no importance or may correct themselves. There is thus a need for careful judgment in the selection of cases for surgery, as may be observed in the examples of posterior urethral valvular obstruction and in vesicoureteric reflux. External deformities also contribute an important requirement for surgery, and the long-term view required in pediatric urology may be well illustrated by considering the problem of exstrophy of the bladder. These children must be seen shortly after birth for rational planning of their treatment and for a full explanation to the parents even if definitive surgery is to be postponed. It has become clear over the years that a small proportion of these bladders, where the epithelium is healthy, the muscle active and the potential capacity adequate, are suitable for functional reconstruction with a fair prospect of continence. If the newborn child falls into this category, early surgical closure is advised: some surgeons prefer to perform an immediate operation, others are prepared to wait for a few weeks or months, but at this stage it is usually impossible to aim at sphincteric reconstruction or reflux prevention and the male urethra and bladder neck are therefore left open. Reflux is almost always a consequence of closure and can be dangerous if there is outflow obstruction; postoperative pyelograms are therefore essential. After three or four years the situation is reviewed: if the bladder capacity is good and active micturition is possible, a further procedure is undertaken to tighten the bladder neck and reimplant the ureters,
833
after which training for continence can begin. Once again, however, the condition of the upper tract must be watched and the sterility of the urine maintained. There will be some failures which will require subsequent diversion, and some children who will grow up with well-managed, though seldom normal, continence. For the poorly developed bladder, diversion offers the only hope of reasonable control, but this operation is seldom urgent and may well be postponed beyond infancy in order to assess the adequacy of the anal sphincter. In recent years, simple ureterosigmoidostomy has received renewed support after a period in which it was illregarded; success, however, depends on choosing a suitable case with normal ureters and a normal bowel, and on performing an anastomosis which is both unobstructed and valvular. Most of the established operative methods are capable of providing such a result if carefully performed, but as with reconstruction, follow up is essential and if reflux or obstruction are found, then the anastomosis must be revised. Usually this can be detected during the first six months, but late deterioration after ten to fifteen years is still possible and these children require continuous supervision. Biochemical disorders may be a problem but usually only in cases with unsatisfactory urinary drainage. Ileal conduit ureterostomy, which was originally regarded as a hazard-free alternative to ureterosigmoidostomy, has proved in the long term to have its disadvantages. Not only is the abdominal urinary stoma unwelcome to the adolescent or young adult, but late deterioration of renal function can be seen, sometimes due to stomal or ureteroileal obstruction, sometimes to chronic infection, sometimes perhaps to ileoureteric reflux. To avoid the last complication, the colonic conduit has become popular, since a reflux-preventing ureterocolic anastomosis can be constructed without difficulty. Some urologists prefer to perform a colonic conduit diversion in early infancy to ensure sterile urine during the period of maximum renal growth and then, later in childhood, when the stoma itself threatens psychological complications, to rejoin the conduit to the continuity of the colon. Others have attempted to use the anal sphincter to control two passages, urinary and fical, one an isolated rectal bladder and the other a pulledthrough colon. These procedures have a relatively high complication rate, however, and continence in both systems is seldom perfect so that they are now seldom performed in Britain or North America. In general it must be recognized that no diversion is perfect and that the child with exstrophy, whether reconstructed or diverted, requires life-long supervision. The problems of exstrophy are not, of course,
834
Proc. roy. Soc. Med. Volume 70 December 1977
confined to the urinary tract. The bony gap in the pelvis is seldom a difficulty from the orthopxdic point of view, but the abdominal wall requires reconstruction. Pelvic osteotomy may be performed to allow the pubes to be brought together, or rectus sheath flaps can be rotated inwards to secure an adequate linea alba. If the bladder is not to be preserved, however, its mucosa can be removed and the detrusor layer employed to fill the gap between the separated rectus muscles. Skin closure must ensure that the hair bearing areas, which are placed laterally over the separated pubic bones, are rotated inwards to provide a normal pubic appearance. In the male, reconstruction of the penis must secure correction of the upward chordee which results from the short urethral strip and the lateral displacement of the crura. It is now recognized that this can only be satisfactorily
attained by an extensive mobilization of the corpora cavernosa and skin replacement of the urethra. Inadequate operation in the past has left too many young men with exstrophy as sexual cripples, even though the genital tract from the verumontanum upwards is normal. In girls the vagina is short and anteriorly placed; it does not require specific treatment in childhood, but some enlargement of the introitus may be required at puberty. Menstruation and fertility are normal, but because of the short vagina and poorly developed pelvic floor, uterine prolapse may occur, particularly after pregnancy. Genital tract malformations, like those of the urinary tract, require attention through childhood into adult life. D INNES WILLIAMS
Dean of the Institute of Urology London WC2H 8JE
Proc. roy. Soc. Med. Volume 70 December 1977
One can well understand the formidable problems of communication facing the drug regulatory authority described by Dr Harris. Although information appears to be fundamental to communication, more and better information does not solve the problem; on the contrary, the more the information the greater is the need for effective communication. Thus, in simply providing a mass of informative data the authority does not liquidate its responsibilities, for men hear only what they are capable of hearing. This is what makes communication from above downwards so difficult, unless the communicator knows what the recipient is capable of perceiving, which will be very different in the case of an Oxford don and that of a Beotian labourer. Success demands communication from below upwards as well as above downwards and it may be that drug regulatory authorities do not always take sufficient notice of the opinions of those to whom they attempt to communicate. In this connexion it may be significant to note that Dr Harris starts his address by quoting Dr Charles Fletcher's eight principles of communication but leaves out the last sentence of the eighth aphorism: 'effective communication between colleagues also demands willingness on the part of the giver to discover that more may be learnt than taught'. Undoubtedly, the presentation of any message must be sufficiently clear and unambiguous for the category of recipient for whom it is intended. Thus, perhaps the biggest problem facing drug regulatory authorities is their relationship with the media, for journalists and broadcasters are experts in communication and they reach individuals in their own homes giving a personal approach. Dr Charles Fletcher has done more than anyone to encourage communication in medicine, but it is doubtful if he is right when, in his Nuffield Provincial Trust monograph on the subject (Fletcher 1973), he adjures doctors 'to appreciate that journalists and broadcasters are no less responsible than they are themselves and are just as concerned with the good of the public'. It is not denied that the mass media have made outstanding contributions to preventive and therapeutic medicine, but there are very few doctors or scientifically qualified men on editorial staffs and it is doubtful if most journalists are as responsible as most doctors in being concerned with the good of the public. They have to earn their livings by pandering to the public taste for sensationalism, scandal, prurience and anything connected with sex - even the contraceptive pill. Dr Harris gave a very striking example of the harm that can be done when, in his address, he described the leak of information to the press about the cestrogenic content of the pill. Reporters who got hold of this confidential information gave it publicity before the circular had
reached doctors, declaring that there was a new risk of the contraceptive pill, rather than the actual discovery of how to reduce an already-known small risk of thromboembolism. In this area, much might be achieved by drug regulatory authorities if they were to improve their relationship with the media, perhaps by the incorporation of an able press-relations officer taking the media into his confidence. Manifestly it is difficult to establish such a relationship but, in lacking it, communication to the public about drugs is always going to be misunderstood and misinterpreted. A perusal of Dr Harris' most thought-provoking address impresses one with the fact that democracy is a very difficult form of government. We are all now aware of the disastrous results of the attempt to prohibit alcohol in the USA. In the same way, the apparently very necessary measures to control the prescription, use and production of modern medicines might possibly become the thin edge of the bureaucratic wedge to professional and industrial freedom. The trouble is that, although we nearly all maintain that freedom is good and restriction bad, when someone else's freedom of action becomes inconvenient we usually clamour for its restriction, a restriction which then seems essential in the public interest and based on the purest of motives. 'The Government must do something about it', we say. Such restrictions may be peculiarly undesirable when imposed hysterically to meet a crisis. DERRICK DUNLOP
Emeritus Professor of Therapeutics and Clinical Medicine University ofEdinburgh REFERENCES Fletcher C M (1973) Communication in Medicine. The Nuffield Provincial Hospitals Trust; p 93
Surgery of Congenital Urinary Tract Disease In pediatric urology, as in many branches of surgery, there is an increasing scope for the operative correction of disorders of form and function, but also a need for long-term supervision of surgical cases. Most problems relate to congenital urinary tract anomalies, though the surgery of stone and tumour is still of vital importance. Some of the anomalies are familiar from adult urological experience and are readily amenable to standard operative procedures; others are encountered in large numbers only in infancy and require some
Editorials specialized knowledge for successful treatment. The volume of work in pediatric urology will never approach that in the adult field, but its variety and intricacy are at least as great, so there will always be a place for specialists in this area playing their part, along with other pediatric physicians and surgeons, in children's hospitals where the difficult problems can be collected and intensively studied. The advances in surgical management concern particularly the infant, and it is clear that our best chances of securing normal or near normal function in congenital disorders of the urinary tract lie in early diagnosis and accurate correction. For the initial recognition of most urinary tract anomalies we must be dependent upon the hospital pediatrician who sees the infant soon after birth, and upon the community pidiatricians or general practitioners who are responsible for family care and infant welfare clinics. In spite of all that has been written on the subject, it is regrettable how often one sees children whose urinary tract infections in infancy have been missed or treated without investigation by short courses of chemotherapy. It is true, of course, that an extensive programme of investigation will not only show up those in urgent need of treatment, but will also distinguish the many minor abnormalities which are of no importance or may correct themselves. There is thus a need for careful judgment in the selection of cases for surgery, as may be observed in the examples of posterior urethral valvular obstruction and in vesicoureteric reflux. External deformities also contribute an important requirement for surgery, and the long-term view required in pediatric urology may be well illustrated by considering the problem of exstrophy of the bladder. These children must be seen shortly after birth for rational planning of their treatment and for a full explanation to the parents even if definitive surgery is to be postponed. It has become clear over the years that a small proportion of these bladders, where the epithelium is healthy, the muscle active and the potential capacity adequate, are suitable for functional reconstruction with a fair prospect of continence. If the newborn child falls into this category, early surgical closure is advised: some surgeons prefer to perform an immediate operation, others are prepared to wait for a few weeks or months, but at this stage it is usually impossible to aim at sphincteric reconstruction or reflux prevention and the male urethra and bladder neck are therefore left open. Reflux is almost always a consequence of closure and can be dangerous if there is outflow obstruction; postoperative pyelograms are therefore essential. After three or four years the situation is reviewed: if the bladder capacity is good and active micturition is possible, a further procedure is undertaken to tighten the bladder neck and reimplant the ureters,
833
after which training for continence can begin. Once again, however, the condition of the upper tract must be watched and the sterility of the urine maintained. There will be some failures which will require subsequent diversion, and some children who will grow up with well-managed, though seldom normal, continence. For the poorly developed bladder, diversion offers the only hope of reasonable control, but this operation is seldom urgent and may well be postponed beyond infancy in order to assess the adequacy of the anal sphincter. In recent years, simple ureterosigmoidostomy has received renewed support after a period in which it was illregarded; success, however, depends on choosing a suitable case with normal ureters and a normal bowel, and on performing an anastomosis which is both unobstructed and valvular. Most of the established operative methods are capable of providing such a result if carefully performed, but as with reconstruction, follow up is essential and if reflux or obstruction are found, then the anastomosis must be revised. Usually this can be detected during the first six months, but late deterioration after ten to fifteen years is still possible and these children require continuous supervision. Biochemical disorders may be a problem but usually only in cases with unsatisfactory urinary drainage. Ileal conduit ureterostomy, which was originally regarded as a hazard-free alternative to ureterosigmoidostomy, has proved in the long term to have its disadvantages. Not only is the abdominal urinary stoma unwelcome to the adolescent or young adult, but late deterioration of renal function can be seen, sometimes due to stomal or ureteroileal obstruction, sometimes to chronic infection, sometimes perhaps to ileoureteric reflux. To avoid the last complication, the colonic conduit has become popular, since a reflux-preventing ureterocolic anastomosis can be constructed without difficulty. Some urologists prefer to perform a colonic conduit diversion in early infancy to ensure sterile urine during the period of maximum renal growth and then, later in childhood, when the stoma itself threatens psychological complications, to rejoin the conduit to the continuity of the colon. Others have attempted to use the anal sphincter to control two passages, urinary and fical, one an isolated rectal bladder and the other a pulledthrough colon. These procedures have a relatively high complication rate, however, and continence in both systems is seldom perfect so that they are now seldom performed in Britain or North America. In general it must be recognized that no diversion is perfect and that the child with exstrophy, whether reconstructed or diverted, requires life-long supervision. The problems of exstrophy are not, of course,
834
Proc. roy. Soc. Med. Volume 70 December 1977
confined to the urinary tract. The bony gap in the pelvis is seldom a difficulty from the orthopxdic point of view, but the abdominal wall requires reconstruction. Pelvic osteotomy may be performed to allow the pubes to be brought together, or rectus sheath flaps can be rotated inwards to secure an adequate linea alba. If the bladder is not to be preserved, however, its mucosa can be removed and the detrusor layer employed to fill the gap between the separated rectus muscles. Skin closure must ensure that the hair bearing areas, which are placed laterally over the separated pubic bones, are rotated inwards to provide a normal pubic appearance. In the male, reconstruction of the penis must secure correction of the upward chordee which results from the short urethral strip and the lateral displacement of the crura. It is now recognized that this can only be satisfactorily
attained by an extensive mobilization of the corpora cavernosa and skin replacement of the urethra. Inadequate operation in the past has left too many young men with exstrophy as sexual cripples, even though the genital tract from the verumontanum upwards is normal. In girls the vagina is short and anteriorly placed; it does not require specific treatment in childhood, but some enlargement of the introitus may be required at puberty. Menstruation and fertility are normal, but because of the short vagina and poorly developed pelvic floor, uterine prolapse may occur, particularly after pregnancy. Genital tract malformations, like those of the urinary tract, require attention through childhood into adult life. D INNES WILLIAMS
Dean of the Institute of Urology London WC2H 8JE
