- Email: [email protected]
France
95
promotion and in the development of health services closely integrated with other sectors of social development is desirable, yet remains, in large measure, as unsatisfactory as it was in 1948. Another theme that echoed through the corridors of power from before the inception of the NHS was the key role envisaged for health centres. Yet, throughout most of the period covered in Webster’s study, very little happened on the ground and, where it did, it was usually in terms of bricks and mortar rather than of bases to facilitate the establishment of multidisciplinary primary care teams; that was to come later. Similarly, the sadly run-down inheritance of capital stock at the beginning of the NHS was recognised, but the economic situation of the time allowed little to be done about it; and too much of that inheritance is still with us.
Many other topics of continuing interest are explored. These include the parts played by chairmen of health authorities who, incidentally, were appointed on a remarkably non-political basis by Bevan; proposals for
Round the World From
our
Correspondents
France EVALUATING HOMOEOPATHY
The trial of homoeopathy published in The Lancet of March 5 (p 528) was part of a programme that began in 1984. Complementary medicine has been a growth area in France in recent years. In April, 1984, the Academy of Medicine decided that the time was not ripe for the establishment of a diploma in homoeopathy and asked for placebo-controlled trials. In December of that year the Academy asked for the marketing of homoeopathic preparations to be subject to regulation. A year later Madame Georgina Dufoix, then the Minister of Social Affairs, announced a programme for alternative medicine. For homoeopathy this was to cover marketing, education, and clinical and biological research. The purchase of drugs would still be reimbursed by Social Security but the Ministry’s department of pharmacy and medication was asked to study ways of licensing homoeopathic preparations. A commission would be set up to prepare for a university diploma in homoeopathy. On the research side she asked for an evaluation of studies already done and for controlled trials to be set up. This last recommendation was well received by the Academy of Medicine but the first two were not, for the Academy wanted to see positive results of the evaluation first. The Minister immediately announced the setting up of a Foundation for the Study of Alternative Medicine, with a centre in Cannes, with 50 medical and 25 surgical beds. This decision was to have dire consequences. Madame Dufoix set up a working group to carry out rigorous clinical trials. This group, called GRECHO (Groupe de Recherches et d’Essais Cliniques en Homeopathie), had eight members: three were homoeopathic practitioners; one was a research worker acquainted with the principles of homoeopathy; and the other four were strictly neutral. GRECHO planned three trials to start with-on postoperative ileus, on the treatment of herpes, and on the prevention of recurrent ear-nose-and-throat disease in children. These last two trials fit established homoeopathic practices in that treatment takes the form of one or more remedies chosen on the basis of the personality of the patient and the way the symptoms have progressed with time. In such settings randomised trials are possible and protocols were drawn up. Meanwhile, because such trial designs were complex and onerous, it was decided to start with something simpler-namely, the return of bowel movement after surgery on the gut. In this situation homoeopathic remedies such as "opium" and "raphanus"
health service charges of various kinds and for limited drug lists; the first modest moves towards cost accountancy and the control of hospital medical establishments; distinction awards; proposals that hospital authorities should be empowered to raise loans; and last, but not least, Webster describes the political vacillation in grasping the nettle of the discovery of the causal relation between the smoking of tobacco and lung cancer in the early 1950s. No review can hope to do more than provide some hors d’oeuvres selected from the rich pabulum of fact and analysis contained in this book. It constitutes compulsive reading for anyone with an interest in a humane national institution of which Britain has every reason to be proud. I look forward with impatience to the publication of further volumes; and, if I could be granted a wish, it would be for some metaphysical adjustment of time whereby I could read the future tome dealing equally factually, analytically, and authoritatively, and in historical perspective, with recent developments in the National Health Service. Oving, Buckinghamshire JOHN REID
could be given at doses which were the same for every patient and without the complication of temporal progression. This treatment approach is unusual in homoeopathy but is allowed in certain cases, and the use in this way of raphanus and opium had already been subjected to three trials, of which two were randomised and double-blind. These trials had come out in favour of homoeopathy although there were serious doubts about the methodological design. Moreover, it was the homoeopathic practitioners in GRECHO who proposed this trial to the group. For this first trial (GRECHO 1) an agreement was signed between the Ministry and INSERM (Institut National de la Sante et de la Recherche Médica1e), relating to a randomised placebo controlled trial in four groups of 150 patients. The test products were made in July, 1985, by Laboratoires Boiron, near Lyon, this firm having been chosen by lot from a list of manufacturers. Representatives of GRECHO were present at the preparation of the trial material, together with the director of the laboratory for the control of medicaments at the Laboratoire National de la Sante. The management at Boiron accepted this control as "fair play". The tubes of granules were sealed and despatched to a central pharmacy, where the randomisation was done in the presence of a court officer. Twelve hospitals took part and the chiefs of service accepted the trial design and the restrictions-notably, visits without warning from a research-worker to see how the trial was going. Everyonehomoeopaths and non-homoeopaths, production laboratory, and surgeons-took part in the study in a spirit of collaboration seldom encountered before in a trial of homoeopathy. The trial began in October, 1985. In February, 1987, the protocol was published in Presse Medicale, and this included an undertaking to publish the results whether they were positive or negative (as the agreement had specified). The results were circulated to the participants in December, 1987, and everyone recognised that the evidence pointed to the absence of any significant effect of the homoeopathic preparations (with reservations about the extrapolation to homoeopathic practice in general). Everyone decided to keep quiet, to avoid a media debate before the data were published in an international journal. Once the Lancet letter appeared the expected furore began, with newspapers, radio, and television coverage that usually reduced the issue to the question-Homoeopathy, does it work or not? Le Monde’s story came under the heading "L’homeopathie inefficace", while Quotidien du Médecin opted for "Homeopathic: un proces bâc1é [slapdash]". Six days later Laboratoires Dolisos took a large advertisement in Le Monde with the heading "L’homeopathie est efficace" and providing a dossier of published references and referring to the millions of patients who used homoeopathy and, by implication, the thousands of doctors who prescribed it.
96 To go further than the restrained conclusion of this particular trial would require further studies, as GRECHO envisaged. However, GRECHO fell victim to politics for, in May, 1986, the government had changed and the new Minister of Social Affairs, Madame Michele Barzach, found in the file on alternative medicine a sensitive issue, which was the setting up in Cannes of an inpatient evaluation unit. The project had drawn several protests, including one from the governing council of the Centre Hospitalier Regional de Nice. As ever, a change in government meant a change in political
In England Now IN Spanish the word "Jubilacion" means retirement. I picture the newly retired GP dancing with delight and waving his stethoscope before putting it away for good. Etymological check shows that our "jubilation" comes from the Latin shout with joy, but "jubilee" has Greek and Hebrew antecedents indicating a festival of emancipation, or a time of indulgence after 50 years! So why did I retire when I still found myself bouncy, reasoning, and able to continue work for quite a while? I had believed (and said to anyone who could not avoid listening), for years, that the joy of general practice was constant surprise. One just did not know what was going to happen next. Each day brought new experience and new lessons. And then one morning, glooming over the appointments list, it struck me that surprises were no more. Everything had happened before. Try as I might to diversify, routine and repetition had set in. It was time to retire from the practice and to hunt for some other medical activity. Rejoicing certainly followed, but so did regret. I was sorry at walking out on so many patients who had become friends. I was elevated by their kind messages of farewell. I was moved by a small deputation bearing a large and gaudy card signed by all the district nurses and midwives. I received many other Happy Retirement cards, basically of two sorts. The one featured a male chauvinistic type relaxing in a hammock with all sorts of drinks alongside. The other showed the same sort of man protestingly coerced into some domestic job like washing up. Only one card was quite different. It came from a young Saudi Arabian patient. He had only recently entered Britain and was still trying to puzzle out our culture. The card pictured an ornate and golden key, with the message "Congratulations on your Coming of Age". Looking at my grey hairs, my wife commented: "He’s the only one who got it right". *
*
*
My peripatetic colleague’s comments on the naming of hospital wards (May 28) reminded me that ward names can sometimes lead to unwarranted anxiety. At my teaching hospital, one of the surgical wards had been endowed by the Shanghai Race Club, and it was called the Shanghai Race Club Ward in recognition of their largesse. The title was something of a mouthful, and so the ward was popularly referred to as "Shanghai". Towards the end of one wintry afternoon, an elderly woman was admitted to the ward from casualty with obstruction of the large bowel. By the time she had been operated on and returned to the ward the night staff were on duty. When the patient regained consciousness, though still groggy, she was sufficiently alert to ask "Where am I?" The reply "You’re quite alright, dear, you’re in Shanghai" would have been less confusing had the night nurse not been Chinese. Perhaps ward identification by letter and number has its merits after all. *
MY contributions to
*
*
victory in the last world war have not been
publicised, but by now there can be no harm in revealing them. I’ll start with the time the Navy investigated my spying activities. As a new surgeon-lieutenant RNVR I learned a lot the hard way. My first days in the destroyer coincided with a storm of such ferocity that, had there been no meteorological censorship, it would
direction, and public health was not spared. Research into alternative medicine, which had owed much of its development to the drive of Madame Dufoix, was no longer given the same priority; other matters, such as AIDS, seemed more urgent. The new Minister annulled the commitment to set up a research foundation. GRECHO, not without difficulty, completed the first trial but the protocols for the others now gather dust, rendering useless the time put in by research workers and putting an end to an unusual two-year collaboration.
news. Holding a basin and watching my possessions rolling about, I wondered on the quickest way out of the Navy. The marvellous relief of calm weather followed. The flotilla was moving into enemy waters with the mission to destroy German fuel depots on the coast of Norway The smooth beauty of the sea made a strange background for a successful shelling and the fires that followed. Pride of achievement filled the ship’s company. As soon as censorship restrictions were lifted we all wrote home with nautical pride. My brother, training in the RAF at home, responded with a crazy, ironic, epic poem, a caricature of my account, including sly comments on many of the ratings and officers. Of course the poem went up on the ship’s noticeboard, and was thoroughly enjoyed by everyone. With the poem came his letter telling me that he had mumps. "The MO orders me to rest quietly," he wrote. "Of course I shall do nothing of the sort. He is just fussing." I was alarmed, picturing the flaming orchitis which could hit a parotitic youth disobeying wise medical advice. I had to save him, and to thank him for his poem. On next shore leave I sent the following telegram: "Many thanks. Poem took ship by storm. Obey your orders. Orchids are valuable." He was a bright fellow and would
have made front page
understand. He did. Not so the Admiralty which intercepted the message. A week later the captain called me to his cabin. "Doc," he stated grimly, "if you have tears, prepare to shed them now." An immense dossier from the commanding Rear Admiral inquired what was hidden in the word "poem"?; what vessel had been taken by storm?; who had to obey what orders?; and what was the code meaning of "orchids"? It took an uncomfortable half hour to convince the captain, who remained unamused. My task now, he ordered, was to augment his report by sending, in an official manner, a complete account of my behaviour. It was thus that, early in my Naval career, I corresponded with a Rear Admiral. That day was spent penning a formal letter in triplicate. Between the opening "Sir, I have the honour to submit" and the signing off "I have the honour to be, Sir, your obedient servant" I wrote in triplicate protocol the tale of my brother’s testicles. *
*
*
13 years after my retirement, it was exciting to revisit the general I had singlehandedly created. An infected sebaceous cyst on my back was medically uninteresting (except to me). But it brought me to consult my doctor, previously the junior of my two young partners and now the principal of the firm. He managed my small problem with reassuring expertise, which went well with the slight expanse of his figure and the sprinkling of grey in his hair. It was delightful to see that after so long the practice seemed virtually unaltered. The clinical record cards I had devised were still in use; the meticulously chosen furnishings were as before; even the special wallpaper and pictures had not changed; and the expensive baby-weighing machine continued to serve well. I noted the familiar parquet flooring, the old appointments system, the well-designed desk, the visits register, the smart signal lights in the waiting room. Everything had been part of my planning. With quiet pride I could see that my influence was still strong. As I walked out, feeling considerably taller, the receptionist looked up, puzzled. She asked, "Weren’t you once employed here for a little while?", I replied, "Yes ... came twice a week to polish the floors," and shuffled out, cut down to size.
practice
promotion and in the development of health services closely integrated with other sectors of social development is desirable, yet remains, in large measure, as unsatisfactory as it was in 1948. Another theme that echoed through the corridors of power from before the inception of the NHS was the key role envisaged for health centres. Yet, throughout most of the period covered in Webster’s study, very little happened on the ground and, where it did, it was usually in terms of bricks and mortar rather than of bases to facilitate the establishment of multidisciplinary primary care teams; that was to come later. Similarly, the sadly run-down inheritance of capital stock at the beginning of the NHS was recognised, but the economic situation of the time allowed little to be done about it; and too much of that inheritance is still with us.
Many other topics of continuing interest are explored. These include the parts played by chairmen of health authorities who, incidentally, were appointed on a remarkably non-political basis by Bevan; proposals for
Round the World From
our
Correspondents
France EVALUATING HOMOEOPATHY
The trial of homoeopathy published in The Lancet of March 5 (p 528) was part of a programme that began in 1984. Complementary medicine has been a growth area in France in recent years. In April, 1984, the Academy of Medicine decided that the time was not ripe for the establishment of a diploma in homoeopathy and asked for placebo-controlled trials. In December of that year the Academy asked for the marketing of homoeopathic preparations to be subject to regulation. A year later Madame Georgina Dufoix, then the Minister of Social Affairs, announced a programme for alternative medicine. For homoeopathy this was to cover marketing, education, and clinical and biological research. The purchase of drugs would still be reimbursed by Social Security but the Ministry’s department of pharmacy and medication was asked to study ways of licensing homoeopathic preparations. A commission would be set up to prepare for a university diploma in homoeopathy. On the research side she asked for an evaluation of studies already done and for controlled trials to be set up. This last recommendation was well received by the Academy of Medicine but the first two were not, for the Academy wanted to see positive results of the evaluation first. The Minister immediately announced the setting up of a Foundation for the Study of Alternative Medicine, with a centre in Cannes, with 50 medical and 25 surgical beds. This decision was to have dire consequences. Madame Dufoix set up a working group to carry out rigorous clinical trials. This group, called GRECHO (Groupe de Recherches et d’Essais Cliniques en Homeopathie), had eight members: three were homoeopathic practitioners; one was a research worker acquainted with the principles of homoeopathy; and the other four were strictly neutral. GRECHO planned three trials to start with-on postoperative ileus, on the treatment of herpes, and on the prevention of recurrent ear-nose-and-throat disease in children. These last two trials fit established homoeopathic practices in that treatment takes the form of one or more remedies chosen on the basis of the personality of the patient and the way the symptoms have progressed with time. In such settings randomised trials are possible and protocols were drawn up. Meanwhile, because such trial designs were complex and onerous, it was decided to start with something simpler-namely, the return of bowel movement after surgery on the gut. In this situation homoeopathic remedies such as "opium" and "raphanus"
health service charges of various kinds and for limited drug lists; the first modest moves towards cost accountancy and the control of hospital medical establishments; distinction awards; proposals that hospital authorities should be empowered to raise loans; and last, but not least, Webster describes the political vacillation in grasping the nettle of the discovery of the causal relation between the smoking of tobacco and lung cancer in the early 1950s. No review can hope to do more than provide some hors d’oeuvres selected from the rich pabulum of fact and analysis contained in this book. It constitutes compulsive reading for anyone with an interest in a humane national institution of which Britain has every reason to be proud. I look forward with impatience to the publication of further volumes; and, if I could be granted a wish, it would be for some metaphysical adjustment of time whereby I could read the future tome dealing equally factually, analytically, and authoritatively, and in historical perspective, with recent developments in the National Health Service. Oving, Buckinghamshire JOHN REID
could be given at doses which were the same for every patient and without the complication of temporal progression. This treatment approach is unusual in homoeopathy but is allowed in certain cases, and the use in this way of raphanus and opium had already been subjected to three trials, of which two were randomised and double-blind. These trials had come out in favour of homoeopathy although there were serious doubts about the methodological design. Moreover, it was the homoeopathic practitioners in GRECHO who proposed this trial to the group. For this first trial (GRECHO 1) an agreement was signed between the Ministry and INSERM (Institut National de la Sante et de la Recherche Médica1e), relating to a randomised placebo controlled trial in four groups of 150 patients. The test products were made in July, 1985, by Laboratoires Boiron, near Lyon, this firm having been chosen by lot from a list of manufacturers. Representatives of GRECHO were present at the preparation of the trial material, together with the director of the laboratory for the control of medicaments at the Laboratoire National de la Sante. The management at Boiron accepted this control as "fair play". The tubes of granules were sealed and despatched to a central pharmacy, where the randomisation was done in the presence of a court officer. Twelve hospitals took part and the chiefs of service accepted the trial design and the restrictions-notably, visits without warning from a research-worker to see how the trial was going. Everyonehomoeopaths and non-homoeopaths, production laboratory, and surgeons-took part in the study in a spirit of collaboration seldom encountered before in a trial of homoeopathy. The trial began in October, 1985. In February, 1987, the protocol was published in Presse Medicale, and this included an undertaking to publish the results whether they were positive or negative (as the agreement had specified). The results were circulated to the participants in December, 1987, and everyone recognised that the evidence pointed to the absence of any significant effect of the homoeopathic preparations (with reservations about the extrapolation to homoeopathic practice in general). Everyone decided to keep quiet, to avoid a media debate before the data were published in an international journal. Once the Lancet letter appeared the expected furore began, with newspapers, radio, and television coverage that usually reduced the issue to the question-Homoeopathy, does it work or not? Le Monde’s story came under the heading "L’homeopathie inefficace", while Quotidien du Médecin opted for "Homeopathic: un proces bâc1é [slapdash]". Six days later Laboratoires Dolisos took a large advertisement in Le Monde with the heading "L’homeopathie est efficace" and providing a dossier of published references and referring to the millions of patients who used homoeopathy and, by implication, the thousands of doctors who prescribed it.
96 To go further than the restrained conclusion of this particular trial would require further studies, as GRECHO envisaged. However, GRECHO fell victim to politics for, in May, 1986, the government had changed and the new Minister of Social Affairs, Madame Michele Barzach, found in the file on alternative medicine a sensitive issue, which was the setting up in Cannes of an inpatient evaluation unit. The project had drawn several protests, including one from the governing council of the Centre Hospitalier Regional de Nice. As ever, a change in government meant a change in political
In England Now IN Spanish the word "Jubilacion" means retirement. I picture the newly retired GP dancing with delight and waving his stethoscope before putting it away for good. Etymological check shows that our "jubilation" comes from the Latin shout with joy, but "jubilee" has Greek and Hebrew antecedents indicating a festival of emancipation, or a time of indulgence after 50 years! So why did I retire when I still found myself bouncy, reasoning, and able to continue work for quite a while? I had believed (and said to anyone who could not avoid listening), for years, that the joy of general practice was constant surprise. One just did not know what was going to happen next. Each day brought new experience and new lessons. And then one morning, glooming over the appointments list, it struck me that surprises were no more. Everything had happened before. Try as I might to diversify, routine and repetition had set in. It was time to retire from the practice and to hunt for some other medical activity. Rejoicing certainly followed, but so did regret. I was sorry at walking out on so many patients who had become friends. I was elevated by their kind messages of farewell. I was moved by a small deputation bearing a large and gaudy card signed by all the district nurses and midwives. I received many other Happy Retirement cards, basically of two sorts. The one featured a male chauvinistic type relaxing in a hammock with all sorts of drinks alongside. The other showed the same sort of man protestingly coerced into some domestic job like washing up. Only one card was quite different. It came from a young Saudi Arabian patient. He had only recently entered Britain and was still trying to puzzle out our culture. The card pictured an ornate and golden key, with the message "Congratulations on your Coming of Age". Looking at my grey hairs, my wife commented: "He’s the only one who got it right". *
*
*
My peripatetic colleague’s comments on the naming of hospital wards (May 28) reminded me that ward names can sometimes lead to unwarranted anxiety. At my teaching hospital, one of the surgical wards had been endowed by the Shanghai Race Club, and it was called the Shanghai Race Club Ward in recognition of their largesse. The title was something of a mouthful, and so the ward was popularly referred to as "Shanghai". Towards the end of one wintry afternoon, an elderly woman was admitted to the ward from casualty with obstruction of the large bowel. By the time she had been operated on and returned to the ward the night staff were on duty. When the patient regained consciousness, though still groggy, she was sufficiently alert to ask "Where am I?" The reply "You’re quite alright, dear, you’re in Shanghai" would have been less confusing had the night nurse not been Chinese. Perhaps ward identification by letter and number has its merits after all. *
MY contributions to
*
*
victory in the last world war have not been
publicised, but by now there can be no harm in revealing them. I’ll start with the time the Navy investigated my spying activities. As a new surgeon-lieutenant RNVR I learned a lot the hard way. My first days in the destroyer coincided with a storm of such ferocity that, had there been no meteorological censorship, it would
direction, and public health was not spared. Research into alternative medicine, which had owed much of its development to the drive of Madame Dufoix, was no longer given the same priority; other matters, such as AIDS, seemed more urgent. The new Minister annulled the commitment to set up a research foundation. GRECHO, not without difficulty, completed the first trial but the protocols for the others now gather dust, rendering useless the time put in by research workers and putting an end to an unusual two-year collaboration.
news. Holding a basin and watching my possessions rolling about, I wondered on the quickest way out of the Navy. The marvellous relief of calm weather followed. The flotilla was moving into enemy waters with the mission to destroy German fuel depots on the coast of Norway The smooth beauty of the sea made a strange background for a successful shelling and the fires that followed. Pride of achievement filled the ship’s company. As soon as censorship restrictions were lifted we all wrote home with nautical pride. My brother, training in the RAF at home, responded with a crazy, ironic, epic poem, a caricature of my account, including sly comments on many of the ratings and officers. Of course the poem went up on the ship’s noticeboard, and was thoroughly enjoyed by everyone. With the poem came his letter telling me that he had mumps. "The MO orders me to rest quietly," he wrote. "Of course I shall do nothing of the sort. He is just fussing." I was alarmed, picturing the flaming orchitis which could hit a parotitic youth disobeying wise medical advice. I had to save him, and to thank him for his poem. On next shore leave I sent the following telegram: "Many thanks. Poem took ship by storm. Obey your orders. Orchids are valuable." He was a bright fellow and would
have made front page
understand. He did. Not so the Admiralty which intercepted the message. A week later the captain called me to his cabin. "Doc," he stated grimly, "if you have tears, prepare to shed them now." An immense dossier from the commanding Rear Admiral inquired what was hidden in the word "poem"?; what vessel had been taken by storm?; who had to obey what orders?; and what was the code meaning of "orchids"? It took an uncomfortable half hour to convince the captain, who remained unamused. My task now, he ordered, was to augment his report by sending, in an official manner, a complete account of my behaviour. It was thus that, early in my Naval career, I corresponded with a Rear Admiral. That day was spent penning a formal letter in triplicate. Between the opening "Sir, I have the honour to submit" and the signing off "I have the honour to be, Sir, your obedient servant" I wrote in triplicate protocol the tale of my brother’s testicles. *
*
*
13 years after my retirement, it was exciting to revisit the general I had singlehandedly created. An infected sebaceous cyst on my back was medically uninteresting (except to me). But it brought me to consult my doctor, previously the junior of my two young partners and now the principal of the firm. He managed my small problem with reassuring expertise, which went well with the slight expanse of his figure and the sprinkling of grey in his hair. It was delightful to see that after so long the practice seemed virtually unaltered. The clinical record cards I had devised were still in use; the meticulously chosen furnishings were as before; even the special wallpaper and pictures had not changed; and the expensive baby-weighing machine continued to serve well. I noted the familiar parquet flooring, the old appointments system, the well-designed desk, the visits register, the smart signal lights in the waiting room. Everything had been part of my planning. With quiet pride I could see that my influence was still strong. As I walked out, feeling considerably taller, the receptionist looked up, puzzled. She asked, "Weren’t you once employed here for a little while?", I replied, "Yes ... came twice a week to polish the floors," and shuffled out, cut down to size.
practice