- Email: [email protected]
A DISTURBING WEEK
1121 the shaft of a pin", and may be superficial or deeply placed; it is spindle shaped, lies in the line of the fibres of the muscle in question, and almost always affects the antigravity muscles. Spasm shuts off the blood-supply, preventing the removal of metabolites; until the circulation is restored, the pain and spasm persist. What is more, muscle in spasm can by itself give rise to referred pain. A patient with an acute stiff neck or severe lumbago may also feel pain radiating down the arm and forearm or down the anterolateral or posterior aspect of the thigh. In this event, if X-rays disclose lipping of vertebrae and narrowing of the disc spaces, it is all too easy to ascribe the pain to changes in the spine, which, as Mr. St Clair Strange says, are almost universal after middle age. Muscle spasm and radiating pain, it is true, may signify a prolapsed disc; but in the great majority of instances the disc is blameless. If the tender bundles in spasm have hyperxmia induced in them by deep friction and the application of warmth, without interference with the spinal column, the radiating pain will disappear along with the pain in the muscle-proof positive, according to Mr. St Clair Strange, that the pain in the distribution of radiation was referred and that spasm, and not root irritation, was the cause. Lumbosacral supports and other mechanical contraptions restrict the movement of muscles-the very opposite of what is needed. For Mr. St Clair Strange they are a " constant reminder to the patient’s spouse that the wearer must be excused any effort which is distasteful and a boon to the malingerer to enable him to evade any physical effort at work. Its possession is also a powerful inducement to the Ministry of Pensions Medical Boards that the owner is entitled, quite wrongly, to a disability pension for life." To tell the patient to avoid lifting and stooping, or to recommend the use of corsets and supports, is wrong. Graded exercises to strengthen the back muscles are much more to the point and are more likely to prevent recurrence of the spasm and pain. There will be outraged cries from some of Mr. St Clair Strange’s colleagues that what he is saying is not new, and protestations that the treatment he advocates is universal in well-managed orthopaedic clinics. No doubt this is so: few, however, will deny his assertion that far too many unnecessary operations are being undertaken to cure " slipped discs " when simpler methods are just as likely to succeed. Russell Howard’s injunction to his students not to forget to palpate the muscles of the back with as much care as they devote to the abdominal muscles still holds good.
one of the less fair aspects. If a man knows be both attack-free for a number of years and drug-free at the time of application, he will understandably be tempted to stop taking drugs, perhaps before this is medically advisable. Apart from variations in the interpretation of the words " do you suffer from epilepsy ?", another cause of discontent is the limitation of the right to appeal, since an applicant can appeal from a licensing " authority’s decision only if he has answered " no to the
emphasises he
THE EPILEPTIC DRIVER
expressed in the Divisional Court (see p. 1127) already re-firedthe debate on the granting of driving-licences to applicants with a history of epilepsy. The Lord Chief Justice said1 that anticonvulsant drugs "... prevent the disease from manifesting itself, but so long as they are necessary he must still be suffering from it." (In some ways this opinion is similar to that expressed in the judgment in the case of an airline pilot with diabetes controlled by diet alone, who had been refused a pilot’s licence.2) The situation has not changed since we noted earlier this year 3 how confused it was; and this recent judgment A VIEW
has
Times, Nov. 12. 2. Lancet, July 9, 1966, p. 101. 3. ibid. 1966, i, 1143. 1.
must
all-important question.4 Here is
a
situation where the medical issues
seem more
important than any legal argument; and we must ask again, as others have done,34 whether a magistrates’ court is the best arena in which to settle such questions.
A DISTURBING WEEK
THE surge of disquiet among hospital and university medical staffs was plain enough at meetings in London last week. The conference of hospital medical staffs at B.M.A. House on Nov. 9 heard sharp criticism of the new memorandum 5 on the ills of the hospital service and their cure. For the junior hospital doctors, Dr. Peter Scott spoke sadly of the gulf which separated them from those who guided their affairs and negotiated for them: changes in representation were essential. The provisions of the " charter " as it affected medical staffing and training would have to be recast if it was to meet the junior doctors’ needs adequately. They sought: a secure career structure; more time and means for postgraduate education (the proposed " associate registrar " non-training post was completely unacceptable); the revision of salary scales by the Review Body; and substantial improvements in the disgraceful conditions of service. But no-one supplied the answer to the basic dilemma in the reform of career structure-namely, how could security be offered to 4000 registrars when there were only about 2000 consultant posts to which they could succeed ? As Dr. T. Rowland Hill, chairman of the conference, put it, he had a distinct sensation of deja-vu. Prof. M. L. Rosenheim mentioned the proposal s to establish a small central committee (6 members from the universities and 6 from the colleges) to improve the administrative machinery of
postgraduate training. In his contribution to a discussion on impending constitutional changes in the representative machinery of the profession, Sir Robert Platt said the doctors had got to make up their minds whether they were going to have a Health Service or not: if they were, they should start with the idea of collaborating with the Government and not making an enemy of the Minister. The B.M.A. had negotiated through threats. When a financial concession was wanted, the technique was to build up indignation and grievances. " You have robbed the profession of most of its morale and self-esteem," Sir Robert declared, " and you have done a disservice to medicine which possibly can never be put right." Since Dr. D. H. Smith had earlier condemned the leaders of the B.M.A. for being "weak, insipid, and ineffective", the day was certainly one for plainer speaking than is usually heard in Tavistock
Square. On the same day over 150 members of the clinical academic staffs from the undergraduate and postgraduate 4. Br. med. J. 1966, i, 1536. 5. Br. med. J. Oct. 29, 1966, suppl. p. 171. See 6. See Lancet, Nov. 12, 1966, p. 1073.
Lancet, Nov. 5, 1966, p. 1016.
1122 medical and dental schools of the University of London met in the Senate House. Their purpose was to establish permanent machinery to enable all medical and dental school staff to be kept informed of administrative matters affecting them and their schools, and to place their opinions and influence at the disposal of the University authority. To this end, the meeting set up a permanent body to be known as London University Clinical Academic Staff. The strongest view to emerge from the meeting was that the Government’s delay in announcing and implementing new salary scales was having serious effects on recruitment and on retention of clinical academic staff. The basis of the salary structure, it was urged, should be that all holders of honorary consultant contracts and staff performing consultant duties should receive at least parity with their full-time N.H.S.
equivalents. Finally, on Nov. 12, a meeting of clinical academic staff from many of the medical schools in the United Kingdom agreed to set up an Association of Clinical Academic Staff, which would seek to become the negotiating body for wholetime university clinical, medical, and dental teachers. The new body would work closely with the B.M.A.
controls. Such abnormal responses might be exploited either as a diagnostic test or as a further experimental
technique. Mr. Lindsay Symon had been investigating the thorny question of cerebral arterial spasm. He had a technique for inducing traumatic vasospasm in exposed cortical vessels in the baboon, and this might serve as a model to observe the effects of drugs in provoking or alleviating spasm. 5-hydroxytryptamine had been without effect on vessel calibre, even though its antagonist, methysergide, seemed to relieve migraine occasionally in man. In fact, though vasospasm was the inferred cause of migraine, it had been shown to affect the intracerebral vessels only in patients who had had subarachnoid hxmorrhage. Vasospasm had been seen in 32 out of 86 arteriograms after subarachnoid hxmorrhage; it bore no clear relation to age; and it was commonest within twelve hours of bleeding, persisting for up to four weeks. Mr. Symon confessed that he had not seen such spasm cause migraine. Reviewing the effects of various drugs on blood-vessels,
Prof. J. M. Robson found " so much of the material irrelevant to migraine ". Neither 5-H.T. nor its lipidsoluble precursors caused migraine; nor was migraine common in carcinoid syndrome. Analysis of the drugs causing vasoconstriction and vasodilation disclosed little consistent pattern in the provocation or relief of migraine. Reserpine, which released noradrenaline and blocked its MIGRAINE into stores, sometimes provoked migraine; As Dr. Macdonald Critchley remarked at a Migraine reabsorption but the complexity of the subject was illustrated by the Trust symposium in London last week, migraine had the fact that slow infusions of noradrenaline relieved headache dubious honour of 2000 years’ of continuous study. Yet, while rapid infusions provoked it. In short, Professor with the exception of Harold Wolff’s pioneer work,l it Robson did not find the constriction and dilation hypowas the chastening (but perhaps appropriate) task of the thesis convincing. While some cases of migraine were Trust’s inaugural symposium to note the continuing associated with extracerebral arteriolar vasodilation and inadequacies of research, investigation, and treatment. certain drugs which could reverse this (such as ergotamine) Even a definition of migraine eluded the conference; and relieved migraine, more attention should be paid to factors Dr. Critchley remarked on the wide range between the affecting the intracerebral vessels. rigid textbook description (prodromal scotomas, fortificaDiscussing the connection between polypeptides and tion spectra, and scalp tenderness, ushering in vomiting vascular headache, Prof. C. A. Keele mentioned work on and hemicrania) and (the picture he preferred) a much pain induced by chemical agents applied to the exposed more protean disease, including any severe, episodic, and base of cantharidin blisters. Two observations might be predominantly unilateral headache which yielded to relevant to migraine. 5-H.T. was capable of provoking ergotamine. pain and also of sensitising tissues to pain induced by Assessing the value of radiological investigation, Dr. plasma kinins, such as bradykinin. These substances James Bull had found that the incidence of migraine in were themselves present in blister fluid and plasma, but patients with normal cerebral arteriograms and in those they required activation by clotting-factor xil. Fluid with angiomatous malformation was similar to that in the withdrawn from the proximity of painful temporal general population. In only a few of the patients with arteries during a migraine attack had kinin-like activity angioma was operation possible, and migraine was not and contained a kinin-producing enzyme. This led to the inevitably relieved. Radiography therefore had little to hypothesis that the process underlying migraine was an offer in diagnosis, although a single lateral film of the acute sterile inflammatory reaction with release of plasmaappropriate side was reassuring to patient and physician kinin, sensitising pain fibres in the vicinity of dilated and might reveal appearances characteristic of an angioma. blood-vessels. But steroids failed to relieve migraine; Arteriography was very rarely necessary, except in the and Prof. C. W. M. Adams and Dr. K. J. Zilkha reported presence of permanent hemisphere signs, a bruit, or an that temporal-artery biopsy in 3 patients during a migraine abnormal plain X-ray. A history of migraine alone, howattack showed histologically normal vessels. ever long or however firmly the headache was fixed to one Dr. J. N. Blau and his colleagues had examined the side, was not itself an indication. observation that may be provoked by fasting. Turning to the electrophysiological findings in migraine, Of 10 patients migraine who reported the association, 3 had Dr. H. R. A. Townsend discussed the concept of a commigraine during the experimental deprivation and 1 after mon constitutional E.E.G. dysrhythmia manifesting itself the fast had ended; but no biochemical abnormalities as epilepsy or migraine. The evidence was inconclusive coincided with the attacks. Nevertheless these findings and the few abnormalities detected might be secondary further researches into trigger mechanisms. rather than causal. A more fruitful line had been the may prompt
discovery of abnormalities evoked by stroboscopic flicker (the " H response) in most migraine patients but in few "
1.
Wolff,
H. Headache and Other Head Pains. New
York,
1963.
Prof. J. H. HUTCHISON has been appointed of Physicians and Surgeons of
Royal College
president of the Glasgow.
’
I ’
’
one of the less fair aspects. If a man knows be both attack-free for a number of years and drug-free at the time of application, he will understandably be tempted to stop taking drugs, perhaps before this is medically advisable. Apart from variations in the interpretation of the words " do you suffer from epilepsy ?", another cause of discontent is the limitation of the right to appeal, since an applicant can appeal from a licensing " authority’s decision only if he has answered " no to the
emphasises he
THE EPILEPTIC DRIVER
expressed in the Divisional Court (see p. 1127) already re-firedthe debate on the granting of driving-licences to applicants with a history of epilepsy. The Lord Chief Justice said1 that anticonvulsant drugs "... prevent the disease from manifesting itself, but so long as they are necessary he must still be suffering from it." (In some ways this opinion is similar to that expressed in the judgment in the case of an airline pilot with diabetes controlled by diet alone, who had been refused a pilot’s licence.2) The situation has not changed since we noted earlier this year 3 how confused it was; and this recent judgment A VIEW
has
Times, Nov. 12. 2. Lancet, July 9, 1966, p. 101. 3. ibid. 1966, i, 1143. 1.
must
all-important question.4 Here is
a
situation where the medical issues
seem more
important than any legal argument; and we must ask again, as others have done,34 whether a magistrates’ court is the best arena in which to settle such questions.
A DISTURBING WEEK
THE surge of disquiet among hospital and university medical staffs was plain enough at meetings in London last week. The conference of hospital medical staffs at B.M.A. House on Nov. 9 heard sharp criticism of the new memorandum 5 on the ills of the hospital service and their cure. For the junior hospital doctors, Dr. Peter Scott spoke sadly of the gulf which separated them from those who guided their affairs and negotiated for them: changes in representation were essential. The provisions of the " charter " as it affected medical staffing and training would have to be recast if it was to meet the junior doctors’ needs adequately. They sought: a secure career structure; more time and means for postgraduate education (the proposed " associate registrar " non-training post was completely unacceptable); the revision of salary scales by the Review Body; and substantial improvements in the disgraceful conditions of service. But no-one supplied the answer to the basic dilemma in the reform of career structure-namely, how could security be offered to 4000 registrars when there were only about 2000 consultant posts to which they could succeed ? As Dr. T. Rowland Hill, chairman of the conference, put it, he had a distinct sensation of deja-vu. Prof. M. L. Rosenheim mentioned the proposal s to establish a small central committee (6 members from the universities and 6 from the colleges) to improve the administrative machinery of
postgraduate training. In his contribution to a discussion on impending constitutional changes in the representative machinery of the profession, Sir Robert Platt said the doctors had got to make up their minds whether they were going to have a Health Service or not: if they were, they should start with the idea of collaborating with the Government and not making an enemy of the Minister. The B.M.A. had negotiated through threats. When a financial concession was wanted, the technique was to build up indignation and grievances. " You have robbed the profession of most of its morale and self-esteem," Sir Robert declared, " and you have done a disservice to medicine which possibly can never be put right." Since Dr. D. H. Smith had earlier condemned the leaders of the B.M.A. for being "weak, insipid, and ineffective", the day was certainly one for plainer speaking than is usually heard in Tavistock
Square. On the same day over 150 members of the clinical academic staffs from the undergraduate and postgraduate 4. Br. med. J. 1966, i, 1536. 5. Br. med. J. Oct. 29, 1966, suppl. p. 171. See 6. See Lancet, Nov. 12, 1966, p. 1073.
Lancet, Nov. 5, 1966, p. 1016.
1122 medical and dental schools of the University of London met in the Senate House. Their purpose was to establish permanent machinery to enable all medical and dental school staff to be kept informed of administrative matters affecting them and their schools, and to place their opinions and influence at the disposal of the University authority. To this end, the meeting set up a permanent body to be known as London University Clinical Academic Staff. The strongest view to emerge from the meeting was that the Government’s delay in announcing and implementing new salary scales was having serious effects on recruitment and on retention of clinical academic staff. The basis of the salary structure, it was urged, should be that all holders of honorary consultant contracts and staff performing consultant duties should receive at least parity with their full-time N.H.S.
equivalents. Finally, on Nov. 12, a meeting of clinical academic staff from many of the medical schools in the United Kingdom agreed to set up an Association of Clinical Academic Staff, which would seek to become the negotiating body for wholetime university clinical, medical, and dental teachers. The new body would work closely with the B.M.A.
controls. Such abnormal responses might be exploited either as a diagnostic test or as a further experimental
technique. Mr. Lindsay Symon had been investigating the thorny question of cerebral arterial spasm. He had a technique for inducing traumatic vasospasm in exposed cortical vessels in the baboon, and this might serve as a model to observe the effects of drugs in provoking or alleviating spasm. 5-hydroxytryptamine had been without effect on vessel calibre, even though its antagonist, methysergide, seemed to relieve migraine occasionally in man. In fact, though vasospasm was the inferred cause of migraine, it had been shown to affect the intracerebral vessels only in patients who had had subarachnoid hxmorrhage. Vasospasm had been seen in 32 out of 86 arteriograms after subarachnoid hxmorrhage; it bore no clear relation to age; and it was commonest within twelve hours of bleeding, persisting for up to four weeks. Mr. Symon confessed that he had not seen such spasm cause migraine. Reviewing the effects of various drugs on blood-vessels,
Prof. J. M. Robson found " so much of the material irrelevant to migraine ". Neither 5-H.T. nor its lipidsoluble precursors caused migraine; nor was migraine common in carcinoid syndrome. Analysis of the drugs causing vasoconstriction and vasodilation disclosed little consistent pattern in the provocation or relief of migraine. Reserpine, which released noradrenaline and blocked its MIGRAINE into stores, sometimes provoked migraine; As Dr. Macdonald Critchley remarked at a Migraine reabsorption but the complexity of the subject was illustrated by the Trust symposium in London last week, migraine had the fact that slow infusions of noradrenaline relieved headache dubious honour of 2000 years’ of continuous study. Yet, while rapid infusions provoked it. In short, Professor with the exception of Harold Wolff’s pioneer work,l it Robson did not find the constriction and dilation hypowas the chastening (but perhaps appropriate) task of the thesis convincing. While some cases of migraine were Trust’s inaugural symposium to note the continuing associated with extracerebral arteriolar vasodilation and inadequacies of research, investigation, and treatment. certain drugs which could reverse this (such as ergotamine) Even a definition of migraine eluded the conference; and relieved migraine, more attention should be paid to factors Dr. Critchley remarked on the wide range between the affecting the intracerebral vessels. rigid textbook description (prodromal scotomas, fortificaDiscussing the connection between polypeptides and tion spectra, and scalp tenderness, ushering in vomiting vascular headache, Prof. C. A. Keele mentioned work on and hemicrania) and (the picture he preferred) a much pain induced by chemical agents applied to the exposed more protean disease, including any severe, episodic, and base of cantharidin blisters. Two observations might be predominantly unilateral headache which yielded to relevant to migraine. 5-H.T. was capable of provoking ergotamine. pain and also of sensitising tissues to pain induced by Assessing the value of radiological investigation, Dr. plasma kinins, such as bradykinin. These substances James Bull had found that the incidence of migraine in were themselves present in blister fluid and plasma, but patients with normal cerebral arteriograms and in those they required activation by clotting-factor xil. Fluid with angiomatous malformation was similar to that in the withdrawn from the proximity of painful temporal general population. In only a few of the patients with arteries during a migraine attack had kinin-like activity angioma was operation possible, and migraine was not and contained a kinin-producing enzyme. This led to the inevitably relieved. Radiography therefore had little to hypothesis that the process underlying migraine was an offer in diagnosis, although a single lateral film of the acute sterile inflammatory reaction with release of plasmaappropriate side was reassuring to patient and physician kinin, sensitising pain fibres in the vicinity of dilated and might reveal appearances characteristic of an angioma. blood-vessels. But steroids failed to relieve migraine; Arteriography was very rarely necessary, except in the and Prof. C. W. M. Adams and Dr. K. J. Zilkha reported presence of permanent hemisphere signs, a bruit, or an that temporal-artery biopsy in 3 patients during a migraine abnormal plain X-ray. A history of migraine alone, howattack showed histologically normal vessels. ever long or however firmly the headache was fixed to one Dr. J. N. Blau and his colleagues had examined the side, was not itself an indication. observation that may be provoked by fasting. Turning to the electrophysiological findings in migraine, Of 10 patients migraine who reported the association, 3 had Dr. H. R. A. Townsend discussed the concept of a commigraine during the experimental deprivation and 1 after mon constitutional E.E.G. dysrhythmia manifesting itself the fast had ended; but no biochemical abnormalities as epilepsy or migraine. The evidence was inconclusive coincided with the attacks. Nevertheless these findings and the few abnormalities detected might be secondary further researches into trigger mechanisms. rather than causal. A more fruitful line had been the may prompt
discovery of abnormalities evoked by stroboscopic flicker (the " H response) in most migraine patients but in few "
1.
Wolff,
H. Headache and Other Head Pains. New
York,
1963.
Prof. J. H. HUTCHISON has been appointed of Physicians and Surgeons of
Royal College
president of the Glasgow.
’
I ’
’