- Email: [email protected]
FAMILY PLANNING IN THE N.H.S.
1350
early life, and their siblings who had had no such illness, suggested that the differences previous investigators had found between well and poorly nourished groups could be accounted for by the independent operation of other children who had kwashiorkor in
adverse factors in the social and emotional environment. It is to be hoped that a paired-sibling study at present under way in Bogota, Colombia,14 expressly designed with careful statistical techniques to separate nutritional effects acting alone, if they exist, from the numerous other variables which have dogged previous studies, will succeed. In any event, as VON MURALT1 points out, though this critical attitude to whether such malnutrition of itself really does cause mental retardation in man or not is to be welcomed as a stimulus to further research, the basic problem of the sum of malnutrition, poverty in its widest emotional, cultural, and physical sense, and disease in certain countries remains. We are on more certain ground in supposing that some harm to the developing human brain results from inadequate nutrition in the second half of pregnancy, for this is when the velocity of the growth spurt is at its height. Though all the factors influencing growth in and out of the uterus can never be identical for any two children, perhaps it is possible to come closest to perfection of control with monozygous twins. Those weighing 25% less than their twin at birth have a significantly smaller head size and intelligence quotient later,15 though even here the possibility exists of a less favoured postnatal environment for the smaller twin. Other small-for-dates infants of very low birth-weight are known to include a disproportionate number with a small head at later follow-up.16 Furthermore, inadequate nutrition after very immature birth has the same effect,16 and in previous follow-up studies of low-birth-weight babies a direct association between later intelligence and weight at birth has been found." It is hoped that more liberal feeding in the first weeks of life, and further conservation of calorie expenditure for
environment, growth by providing suitably will continue to improve matters for this small group of infants. An inappropriately low birthweight for gestational age occurs much more commonly in those countries where childhood a
warm
malnutrition is also common, and the two may be closely linked. The role of lipids in brain development was discussed in detail at the Ciba symposium. One of the most interesting contributions was that of CRAWFORD and SINCLAIR,18 who presented evidence 14. Cobos, F. in
Lipids, Malnutrition and the Developing Brain;
p. 227. Amsterdam, 1972. 15. Babson, S. G., Kangas, J., Young, N., Bramhall, J. L. Pediatrics,
Springfield, 1964, 33, 327. Davies, P. A., Davis, J. P. Lancet, 1970, ii, 1216. Wiener, G., Rider, R. V., Oppel, W. C., Harper, P. A. Pediat. Res. 1968, 2, 110. 18. Crawford, M. A., Sinclair, A. J. in Lipids, Malnutrition and the Developing Brain; p. 267. Amsterdam, 1972. 16. 17.
that the attributes of the nervous system in land mammals were closely correlated with the availability of various lipid nutrients. In comparative studies of herbivores and carnivores they demonstrated that, while different mammals showed wide variations in the polyunsaturated fatty acids of liver lipids, and in brain size, the ratios of brain fatty acids, as judged by analysis of ethanolamine phosphoglycerides from grey matter, were remarkably The ability to synthesise and oxidise constant. was present in all species, and they suggested lipids that the closer the ingested lipids were to those of the brain, the greater the potential for development. They speculate that high-protein feeds may lead to lipid synthesis becoming out of phase with protein synthesis, with qualitative changes in the development of the nervous system. This has relevance both for low-birth-weight babies and for children with kwashiorkor who may be treated in this way. As breast-feeding becomes less and less the custom, we may also do well to reflect that the essential-fattyacid content of human milk is three times greater than that of cow’s milk.19
suggesting
FAMILY PLANNING IN THE N.H.S. THE statement in the House of Commons
on
Dec. 12
by Sir Keith Joseph, Secretary of State for Social Services, on family planning, was greeted with scant enthusiasm in the short time available for its discussion. It may be debated later. As it was, Sir Keith’s proposals met such strictures as " totally " " inadequate and very disappointing ". Yet he and his colleagues for Scotland and Wales had decided on " a substantial expansion in N.H.S. family-planning services which was expected to push annual expenditure up to £12 million over the next four years (current "
family-planning costs are about E4 million a year). This E12 million, Sir Keith added, was more than half the estimated cost of a totally free service for all who wished it " which I do not accept is necessary ". If it comes to a fuller debate, many members will at the chance to argue again that a totally free service is indeed necessary-and overdue. The new proposals provide for a comprehensive service of family-planning advice " readily available free of charge to all who wish to have it " from April, 1974, when the reformed National Health Service authorities are timed to assume their responsibilities. More clinics, more easily accessible, and an expansion of domiciliary services are welcome; but unless the free advice is followed by free supplies the old deterrent will operate. The Government sees some answer to this criticism in the provision of free supplies for those who have special social and financial needs and in a new category for automatic exemption from charges for family-planning supplies-women who have had a baby or an abortion within the previous
jump
19. Mellander, O., Vahlquist, B., Mellbin, T. Acta pœdiat. scand.
1959, 48, suppl. 116, p. 31.
1351
twelve months. " Apart from these, people with a medical need will pay no more than the standard prescription charge. Others will pay the full cost of It is hard to see a big deal here, their supplies." since many local authorities already offer more of a free service than this in their own clinics or through the Family Planning Association under one of the It is to be hoped that such free agency schemes. local-authority services are not to be restricted to conform with pay and non-pay groups as outlined in Sir Keith’s statement. The Government is treading cautiously in the area of family-planning services provided by general practitioners. Sir Keith proposes " to enter into discussions with the medical and pharmaceutical professions to see whether satisfactory arrangements can be agreed with them under which the fees which general practitioners may at present charge National Health Service patients who have no health reasons for avoiding pregnancy, for the work of prescribing the pill or the fitting of an appliance, can be replaced by appropriate remuneration from official sources ". The pity here is that such an arrangement acquiesces in the continued setting apart of family planning in the general-practitioner services. The time is long past when such guidance should be accepted as a normal part of the family doctor’s help not as something extra and special.
MYOCARDIAL SARCOIDOSIS SARCOIDOSIS—a multisystem granulomatous disorder of unknown cause-predominantly affects lungs, reticuloendothelial system, eyes, and skin. Central nervous system, heart, bone, and salivary glands 1 Siltzbachbelieves are only occasionally affected. that myocardial localisation produces significant symptoms in less than 5% of patients, although at necropsy cardiac lesions are found in as many as 20%. This discrepancy stems from the difficulty in recognising myocardial sarcoidosis in life. Heart involvement is suspected when a patient with pulmonary, ocular, or cutaneous sarcoidosis develops cardiac arrhythmia or bundle-branch block. Although this evidence is only circumstantial, it is a cue for a therapeutic trial of corticosteroids, to see whether the
arrhythmia
or
electrocardiographic abnormality
can
be corrected. Ghosh and his colleagues3 have lately analysed a series in which 4 of their 6 patients died suddenly and unexpectedly, usually with no suspicion of myocardial involvement clinically. Current clinical patterns of sarcoidosis correspond only to the visible and obvious components: deep digging is needed to uncover latent forms of the disease. This is what Siltzbach and his colleagues* have been doing at the Mount Sinai Hospital, New 1.
James, D. G., Siltzbach, L. E., Sharma, O. P., Carstairs, L. S. Archs intern. Med. 1969, 123, 187. 2. Siltzbach, L. E. in Current Diagnosis (edited by H. & R. Conn); p. 935. Philadelphia, 1968. 3. Ghosh, P., Fleming, H. A., Gresham, G. A., Stovin, P. G. I. Br. Heart J. 1972, 34, 769. 4. Stein, E., Jackler, I., Stein, W., Stimmal, B., Siltzbach, L. E. Trans. VI int. Conf. Sarcoidosis (in the press).
York City, and also Mikhail and his co-workers5 in London; both groups have surveyed their sarcoidosis patients by electrocardiography and other means and noted a surprisingly high incidence of abnormalities. The results of these two surveys were reported at the Sixth International Conference on Sarcoidosis held At the Mount Sinai in September in Tokyo. Hospital, 80 patients with histologically confirmed sarcoidosis but without cardiac complaints had routine electrocardiographs, and half of these were abnormal; there were changes of conduction or rhythm, ST deviations, or T-wave changes. Factors such as sex, chronicity, or corticosteroid therapy did not seem to influence the frequency of E.C.G. changes. Prospective investigations are in progress to determine which of the symptomless E.c.G. abnormalities in sarcoidosis patients may represent precursors or more serious and potentially dangerous sarcoidosis. At Central Middlesex Hospital, London, 14 of 147 histologically confirmed sarcoidosis patients were found to have abnormal E.C.G. changes.5 In 11 patients, the E.C.G. showed a changing pattern coinciding with resolution of the sarcoidosis, suggesting myocardial involvement by sarcoidosis. The presence of cardiac involvement in about 10% of sarcoidosis patients will not only stimulate increased awareness in clinicians but also lead to further work on unravelling the discrepancy between clinical and necropsy evidence of cardiac involvement.
DEATHS FROM DOMESTIC FALLS
THE increasing fragility of bone in the elderly and the liability of elderly patients to succumb to fractures, particularly of the proximal femur, contribute considerably to mortality-and morbidity in the older agegroups. There are two sides to this problem. Investigations of osteomalacia and osteoporosis6 throw light on the intrinsic cause; but the extrinsic factors - the increased liability of the old to fall 7--also need careful consideration. In an interesting paper, Eddy8 has reviewed the statistics of fractures and falls in the old and analysed the comparative mortality figures in different age-groups and the secular trends in mortality between 1900 and 1968 for these conditions. Fractures of the femoral neck, of the upper part of the humerus, and of the Pott’s and Colles’ type show a similar age and sex incidence. This increases sharply over the age of 55 and is about 2-3 times greater in elderly women than in elderly men."9 Fractures of this kind have been described as the post-wage-earning fracture panem.10 A similar age and sex incidence has been described in osteoporosis. 11 Falls, particularly at home, are the most common accidents in the elderly with the highest rate of accidental death. Fractures, Mitchell, D. N., Ball, K. P. ibid. Lancet, 1972, i, 1059. Sheldon, J. H. Br. med. J. 1960, ii, 1685. Eddy, T. P. Br. J. prev. soc. Med. 1972, 26, 173. Knowelden, J., Buhr, A. J., Dunbar, O. ibid. 1964, 18, 130. Buhr, A. J., Cooke, A. M. Lancer, 1959, i, 531. Nordin, B. E. C., MacGregor, J., Smith, D. A. Q. Jl Med. 1966, 35,
5. Mikhail, J. L., 6.
7. 8. 9. 10. 11.
25.
early life, and their siblings who had had no such illness, suggested that the differences previous investigators had found between well and poorly nourished groups could be accounted for by the independent operation of other children who had kwashiorkor in
adverse factors in the social and emotional environment. It is to be hoped that a paired-sibling study at present under way in Bogota, Colombia,14 expressly designed with careful statistical techniques to separate nutritional effects acting alone, if they exist, from the numerous other variables which have dogged previous studies, will succeed. In any event, as VON MURALT1 points out, though this critical attitude to whether such malnutrition of itself really does cause mental retardation in man or not is to be welcomed as a stimulus to further research, the basic problem of the sum of malnutrition, poverty in its widest emotional, cultural, and physical sense, and disease in certain countries remains. We are on more certain ground in supposing that some harm to the developing human brain results from inadequate nutrition in the second half of pregnancy, for this is when the velocity of the growth spurt is at its height. Though all the factors influencing growth in and out of the uterus can never be identical for any two children, perhaps it is possible to come closest to perfection of control with monozygous twins. Those weighing 25% less than their twin at birth have a significantly smaller head size and intelligence quotient later,15 though even here the possibility exists of a less favoured postnatal environment for the smaller twin. Other small-for-dates infants of very low birth-weight are known to include a disproportionate number with a small head at later follow-up.16 Furthermore, inadequate nutrition after very immature birth has the same effect,16 and in previous follow-up studies of low-birth-weight babies a direct association between later intelligence and weight at birth has been found." It is hoped that more liberal feeding in the first weeks of life, and further conservation of calorie expenditure for
environment, growth by providing suitably will continue to improve matters for this small group of infants. An inappropriately low birthweight for gestational age occurs much more commonly in those countries where childhood a
warm
malnutrition is also common, and the two may be closely linked. The role of lipids in brain development was discussed in detail at the Ciba symposium. One of the most interesting contributions was that of CRAWFORD and SINCLAIR,18 who presented evidence 14. Cobos, F. in
Lipids, Malnutrition and the Developing Brain;
p. 227. Amsterdam, 1972. 15. Babson, S. G., Kangas, J., Young, N., Bramhall, J. L. Pediatrics,
Springfield, 1964, 33, 327. Davies, P. A., Davis, J. P. Lancet, 1970, ii, 1216. Wiener, G., Rider, R. V., Oppel, W. C., Harper, P. A. Pediat. Res. 1968, 2, 110. 18. Crawford, M. A., Sinclair, A. J. in Lipids, Malnutrition and the Developing Brain; p. 267. Amsterdam, 1972. 16. 17.
that the attributes of the nervous system in land mammals were closely correlated with the availability of various lipid nutrients. In comparative studies of herbivores and carnivores they demonstrated that, while different mammals showed wide variations in the polyunsaturated fatty acids of liver lipids, and in brain size, the ratios of brain fatty acids, as judged by analysis of ethanolamine phosphoglycerides from grey matter, were remarkably The ability to synthesise and oxidise constant. was present in all species, and they suggested lipids that the closer the ingested lipids were to those of the brain, the greater the potential for development. They speculate that high-protein feeds may lead to lipid synthesis becoming out of phase with protein synthesis, with qualitative changes in the development of the nervous system. This has relevance both for low-birth-weight babies and for children with kwashiorkor who may be treated in this way. As breast-feeding becomes less and less the custom, we may also do well to reflect that the essential-fattyacid content of human milk is three times greater than that of cow’s milk.19
suggesting
FAMILY PLANNING IN THE N.H.S. THE statement in the House of Commons
on
Dec. 12
by Sir Keith Joseph, Secretary of State for Social Services, on family planning, was greeted with scant enthusiasm in the short time available for its discussion. It may be debated later. As it was, Sir Keith’s proposals met such strictures as " totally " " inadequate and very disappointing ". Yet he and his colleagues for Scotland and Wales had decided on " a substantial expansion in N.H.S. family-planning services which was expected to push annual expenditure up to £12 million over the next four years (current "
family-planning costs are about E4 million a year). This E12 million, Sir Keith added, was more than half the estimated cost of a totally free service for all who wished it " which I do not accept is necessary ". If it comes to a fuller debate, many members will at the chance to argue again that a totally free service is indeed necessary-and overdue. The new proposals provide for a comprehensive service of family-planning advice " readily available free of charge to all who wish to have it " from April, 1974, when the reformed National Health Service authorities are timed to assume their responsibilities. More clinics, more easily accessible, and an expansion of domiciliary services are welcome; but unless the free advice is followed by free supplies the old deterrent will operate. The Government sees some answer to this criticism in the provision of free supplies for those who have special social and financial needs and in a new category for automatic exemption from charges for family-planning supplies-women who have had a baby or an abortion within the previous
jump
19. Mellander, O., Vahlquist, B., Mellbin, T. Acta pœdiat. scand.
1959, 48, suppl. 116, p. 31.
1351
twelve months. " Apart from these, people with a medical need will pay no more than the standard prescription charge. Others will pay the full cost of It is hard to see a big deal here, their supplies." since many local authorities already offer more of a free service than this in their own clinics or through the Family Planning Association under one of the It is to be hoped that such free agency schemes. local-authority services are not to be restricted to conform with pay and non-pay groups as outlined in Sir Keith’s statement. The Government is treading cautiously in the area of family-planning services provided by general practitioners. Sir Keith proposes " to enter into discussions with the medical and pharmaceutical professions to see whether satisfactory arrangements can be agreed with them under which the fees which general practitioners may at present charge National Health Service patients who have no health reasons for avoiding pregnancy, for the work of prescribing the pill or the fitting of an appliance, can be replaced by appropriate remuneration from official sources ". The pity here is that such an arrangement acquiesces in the continued setting apart of family planning in the general-practitioner services. The time is long past when such guidance should be accepted as a normal part of the family doctor’s help not as something extra and special.
MYOCARDIAL SARCOIDOSIS SARCOIDOSIS—a multisystem granulomatous disorder of unknown cause-predominantly affects lungs, reticuloendothelial system, eyes, and skin. Central nervous system, heart, bone, and salivary glands 1 Siltzbachbelieves are only occasionally affected. that myocardial localisation produces significant symptoms in less than 5% of patients, although at necropsy cardiac lesions are found in as many as 20%. This discrepancy stems from the difficulty in recognising myocardial sarcoidosis in life. Heart involvement is suspected when a patient with pulmonary, ocular, or cutaneous sarcoidosis develops cardiac arrhythmia or bundle-branch block. Although this evidence is only circumstantial, it is a cue for a therapeutic trial of corticosteroids, to see whether the
arrhythmia
or
electrocardiographic abnormality
can
be corrected. Ghosh and his colleagues3 have lately analysed a series in which 4 of their 6 patients died suddenly and unexpectedly, usually with no suspicion of myocardial involvement clinically. Current clinical patterns of sarcoidosis correspond only to the visible and obvious components: deep digging is needed to uncover latent forms of the disease. This is what Siltzbach and his colleagues* have been doing at the Mount Sinai Hospital, New 1.
James, D. G., Siltzbach, L. E., Sharma, O. P., Carstairs, L. S. Archs intern. Med. 1969, 123, 187. 2. Siltzbach, L. E. in Current Diagnosis (edited by H. & R. Conn); p. 935. Philadelphia, 1968. 3. Ghosh, P., Fleming, H. A., Gresham, G. A., Stovin, P. G. I. Br. Heart J. 1972, 34, 769. 4. Stein, E., Jackler, I., Stein, W., Stimmal, B., Siltzbach, L. E. Trans. VI int. Conf. Sarcoidosis (in the press).
York City, and also Mikhail and his co-workers5 in London; both groups have surveyed their sarcoidosis patients by electrocardiography and other means and noted a surprisingly high incidence of abnormalities. The results of these two surveys were reported at the Sixth International Conference on Sarcoidosis held At the Mount Sinai in September in Tokyo. Hospital, 80 patients with histologically confirmed sarcoidosis but without cardiac complaints had routine electrocardiographs, and half of these were abnormal; there were changes of conduction or rhythm, ST deviations, or T-wave changes. Factors such as sex, chronicity, or corticosteroid therapy did not seem to influence the frequency of E.C.G. changes. Prospective investigations are in progress to determine which of the symptomless E.c.G. abnormalities in sarcoidosis patients may represent precursors or more serious and potentially dangerous sarcoidosis. At Central Middlesex Hospital, London, 14 of 147 histologically confirmed sarcoidosis patients were found to have abnormal E.C.G. changes.5 In 11 patients, the E.C.G. showed a changing pattern coinciding with resolution of the sarcoidosis, suggesting myocardial involvement by sarcoidosis. The presence of cardiac involvement in about 10% of sarcoidosis patients will not only stimulate increased awareness in clinicians but also lead to further work on unravelling the discrepancy between clinical and necropsy evidence of cardiac involvement.
DEATHS FROM DOMESTIC FALLS
THE increasing fragility of bone in the elderly and the liability of elderly patients to succumb to fractures, particularly of the proximal femur, contribute considerably to mortality-and morbidity in the older agegroups. There are two sides to this problem. Investigations of osteomalacia and osteoporosis6 throw light on the intrinsic cause; but the extrinsic factors - the increased liability of the old to fall 7--also need careful consideration. In an interesting paper, Eddy8 has reviewed the statistics of fractures and falls in the old and analysed the comparative mortality figures in different age-groups and the secular trends in mortality between 1900 and 1968 for these conditions. Fractures of the femoral neck, of the upper part of the humerus, and of the Pott’s and Colles’ type show a similar age and sex incidence. This increases sharply over the age of 55 and is about 2-3 times greater in elderly women than in elderly men."9 Fractures of this kind have been described as the post-wage-earning fracture panem.10 A similar age and sex incidence has been described in osteoporosis. 11 Falls, particularly at home, are the most common accidents in the elderly with the highest rate of accidental death. Fractures, Mitchell, D. N., Ball, K. P. ibid. Lancet, 1972, i, 1059. Sheldon, J. H. Br. med. J. 1960, ii, 1685. Eddy, T. P. Br. J. prev. soc. Med. 1972, 26, 173. Knowelden, J., Buhr, A. J., Dunbar, O. ibid. 1964, 18, 130. Buhr, A. J., Cooke, A. M. Lancer, 1959, i, 531. Nordin, B. E. C., MacGregor, J., Smith, D. A. Q. Jl Med. 1966, 35,
5. Mikhail, J. L., 6.
7. 8. 9. 10. 11.
25.