MANIPULATIVE TREATMENT IN GENERAL PRACTICE

1189 The details of the present series of families will be submitted

elsewhere, and will

publication analysed by linkage experts, together Sardinian and perhaps other series. for

we

hope be statistically with the data of the

J. D. Mann, of the Butterworth greatly Hospital, Grand Rapids, Michigan, and to Dr. A. Cahan, of Knickerbocker Biologicals, New York, for generous supplies of the most We are also indebted to Dr. I. Dunsford, preciousanti-Xga serum. Dr. T. E. Cleghorn, and Dr. R. R. A. Coombs for antiglobulin sera which have proved specially suited to the rather exacting needs of and.Xga. The work has been supported in part by Grant A-2470We

are

indebted

to

Dr.

in detail but they must be debated against a background cleared of stumbling-blocks which have signally failed to be landmarks.

One can only re-echo Dr. Batten’s words-" anything is better than unintended liquidation "-but it is later than we think. B. BARNETT. Birmingham. MANIPULATIVE TREATMENT IN GENERAL PRACTICE

Hema. from the U.S. Public Health Service. Government

Hospital, Tel-Hashomer, Israel.

Medical Research Council Blood Group Research Unit, Lister Institute, London, S.W.1.

A. ADAM C. SHEBA. R. R. RACE RUTH SANGER PATRICIA TIPPETT JEAN HAMPER JUNE GAVIN.

FUTURE OF MEDICAL PRACTICE OUTSIDE HOSPITAL SIR,-Professor McKeown (May 5) bypasses the Platt report on hospital staffing in that he suggests roles for the general practitioner in the hospital which were not envisaged by that committee. He also goes completely against one of the fundamental tenets of the Pilkington commission in its desire for a widespread differential scale of payments between consultants and G.P.s. He is to be thanked for his broader, bold approach. To be tied to these reports which dealt with part-issues (and, particularly the Pilkington commission to my, mind, wrongly) would be to obstruct constructive thought on the very basis of future development of the country’s Health Service. Professor McKeown’s very title inspires confidence as implying an approach which would seem obvious yet fundamental in that the possibilities of care and work outside the

hospitals should be first assessed before launching out on specialist units. However, he does not really carry such analysis far and is soon taken back by the prevalent current of thought focused on hospitals. (While there have been high-powered committees dealing with hospitals and vast sums earmarked for future development, it has been left to individuals to delve into the state of general practice and to the Medical Practitioners’ Union to produce a report on health centres!) Comparisons at this juncture with health services of other countries by Professor McKeown and your correspondents will not really take us far. Asa member of an M.P.U. delegation visiting the Soviet Union I was profoundly impressed by the scope and achievements of Soviet health services and the doctors that I met. Yet I am more convinced than ever that a health service of a country is so much a part of the social fabric of that community, with its own history, acting against social and economic backgrounds, housing, and other facilities that any comparisons except technical ones must be very superficial and of doubtful value, or be so detailed and qualified as to make it a special study. At present the main problems would be initially to determine the role and organisation of the G.P. While it is true that the status of the G.P. has declined despite the increased work that he often does, and certainly the vastly increased potentialities of doing scientific medicine, this may not be an irreversible process. There are many complex reasons for this, some social in that the public is weaned from the idea of the family doctor (compare the value of Mrs. Dale’s Diary with EmergencyWard 10 as propaganda), others must be laid squarely at the feet of the profession. Function and structure cannot be divorced and if the profession chases the chimxra of " independent contractor " things can only get worse. Professor McKeown raises many points which will have to be argued

SIR,-Dr. Wilson (May 12) has done well in focusing attention on a controversial subject, and shows how much the climate of opinion is changing in favour of the use of manipulation in medical practice. As a physical-medicine consultant myself, and having qualified originally in osteopathy, I am singularly well placed to sense this change of opinion. I well remember 20 years ago that many patients, having decided to have osteopathic treatment, would be told by their doctors that if they proceeded in this folly they, their doctors, would have nothing more to do with them, and would refuse to have them back on their lists. This sort of reaction is rare nowadays. The majority of general practitioners either agree with their patients that they should see a qualified osteopath, in the event of the hospital being unable to provide this form of treatment, or the doctors actively encourage and suggest names of osteopaths to their

patients.

,

As I see it, this change of opinion has been brought about by two influences, the main one being the good professional work and conduct of the registered osteopaths, and the other one being the work of Dr. Cyriax and others at St. Thomas’s Hospital. There is, however, as much controversy within the medical profession over Dr. Cyriax’s views as there is outside the medical profession over osteopathic views. I agree with Dr. Wilson that the

orthopaedic and physicaldepartments are failing to provide manipulative treatment in the majority of hospitals and this deficiency ought to be remedied. It is noteworthy that whenever I have broached the subject at meetings of the British Association of Physical Medicine, I have either been criticised or actively discouraged, though a small number in this circle would like medicine

learn more about the method. The Association has now gone far as to say that a certain selection of manipulative techniques should be taught to physical-medicine consultants. It is curious that in England, although we have a welltrained group of practitioners in the Register of Osteopaths and there are two schools-the London College of Osteopathy, and the British School of Osteopathy for nonmedical osteopaths-there are complaints that there are no facilities for training in manipulative work. I know that whenever the word " osteopathy " is mentioned it conjures up in the mind of the medical man outlandish claims that lesions of the spine cause systemic diseases, but these excessive statements have long since been abandoned by the responsible members of the osteopathic profession. The claim now is a much more moderate one-that mechanical faults in the body have an influence on the health and wellbeing of the individual -and who would deny this ? As I see it, the osteopathic profession is willing and anxious to work in harmony with the medical profession so long as they are given a reasonable status. They are afraid however, as I am, that medical practitioners will just pick out a few isolated manipulative tricks themselves and then say and think that this is all there is to the art of manipulation. It is quite feasible for general practitioners to learn these few tricks and the patients benefit even from this limited knowledge, so long as due care is taken to avoid excessive force; but to become an adept at to

so

1190

manipulation requires painstaking practice and close study. It be learned in a few easy lessons. Perhaps this is why the orthopaedic and physical-medicine consultants fight shy of it ? cannot

I would make a plea that the whole medical profession should utilise the services of the osteopathic profession now. If they do not, the weight of public opinion will force the issue. I recently applied to the regional board of for the appointment of a registered in osteopath my physical-medicine department. It is that all my colleagues agreed with this request significant in principle but it was turned down on the grounds of finance, and that there was no category under which an osteopath could work in hospital. The Medical Defence Union stated that there was no legal objection to such an appointment. What about this ? The time is ripe for a my

own

hospital

change. London, N.W.I.

ALAN STODDARD.

SIR,-Dr. Wilson’s article of May 12 is heartening proof of the increasing interest in osteopathy taken by the medical profession. The public have for many years accepted that we have something tangible to offer. To both these ends I append a few facts to answer the many queries in the article. The London College of Osteopathy has been in existence since 1946 to teach only medically qualified practitioners the art of osteopathy. Our teaching staff consists of medically qualified osteopaths. Since its inception 50 doctors have qualified for the L.F.O. diploma, which is taken after 15 months’ training. These have included doctors from France and as far as South Africa and New Zealand. There is a British Osteopathic Association register of names of our association obtainable from the secretary. This contains (1) American qualified D.o.s who do a 7-year course and are rated in most of the United States on a par with doctors, and (2) our own college-trained doctors. For patients we have a flourishing clinic run by doctors, with an excellent X-ray department attached. Patients can come here voluntarily and sometimes are even recommended by doctors.

J. R. LESTER. London, N.W.I.

Dean, London College of Osteopathy.

ANTI-HISTAMINES IN MEASLES SIR,-We were pleased to read the comments of Dr. Wiener (May 26) on our letter. It would be excellent if a double-blind study could be carried out during an epidemic, perhaps in a closed community, and we hope that doctors with such an opportunity will be stimulated to do just this. We have used placebos and sedatives previously but without the dramatic improvement seen with anti-histamines. Meanwhile it would be interesting to have the comments of colleagues who have used the treatment. Richmond, K. C EASTON. K E

C. Yorkshire... MONDOR’S DISEASE

SIR,-Mondor’s disease may be even more than Mr. Oldfield (May 12) suggests. I have

common

seen two

in general practice within the past year. A woman of 34, had a painful thrombosed superior epigastric vein three days after a local excision of a small fibroadenoma of the right breast. This resolved without treatment in three to four weeks. A woman of 62 noticed a cord-like swelling under and extending into the left breast while she was engaged in moving house. Fearing cancer, she reported this at once. The vein was impalpable and pain-free within three weeks. cases

Knebworth, Herts.

RICHARD GARDNER.

THE NURSES’ CLAIM

SIR,-As one of many of our profession interested in the pay claims of our nursing colleagues, I was somewhat dismayed by your annotation of May 5. Surely the value of board and lodging varies with the district and the type of accommodation available. Like accommodation for medical staff, this varies considerably up and down the country. Your suggestion of " more realistic " value being placed on accommodation reminds me of the situation faced by junior medical staff when they received a belated award only to find its actual value " considerably less than anticipated due to more realistic values " being placed on often indifferent and indeed unchanged accommodation. The rather glib statement that " the nurses’ best course might be to accept the 21/2 % increase ..." I feel to be an insult to a sister profession on whom we rely so much and to whom the public’s debt is so great. Rather than be counsellors of such advice, let us give them the vigorous and unstinted support which is their due. B. C. COHNEY. Oxford.

* *In our annotation we said: "The nursing profession have a right and proper claim to more than the 22 % they have been offered."-ED. L. PERITONEOCAVAL SHUNT WITH A HOLTER VALVE IN THE TREATMENT OF ASCITES

SIR,-Iwas interested in Mr. Smith’s preliminary communication (March 31). I used this technique in the

University Hospital, Saskatoon, unfortunately without success.

on

Jan. 24, 1958,

The patient was a 68-year-old man who had had ascites for eighteen months. This was treated with mercaptomerin and acetazolamide and controlled for one year. For the four months before admission he had cedema of the ankles, and his ascites had been drained every two weeks. About this time he also had a massive hxmatemesis from oesophageal varices attributed to cirrhosis of the liver with portal hypertension. He was admitted to the University Hospital on Jan. 9 for a portocaval anastomosis. However, it was evident that he was in no condition for such a procedure. Three days after admission 3550 ml. of amber peritoneal fluid was aspirated. Two days later, he had a massive hxmatemesis which was controlled by a Sengstaken tube. Five days later, a further 2300 ml. of ascitic fluid was removed. In order to control the rapidly accumulating ascites, it was decided to do a peritoneocaval shunt using a low-pressure Holter valve. On Jan. 24, under local anaesthesia, this was inserted. A special plastic sump-drain was put into the pelvis through a small incision in the right lower rectus muscle. Into this sump-drain was passed the proximal end of the Holter valve tubing to prevent omentum and bowel from obstructing the lumen of the Holter valve tubing. The valve itself was placed over the region of anterior superior spine of the ilium. The distal end of the Holter valve tubing was passed up the divided long saphenous vein until it reached the inferior vena cava. The valve could then be pumped against the bony prominence of the anterior superior spine of the ilium every hour for the first 24 hours. But the ascites returned rapidly and three days later a further 3500 ml. of fluid had to be removed by paracentesis. The next day he had a further haematemesis requiring the Sengstaken tube again. Three days after this he died in hepatic coma.

At necropsy he had moderate portal cirrhosis with a supermulticentric hepatic carcinoma. There was 4800 ml. of ascitic fluid in the abdomen. Both proximal and distal

imposed