- Email: [email protected]
On Convalescence
DIVERTICULUM Sir Thomas Gresham, founder of the1 London Stock Exchange four centuries1 ago, is credited with the discovery of an economic law that bears his name (Nichole Oresme, bishop of Lisieux had formulated it previously; unfortunately his profession frowned upon such a materi- 1 alistic hobby as economic laws, so the opportunity remained available for Gre- 1
sham).
dilution is now advocated. Here, the new test is definitely less modern and precise than the previous one, but more adapted to the uncertain clinical situation. Every practitioner can recall such examples and verify the validity of Gresham’s law in medicine. Major conclusions can also be drawn by research, development, and marketing managers from Gresham’s law of adequacy of laboratory testing to a given clinical situation : a good test can prove a commercial flop, and (most of them know this intuitively) a bad test can often be sold, provided a suitable target disease can be found.
lymphocytes by limiting
Gresham’s law
j
Gresham’s law states that, in some circumstances, bad money drives good money out of circulation. There are parallels in medicine. A common opin- 1 ion is that laboratory tests fall out of favour when they become technically obsolete and are replaced by more1 accurate tests, achieved with modem1 technology. I suggest that two points1 are overlooked: the ritual (in the literal sense) part of each test, and the relationship between a clinical situation and its associated tests. When we can do little for patients suffering from a disease we still wear; "gowns and mortarboards to impress1 people by the ritual aspect of medical practice" (Blaise Pascal) at the bedside, but also in the laboratory. Mysterious,;1 complex tests with obscure interpretation are then required (for example, autoantibodies that recognise soluble ;1 nuclear antigens.) Modern tests replace old tests only when the diagnosis or treatment of dis- 1 ease is also changed. Better tests cannot evolve when the clinical situation remains static. In the most extreme example, an entirely random test is adequate for a totally unsolved clinical situation. As in some economic situations, the bad money drives out the good (Gresham’s law). A test needs only to be as accurate as the scientific solution .’ to the clinical conundrum, not one step ahead. As far as AIDS is concerned, there are numerous predictive tests easier to perform and as accurate as CD4 cell counts; but these are not "ritual" enough for a clinical situation with poor1 scientific justification for clinical decisions. Even ELISA for CD4, although available for many years, is not replacing complex and expensive flow cytometers. Histocompatibility testing has been1 changing from far-from-perfect serological tests to modern molecular biology, but the problem of selection of bone marrow transplants from non-related v donors for leukaemia remains unsolved.1 Some degree of graft-versus-host reaction-and its treatment-are needed for preventing relapses. Since molecular biological histocompatibility testing is v too accurate, new imprecise tests are needed and the enumeration of the precursor of specific allogenic cytotoxic T-
Reims, France
J H M Cohen
On looking old
966
I
visited our patient in Bart’s youngest daughter, where I was a medical student during the war. She was in W G Grace ward, and on entry I was wearing the rather gaudy scarlet and gold tie worn by MCC members on match days. I introduced myself to a very pleasant young staff nurse who immediately recognised the tie and said "Why you must have known W G Grace". At the entrance of the ward was a photograph of the celebrated Dr Grace-this tall bearded figure still instantly recognisable today wherever cricket is played. Born in 1848 he died in 1915.
During
the
summer a
Anthony G
Freeman
Swindon, UK
On Convalescence
social events and concerts were part of the programme. The popularity of spa convalescence ensured its survival after the Czech "velvet revolution" and the rebirth of the Czech health service with traditional family doctors. Patients can now refer themselves for spa treatment or have a subsidised stay on medical recommendations. In France too, the tradition of formal convalescence continues. Despite recent stringent economies, the French health service still reimburses patients for courses of treatment at various stations thermales after referral by their family doctors. Hydrotherapy, mud baths, and inhalations are often part of a cure and, rather alarmingly, some spa for rheumatology are waters used described as radioactive. "Taking the waters" (radioactive or otherwise) is out of fashion nowadays in the UK, (a splendid Victorian pump room lies derelict in my own street) but I could not recall when one of my patients had last been sent for NHS convalescence. Presumably the resources used during my house surgeon days were easy targets for NHS cost cutting-but was their effectiveness ever properly audited? Unable
find a local match for the charms of Marienbad or the boulevard cafes of Eugenie-lesBains, I spent a week in north Cornwall enjoying cliff walks and the bracing surf with palpable benefit. We seem to have lost the tradition of convalescence in the UK; as surgical admissions become more abbreviated, beds are closed, lying in after child birth is abolished, and patients are discharged home earlier and earlier (to circumstances often less comfortable than my own), might our patients likewise benefit from formal convalescence (if not hydrotherapy)-or have we thrown out the baby with the spa water? to
art nouveau
"None of my friends have to help with the housework." "Who said you could borrow my Walkman ?" Stefan Cembrowicz "You’ve used up all the hot water ’,
again." At the sound of teenage dispute, the Helicobacter which was an unwelcome guest in my stomach gave me a reproachful twinge. "Take some time off and have some peace and quiet at home" my GP had advised. As the sound of Jimi Hendrix reissues echoed through the house, blending unforgettably with the Mr Blobby song, I wondered whether this advice was a contradiction in terms. When I visited some Czech GP friends in Prague recently, I had been rather bemused by their network of spas-patients would be sent off to one of about fifty spa resorts to recuperate and take the waters. Treatment could include diet, hydrotherapy, and a wide range of physical therapies. The minimum stay was for three weeks, and
Bristol, UK
bears and Finnish forests
Breeding
Thomas Wakley, reformer and founder of The Lancet, would have undoubtedly espoused the green movement. One may suspect that, by now, he would have been printing The Lancet on recycled paper, notwithstanding the poorer quality and grumbles from printers. As it is, The Lancet has resort to the next best thing. The paper used is described as "Saimatech machine-finished coated paper". It is imported by Kymmene UK Ltd from well-managed Finnish forests in which, readers will be relieved to learn, there are the required number of breeding bears. Alan Porter
Camberley, UK
sham).
dilution is now advocated. Here, the new test is definitely less modern and precise than the previous one, but more adapted to the uncertain clinical situation. Every practitioner can recall such examples and verify the validity of Gresham’s law in medicine. Major conclusions can also be drawn by research, development, and marketing managers from Gresham’s law of adequacy of laboratory testing to a given clinical situation : a good test can prove a commercial flop, and (most of them know this intuitively) a bad test can often be sold, provided a suitable target disease can be found.
lymphocytes by limiting
Gresham’s law
j
Gresham’s law states that, in some circumstances, bad money drives good money out of circulation. There are parallels in medicine. A common opin- 1 ion is that laboratory tests fall out of favour when they become technically obsolete and are replaced by more1 accurate tests, achieved with modem1 technology. I suggest that two points1 are overlooked: the ritual (in the literal sense) part of each test, and the relationship between a clinical situation and its associated tests. When we can do little for patients suffering from a disease we still wear; "gowns and mortarboards to impress1 people by the ritual aspect of medical practice" (Blaise Pascal) at the bedside, but also in the laboratory. Mysterious,;1 complex tests with obscure interpretation are then required (for example, autoantibodies that recognise soluble ;1 nuclear antigens.) Modern tests replace old tests only when the diagnosis or treatment of dis- 1 ease is also changed. Better tests cannot evolve when the clinical situation remains static. In the most extreme example, an entirely random test is adequate for a totally unsolved clinical situation. As in some economic situations, the bad money drives out the good (Gresham’s law). A test needs only to be as accurate as the scientific solution .’ to the clinical conundrum, not one step ahead. As far as AIDS is concerned, there are numerous predictive tests easier to perform and as accurate as CD4 cell counts; but these are not "ritual" enough for a clinical situation with poor1 scientific justification for clinical decisions. Even ELISA for CD4, although available for many years, is not replacing complex and expensive flow cytometers. Histocompatibility testing has been1 changing from far-from-perfect serological tests to modern molecular biology, but the problem of selection of bone marrow transplants from non-related v donors for leukaemia remains unsolved.1 Some degree of graft-versus-host reaction-and its treatment-are needed for preventing relapses. Since molecular biological histocompatibility testing is v too accurate, new imprecise tests are needed and the enumeration of the precursor of specific allogenic cytotoxic T-
Reims, France
J H M Cohen
On looking old
966
I
visited our patient in Bart’s youngest daughter, where I was a medical student during the war. She was in W G Grace ward, and on entry I was wearing the rather gaudy scarlet and gold tie worn by MCC members on match days. I introduced myself to a very pleasant young staff nurse who immediately recognised the tie and said "Why you must have known W G Grace". At the entrance of the ward was a photograph of the celebrated Dr Grace-this tall bearded figure still instantly recognisable today wherever cricket is played. Born in 1848 he died in 1915.
During
the
summer a
Anthony G
Freeman
Swindon, UK
On Convalescence
social events and concerts were part of the programme. The popularity of spa convalescence ensured its survival after the Czech "velvet revolution" and the rebirth of the Czech health service with traditional family doctors. Patients can now refer themselves for spa treatment or have a subsidised stay on medical recommendations. In France too, the tradition of formal convalescence continues. Despite recent stringent economies, the French health service still reimburses patients for courses of treatment at various stations thermales after referral by their family doctors. Hydrotherapy, mud baths, and inhalations are often part of a cure and, rather alarmingly, some spa for rheumatology are waters used described as radioactive. "Taking the waters" (radioactive or otherwise) is out of fashion nowadays in the UK, (a splendid Victorian pump room lies derelict in my own street) but I could not recall when one of my patients had last been sent for NHS convalescence. Presumably the resources used during my house surgeon days were easy targets for NHS cost cutting-but was their effectiveness ever properly audited? Unable
find a local match for the charms of Marienbad or the boulevard cafes of Eugenie-lesBains, I spent a week in north Cornwall enjoying cliff walks and the bracing surf with palpable benefit. We seem to have lost the tradition of convalescence in the UK; as surgical admissions become more abbreviated, beds are closed, lying in after child birth is abolished, and patients are discharged home earlier and earlier (to circumstances often less comfortable than my own), might our patients likewise benefit from formal convalescence (if not hydrotherapy)-or have we thrown out the baby with the spa water? to
art nouveau
"None of my friends have to help with the housework." "Who said you could borrow my Walkman ?" Stefan Cembrowicz "You’ve used up all the hot water ’,
again." At the sound of teenage dispute, the Helicobacter which was an unwelcome guest in my stomach gave me a reproachful twinge. "Take some time off and have some peace and quiet at home" my GP had advised. As the sound of Jimi Hendrix reissues echoed through the house, blending unforgettably with the Mr Blobby song, I wondered whether this advice was a contradiction in terms. When I visited some Czech GP friends in Prague recently, I had been rather bemused by their network of spas-patients would be sent off to one of about fifty spa resorts to recuperate and take the waters. Treatment could include diet, hydrotherapy, and a wide range of physical therapies. The minimum stay was for three weeks, and
Bristol, UK
bears and Finnish forests
Breeding
Thomas Wakley, reformer and founder of The Lancet, would have undoubtedly espoused the green movement. One may suspect that, by now, he would have been printing The Lancet on recycled paper, notwithstanding the poorer quality and grumbles from printers. As it is, The Lancet has resort to the next best thing. The paper used is described as "Saimatech machine-finished coated paper". It is imported by Kymmene UK Ltd from well-managed Finnish forests in which, readers will be relieved to learn, there are the required number of breeding bears. Alan Porter
Camberley, UK