- Email: [email protected]
PERIODIC MEDICAL OVERHAUL
993
single unoffending cow, although annoyed a good many people.
our
failure to do
so
has
a
When in 1895 the use of tuberculin had revealed the of bovine tuberculosis in Great Britain it was concluded that any attempt at eradication was quite impracticable. It was true that sudden radical measures were impracticable and nothing was done for some 40 years, during which time the incidence of infection remained nearly constant ; but as soon as the community decided it would try to eradicate the bovine tubercle bacillus it was found that steady progress could be made, and eradication areas have now been established. I realise that eradication of human infection is a far more difficult and complex task, but let us agree that the presence of virulent tubercle bacilli in the human population is as undesirable as it is in cattle. It may then be found, sooner than some people expect, that improved living conditions allied with specific measures against the tubercle bacillus, which I am sure would have the support of Dr. Paul and Dr. Hoffstaedt, have reduced the incidence of infection to such a low level that virtual eradication is not an impossibility. It is a matter of fact that good progress towards eradication of the tubercle bacillus has been achieved in several communities without apparently exciting any serious opposition. Veterinary School, University of Queensland, JOHN FRANCIS. Yeerongpilly, Brisbane, Australia.
high incidence
CONTROLS matter for regret that the use of normal children (or children suffering from some irrelevant disease) as controls in clinical research appears to be
SiR,—It is
essential article of the diet, and Roserecommends 3 g. Earlier work on normal adults 2 and on children 45 has shown that considerably larger amounts of phenylalanine may be ingested, as they are rapidly metabolised and cause no untoward effects. Our work was undertaken to observe the blood-levels of a normal child after doubling the normal phenylalanine intake in order to compare the normal tolerance curve is
a
increasing. No medical procedure involving the slightest risk or accompanied by the slightest physical or mental pain may be inflicted on a child for experimental purposes unless there is a reasonable chance, or at least a hope, that the child may benefit thereby. If this is true-and I hope that there are few doctors in this country who would disagree-then it must surely be difficult to justify the use of two hydrocephalic infants reported in the paper by Dr. Doxiadis and his colleagues, and the use of a normal control by Dr. Bickel and his colleagues. Both papers appeared in your issue ’
of Oct. 17. It may be, of course, that there were some good reasons for the use of these children which have’ not been made clear. If so, the authors owe it to themselves to explain. R. E. W. FISHER. London, N.I. we have shown *Dr. Doxiadis is nowabroad, the above letter to the other medical authors of the two papers.. They reply as follows : " It is quite reasonable that Dr. Fisher should raise the question of the use of normal children or children suffering from some irrelevant disease as controls in clinical research. - There are extreme opinions on both sides, but I feel must of us adopt a policy between the two-somewhere in the grey between the rather theoretical white and black. My own working policy, which differs slightly from that expounded by Dr. Fisher in the second paragraph of his letter, is that no procedure should be carried out involving risk or discomfort without a reasonable chance of benefit to that child or other children;; and this principle was followed throughout our work. The crux of the matter is contained in the last sentence of Dr. Fisher’s letter-we owe it to ourselves to explain our actions. Surely we all weigh these matters most carefully in our own consciences." - K. S. HOLT. " We are grateful to Dr. Fisher for raising a problem of which we are fully conscious in our daily work. Xevertheless, errors of metabolism constituting the underlying cause of many diseases cannot be understood or properly treated without knowledge of normal physiology. With regard to our own work, phenylalanine
but
an
daily intake of 2-2
with the pathological curve in phenylketonuria. This may be regarded as closely comparable with a glucosetolerance test in that it is both harmless to the normal and of great importance for the assessment of pathological curves."——H. BICKEL, J. GERRARD. BASIC GROUP PRACTICE
SiR,—We have followed, with great interest, the series of articles on general practice which have appeared from time to time in The Lancet under the name of Joseph S. Collings. We have been impressed with the tireless energy he has displayed in pirouetting round this country studying and reporting on individual practices and issuing reports on how general practice really ought to be conducted. Then we read in his article of Oct. 24 : "
In its first five years the National Health Service has done little to stimulate the development of group practice. Hopes were centred at first on the possibilities of ill-defined and little-understood health centres ; but these hopes have only been fulfilled in two or three places, and by now have lost their charm both for the general practitioner and for the Exchequer. They are monuments to the local authorities and the outcome of a ’do-nothing’ policy in regard to the main structure of
general practice." Such ex-cathedra statements are rather mischievous, we know that Dr. Collings has never taken the trouble to visit the William Budd Health Centre in Bristol to find out what progress has been
particularly when
made. If he is so ready to condemn health centres which as yet have had little chance of proving themselves, and even without any first-hand knowledge of how at least one of them is working, then we fear we must reconsider our judgment of the value of his previous articles. Bristol.
R. C. WOFINDEN J. SLUGLETT. PERIODIC MEDICAL OVERHAUL
SrR,—Sir Adolphe Abrahams generalises against periodic overhauls on the basis of three cases, although undoubtedly he could cite more. Surely no-one in Medicine, least of all Sir Adolphe with his vast experience, would suggest that any examination, advice, or treatment was likely to be 100% successful in all cases. What does Sir Adolphe mean by sensible people " ? As regards health, few people are sensible. Has he never met any people, even doctors, who have had headaches, indigestion, piles, or a cough for months and who have never done anything about it and eventually been found to be severe hyperpietics or to have inoperable carcinoma or advanced pulmonary tuberculosis ? Admittedly many of these people would not have a periodic overhaul anyway, but the whole idea of such a check is to try and catch some of the early cases of tuberculosis, carcinoma, anaemia, hyperpiesis, diabetes, &c., explain what is or to cured and them be relieved before they help wrong, "
become invalids. There are difficulties in that few, even intelligent, people will give the time to have an overhaul, or they are scared of the possible result ; and the doctors in the National Health Service have not got the time or the facilities to do their job as they would wish. 1. Rose, W. C. Fed. Proc. 1949, 8, 546. 2. Penrose, L., Quastel, J. H. Biochem. J. 1937, 31, 266. J. biol. Chem. 1947, 169, 651. 3. Jeryis, G. A. 4. Woolf, L. I , Edmunds, M. E. Biochem. J. 1950, 47, 630. 5. Levine, S. Z., Dann, M., Marples, E. J. clin. Invest. 22, 551.
1943,
994 Those of us who have the time to take a proper history, carry out a detailed examination of the patient, and talk to him afterwards, know that hardly a day passes when someone is not found with some complaint which can be cured or at any rate ameliorated in its early stages ar.d thereby save him a great deal of discomfort and possible anxiety in the future. Finally, if not the doctor, who would Sir Adolphe suggest is the best person to give common-sense health education ? R. H. SCOTT. Hook, Hampshire. ’
POSTURE, BACKACHE, AND HEALTH an
SiR,-In his letter of Oct. 17, Mr. Tucker describes ideal posture and guarantees that if one learns to
stand in this way continuously one never seems to grow tired. Many different postures have, in the past, been advocated as ideals and their theoretical mechanical advantages have been described, but, as far as I am aware, little practical evidence has ever been produced to show that any of them have, per se, any influence on the incidence of postural disorders of the supporting tissues. Posture is the sum of the conditions pertaining at all the joints of the body. In the majority of those postures which are regarded as bad, poor, or abnormal, no joint is outside The crux of the matter its normal range of movement. therefore seems to be, why joint positions which can be utilised with impunity in some circumstances become fraught with danger to the joint tissues if utilised in standing. Joint tissues, although they are living tissues, conform, in their reactions to stress to the same physical laws as All the tissues inanimate objects such as steel or rubber. which may be involved in maintaining the position of a joint -namely, bone, cartilage, muscle, ligament, and fasciaall these tissues are elastic to momentary stresses of a magnitude less than the breaking load : each is deformed when stress is applied to it and recovers its original dimensions when the stress is removed. On the other hand, these tissues A stress which react in a different way to prolonged stress. is less than the breaking load will, if it is allowed to persist for longer than an optimum time, produce a gradual progressive distortion of the tissues. Moreover, part of this distortion will be permanent unless it is slowly corrected by a vital reaction within the tissues. In standing, the stress on any joint tissue is never as great as the breaking load, and it is therefore only the duration of the stress and not the stress itself-only the duration of the posture rather than the posture itself-which can cause permanent changes in the joint tissues. In other words a posture which is maintained continuously for a long time will damage the supporting tissues irrespective of whether it is regarded as an ideal posture or a bad posture, whereas any posture into which the body can be painlessly moulded will be harmless if it is of a short duration. The work of Ingelmark and his colleagueshas suggested that the time factor may also be important in another way. They have produced considerable evidence in support of the hypothesis that the nutrition of articular cartilage and the production of synovial fluid are, in part at least, dependent the rhythmical compression and release of articular on cartilage. A corollary to this hypothesis is that continuous compression of articular cartilage by the continuous maintenance of any posture would adversely affect both these
functions. Observation of people in the street or of any person who is unaware that he is being watched shows that natural standing (in contrast to that of a soldier standing at attention) is A person stands still never a continuously immobile act. for a short time, then shifts his lower limbs, pelvis, and trunk before becoming still again for another short period, and this alternation between movement and immobility continues throughout the stance. The average duration of the immobile periods is only about thirty seconds.2 Moreover, not only is the continuity of the stress on joint tissues repeatedly broken in this way, but different postures may be assumed
1. Ingelmark, R. E., Ekholm, R. Uppsala LäkFören. Förh. 1948, 53, 61 ; Ingelmark, R. E. Acta orthopœd. scand. 1950, 17, 303. 2. Smith, J. W. Acta orthopœd. scand. 1953 (in the press).
during successive immobile periods, so that the tissues on the right and left sides of the body are alternately subjected to the
greater part
of the total stress.
Because the method of normal standing is so much in with the physical properties and physiological processes of joint tissues, it seems reasonable to suggest that aberrations of the normal periodicity of standing might have a closer causal relation to postural disorders than the form of the various postures which are adopted during that act. It was observed in the course of the investigations quoted above that in a small proportion of the subjects studied each immobile period of standing I feel it would be of was prolonged beyond one minute. interest if the incidence of such habitual prolongation of the immobile periods of standing could be correlated with the incidence of postural disorders.
keeping
Anatomy Department,
J. W. SMITH
University of St. Andrews.
COARCTATION OF THE AORTA
SiR,-We have read with great interest your excellent editorial (Oct. 24) on this subject, and there is one point upon which we should like to comment. You say that direct aortography should always be used in the preoperative investigation of coarctation, This investigation, although undoubtedly more precise and informative than venous angiocardiography, is not without risk, principally because of the high conceiitration of dye which enters the cerebral vessels and the coronary arteries. In addition, the retrograde route involves the use of a peripheral artery, and intubation of the main artery to one upper limb, with the risk (admittedly small) of subsequent arterial thrombosis and ischsemia of the limb. Positioning of the catheter in the arch of the aorta is not as easy as it may sound, and in short the investigation is usually far more time-consuming, difficult, and hazardous than angiocardiography by the venous route. In
our experience, venous angiocardiography gives adequate picture of the site and extent of the coarctation, of the aorta above and below, of the origin of the left subclavian artery, and of the collateral circulation in the majority of cases.1 The risk is very small indeed, but sufficient contrast medium must be used (1-1-5 ml. of 70% diodone per kg. body-weight) in order to obtain a good result. We believe that aortography should only be performed in cases in which venous angiocardiography has been inadequate, or in which special problems of diagnosis exist, or when the surgeon expressly requests it. an
’
Departments of Medicine
and
Radiology,
Postgraduate Medical School
of London and Hammersmith
Hospital.
J. F. GOODWIN R. E. STEINER.
SiR,-You say in your leading article (Oct. 24) that
entirely satisfactory explanation has been found for the dilatation of the vessel so often noted distal to the constriction. You mention the defective structure of the aortic wall as a factor, but perhaps the most important cause of dilatation of this segment is the turbulence which must invariably be created there. While, from above, we have the blood passing through the narrowed part of the aorta under high pressure, below the constriction we find, as a result of the collateral circulation, a retrograde flow from the intercostal vessels into the distal segment, again at a pressure only slightly lower than that in the proximal part of the aorta. Even when the coarctation is complete, as it rarely is, the bloodflow from the intercostals into the aorta must create a considerable amount of turbulence, and it would be surprising if some dilatation did not result. The position no
1. Goodwin, J. F., Steiner, R. E., Mounsey, J. P. D., A. G., Wayne, E. J. Brit. J. Radiol. 1953, 26, 161.
Macgregor
single unoffending cow, although annoyed a good many people.
our
failure to do
so
has
a
When in 1895 the use of tuberculin had revealed the of bovine tuberculosis in Great Britain it was concluded that any attempt at eradication was quite impracticable. It was true that sudden radical measures were impracticable and nothing was done for some 40 years, during which time the incidence of infection remained nearly constant ; but as soon as the community decided it would try to eradicate the bovine tubercle bacillus it was found that steady progress could be made, and eradication areas have now been established. I realise that eradication of human infection is a far more difficult and complex task, but let us agree that the presence of virulent tubercle bacilli in the human population is as undesirable as it is in cattle. It may then be found, sooner than some people expect, that improved living conditions allied with specific measures against the tubercle bacillus, which I am sure would have the support of Dr. Paul and Dr. Hoffstaedt, have reduced the incidence of infection to such a low level that virtual eradication is not an impossibility. It is a matter of fact that good progress towards eradication of the tubercle bacillus has been achieved in several communities without apparently exciting any serious opposition. Veterinary School, University of Queensland, JOHN FRANCIS. Yeerongpilly, Brisbane, Australia.
high incidence
CONTROLS matter for regret that the use of normal children (or children suffering from some irrelevant disease) as controls in clinical research appears to be
SiR,—It is
essential article of the diet, and Roserecommends 3 g. Earlier work on normal adults 2 and on children 45 has shown that considerably larger amounts of phenylalanine may be ingested, as they are rapidly metabolised and cause no untoward effects. Our work was undertaken to observe the blood-levels of a normal child after doubling the normal phenylalanine intake in order to compare the normal tolerance curve is
a
increasing. No medical procedure involving the slightest risk or accompanied by the slightest physical or mental pain may be inflicted on a child for experimental purposes unless there is a reasonable chance, or at least a hope, that the child may benefit thereby. If this is true-and I hope that there are few doctors in this country who would disagree-then it must surely be difficult to justify the use of two hydrocephalic infants reported in the paper by Dr. Doxiadis and his colleagues, and the use of a normal control by Dr. Bickel and his colleagues. Both papers appeared in your issue ’
of Oct. 17. It may be, of course, that there were some good reasons for the use of these children which have’ not been made clear. If so, the authors owe it to themselves to explain. R. E. W. FISHER. London, N.I. we have shown *Dr. Doxiadis is nowabroad, the above letter to the other medical authors of the two papers.. They reply as follows : " It is quite reasonable that Dr. Fisher should raise the question of the use of normal children or children suffering from some irrelevant disease as controls in clinical research. - There are extreme opinions on both sides, but I feel must of us adopt a policy between the two-somewhere in the grey between the rather theoretical white and black. My own working policy, which differs slightly from that expounded by Dr. Fisher in the second paragraph of his letter, is that no procedure should be carried out involving risk or discomfort without a reasonable chance of benefit to that child or other children;; and this principle was followed throughout our work. The crux of the matter is contained in the last sentence of Dr. Fisher’s letter-we owe it to ourselves to explain our actions. Surely we all weigh these matters most carefully in our own consciences." - K. S. HOLT. " We are grateful to Dr. Fisher for raising a problem of which we are fully conscious in our daily work. Xevertheless, errors of metabolism constituting the underlying cause of many diseases cannot be understood or properly treated without knowledge of normal physiology. With regard to our own work, phenylalanine
but
an
daily intake of 2-2
with the pathological curve in phenylketonuria. This may be regarded as closely comparable with a glucosetolerance test in that it is both harmless to the normal and of great importance for the assessment of pathological curves."——H. BICKEL, J. GERRARD. BASIC GROUP PRACTICE
SiR,—We have followed, with great interest, the series of articles on general practice which have appeared from time to time in The Lancet under the name of Joseph S. Collings. We have been impressed with the tireless energy he has displayed in pirouetting round this country studying and reporting on individual practices and issuing reports on how general practice really ought to be conducted. Then we read in his article of Oct. 24 : "
In its first five years the National Health Service has done little to stimulate the development of group practice. Hopes were centred at first on the possibilities of ill-defined and little-understood health centres ; but these hopes have only been fulfilled in two or three places, and by now have lost their charm both for the general practitioner and for the Exchequer. They are monuments to the local authorities and the outcome of a ’do-nothing’ policy in regard to the main structure of
general practice." Such ex-cathedra statements are rather mischievous, we know that Dr. Collings has never taken the trouble to visit the William Budd Health Centre in Bristol to find out what progress has been
particularly when
made. If he is so ready to condemn health centres which as yet have had little chance of proving themselves, and even without any first-hand knowledge of how at least one of them is working, then we fear we must reconsider our judgment of the value of his previous articles. Bristol.
R. C. WOFINDEN J. SLUGLETT. PERIODIC MEDICAL OVERHAUL
SrR,—Sir Adolphe Abrahams generalises against periodic overhauls on the basis of three cases, although undoubtedly he could cite more. Surely no-one in Medicine, least of all Sir Adolphe with his vast experience, would suggest that any examination, advice, or treatment was likely to be 100% successful in all cases. What does Sir Adolphe mean by sensible people " ? As regards health, few people are sensible. Has he never met any people, even doctors, who have had headaches, indigestion, piles, or a cough for months and who have never done anything about it and eventually been found to be severe hyperpietics or to have inoperable carcinoma or advanced pulmonary tuberculosis ? Admittedly many of these people would not have a periodic overhaul anyway, but the whole idea of such a check is to try and catch some of the early cases of tuberculosis, carcinoma, anaemia, hyperpiesis, diabetes, &c., explain what is or to cured and them be relieved before they help wrong, "
become invalids. There are difficulties in that few, even intelligent, people will give the time to have an overhaul, or they are scared of the possible result ; and the doctors in the National Health Service have not got the time or the facilities to do their job as they would wish. 1. Rose, W. C. Fed. Proc. 1949, 8, 546. 2. Penrose, L., Quastel, J. H. Biochem. J. 1937, 31, 266. J. biol. Chem. 1947, 169, 651. 3. Jeryis, G. A. 4. Woolf, L. I , Edmunds, M. E. Biochem. J. 1950, 47, 630. 5. Levine, S. Z., Dann, M., Marples, E. J. clin. Invest. 22, 551.
1943,
994 Those of us who have the time to take a proper history, carry out a detailed examination of the patient, and talk to him afterwards, know that hardly a day passes when someone is not found with some complaint which can be cured or at any rate ameliorated in its early stages ar.d thereby save him a great deal of discomfort and possible anxiety in the future. Finally, if not the doctor, who would Sir Adolphe suggest is the best person to give common-sense health education ? R. H. SCOTT. Hook, Hampshire. ’
POSTURE, BACKACHE, AND HEALTH an
SiR,-In his letter of Oct. 17, Mr. Tucker describes ideal posture and guarantees that if one learns to
stand in this way continuously one never seems to grow tired. Many different postures have, in the past, been advocated as ideals and their theoretical mechanical advantages have been described, but, as far as I am aware, little practical evidence has ever been produced to show that any of them have, per se, any influence on the incidence of postural disorders of the supporting tissues. Posture is the sum of the conditions pertaining at all the joints of the body. In the majority of those postures which are regarded as bad, poor, or abnormal, no joint is outside The crux of the matter its normal range of movement. therefore seems to be, why joint positions which can be utilised with impunity in some circumstances become fraught with danger to the joint tissues if utilised in standing. Joint tissues, although they are living tissues, conform, in their reactions to stress to the same physical laws as All the tissues inanimate objects such as steel or rubber. which may be involved in maintaining the position of a joint -namely, bone, cartilage, muscle, ligament, and fasciaall these tissues are elastic to momentary stresses of a magnitude less than the breaking load : each is deformed when stress is applied to it and recovers its original dimensions when the stress is removed. On the other hand, these tissues A stress which react in a different way to prolonged stress. is less than the breaking load will, if it is allowed to persist for longer than an optimum time, produce a gradual progressive distortion of the tissues. Moreover, part of this distortion will be permanent unless it is slowly corrected by a vital reaction within the tissues. In standing, the stress on any joint tissue is never as great as the breaking load, and it is therefore only the duration of the stress and not the stress itself-only the duration of the posture rather than the posture itself-which can cause permanent changes in the joint tissues. In other words a posture which is maintained continuously for a long time will damage the supporting tissues irrespective of whether it is regarded as an ideal posture or a bad posture, whereas any posture into which the body can be painlessly moulded will be harmless if it is of a short duration. The work of Ingelmark and his colleagueshas suggested that the time factor may also be important in another way. They have produced considerable evidence in support of the hypothesis that the nutrition of articular cartilage and the production of synovial fluid are, in part at least, dependent the rhythmical compression and release of articular on cartilage. A corollary to this hypothesis is that continuous compression of articular cartilage by the continuous maintenance of any posture would adversely affect both these
functions. Observation of people in the street or of any person who is unaware that he is being watched shows that natural standing (in contrast to that of a soldier standing at attention) is A person stands still never a continuously immobile act. for a short time, then shifts his lower limbs, pelvis, and trunk before becoming still again for another short period, and this alternation between movement and immobility continues throughout the stance. The average duration of the immobile periods is only about thirty seconds.2 Moreover, not only is the continuity of the stress on joint tissues repeatedly broken in this way, but different postures may be assumed
1. Ingelmark, R. E., Ekholm, R. Uppsala LäkFören. Förh. 1948, 53, 61 ; Ingelmark, R. E. Acta orthopœd. scand. 1950, 17, 303. 2. Smith, J. W. Acta orthopœd. scand. 1953 (in the press).
during successive immobile periods, so that the tissues on the right and left sides of the body are alternately subjected to the
greater part
of the total stress.
Because the method of normal standing is so much in with the physical properties and physiological processes of joint tissues, it seems reasonable to suggest that aberrations of the normal periodicity of standing might have a closer causal relation to postural disorders than the form of the various postures which are adopted during that act. It was observed in the course of the investigations quoted above that in a small proportion of the subjects studied each immobile period of standing I feel it would be of was prolonged beyond one minute. interest if the incidence of such habitual prolongation of the immobile periods of standing could be correlated with the incidence of postural disorders.
keeping
Anatomy Department,
J. W. SMITH
University of St. Andrews.
COARCTATION OF THE AORTA
SiR,-We have read with great interest your excellent editorial (Oct. 24) on this subject, and there is one point upon which we should like to comment. You say that direct aortography should always be used in the preoperative investigation of coarctation, This investigation, although undoubtedly more precise and informative than venous angiocardiography, is not without risk, principally because of the high conceiitration of dye which enters the cerebral vessels and the coronary arteries. In addition, the retrograde route involves the use of a peripheral artery, and intubation of the main artery to one upper limb, with the risk (admittedly small) of subsequent arterial thrombosis and ischsemia of the limb. Positioning of the catheter in the arch of the aorta is not as easy as it may sound, and in short the investigation is usually far more time-consuming, difficult, and hazardous than angiocardiography by the venous route. In
our experience, venous angiocardiography gives adequate picture of the site and extent of the coarctation, of the aorta above and below, of the origin of the left subclavian artery, and of the collateral circulation in the majority of cases.1 The risk is very small indeed, but sufficient contrast medium must be used (1-1-5 ml. of 70% diodone per kg. body-weight) in order to obtain a good result. We believe that aortography should only be performed in cases in which venous angiocardiography has been inadequate, or in which special problems of diagnosis exist, or when the surgeon expressly requests it. an
’
Departments of Medicine
and
Radiology,
Postgraduate Medical School
of London and Hammersmith
Hospital.
J. F. GOODWIN R. E. STEINER.
SiR,-You say in your leading article (Oct. 24) that
entirely satisfactory explanation has been found for the dilatation of the vessel so often noted distal to the constriction. You mention the defective structure of the aortic wall as a factor, but perhaps the most important cause of dilatation of this segment is the turbulence which must invariably be created there. While, from above, we have the blood passing through the narrowed part of the aorta under high pressure, below the constriction we find, as a result of the collateral circulation, a retrograde flow from the intercostal vessels into the distal segment, again at a pressure only slightly lower than that in the proximal part of the aorta. Even when the coarctation is complete, as it rarely is, the bloodflow from the intercostals into the aorta must create a considerable amount of turbulence, and it would be surprising if some dilatation did not result. The position no
1. Goodwin, J. F., Steiner, R. E., Mounsey, J. P. D., A. G., Wayne, E. J. Brit. J. Radiol. 1953, 26, 161.
Macgregor