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Population structure
452
The Journal of HAND SURGERY
Leuers to the editor
nerve is free even with the forearm in full pronation, and one can then rarely incriminate the tendinous origin of the ECRB. ECRB release. I have not released this structure in my last 28 cases, and the results appear equally good. While I always doubted the role of the ECRB, my tenotomy cessations followed the unexpected postsur gical retirement of a promising teenage tennis star. While her radial nerve signs and symptoms were gone, her iatrogenic ''tennis elbow'' secondary to the disrup tion of the ECRB led to this exit. Skin incision. I prefer to decompress this nerve through a 5-centimeter transverse incision 3 to 4 em distal to the elbow flexion crease. An excellent view is encountered by laterally mobilizing the entire brachial radialis and radial wrist extensors and flexing the elbow to view the tunnel proximally. While this skin incision can hypertrophy, it does so less often than the longitu dinal and S-shaped incisions. Conservative care consists of anti-inflammatory medications and, if possible, avoidance of activities requiring extensive forearm pronation. Patients with symptoms of less than 3-months' duration often do not require surgery. I believe that symptoms should be present for 6 months before intervention unless there has been improvement, and then additional time is war ranted. Finally, I do not believe that corticosteroid in jections should be used in management of this disorder. Gary P. Crawford, M.D. 231 West Pueblo St. Santa Barbara, CA 93105
REFERENCES 1. Capener N: The vulnerability of the posterior interosseous nerve of the forearm. A case report and an anatomical study. J Bone Joint Surg [Br] 48:770-3, 1966 2. Sharrard WJW: Posterior interosseous neuritis. J Bone Joint Surg [Br] 48:777-80, 1966 3. Crawford GP, Narakas A: Radial nerve entrapment as a cause of tennis elbow-fact or fiction. Proc LeRoy Abbott Orthop Soc 7:92-9, 1976 4. Crawford GP, Narakas A: The radial nerve and tennis elbow. Orthop Trans 2:243, 1978
Population structure To the Editor: Robert A. Chase's recent article in THE JouRNAL OF HAND SuRGERY 1 correctly identifies a key problem in cost-benefit analysis, namely how to unambiguously measure the benefits of various medical procedures. He is also correct in calling attention to the need to include measures of the quality of life as real and important
90 80 70
60
30
20 10
40
20
0
20
40
POPULATION (MILLIONS) Fig. 1.
benefits of medical intervention of all sorts, including hand surgery. Unfortunately, the value of Chase's article is con siderably diminished by his misunderstanding of the evidence he provides on the impact of medical care around the world. Chase presents five figures represent ing the age distribution of various populations. (The figures were previously given by Krishna2 and Ma loney3.) One of these figures is repeated in this letter. The white portion of the figure represents a ''typical developing nation'' and is triangular. The black portion of the figure, demonstrating the age distribution of a "typical industrialized nation, " is rectangular. Chase concludes, ''the population triangle becomes more rectangular as more and more people live to maximum age." Not so. The triangular shape characteristic of the age distri bution of most developing countries is the result of high fertility and not high mortality .4 Indeed, reducing death rates would make the population younger and the dis tribution even more triangular. The triangle signifies there are more children than adults, precisely what happens in circumstances where fertility is high. Chase concludes that the difference between the rectangular and triangular population-age distributions clearly indicates that "medical tasks as far as life ex pectancy is concerned are largely accomplished'' in developed nations. This may be true, but the evidence Chase proposes does not support his argument. The
Vol. 9A, No. 3 May 1984
Letters to the editor
difference between the age distributions Chase cites as proof that medicine's goals have been achieved is a by-product of differential fertility and not differences in death rates or health status. It might interest Dr. Chase and other readers of this JoURNAL to know that reducing fertility would, after a period of years, lead to the rectangular age structure typical of developed countries. In the process the num ber of deaths per 1000 population might increase slightly because the youthful age structure typical of most developing countries is associated with extremely low crude death rates. The infant mortality rate would decline, however, as would maternal mortality, both of which are higher among high parity births and mothers. Peter J. Donaldson, PhD. Family Health International Research Triangle Park, NC 27709
REFERENCES I. Chase RA: Costs, risks and benefits of hand surgery. J HAND SURG 8:644-648, 1983 2. Krishna R: Economic development in India. Sci Am 243:166-82, 1980 3. Maloney JV: The limits of medicine. Ann Surg 194:247, 1981 (presidential address) 4. Coale AJ: In Freedman R, editor: Population: The vital revolution. New York, 1964, Doubleday & Co, pp 47-58
Reply To the Editor: In his critique of my paper, "Costs, risks, and ben efits of hand surgery,'' Donaldson displays his single focus on fertility control. Elementary geometry tells me that no matter what the birth rate, if premature death could be prevented, the configuration of the population curve would become progressively more rectangular, albeit a larger rectangle. Conversely, diminishing the birth rate and keeping premature monality rates the
453
same would not affect the configuration of the curve. Obviously, from the prognostic point of view, one of the health-care advances in a developed country such as ours is a better control on birth rate that generates an annual cohort that has a better chance of long-term survival. I agree with Donaldson that "reducing fer tility would, after a period of years, lead to the rectan gular age structure typical of developed countries, '' but I would add only if premature death rates per age cohort were also reduced. I consider control of birth rates to be one of the important advances in health care but not the only one. Donaldson's sentence supports the point both Jim Maloney and I make and that he disparages-' 'the population triangle becomes more rectangular as more and more (or a larger percentage of) people live to maximum age." In support of the thesis that ''medical tasks as far as life expectancy is concerned are largely accom plished," I linked the statement to the J. Fries curve of survival (Fig. 1) that displayed changes from 1900 to 1980. If survival likelihood for each cohort on the In dian curve were that shown by Fries, it seems obvious that in one generation the pattern for the population would look more like that for the United States, al though its gross numbers would be larger. Donaldson's single focus on reducing fertility has blinded him to the other important influences impacting on the configuration of the mortality curve. The whole issue, by the way, is not the primary thrust of my paper. The issue for hand surgeons and other health-care providers is that of improving the quality of life for the population that, in the absence of present health-care measures, would be dead. Robert A. Chase, M.D. Emile Holman Professor of Surgery and Professor of Anatomy Stanford University Stanford, CA 94305
The Journal of HAND SURGERY
Leuers to the editor
nerve is free even with the forearm in full pronation, and one can then rarely incriminate the tendinous origin of the ECRB. ECRB release. I have not released this structure in my last 28 cases, and the results appear equally good. While I always doubted the role of the ECRB, my tenotomy cessations followed the unexpected postsur gical retirement of a promising teenage tennis star. While her radial nerve signs and symptoms were gone, her iatrogenic ''tennis elbow'' secondary to the disrup tion of the ECRB led to this exit. Skin incision. I prefer to decompress this nerve through a 5-centimeter transverse incision 3 to 4 em distal to the elbow flexion crease. An excellent view is encountered by laterally mobilizing the entire brachial radialis and radial wrist extensors and flexing the elbow to view the tunnel proximally. While this skin incision can hypertrophy, it does so less often than the longitu dinal and S-shaped incisions. Conservative care consists of anti-inflammatory medications and, if possible, avoidance of activities requiring extensive forearm pronation. Patients with symptoms of less than 3-months' duration often do not require surgery. I believe that symptoms should be present for 6 months before intervention unless there has been improvement, and then additional time is war ranted. Finally, I do not believe that corticosteroid in jections should be used in management of this disorder. Gary P. Crawford, M.D. 231 West Pueblo St. Santa Barbara, CA 93105
REFERENCES 1. Capener N: The vulnerability of the posterior interosseous nerve of the forearm. A case report and an anatomical study. J Bone Joint Surg [Br] 48:770-3, 1966 2. Sharrard WJW: Posterior interosseous neuritis. J Bone Joint Surg [Br] 48:777-80, 1966 3. Crawford GP, Narakas A: Radial nerve entrapment as a cause of tennis elbow-fact or fiction. Proc LeRoy Abbott Orthop Soc 7:92-9, 1976 4. Crawford GP, Narakas A: The radial nerve and tennis elbow. Orthop Trans 2:243, 1978
Population structure To the Editor: Robert A. Chase's recent article in THE JouRNAL OF HAND SuRGERY 1 correctly identifies a key problem in cost-benefit analysis, namely how to unambiguously measure the benefits of various medical procedures. He is also correct in calling attention to the need to include measures of the quality of life as real and important
90 80 70
60
30
20 10
40
20
0
20
40
POPULATION (MILLIONS) Fig. 1.
benefits of medical intervention of all sorts, including hand surgery. Unfortunately, the value of Chase's article is con siderably diminished by his misunderstanding of the evidence he provides on the impact of medical care around the world. Chase presents five figures represent ing the age distribution of various populations. (The figures were previously given by Krishna2 and Ma loney3.) One of these figures is repeated in this letter. The white portion of the figure represents a ''typical developing nation'' and is triangular. The black portion of the figure, demonstrating the age distribution of a "typical industrialized nation, " is rectangular. Chase concludes, ''the population triangle becomes more rectangular as more and more people live to maximum age." Not so. The triangular shape characteristic of the age distri bution of most developing countries is the result of high fertility and not high mortality .4 Indeed, reducing death rates would make the population younger and the dis tribution even more triangular. The triangle signifies there are more children than adults, precisely what happens in circumstances where fertility is high. Chase concludes that the difference between the rectangular and triangular population-age distributions clearly indicates that "medical tasks as far as life ex pectancy is concerned are largely accomplished'' in developed nations. This may be true, but the evidence Chase proposes does not support his argument. The
Vol. 9A, No. 3 May 1984
Letters to the editor
difference between the age distributions Chase cites as proof that medicine's goals have been achieved is a by-product of differential fertility and not differences in death rates or health status. It might interest Dr. Chase and other readers of this JoURNAL to know that reducing fertility would, after a period of years, lead to the rectangular age structure typical of developed countries. In the process the num ber of deaths per 1000 population might increase slightly because the youthful age structure typical of most developing countries is associated with extremely low crude death rates. The infant mortality rate would decline, however, as would maternal mortality, both of which are higher among high parity births and mothers. Peter J. Donaldson, PhD. Family Health International Research Triangle Park, NC 27709
REFERENCES I. Chase RA: Costs, risks and benefits of hand surgery. J HAND SURG 8:644-648, 1983 2. Krishna R: Economic development in India. Sci Am 243:166-82, 1980 3. Maloney JV: The limits of medicine. Ann Surg 194:247, 1981 (presidential address) 4. Coale AJ: In Freedman R, editor: Population: The vital revolution. New York, 1964, Doubleday & Co, pp 47-58
Reply To the Editor: In his critique of my paper, "Costs, risks, and ben efits of hand surgery,'' Donaldson displays his single focus on fertility control. Elementary geometry tells me that no matter what the birth rate, if premature death could be prevented, the configuration of the population curve would become progressively more rectangular, albeit a larger rectangle. Conversely, diminishing the birth rate and keeping premature monality rates the
453
same would not affect the configuration of the curve. Obviously, from the prognostic point of view, one of the health-care advances in a developed country such as ours is a better control on birth rate that generates an annual cohort that has a better chance of long-term survival. I agree with Donaldson that "reducing fer tility would, after a period of years, lead to the rectan gular age structure typical of developed countries, '' but I would add only if premature death rates per age cohort were also reduced. I consider control of birth rates to be one of the important advances in health care but not the only one. Donaldson's sentence supports the point both Jim Maloney and I make and that he disparages-' 'the population triangle becomes more rectangular as more and more (or a larger percentage of) people live to maximum age." In support of the thesis that ''medical tasks as far as life expectancy is concerned are largely accom plished," I linked the statement to the J. Fries curve of survival (Fig. 1) that displayed changes from 1900 to 1980. If survival likelihood for each cohort on the In dian curve were that shown by Fries, it seems obvious that in one generation the pattern for the population would look more like that for the United States, al though its gross numbers would be larger. Donaldson's single focus on reducing fertility has blinded him to the other important influences impacting on the configuration of the mortality curve. The whole issue, by the way, is not the primary thrust of my paper. The issue for hand surgeons and other health-care providers is that of improving the quality of life for the population that, in the absence of present health-care measures, would be dead. Robert A. Chase, M.D. Emile Holman Professor of Surgery and Professor of Anatomy Stanford University Stanford, CA 94305